Q. Why is the software so dang simplistic?

A. In the early days of the Joel on Software forum, achieving a critical mass to get the conversation off the ground was important to prevent the empty restaurant phenomenon (nobody goes into an empty restaurant, they’ll always go into the full one next door even if it’s totally rubbish.) Thus a design goal was to eliminate impediments to posting. That’s why there’s no registration and there are literally no features, so there’s nothing to learn.

- Joel Spolksy in Building Communities with Software

I have a few skeleton pieces of that software sitting on my hard drive right now.  While trying to figure out how to make it work like Joel’s message board, I remembered one of the other axioms of software development: The Best Code is No Code.  It doesn’t make sense to write a new piece of software and waste others time learning a new piece of software when there are very good free alternatives already out there.  They don’t even require me to futz around with servers and hosting.  So instead I’m going to put my effort into building connections on Twitter and Friendfeed.

For the time being, anything cool and healthcare related that I find online is going into one of those two places.  If I outgrow it I’ll move on, but I don’t think that’ll be an issue.  Incidentally, I think that choosing to use these services instead of rolling my own is an example of what I’m trying to learn with this blog.

Why bring this up?  Well, in my last post I mentioned the need for zero-friction ways to share information about the healthcare problem and potential solutions.  While I don’t think a social news site is the be-all end-all solution, I think it’s a great first step.  The only problem is that I’m not aware of any such sites. I may just have to buckle down and build one myself.  No promises though… If I do get something together, I’ll post it here first.

A small, but very interesting, development on the web that I’d like to explore further is GitHub.  GitHub is a very niche operation that is doing something that probably would have been considered impossible a few years back: commercial source code hosting.  For a small fee, the promise to maintain the intellectual property of software shops.  For an established company, this idea is ludicrous.  They are asking their customers to move their most valuable asset outside the walls of their company and put it in the hands of this little startup.

GitHub seems to be making money so it seems that enough organizations are willing to trust their IP to this small software shop.  What really makes GitHub interesting though is how they’ve used Open Source technology to build not just a for-profit company, but a vibrant community around their service.  The GitHub website is actually a social networking site.  Instead of throwing sheep at each other though, they’re trading code.  This is one social networking site that has figured out how to enable valuable intellectual and commercial activity.

So what does this mean for healthcare?  Can their be a healthcare github?  I think sage might be on the right track.  This article from xconomy has some more info on sage.  They’ve already signed up some big names, but they’re also running into some of the same problems that you’d expect when you ask big companies to share IP.  While I hope they’re successful and I think that they’re structured appropriately for what they want to accomplish, the barriers to entry still seem to high.

I still don’t know what the right approach is to deploying mass creativity and the wisdom of the crowds to the healthcare problem.  It will, however, need near zero friction toward sharing ideas and data.

The people that are going to solve the healthcare problem are doctors and policy makers and probably even a few quants (I hear that some of them aren’t too busy right now).  Some of them are very good at what they do, but they don’t necessarily have the means (well, the quants might) to harness Open Data and really deploy the smart, data driven, solutions that I think are necessary.  So where does this leave me?

Both the promise and the problem of an Open Source solution is that it relies wholly on collaboration.  A brilliant spark by itself will flame out almost immediately, but many sparks connected by a combustible fuel can burn hot and bright.  To switch metaphors, open healthcare does not necessarily need a Google, it instead needs its Facebook.

I’m writing this blog because I’m hoping it will help me discover what I can contribute to the solution.  I like to think I can write really cool software, but I’m fully aware that even the greatest software is useless without a market or a community to exploit it.  I’m not one of the primary solution providers I listed above so what I can build won’t solve the problem directly.  My best hope is not to be the spark, but the fuel.  If someone like me wants to hack the healthcare system, I need to do it by building an open network of people that can actually solve the problem.

When we make a system hackable, uses emerge that the designers and administrators never intended.  Sometimes those uses exploit the system (think email spam), and we must actively manage against them.  However, these novel emergent uses often add considerable value.  My hope is that open healthcare can save more lives at lower cost because it can recruit and deploy so many more participants than a closed, top-down system would even consider.

There is a lot of effort going into standardizing healthcare in every way from electronic medical records to treatment protocols.  What these standards have in common though is top-down specification and increasingly complex implementations.  Not only do these forces generally inhibit mass creativity, they actively discourage it.  Mass creativity is a threat to traditional hierarchies.

Healthcare is the epitome of complexity.  Not only is it a very hard problem requiring extreme amounts of talent to carry out even the most basic functions, there is so much money involved that the politics and red tape put every action under the microscope, thus regimenting the whole practice.  There is not an open system in sight.

The problem, though, is that bureaucracy doesn’t scale and it doesn’t adapt.  Past a certain point, it takes more effort to maintain the bureaucracy than it does to do the actual job.  To make matters worse, the bureaucracy is too slow to adapt to change.  It can’t evolve and improvise.  But how do we ensure quality of care while at the same time harnessing mass creativity?  The answer is in a little slight of hand.  What we really want is complex behavior, not complex systems.

Dee Hock, founder of Visa observed that:

Simple, clear purpose and principles give rise to complex and intelligent behavior. Complex rules and regulations give rise to simple and stupid behavior.

~ Dee Hock Quotes

The problem is in finding the right set of simple rules.

Coming from the technology world, I have a lot of faith in the lessons that the web has taught us.  In this realm, simple, open architectures and a philosophy of information sharing have lead to a vast ecosystem that simply didn’t exist 20 years ago.  While I have no illusions about silver bullets and quick fixes, applying some of the lessons of the web should get us a long way towards the goal of a fair and effective healthcare system.

There are two important lessons from the web that I want to address in the near future: Open Source and Standards Based APIs (call it Open Data?).  Individually and taken together, these areas of the web have made contributions on the same scale as many multi-billion dollar companies.  And they’ve done it on a shoestring.  Of course, I doubt that such a thing as an open source surgeon will ever exist, but adding billions of dollars of value (without billions in costs) on top of the existing healthcare infrastructure would be simply revolutionary.

Obviously, public health systems in the US can’t to coordinate their activities, but this looks like its an early stage disruptive innovation.  It’s cheap, it’s “good enough” where it’s deployed, and it’s sufficiently ad-hoc that it could start popping up unexpectedly in scenarios that normally call for more sophisticated solutions.  That’s the classic pattern of disruptive innovation.

More info:

• The BBC on a mobile health campaign launched by the UN, Vodafone, and the Rockefeller Foundation.
• Clayton Christensen describes disruptive innovation in his book The Innovator’s Solution: Creating and Sustaining Successful Growth

1. Outcomes, not income
2. Connections, not transactions
3. People, not product
4. Creativity, not productivity

I find them intriguing, but as a recovering libertarian, a little alien. Well, since this blog is all about learning (for me in particular), I’m going to dive right in anyway and try to make sense of them in terms of health care and open systems.

Open systems really dovetail well with Haque’s four pillars.  The goal of open system is really about creating value by giving the user’s control.  That by itself satisfies 1, 3, and 4.  Number 2 actually enables the openness by making it possible to achieve a critical mass and make the system self sustaining.

Health care, on the other hand, is mired in closed, top down systems.  Insurance companies (or governments) are worried about income (or costs).  The focus is on proceedures, not outcomes.  And I don’t see how creativity can exist in such a system.

Of course, the system exists this way for a reason.  It’s not malice.  It’s just that high assurance requires some amount of bureaucracy.  On the other hand, anyone that can figure out how to build openness into, on top of, or around the system and apply Haque’s four pillars probably will stand to do a lot of good and maybe make some money in the process.

(Just to clarify, hackers make cool things, they don’t break into computers.  Those are crackers)

So, I have no expertise to share with this blog.  Instead, I’m using it to learn.  The state of healthcare in this country hits pretty close to home, and coming from the software field, I think its strange that there are so few hackers tackling this problem.  

What I’m looking for are the grassroots innovators that are building cool things in their garages with off the shelf parts.  Obviously, no one is going to be building anything like a CT scanner in their garage, but that’s actually the fun part.  There’s no way to know what’s cool and important (disruptive in MBA speak) until it sneaks into people’s hands and we all exclaim how obvious it was.