Saturday, June 6, 2009

Let's discuss Clay Christensen's "Innovator's Prescription"

I want to start a discussion among people who've read, or are reading, Clay Christenson's Innovator's Prescription.

Harvard Business School professor Clayton Christensen is, arguably, the most important observer of what makes some technical changes take off and others not. He's the one who created the concept of "disruptive innovation."

It's important to understand that "disruptive" in this sense is not about being socially disturbing or rebellious, it's about developing a new solution that comes from a new direction, rather than being a continuation of the "same-old same-old." The Wikipedia article has good examples of what is and isn't disruptive, in this sense.

In my own career, I witnessed the disruption of the typesetting industry (where I worked) by desktop publishing, which let consumers get what they needed without going through conventional typesetters. To be sure, it was painful to watch my industry die, but die it did – because customers wanted more than we were giving them in service and value.

Because disruption generally rejects the establishment, it's often accompanied by denial on the part of the dominant technology; in my case, we in typesetting said "Our craft is full of skill and knowledge; it takes years to get good at it. Desktop publishing is a toy. It has none of our professional features." But it turned out that consumers were happy to make do with something they could do themselves at a fraction of the cost.

And – and this is pivotal – as the use of desktop publishing spread, its features grew: it became not just a toy. We in typesetting watched the list of our advantages shrink. It was an extreme case, because our entire industry pretty much disappeared in about five years.

Christensen introduced the disruptive concept in 1995 after studying the rapid evolution of disk drive technology. He's since applied it to many industries, and it's been said that entire new national economies have used it (successfully) to plan growth strategies.

But he says his hardest project "by a full order of magnitude" has been to understand healthcare. He's been working on it for ten years – most of the time since he developed the concept – and his healthcare book was just published this February. Importantly, he's not just a techie geek who rejects the medical establishment. He worked closely with some serious doctors, who concur with his conclusions.

But not everyone does agree. One doctor I highly respect says Christensen "nailed the diagnosis but blew the prescription."

I want to discuss it here because I'm someone who's not mired in the industry, but who HAS seen industries get disrupted, and it seems screamingly obvious to me that US healthcare is ripe for disruption. Although its services are life-saving (I'm an example of that), the work is overpriced, consumer satisfaction is very low, people generally can't get what they want when they want it, yet prices keep going up, to the point where some people and some employers are just saying "Screw it" and going without. (Recent statistics have pointed to increases in both; I'm too tired to dig out the links, but it's real, especially for small businesses and all their employees. The healthcare system is pricing itself out of a job.)

Dr. Alan Greene, president of the Society for Participatory Medicine, often mentions in his speeches that healthcare is a bubble, not unlike the internet bubble that popped a while ago. He talks about Disruption and the healthcare bubble. That's an excellent little post – please read it if you want a deeper understanding of what' s up.

I'm only partway through the book, and my free time for reading has been unpleasantly low, so I'd like to hear the thoughts of those who've read it। If you have, please comment.

Quick start: see the reader reviews on Amazon.

Sequel: Christensen: "The general hospital is not a sustainable business model"


  1. I read this book in March and think that it is one of the most important books on healthcare reform of this century. I agree that Clayton and his colleagues are strong on diagnosis, but might be short on prescription. But I also believe that correctly identifying the problem is a large part of solving it.
    I look forward to discussing the ideas from this book. As a start I would like to get impressions from others on the proposal for high deductible insurance coupled with a health savings account. This model has been very successful for some business people I know.

  2. So Brian, why do you think it's one of the most important books? And can you give us a concise synopsis of what the prescription is and why you feel it misses the mark?

  3. Here's how the top-rated ("most useful") Amazon review says about the prescription:


    (1) Fee for service would continue to apply to diagnostic services, where - due to the nature of the patient's condition and the state of medical knowledge - there is a high need for intuitive investigation versus results-based treatment for conditions that are well understood.

    (2) Fee for result would apply for treating conditions that are well understood and have a clearly defined solution -- colonoscopies, laser eye surgery, implantation of stents, etc.

    (3) User networks for patients with chronic conditions/ unhealthy practices to learn how they can help themselves and be motivated to do so.


    I would extend (3) to include more than chronic conditions. My perfect example is my kidney cancer patient group. In business terms, there's much value that can be created by patients. Another example: after I spoke in DC last Tuesday a citizen in the audience raced up to me and asked if I knew of ACOR-like groups for patients of congestive heart failure, like his father, because his gut was telling him that there must be more useful tips available from people who have the condition than from the professionals who treat it. (Nothing wrong with the pro's; he just has a sense that there's something more available.)

  4. Thanks for including the Amazon reviews Dave - they are what actually led me to the book!
    I will write up some commentary on why I feel the issues raised in the book are so vital. As far as the prescription for healthcare reform, I only wish I knew. What I meant to say was that the book did a great job at diagnosing many of the troubles, but did not offer as much solution as I would have liked. I jokingly say that a better title would be "The Innovator's Diagnosis" :-)

  5. Those three things look like a pretty solid framework - much more "framey" than, for instance, the term "meaningful use" that's being debated so much in recent weeks.

    What's not clear enough for your tastes? Or when you say "did not offer as much solution," where were you looking for more detail?

    Seems to me we could (and probably will) get into a BIG wrestling match over whether to do those specific things, never mind if he'd gotten into more detail, which itself could be the site of much wrangling.

  6. I have only read the first part of the book, but I do think Christensen is "right."

    Unfortunately, what is right won't necessarily get done and I think truly exciting disruptive innovation will be unlikely to occur in the heavily regulated areas of the health care system. Because it is a heavily regulated industry, the establishment in health care can modulate the pace of change.

    However, I do think that disruption can occur on the less regulated fringes of health care, although probably not in response to disease treatment.

    Your post prompted a blog post of my own on the topic:

  7. Good to meet you, Jason. I'm starting to wonder if the real disruption will happen outside the system - as more and more people get priced out of the market, they/we will develop new solutions from scratch, ignoring the current rules of the game by simply exiting the game.

    I encourage people to read Jason's thoughtful post (

  8. I have read the book, and also had the opportunity to hear and speak with Clayton Christensen in Minneapolis in March. In my role as Chief Knowledge Officer for the Institute for Clinical Systems Improvement (ICSI), I have the chance to explore and introduce new concepts and topics to our members (comprised of over 50 health care organizations) and others.

    Since reading the book, I've been sharing the introductory chapter shamelsessly with many around the state, and the country. From my perspective, Christensen is "dead on" with his diagnosis of the issues. With regard to the prescriptions, while as someone who's lived within the health care system for over 35 years, I'm not sure if he's incorrect with his solutions, or if I'm just mired in my paradigm, and as "out of the box:" as I think I am, I'm only in a larger box than others, and still restricted by my experience and training.

    That being said, I'm introducing this in book club discussions with others in Minnesota, interested in engaging in animated (a nice term for high cognitive conflict opportunities) discussions, and addressing his concepts of "intuitive", "value added" and "precision" medicine.

    While we in health care always use the old chestnut--"Health care is different"--we need to recognize that the similarities to other industries are likely more significant than the true differences. Additionally, another great read, Here Comes Everybody by Clay Shirky, challenges much of what I thought made me special as a physician. Indeed, are physicians susceptible to becoming the "scribes" of the 21st century. If you read the book you'll understand the reference.

    ePatient Dave, I know you're linking up in discussions with ICSI and will be speaking to our audience next spring, but thanks for creating a different venue for discussing what is potentially one of the most provocative threads in some time

  9. Last call, everyone - tomorrow morning I'm attending a breakfast meeting where Christensen is speaking. Anybody have any questions they want answered?

  10. Question: What role does Clay envision the consumer/taxpayer playing as we (hopefully) transition to an improved health care system?

  11. With the developments in healthcare reform and push towards EHR, would Mr. Christensen have any new advice for the healthcare industry?

  12. In an interview by by Scott Shreeve, M.D. in Crossover Health Jason Hwang, M.D. said "We obviously chose the title because we felt it had some shelf appeal and also to stay congruent with the Clay’s past books. We did not intend for the concept of prescription to mean prescriptive, or to assume that an understanding of DI unlocks all the answers."
    Jason then goes on to lay out the root causes of the problems in healthcare. He also addresses on of the main criticisms leveled at the book, a seeming attack on the Medical Home Model.
    He said, "In our evaluation of the medical home, we believe there is clearly a job-to-be-done that most patients require – “help me coordinate my care” – which is important in an increasingly fragmented health care system. But my criticism is mainly targeted at the assumption that this care coordination must be headed up by a physician. For some situations, this job could be fulfilled by a non-physician or even a software program. In other cases, the amount of information required to manage and coordinate care well goes far beyond the realm of a primary care provider."
    I think this book opens up a great discussion on many facets of the healthcare debate. I would like to keep discussing some of these issues on this blog.

  13. Dave,

    BIDMC happens to be my hospital also- I work there. I'd like to point out a wrinkle most people do not think about. Doctors have a very clear cultural divide between the young and the old (pre-computer trained) doctors. Young doctors want EMR, physician management systems, and the whole shebang as part of their hiring package. Older doctors, who are the attendings and arbiters of power, resist the implementation of technology. And even the attendings that are receptive have a very hard time participating in this cultural shift because the language of the computer, like any language, takes a while to pick up.

    I imagine that the new crop of doctors will effectively be able to supplant practices run with outdated methods because the two kinds of practice will have very different cost structures (practices run by the old guard vs. practices run with efficient technology). How's that for disruptive innovation?

  14. Great to meet you, Frank.

    Funny, in the online healthcare discussions I've read and conferences I've been to, I've heard lots of people mention that "the old guard" has very different habits from the generation that grew up online.

    I think you're right, and to me it's vital that we bear this in mind as Washington writes new regulations regarding medical record systems. Laws tend to be around for a long time, and we need to plan accordingly.

    I wrote about the advancing generations issue in May regarding the pivotal definition of "meaningful use" for EMR systems - I think you're exactly right.

  15. Dave, no doubt "because disruption generally rejects the establishment, it's often accompanied by denial ... of the dominant technology".

    So reject all current Health care? Just build on blogs and small clinics? Once again the PC overwhelms the mainframe?

    Or does this call for Toyota? Continuous improvement, evolution, improve the supply chain. More Canada than tea party?

    The first course has glamour - who doesn't want the rush of "throw the bums out"? The second is somewhat banal, but which best fits here?

    Given the scale of waste in the current system - some due to the way we compensate, a lot due to the way we treat data - the current system seems ripe for improvement to me. In banal steps, a few jogs and a leap or two (Kaiser's stuff is in this vein).

    One possible step - take current data - a lot stuck in HL7 messages -, get it into a Semantic Web and let all from Patients to Researchers at it. Hospitals run better, Patients know more, Research exposes waste and drug possibilities (more at

    Are such steps "disruptive"? Is this "rejection", "innovation"? Well, that's in the eye of the beholder.


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