Introduction: Magic Pudding
To effect change within governmental institutions, you need to be conscious of two important limits. First, resources are always at a premium; you need to work within the means provided. Second, regulatory change is difficult and takes time. When these limitations are put together, you realize that you’ve been asked to cook up a ‘magic pudding’. How do you work this magic? How do you deliver more for less without sacrificing quality?
In any situation where you are being asked to economize, the first and most necessary step is to conduct an inventory of existing assets. Once you know what you’ve got, you gain an insight into how these resources could be redeployed. On some occasions, that inventory returns surprising results.
There’s a famous example, from thirty years ago, involving Disney. At that time, Disney was a nearly-bankrupt family entertainment company. Few went to see their films; the firm’s only substantial income came from its theme parks and character licensing. In desperation, Disney’s directors brought on Michael J. Eisner as CEO. Would Eisner need to sell Disney at a rock-bottom price to another entertainment company, or could it survive as an independent firm? First things first: Eisner sent his right-hand man, Frank Wells, off to do an inventory of the company’s assets. There’s a vault at Disney, where they keep the master prints of all of the studio’s landmark films: Snow White and the Seven Dwarves, Pinocchio, Peter Pan, Bambi, A Hundred and One Dalmatians, The Jungle Book, and so on. When Wells walked into the Vault, he couldn’t believe his eyes. Every few minutes he called Eisner at his desk to report, “I’ve just found another hundred million dollars.”
Disney had the best library of family films created by any studio – but kept them locked away, releasing them theatrically at multi-year intervals designed to keep them fresh for another generation of children. That worked for forty years, but by the mid-1980s, with the VCR moving into American homes, Eisner knew more money could be made by taking these prize assets and selling them to every family in the nation – then the world. That rediscovery of locked-away assets was the beginning of the modern Disney, today the most powerful entertainment brand on the planet.
When I began to draft this essay, I felt as constrained as Disney, pre-Eisner. How do you bake a magic pudding? Eventually, I realized that we actually have incredible assets at our disposal, ones which didn’t exist just a few years ago. Let’s go on a tour of this hidden vault. What we now have available to us, once we learn how to use it, will change everything about the way we work, and the effectiveness of our work.
I: What’s Your Number?
The latest surveys put the mobile subscription rate in Australia between 110-115%. Clearly, this figure is a bit misleading: we don’t give children mobiles until they’re around eight years old, nor the most senior of seniors own them in overwhelming numbers. The vast middle, from eight to eighty, do have mobiles. Many of us have more than one mobile – or some other device, like an iPad, which uses a mobile connection for wireless data. This all adds up. Perhaps one adult in fifty refuses to carry a mobile around with them most of the time, so out of a population of nearly 23 million, we have about 24 million mobile subscribers.
This all happened in an instant; mobile ownership was below 10% in 1993, but by 1997 Australia had passed 50% saturation. We never looked back. Today, everyone has a number – at least one number – where they can be reached, all the time. Although Australia has had telephones for well over a hundred years, a mobile is a completely different sort of device.
A landline connects you to a place: you ring a number to a specific telephone in a specific location. A mobile connects you to a person. On those rare occasions when someone other than a mobile’s owner answers it, we experience a moment of great confusion. Something is deeply disturbing about this, a bit like body-snatching. The mobile is the person; the person is the mobile. When we forget the mobile at home – rushed or tired or temporarily misplaced – we feel considerably more vulnerable.
The mobile is the lifeline which connects us into our community: our family, our friends, our co-workers. This lifeline is pervasive and continuous. All of us are ‘on call’ these days, although nearly all of the time this feels more like a relief than a burden. When the phone rings at odd hours, it’s not the boss, but a friend or family member who needs some help. Because we’re continuously connected, that help is always there, just ten digits away. We’ve become very attached to our mobiles, not in themselves, but because they represent assistance in its purest form.
As a consequence, we are away from our mobiles less and less; they spend the night charging on our bedstands, and the days in our pockets or purses.
Last year, a young woman approached me after a talk, and said that she couldn’t wait until she could have her mobile implanted beneath her skin, becoming a part of her. I asked her how that would be any different than the world we live in today.
This is life in modern Australia, and we’re not given to think about it much, except when we ponder whether we should be texting while we drive, or feel guilty about checking emails when we should really be listening to our partner. This constant connectivity forms a huge feature of the landscape, a gravitational body which gently lures us toward it.
This connectivity creates a platform – just like a computer’s operating system – for running applications. These applications aren’t software, they’re ‘peopleware’. For example, fishermen off of India’s Kerala coast call around before they head into port, looking for the markets most in need of their catch. Farmers in Kenya make inquiries to their local markets, looking for the best price for their vegetables. Barbers in Pakistan post a sign with their mobile number, buy a bicycle, and go clipper their clients in their homes. The developing world has latched onto the mobile because it makes commerce fluid, efficient, and much more profitable.
If the mobile does that in India and Kenya and Pakistan, why wouldn’t it do the same thing for us, here in Australia? It does lubricate our social interactions: no one is late anymore, just delayed. But we haven’t used the platform to build any applications to leverage the brand-new fact of our constant connectivity. We can give ourselves a pass, because we’ve only just gotten here. But now that we are here, we need to think hard about how to use what we’ve got. This is our hundred-million dollar moment.
II: Sharing is Daring
A few years ago, while I waited at the gate for a delayed flight out of San Francisco International Airport, I grew captivated with the information screens mounted above the check-in desks. They provided a wealth of information that wasn’t available from airline personnel; as my flight changed gates and aircraft, I learned of this by watching the screen. At one point, I took my mobile out of my pocket and snapped a photo of the screen, sharing the photo with my friends, so they could know all about my flying troubles. After I’d shot a second photo, a woman approached me, and carefully explained that she was talking to another passenger on our delayed flight, a woman who worked for the US Government, and that this government employee thought my actions looked very suspicious.
Taking photos in an airport is cause for alarm in some quarters.
After I got over my consternation and surprise, I realized that this paranoid bureaucrat had a point. With my mobile, I was breaching the security cordon carefully strung around America’s airports. It pierced the veil of security which hid the airport from the view of all except those who had been carefully screened. We see this same sensitivity at the Immigration and Customs facilities at any Australian airport – numerous signs inform you that you’re not allowed to use your mobile. Communication is dangerous. Connecting is forbidden.
We tend to forget that sharing information is a powerful act, because it’s so much a part of our essential nature as human beings.
In November, Wikileaks shared a massive store of information previously held by the US State Department; just one among a quarter million cables touched off a revolt in Tunisia, leading to revolutions in Egypt, Bahrain, Yemen, Libya, Syria and Jordan. Sharing changes the world. Actually, sharing is the foundation of the human world. From the moment we are born, we learn about the world because everyone around us shares with us what they know.
Suddenly, there are no boundaries on our sharing. All of us, everywhere – nearly six billion of us – are only a string of numbers away. Type them in, wait for an answer, then share anything at all. And we do this. We call our family to tell them we’re ok, our friends to share a joke, and our co-workers to keep coordinated. We’ve achieved a tremendously expanded awareness and flexibility that’s almost entirely independent of distance. That’s the truth at the core of this hundred-million dollar moment.
All of your clients, all of your patients, all of your stakeholders – and all of you – are all unbelievably well connected. By the standards of just a generation ago, we are all continuously available. Yet we still organize our departments and deliver our services as if everyone were impossibly far-flung, hardly ever in contact.
Still, the world is already busy, reorganizing itself to take advantage of all this hyperconnectivity.
I’ve already mentioned the fishermen and the farmers, but as I write this, I’ve just read an article titled “US Senators call for takedown of iPhone apps that locate DUI (RBT) checkpoints.” You can buy a smartphone app which allows you to report on a checkpoint, posting that report to a map which others can access through the app. You could conceivably evade the long arm of the law with such an app, drink driving around every checkpoint with ease.
Banning an app like this simply won’t work. There are too many ways to do this, from text messages to voice mail to Google Maps to smartphone apps. There’s no way to shut them all down. If the Senate passes a law to prevent this sort of thing – and they certainly will try – they’ll find that they’ve simply moved all of this connectivity underground, into ‘darknets’ which invisibly evade detection.
This is how potent sharing can be. We all want to share. We have a universal platform for sharing. We must decide what we will share. When people get onto email for the first time, they tend to bombard their friends and family with an endless stream of bad jokes and cute photographs of kittens and horribly dramatic chain letters. Eventually they’ll back off a bit – either because they’ve learned some etiquette, or because a loved one has told them to buzz off.
You also witness that exuberant sharing in teenagers, who send and receive five hundred text messages a day. When this phenomenon was spotted, in Tokyo, a decade ago, many thought it was simply a feature peculiar to the Japanese. Today, everywhere in the developed world, young people send a constant stream of messages which generally say very little at all. For them, it’s not important what you share; what is important is that you share it. You are the connections, you are the sharing.
That’s great for the young – some have suggested that it’s an analogue to the ‘grooming’ behavior we see in chimpanzees – but we can wish for more than a steady stream of ‘hey’ and ‘where r u?’ We can share something substantial and meaningful, something salient.
That salience could be news of the nearest RBT checkpoint, or, rather more helpfully, it might be a daily audio recording of the breathing of someone suffering with Chronic Obstructive Pulmonary Disease. It turns out that just a few minutes listening to the sufferer – at home, in front of a computer, or, presumably their smartphone – will cut their hospitalizations in half, because smaller problems can be diagnosed and treated before they become life-threatening. A trial in Tasmania demonstrated this conclusively; it’s clear that using this connection to listen to the patient can save lives, dollars, and precious time.
This is the magic pudding, the endless something from nothing. But nothing is ever truly free. There is a price to be paid to realize the bounty of connectivity. Our organizations and relations are not structured to advantage themselves in this new environment, and although it costs no money and requires no changes to the law, transforming our expectations of our institutions – and of one another – will not be easy.
III: Practice Makes Perfect
To recap: Everyone is connected, everyone has a mobile, everyone uses them to maintain continuous connections with the people in their lives. This brand-new hyperconnectivity provides a platform for applications.
The first and most natural application of connectivity is sharing, an activity beginning with the broad and unfocused, but moves to the specific and salient as we mature in our use of the medium. This maturation is both individual and institutional, though at the present time individuals greatly outpace any institution in both their agility with and understanding of these new tools.
Our lives online are divided into two separate but unequal spheres; this is a fundamental dissonance of our era. Teenagers send hundreds of text messages a day, aping their parents, who furiously respond to emails sent to their mobiles while posting Twitter updates. But all of this is happening outside the institution, or, in a best practice scenario, serves to reinforce the existing functionality of the institution. We have not rethought the institution – how it works, how it faces its stakeholders and serves its clients – in the light of hyperconnectivity.
This seems too alien to contemplate – even though we are now the aliens. We live in a world of continuous connection; it’s only when we enter the office that we temper this connection, constraining it to meet the needs of organizational process.
If we can develop techniques to bring hyperconnectivity into the organization, to harness it institutionally, we can bake that magic pudding. Hyperconnectivity provides vastly greater capability at no additional cost. It’s an answer to the problem. It requires no deployment, no hardware, no budgeting or legislative mandates. It only requires that we more fully utilize everything we’ve already got.
To do that, we must rethink everything we do.
Service delivery in health is something that is notoriously not scalable. You must throw more people at a service to get more results. All the technology and process management in the world won’t get you very far. You can make systems more efficient, but you can’t make them radically more effective. This has become such a truism in the health care sector that technology has become almost an ironic punchline within the field. So much was promised, and so much of it consistently under-delivered, that most have become somewhat cynical.
There are no magic wands to wave around, to make your technology investments more effective. This isn’t a technology-led revolution, although it does require some technology. This is a revolution in relationship, a transformation from clients and customers into partners and participants. It’s a revolution in empowerment, led by highly connected people sharing information of vital importance to them.
How does this work in practice? The COPD ‘Pathways‘ project in Tasmania points the way toward one set of services, which aim at using connectivity to monitor progress and wellness. Could this be extended to individuals with chronic asthma, diabetes, high blood pressure, or severe arthritis? If one is connected, rather than separate, if one is in constant communication, rather than touching base for widely-spaced check-ins, then there will be a broad awareness of patient health within a community of carers.
The relationship is no longer one way, pointing the patient only to the health services provider. It becomes multilateral, multifocal, and multiparticpatory. This relationship becomes the meeting of two networks: the patient’s network of family, friends and co-afflicted, meeting the health network of doctors and nurses, generalists and specialists, clinicians and therapists. The meeting of these two continuous always-on networks forms another continuity, another always-on network, focused around the continuity of care.
If we tried to do something like this today, with our present organizational techniques, the health service providers would quickly collapse under the burden of the additional demands on their time and connectivity required to offer such continuity in patient care. Everything currently points toward the doctor, who is already overworked and impossibly time-poor. Amplifying the connection burden for the doctor is a recipe for disaster.
We must build upon what works, while restructuring these relationships to reflect the enhanced connectivity of all the parties within the healthcare system. Instead of amplifying the burden, we must use the platform of connectivity to share the load, to spread it out across many shoulders.
For example, consider the hundreds of thousands of carers looking after Australians with chronic illnesses and disabilities. These carers are the front line. They understand the people in their care better than anyone else – better even than the clinicians who treat them. They know when something isn’t quite right, even though they may not have the language for it.
At the moment Australia’s carers live in a world apart from the various state health care systems, and this means that an important connection between the patient and that system is lacking. If the carer were connected to the health care system – via a service that might be called CarerConnection – there would be better systemic awareness of the patient, and a much greater chance to catch emerging problems before they require drastic interventions or hospitalizations.
These carers, like the rest of Australia, already have mobiles. Within a few years, all those mobiles will be ‘smart’, capable of snapping a picture of a growing rash, or a video of someone’s unsteady gait, ready to upload it to anyone prepared to listen. That’s the difficult part of this equation, because at present the health care system can’t handle inquiries from hundreds of thousands of carers, even if it frees up doctor’s surgeries and hospital beds.
Perhaps we can employ nurses on their way to a gradual retirement – in the years beyond age 65 – to connect with the carers, using them to triage and elevate or reassure as necessary. In this way Australia empowers its population of carers, creating a better quality of life for those they care for, and moves some of the burden for chronic care out of the health care system.
That kind of innovative thinking – which came from workshops in Bendigo and Ballarat – which shows the real value of connectivity in practice. But that’s just the beginning. This type of innovation would apply equally effectively to substance abuse recovery programs or mesothelioma or cystic fibrosis. Beyond health care, it applies to education and city management as well as health service delivery.
This is good old-fashioned ‘people power’ as practiced in every small town in Australia, where everyone knows everyone else, looks out for everyone else, and is generally aware of everyone else. What’s new is that the small town is now everywhere, whether in Camperdown or Bendigo or Brunswick, because the close connectivity of the small town has come to us all.
The aging of the Australian population will soon force changes in service delivery. Some will see this as a clarion call for cutbacks, a ‘shock doctrine‘, rather than an opportunity to re-invent the relationships between service providers and the community. This slowly unfolding crisis provides our generation’s best chance to transform practices to reflect the new connectivity.
It’s not necessary to go the whole distance overnight. This is all very new, and examples on how to make connectivity work within healthcare are still thin on the ground. Experimentation and sharing are the orders of the day. If each regional area in Victoria started up one experiment – a project like CasConnect - then shared the results of that experiment with the other regions, there’d soon be a virtual laboratory of different sorts of approaches, with the possibility of some big successes, and, equally, the chance of some embarrassing failures. Yet the rewards greatly outweigh any risks.
If this is all done openly, with patients and their community fully involved and fully informed, even the embarrassments will not sting – very much.
In order to achieve more with less, we must ask more of ourselves, approaching our careers with the knowledge that our roles will be rewritten. We must also ask more of those who come forward for care. They grew up in the expectation of one sort of relationship with their health services providers, but they’re going to live their lives in another sort of arrangement, which blurs boundaries and which will feel very different – sometimes, more invasive. Privacy is important, but to be cared for means to surrender, so we must come to expect that we will negotiate our need for privacy in line with the help we seek.
The magic pudding isn’t really that magic. The recipe calls for a lot of hard work, a healthy dash of risk taking, a sprinkle of experiments, and even a few mistakes. What comes out of the oven of innovation (to stretch a metaphor beyond its breaking point) will be something that can be served up across Victoria, and perhaps across the nation. The solution lies in people connected, transformed into people power.