In Digital Health everything changes. Entrepreneurs have to navigate the well-known and the unknown to bring their ideas to life.
When I was young, it seemed that life was so wonderful, a miracle... oh it was beautiful, magical. [...]
But then they send me away to teach me how to be sensible, logical, responsible, practical.
And they showed me a world where I could be so dependable, clinical, intellectual, cynical.
Roger Hodgson (Supertramp), The Logical Song
Management theories teach us that to run a successful business, you have to manage risks, to have contingency plans. You may use decision trees, SWAT analysis, industry benchmarking, market forecasts and so on. All good, excellent practices for established markets.
Recently, on social media platforms, a quotation from Elizabeth Holmes became a forum for debate as to whether you should/could not have a plan B. (It may come as a surprise, but this is not a story about Elizabeth Holmes, nor Theranos.) Most comments were either unfavourable or simply distrustful.
I will start with the distrust. Commitment, in terms of identification with a cause or value, is not that rare. I am sure that quite a few corporate titans and entrepreneurs would testify to this.
The entrepreneur who runs the “gale of creative destruction” (Schumpeter 1942) and almost single-handedly causes “industrial mutation” (ibid.) is captured by the academic literature on innovation. It is the capacity of these entrepreneurial heroes to summon resources, inspire and co-opt others when all reason would say otherwise. Therefore, let’s accept it, the business world does not escape passion (see my previous post You, Me and Digital Health).
Elizabeth Holmes (CHM Revolutionaries interview 2014) quite candidly explained how her upbringings prepared her for a life of purpose—in her case, to make blood tests available when it matters (Theranos). Scanadu’s Walter de Brouwer embarked on a commitment to make health information available in the palm of your hand. Founders of Ieso Digital Health, Sue Wright and Nadine Field, had their own quest to make psychological therapy available to people when it’s needed.
These are only a few examples of where it is not business as usual, it’s personal. And this is a good thing.
When in Digital Health…
Digital technologies have always escaped the rules of traditional markets, not only due to the constant morphing of technologies, but also due to their inherent unfinished character (Garud et al. 2008). These technologies take various shapes based on the user’s input, or they are rendered insignificant without user-generated data. Therefore, we find here that “operations are emergent and fluid, goods and services are intangible and informational, authority is distributed and diverse, and accountability is multiple and shifting” (Orlikowski 2010: 243).
In healthcare, digital technologies will enable the shift in “the locus of care [...]. It will enable doctors, nurses, and patients to help each other; and it will provide the enabling fuel for primary care doctors to disrupt specialists, and for nurse practitioners to disrupt doctors” (Christensen et al. 2009: xxxiv). And surely it will enable patients to disrupt healthcare professionals, payers, regulators…
Digital Health is an emerging market. What does that mean? It means that there are ambiguities from top to bottom: terminological, social, political and professional.
Digital Health emerges (primarily) between healthcare and consumer technologies and it attacks the healthcare system as we know it. Had the healthcare systems not been already crumbling, this attack may not have been so direct.
Some of the causes for the precarious state of healthcare systems: scarcity of resources, over-regulation, irreconcilable logics (i.e. managerial and medical profession), poor outcomes for consumers (patients), hassle for politicians… Even doctors lost plenty of their professional prerogatives (Scott et al. 2000), for better or worse.
Go ahead, take over the cockpit and storm the O.R. Fly your own plane, remove your own tumour. [...] Give the carcass of expertise a good kick as you go by."
- David L. Katz 2015
Long story short, no one is happy; healthcare has been in a state of an increasingly fragile equilibrium for a long, long time now.
Doctors and hospitals, regulators, and policy makers need to convert to this religion [...]. The fact that cost-lowering, accessibility-enhancing disruptive enablers can address only the simplest of problems at the outset is indeed a gospel of good news. (Christensen et al. 2009: xlviii)
In other words, Digital Health might in fact be the salvation for healthcare which can allow for healing to begin (for all parties involved).
All healthcare stakeholders are aware that this is only the beginning of a new chapter. Digital Health builds on this momentum. For a new market to mature, a few aspects have to settle: socio-political (governance, regulation, ownership), resources (human, technical, investments) and rules of the game (exchanges, networks). All of these are in the making.
Be dependable, clinical, intellectual, cynical
And I finally loop back to the issue of unfavourable comments on social media regarding Holmes' statement about being a plan A kind of person.
Aldrich (1994), in his brilliant article about the peculiar condition of start-ups in emerging fields, points out that they are trapped in a socio-political limbo, sometimes even in a hostile context.
“In addition to the normal pressures facing any new organisations, they also must carve out a new market, raise capital from sceptical sources, recruit untrained employees and cope with other difficulties stemming from their nascent status” (ibid.: 645).
In this context, entrepreneurs in emerging fields may seem foolish, but only because they have “the ability to perceive new opportunities that cannot be proved at the moment” (Schumpeter 1947: 157).
All things changing...
How do you know if your plan A is good? How do you know if plan B is not actually better than A? How do you plan?
John Nosta (2015) pointed out in a recent post that Digital Health accelerators are still finding their way between the old and the new. “Not a lack of talent on the innovation side—but a lack of talent to guide, mentor, nurture and foster the complicated aspects of typical accelerators and the digital health movement” (ibid.).
Do you take for granted the input you get from others?
I would not be in this business if I did not have unrealistic expectations of what this company can do in society.
I also think you have to be a bit crazy and take the risks. Some will pay off and some will not, but you’ll never get there if you don’t try.
The brilliance of science and technology that defines digital health is just part of the process. And while it tends to define this area, I remain concerned that some bold ideas will wither and die as the lone voice of innovation fails to be heard by the bean counters and paper pushers that are becoming a functional reality (and necessity) in the accelerator movement.
- John Nosta 2015
True, not all good ideas or technologies will make it. Risk is intrinsic for new beginnings. This endeavour takes more than a brilliant idea.
Sue Wright talks about her and Nadine Field’s saga:
I guess we never ever had any doubts about IESO Digital Health. Nadine and I always knew why we were doing it, and there was a reason for it, so we kept that faith! And along the way, I mean personally, financially, it was difficult.
- Sue Wright, personal conversation 2015, with permission
In Digital Health…What’s Your Plan?
However, I believe there are more upsides to the situation than downsides. Changes in healthcare and the regulatory environment are imminent. Although there is uncertainty, and there will be trials and errors, the status quo in healthcare is unstainable (see also my previous post What Have the Regulators Ever Done for Us? 2014).
In itself, this translates to a constant flow of opportunities to come. So there is plenty of material for brave hearts here.
And in the midst of these uncertainties, one thing is clear: money is rushing in—and there is no point in reiterating how many billions the market is worth and how bright the projections are.
Bringing a good idea to the real world requires the will to make it happen (Schumpeter 1947). Walter de Brouwer comments on what leaders and innovators need: “Determination. You are not going to succeed if you tell yourself no.”
This is not blind determination. On the contrary, the more disruptive it gets, the more awareness, flexibility, creativity and endurance it requires. It simply means keeping your eyes on the end game—on where you want to be.
And if I had to start a company and fail a thousand times and start it over again and fail, I would do that. And so when I realized that, then it was about doing whatever it takes to make this a reality. Because it's a change that can happen and has to happen in our world!
- Elizabeth Holmes, CHM Revolutionaries interview 2014
In the end, if you have a good idea—believe in it. And if you have the value rationality—that insatiable passion to create and the irrationality of will to follow through—then there is no better place to be than Digital Health.
The nuviun blog is intended to contribute to discussion and stimulate debate on important issues in global digital health. The views are solely those of the author.