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Dr. Arati Prabhakar

Remarks
The National Information Infrastructure: A Revolution for the Millennium

Mayo Clinic
Rochester, MN
October 4, 1995

It's really a pleasure to be here with all of you tonight.

I'd like to talk about a tremendous transformation that we're all living through right now -- the Information Revolution. It is a change that is happening over a period of some years which has tremendous implications for us throughout our society. I'd like first to explore the scope of that transformation and what some of those changes might mean for us as a society. Then I want to share with you some of my observations from outside the health care system, about what those changes may mean and what the challenges may be for the business of health care.

Let's start by thinking about what's happening with the information revolution. When we've talked in the last few years about the National Information Infrastructure, the analogy that gets used the most often is the "Information Super Highway," an analogy made to the physical highway structure in this country. It's a useful analogy, but I'm tired about all the jokes about roadkill. The analogy actually starts to break down after a while, so I want to suggest that we might take a little bit broader look at this transformation that's underway today by zipping back about a hundred years and looking at the transformation that was underway at the turn of the last century -- the Industrial Revolution. There are several characteristics of the changes we're going through today that map to some of the changes a century ago. Fundamentally, the period of time we are living through right now corresponds to, if you like, a knee in the curve of the Information Revolution -- much in the same way that a century ago we were going through a period of change in the pace of change of the Industrial Revolution. So if you think about the turn of the last century, industrialization had been going on for many, many years. We'd had railroads, mechanization, and automation. But what was dramatically different and was really dramatically changing the pace of the Industrial Revolution was the idea of interchangeable parts. And it was really from that concept that flowed the fundamental change in the way we build systems. Instead of everything being a lovingly hand-crafted system, all of a sudden I could build something by using the component that you supplied so that your widget would really fit into my socket. And that was a pretty basic transformation. It had tremendous implications for the kinds of capabilities we possessed, for the kinds of products we were able to build. It transformed the industrial enterprise. It introduced the idea of economies of scale. It created the kind of industrial system that we really have today.

So what's happening in the Information Revolution today? Well, again, it's not new to have computers and communication technologies; those have been around in some form for literally decades already. But there is a qualitative change that's happening today that has technical characteristics, as well as some social characteristics, that are very important if we are to understand what this inflection point means in our own revolution that's going on right now. And part of this change happening in the Information Revolution has to do with interoperability. If you think about how we've developed information capabilities in the past, it's tended to be islands, or, if you like, stove pipes of different kinds of infrastructure. We have a broadcast information infrastructure. We have a telephone information infrastructure. We have the Internet, which is a completely different and wild and wonderful creature, but another kind of infrastructure. Today we are at the threshold of creating the kind of interoperability that lets us cross those traditional domains and really start changing the way that people use information technology. That really is the social side of it, and the more compelling part, as a matter of fact. For years and years and years I've been in communities where people were talking about how wonderful information technology was. A few years ago most of those people were computer scientists or electrical engineers, and we all said, "Boy, is this stuff gonna be great!" I find today that I am often in conversations where people who educate our kids, or people who operate financial systems, or people who manage factory floors, or people who are in the business of health care -- these are the people who now are talking about the transformations that are happening in their business because they can use the kinds of new information tools and technologies that have developed. That transformation from a technology push to a user pull has begun, and I think it has a long way to go. But that is an important part of the qualitative change that's happening in this Information Revolution. This business is pervasive. As they say, really it is too important to leave to the computer scientists anymore. It really has already begun to affect so many facets of how we live our lives and how we create the future.

Let's go back to the Industrial Revolution for a moment. I find it very hard to imagine any part of our society that was left untouched by the Industrial Revolution. Even though it's still early in this transformation to the information age, I think it's possible to predict that that will be the case as well. There will really be no profession, no walk of life, that is left unaffected. If you look at what happened in the last century, one of the obvious things, of course, was that we were transformed from a largely agrarian society. When this country was founded something like 90% of the nation were people who made their living off the land; they were in the agriculture business one way or the other. Today that number is around 3%. Please note we didn't stop farming. Farming production and our ability to create food and other products from the soil is up dramatically; we feed ourselves and much of the rest of the world. So, we need to be clear that there is a distinction between what fraction of our work force is doing a particular job and our capability to do that job.

As we are transforming now in this next revolution, the key question becomes, "Where is manufacturing going?" I think we see some trends already in that area. Manufacturing employment has continued to shrink as a fraction of our total work force today. It's about 16% in this country, and it continues to decline. We face some fundamental questions about where those numbers are going and what that means about the kinds of capabilities we believe are important in our economies and our societies for manufacturing in the information age.

Let's look a little bit deeper. If you look at the changes that came out of the Industrial Era in terms of education, it's really quite phenomenal. There is a recent article in the National Journal that I would recommend to any of you who are interested in this subject. It describes some of the changes in the last century, and it points out that in 1900, about 10% of our youth were going all the way through high school, were graduating from high school. Within 25 years that number had grown to 50% of the people in this country -- a phenomenal increase in the level of education driven by the Industrial Revolution's need for a much higher education level. In the changes that are going on today we begin to see some early signs of that. There have been studies looking at wages during the 1980s, and already we can see quite a distinct differentiation in wage level according to people's ability to use computers. For a variety of different occupations, people have now documented something like 10% or 15% higher wages, depending on the skills and the ability to use these automated technologies. There is a lot of discussion about how the use of information technology transforms education. There's a major national push to try to make sure school children have access to these technologies. But in addition to a transformation in how our children learn, there's also a new question, which is how much and what kinds of things do our children need to learn? How do we need to educate these new workers coming out of schools if they are to be productive and constructive members of our economy and our society? Dramatic changes lie ahead.

If you look at social policy in this country, so many of the things that today are under a phenomenal debate and a raging discussion are about the way we deal with the government's role in society. So many of these ideas are rooted in changes that happened during the last century -- regulatory policies, and the whole concept of anti-trust and the role that it played in facilitating the growth of the industrial economy. Even simple ideas like unemployment compensation. It's worth thinking about the fact that on farms unemployment was really not an issue, but in the industrial era it became a quite significant issue, and there was a social policy to respond to that. Think about the changes that had to be made to accommodate the transformation a century ago, and I think it may give us a sense of the kinds of dramatic changes that may be necessary in our social policies.

In the business I'm in, research and development -- the business of creating technologies -- part of what came out of industrialization was about a 50 year trajectory for technology in this country in which there's been a public and a private component in R&D. Major advances came as companies took technology out into the market place while the government funded basic research and technologies for missions like national security. Those traditions of technology development also are rooted in our ways of thinking about the Industrial Era. They didn't really exist before that, and in the new transformation that's coming up we're going through a lot of changes to figure out how do we really do this job for the nation. Because it is going to be different.

What is happening today with the information revolution is not a glorious panacea. It is a dramatic change. It will call into question over a period of some years a lot of our fundamental assumptions, things that for our generation and our parent's generation, we just took for granted. A lot of our fundamentals are shifting, and that is going to demand that we start thinking in very basic ways about many, many issues that affect our society.

What is this Information Revolution made up of? It is a set of technologies and tools and applications. One way of thinking about the Information Infrastructure, the basis for the Information Revolution that's unfolding, is a three-layer cake in which, in technology terms, the base layer is the physical technologies that allow us to handle and process and transmit and share information. This includes computers. It includes telephone networks. It includes the local area network that allows you to move bits around from your office to the next office. It includes wireless and broadcast media. Basically, it includes all the ways that we have of capturing, processing, storing, transmitting information. That layer is a critical element, but it's not enough to create an information capability, obviously. Because on top of that, the second layer of my cake, is the amorphous stuff, typically software. It's so amorphous it is usually called middleware in this community. But what it really is are the services that turn all the ones and zeros, all the bits of information in the networks and in the computers, into useful information. So it's everything from the search tools that let you look in heterogeneous data bases and find exactly what you're looking for to network protocols that allow networks to operate seamlessly. So, this layer includes the generic tools that in many, many different application areas are necessary but which really live on top of the physical layer of the information infrastructure. So that's the first two layers of the cake. The third layer is actually the most important one because it is the set of applications that are now driving these information capabilities. The typical list usually includes education, health care, manufacturing, electronic commerce, and digital libraries. You can make up your own list. But, all of those applications share some needs in terms of ability to use information technology, the ability to access information that's in physically different areas, the ability to massage and process data bases, etc. But then again, within each of those application areas you will find some distinct demands. For example, your application area, health care, is one that is particularly demanding in terms of band width, in terms of processing capabilities. From our point of view, you constitute a wonderfully demanding customer who is always saying, "the image quality has to be absolutely perfect." "We can't stand any degradation." "Give us more band width." Or, "I have this enormous number of bits coming down from this imaging system and I've got to be able to process them instantaneously for this to be a useful diagnosis tool." Those kinds of drivers are critical for the technology. There are also some very tough issues. Privacy is a key one because while information technology gives us the opportunity to collect and massage and have easy access to an enormous amount of information, it also could create problems in terms of letting us have access to all kinds of information. Without the kinds of structures and controls to assure privacy and security, particularly in this field, these technologies simply won't go forward and won't be used. In every application area, if this is to be a user-pulled technology revolution rather than one that is merely driven by the bits and the bytes and the band width, it really has to be something that users can grasp and use. It cannot be a painful thing, that is a time sink, but something that actually adds value in doing your job everyday. For this business as well as many, many others, getting beyond the idea that "We'll have this computer sit on your desk, and after you've had the proper training and gone through rigorous and boring lectures, it will finally be valuable." So we need to figure out how to use the technology to "hide" itself, to make user interfaces so seamless, so friendly, so easy to use that you don't have to sit in lecture halls and you don't have to read manuals. It should be something that we've fairly seamlessly integrated into the way that you do business. Then you can start seeing value rather than a drain of time. Those are the kinds of user issues that are pervasive but that we see over and over and over in the health care business.

So, again, if this is a three-layer cake, many, many forces are driving the technology. I find when I talk to users today in many different areas, they basically assume that the technology will continue to grow in capability and drop in cost. That has been the fuel really for this entire Information Revolution -- the fact that every two years you can buy more technology on an integrated circuit, twice as much technology for half the price. The fact that the amount of band width that's available doubles and the cost drops every time you blink. Those things are, in fact, essential to the continuing of this revolution. There's a lot of work involved in making that happen, but I find that users are assuming that is going to happen, and instead, they worry about how we make real applications that work in our domains and in our environments.

One of the things I'm very interested in exploring with this group while I'm here in the next day or so, the health care business, is living in the midst of a phenomenal number of changes and pressures. I've been talking about one revolution that's going on. I suspect you could tell me an equally complex story about what is going on in terms of the pressures in this business, cost pressures, focus on how you deliver quality health care. I find that it creates a vortex of changes that creates simultaneously tremendous opportunity and tremendous challenges for this business. Mayo has been one of the places that, from its inception, has been very focused on how you use technology effectively to do your job. I had the pleasure when I was here some months ago of having a tour from Craig Smoldt that was just fascinating. We got to talking about what kind of infrastructure supports an organization like this, and the next thing I knew Craig and I were running down the hall and he was showing me what was behind all those wooden doors I had walked by all the years I've been coming to Mayo. And what was behind those doors was the kind of infrastructure you'd sort of expect, plumbing, and wires, and telephone cables. But there were also things like pneumatic tubes for shipping around documents and samples used in your practice here. That's not a new kind of infrastructure, but to me it was a compelling example of how thoughtful this organization had been for decades. About how you create an infrastructure that allows you to do your job as well as you possibly can.

For the business of information technology in health care today, there is simultaneously good news and bad news. The good news is that there is an extremely compelling vision. It is a vision that not only can we use information technology to do a lot of traditional things better -- and better means both more efficiently but also to deliver more capable, higher quality health care -- but that we can also start doing some things that we have never even thought of being able to do before. Both of these are important. The numbers that get thrown around about our health care system in this country are truly phenomenal. Of the canonical trillion dollars of health care, an estimated 20% of costs are associated with administrative matters, dealing with paperwork. If you can imagine taking even a small slice of that $200 billion and reducing that cost by making the system more efficient, you can imagine how high the leverage could be. But beyond just doing the traditional job better and more efficiently, if you start thinking about the opportunities in telemedicine, and again Mayo has been such a leader in this field, and you start thinking about the ability to deliver health care in ways that we simply had not considered possible before, that really opens up dramatic new vistas.

You are starting to chart some of those new domains that are possible by using these new technologies. That's the good news. The potential is really quite phenomenal and quite positive, and there are tremendous advances that can be made.

The bad news is that after I go to meetings and talk to people and I hear all these glowing visions about what's happening with information technology in health care, I then go visit my doctor at home. At one of my doctor's offices they just upgraded from a manual typewriter to an electric typewriter, and they still have the three walls lined with folders. The quality of the health care I receive is absolutely superb but it is an inefficient way to do business. And it is one that is not linked to the rest of my health care providers, which has on occasion caused some interesting things to happen, or not happen as the case may be. What we see happening today are phenomenal examples of where this technology could take us, islands of information technology use. Islands where automation and these new ideas are really starting to be tried out. Even when the island is a relatively large one, as it is here at Mayo, it's still something that is very far from a vision of the kind of seamless information infrastructure that all of us who depend on our health care system could really rely on and assume that information was being shared and easily provided and reliably available. That is a vision that we can get to, but we really are not there yet. In fact, it's a fundamental challenge for any kind of infrastructure, because getting that kind of seamlessness requires more than just each individual organization doing its own thing. In order to try to get over the technical barriers, to trigger that kind of broader national infrastructure for the health care business, one of the programs we're involved in at NIST through our Advanced Technology Program is explicitly targeting that area. Our question is, what are the technologies that we can co-fund with companies and other organizations that will create and catalyze this kind of transformation so that we don't end up just with a lot of separate islands that have to arduously be hooked together? How can we create some kind of a common technology basis so that information can be shared in a more seamless way? Several of the themes that come out of our program echo the comments I made a moment ago. It's very clear that for any of this to work it has to be user focused and user driven. I think you could argue that the approach that has been used in the past to some degree has been "if we build it they will come." That doesn't work. They didn't come. It really has to be something that's thoughtfully designed with users involved from the beginning.

We also must deal with legacy systems. You have a huge number of patient records here, and obviously you are not going to throw all those away or transform them into electronic records. It's a very tough challenge to figure out how to deal with all the existing systems. But it is absolutely necessary if we are going to be practical about building these new capabilities.

A third fundamental theme that we must address is the whole question of what patient records should be. How should they be organized? How should they be handled? How do you physically store and make that data accessible? Those are pretty challenging issues. Our program's approach is to do experiments, being very pragmatic and trying things with a community of people. I think that's likely to succeed, because a lot of the right players are starting to talk together, including this community here.

Let me finish by saying that this business of using information technology in health care, something that you all really are helping to drive in such an important way, is a tremendous opportunity, but it is tremendously difficult. It's a brave job and a necessary one. It is part of a much broader transformation that is happening that will have deep repercussions for all parts of our society. It's very encouraging to see a lot of the early examples of the positive changes that these kinds of technologies can make. Information technology is not a magic pill that you take and it solves all your problems. Like every other tool that human beings use, it will be a two-edged sword, which is why it will be so important to have positive examples of the benefits that we can derive from it. The early pioneers in this business have some important responsibilities, so it's a real pleasure to be able to work with you all to try to do that job well.