Union Square Ventures had a great blog post the other day on The Myth of the infrastructure Phase.

They argue that the narrative in tech that says there’s an orderly infrastructure phase followed by an application phase is a bit of a myth. Instead of orderly and distinct phases, they argue, it looks more like an ebb and flow. Apps, in many cases, drive infrastructure then that infrastructure enables new apps, and vice-versa. From the post:

“Planes (the app) were invented before there were airports (the infrastructure). You don’t need airports to have planes. But to have the broad consumer adoption of planes, you do need airports, so the breakout app that is an airplane came first in 1903, and inspired a phase where people built airlines in 1919, airports in 1928 and air traffic control in 1930 only after there were planes.

The same pattern follows with the internet. We start with the first apps: messaging (1970) and email (1972), which then inspire infrastructure that makes it easier to have broad consumer adoption of messaging and email: Ethernet (1973), TCP/IP (1973), and Internet Service Providers (1974). Then there is the next wave of apps, which are web portals (Prodigy in 1990, AOL in 1991), and web portals inspire us to build infrastructure (search engines and web browsers in the early 1990’s). Then there is the next wave of apps, which are early sites like Amazon.com in 1994, which leads to a phase where we build infrastructure like programming languages (PHP in 1994, Javascript and Java in 1995) that make it easier to build websites. Then there is the next wave of more complicated apps like Napster (1999), Pandora (2000), Gmail (2004) and Facebook (2004) which leads to infrastructure that makes it easier to build more complex apps (NGINX and Ruby on Rails in 2004, AWS in 2006). And the cycle continues.”

We’ve seen this trend in healthcare technology as well.

The first electronic medical record dates back to the 1960s when Dr. Larry Weed created the problem-oriented medical record that allowed his fellow providers to see notes, medical history, etc. in an electronic format (application). The first EMR as we know it that included additional functionality such as billing and scheduling was launched in 1972 by the Regestrief Institute, though adoption was extremely slow. In the 1980s, the need to transfer clinical information between providers led to the creation of Health Level 7 (HL7), a set of international standards for transfer of clinical data between different applications (infrastructure). By the late 1980s, low-cost personal computers (more infrastructure) allowed providers to do what Dr. Weed was doing at scale. The emergence of the internet in the 1990s (more infrastructure) allowed providers to use electronic medical records remotely, increasing adoption and leading to more use cases (more applications).

Today, thanks to meaningful use incentives enacted under President Obama, the vast majority of healthcare providers use electronic medical records and Dr. Weed’s initial application has become an infrastructure of its own. EMRs, originally just a collection of apps that sat on top of an infrastructure, have now become the infrastructure for a new wave of applications that can plug-in to the data stored within the EMR.

Now we’re seeing a new layer of infrastructure being built that will connect all of these EMRs to one another across the full continuum of care — acute to subacute to post acute to home care to ambulatory, etc. There are lots of organizations working on this (including my own) and there’s no doubt that success is on the horizon.

Once this “connective” infrastructure is built we’ll see a new wave of health tech applications that will be built on top and will bring enormous value to our healthcare system.

We don’t need airports to have planes, and we don’t need connectivity to have medical records. But pilots, patients, and providers are a lot better off when we do.