Watching the falling barometer. (Next!).

Amelia Island, Florida. From here, the sea looks terrifying.

I'm at a viewing platform atop the dune banks separating the hotel from the ocean. The laptop, partly sheltered by a wooden bench, is downloading the latest weather satellite photo. The photo is nearly all white. Hurricane Floyd, 600 miles wide, winds at 155 miles per hour, ravaging the Bahamas and much of south Florida, headed for landfall, they say, right here, on the Georgia border. We have been ordered to evacuate.

The surf pounds the shore, wild, confused, the tops of the waves whipped off into spray by the winds already hitting 50 in the gusts. An enormous oak, broken off somewhere else, lies shattered In the surf Behind me, the hotel employees are scurrying to tape windows and pull the balcony furniture inside. They are pulling the huge oil paintings off the walls, and taking all the plants to upper stories, in case the storm surge comes right across this flimsy barrier island. Yesterday, I watched the gardeners picking litter out of the shrubs, pruning carefully, picking off dead flowers, ignoring the high surf and growing winds.

Driving up the island an hour ago, I saw workers scrambling to nail plywood sheets over the windows and doors of the luxury houses that line the shore. But many of the houses, the poorer ones it seemed, the older ones, the ones on the low-lying land, had no plywood on the windows, no evident preparation. I pointed one out to the driver, an old island hand: "They can't afford plywood?"

"Oh, might be," he said. "But what would be the point? A few sheets of plywood's not going to help a little old house down on the bottom land like that. If Floyd comes this way, that house is gone."

A little plywood is not going to help

If there's a Weather Channel for health care, turn it on. There's white to the horizon: genomics, proteomics and bioinformatics, communications and imaging technologies, databasing and outcomes management, the Internet, all the new biological and digital technologies, plus the mounting pressures to cut costs and the aging of the population, all swirling together in a vast storm of change, headed for landfall right where you are. And a little plywood is not going to help.

I do not believe that in ten years we will be doing the same things in health care, the same way, that we do now. We will not be in the same portfolio of businesses, with the same revenue streams, that we have now. Clinical practice will not look like it does now.

The time is past when we could cost-cut our way to profitability. It's time to stop giving our customers less (less access to doctors, poorer service, fewer clinic hours, fewer choices) while asking them to pay more. We must each find ways to differentiate ourselves from the competition, to become in some way visibly better, faster, cheaper, more of what people want. This is Marketing 101: in a cost-driven market, becoming a commodity is doom, unless you can control the entire value chain-which we can never do in health care, since the value chain consists of real cases, real bodies, with all their variables. If you have nothing to offer employers, insurers, and the government that makes you different from the next institution down the freeway, you're in real trouble.

We can't problem-solve our way through the coming turbulence. Of course we have to solve today's problems. Like the gardeners picking litter out of the shrubs, that's our job. But someone's got to watch the failing barometer.

Cost-cutting, by itself, is not a strategy. Problem-solving is not a vision. Incremental improvement is not a path to a future that works. What the venture capitalists call "FBC" ('faster, better, cheaper") is great, it's important, but the time is coming soon when it will not be enough to deal with the forces headed our way. We are not going to refine our way to a whole new health care.

Turn on the Weather Channel

So how do we create a vision, a strategy, in the face of such overwhelming forces for change? The answer has two pieces. The first piece is the Weather Channel: scanning the future for warning, for opportunities, for new business possibilities.

That future comes in three broad packages:

1. Shifting demographics. As the Boomers clamber past 50, and their parents into the frail elderly end-stage, the population as a whole is aging rapidly. But many parts of the country face, at the same time, rapidly changes in ethnic and cultural background that have profound effects on health care use.

2. Political changes. Far less predictable are the political shifts that will shape the business environment. Health care is once again a reform issue, and managed care seems increasingly fragile, but few visions have bubbled up to take its place.

3. New technologies. From genomics and proteomics through imaging and robotics, every aspect of health care is transforming itself through new technologies.

Each of these areas is full of risks--and opportunities for new lines of business and new ways to compete.

What is your foundation?

The other piece turns us inward, first to such questions as: What, exactly, is your situation? Financially? In market terms? In terms of competition. physical plant, politics, public impressions, and customer loyalty? Assume that each of these is in your power to change, then ask yourself how that would happen.

Secondly, it leads us back to the question we asked last time: Why are you here? Why are you in health care? For you and your institution, what is your reason for being in this business? In other words, what is your foundation? Are you built soundly, on a strong foundation, well above the storm surge levels? Or are you on low-lying ground, sitting on cinder blocks?

Ask yourself:

* If your institution were in danger of closing, how big would the protest rally be? Would you see people there that you don't even know?

* Would employees drive farther, and accept less pay and fewer benefits, just to work for you, because they are excited about what the institution is trying to do?

* Would anyone stop by your institution if they didn't have to, just because it's a great place to be, to learn, to show their friends, or to help out?

* What is special and different about what you offer in the health care marketplace? What would your competitors say? How long would it take them to think of it?

* Are you really here because you have a passion for this? Does It give you joy and fulfillment?

For you individually, for your staff, and for your institution, the place to begin creating a path to the future is this place of passion, joy, and fulfillment--not the place of convenience, pandering, compromise, and begging.

In the coming years, we will begin to create entire new ways of doing health care, new roles for hospitals, new types of medicine--and the time to begin the creation is now. If you wait until the hurricane hits, it will be too late.

Joe Flower is Principal of The Change Project, in Larkspur, California. He has written about change in health care for over a decade. Author of hundreds of articles, he is a Contributing Editor for the Healthcare Forum Journal and New Scientist, a system host of The Well Computer Conference, and a faculty member of HealthOnline. If any of the ideas presented in this column resonate with your experience, drop Joe a line at The Physician Executive, or at [e-mail] on the Internet.