Everyone seems to agree that health care is the next big industry waiting to be disrupted. But who will force that change on a massive system full of conservative players? Three possibilities present themselves:

Ive seen plenty of evidence to support each of these three scenarios, and I think that your position in the system and personal philosophy, more than any evidence, probably determine how youll cast your vote. In this article Ill list some of the activities in health care that illuminate the chances for each scenario to come alive, drawing on the recent Strata Rx conference put on by OReilly Media.

Many reformers, notably Clayton Christensen, have declared current hospitals and other health institutions irreparabletoo caught up in the treatment and payment models they have used for decades. Other people in the health care field are equally committed to change, determined to do it through the health institutions themselves. I believe, from what Ive read and heard of Dr. Eric J. Topol, that he falls in this category.

Another leader I would place here is Jonathan Bush, cofounder and CEO of athenahealth. The vibes I pick up from him react very negatively with government regulations. He believes the market can bring about reform, one of the solutions in his keynote at StrataRx.

In a five-minute Ignite! talk, Lisa Maki suggested turning the high cost of health care into an opportunity for change. Maki seems to be an adherent to the same market-driven point of view as Jonathan Bush, believing that converting health care into a market with transparency and patient choice can bring about the change. Makie held up the PokitDok site as a way to help patients find out what theyre spending.

Two talks by representatives of the Department of Health and Human Services at Strata Rx could have health care reformersalong with anyone interested in a more collaborative and responsive governmenton their feet cheering. So long as shutdowns dont cripple agencies plans, theres a lot government can do to stoke the health care revolution.

Bryan Sivaks speech paid homage to the power of independent developers, open data sets, and power to the patient. He marked the milestone of HHS releasing 1,000 data sets, which they are seeking to combine with other peoples data. And he announced a pilot test bed at hospitals and other data users so developers can test their apps on real systems. This will reduce the risk of deploying apps, which very important to these naturally conservative institutions.

Claudia Williams continued this theme by highlighting the value of data to patients and describing the contributions of BlueButton Plus, a tool that tries to standardize patient access to data, and Direct, an HHS project to make secure data exchange simple.

HHS is not intent, of course, on changing the health care field purely through its own dictats (notwithstanding the paranoid fears of a few fringe commenters). Rather, it hopes to provide tools for change in collaboration with private actors, who have always contributed to projects such as BlueButton Plus and Direct. That, together with incentives for improving quality and providing payment for outcomes, will hopefully create a new environment where the drive and intelligence of the private sector can find a way forward.

Not a single trouble, actually, but many. Lets look first at what an ACO is: a collaboration among providers and possible payers to give patients integrated care. Several models for ACOs already exist, of which the biggest is Kaiser Permanente (I dont include the Veterans Affairs system because of its unique characteristics). CMS now defines ACOs in detail for reimbursement purpose.

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Where are the chances for change in health care top-down or bottom-up?