Discovery Systems, Decentralization and Health Outcomes

Hang around any healthcare system and you’ll hear lots about outcomes. Outcomes are a result, temporal or end-point of medical intervention. We expect outcomes to be positive, a net benefit to the patient, but that is not always the case. Biology is the definition of a complex system; not everything works out as anticipated.

The typical dance goes like this. The cardiologist wants your blood pressure under control and for you to walk regularly. An internist might be fixated on your body mass index on this visit, perhaps your HbA1c the next, and then there are diets around which no one can agree. Still, each are focused on specific goals they want you to achieve. What if we're wrong? What if we're focusing on the wrong objective?

Systems not Goals

Goals, according to "How to Fail at Almost Everything and Still Win Big" by Scott Adams don't work. Goals are binary, either you make them or you do not. Focusing on goals creates an illusion of accomplishment preceded by stress along with failure when things don't work out. And what then if the goal is reached? Typically having touched the objective, old habits return as do the predicate problems that led to the need of the goal in the first place. Goals don't work, systems do.

Systems, as Adams puts it, succeed every time you apply your system. Systems provide us a way to focus upon the means by which one might achieve a desired outcome, separate from the outcome itself. Meaningful, sustainable outcomes in healthcare are best achieved through a focus upon lifestyle, small things you can choose to do regularly and then actually do them. This is where we are today.

The Decentralizing of Healthcare

Choose to acknowledge it or not, there is a forceful trend toward decentralization rolling across all areas of the economy and society. Early evidence of this trend was Brexit, where by way of referendum, England decided that the European Unions centralized processes were no longer needed. Similarly, populism is wholly consistent with this macro trend where there is rolling back of regulations and moving away from paternalistic, or maternalistic, centralized decision making. Cryptocurrency and the growth of blockchain technologies enable trust less interactions and commerce not well understood today. This is for certain, it will be a financially damaging mistake to ignore this shift toward a decentralized world in which the individual plays the driving role in what we do.

To put this into focus, here is a description by way of a tweet from Jimmy Song

In a centralized system, focus is on the words of the people in charge and individual actions don't mean much.
In a decentralized system, focus is on the actions of everyone and words don't mean much.

The focus lies around what people do rather than what they say, though this might sound trite, its impact is anything but. Outcomes are a product of actions, what patients and families actually do. Now contrast that to what healthcare talks about. We talk about teaching, educational programs, awareness programs, and support groups, but we're not especially good about motivating individuals into the doing their part. We need a lifestyle system.

Lifestyle as a System

Lifestyle is a system of individual and persistent choices which lead to desired outcomes. Your education was a system, beginning in pre-school through primary and secondary school, college and beyond. Each step in this process is part of a system. In medicine, there is a lot of talk and coordination within clinical systems which have been working. But when the system required for success runs across clinical morbidities, things get incoherent in a hurry.

One way to address this reality is to look from the outside in, from the community into the clinical environment, including from the home. In the perspective from these domains, centralized organizations have power to respond but not control. As Jimmy Song points out above, this is a decentralized domain where actions count more than words.

This all provides a challenge to centralized organizations who know of no other way. Inside these organizations is a Change Blindness of the kind well-explored by Daniel Simmons where the complicated activities of the day inhibit awareness of larger issues swirling around. Here is where we are today.

Discovery Systems

An increasingly decentralized healthcare environment describes the future more than the past. This is hard for us to see, but it's well on its way. Technology plays a crucial role, but not where you might think. It's not about replacing people with Artificial Intelligence, but rather expanding clinical reach; well-trained clinicians are essential, though the mix might change.

The solution lies in building a system within which knowledge can be acquired and innovation engaged. A new clinical system built around curiosity, humility and surprise, where the desired outcome is discovery. Such discovery systems may not be possible from within predicate structures. Discovery Systems requires freedom to question and boldness to ask, both of which are highly undesirable traits within formal healthcare organizations. Discovery systems uses clinical backgrounds as a lens through which to view where innovation, but not impose it. Most hospitals already have a discovery systems somewhere inside the organization, what is needed is a means by which ideas can come forward and be heard.

Absent an intentional process of discovery, hospitals will continue to be reactive, and jealous of organizations who have decided to heed the innovation around them, regardless of the humble nature of its source.