Copyright © 2010 Tennenbaum Institute. All rights reserved. Knowledge and Skills for Enterprise Transformation. Coping with the Complexity of Healthcare

Copyright © 2010 Tennenbaum Institute. All rights reserved.

Knowledge and Skills for Enterprise Transformation.Knowledge and Skills for Enterprise Transformation.

Coping with the Complexity of Coping with the Complexity of

Healthcare Delivery Healthcare Delivery William B. RouseWilliam B. Rouse

Knowledge and Skills for Enterprise Transformation. 2

OverviewOverview• System StudiesSystem Studies

– Understanding Systemic Consequences of ChangesUnderstanding Systemic Consequences of Changes

• Complexity of Healthcare DeliveryComplexity of Healthcare Delivery– Increasing Complexity Where It Can Best Be ManagedIncreasing Complexity Where It Can Best Be Managed

• Health IT RoadmapHealth IT Roadmap– Efficiency, Effectiveness, Evidence BaseEfficiency, Effectiveness, Evidence Base

• Organizational SimulationOrganizational Simulation– Driving the Future Before Writing the CheckDriving the Future Before Writing the Check

• SummarySummary


System StudiesSystem Studies

• Understanding the SystemUnderstanding the System– ““Healthcare as a Complex Adaptive System: Implications for Healthcare as a Complex Adaptive System: Implications for

Design and Management”Design and Management”

• Affordability of HealthcareAffordability of Healthcare– ““Engineering Perspectives on Healthcare Delivery: Can We Engineering Perspectives on Healthcare Delivery: Can We

Afford Technological Innovation in Healthcare?” Afford Technological Innovation in Healthcare?”

• Impact of Government Price ControlsImpact of Government Price Controls– ““Impacts Of Healthcare Price Controls: Potential Unintended Impacts Of Healthcare Price Controls: Potential Unintended

Consequences of Firms’ Responses to Price Policies”Consequences of Firms’ Responses to Price Policies”

• Issues, Information, Incentives & Change Issues, Information, Incentives & Change – ““Engineering the System of Healthcare Delivery”Engineering the System of Healthcare Delivery”


ComplexityComplexity

• Complex Adaptive SystemsComplex Adaptive Systems• Stakeholders & InterestsStakeholders & Interests• Disease ControlDisease Control• Networks of NetworksNetworks of Networks• Healthcare NetworkHealthcare Network• Complexity AssessmentComplexity Assessment• ImplicationsImplications• ObservationsObservations


Complex Adaptive SystemsComplex Adaptive Systems• They are They are nonlinear, dynamicnonlinear, dynamic and do not inherently reach fixed equilibrium points. and do not inherently reach fixed equilibrium points.

The resulting system behaviors may appear to be random or chaotic. The resulting system behaviors may appear to be random or chaotic.• They are composed of They are composed of independent agentsindependent agents whose behavior can be described as whose behavior can be described as

based on physical, psychological, or social rules, rather than being completely based on physical, psychological, or social rules, rather than being completely dictated by the dynamics of the system.dictated by the dynamics of the system.

• Agents' needs or desires, reflected in their rules, are not homogeneous and, Agents' needs or desires, reflected in their rules, are not homogeneous and, therefore, their therefore, their goals and behaviors are likely to conflictgoals and behaviors are likely to conflict -- these conflicts or -- these conflicts or competitions tend to lead agents to adapt to each other's behaviors.competitions tend to lead agents to adapt to each other's behaviors.

• Agents are Agents are intelligent, learnintelligent, learn as they experiment and gain experience, and as they experiment and gain experience, and change behaviors accordingly. Thus, overall systems behavior inherently change behaviors accordingly. Thus, overall systems behavior inherently changes over time.changes over time.

• Adaptation and learning tends to result in Adaptation and learning tends to result in self-organizingself-organizing and patterns of and patterns of behavior that emerge rather than being designed into the system. The nature of behavior that emerge rather than being designed into the system. The nature of such emergent behaviors may range from valuable innovations to unfortunate such emergent behaviors may range from valuable innovations to unfortunate accidents.accidents.

• There is There is no single point(s) of controlno single point(s) of control – systems behaviors are often – systems behaviors are often unpredictable and uncontrollable, and no one is "in charge." Consequently, the unpredictable and uncontrollable, and no one is "in charge." Consequently, the behaviors of complex adaptive systems usually can be influenced more than behaviors of complex adaptive systems usually can be influenced more than they can be controlled.they can be controlled.


Stakeholders & InterestsStakeholders & InterestsStakeholderStakeholder Risk Mgt.Risk Mgt. PreventionPrevention DetectionDetection TreatmentTreatment

PublicPublic e.g., Buy Insurancee.g., Buy Insurance e.g., Stop e.g., Stop SmokingSmoking

e.g., Get e.g., Get ScreenedScreened

Delivery SysDelivery Sys PhysiciansPhysicians Physicians & Physicians & HospitalsHospitals

GovernmentGovernment Medicare, Medicare, Medicaid, Medicaid, CongressCongress

NIH, CDC, DoD, et al.NIH, CDC, DoD, et al.

Non-ProfitsNon-Profits American Cancer Society, American Heart American Cancer Society, American Heart Association, et al.Association, et al.

AcademiaAcademia Business SchoolsBusiness Schools Basic Science Basic Science DisciplinesDisciplines

Technology & Technology & Medical SchoolsMedical Schools

Medical Medical SchoolsSchools

BusinessBusiness Employers, Employers, Insurance Insurance

Companies, HMOsCompanies, HMOs

Guidant, Guidant, Medtronic, et al.Medtronic, et al.

Lilly, Merck, Lilly, Merck, Pfizer, et al.Pfizer, et al.


Disease ControlDisease ControlCosts

CoveredPublic

AwarenessPublic

ReadinessScreeningAvailable

ScreeningEffective

PublicCommunication

PublicEducation

PhysicianEducation

ConsumerAdvocacy

MedicalResearch

$$$ $ $Public, Delivery System, Government, Non-Profits, Academia, Business


Accreditation & Licensing• American Board of Medical Specialties• Accreditation Council for Graduate Medical Educ.• Accreditation Council for Continuing Medical Educ.• AOA Council on Postdoctoral Training• Federation of State Medical Boards• Joint Commission on Accreditation of Healthcare Org.• Liaison Committee on Medical Education

Examples of Other Stakeholders• American Assoc of Retired Persons• Leapfrog Purchasing Group• National Business Group on Health• Etc.

Networks of NetworksNetworks of Networks

Professional Associations• American Academy of Family Physicians• American Medical Association• American Osteopathic Association (AOA)• Council of Medical Specialty Societies• Etc.


MedicalDevicesMedicalDevices

Society

Economy

Organization

Care

Medicine

Behavior

Physiology

Biology

HumanitarianLogistics

TissueEngineering

Economics ofPrevention

IntegrativeMedicine

Genomics &Proteomics

Individuals Cohorts Populations

VaccineDelivery

MedicalHome

Social HealthNetworks

HospitalEngineering

PredictiveHealth

UbiquitousCare

Genetic RiskAssessment

InsuranceReform

IncentiveReform

DrugDelivery

DrugDelivery


Pharmaceuticals HealthWholesalers

HealthProviders

Consumers

Pharmacy

MedicalEquipment

OtherEquipment

HealthInsurance

Government &Policy Makers

R&D Laboratories

Healthcare NetworkHealthcare Network


Network ModelNetwork Model1

2

3

Ni

1

2

3

Nij

1

2

3

Nijk

1

2

3

Nijkl

t01234

Ni = No. of 1st tier suppliers to ith product/service outletsNij = No. of 2nd tier suppliers to ijth Tier 1 supplier, e.g., OEMNijk = No. of 3rd tier suppliers to ijkth Tier 2 supplierNijkl = No. of 4th tier suppliers to ijklth Tier 3 suppliers


Calculating ComplexityCalculating Complexity

Σi = 1

Ni

- p (ni | t) log [p (ni | tm)] +

Σj = 1

Nij

- p (nj | ni t) log [p (nj | ni tm)] +

Σk = 1

Nijk

- p (nk | ni nj t) log [p (nk | ni nj tm)] +

Σl = 1

Nijkl

- p (nl | ni nj nk t) log [p (nl | ni nj nk tm)]

C = Σ ptmm = 1

T

{

}


0

5

10

15

20

25

30

35

Aerospace Automotive Retail Healthcare Telecom

Co

mp

lexi

ty (

Bit

s)

Consumer Total

Complexity AssessmentComplexity Assessment

Great opportunity forHCI research


ImplicationsImplicationsTraditional SystemTraditional System Complex Adaptive SystemComplex Adaptive System

RolesRoles ManagementManagement LeadershipLeadership

MethodsMethods Command & ControlCommand & Control Incentives & InhibitionsIncentives & Inhibitions

MeasurementMeasurement ActivitiesActivities OutcomesOutcomes

FocusFocus EfficiencyEfficiency AgilityAgility

RelationshipsRelationships ContractualContractual Personal CommitmentsPersonal Commitments

NetworkNetwork HierarchyHierarchy HeterarchyHeterarchy

DesignDesign Organizational DesignOrganizational Design Self OrganizationSelf Organization


ObservationsObservations

• Healthcare is a complex adaptive system and highly Healthcare is a complex adaptive system and highly complex, but not as complex as retail markets that complex, but not as complex as retail markets that manage complexity to minimize burden on consumers manage complexity to minimize burden on consumers

• Objective should be to increase overall complexity, Objective should be to increase overall complexity, where it can best be managed, in order to decrease where it can best be managed, in order to decrease complexity for patients and clinicianscomplexity for patients and clinicians

• Information management is a key issue, as is creation of Information management is a key issue, as is creation of incentives and inhibitions that will motivate stakeholders incentives and inhibitions that will motivate stakeholders to provide quality, affordable care for everyoneto provide quality, affordable care for everyone


Health IT Health IT RoadmapRoadmap

• Healthcare EcosystemHealthcare Ecosystem• Hierarchical NetworkHierarchical Network• Value-Driven EnterprisesValue-Driven Enterprises• Health IT RoadmapHealth IT Roadmap• Health IT ReadinessHealth IT Readiness


Clinical Practices(People)

Economic Model &Incentive Structure

Healthcare Ecosystem(Society)

Human Productivity &Healthcare Costs

Delivery Operations(Processes)

Patient Care &Health Outcomes

Care Capabilities &Health Information

System Structure(Organizations)

Economic Returns &Performance Information

Competitive Positions &Economic Investments


Hierarchical NetworkHierarchical Network

Intra-Level Information Flow & Incentives

Inter-Level Information Flow

& Incentives

Delivery Operations(Processes)

Clinical Practices(People)

Healthcare Ecosystem(Society)

System Structure(Organizations)


Value = Money, Lives, Advantage, Etc.

Delivered Via Value Streams

Enabled by Work Processes

Supported by Information Motivated by Incentives

EnterpriseEfficiency

Evidence Base

Revenue& Profits

Investment& Returns

Designed Via Analytics

Complex System Models, System Architecture Frameworks, Organizational Simulations & Games, Network and Ecosystem Visualizations, and Statistical

Methods for Data Mining and Enterprise Intelligence

Value-Driven Nature of Enterprises


Health IT RoadmapHealth IT Roadmap• Milestone 1: EfficiencyMilestone 1: Efficiency

– Value Stream & Work Process MappingValue Stream & Work Process Mapping– Back Office Integration & AutomationBack Office Integration & Automation– Electronic Medical Records & Health Information ExchangesElectronic Medical Records & Health Information Exchanges

• Milestone 2: EffectivenessMilestone 2: Effectiveness– Clinical Decision SupportClinical Decision Support– Patient & Family SupportPatient & Family Support– Personalized MedicinePersonalized Medicine

• Milestone 3: Evidence BaseMilestone 3: Evidence Base– Operational & Clinical Database MiningOperational & Clinical Database Mining– Every Performance Shortfall & Failure UnderstoodEvery Performance Shortfall & Failure Understood– Learning System Learning System Identify & Deploy Best Practices Identify & Deploy Best Practices


Healthcare IT ReadinessHealthcare IT ReadinessA Web-Based Assessment ToolA Web-Based Assessment Tool


Organizational SimulationOrganizational Simulation

• Using IT to Explore Healthcare Futures Using IT to Explore Healthcare Futures – ““Driving the Future Before Writing the Check”Driving the Future Before Writing the Check”

• OrgSim ConceptOrgSim Concept

• OrgSim ArchitectureOrgSim Architecture

• Health AdvisorHealth Advisor


OrgSim ConceptOrgSim ConceptAn immersive environment that:An immersive environment that:• Simulates future organizations, including Simulates future organizations, including

behavioral and social changesbehavioral and social changes• Enables decision makers to interact within Enables decision makers to interact within

changed organizational culturechanged organizational culture• Synthesizes “people” who behave as if Synthesizes “people” who behave as if

changes have already happenedchanges have already happened• Provides compelling feel for “what it will Provides compelling feel for “what it will

be like”be like”


Facilitation, e.g., Training, Advising, Guiding

User Interface, e.g., Large Screens, Voice, Gestures

Organizational Story, e.g., Aging Population

Characters, e.g., Patients, Doctors, Vendors

World Model, e.g., Hospital, City, Economy

Distributed Simulation Software

Hardware, e.g., Computers, Networks

OrgSim ArchitectureOrgSim Architecture


Health AdvisorHealth Advisor• MotivationMotivation

– 10,000 eleven year olds10,000 eleven year olds

• Back StoryBack Story

• The GameThe Game– Reception AreaReception Area– Player’s OfficePlayer’s Office– Client InterviewClient Interview– Decision OptionsDecision Options

• Research QuestionsResearch Questions


Back StoryWelcome to the Health Advisor business. Your firm helps clients successfully navigate the healthcare system. People pay you – actually, they pay an annual fee -- for you to help them make the highest-value decisions regarding their health. You are not a doctor, but you have much data and information available to help your clients make the best choices. Your goal is to maximize their health state. Your score is the average health state of your clients divided by the costs of providing these outcomes.

You also need to stay in business! As you are responsible for all of the costs associated with your clients’ health, you need to pay careful attention to the performance and costs of the providers you select for both test and treatments. If you spend more than a client’s annual fee, the excess costs come out of your account. If you spend less than the fee, the excess payment goes into your account. Of course, you could save money by providing minimal treatment, but then your reputation will quickly fade and you would have few if any clients.

Keep in mind that you are providing health advice, but not healthcare. You decide which doctors and other services to employ. For these providers, your clients are patients. For you, they are clients who expect value for their annual payment.







MedFileMedFile• Online medical resourceOnline medical resource• For each diseaseFor each disease

– SymptomsSymptoms

– Confirming testsConfirming tests

– TreatmentsTreatments

• Description of diseases, Description of diseases, tests, etc.tests, etc.

• Description of medical Description of medical specialtiesspecialties


Research QuestionsResearch Questions• Game PlayGame Play

– What strategies do players employ to maximize value?What strategies do players employ to maximize value?– What strategies do players employ to stay in business?What strategies do players employ to stay in business?– How successful are these strategies?How successful are these strategies?

• Information ServicesInformation Services– What information do players access to make decisions?What information do players access to make decisions?– How do the type and form of information affect decisions?How do the type and form of information affect decisions?– How is value affected by information and decisions?How is value affected by information and decisions?

• Hedging RisksHedging Risks– How do players hedge the downside risks of client costs?How do players hedge the downside risks of client costs?– What types of insurance do players find attractive?What types of insurance do players find attractive?– How does insurance affect decisions?How does insurance affect decisions?

• EducationEducation– What do players learn from What do players learn from Health AdvisorHealth Advisor??


Emory StudyEmory Study• Study DesignStudy Design

– 42 Emory undergraduates42 Emory undergraduates– Game played over 3 weeksGame played over 3 weeks– Survey administered over 1 weekSurvey administered over 1 week– Each player saw 25 clientsEach player saw 25 clients– Access to EHR and MedFileAccess to EHR and MedFile– Clients across gender, age & conditionsClients across gender, age & conditions

• Game Evaluation SurveyGame Evaluation Survey– Interesting – 4.3Interesting – 4.3– Educational – 4.2Educational – 4.2– MedFile understandable – 4.2MedFile understandable – 4.2– Provider info. understandable – 3.5Provider info. understandable – 3.5– Tests and treatments appropriate – 4.0Tests and treatments appropriate – 4.0– Client dialogs make sense – 4.0Client dialogs make sense – 4.0– Advisor options reasonable – 3.9Advisor options reasonable – 3.9

• Descriptive StatisticsDescriptive Statistics– Doctor SelectionDoctor Selection

• Specialists = 63%Specialists = 63%• PCP = 37%PCP = 37%

– Client Evaluation & Test SelectionClient Evaluation & Test Selection• Picked a Body Part 34%Picked a Body Part 34%• Picked a Specific Condition 42%Picked a Specific Condition 42%• Picked a Severity Level 10%Picked a Severity Level 10%• Picked a Specific Test 56%Picked a Specific Test 56%

– EHR ViewEHR View• Avg./Player = 9.3Avg./Player = 9.3• Avg./Client = 0.5Avg./Client = 0.5

– MedFile AccessMedFile Access• Avg./Client = 0.41Avg./Client = 0.41• Avg./Player = 9.45Avg./Player = 9.45

– Click DataClick Data• Avg. Click/Client = 30.7Avg. Click/Client = 30.7• Avg. Clicks/Player = 719.1Avg. Clicks/Player = 719.1

– Play TimePlay Time• Avg. Time = 1:08hrAvg. Time = 1:08hr• Avg. Time /Client = 3:00minAvg. Time /Client = 3:00min


Preliminary ResultsPreliminary Results• Performance – Assessments & ReferralsPerformance – Assessments & Referrals

– Players who spend more time, and clicks, with clients tend to Players who spend more time, and clicks, with clients tend to perform betterperform better

– Players who more frequently access MedFile tend to perform Players who more frequently access MedFile tend to perform betterbetter

• EHR access does not impact performance in our context EHR access does not impact performance in our context and, in fact, has slight negative influenceand, in fact, has slight negative influence– This is expected as the information contained in the EHR -- for This is expected as the information contained in the EHR -- for

the first visit -- does not provide additional knowledgethe first visit -- does not provide additional knowledge

• Players assessments and referrals improve over timePlayers assessments and referrals improve over time• Players assessments of a previously seen condition, with Players assessments of a previously seen condition, with

another client, improve significantly another client, improve significantly


SummarySummary• System StudiesSystem Studies

– Understanding Systemic Consequences of ChangesUnderstanding Systemic Consequences of Changes

• Complexity of Healthcare DeliveryComplexity of Healthcare Delivery– Increasing Complexity Where It Can Best Be ManagedIncreasing Complexity Where It Can Best Be Managed

• Health IT RoadmapHealth IT Roadmap– Efficiency, Effectiveness, Evidence BaseEfficiency, Effectiveness, Evidence Base

• Organizational SimulationOrganizational Simulation– Driving the Future Before Writing the CheckDriving the Future Before Writing the Check


Documents

Copyright © 2010 Tennenbaum Institute. All rights reserved. Knowledge and Skills for Enterprise Transformation. Coping with the Complexity of Healthcare