Coping with the Complexity of Healthcare Delivery

1. Coping with the Complexity of Healthcare Delivery William B. Rouse

2. Overview • System Studies • Understanding Systemic Consequences of Changes • Complexity of Healthcare Delivery • Increasing Complexity Where It Can Best Be Managed • Health IT Roadmap • Efficiency, Effectiveness, Evidence Base • Organizational Simulation • Driving the Future Before Writing the Check • Summary

3. System Studies • Understanding the System • “Healthcare as a Complex Adaptive System: Implications for Design and Management” • Affordability of Healthcare • “Engineering Perspectives on Healthcare Delivery: Can We Afford Technological Innovation in Healthcare?” • Impact of Government Price Controls • “Impacts Of Healthcare Price Controls: Potential Unintended Consequences of Firms’ Responses to Price Policies” • Issues, Information, Incentives & Change • “Engineering the System of Healthcare Delivery”

4. Complexity • Complex Adaptive Systems • Stakeholders & Interests • Disease Control • Networks of Networks • Healthcare Network • Complexity Assessment • Implications • Observations

5. Complex Adaptive Systems • They are nonlinear, dynamic and do not inherently reach fixed equilibrium points. The resulting system behaviors may appear to be random or chaotic. • They are composed of independent agents whose behavior can be described as based on physical, psychological, or social rules, rather than being completely dictated by the dynamics of the system. • Agents' needs or desires, reflected in their rules, are not homogeneous and, therefore, their goals and behaviors are likely to conflict -- these conflicts or competitions tend to lead agents to adapt to each other's behaviors. • Agents are intelligent, learn as they experiment and gain experience, and change behaviors accordingly. Thus, overall systems behavior inherently changes over time. • Adaptation and learning tends to result in self-organizing and patterns of behavior that emerge rather than being designed into the system. The nature of such emergent behaviors may range from valuable innovations to unfortunate accidents. • There is no single point(s) of control – systems behaviors are often unpredictable and uncontrollable, and no one is "in charge." Consequently, the behaviors of complex adaptive systems usually can be influenced more than they can be controlled.

6. Stakeholders & Interests

7. Public Awareness Public Readiness Screening Available Costs Covered Public Communication Public Education Physician Education Consumer Advocacy Medical Research Disease Control Screening Effective $ $ $ $ $ Public, Delivery System, Government, Non-Profits, Academia, Business

8. 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 • Professional Associations • American Academy of Family Physicians • American Medical Association • American Osteopathic Association (AOA) • Council of Medical Specialty Societies • Etc. • Examples of Other Stakeholders • American Assoc of Retired Persons • Leapfrog Purchasing Group • National Business Group on Health • Etc. Networks of Networks

9. Society Economy Organization Care Medicine Behavior Physiology Biology Insurance Reform Hospital Engineering Economics of Prevention Humanitarian Logistics Medical Home Ubiquitous Care Vaccine Delivery Incentive Reform Drug Delivery Integrative Medicine Tissue Engineering Social Health Networks Medical Devices Predictive Health Genomics & Proteomics Genetic Risk Assessment Individuals Cohorts Populations

10. Healthcare Network Government & Policy Makers Health Insurance Pharmacy Health Wholesalers Pharmaceuticals Health Providers Consumers Medical Equipment R&D Laboratories Other Equipment

11. 1 1 1 1 2 2 2 2 3 3 3 3 Ni Nij Nijkl Nijk Network Model t 4 3 2 1 0 Ni = No. of 1st tier suppliers to ith product/service outlets Nij = No. of 2nd tier suppliers to ijth Tier 1 supplier, e.g., OEM Nijk = No. of 3rd tier suppliers to ijkth Tier 2 supplier Nijkl = No. of 4th tier suppliers to ijklth Tier 3 suppliers

12. T C = Σ ptm Nijkl Ni Nijk Nij - p (ni| t) log [p (ni| tm)] + m = 1 Σ Σ Σ Σ j = 1 i = 1 l = 1 k = 1 - p (nj| ni t) log [p (nj| ni tm)] + - p (nk| ni nj t) log [p (nk| ni nj tm)] + - p (nl| ni nj nk t) log [p (nl| ni nj nk tm)] Calculating Complexity { }

13. Complexity Assessment Great opportunity for HCI research

14. Implications

15. Observations • Healthcare is a complex adaptive system and highly complex, but not as complex as retail markets that manage complexity to minimize burden on consumers • Objective should be to increase overall complexity, where it can best be managed, in order to decrease complexity for patients and clinicians • Information management is a key issue, as is creation of incentives and inhibitions that will motivate stakeholders to provide quality, affordable care for everyone

16. Health IT Roadmap • Healthcare Ecosystem • Hierarchical Network • Value-Driven Enterprises • Health IT Roadmap • Health IT Readiness

17. System Structure (Organizations) Healthcare Ecosystem (Society) Economic Model & Incentive Structure Human Productivity & Healthcare Costs Competitive Positions & Economic Investments Economic Returns & Performance Information Care Capabilities & Health Information Patient Care & Health Outcomes Delivery Operations (Processes) Clinical Practices (People)

18. Hierarchical Network Healthcare Ecosystem (Society) System Structure (Organizations) Inter-Level Information Flow & Incentives Delivery Operations (Processes) Clinical Practices (People) Intra-Level Information Flow & Incentives

19. Value = Money, Lives, Advantage, Etc. Delivered Via Value Streams Enabled by Work Processes Supported by Information Motivated by Incentives Enterprise Efficiency 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 EnterpriseIntelligence Value-Driven Nature of Enterprises

20. Health IT Roadmap • Milestone 1: Efficiency • Value Stream & Work Process Mapping • Back Office Integration & Automation • Electronic Medical Records & Health Information Exchanges • Milestone 2: Effectiveness • Clinical Decision Support • Patient & Family Support • Personalized Medicine • Milestone 3: Evidence Base • Operational & Clinical Database Mining • Every Performance Shortfall & Failure Understood • Learning System  Identify & Deploy Best Practices

21. Healthcare IT ReadinessA Web-Based Assessment Tool

22. Organizational Simulation • Using IT to Explore Healthcare Futures • “Driving the Future Before Writing the Check” • OrgSim Concept • OrgSim Architecture • Health Advisor

23. OrgSim Concept An immersive environment that: • Simulates future organizations, including behavioral and social changes • Enables decision makers to interact within changed organizational culture • Synthesizes “people” who behave as if changes have already happened • Provides compelling feel for “what it will be like”

24. 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 Architecture

25. Health Advisor • Motivation • 10,000 eleven year olds • Back Story • The Game • Reception Area • Player’s Office • Client Interview • Decision Options • Research Questions

26. Back Story Welcome 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.

32. MedFile • Online medical resource • For each disease • Symptoms • Confirming tests • Treatments • Description of diseases, tests, etc. • Description of medical specialties

33. Research Questions • Game Play • What strategies do players employ to maximize value? • What strategies do players employ to stay in business? • How successful are these strategies? • Information Services • What information do players access to make decisions? • How do the type and form of information affect decisions? • How is value affected by information and decisions? • Hedging Risks • How do players hedge the downside risks of client costs? • What types of insurance do players find attractive? • How does insurance affect decisions? • Education • What do players learn from Health Advisor?

34. Study Design 42 Emory undergraduates Game played over 3 weeks Survey administered over 1 week Each player saw 25 clients Access to EHR and MedFile Clients across gender, age & conditions Game Evaluation Survey Interesting – 4.3 Educational – 4.2 MedFile understandable – 4.2 Provider info. understandable – 3.5 Tests and treatments appropriate – 4.0 Client dialogs make sense – 4.0 Advisor options reasonable – 3.9 Descriptive Statistics Doctor Selection Specialists = 63% PCP = 37% Client Evaluation & Test Selection Picked a Body Part 34% Picked a Specific Condition 42% Picked a Severity Level 10% Picked a Specific Test 56% EHR View Avg./Player = 9.3 Avg./Client = 0.5 MedFile Access Avg./Client = 0.41 Avg./Player = 9.45 Click Data Avg. Click/Client = 30.7 Avg. Clicks/Player = 719.1 Play Time Avg. Time = 1:08hr Avg. Time /Client = 3:00min Emory Study

35. Preliminary Results • Performance – Assessments & Referrals • Players who spend more time, and clicks, with clients tend to perform better • Players who more frequently access MedFile tend to perform better • EHR access does not impact performance in our context and, in fact, has slight negative influence • This is expected as the information contained in the EHR -- for the first visit -- does not provide additional knowledge • Players assessments and referrals improve over time • Players assessments of a previously seen condition, with another client, improve significantly

36. Summary • System Studies • Understanding Systemic Consequences of Changes • Complexity of Healthcare Delivery • Increasing Complexity Where It Can Best Be Managed • Health IT Roadmap • Efficiency, Effectiveness, Evidence Base • Organizational Simulation • Driving the Future Before Writing the Check