The Sixth Discipline for Learning Organizations

There are some things common to the diverse fields of medicine, public health, business, religion, science, and the military.

• They all tackle problems which result in "success" or "failure" in a changing world.
• Failure can cost property, lives, or even entire nations and cultures.
  
• "Success" depends on how well they can detect failure and adapt to it.
• They all have bright people, but really operate more at the organizational level
  
• Adaptation depends on how good the organization is at seeing and learning.

So, a book like Peter Senge's The Fifth Discipline - The Art and Practice of the Learning Organization is very important to us all, and impacts us on many fronts.

Senge points out an extremely pivotal insight: there are two different kinds of complexity, and most of what we do is focused on the wrong one.

He describes "detail complexity", which is the type we are familiar with, where there are thousands or even millions of details to be kept track of and managed. That one we're pretty good at, with the help of computers.

But then he goes on (on page 71 of the 2006 revision):

But there is a second type of complexity. The second type is dynamic complexity, situations where the cause and effect are subtle, and where the effects over time of interventions are not obvious. Conventional forecasting, planning, and analysis methods are not equipped to deal with dynamic complexity...

When the same action has dramatically different effects in the short run and the long, there is dynamic complexity. When an action has one set of consequences locally and a very different set of consequences in a different part of the system, there is dynamic complexity. When obvious interventions produce non-obvious consequences, there is dynamic complexity.

He adds

"The real leverage in most management situations lie in understanding dynamic complexity, not detail complexity."

This understanding comes from "system thinking" and that, in turn "starts with understanding a simple concept called feedback."

Of course, to say feedback is "simple" is misleading. The impact of feedback is wildly subtle, counter-intuitive, perplexing, and paradoxical to most of us. Some simply refuse to accept the concept at all because it overturns so many cherished notions of how the world works and how things "should" be.

Senge goes on, echoing many others and American Indian culture, "Reality is made up of circles but we see straight lines."

The point is that when people or things form a causal loop, where each thing influences the next one down the chain, and the chain is closed, then all our notions of "causality" are thrown out the window. Every actor in that loop is both the cause and the prisoner of the effects of the entire loop. In many ways, the shape of the loop becomes the dominant "cause" of what unfolds, far more so than the people caught up within it.

Senge describes a person filling a glass of water. As seen by a person, their hand is controlling the level of water in the glass, and adjusting it as the glass fills. A perfectly valid alternative description is that the level of the water in the glass is controlling the hand, causing the hand to close the faucet as the level reaches the right place.

Both descriptions are partially correct. The hand affects the water level, and the water level, in turn affects the hand. There is a feedback loop in place. Both are "causes" and both are "effects," and "which came first" is an irrelevant question.

It is the intrinsic property of complex systems to be dense with such feedback loops between the people inside them, making everyone a cause and everyone a trapped recipient of effects.

This means bad news and good news.

The bad news is that, if the output of "the system" is wrong, then the blame should be shared among everyone in the system, not just the last person to touch something that failed.

The good news is that every person in the system therefore also has the opportunity to change the flows and impact the system's output. In conflict situations, either party has the ability to increase the tension or decrease the tension.

In fact, in most conflict situations, the whole reason for the conflict in the first place is that there are feedback loops that are reflecting each sides actions into later behaviors by the other side, which are misinterpreted as new "actions", not "reactions."

Thus, in 2006, when Hezbollah forces in Syria reacted to Israel's capture of many of their own, they captured two Israeli soldiers in return. However, Israel saw this not as a reaction, but as a new "unprovoked action", which therefore demanded a new massive "reaction" and counter strike - a 34 day assault by Israel. The counter strike, in turn, was perceived by Hezbollah as a new "unprovoked attack", and the cycle simply continues to feed itself.

This is a classic no-win situation, where each side downplays the value of lives of the other side, and feels that the loss of one of their own should be responded to by killing two of the "others",
in order to "get even" and also "be even." By that flawed match, the conflict spirals out of control because there will never be an "even" situation.

On a smaller scale, within organizations, the same phenomenon occurs - but generally without actual explosives and death. The vast majority of conflicts can actually be traced back to people, or teams, or departments, or divisions, or managers blaming others for behavior that is simply the downstream result of their own earlier behavior, reflected and sometimes amplified through the structure of "the system" of feedback loops and lags. Similarly, management and labor can get into the same endless loop of conflict over "getting even" for behaviors that are the result of their own, forgotten, earlier actions.

In a bizarre sort of hallucinogenic dance, at all levels from personal to national, we are fighting demons that are simply the delayed reflections of our own earlier behavior, which we fail to recognize and blame instead on the "others" being "bad."

Senge mentioned the problem with dynamic complexity over space and over time, but he missed the third dimension, namely, over scale, or location in the hierarchy of life. Actions or interventions may look very different, ranging from great to wretched, as we rotate the lenses in our microscope stage and view different time-horizons, different space-horizons, and different perspectives from the bottom of the organization to the top.

Worse, actors in one place who perceive, at their location, time, and scale that their own actions are "good" may be completely baffled by hostile responses coming from actors at other locations, times, or level who are only responding to the "terrible" thing being done to them by that obviously uncaring and bad person somewhere else. And, of course, this would mean that those people responding with hostility must be "bad people" and need to be fired, neutralized, or killed, depending on the context of the conflict.

Dennis Severance describes the same kind of error being made by a mythical management in the book Making I/T Work. That management tries to impose an an enterprise-wide computer system, runs into "hostility", tries to "deal with" the "opponents" by firing them, and then is blind-sided when the computer system, "out of the blue, with no notice", fails to operate as intended, and they can't grasp why no one ever warned them of problems. The fact that those who raised these issues at the start were fired for their "hostility" is completely lost. This is a very common problem across industries.

These problems are not, as they might seem, problems of perception, but are actually problems of the intrinsic properties of systems. The people in these systems are all well-intended, doing "good jobs" locally, and yet, like M.C. Escher's pictures, taken together form an impossible loop that simply can't operate.

The variables that depend on the horizon of space, time, or scale are the keys here, and are as surprising as seeing an object that is red close up turn to look green when you back up several steps. This seems "impossible". Actually, New Scientist published a marvelous picture a month ago that, if viewed close up, was Albert Einstein, but if you backed up across the room, changed into Marilyn Monroe.

( Hybrid images: Now you see them…

• 31 March 2007
• NewScientist.com
• Gregory T. Huang )
  

These system effects are much more prevalent than people realize, and are the things that are "to blame" for most of the conflict and corporate dysfunction and national conflict around us.

It is clear to me, and I'd say to Peter Senge, that these effects need to be somehow made visible and accessible to everyone, at every level, from every country, so that we can get enough comprehension for people to see that, in Walt Kelly's Pogo's words, "We have met the enemy and he is us."

Of course, many scientists, working a small scales, would have a hard time accepting wisdom from theologians, working at large scales, who see different pictures in the same world. Biomedical researchers, used to looking down the microscope for the cause of problems, are not prone to look out the window instead, and even less to consider that their own scientific culture could be implicated in producing the conditions that produced the cancer that they are now working to "cure".

Still, the logic of Senge's arguments is sound. "All" that is required is for people to stop blaming others for all the pain and recognize that the others are just as good people and are just as trapped in the pain, and, in any case, as with Jimmy Buffet in Margaritaville, they might realize that, yes, maybe, they themselves might be partly to blame.

If this looks remarkably like the basic golden rule of most religions ("Do unto others what you would have them do unto you") that's because it is. Other really annoying commandments like "Forgive us our sins as we forgive others" also come readily to mind.

Like the "Marilyn Einstein" photo, reality is multi-scaled, and the scientists have the fine-detail or high-frequency detail right, and the religions may be wrong on details but have the long-wavelength, larger picture right.

All of this should be something that can be animated, simulated, and taught in K-12 school, as well as in continuing education. And it should be.

We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.
T.S. Eliot

Baha'i views

The weblog Baha'i Views offers "Pithy excerpts & mentions of Baha'i in the blogosphere" and looks like a nice daily "clipping service" for who's doing what where. It has nice pictures and short postings by different people of their very individual thoughts and experiences.

It's at http://bahaiviews.blogspot.com/ and I added it to my permanent links list.

Here's a few sample topics on there today:

On Speaking of Religion: Being open-minded and contemplative

On Resisting Divisive Influences: God Unites, Man Divides

On Harmfully Divisive Influences to Humanity's Unity: Unlearning the the prideful nationalistic feelings that drive us apart

On Another Way to Participate in the "Cultivating the Roots" Conference: Audio Streaming and Blogging from the Event

On Wealth and Poverty: Thought-Provoking Reflections

On Baha'i Devotionals: One Buddhist quote was meant for me

Wade

Agile Links for Busy Health Executives

"Agile Links for Busy Health Executives" is the description of the weblog HealthCxecLynx at "http://www.healthexeclynx.org/".

That site is maintained by Department of Health Policy and Administration at the School of Public Health of the University of North Carolina at Chapel Hill.

It's a nice clearinghouse. I added it to my permanent links (on the right side of this page).

Wade

Subtle nuances matter

It's not obvious what matters.

Whether we are just thinking, or doing fancy math, there's the stuff we leave in our model, and the stuff that we throw out, because it doesn't matter. Sometimes we think things don't matter because they have such a small effect that they are "negligible."

Sometimes we are wrong.

A classic example was the mistake that pouring toxins, like mercury, into the sea would dilute them to the point where they didn't matter. We forgot that nature has natural filters and amplifiers that recollected all those dilute molecules in one place, namely, the tissue of fish, so that the concentration was again dangerous or lethal to humans.

Or sometimes we forget some other factor. Nuclear scientists at Dugway Proving ground computed how much fallout would land on the ground and how much would wash away and "go away", and figured it was safe. After the sheep died and many people got cancer they found out, oopsie, that grass is remarkably good at harvesting water and holding onto it, so instead of the toxins washing away, they were recollected.

So, sometimes things that look like "small" effects do "go away", and sometimes they don't.

One conceptual problem we have is that we're not used to math where the answer depends on what time scale or geogrphic scale we're working in. So, yes, in the short run, "rock" is stronger than "water". In the long run, "rock" is demolished and destroyed by "water".

Or, in the short range, electromagnetic forces dominate gravity. A balloon, rubbed on the sleeve, will stick on the wall, not fall. For many purposes, gravity "goes away." But, if you look on longer time scales, it's the "strong" force of electromagnetism that "goes away", and the end state of the world is determined by that "weak" force of gravity, on a cosmological scale.

Or, if you look at an M.C. Escher painting of a staircase or waterfall, locally, there is nothing wrong, aside from a very slight noise or error -- but that error accumulates and on the larger scale, the total painting is absurd, even though locally any small part of it makes sense.

So we need to be careful about not "throwing out the baby with the bathwater."
It's not always obvious which is which.

Then there are other effects even more insidious or subtle. As the philosopher "Snoopy" observed one day, lying on top of his doghouse in the cartoon strip "Peanuts",

"Did you ever notice, that if you think about something at 2 am, and then again at noon the next day, you get two different answers?"

Or, another example I love, the story of two stone masons working on a church in the 1600's. One was doing very good work, and the other was doing work that needed to be redone often. The supervisor came to talk to each and asked them what they were doing. The one with poor outcomes replied "I'm building a wall." The one with great outcomes replied "I'm building a cathedral."

So, at least to human beings, it seems to matter a great deal whether the work they are doing makes sense in a larger context, whether it has "meaning" to them or not.

Is this true for people who write computer programs or "provide" health care services as well? Probably. How would we know for sure? And if it does matter, are we designing our systems in light of that effect, whatever it's called?

And is this just some "mental" or "psychological" effect, or is it an effect so "real" or fundamental that it would show up even if the agents building things were robots not people? Does this sort of thing matter to ants or bees or termites or bird swarms or swarms of viruses or bacteria?
Does it matter to the US Army?

Do real, tangible outcomes depend on "meaning"?

Certainly, from the model I described yesterday of nested contexts, the outer, distant contexts matter a great deal, although, again, the effects may take longer and longer as the context gets more distant. So, as many computer system designers and nation builders have discovered, "culture matters", and the survival of some change imposed from outside on a system depends, in the long run, on whether it fits with culture or not. If it fits, or can transform the culture to fit, it will remain. If it doesn't fit, the cultural equivalent of the body's immune system will identify it as "foreign tissue" and reject it. You can take that one to the bank.

Today's International Herald Tribune has an opinion piece on this subject at the scale of nation building, reflecting on Iraq and Afghanistan. Here's a brief snippet.

Do Not Neglect Culture
International Herald Tribune (on-line)
May 8, 2007
by Nassrine Azimi (Hiroshima, Japan)

The Rand Corporation recently published a study called "The Beginner's Guide to Nation-Building." It covers the basics with clarity and objectivity, defining the roles of the military, the police and the judiciary; distinguishing humanitarian relief from economic stabilization and development, explaining the complexities of governance and democratization.

But the book has almost nothing about what is clearly the Achilles' heel of recent nation-building adventures: culture. No single chapter is devoted to it - nothing on the role of culture in countries being rebuilt and, just as importantly, nothing on the culture of the nation-builders themselves.

Though we are reminded that six of the seven cases of nation-building initiated in the last decade by the United States were in Islamic countries, we do not learn much of the lessons of this extraordinary experience.

How, for example, did it inform the dispatch of some 120,000 mostly Christian soldiers to Iraq - a Muslim country and one of the most ancient civilizations on earth?

Neither do we learn much about what kind of cultural preparations, if any, were undertaken in advance of embarking in Afghanistan, also an ancient and proud land, with subtle values and vulnerabilities not readily accessible to the Western mind.

The fault, however, may not lie as much with the Rand book as with nation-building operations themselves. In most, culture has been at best an afterthought and at worst a shallow and cynical exercise in public relations.

This was not always so. The U.S. occupation of Japan between 1945 and 1952, so often cited as a model for Iraq, was quite different. American planners then appeared to have asked themselves some hard questions about dealing with a country they barely knew or understood, with which they had fought for almost four years, and which lay in ruins....

Perhaps this same effect is as evident in the many failed efforts across the country to install "Electronic Medical Record systems" where the system did not fit the culture or "the way we do things here", and the hope that the culture would "come to the system" was dashed by the fact that the system yielded to the culture.

This phenomenon is very well known and studied in public health, after a century or so of attempting to impose behavioral patterns on indiginous people who tended, as soon as the intervention team was gone, to keep the goodies and discard the behaviors that the strangers had imposed. The natives happily nodded "Yes!" while thinking to themselves "In your dreams!"

The lessons are that lasting change has to be rooted, and, in a mixed metaphor, rooted "deeper and deeper" upwards into the hierarchy of contexts that surround the point of intervention, or the unit of the hierarchy of life that is being tinkered with.

This effect is dimly and incorrectly perceived by many in McGregor's "Theory X" camp as "resistance to management", and as something that needs to be attacked, proponents of such resistance located and rooted out and fired, and overcome by brute force. In the short run, rock beats water. But, in the long run, water beats rock. If the intervention is "not me", the culture will ultimately find some way to reject it, or perhaps the culture will simply collapse under the conflict.

I think the prophet Yogi Berra once said "You can hear a lot by listening" , or words to that effect. It seems advisable that those messing with systems behavior at any scale should first investigate the system's "culture" before investing a lot in a particular change that seems, from the outside, to make sense. There are subtleties that are not obvious, "small things" that don't fit that turn out not to be so small after all, as the mercury or the fallout or the stone mason examples showed.

Whether a piece of the developmental puzzle "fits" or "is good" or "goes there" needs to be assessed at the cultural level, after all the "small things" have been given a chance to accumulate and add up again. This is a "complex adapative system" and the behavior at large scale is not reflected, in any obvious way, by the behavior at small scale.

The very fact that that's the problem is not widely understood.

There is no way that, for example, the CCHIT assessment of electronic medical record systems, at the individual user level, can possibly reveal whether this overall system will "fit" or "work" if "installed" at a particular site, in a particular "culture".

Collaboration-ware needs a completely different scale approach than classic IT software.
Again, that's not recognized as a problem to even fret about.

We are desperately short of good tools and accepted practices in this area. Maybe public health informatics can address that in the coming decade.

W.

Credits: Photo above is "The Hierarchy of Consciousness" by slark on flickr.

The hierarchy of life and implications for interventions

Apparently, we don't exist.

Every day more studies come out showing something that we'd suspected all along - namely, we actually have very little control over our own lives and even over our own decisions.

The people around us and our neighborhoods, at work and at home, are increasingly seen as the main cause of our beliefs, our decisions, and our actions.

Well, that just messes up everything, thank you. Our whole system of justice, and education, and rewards at work, and "the American way" are all based on the concept of rugged individualism, on one dominant person surrounded by a sea of "environment", making decisions, navigating the shoals of life, and deserving rich rewards for success or punishment for "being bad."

But that concept doesn't seem to survive the light of day, or a careful look at the evidence. And much of the evidence lately is coming from public health, including studies of the "health" of the "healthcare system" itself.

A very "robust" finding of the field of "social epidemiology" is that the physical health of a person seems to be very strongly associated with his or her "connectedness" with the tissue of society around them. The more someone is connected to the social fabric, the healthier they will generally be. The more someone disconnects and drops out of social interactions, the worse they will tend to be, across the board, in terms of almost every measure of morbidity and mortality. They'll be more depressed, more fatigued, less successful, less wealthy, more likely to be obese, more likely to have depression, diabetes, heart disease, asthma, the flu, common colds, etc.

But, does disconnection cause disease, or does disease cause disconnection?

The answer is "yes" to both, because this is not a linear chain of causality, but a causal loop. That means it can spiral downwards or upwards.

That's familiar. The more a person becomes depressed, the more likely they are to fail to cope, to get into trouble at work and home, and to worsen their situation at work and home. And, the worse their situation becomes, the more depressed they become. It's a "vicious cycle."

The ultimate end of that death spiral is, in fact death. There is complete disconnection and isolation, total dropping out, followed by catching the next excuse to die, from natural disease or neglect or violence, or violence against others (death by police). Just as a human cell, removed from the body, will lose the will to live and commit suicide ("apoptosis"), humans,
disconnected from the social body, lose the will to live, and find a way to die.

This is a real bummer in several ways. One unexpected way is that almost all research studies are based on statistics developed by a guy (Sir R. A. Fisher) studying crop yields where the causality only goes one way. The crops do not realizing they aren't growing and make midnight raids on the fertilizer shed. People, however, do. In fact, almost everything people do, or collections of people, are just drenched and dominated by feedback loops. And feedback loops invalidate classical statistics based on lines, not circles. (It's based on the "General Linear Model"). So, it's hard to study. So, people don't study it and go study something else.

Of course, there are tools that can easily handle such loops, including electronic circuit design or "system dynamics" or "feedback control system engineering." But those are almost unknown in public health so don't hold your breath.

Despite that, the evidence just leaps off the page. The most successful interventions in health care, as described in "Health Program Planning - An Educational and Ecological Approach" (4th ed) by Green and Kreuter, apologizes for abandoning classical models on page 3, with the comment that

"Ecological approaches, however have proven difficult to evaluate because the units of analysis do not lend themselves to the random assignment, experimental control, and manipulation characteristic of preferred scientific approaches to establishing causation."

Which is a long way of saying that the old set of "linear" tools and linear thinking really doesn't work, if you try to apply it to the real world that people, not billiard balls, deal with daily - a world dominated by feedback.

But, all is not lost. Even despite that, the healers of the healers, the designers of the health care system itself, have studied their own problem and concluded that the right unit of intervention is the small team on the front lines, which they call a "microsystem." In between the one doctor who is hard to change, and the hospital, which is hard to change, is the small practice team, which, fascinatingly, the Institute of Medicine has found easy to change.
(See Crossing the Quality Chasm.)

And, ta da!, big surprise, the recommended method of changing that unit of life, the small team, turns out to be "feedback." Well, of course it's feedback - that much becomes obvious once you shift lenses and realize that everything, at every scale, is more defined by what's outside it than what's inside it. (Mach's principle in cosmology.)

So, a single doctor or staff member can't really be changed by an intervention, because their behavior isn't really "theirs" -- it is a feedback property of the small team they work with. So, if a doctor or nurse "makes a mistake", it usually turns out that the place to fix isn't the individual, it's the larger structural team around them that effectively forced them to make the mistake. The system buys the gun, loads the gun, cocks the gun, hands it to the person on the front line who pulls the trigger.

And, on the flip side, there is no such thing as "the patient." Patients are people, and people come with a posse, an aura, their own small team of friends and family that mutually influence each other. So, ta da!, if you want to change how "a patient" behaves, or go a step further upstream and change what they believe, you have to address how the patient's "microsystem" behaves. The IOM didn't make that leap, but the rest of health education has realized that "family-centered" interventions are way more effective than "patient" interventions.

Of course, this really only changes the geographic and time scale, something the IOM hasn't yet realized.

This property of being defined by the outside peers is not restricted to cells or to people - it's a universal property of living things or any regulatory control system.

So, it's "scale invariant". That means if we flip to the next lens on our microscope and stand back another hundred yards, now we see the unit we are messing with is "the microsystem" but it is swimming in a sea of other "microsystems", and is ultimately dominated by the other microsystems as a peer group. Now, the time constant is much longer, so it may take months not days, but simply changing one small team and leaving its environment unchanged will sooner or later result in the change being undone, rejected like foreign tissue, and discarded by the larger living tissue of the body of the health care system. People will revert in hours. Clincial services may take months or years to revert, once the intervention pressure is released.

Man, how far does this thing go? Well, according to many people such as myself or Ken Wilber, it just keeps on going upwards. Wilber refers to one of these structural ladders of the hierarchy of life as a "holon." Norm Anderson, when at the NIH, refered to the same hierarchy from cells to tissues to organs to people to groups to neighborhoods to populations -- but nobody really wanted to hear that, so Norm left. The tissue rejected the novel idea.

Well, that math just gets impossible then, doesn't it? Not really, it just rotates. Large, tall, hierarchical structures have their own basic modes, as does anything else. There are almost certainly solutions that can be found, or descriptions, based on combinations of scale-invariant (symmetric) properties as basis vectors. And one such scale-invariant property is the concept of a regulatory feedback loop. At every level of this nested hierarchy, exactly the same problem has to be solved - how to maintain the equivalent of homeostatis in a sea of change. Cells do it. The pancreas does it. The Endocrine system does it. The body does it. People do it. Small teams (microsystems) do it. Hospitals do it. Health care chains do it. Whole cultures do it. Nations do it. They're all doing the same abstract dance, of seeking to reestablish their own feedback loop that works for them.

So it's kind of a fractal, a Christmas tree shape, where each branch is the same shape as the tree itself. The question is, what are the fundamental modes of vibration of such thingies? If it were made of steel and you plucked a branch, what would it sound like? (There would surely be harmonics of harmonics of harmonics.)

And, do such things have "resonant frequencies"? Is there some speed of change that will work far better than other speeds, or one that is far easier to "fall into" because it "aligns" with the larger resonance of the larger system around it?

Those are the interesting questions. In the short run, we have some immediate insights that don't need years of theoretical simulation and wisdom, based on this model or framework or lens, whatever you call it.

Here's a few:

1) To change a person, you have to change their peer group. They can move to a different peer group, or the peer group itself can be altered, but it has to happen.

2) etcetera. That is, you can't change that peer group, stably, without clicking up one more rung of the ladder, using a new power lens, and finding the peer-group's peer group.

3) Therefore, either you have a cascading, exponentially growing evangelical type of change, or you have a diminishing, exponentially decreasing, tissue-rejection kind of change. There is no such thing as a stable change of one "unit" at any scale. Life doesn't support constants, only growth or decay.

4) Our whole system of justice, education, rewards, and punishments is based on a flawed model of the world. That's all going to have to be rethought. All this emphasis on individual education has already run into the increasing emphasis on "teamwork" and "groupwork" and a realization that the unit of research, of discovery, of industrial production, of making or preventing errors is not a person, but a "Microsystem", a team, a cockpit crew, an operating room team, etc.

5) We're going to have to "bite the bullet" and start using the right tools to address these problems. They don't fit into the general linear model. All linear statistics break down and all linear thinking leads to erroneous intuition.

6) Collaborative IT systems are feedback loop generators, not huge replications of a single human-machine interaction. The "electronic health record", viewed this way, is part of the feedback loops that a patient uses to control his own life, or a doctor uses to control and manage their care for the patient, each side also calling on their own "microsystem" team to support this activity. Such systems cannot be evaluated or tested as if they were an Excel spreadsheet with a Graphic User Interface -- the human factors are feedback loops that can't possibly even show up in single user testing. The system will be made or broken on how the larger social fabric changes feedback loops when the system is put in place. That won't be revealed by the current CCHIT test suite.

7) This model would say that the right thing to be tracking for hospital adminstrators would be microsystems and teams, more so than individuals. The "dashboards" should reveal whether the microsystems are working, and, moreover, the people who need the dashboard aren't just the management outside the team, which is post-hoc, but the team members themselves for real-time self-management, steering and navigation. (That's straight out of the IOM's Crossing the Quality Chasm.)

8) Ditto for patients. This model would say that patient teams need their own Personal Health Record as part of a real-time feedback self-management model, that the doctors or clinical staff are only a very small remote second-order part of, for chronic disease management that involves life-style changes.

9) And, ultimately, this model points ever upwards. It says that people cannot be healthy unless their peer-group is healthy, and that cannot be healthy unless it's peer group is healthy, and, ultimately, all this depends on the national culture and planetary population being healthy.

So, yes, not only are you your brother's keeper, but your brother is, in many real ways, your keeper.

10) The "public" that "public health" must be concerned with (among others) is actually a fractal, nested, hierarchical part of the hierarchy of life. This cannot be made to "go away."
We need to "go to the mountain." Predictions as to the value of interventions in the behavior of a part of that hierarchy, on some level, whether cellular drugs or pancreas care of health system regulations, have to take into account that the parts are connected and will determine each other's behavior through feedback responses to interventional pressures.

It doesn't make sense to say "we put in a good system but the culture rejected it." The word "good" needs to be defined with respect to the whole hierarchy of life including culture. If the system is "good' in that metric, then the culture will, almost by definition, not reject it.

Well, that's pretty pedantic, and maybe you have a different view or some contrary evidence. I'd love to hear it. Let's have a good debate! See that "comment box" down there? Please use it and tell me whether you think I'm right, wrong, or need to increase my meds! Or email me. My email is in my profile.

Wade

Patient team empowered diabetes care in LA

Much of the model I suggest in my Capstone presentation is in use in Los Angeles - including teams of caregivers amplified by teams of local residents in a cascading help-your-neighbor approach.

Here's excerpts from an article Diabetics Need Much More Than a Shot from today's LA Times.

Managing the disease requires constant support and substantial investment, but would pay off in the end for thousands of people.

By Susan Brink
[Los Angleles] Times Staff Writer

May 7, 2007

Diabetes is afflicting more people, at younger and younger ages, sending doctors, insurers and public health officials into a tizzy as the epidemic threatens to overwhelm the healthcare delivery system. The annual cost of healthcare for an adult with diabetes is more than $13,000, and rates of Type 2 have risen sharply in the wake of the upsurge in obesity in this country.

A bold experiment is unfolding in Los Angeles County that may serve as a lesson for the nation as it battles the epidemic.

Experts know that the cost of care could be much lower if patients could take simple measures to control their disease and avoid complications: nerve damage, amputations, heart disease, blindness, even death. But surveys show that many, even those with adequate health insurance, do not get that care, which is costly and labor intensive, demanding daily attention from patients and timely responsiveness from doctors.

Poverty creates additional obstacles, such as finding fresh vegetables or a safe place to exercise. Study after study shows that low-income people have less access to healthcare and a greater risk of getting sick and dying prematurely.

But in an odd twist to the usual healthcare disparity story, more than 1,000 L.A. residents in low-income areas, most of them uninsured or on MediCal, are getting the gold standard of aggressive diabetes management — better, even, than many with insurance who live in ritzy ZIP codes.

The care is taking place at clinics in East L.A. and South L.A., two communities with the highest rates of diabetes in the county, as well as three other outlying clinics. A team of L.A. doctors is participating in the experiment, training nurse practitioners, pharmacists, social workers and community educators to intervene in a way that doctors cannot do.

They're offering frequent patient checkups to monitor the disease, and teaching patients to track blood sugar, get out and take a walk, cut out the doughnuts, all the things they need to do to keep complications at bay.

They are reaching people with uncontrolled disease in some of the county's poorest pockets.

"The county patients [in the program] receive care that is as good, and probably better, as anywhere in the country," says Dr. Mayer B. Davidson, endocrinology professor at Charles Drew Medical Center and UCLA.

There are signs that it's working. Studies so far show that patients in the program have improved blood sugar and have had fewer emergency room visits and hospitalizations.

Local pioneers

The intensive program is a response from local academic and public health experts to the crisis ahead. One of those experts, Dr. Anne Peters, professor at USC's Keck School of Medicine and an endocrinologist who specializes in diabetes, works both sides of the disease's socioeconomic divide.

Peters has a Beverly Hills practice ... But she also has a second job: supervising teams of workers on the same intensive model at five clinics including the Edward Roybal Health Center in East L.A., and the Hubert Humphrey Health Center in South L.A.

Reducing complications is key to protecting patients and controlling costs. It's not rocket science: lose weight, watch your diet, exercise, monitor blood sugar, blood pressure and cholesterol, take your medications, have regular eye and foot exams.

But often, these simple things aren't done.

Doctors needed

Peters' practice is an exception. She's a private practice doctor who spends as much time with her patients as they need. Her practice follows a team model, with a staff of nutritionists, educators, nurses and nurse practitioners to advise and prod patients via face-to-face discussions, phone calls and e-mails.

"I personally believe that anyone can take good care of their diabetes, no matter who they are or what their level of education," she says. "But they need a team, or at least a guide."

So successful has Peters' method been, that six years ago, she launched a pilot program for the county, supervising a team of professionals trained to educate, monitor and, when necessary, nag. The program took off in four other county centers in 2005.

The treatment team members make phone calls, hold classes, help patients change their diets, prescriptions or medication doses. They will even visit patients' homes to keep treatment on track.

Community members who speak the same language and share the same culture and who have successfully controlled their diabetes are recruited to teach classes and help coordinate care for newcomers to diabetes management. The idea is to allow specialist physicians to become consultants to community-savvy teams who offer up a steady drumbeat of medical attention and lifestyle education.

"It makes more sense to reach out to people where they live 24/7, and not think that a visit every three months to a provider is where all the care happens," says Dr. Jeffrey Guterman, medical director of the L.A. County Department of Health Services.

Before being accepted, patients in the county program sign an agreement that they will keep appointments and follow medical instructions. If they fail to comply, they're out. [editor note - it's hard to evaluate the success rate if failures are excluded. The point of my Capstone is to try to figure out what determines the drop-out rate and address that.]

Because funding is limited, patients can stay with the program only 6 to 9 months, but the expectation is that they can learn to control their disease in that time, then go back to a primary care physician. Those county doctors are ready, having been trained in how to manage diabetes patients.

Early studies suggest that the program works. A report in the April 2006 American Journal of Managed Care looked at how a key blood sugar test, called A1c, was controlled in 367 patients in the L.A. County program the year before and the year after they entered the program.

The A1c guideline was met by only 28% of participants when they were under traditional medical care. After a year in the program, 60% of patients met the blood sugar level goal.

[Effective Diabetes Care by a Registered Nurse Following Treatment Algorithms in a Minority Population -

Conclusion: A nurse making clinical decisions based on detailed treatment algorithms did a better job of achieving ADA-recommended process and outcome measures than physicians providing usual care.

(Am J Manag Care. 2006;12:226-232)

A second study published in February in the journal Diabetes Care found that diabetic patients in the program reduced their use of emergency rooms by half and cut down on hospitalizations. Total hospital charges dropped that year for the 331 patients studied to $24,630, from $129,176 the year before.

[ Effect of a Nurse-Directed Diabetes Disease Management Program on Urgent Care/Emergency Room Visits and Hospitalizations in a Minority Population

Mayer B. Davidson, MD¹, Adeela Ansari, MD¹ and Vicki J. Karlan, MPH

Diabetes Care 30:224-227, 2007]



Peters, ... keeps her private practice going only through donations from grateful, wealthy diabetic patients to a foundation she has started.

The health insurance benefits that her Westside patients have cover visits — generally about every three months. They don't cover extra visits to change medications or search out the reason blood sugar has fallen out of control. They don't cover time spent analyzing complex blood glucose printouts, insulin pump data or teaching patients to adjust insulin and drug doses.

Nor do they cover time for long discussions, phone calls, e-mails or the nutritionist, educators and nurses she employs to advise and prod patients....

---

susan.brink@latimes.com

Microsystem? What's that?

The confusing concept of a "microsystem" is central to the Institute of Medicine's recommendations for improving hospital-based health care, as presented in Crossing the Quality Chasm. What do they mean by that term? Where do we have to stand so that it becomes as obvious to us as it is to them that microsystems are important?

In this post I want to try to address those questions.
Here's two links to the IOM report:

IOM's "Executive summary

Entire IOM "Crossing the Quality Chasm" book (readable on-line)
http://www.nap.edu/catalog/10027.html#toc

First, where does the IOM refer to this? Searching the full text of the IOM report doesn't even hit that word? We have to start with the main author's after-thought (reformatted for clarity below):

A User's Manual for the IOM's 'Quality Chasm' Report
by Donald M. Berwick, Health Affairs, V 21 No. 3 May/June 2002, p 80-90,
http://content.healthaffairs.org/cgi/reprint/21/3/80.pdf

ABSTRACT: Fifteen months after releasing its report on patient safety (To Err Is Human), the Institute of Medicine released Crossing the Quality Chasm. Although less sensational than the patient safety report, the Quality Chasm report is more comprehensive and, in the long run, more important. It calls for improvements in six dimensions of health care performance: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity; and it asserts that those improvements cannot be achieved within the constraints of the existing system of care. It provides a rationale and a framework for the redesign of the U.S. health care system at four levels: patients’ experiences; the “microsystems” that actually give care; the organizations that house and support microsystems; and the environment of laws, rules, payment, accreditation, and professional training that shape organizational action.

From the "Prologue" to the article

One of the architects of the [IOM] report, Donald Berwick, decided that it would be
worthwhile to condense the message into a “user’s manual” for interested readers
in the United States and abroad. In this paper he synthesizes the report’s structural
themes and presents them, executive summary–style, as a framework that
did not appear in the final report but was the basis for the months of discussion
that led up to the report’s writing and dissemination.

This framework comprises four levels of interest:

• the experience of patients (Level A),
• the functioning of small units of care delivery (or “microsystems”) (Level B);
• the functioning of the organizations that house or otherwise support microsystems (Level C);
• and the environment of policy, payment, regulation, accreditation, and other such factors (Level D) that shape the behavior, interests, and opportunities of the organizations at Level C...

As the author of more than 100 peer-reviewed papers in numerous journals,
Berwick was ideal for the task. A pediatrician by training, Berwick is chief executive
officer of the Institute forHealthcare Improvement (IHI).

So we can see here a four-level multi-level model of patient care with a very surprising twist - namely, it seems to have skipped over the doctor, going from the patient right up to the whole small team that includes the doctor(s), nurses, and other staff who collectively deliver care within that clinic or unit.

This gap is no oversight. It embodies two more very critical, dramatic, and profound concepts:

#1) when caught up in an institutional environment, the boundaries of individuals blur, because doctors behave differently than they would in solo practice. Their behavior is as much a function of the team they are in as it is of their own "self".

and

#2) if we want to intervene in this 4-level health care system to improve things, the place we should intervene is at the small team level, not at the level of the individual doctor.

The first concept is an inevitable consequence of putting together groups of any kind of actor that is aware of and sensitive to its environment, in a social setting where collective action is the norm. It shows up in primates where there is a rule that "There is no thing as one chimpanzee," because the behavior of the "one", when isolated in a room, is so different than when the "one" is in social context. This phenomenon shows up among interacting robots, or interacting electronic components in some device. This is a "systems" concept, and as primal as any physical law, such as conservation of energy or conservation of momentum.

The second concept then, that this is the place to intervene, follows from the first. Again, experience robustly supports this in public health, where trying to change the behavior of "an individual" while not changing their peer group or family has proven to be extremly difficult, and the trend is dramatically shifting to "family-centered" interventions.

But, this is not just a theoretical model. Experience in the field shows that this does in fact appear to be universally true in institutional health care, and that interventions at the team level are, in fact, dramatically successful.

This document discusses 20 different health systems in which this was found to be true.

Executive Summary for Health Care Leaders
Microsystems in Health Care
Robert Wood Johnson Foundation
Dartmouth

Third, what sort of "Intervention" is necessary to improve the performance and behavior of this team level entity and produce safer care in a more cost-effective manner? Very little. In fact, the primary intervention required is simply to provide them sufficient real-time feedback of how they are doing, and trust them to respond to it appropriately, without any further management intervention. This is a mix of "Theory Y" of management, and Deming's models of the behavior of employees, who, he asserted, given the tools to do their jobs, would do them.
(But note that the team remains within the context of a larger health system, and that is important too.)

Here's a detailed but readable discussion of how that feedback can work:
Microsystems in Health Care, part 2:
Creating a Rich Information Environment
Joint Commission Journal of Quality and Safety

So, what does this tell us about the role of Information Technology (IT) within a health system? It seems to me that this clearly indicates crucial role for the real-time capturing of outcomes and visible feedback to the team, as well as a crucial role for interactive collaboration tools between the team members.

This is IT at the microsystem level, and is almost entirely absent in many health systems, in which IT is considered the exclusive province of levels C and D - the enterprise and national statistics. This focuses on "technology-mediated collaboration."

Fourth, a fully-integrated national health care system would actually provide the necessary IT support for all four levels - A,B,C and D in a coherent fashion.

In other posts, such as the Capstone presentation below, I discuss why empowering teams of patients, or the patient and the patient's family or "posse", is equally important for dealing with chronic care for such diseases as diabetes or obesity, in which the patient is the locus of control.
That need increasingly will be met by RHIO's and Personal Health Records, although, for reasons I discuss elsewhere, I think PHR's will be far more able to cover this gap than RHIOs because they are so much less risk-averse and more able to experiment, adapt, and fill small niches.

In conclusion, the national health information infrastructure model, as perceived by the IOM, really includes providing real-time self-managment tools as the crucial, key IT support to small teams of caregivers, whether the caregivers are "providers" in a hospital, or patients and their friends and family.

This is not a familiar role to IT, and so far has been embraced more by the School of Information at the University of Michigan ("technology-mediated collaboration") than by health systems in the USA.

This needs to be more central to the discussion of IT in a health-care environment, and it is a very different subject than simply automating medical records -- it is empowering small-team collaboration. That, according to the IOM, is where we need to focus our energies.

capstone presentation index

Welcome! This is a "work in progress" and comments are welcome. Follow the links below, or just go to the relevant slide and add your comment below it.

Or, e-mail me (see last slide) if you'd like to chat or have me include references to your own work here.

Here's an index to the slides that follow, because they will get spread out after people add comments.


1) Title page
2) photo of the author (me)
3) the problem of diabetes
4) NIH grant link
5) Wagner's Chronic Care model
6) Evolution of computing - and computing driven evolution
7) theories of behavior change
8) Personal Health Records arrive
9) two different PHR agendas
10) redefining the problem to solve
11) what would results look like?
12) prior data - Cho, 2006, Korea
13) prior data - O'Connor 2005 EMR
14) tentative proposal part A
15) tentative proposal part B
16) the universal feedback control pattern
17) wayfinding questions for the team
18) smart process control chart for teams
19) the "blue gozinta"
20) refocus - first pass design
21) grant development next iteration
22) take home messages
23) great free collaboration tools at 37signals
24) reflexive link and MC Escher strange loops
25) credits, and author e-mail

capstone slide 1

capstone slide 2

My Quantitative Biomedical home-page.

My web logs:
Perspectives in Public Health


Systems Thinking in Public Health

Other links:
Intelligent Agent Infrastructures For Supporting Collaborative Work (Sen, Durfee, and Schuette, 1995 - Computer Science and Engineering graduate project, EECS department, University of Michigan)

Evaluation of Blogger. Ching-I Chang. Narayan Kansal. Younah Kang. Wade Schuette. SI 689 (Computer-supported Coooperative Work, UM School of Information graduate program Group Project. December 13, 2005. )

Evaluation of Blogger - powerpoint presentation.

Biographic:

I inherited my interest in computing from my uncle, Roger Schuette, who is shown in slide 6 in a publicity photo from 1952 (roughly), which shows the computer his team had just designed and built at the Barber-Coleman Company in Rockford Illinois. Unfortunately, Howard Coleman's genius at invention wasn't matched with his insight into business, and the company decided these "computers" had too many bugs to ever amount to much, and sold their patents to other companies, such as, I think, IBM.

In any case, I built my own first analog computer, from a kit, in 1956 - it played Tic-Tac-Toe and would always either beat you or tie the game, depending on who went first. I was trained in the language "1401 Autocoder" at IBM in Cleveland, Ohio, in1965 while working for the Thompson Ramo Woldridge company, which became today's TRW.

In 1976, I got my MBA and joined a team at the New York State College of Veterinary Medicine and the NYS Diagnostic Laboratory that copied the Electronic Medical Record system developed by G. Octo Barnett at Massachusetts General Hospital, written in a new language called MUMPS, and converted it to handle multiple species. The work was led by John Lewkowicz, (The Complete MUMPS: An Introduction and Reference Manual for the MUMPS Programming Language, John Lewkowicz) , and was part of what led ultimately to the current largest medical records system in the USA, the Veterans Administration system VistA. (Veterans Health Information Systems and Information Architecture, with a name that precedes Microsoft's use of the name for their own operating system, no relation.)

We had the animal hospital up with sub-second response time, 80 functions - admissions, discharge, billing, histopathology slide indexing, decision-support for medication orders, etc. - fully implemented in 1976.

In 1976, we all thought that human hospitals were going to be just a few years behind us in putting in Electronic Medical Records systems. Given 30 years perspective, I think that was optimistic.

My major lesson, however, is that "There is no such thing as a technical problem." The technology to build entire EMR systems has been available for 30 years. The designs are freely available from the VA system, or from the state-run national health service in the Netherlands, to name two. The impedance, reluctance, resistance to implementation of such systems is not due to money, because we did the whole thing in 2.5 years with a team of 5 people, technically.

The issues hospitals have are psychosocial issues, often perceived as "political" issues, or discovered with shock and awe by yet another technical team as "implementation" or "acceptance" issues, which were mistakenly thought to be "minor issues" or "bumps in the road to be dealt with as they arose, at the end of the project."

After 30 years watching this field, I'd go the other way and say these are psychosocial issues and the technology is the trivial part. A standard laptop today has more computing power than we used to run an entire hospital system in 1976, or than the Netherlands uses to run a gigantic 2,500 bed hospital with sub-second response time. (in 1989 at SCAMC in San Francisco I had lunch with their chief developer - they were running a hospital on one "MicroVAX", with a second one as a hot-spare, and power left over. Of course, they had to rewrite the operating system to do it...)

Of course, no technology group wants to "hear" the message that the shoals they are crashing on are social in nature and that their whole concept needs to be rethought. The good news is that there is a growing body of expertise, in places such as the School of Information at the University of Michigan, in "social computing" - now an official graduate major at UM, which has a 30 year background in "Technology-Mediated Collaboration".

The design features of collaborative software are so different from those of single-user software, such as a spread sheet or word processor, that the old insights about software design and evaluation are worse than valueless - they actually lead you down the wrong pathways. Software that looks great when one person tests it in isolation, and has a good "human interface" (for 1 human) can still have a wretched "multi-human interface" behavior.

The national CCHIT approval process for medical record systems doesn't even begin to assess this level of this multi-level problem, but you can be sure that the hospital staff will experience that level and respond to it. You can also be confident that, if this level wasn't consciously and explicity well-designed, that it will be somewhere between poorly-designed and pathologically designed.

And, it's rather hard to design such a system without substantial interaction with and feedback from the entire contemplated user community.

The odds that an off-the-shelf system can be simply dropped into an unprepared hospital setting and "take" are low, regardless how strongly this is desired or mandated from above, or promised by the vendor. In fact, there may be an inverse relationship between how much the system is seen as imposed from above ("take it or leave") and social acceptance of the corresonding cultural change that is required to readjust to that technology. As Public Health has learned repeatedly, outside interventions that are not culturally-sensitive, dropped from a speeding helicopter in local villages, tend to be barely tolerated with false smiles during implementation, then die a rapid death as soon as the implementation team leaves.

We'll have a sense that this concept is finally understood when we see EMR development teams start with the idea of social acceptance of this new paradigm (electronic collaboration), and when the planning team includes social psychologists, cultural anthropologists, and people from the Information Sciences. If the problem is perceived as simply "electronic records", that is, as one related to databases and messaging tasks, and human beings interacting are not prominantely featured on any of the architecture diagrams, then the odds are against success of the project. There will be large-scale social "tissue rejection" of the kind that Public Health has encountered routinely so much for decades, in response to which Public Health has developed the ecological model, "PRECEDE/PROCEED", etc. (See Health Program Planning - An Educational and Ecological Approach ed., by Lawrence W. Green and Marshall W. , 4thKreuter, McGraw-Hill, (c) 2005 - 1st ed (c) 1961.)

So, it's not that the solution to such problems are unknown - they are just not part of the "Information Technolgy" literature, but are instead over in the "Public Health" literature, and the two have very little cross-talk. This is where there is a pressing need for Public Heath Informatics to step in and take a lead getting these disparate groups to talk to each other.

Later I'll also recommend that Public Health Informatics may be required to cross the bridge between the "feedback control problem" that public health keeps crashing into, and the "feedback control solutions" that Control System Engineering has mastered, off in a different universe that again has no cross-talk in the literature.

capstone slide 3

capstone slide 4

NIH grant announcement PA-06-337 (an R21)
NIH New Investigator's Guide

Also, of potential interest, is the funding opportunity announcement from the CDC in REACH - Racial and Ethnic Approaches to Community Health - although the closing date for that is May 7, 2007.

The REACH Detroit Partnership is of the most interest to me for future work and collaboration, as it is located in Ann Arbor, Michigan, and is supported by the University of Michigan School of Public Health and the UM School of Social Work and a number of local health systems such as Henry Ford.

Reach also has a "New Internet Computer" (NIC) initiative to explore low-cost web-based empowerment strategies. Bill Gates recently came out in favor of cell-phones as the way to go for the poor. On that subject, Gates also just gave $25,000,000 to Cornell University to develop a program in "systems thinking", a subject relevant to this presentation. Obviously, along with other Gates Foundation initiatives in TB control, etc., Gates thinks this is an important direction to explore.

capstone slide 5

Ed Wagner's Institute for Healthcare Improvement Chronic Care Model


As an afterthought, maybe this is not the best place to start from.

The CDC has a REACH program - Racial and Ethnic Approaches to Community Health -- Finding Solutions to Health Disparities 2007.

Within that is the program REACH Detroit Partnership.

Also, of potential interest, is the funding opportunity announcement from the CDC in this field although the closing date, May 7, 2007 is 6 days after this presentation is scheduled and might be a tad hard to reach.

The Johns Hopkins Bloomberg School of Public Health new department of Health, Behavior, and Society also represents the new way of looking at chronic care and lifestyle problems.
The 2006 Johns Hopkins Public Health Magazine on-line has an article "reach out to immigrants" with links to work being done at Hopkins in this area.

There are 20 or so 1-page articles there on "Urban Health" and all of them are relevant to this presentation and appear to me to be fully consistent with what I am suggesting here - so while my direction may be at odds with Wagner, it is aligned with Hopkins.

Also, the idea of using cell-phones to manage diabetes is not one of my own innovations. In fact, a recent JHU Division of Health Science Informatics seminar at Johns Hopkins was on a private company that is doing just that in Baltimore:
=============================================
February 23, 2007 10:45
Managing Diabetes by Cellphone

Suzanne Sysko, M.D., James Minor, Ph.D and Ryan Sysko (WellDoc)
***NO WEBCAST/VIDEO***
welldoc-communications

The technology link is clear to me, and under the covers the software is sophisticated (judging from their want-ads for software engineers), and I assume they are building an electronic record behind all that, but I don't know to what extent they are looking at team or group activities and using the phone as a collaboration tool, not a wireless data-processing device, and to what extent the patient is empowered, versus a data-entry clerk.

Those distinctions are the important innovative ones that this Capstone analysis contributes to the mix -- getting past using technology as a data-processing tool and looking to "technology-mediated collaboration" as the fertile ground for exploration and progress.
The focus has to be on the collaboration end, not on the technology end, to get this design to work, however -- making it very distinct from the approach most Electronic Health Record, or EMR, or PHR, or CPOE, or even the whole National Health Information Infrastructure is heading, which I think needs adjusting.

Lee Green, M.D., M.P.H., Professor and Associate Chair for Information Management int he Department of Family Medicine at the University of Michigan Medical School gave a seminar last week (Health Informatics Grand Rounds, April 18, 2007, contact health.information.grand.rounds@umich.edu) titled "Electronic Health Records: Solutions to the Right Problems?" where he similarly challenged the growing focus on a Computerized Physician Order Entry system as being the Holy Grail, saying "[EHRs] fare poorly at supporting system-based care, translation of evidence into practice, and quality improvement despite widespread belief in academic and policy circles that they provide these functions." A PR piece on Lee Green and type-2 diabetes is here.

It is important to note that I am not opposed to electronic health records or CPOE systems, provided they are designed with collaboration as the central design pillar, not an afterthought tacked on at the end. The technology for decent EMR's and CPOE with decision support has been around for over 30 years -- which I'm sure of because I was on a team that successfully ported Mass General's medical record system, in MUMPS, to multi-species use and put up 200 on-line terminals with sub-second response time in 1976 at Cornell University's Vet School, under the direction of John Lewkowitz.

ALL of the delays and obstacles since that time in human hospitals becoming similarly empowered have to be laid the doorstep of the social end of the socio-technology solution. That's why I'm so confident that solving technical problems of "interoperability" will not magically open the door to a flood of improved medical care.

To quote T.S. Eliot, my favorite author, who I notice is also quoted by the Software Engineering Institute's staff: T. S. Eliot noted, in Choruses from The Rock (1934):

They constantly try to escape
From the darkness outside and within
By dreaming of systems so perfect that no one will need to be good.
But the man that is shall shadow
The man that pretends to be.

After watching this field for 40 years, I am increasingly convinced that the core problems in the way of good medical care, and good health care, are spiritual problems, not technical problems. We have the technology, and have had it for 30 years. That is not the problem, and twiddling with it is not going to fix the problem.

We treat each other poorly, and that needs to be fixed. Then, the technology will matter. Until then, looking to technology for "solutions" will only rotate the problem and burn time and money and lives while Rome burns.

============================================

capstone slide 6

Note: To really appreciate what you can get on a "mobile-phone" now, take a look at Yahoo's new "Go" service and their video tour.


Changes:
* Tremendous reduction in size, increase in power.
* Much nicer packaging - now "wearable" and wireless
* Change from "do computations" to "support collaboration"
At the same time
* supercomputers went from 1 big box to an interconnected grid of thousands of small boxes - because it works better
* programs to solve very hard problems went from 1 huge program with very complex logic to thousands of collaborating rules or sub-programs - because it works better and, in fact, can learn to solve problems that the program author could not!
* Artificial intelligence went from a huge complex logic to thousands of small rules, for the same reason -- because it works better.
* It's not just a box, you're talking to the world on the web
* It's not just the web, it's "Web-2" -- you don't just read it, you can write it as well, like Wikipedia.
* This has changed tremendously in the last 5 years. Time to update your concept of what "computing" and "informatics" is about.
* The key is "technology mediated collaboration" not "databases" or "communication" or "computerized physician order entry systems" or "electronic health records" or even "personal health records."

These are no longer "shared data storage and retrieval" systems where the problem is indexing and maybe a little, annoying "decision-support" is included but typically shut off because it is annoying.

These are "collaborative decision-making systems" where ease of successful collaboration is the first and primary objective, and the "patient" is the one running the show and collaborating with his or her support network.

That network includes clinical caregivers as just one minor component. Mostly, this is about a person managing her life, not about a doctor managing patient visits and reimbursement coding.

* University of Michigan School of Information now offers the world's first graduate course in "Social Computing" this year.

The man proudly demonstrating his computer in the year 1952 in the picture above the left is Roger Schuette, my uncle. (see slide 2 for more info). Here's a December 2006 article that mentions him from the Rockford Register Star, Dec 14, 2006.



And here's the detail blown up to be readable.



..

capstone slide 7

McGreggor's Theory X and Theory Y reference will go [here].
Barbara Fredrickson's Positive Psychology reference will go [here].

Discussion of High-Reliability Organizations and the role of mindfulness (Karl Weick, Patient Safety and Peter Pronovost, Threat and Errror Management, etc.) goes [here] and all have links to the literature at the bottom of this post.

Discussion of Institute of Medicine's MICROSYSTEMS and references (below) goes [here]

Role of integrity, honesty, and virtue in all of the above: see my early post Virtue drives the bottom line with many links at the end to such literature. (excuse the formatting near the top of that post - it fights back.)

Discussion of authority structure versus open structure trade-offs in agility
and ability to react rapidly in a crisis goes here. Compare Oxford University's inability after 1,100 years to agree on a mail system to FedEx ability to turn on a dime. When is there "too much" collegiality? When does a "crisis" justify over-riding "personal liberty" in the interests of "national security" for "the duration of this crisis" and how has that played out all the last 20 times it was tried?

The Current US Army solution - Leadership Doctrine (Basically theory xYx', "ex-why-ex-primed"). Same as Karl Weick's fire-fighter solution. Theory Y during peacetime as establish valid command channels, with theory X (informed eyes open) during a crisis, (the exact opposite of FEMA during Katrina). See US Army Leadership Field Manual FM22-100
and What relates Public Health and the US Army?

Same problem that hospitals have - how to keep CONTROL OF THE MISSION, not have substantial loss-of-life during the learning period, and yet otherwise keep the structure open, flexible, agile, responsive to the environment, eyes-open, and a cybernetic "unit" - which is the "unity amid diversity", the "e pluribus unum", the "specialization and reintegration", the "silos and single system" and the core problem of "democracy" and "corporate governance and decision-making."

Key - whatever else happens, you can't violate:
* the laws of thermodynamics
* the laws of cybernetics and control system engineering

Which says this: if there is not a COMPLETE LOOP between the bottom and the top, that allows commands to flow downward and NEW, surprising, model-changing DATA to flow upwards, it will crash and burn.

Also, as shown in FEMA, in any organization it is ultimately fatal to use a "star" architecture and have all decisions made "at the top", especially in a crisis. The model that works, and worked in Katrina, was the Coast Guard, where decision-making had already been delegated downward to each ship's captain who had authority to take sensible action on their own in a crisis, particuarly if communications with "the top" were cut off. So, if the top is functioning, listen to the top ("x"), if it's not, listen to own judgement "Y", but judgment that has been formed by previously listening to the top that, in turn, had been actively and adequately listening to the troops at the front "x-prime", which gets me model xYx' .

In any true crisis, the top command will be completely preoccupied with a few huge questions and 100% unresponsive to "small problems" from the front, so, as in New Orleans, the guys at the front will be "on their own" anyway, cut off from communications with the top - or, more precisely, it doesn't matter if the phone lines are up, because no one there will be answering the phones - they're all off in a meeting deciding something of cosmic importance and can't be bothered to take your call.

So you better have an action-based method that doesn't depend on the "top" being useful at all during a crisis,which means you better practice that most of the time so you get good at it, which means that Microsystems need to get by on their own anyway.

Interestingly enough, the human body delegates as much as possible downwards. It's not actually possible to touch-type, as I am doing at this second, under brain "control", because it takes 100 milliseconds for the neural impulse to go round trip from the finger to the brain and back, and the inter-key interval is often down to 15 milliseconds.

So, with 100% certainty, we can predict that the "control" exercised must be a more general "feed forward" control, which I need to have a link to [here]. In any case the whole concept of "time" and "causality" becomes smeared out in a multi-pass feedback loop with phase-locking, which means that the directions "forwards" and "backwards" lose their typical meaning, and every loop becomes an M.C. Esher staircase or a Richard Hofsteader's "Strange loop" (Esher, Godel, and Bach) where "up" and "down" take you to the same place and non-transitive links are the norm, not the exception. (link needs to go [here]).

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References and further reading

High-Relability Organizations and asking for help

Secrets of High-Reliability Organizations (in depth, academic paper)

High-Reliability.org web site

Threat and Error Management - aviation and hospital safety

Failure is perhaps our most taboo subject (link to John Gall Systemantics)

Houston - we have another problem (on complexity and limits of one person's mind)

Institute of Medicine - Crossing the Quality Chasm and microsystems (small group teamwork)

Pathways to Peace - beautiful slides and reflections to music on the value of virtues

A User's Manual for the IOM's 'Quality Chasm' Report
Berwick
http://content.healthaffairs.org/cgi/reprint/21/3/80.pdf

Executive Summary for Health Care Leaders
Microsystems in Health Care
Robert Wood Johnson Foundation
Dartmouth

Microsystems in Health Care, part 2:
Creating a Rich Information Environment
Joint Commission Journal of Quality and Safety

IOM's "Executive summary

Entire IOM "Crossing the Quality Chasm" book (readable on-line)
http://www.nap.edu/catalog/10027.html#toc


University of Michigan School of Information "Alliance for Community Technology".
The mission of the Alliance for Community Technology (ACT) is to lead in advancing the use of computing and communication technology globally to serve people (to help people help themselves) through community serving organizations. It is committed to a human-centered focus on the creation, use, understanding, training and dissemination of appropriate technologies to support communities whether these communities are defined by geography, organizational structure or common interest (i.e. whether they are defined physically or conceptually).It will focus particularly on disadvantaged communities. ...

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A good place to start learning about PHR's is the joint site for AHIMA and HIMSS: myPHR

As that site notes "The American Health Information Management Association (AHIMA) demonstrated its advocacy for the empowerment of individuals to manage their healthcare by issuing a joint Position Statement for Consumers of Health Care on the Value of Personal Health Records with the American Medical Informatics Association (AMIA) in February 2007."

The US Department of Health and Human Services has a much longer formal report in pdf format on PHR's, Personal Health Records and Personal Health Record Systems.

Wikipedia, not an authoritative source but often with more current links than other sites and freely available, has an article on the Personal Health Record with, as of today, 95 links to other sources of information on them, with the most recent cited article being February 2007.
A Chinese version (very abbreviated) of that article is linked there (on the left margin), but there is no Spanish language version given.

An article with the UK viewpoint from the UK's National Health Service titled Personal Health Records and Sharing Patient Information is here, with many good references. Two in particular are these:

Winkleman W, Leonard K & Rossos P. Patient-Perceived Usefulness of Online Electronic Medical Records: Employing Grounded Theory in the Development of Information and Communication Technologies for Use by Patients Living with Chronic Illness. JAMIA Vol. 12, 205:306-314.

and

Winkelman W & Leonard K. Overcoming Structural Constraints to Patient Utilization of Electronic Medical Records: A Critical Review and Proposal for an Evaluation Framework. JAMIA. Vol 11, 2004:151-161.

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