You have been pre-rejected!

Welcome to the Hospital.  By the way, you have been pre-rejected, so don't even think about trying to make a permanent friend while here.   You're not THAT special.   Oh, have a nice day....

I'm simply articulating the implicit message sent to every patient by the hospital.   Kind of like "Thou shalt not eat popcorn during the sermon."

We may smile at you,  but don't think for a moment it's because we want to be friends.  You must not be from around here...  Hospitals are places where friendship is not expected, nor desired.

We do NOT want your letters,  phone calls, or invites to your backyard barbecue.   We do NOT want to exchange phone numbers.  We are not that kind of people.  

Well, actually, we ARE that kind of people,  JUST NOT WITH YOU!

Now,  how are we feeling today?  Better?

Should we simply close all hospitals?

Should we close all the hospitals?  Are hospitals good for the health of the country?  If we really want to look at "health care" in the country, and do some "zero-based budgeting" with our health care billions of dollars, we should ask this kind of question.    This is not entirely an exercise in cynicism or satire.  

From a population health point of view, it's not clear that hospitals help, everything considered.

What would things look like if we simply closed all the hospitals and then let that situation stabilize?



Hospital roles in epidemics and pandemics

For one thing,  hospitals are currently the largest single breeding ground for the new generations of massively drug-resistant germs.   No where else are so many sick and vulnerable people brought into such proximity with each other.

It's not just that patients become "infected" at hospitals.  Patients ALSO become the petri-dish in which hospital-based infections can expermient,  mix and match their DNA segments,  searching out for a yet more powerful way to kill people and spread.

In the Congo, during the Ebola epidemic,  the primary mechanism for spread of Ebola was the "health care system".   Ebola otherwise would incapacitate and kill a person near where they lived, and therefore be somewhat self-limiting.    But,  the patients were brought to hospitals, where it was much easier for them to infect the health care workers and other very sick patients.

But, some might say, in a serious epidemic, woudn't hospitals be a big help?  Actually, no.  in a serious wide-spread epidemic,  hospitals might effectively shut down themselves.   There is essentially ZERO "stretch" or "surge capacity" or slack built into the US Hospital system.  There are no EXTRA BEDS for people who have some serious contagious disease -- although maybe inflatable tents and gymnasiums or stadiums might be commandeered to hold dying patients,   if the 1918 "Spanish Flu" epidemic is a guide to what to expect the next time this happens, which it will.  

If you experience a 4-hour waiting time in the Emergency room NOW,   imagine (a) what it would be like if everyone with a wide-spread contagious disease went there TOO all at the same time, and (b) how much you, if you had anything else wrong with you besides that, would be willing to go sit amid all those sick  and contagious people waiting for YOUR examination and treatment.  

It's only a question of when, not whether.


Hospital roles in Intensive Care / End of Life care

So there is at least one reason to consider closing hospitals. Also, they are quite expensive to operate, so there's a second reason.

Hospitals, being "systems",  as John Gall pointed out,  will of course be very good at coming up with all sorts of narratives and justifications for why they should continue to exist.  By itself, that proves nothing.

Let's suppose that,  if we didn't have hospitals, most very sick patients would simply die and we'd remove  the last 3 weeks of the patients lives,  and associated transfer of wealth from the patient's estate to the hospital,  device manufacturers, drug-manufacturers, etc.     Something like 40%, almost half of all health care expenses are incurred in the last few weeks of patient's lives -- and often, the patient is not really even conscious during this time period.

In terms of cost-reduction of total health care bill for the country,   frankly, that looks like one candidate.   It turns out many patients themselves are not really interested in living their last 3 weeks attached to machines and drugged up with tubes down every orifice in their body -- they'd rather simply die and get it over with when it's that time in their lives.

Hospitals, in other words, are being paid a huge amount of money, total, and from families life-time earnings, in order to sustain the myth for a few more weeks that the patient is not actually going to die. We are paying for delusion.   And we are paying a LOT for it.  

In most senses, terminal patients have already died as interacting human beings and members of society, and it's all over except the admitting it and the falling down part.

I realize there is a vast stereotyping regarding "death panels" and other wild imaginings. I'm not suggesting some panel of "experts" decide they will not treat a sick patient, in the interests of saving money.   I'm suggesting the patients themselves, in many cases,   would actually prefer not to be treated like some kind of side-of-beef for their last experience on Earth.  They would rather be remembered in a different way by their children and friends.


Chronic Disease care over the lifetime

Hospitals are set up for very short burst events of "acute care", not for long-term, daily care processes that go on your entire life.   If our need is to counsel people who are diabetics, or overweight, or under stress,   we don't need "hospitals" in order to meet that need.   Hospitals would be, pardon the phrasing, "overkill".     They'd be like using a bulldozer to plant a rose bush.


Mid-range problems and the Lawn-Mower Repair model

OK, overstating the case somewhat but with more than zero truth in it,  hospitals don't do much for intense end-of-life care, because you're going to die anyway;  they don't do much for chronic care, because they have way too much overhead to be cost-effective means of interacting with people regarding their lives at home and work.

There is a much deeper and more profound problem, however, with the entire hospital model, which I will call the "lawn-mower repair model" of care.

The whole idea of hospital care is based, effectively, on the model of Western Science that was rampant and dominant during the last century.   

Science was, and mostly still is,  the activity of studying things that are easy to study because you can isolate them from their home environment and bring them into the lab and they still behave the same way they did at home.

Anything that was effectively inert, such as a lawn-mower,  could be repaired as easily in a lawn-mower repair shop as it could be at home, in its natural lawn environment. 

The hospital model is based on the assumption that people are, in that sense, lawn-mowers -- that a person,  pulled out of their home and work life,   stripped (literally) of their clothes,  put in a sterile room that emphasizes their vulnerability and dependency,   removed from friends and family,  is, in fact, the "entity" that is broken and needs to be fixed.

In this environment, a doctor can look at such a context-stripped patient-mower,   and with a straight face,  give what is called a medication order, saying  "You need to take this drug 3 times a day for 8 weeks, and you need to cut down the carbs, and get more rest - at least 8 hours a day."

The doctor does not need to think about whether the patient can afford that drug, or whether the patient has a refrigerator or a home for that matter,  or whether the patient's family or room-mates will steal the drugs,  or whether the patient has a job that lets them carry their noon dose with them at work, or whether the patient has it "together" and is sufficiently organized to do ANYTHING 3 times a day at given times,  let alone take a drug that has some annoying side-effects.

The doctor does not need to think about the fact that the patient has only 3 friends left in the world, and the only time he sees them is when they go out drinking and eating pizza, and if the patient were to turn down the beer or pizza, they would, due to our sub-culture training, be seen as rejecting their friends and therefore be rejected and lose their only remaining friends in the world. 

The doctor does not need to deal with the fact that the patient is under huge stress at the workplace, which has been "cutting staff like crazy lately" and has been told effectively or literally "If you don't come in Sunday, don't bother coming in Monday."   This is not the doctor's concern.

All of these considerations are stripped away, in moving the patient-mower object into the hospital-laboratory setting to be examined, tuned, and "fixed." 

The patient, given their marching orders, will probably nod and mumble "Uh, .... OK" or something and walk out.    When they get to the drug store and find out what the drug costs, they may realize they cannot afford $200 for some pill that might or might not help.   They also quickly realize they coudn't take it, realistically, 3 times a day if they tried.   Nor could they cut out carbs.  Nor could they get good sleep.  Heck -- if they could get sleep and good food, they wouldn't have gotten sick in the first place, they don't need some doctor to tell them that.

The point is this:   the THINGY that's broken is the patient's LIFE -- the part that the hospital system insists they check at the door when they arrive, and the part that the doctor is too busy and too important to go see.     The patient's BODY is only a downstream symptom of their LIFE.

So, what needs to be FIXED is their LIFE, not their BODY.   If you could fix their life,  the body would take care of itself and heal.     There's little or no value in doing a one-time "fix" of the body, if the underlying causes of the problems aren't also fixed.   The patient will just "be back" in 6 weeks. The doctor will be angry at this "bad patient" because they are "non-compliant" and REFUSE TO FOLLOW MEDICAL ADVICE.    The doctor throws up his hands in disgust.  What can he do? It's yet another "bad patient".

So, in the lawn-mower analogy, maybe the mower could be "fixed" but shouldn't someone look at why it was used to mix gravel in the first place?

The hospital is part of a much larger Myth-Maintenance system that tells us what is broken is the person, not the society.    In reality, the 'repairs" done by the hospital to the lawn-mower-body are going to be short-lived, if successful at all.   Probably, in fact, even if the patient were to follow the advice, it would only ROTATE the problem,  like "whack-a-mole",  so that yes, now they no longer had THAT set of problems ... but, um, ... now they have a whole NEW set of problems somewhere else, because the true CAUSE of their problems, their broken life,  has not been addressed.

In fact, we have a name for recommending a strategy that clearly fails to fix a root problem, and at the same time masks or prevents addressing the root problem -- it is called "Quack medicine".


The basic fact is that hospitals are designed for the lawn-mower repair model.  They are designed to detect and repair relatively simple problems that exist INSIDE the patient's body, and that come in the door with the patient, and that can be fixed INSIDE the body in a visit or two.  For these things, all the "tests" and "vital signs monitors" and "charts" can be very helpful, as well as the high-technology drugs and equipment to "see inside" a body-lawn-mower.

Hospitals, however, are just terrible at the person-with-broken-life situation. The things that are broken are OUTSIDE the patient's body, and in fact, are OUTSIDE the hospital walls.   You can let the vital signs monitor run all day and you will not see them go by.  You stripped them out with the patient's clothes, because they don't FIT the lawn-mower-repair model of care.

 It is not surprising, given the mismatch between what is wrong and what it is hospitals do that people in general are getting sicker and, at the same time,  now spending more money on "alternative medicine" than on hospital care, because, frankly they are voting with their feet and this hospital lawn-mower-repair model isn't doing much to help their actual needs.




On detecting failure


We as human beings hate "failure".    We avoid it and deny it.  It's very uncomfortable. 
Systems hate failure as well, and also do what they can to emphasize the bright side of things while covering up or deleting entirely any mention of the darker side of things.

Humans also have a fascinating tendency, when something doesn't work that "should",  to just keep on trying it with increasing intensity. 



We can detect something that looks awfully much like a totally broken health care system, but more to the point it's not just the "working-out-the-details" or "paying for it" part of the health care system that's broken -- it's the whole underlying premise that humans are lawn mowers so a chain of mower-repair shops ("hospitals") SHOULD do the job.




I just love John Gall's insightful work "Systemantics .. how things fail".   Here's what John has to say about system failure.( page 69-70,  in  the text.)

IN COMPLEX SYSTEMS, MALFUNCTION AND EVEN TOTAL NON-FUNCTION MAY NOT BE DETECTABLE FOR LONG PERIODS, IF EVER. 

When first propounded this Theorem elicits surprise. However, illustrative examples abound, especially from the field of History.  for example, it would seem reasonable to suppose that absolute monarchies, oriental despotisms, and other governments in which all power is concentrated in the will of one person would require- as a minimum for the adequate functioning of those governments -- that the will of the despot be intact.   Nevertheless, the list of absolute monarchs who were hopelessly incompetent, even insane, is surprisingly long. They ruled with utter caprice,  not to say whimsically, for decades on end and the net result to their countries was -- undetectably different from the rule of the wisest kings.

 
LARGE COMPLEX SYSTEMS ARE BEYOND HUMAN CAPACITY TO EVALUATE.
 The problem of evaluating "success" or "failure" as applied to large systems is compounded by the difficulty of finding the proper criteria for such evaluation. What is the system really supposed to be "doing"?

 Another example from history might the the huge activity called the Vietnamese War, which "succeeded" (to hear the government's opinion) for years until it finally "ended" and we came home.  To many people, the "success" was indistinguishable from "failure".


In any case, let's return to the questions of what exactly it is that we thought Hospitals would be accomplishing for us, that we bought so many of them (as a society), and ponder whether they are, in fact,  delivering what we paid for, or if we have, as a people, been sold a bill of goods.

Sadly, this gets into the success or failure of an even larger system, Capitalism,  the work ethic,  a college degree as the ticket to success,  the entire nation, Western Science, and the economy.      Are we better off due to Western Science?  Did it "work" to alleviate suffering and pain and give us all a "better life?"

We seem to be surrounded by things that some people are championing as wildly successful, while many other people, to put it mildly, aren't experiencing that success quite so vividly in their own lives.

OK.   Let's review some thoughts.  First, if we eliminated all hospitals,  the same number of people would die as die now -- we get exactly one death per person per lifetime.  That's a given.

Second,  if we eliminated the illusion that people could lead terrible lifestyles and then go to the doctor to pop a pill or get surgery so they could go on with their terrible lifestyles,  MAYBE people might take responsibility for their own lives and clean up their acts.   MAYBE having hospitals perpetuates the myth that we don't need to take care of ourselves, because someone else will clean up our mess for us.

We would probably be no worse off in any major disaster scenario, because hospitals have zero "stretch capacity" for huge numbers of injured patients, and essentially zero room as well for dealing with highly-contagious patients in an epidemic.

The point of this thought exercise is not to conclude and assert that we should shut down the hospitals.  It's to make a case that hospitals are not doing for us what we may think they are doing.  We need to have an intelligent debate about how to deal with the health, over the lifetime, of people who do not fit the "lawn-mower"  category,  who have problems that are more structural, in the sense that their lives are broken, which is messing up their bodies, so we should be focusing more attention on fixing their lives, not on fixing the bodies

Computerized Physician Order Entry and human behavior

Successfully installing a Computerized Physician Order-Entry (CPOE) system at some hospitals could make things worse.   There are human factors that the designer probably never considered.

I want to focus on one example -- the working relationships between doctors and nurses.   In some places relationships are harmonious, but in other hospitals there may be substantial tension between doctors and nurses over a variety of issues.  Almost certainly, both sides feel that they are not listened to.

Although what nurses do helps doctors treat patients,   a request for such an action is seldom preceded by  a doctor saying "Jeanne, could you help me here?" or "Nurse Franklin, could you help me here ... "  nor is it followed with a "Thank you .. that helped!"  The fact that the nurse's job includes helping is taken as a given, which often makes the nurses feel like furniture or something.   To facilitate operations, the doctor's orders for a drug for a patient may simply be handed over without a word, or with some brief non-cordial comment such as "room 217", or dropped in a hopper on the nurses station front desk.  At least the doctor is vaguely aware of and reminded that nurses are human beings and are located over there and help dispense medications. The doctor has an opportunity to stop and chat and ask about the kids or not, possibly to joke or flirt,  but at least to have human to human contact.

That is, until the CPOE arrives.  With a CPOE, the doctor will not give medication orders to a human being, or even an in-basket near a human being's desk -- he will "enter them" into a computer. As far as the ape with the upright spear part of the human doctor is concerned,  he is asking the computer to assist him. The computer is cold,  all-business, and not interested in human chatter about how his day is going.

And, as far as the doctor can tell,   some robot is dispensing the medication. It's all further out of sight. The doctor sees nurses less frequently, and when he does see them, it will more frequently be because something went wrong.

The nurses, on their side,  will see less of the doctor than ever before.   He won't come around where they can grab him and get his attention on some issue or question,   because he won't need to -- he can do all his ordering by remote control from his office or some other place.

There will be far fewer occasions to reaffirm the common humanity of nurses and doctors.  There will be fewer occasions to flirt or chat or sympathize or ask how his day is going and be prepared to help him cope.

What there will be instead is a line on a computer screen that lists medication information for a patient.  As far as the human animal is concerned, the computer is the one asking for the medication to be given.

There is, in other words, a new level of screening, shielding, and separation put between doctors and nurses,  making it harder to overcome the barriers with spontaneous chatter at unexpected times.

Now, you have to recall that one reason people become nurses is because they have a strong desire or need to "be appreciated" and to "make a difference".     In general, nurses are "people people" who enjoy interacting with other human beings.   In general, they take a great deal of pain trying to cope with a system that forces them to make hard trade-offs all day, while their feet and back are killing them.   In general, they feel unappreciated,  but look forward to the occasional shining moment when a patient or doctor is overflowingly thankful and appreciative for their hard work.

What they will get more of is only seeing doctors when it's bad news time. They will feel treated as if they are some kind of medication-delivery-robot, which gets "messages" about "events".   There will be no "human touch" involved.   There will be even less appreciation than there was before.

This is no small thing.   This is going to interfere with performance,  lead to more depression, and lead to higher turnover.   If the job is designed for a robot,  more-senior patient-centric human beings will tend to leave it to go find some other job, and new-hire robot-like humans who don't care about human reinforcement will move into the job.  Overall, in a thousand small ways, patient care will suffer.

What is so dangerous about this kind of thing is that it is almost silent.   It is very hard to trace or track down.  In one recent case study,   the effect on lab technicians of installation of a "computerized lab-order system" was to entirely remove their human connection to the people on the floor, which removed their sense of meaning and belonging and mattering,   which led to people quitting their jobs.

If we stand back and look at what's going on here,   on the one hand the system designers are effectively saying "we want this to run more like a well-oiled machine" and the people in the already dehumanizing system are saying "I've had about enough of being treated like a machine instead of a person."

A sense of belonging to a care team, and jointly healing patients is important for retention and for caring how well someone does their job, and determines whether they will "go the extra mile" or not a hundred times each day.  Nurses,  IT staff members, and other "lower level staff" already typically feel they are forgotten, kept in the dark, isolated, and carrying out thankless tasks.  Regardless what problems a CPOE might fix,  it is almost certain to have a negative impact on this sense of camaraderie and team.

And that's important for someone to deal with and think about.

How to improve System performance

If we think of SYSTEMS a living entities,  we get better answers to "How do we improve system performance?"

First,  as humans we tend to think first about the human beings within a system, and tend to ignore the system as a living entity.  This is a mistake.

In fact, for a while, for the insight it provides, we should deal with the growing sludge of unexamined problems at the OTHER end of the spectrum.   We should ignore the humans, and think first and for that matter only about the SYSTEM and its needs, desires,  and behaviors.

In particular,  regardless of country, shape, composition, animal, vegetable, mineral, language or anything else,  all living things, and all things that behave as if they were alive,   MUST CARRY OUT THE BASIC CYBERNETIC LOOP.     This is as true of alien civilizations, martians, or any thing else.

This means any living (or meta-living) thing has to
      * Have some sense it has made of the world around it,  internalized
      * Have some sensors to get new information about the world around it
      *  Have some sensors to get information about its own conditions and depleted resource needs
      *  Have a process to take action,  based in some intelligent way on matching its own possible behaviors to the immediate external environment with an eye to acquiring the needed resources.

If the thing is going to "make it" for any period of time, it will need as well
    * a "learning curve" -- a method for determining which efforts "worked" and which efforts "failed"
   *  A way to feed that news back so as to change internal stuff so that more energy and time is put into successful efforts than the unsuccessful ones

That's pretty much it.    Any living thing MUST carry out those activities.  There are no exceptions.  Anything that does NOT carry those out is not actually "alive".     Anything that DOES carry those out MIGHT AS WELL BE CONSIDERED ALIVE,  for purposes of planning interventions.   (Regardless of your own scientific or religious constraints about what constitutes "life")

This,  we are looking within life for how this Basic Cybernetic Adaptive loop has been implemented, and, in general, if there is a disruption of this loop, there will be worse outcomes.   Or, conversely, if outcomes are not as good as expected,   it would make good sense to look first to this loop and see if some part of it has broken down.

A corporation or government that stopped listening to staff or customers or stakeholders would be an example of a breakdown of this loop. That kind of thing tends to be fatal, in the long run. The thing that was formerly "alive" becomes "dead", sometimes in exciting ways.

So,  then, looking at the converse side -- if a hospital, or military unit,  or banking system, or economy, or entire religious culture, or an entire country BREAKS the core cybernetic loop,  it has essentially become dead, aside from the dieseling on and the falling over and decomposing part.

No "wrath of God" is required.  This is just basic control system engineering.

And,  if a hospital or banking system or government is not functioning well,  the FIRST Thing to look at is the basic cybernetic loop, and see what part is mis-firing.

It is, then, not only a kind of structural "health" we should be focusing on, it is the irreducible universal principles of LIFE.   If a system is not performing well and is at risk of dying,  it is because this core level of LIFE is not functioning well.   What we need to do,  at the heart of it,  is ADD MORE LIFE.

This suggestion triggers intense emotional and religious response, fires multiple hot-buttons and triggers third-rail reactions.  Still, I don't see how to avoid it.

We are, as humans,  in the context of organizations,   capable of building  NEW LIFE.   We do it every day. We do it all around us.  We see all around us an environment actually dominated by the new life forms (corporations, governments, religions) that we were involved in setting into motion, but which then took advantage of some property of the universe that allowed them to "TAKE ON A LIFE OF THEIR OWN".

We do this creating children all the time. Why this is a big deal is surprising.

Still I think this is, this must be,  the single most important first sub-system of any living or almost living thing that needs to be looked at when you are tuning up the engine for better performance.

Ask yourself -- how is the universal cybernetic loop embodied in this organization?   Identify the parts.  Identify the loops and sub-loops.   Identify the flow.   Identify the places where the flow is blocked.   Unblock those parts or add new parts to bypass the blockages.

Voila. How can it NOT work?

But remember -- ignore the people.  To a good first approximation, the people in a large system are pretty much irrelevant.  The structure and functioning of the system has moved beyond the point where any particular person matters that much, in the BIG PICTURE.   The system no longer depends on people, any more than your brain depends on a particular neuron to accomplish something -- your brain will have multiple ways to acccomplish anything and everything.

Formal "organizational structure" and "reporting lines" are probably mostly a myth,and at best advisory.  Once a system becomes alive,   those functions become holographic,  and no longer take place along the lines they once did.      Human distinctions, such as between "management" and "labor" evaporate or dissolve.

What you can be sure of is that this meta-being, the composite entity, having recently been born,  is struggling with the problem of recreating "one-ness" on a whole larger scale.     The parts are not yet all fully integrated and holographically synchronized and reflecting each other -- that's bad, and the system, to survive, needs to address that issue and get on with the urgent task of consolidation and reintegration at a whole new level of being alive.

It is not only possible, it is likely, that "management" in any such organization will transition from being "the solution" to being "the problem."   Once the organization has developed a sense of itself, it WANTS to have holographic control of everything, and total self awareness -- which is exactly what management wants to prevent so that management can keep "control" in its own hands.

We are surrounded by systems we "created" but which we need to get clear are now running out of our control, busy recreating themselves at a whole new level of existence.   Meta-life.

The picture is not the pixels.  The picture has risen above the pixels,  taken charge of the electronic circuitry, and is busy altering the pixels to keep itself alive as an image.  We are past the point where the picture can be changed by "changing the pixels." -- they'll just be changed back again,  and we will just pull back a bloody stump for thanks for our efforts.

What is the biggest threat to humans is all of these half-formed,  nascent living meta-beings that are not yet in touch with themselves,   which are careening about like drunks desperate for their next drink.   The tighter "management" or "government officials" try to take "control" of this living system, the more the system will thrash violently trying to shake them off and be free at least to be itself, without mere humans trying to "run things".

In the US we're way past the point where "government" is either "of the people" or "by the people" , not even rich people.   Those days are gone.   We're into de-facto government by "the corporations" for "the corporations".

It's crazy to fight that trend.   All life on earth has this tendency that appears unstoppable to grow in complexity and scale, and transition from single-celled operation to multi-celled operation to massively parallel synthetic life at the next higher level of complexity and scale.

We, as humans, are stuck in the middle of all of this.  Our ego's like to think it's maybe Obama versus Putin, but each of those "players" is so deeply enmeshed in "a system" that they are no longer free agents or acting like solo human beings.  They have been entrained by, effectively, the BORG (to use Star Trek's favorite enemy image.)

Except there is no reason this has to be a bad thing.  Everyone actually tends to like and prefer to be "part of something larger and nobler" than mere solo humans.  It's built in. If we try to decouple ourselves from it and become solo operators, we tend to die.   Period.  The best predictor of bad medical outcomes is realizing a person has become disconnected from society.  It gets under the skin very quickly.  Our bodies NEED to be PART of something that is alive that is LARGER THAN LIFE, larger than us, anyway.

The sticking point is, Dr. Frankenstein and mommies aside,  we haven't conceptualized our task here as "creation of new life on a higher level".    Many people would feel even raising that concept is some type of religious heresy or offense to God.

My own view on that is expressed pretty well by the poet T.S. Eliot. in "Choruses from 'The Rock'"

"The LORD who created must wish us to create
And employ our creation again in His service
Which is already His service in creating."

This is a message of hope, of recursive creation and recreation, which is, in the end, what we're after for our economy and our society, isn't it?

This is a "natural" or "God directed" process, it doesn't matter which you prefer, because the results are identical.

Eliot says

The soul of Man must quicken to creation.
Out of the formless stone, when the artist united himself with stone,
Spring always new forms of life...

These are profound and fundamental issues -- issues on which commerce, religion,  and science can and should all seek common ground.    These are issues that, if we all look through the lens of our own background and ponder, we can realize we can agree upon as being important core values.

If commerce and management are reconceptualized to become an effort to create (or allow God to create through our lives) a new and higher more beautiful construct of Life, a coherent composite BODY of which we're parts --  it will alter in very substantial ways the entire torque of what goes on in commerce, and alter the results.

These are some pretty strong leaps of perception here, but I think it is a basis for a serious and sober analysis of what has gone wrong to date, what has gone right, and why, and what we might do to get more of the good stuff and less of the bad stuff to come out of that pipeline.

This framework shifts the dialog from whether this person or that person is right or wrong, or slept with his ferret, or whatever slime passes for discourse these days.  (I've turned it off and tuned it out.)

We are God's creation, and our task is to keep on recreating ourselves and our corporations and our culture. Or, for atheists,  our task is to keep on recreating ourselves and our corporations and our culture. Either way, we come out in the same place, with the same action conclusions.

I guess if your religion denies that evolution can or does occur, and believes all that is around us is fixed forever,  these ideas may be threatening.  I personally just see life as FIXED (ie, constant, invariant) on a whole different level.  LIFE, to me,  has the fixed property that it is constantly evolving (or being evolved, or being directed) into ever more beautiful and large scale and more complex life forms.

Again, I guess if your religion or science tells you that man is the highest creation in the universe, and always will be, these ideas are alien.    If you believe in God,  you already believe man is not as "high" as life can go.
The more we can get commerce,  multiple religions, and multiple sciences to all agree on something, like a core direction of the vector of LIFE,    the more we can put aside our differences and gasp in awe and wonder of the engine we find ourselves inside,  part of.

And the more we can use the common architectural guidelines and design principles, like the core cybernetic loop, as an invariant and reliable foundation on which to base all the rest of our human endeavors, to increase their odds of success, and to decrease the odds that what the people over THERE are building will ultimately be in conflict with what the people over HERE are building.

We're all in this together, dudes.

There is one constant of Creation -- and it is .... creation.
Not creation once, in a frozen sculpture for all time, but continuously recursive re-creation of life.
Life is that which recreates itself, and so on.  We should celebrate it. We should understand it.
We should think deeply about where that "goes", over time.
We should discuss with each other what that "says" about our place in it all.

• Our religions all tell us to focus on "higher life", in so many words.  Some are far more explicit, talking about us being "members" in the "Body of Christ" or similar terms.
• Our science is obsessed with creating life from scratch, but can't figure out how.
• Our businessmen and women are busy creating higher life, but haven't realized that's what they're doing while they think they're doing something else.

God, we desperately NEED something all of these factions can agree on, to stabilize the discourse before we get back to large scale trying to kill each other off the face of the planet.  With our new technologies, this time, this next war,  where we have failed before, we have a very good chance at success -- if you call success the elimination of the entire human race.

A massive interdisciplinary effort to pool all our notes and everything we know about "higher life" and "composite life" and "emergent life",  and figure out what that tells us about ways to make our economies "come back to life" and our businesses "come back to life" will help our own personal careers "come back to life."  

We don't have a large pool of concepts we can all come together around.  This seems to be the only one I've seen so far, in fact.  Maybe we should use it as a tool to defuse hostilities.

There are so many ways hostilities could explode and employ technology in unprecendented waves of killing.There are so few ways we can recover common ground and draw attention away from our differences, and put them into perspectives.

We have the SAME GOALS.  We are made of the SAME DNA.    We differ on how to get there, but, in the BIG PICTURE,   that is not really very important.

What is important, socially, is to SHARE a BIG PICTURE about something, ANYTHING.
Without that common ground to fall back on,  we will be perpetually vulnerable to demagogues trying to blow small differences all out of proportion.    It is really crucial to all conflict resolution on all levels that we get a common, explicit, shared framework of BIG things we agree on,   as the context in which all discussion of our remaining differences can take place.    They will all turn out to be small details, that, in the larger mission and picture, we will be finally able to let go of or be flexible on,  if in so doing we can go for the final goal.






T.S. Eliot, in the Four Quartets , said

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

On how to fix hospitals

John Gall, my favorite author on systems antics,  nailed it when he observed:

  "A large system produced by expanding the dimensions of a smaller system does not behave like the smaller system."  *

This profound truth has implications all around us every day,  as we violate it time and again and smash our heads into the same pipe,  while instantly denying that a pipe should be "there" or even could be "there" so maybe it was just a bad imagination and we should forget it immediately.   No learning takes place during the debrief.   We will make exactly the same mistake again tomorrow.

(Aside- This self-sustaining, "error" correcting mechanism of a myth is fully predictable if we take it as a living entity or system simply doing what it needs to in order to survive,   happily doing mental housekeeping and removing the "not me" so that the "me" remains unblemished.)

Gall continues (page 23) with a description of "Climax Design"

that is, in the construction of the largest and most complex examples of man-made Systems, whether buildings, ships and planes, or organizations.  The ultimate model  (the largest, fastest, tallest, etc. ) often ,  if not invariably,  exhibits behavior so unexpected as to verge on the uncanny.  The behavior is often an unsuspected way of failing...

He gives as examples:

The largest building, the Space Vehicle Preparation Shed at Cape Kennedy, which is so large that it creates its own weather and rains on the ships it was built to protect.

The largest [then] telescope, a 230-inch reflector, which takes so long to reach thermal equilibrium at night that the night is over before it can focus on a star image.

More recent examples would be:

The worlds largest airliners  (Airbus A380 and Boeing 787)  with huge engines that tend to burn and explode when used.

US Electronic Intelligence apparatus,  so large that so much energy is spent collecting "intel" that there is no staff or budget left to actually analyze it.   Despite that,  new budget goes to collecting even more intel from the web,   while focusing management's attention on meeting meetings -- ie,  meetings about why there are so many meetings,  and hiring new staff whose job it is, not to process intel, but to analyze why other people are not processing intel.

On finding a "shipbuilder" any more

One of the problems with Climax Systems not doing what their name says they should be doing, is that the parts, also, are no longer doing what the parts say they are doing, or what they are named, or even what they think they are doing.   Everything is caught up, as it always will be,  in a system delusion, which acts as a living being and reinforces and enforces its own dominance.  ( In that sense Frankenstein and Young Frankenstein should move over, because, in creating Climax Systems we have already succeeded in creating new life, we just have yet to spring to the fact that that's what we just did.)

One aspect of the system delusion is what Gall refers to as Manager's Mirage -- "The System takes credit for any favorable outcome".    Along with this I'd add the CEO's mirage -- the CEO of an organization will always take credit for anything that goes right (and demand extraordinary pay for this "accomplishment") while denying any responsibility for anything that goes wrong (and not accepting any cut in pay for this anti-accomplishment.)   The primary skill of a "manager" or "executive" such systems produce, then, of course,  is taking credit and spreading blame.    As with the "Royal we",  the CEO of a huge company will show up on the cover of Fortune or Forbes, speaking in the first person of  "How I tamed the oil feeds", etc. fully convincing and even convinced that what he did was the cause of the observed outcome.

Another aspect of system delusion is what Gall calls "Orwell's Inversion" -- the confusion of Input and Output.  (page 55)

"A giant program to Conquer Cancer is begun. At the end of five years, cancer has not been conquered, but one thousand research papers have been published. In addition, one million copies of a pamphlet entitled "You and the War Against Cancer" have been distributed.  These publications will absolutely be regarded as Output rather than Input.   The cancerous multiplication of paperwork will not be regarded as a malignancy."

Let us return now to our original thrust,  the startling and important realization and insight that nothing in a system is doing what the name would imply it should be doing.

This gets (Chapter 7) to what Gall refers to as The Grand Illusion.  His example is excellent.

Three is a man in our neighborhood who is building a boat in his back yard.  He knows very little of boat-building and still less of sailing or navigation. He works from plans drawn up by himself. Nevertheless, he is demonstrably building a boat and can be called, in some real sense, a boat-builder.

Now, if you go down to Hampton Roads or any other great shipyard and look around for a ship-builder, you will be disappointed. You will find in abundance welders, carpenters, foremen, engineers, and many other specialists, but no ship-builders.  True, the company executives may call themselves ship-builders, but if you observe their work, you will see that it really consists of writing contracts,  planning budgets, and other administrative activities.  Clearly, they are not in any concrete sense building ships.

In cold fact, a SYSTEM is building ships, and the SYSTEM is the shipbuilder.

In my words, we have, in fact,  created a synthetic life form, a "system",  which behaves AS IF IT WERE ALIVE, and carries out observations,  actions,  planning, responses,  consuming energy, growing, having diseases and infirmities, possibly dying, etc.  The system is what I call MAWBA -- "Might as well be alive" -- for legacy religious and psychological reasons,  even though we are willing to grant the moniker of "life" to a lowly virus,  we are strangely unwilling to accept even the mental model that the system has become "living".

Application of all this to Hospitals and Health Care

Now, I want to bring this frame of mind around to bear on the question of what the nature of a large hospital and even larger "health care SYSTEM" might be,  and how an "Electronic Health Record" might play out in such a beast.  Similar issues arise in the nature of a "Military intelligence system", of course, and any other suitable large system,  such as "government intelligence" -- which we already have the social wisdom of tagging as an oxymoron. We know, on a very deep level and by experience, that "government" and "intelligence" don't really go together.

What Gall is trying to say, and so am I, is that the REASON they do not go together is precisely this discrepancy between what a system is / does and the size or scale of the system. Similarly, if we wish to address or intervene or "fix" such a system's output,  we had best start by fully grasping the subtle and surprising nature of the malfunction.

First,  the realization that "the system" does things, not the persons in the system, is one of those concepts that is in the very awkward position of being PARTLY CHEWED and less digested at this time in our society.

If you go to any large teaching hospital you will find that they are "in the process of implementing" a patient safety "system",  based around the poorly grasped concept that "the system does things, not people" and, when bad things happen "it is usually the systems fault, not a bad person's fault".   

These are truly profound insights, which, sadly, are mostly only partially grasped, if that, by everyone involved in implementing them.   I myself, for the first 5 years of exposure to such words coming "from above", thought that this was really some new clever scheme to avoid having the finger of blame ever come around to point at bad people,  surely doctors or managers,   who when confronted with something they had done wrong would pull out their "Dont blame me -- the SYSTEM did it!" card and cloak of protection, and thereby be spared being held to account.   Having slotted this activity into a cynical slot in my mind, I gave no further thought to the possibility that I might have totally misunderstood what was going on.

Still, here's a snippet of news from a researcher at Johns Hopkins, who has done extensive study of commerical airline accidents, and has probably spent more time in aircraft cockpits than any non-pilot person, Bryan Sexton.  

According to his data,  74% of commercial airline accidents occur on the very first day that a set of professionals who had never worked before as a team was assigned to work together as the cockpit crew. 

These are all seasoned professionals. Any one of them, alone, could "pass a test" with flying colors, so to speak, and DID in fact recently do just that.

What has just come into being, however, is "the team".   The "team" is a kind of SYSTEM,  subject to all the rules SYSTEMS follow.   The team, on its very first day of existence,  is still a type of infant, not yet mature, and certainly not very good at flying airplanes.  So, it should come as no surprise that it often does a very bad job of flying the airplane,and crashes it instead.

This is a fact.  This is observed, over and over.   Yet,  we, the upright ape with the spear as Gall would have us,  are unwilling to accept the fact that a synthetic life form, a "team" is flying the plane, not the attractive pilot in the left hand seat.   We are still, in the prior metaphor, looking for "ship-builders".  We are still looking for "pilots" and when something goes wrong, we are looking for "the person" to "blame" or to "fix".

But, pilots do not fly planes any more than ship-builders build ships any more than doctors provide "health care".   SYSTEMS have been created to do these tasks, SYSTEMS do them  albeit generally poorly, and if we wish to intervene, we had best get that straight in our heads from the start.

Hospital as very large doctor

OK,   we know from Gall's work and our own observations that

  "A large system produced by expanding the dimensions of a smaller system does not behave like the smaller system."  *
  
Now we simply need to take that frame of mind, and,  within it,  reflect a few moments on what we are trying to do with hospitals, and why it is failing,  and what would make it work better.

Without getting tangled in the nuances and politics of doctors versus nurses versus "care-givers" versus "providers" -- let's just call the person who, if there was just one of them doing this, a "doctor".

What we, as patients are looking for is precisely "a doctor" -- a person who is kind, caring, loving and at the same time very wise and experienced and competent.   Preferably, this person is our life-partner or someone equally attuned to our nuances and willing to devote 110% of their attention, for as long as it takes, (bathroom breaks excluded),   purely onto us and our needs and researching all that is known about our kind of situation and doing it and monitoring it like a hawk and tweaking and adjusting it, etc.  If there was just one of these person, again, I will use the term "doctor" -- although as I'll get to in a second, of course, there is no such entity so let's not fight over words or an implicit putting down of nurses.

With me so far?  On a single-human basis, we can grasp and point to and nod our heads yes, that, if given the choice and it were free of cost, we would all want such a "doctor" person caring for us when we were not well.

Now comes the "system" part.

For many reasons,  society proceeded to increase the desired size, scale, specialization,  whatever of this "doctor" being,   and, frankly, ran out of the limits of what any one person could do alone.  So, we went to larger and larger and larger SYSTEMS,    each of which was supposed to replicate the concept of "doctor" except on ever larger scales -- just like the "ship-builder" company instead of ship-builder person.

(Or, in the military, we subdivided the concept "Warrior" into a zillion pieces and sub-roles,  and then put them all in the same place and told them "now act as one single coherent system doing what a warrior does except BIGGER" .. .and have been, because we failed to study systems behavior,  surprised at the lack of success of this task.)

We took the idea "carter" or cart-builder, expanded it to the scale of General Motors, and then were surprised that the meta-being couldn't even seem to grasp the concept that, if gas cost more, people would drive less, and if gas cost a lot more,  people would buy way less expensive cars.   This was a SYSTEMS ERROR we made,   not a failing of the CEO or various vice-presidents of GM, who all called each other "auto builders" or some equivalent to ship-buliders, despite, as with ships, the fact that they actually if observed pushed paper and went to meetings, and probably didn't even drive their own cars any more.

OK,  so, this meta-being the META-DOCTOR SYSTEM,   doesn't work very well.  This is not news for composite system beings -- none of them EVER work very well.    In the occasions on which patients "get better" the system proudly takes credit;  on the occasions on which the patients get worse or die, the system of course blames some external agency or "bad person" or even the "bad patient"  for this outcome.   Again, this is predictable behavior of all SYSTEMS.

Now, however, let's go back to pondering how well we, our society, has done at REPLICATING, on a GRAND SCALE,   the functions of "doctor" that we had originally intended it to do (had we planned any of this explicitly, which of course we didn't, but that's another story.)

HOW DID WE DO?

If you, as a patient go to a "hospital",   can you expect that some loving, caring, competent person will be at your bedside every moment, watching over you?

Well, frankly, no.

The persons with  "MD" after their names are way too expensive and busy to be "at your side" -- so they will see you briefly "on rounds" and occasionally "on demand", but otherwise seem to a patient to have gone away entirely.   So, no, THEY are not at your bed-side at every moment.

For a while in the evolution of hospital meta-beings,   a new group of people called "Nurses" took this role, and THEY would be at your bedside paying attention to you and your needs.   Again,  that got kind of expensive (due to "system costs"),  so THESE people were multitasked away,  and are visible only briefly in short bursts,  and callable with a nurse-call-button that seems often to have a one to two hour lag time.

 So, no, THESE people are not at your bed-side every moment, serving the "doctor" role.

In fact,  nurses (due to "systems costs" ) have become too expensive so a new group of people "Nurses aids" (or various other names) instead are the ones who spend more time near you, but they don't really know that much advanced medical theory.  Even THEY are getting too expensive ("to cover all the SYSTEM costs"),so finally there are machines, in some places,  monitors,  computers that look at a few "vital signs" and ring alarm bells if those go out of specs.

These computers do not look at the whole person with wise and loving eyes, nor can they see very much at all, except for the few "vital signs" they are programmed to scan.   They, in fact, don't track downhill progression,  only able, for the most part, to sound an alarm AFTER something has gone seriously wrong. They are not, as the original bedside loving doctor person could have done, able to see that the plan of action is "not working" much earlier in the process, being totally sensitive to your normal state and slight variations.

These of course are the kind of variations that, oh, your spouse or partner or parent might recognize.

So,  in the ultimate slough-off of responsiblity,   the latest word in hospital "health care systems" is a recommendation that you bring along an unpaid family member to "be with you" and "notify the hospital" if something looks wrong.

In other words -- the system has become so self-absorbed by its own functioning needs that it has all but abandoned the role that you originally might have wanted it for.

All aspects of the original role have now fallen through "the cracks".   You cannot identify or locate the "person" who is "responsible, overall ,for your outcomes" -- there is no such person.   There is no "ship-builder".   There is a pain-specialist, a cardiologist,  a nurse,  an aid,   an anesthesiologist,  but every one of them has limits on their field of practice,  and none of them is, overall, responsible for YOU or YOUR CARE.   By expanding the "doctor" concept and attempting to create a META_DOCTOR at a much larger scale,  we have created a zillion cracks in the system into which parts of the original "doctor job" have fallen.

Finally, if you truly wish good care, and you can afford it,  you could hire a private doctor to come sit by your bedside all day in the hospital.

The birth of the new-living entity, the hospital-system,  is thereby complete. It has escaped from the womb,  cut the umbilical cord, and now exists in a self-absorbed state focusing entirely on its own system needs, to the point where the original purpose has been totally and explicitly abandoned and rejected.

From a point of view of  "new species of  life on earth" this is cool.   From a point of view of you, a patient, getting better, this sucks. You are back where you started.  No, you are way worse than when you started, because when you started, you only needed to pay for the doctor person. NOW, you are billed, often out of sight, for the existence of a whole army of "hospitals" and "health care systems" none of which are really interested in taking care of you, and consider you an annoyance to their even-keeled operation.

Don't blame hospitals.   Large banks, similarly,   which once loaned money to people , as they kept on growing and kept the same moniker and sense of entitlement, legitimacy, and reputation for fiduciary responsibility,   first decided they were too big to be troubled with loaning money to individuals, then it was too much trouble to loan it to small businesses,  then it became too much trouble to loan it to large businesses, then it was too much trouble to loan it to entire countries -- so now they simply take in funds and keep them.

The original function of "bank" has been entirely lost, and a new life form "large banks" has evolved, which has divorced itself entirely from the original concept.

If we or policy makers or politicians are surprised by this,  they didn't real John Gall's book and understand it. This is EXACTLY what systems do. This is what systems ALWAYS do.

Gall gives many more examples.  After centuries to learn that products can be made more cheaply in specialized factories by specialized equipment and mass production,   we now have a system that asks consumers to "assemble it yourself" because it is "too expensive" for the system we set up to do it to, well, do it.

Or, of course, the ultimate meta-beings,  state and federal government bureaucracies,   have taken exactly the same life-course of evolution.   Once upon a time,  they were set up to serve roles related to getting things done that needed to get done.    Over time, they grew, encroached,  took on more and more "credit" when things went right (and increased their pay and size),  took on less and less "blame" when things went wrong (and increased their pay and size to deal with that),   and finally got to the state today, where the proudest members of Congress are not embarrassed to state in public that their aim is to prevent anything from getting done.   

This of course leaves all the tasks government was set up to handle no longer handed, because THE SYSTEM doesn't really care about those tasks, now that it can survive on its own without them.


BACK TO HOSPITALS and EHR's

So,   hospitals already would have failed to work if they simply expanded and tried to recreate tasks of "doctors" but spread out over many people,   if they dealt with patients ONE AT A TIME.

But, one of the reasons (perceived by humans) for expanding is that there were a LOT of patients.  So hospitals ALSO transitioned to wanting to deal with many people AT THE VERY SAME TIME. 

It is as if we asked pilots, because much of the time they are not that busy, to multitask and actually fly 8 planes at once from the same cockpit -- something I'm quite sure is creeping into the minds of the management of the dudes who fly the drone unmanned aircraft over Iraq and Afghanistan.

So, we ask the "hospital" meta-doctor being to see, oh, say, 500 "patients" SIMULTANEOUSLY.  Any school child can see that,  if there are 500 children, the parents are going to NOT be spending all their time with any one child.    In other words, there is NO WAY that a 500-patient living entity could conceivably SIMULTANEOUSLY focus its full attention and care on one particular patient.

So,  again without formal planning, just stumbing into it,  we come up with "multitasking".   if we had 500 people, and each of them kept changing which patient they were paying attention to, couldn't we effectively SYNTHESIZE the same thing as 500 doctors all paying full attention to EACH patient?

Well, back to the cockpit example and airplane crashes.   Yes,  if the SAME 500 people learned how to work together and got their act together, ultimately, yes, this might happen.    However, that is not in the cards.  The 500 (or more likely 5000) staff members that are the cell-equivalents of this meta-body keep on CHANGING.  

There is never an opportunity to get past the "First day in the cockpit together" situation, the one that causes accidents.


Next post -- the role of the Electronic Health Record in tying things together -- and making the total result worse.

==== references
* (Chapter 3 in Systemantics - The Underground Text of Systems Lore: How Systems Really Work and How they Fail")

Does the Military Overuse Powerpoint?

We need a word in English for "Bad outcome caused by the use of computers."  The military has the same problem with data as hospitals.  How much can you cram into a PowerPoint briefing?    A weblog post on "The Tank"  titled "Does the Military Overuse Powerpoint" reviewed that issue on 28 April 2010.

Here's some excerpts from that with my highlighting added in yellow.

Does the Military Overuse PowerPoint?

The Tank | April 28, 2010

On April 27, The New York Times took a critical look at the discontent among officers in the U.S. military over the increasing emphasis on constructing Power Point briefings for everything from strategic assessments to tactical movements. Aggressive commanders such as Marine Gen. James Mattis and strategic thinkers like T.X. Hammes say the Power Point obsession is dumbing down critical analysis and too often shifts the focus from ends to means. Others, such as CENTCOM commander Gen. David Petraeus, acknowledge the ubiquity of Power Points but insist it is nonetheless a useful tool when used effectively to deliver succinct and detailed information on a strategic or tactical problem.

The Tank asks the experts: Has the U.S. military gone overboard with its passion for Power Point, or is it just a case of briefers using the tool as a crutch to flesh out an otherwise poorly delivered brief?

Michael Gordon (Senior Fellow, Institute for the Study of War, and N.Y.Times correspondent)

H.R McMaster is entirely correct. The amount of information that gets conveyed in 20 Powerpoint slides is probably less than a five page paper. It takes forever to brief it, which limits the time for serious discussion by the audience or the senior officials who are subjected to the presentation.

With Powerpoint, the military has been moving toward an oral tradition and away from the written word, with all the demands for precision, nuance and serious exposition that writing requires. And it's not just a problem for the military. The procedure has become quite common in other areas of government, among contractors and in think tanks.

Sometimes Powerpoint presentations are used as a kind of bureaucratic filibuster: they can be a way to eat up time and restrict the opportunity for hard questions. But even when that is not the intent they are generally not the best means of communication. Clear and concise writing requires that issues be thought through and that is not always necessary if all that is required is to slap a few bullets on a slide.

It would be far more efficient to prepare a concise and analytical paper that provides the essential information and arguments, circulate it in advance and then take questions about the assessment and recommendations at a meeting. If maps, graphics and charts are important they can be attached to the paper as needed. The essential information could be absorbed before the meeting, which could then be devoted to serious debate and discussion. My Times colleague, Elisabeth Bumiller, did the military community a service by highlighting this issue.

Dave Dilegge (Editor in Chief of Small Wars Journal)
There is an element of truth to each of the statements quoted in Elisabeth Bumillers Times article – from General Mattis' "PowerPoint makes us stupid" to General Petraeus endorsing PowerPoint's capability to display maps and graphical trends. 

Like any tool of the trade; PowerPoint becomes detrimental when it is abused, especially so when it is used as a substitute for critical thinking or to mask a lack of substance behind the subject.  Military blogger Schmedlap summed up the crux of the problem quite nicely, in a PowerPoint slide deck of all things, in his bottom-line: "PowerPoint can be a highly effective tool when used purely to convey information – as in a classroom or general background brief.  It is particularly good if strong pictures or charts accompany the discussion of the material.  But it is poorly suited to be an effective decision aid". 

In regards to the decision aid issue he generically describes the "before" and "after" environment.  Before PowerPoint a staff would prepare a succinct 2-3 page paper, a decision-maker would then read that paper, a meeting would be convened with the staff and/or other experts to discuss the issues, and then a decision would be made.  After PowerPoint a staff receives a 5-minute brief and then constructs the slides that result in a 20-minute presentation to the decision-maker.  After 5-minutes of discussion a decision is made. 

Personally, I have a love-hate relationship with PowerPoint.  I've been subjected to "death by PowerPoint" more times than I care to remember but do use it to "convey information" in the manner described by General Petraeus and Schmedlap.

Dakota Wood (Senior Fellow at the Center for Strategic and Budgetary Assessments in Washington, DC.)
Andrew Krepinevich once wrote, "Simple solutions to complex problems are inherently attractive and almost always wrong." Powerpoint can convey the idea that the most complex issues can be neatly summarized in a series of slides. In an age when people are short on time and, often, attention, this can be very attractive.

Slides are simply easier and quicker to scan than a lengthy report. Powerpoint as a briefing tool has the same challenges as any other used to pass information – the skill of the user, the aptitude/interest of the recipient, and the forum within which it is used. It is good for graphics (maps, imagery, charts) used to quickly provide updates or to focus discussions (e.g. for millennia, military commanders have used maps to shape battle plans). It is a very poor way to transmit the complexity of operations, especially when detached from an accompanying narrative or explanation.

Pre-Powerpoint, field commanders understood the futility of trying to fully capture complexity and nuance in a written order bound to be unintelligible to a recipient tasked with carrying out a mission…hence the importance of the "commander's intent" sub-paragraph, i.e. "if things get so hot and fast moving that the lengthy written order becomes OBE, here is what we're trying to accomplish and why." Clear, concise reporting is important. It is also hard and usually takes time to master.

More important, though, is the effort made by the commander/leader/decision maker to clearly articulate objectives and accompanying rationale when assigning tasks in the first place; time spent questioning underlying assumptions and data sources for reports that come back to him in sitreps; and time spent carefully mulling over the nature of the task/situation before him, vice jumping from issue to issue with only a moment's thought in between.

 
From the New YOrk Times article (4/27/2010) this refers back to,

Gen. H. R. McMaster, who banned PowerPoint presentations when he led the successful effort to secure the northern Iraqi city of Tal Afar in 2005, followed up at the same conference by likening PowerPoint to an internal threat.
“It’s dangerous because it can create the illusion of understanding and the illusion of control,” General McMaster said in a telephone interview afterward. “Some problems in the world are not bullet-izable.”

In General McMaster’s view, PowerPoint’s worst offense is not a chart like the spaghetti graphic, which was first uncovered by NBC’s Richard Engel , but rigid lists of bullet points (in, say, a presentation on a conflict’s causes) that take no account of interconnected political, economic and ethnic forces. “If you divorce war from all of that, it becomes a targeting exercise,” General McMaster said.

Commanders say that behind all the PowerPoint jokes are serious concerns that the program stifles discussion, critical thinking and thoughtful decision-making.

Incidentally, I have no problem with the complexity of the chart at the start of this post.  Real world problems are like that, dense with interconnections.    The point is precisely that there is no way to "flatten out" that network of interactions into a "list" without massive loss of content.   Like the mountain, the problem description is not going to "come down to us".   We are going to need to "go up to it".

This describes in spades the problem we have with using relational databases, incidentally, for trying to capture snapshots of real world entities.  If you go back into the theory underlying relational databases (which I won't ask you to do),   you find out how it is that complex, multidimensional objects can be "flattened out" into a set of 2-dimensional tables  AND A SET OF RELATIONSHIPS BETWEEN THEM.      In the chart above, the tables are the boxes, and the relationships are the arrows.

Because tables are "easy" to understand, and relationships are complex and not so easy to understand, articulate, or describe to a computer,  they are often simply "left out."    The set of tables, minus all the relationships, is all that remains that allegedly describes the original thing you were trying to capture.

It's not needless to say, it may be more needful to shout, THAT IS ILLEGAL!  YOU CAN'T DO THAT! THAT IS WRONG!    The complexity is no longer captured by the tables alone.   If you leave out the constraints, you just destroyed your content, you might as well have put random numbers or words in all the tables.

Also,a few key things about charts like this one.

First,  no one expects you to "grasp" the chart at one glance any more than you would be expected to grasp a book if you put all the words on one huge page,  or to "grasp" music if you put all the notes on one huge page.

What you can do, and must to, to grasp this kind of diagram is work one item at a time. Take one phrase (concept), and, one by one,  look at what comes into it, and one by one, look at what comes out of it,  and each of THOSE things should make sense as an interaction you understand and can independently assess.

This diagram is partly a 2-D list, but it is more, because you can follow the arrows THROUGH the words and out the other side, looking for LONGER pathways of interactions, or LOOPS.   You will never find loops in lists, or even "tree-shaped" lists of lists of lists.   The data structure of Powerpoint does not make it easy to see or find LOOPS.  That's like trying to describe New York City and leaving out the people.  It's not a small oversight or error, it's HUGE.

Another thing is that diagrams like that can be built up, one interaction at a time, using a tool such as Vensim, which can also capture whether the impact of something on something else is to INCREASE it or to DECREASE it.   Again, that's a huge step up from a list, because then you can push a button and Vensim will show you all the reinforcing loops (virtuous or vicious spirals) that are embedded in your situation.

If you can even estimate the mathematical relationship between items, Vensim will actually run the simulation you just described, and show you on a graph how any given object (say,  troop count in Iraq) will vary with time, under the assumptions and interactions you just gave it. Almost always, you will be surprised by the results. If there are loops, things are almost always "counter-intuitive".     You shouldn't trust the model at that point, but should then go back to the real world,  and try to decide, in practice, could this actually happen?

And one last really important thing about such diagrams.  It is crucial that the intended audience be PRESENT WHILE the diagram is being created, in general.    If you simply "drop" this diagram on people, they will instantly go into overload and "tune out" and get exactly zero out of it, except to be annoyed.   If people ARE present while the diagram is being teased out, one arrow at a time, from what people in the room know, the diagram will become suddenly totally comfortable, trustable, a great one page summary of the meeting.

And some published work says, if you take a room of  hositle stakeholders, and sit them down, and force them to go through the process of building such an interaction diagram,    it has a very strong impact on improving relationships between people in the room, not just on getting a diagram.  People are initially surprised by interactions that other people suggest, but as they come to understand the interaction, they come to realize the other person is not as stupid as they had originally though, and they realize the legitimacy of the comment that the world is much more complex than they had thought.

It tends to get rid of "Why  don't they JUST DO X? " type of conclusions, that can easily follow from looking a Powerpoint cartoons.     "Oh, now I see why." is a more common response AFTER the diagram has been painfully worked out.  The side effect of improved working relationships between the parties is no small accomplishment, and one you don't see with Powerpoint sessions.

Two minutes - the myth of EHR's

We are assured by government and IT vendors that Electronic Health Records (EHR's) will improve patient care, if only we could overcome those who resist progress.   Balderdash.

Let's examine this myth.

First,  there is an assumption that, prior to seeing you, a doctor would read the EHR to get the "big picture", making the visit more efficient.   My experience, and that of everyone else I've talked to,  differs.   Another person, such as a nurse,  often has a sort of mini-interview,  capturing data to put it INTO the EHR -- presumably so that the very busy doctor can be spared the effort to ask those questions, as he simply needs to read the EHR to see the answers you just gave.

What actually happens is that the doctor starts with "So why are you here today?" or some such thing,  indistinguishable from what they would ask if you hadn't just talked to the nurse and answered all those questions.

To put it very succinctly, the (EHR + doctor) hybrid unit fails the "OMG" or "Oh, my God!" test.  In situations where any of your good friends who hadn't seen you  for a while, meeting you, would go "Oh my God what's wrong?!!",  the doctor asks "What brings you here today?"

Worse, this does not seem to change with time.   Familiarity with your "normal" state is neither captured by the EHR,  even over time,  nor is it somehow communicated from the EHR to the physician at the point of care where you'd expect it to.   Reliance on the EHR has replaced memory.

Hmm.  Well, how about the value of all those prior visits and what the EHR has captured about those, now that it's all electronic and legible and stuff?    (a) are those read? and (b) if read, what do they change?

In answer to (a),  yes, probably, if you have one prior visit, the information from might be read.  Far more likely, if available, a very short 1 page summary of it might be read, listing allergies and previous diagnoses and major events.

Let's suppose that on a prior visit to a prostate surgeon specialist  the specialist wrote that your prostate was "precancerous" and "immediate surgery was recommended."   Further, let's say you are familiar with this surgeon, who has a reputation that "He never saw a prostate that didn't need to be removed."

So, are you as a doctor going to follow that advice and get the patient admitted and off to surgery?  More likely, you will raise an eyebrow and discretely suggest the patient "get a second opinion."  

In fact, for pretty much anything that is asserted as a "fact" in the EHR,  your opinion may be that the source of that information is biased,  inexperienced,  working off an entirely different model of health,  out of date, or otherwise not to be believed and acted upon.

So, exactly why then was it worth $100,000 to get this information in front of you?

Or, let's take a case where an older patient, seen over 100 times by a health system,  has multiple problems, sees multiple specialists, and has over 1000 medical documents in her file from these visits.

Again,  of the 12 minutes the health system allows the doctor to deal with you,   and the two minutes of that the doctor might choose to spend reading the prior EHR,    what fraction of these 1000 documents do you suppose he'll read?    The most likely answer is:   zero.   In fact, as in the rest of life, the MORE extensive the EHR is, in terms of number of documents and complexity of issues described per document, the LESS likely it is that your current physician at the current visit will elect to READ any of it.

A graph of blood pressure historical data might be glanced at.   Details about blood type might be looked at, with a note that this should be redone before giving blood, "just in case the prior value is wrong."

So let's back up a step and think about what we think should be going on.   There is a lot of information, encoded into text or structured text or forced-choice fields in the EHR.   For the most part, this information is effectively divorced from meta-information, such as the name and qualifications of the source of that data, or any qualifications they might have put on it or caveats regarding it.

Maybe the supposition is that a doctor, in the two minutes allocated,  is going to "process" all that information and produce a "big picture", a mental concept that includes all of the relevant parts of what has been done before, so that, today,  he can look at you and advance "the big picture" even further in understanding what might be wrong with you and the plan of addressing it.       I don't think so.   No one can read 100 documents and process them well in 2 minutes.

So,  let's say there is some process that summarizes the prior documents and sort of encapsulates a distilled "big picture" of the patient.   By definition, unless this is a wiki or otherwise heavily linked electronic document that allows "drill-down" into what lies behind assertions,     the summary is going to leave out most of the details.

However, it is precisely the small details that don't quite fit,  the nuances that aren't quite right, that a doctor's thousand of hours of training can spot and realize that prior diagnoses are incorrect.     These details are suppressed in the summary, because it is a summary.

So,  whoever writes the summary and elects which details are "relevant" and which matter enough to be put into the summary actually, in effect, determines the outcome of anyone reading it.   (The same problem is true of War Rooms in the Pentagon, by the way, and has been studied there.)    By the time some low level person, who has the hours,  has used THEIR judgment to filter out all the "irrelevant details" in this report to his superior officer,    there isn't really any room left for the superior to question.

We have, in effect, by using the hierarchical summary feature of the electronic record,   removed the doctor from the loop.    An army of low-level staff members have, in summarizing, removed the need for a highly-trained doctor at the top to read the summary, because there's no details there left for the highly-trained person to respond to differently than a low-level person would.

So. let's summarize our own thinking so far. The EHR is alternately too thin to be of value, as it is missing too much,  or too thick to be of value, because no one can possibly read it in the 2 minutes allowed. The solution to this problem with text-based concepts is to have low-level people (the only ones with time to do so) do a summary of the case ,which could now be read in the two minutes allowed.  In almost no EHR system are the details of the summary cross-linked with hot-web-links back to the source of the data, in case the source is changed, deleted, addended,  or questioned.   Doctors may be given an opportunity to challenge the summary, but  to do so would require going back and doing the summary themselves, which, by assumption, they don't have time to do.

So, the clinical picture that can EVER be embraced by an EHR is actually quite simplistic, and has to fit in a short series of listed bullet-point items.   The nuanced, net, effective clinical picture of your complex medical condition is limited to what fits on a Poweroint slide,  effectively a cartoon that discards all traces of uncertainty or ambiguity or conflicting readings that might open the door to a realization that your primary diagnosis is incorrect.   Alternative framings of your condition, alternative diagnoses that might be relevant are forcibly discarded since there is ":no field for them on the form."    Clinical impressions of "maybe" are forced into one of "Yes" or "No" to simplify billing or to satisfy the mental model of some low-level non-clinical programmer somewhere who was trying his best to "validate data."  

Furthermore, the clinical picture stored in the EHR does NOT have the property that it improves with time, or with use.     No facility is included to allow a doctor to highlight relevant sections of a document to save themselves time the next time they come back to this patient.    No facility is provided to let them select a section of document and "drag and drop" it into a summary document, pulling along with it all the cross-references to the work cited.     No facility is included for them to put on a yellow sticky with a note to self challenging some fact in the existing record.

In fact,  there is nothing in EHR systems that would look at text descriptions and recognize and flag that completely inconsistent conclusions are drawn in different places in one document or across documents.

I would be most astounded if any hospital had a section of the summary which revealed, let alone highlighted for attention such conflicts.   Picture reading "Well, Doctor Smith thinks X is true, but Doctor Y thinks Smith is an idiot and X is clearly false.  Doctor ignores them both and assumes Z is true. "   It may be a true summary of reality, but it is very very unlikely to ever be clearly articulated in an EHR for lawyers to find. So, instead, it will be covered up and buried.  ALL such conflicts will be suppressed, and even their existence whited-out of the summary report, as if everyone happily and confidently agreed with each other.  The EHR facilitates this, because it has no room for "conflicting opinions" in the structured field, which has to be either "YES" or "NO".  

This is the conflict within a hospital.  Imagine what will occur when different physicians at different practices or hospitals have to contemplate and respond to conflicting opinions from the competing practice or hospital, in order to come up with the "master, nation-wide health summary for this patient."    Imagine the heydey attorneys will have if the differences and discrepancies are revealed and highlighted.  Imagine the fraud and damage to clinical truth that will occur if the differences and discrepancies are shoved under the rug and made to "go away".

So, I challenge the designers of these regional EHR summary databases.  What IS your plan when you run into conflicting and incompatible diagnoses by different doctors for the same patient?    As you surely will, and very quickly indeed.

Are you going to highlight them, so it's clear that none of them can be considered definitive?  Are you going to code them "under dispute"?   Do you even have capacity to store such a code?   Are you going to use your own judgment or your own people to override one, or the other, or both doctors?    Are you going to refuse to show anything until the two doctors reach a consensus opinion?    Who is going to pay for the costs of resolving such discrepancies in "the master patient chart?"  Who is even capable of resolving such disputes? 

Are you going to pretend that such situations don't exist, or only exist "very rarely" in the hope that funding will not be held up on such a little thing?  Nail it down people.  Do you admit that these problems will occur (and therefore open yourself up to questions about how you intend to deal with them?)  Or do you deny that these problems will occur (and therefore open yourself up to a delay in funding until you say how you will deal with them?)

In point of fact, this "unclean data" problem will present not just a problem to regional health warehouses. It will document, clearly, for all to see,  just how BAD clinical records actually are.  It will document, for all attorneys to discover,  just how much disagreement there is among professionals.  It will document, for patients,  that their unqualified trust in any given doctor should be tempered with the evidence. 


And it will document for all that there has been, to this date, a conspiracy of silence about this problem. Did no one know about this?   When exactly were you planning on mentioning it? Only AFTER we'd spent $100,000,000 getting to that point?

Each time a doctor opens up even his own records about his own patients,  he is faced with documents he's not allowed to mark on, cross-link, color-code,  put post-it notes on,  etc.  If he attempts to go into length about complex conditions,  he is punished by failure to meet his scheduled case load as well as called by the transcription department about having documents that are "too long" and cost way more than other doctor's document to transcribe and summarize.

The text stream called an EHR, therefore,  may have a good ability to persist pixels, or facts such as a blood pressure reading,  but as the complexity of the concept or medical condition gets higher,  the EHR is unable to follow along and store, in any kind of retrievable fashion given the 2-minute-rule,   the "big picture" and all the nuances that picture should be resonating.

What will get passed on to the next shift, or the next doctor, or the next visit, is at best a cartoon summary of things to date, prepared by a non-physician with all trace of nuance and uncertainty removed.   One hospital I visited told surgeons they couldn't store the normal pictures with circles and arrows they used to plan a surgery or summarize what happened, as the computer system wasn't sophisticated enough to do what the paper chart system did, ie, allow pictures to be attached to the patient chart.  Again,  what is stored is getting dumbed down and reduced to what is easy to fit in a computer form.

Which perhaps explains why the doctor doesn't bother to read it, or, often, even to read the notes his nurse made at the start of the visit.  He may ask the same questions again, not because he is interested in the "answer" (as seen by the EHR) but because he is interested in the nuances, the body language, the uncertainty or certainty that surrounds those answers.   He cares about the meta-data, because a large part of clinical judgment is based on intuition and reading the meta-data.   Sadly, none of the EHR has room for such metadata.    A transcribed document codes an emphatic "YES!!!" the same as a neutral "yes" the same as a hesitant "um... yes, I suppose, sort of..."   To humans, these are very different answers.  If my girl asks me if I love her and I say "YES!" versus   (pause) (ponder)( delay)( fidget) "... yes?" I am conveying very different (and actionable) information.

The EHR throws out all this meta-data.   If you're going to do that,  you might as well just have clerks sitting and following a flowchart or the computer have a set of rules that guide the "next question" to each issue down some tree that comes up with "the diagnosis" or "the proper recommendation",   at the expense of throwing out every point at which a trained doctor would say "wait, that's the wrong question. That's not quite right."

What it doesn't explain is why the country is so gung-ho on spending billions of dollars to install Electronic Health Record systems in every nook and cranny of the so called "health care system" especially for Medicare.    Children may have relatively simple things wrong with them that "fit" in the EHR.  A broken arm.  65-year olds probably have at least 3 chronic conditions and are taking over ten different prescription medicines for a variety of interlocked an inter-related system problems.

Apparently some programmers, managers, and insurance companies think that can all be neatly and correctly summarized in a few Diagnostic Related Group codes (DRG's) and everything is fine.

In the real world, it's hard to even imagine how such a system could possibly deal with the complexity of even one older patient over multiple visits.

In reality, of course,  every actor in the health-care is multiplexing and distracted. Doctors, nurses, labs are acting like short-order cooks,  starting on one patient,  taking one step,  leaving them to go deal with some other patient or crisis, trying to remember where they were, reprioritizing, re-triaging,  going back to the first patient for a minute, etc.   None of that interrupted action-coordination is contemplated by the programmers who designed systems as if the doctor or nurse, with all the time in the world,  sat down and did everything for one patient before even beginning to think about the next one.

A short order cook who did orders one at a time in serial order would be fired by the end of the first day. You just can't operate that way, you have to overlap, predict what's coming, allow for lag times, etc.

On this account EHR's are equally out of touch with reality.   The EHR expects you to sit and do everything for one patient at one time, so it can do "validation" and help "support your decision."

There is no way that serial text capture and summarization can possibly do that job, in a real environment, with real medical conditions.

The IT people don't need to force clinicians to "get with the program" and "stop resisting computerization." They need to go back to the drawing board with a better sense of how badly they have conceptualized and modeled what goes on in a hospital, and design a system that supports real people doing real work with patients with truly complex clinical conditions, in the fragmented, interrupted, and multiplexing distracted mode that clinicians are forced to accept as terms of employment.

There are other issues as well, that I won't go into in this post. One of the biggest ones is inappropriate persistence or stickiness of a diagnosis.   Once one doctor, whoever goes first,  states an opinion and a diagnosis, regardless how tentative, there is some legal and professional courtesy and psychological pressure on the next doctor to agree with, or by silence not challenge it, even if they believe in their hearts that the diagnosis is pretty suspect.  The third doctor to see the record will have even a harder time going against the flow and disagreeing with the first two doctors.  From then on, very few doctors would challenge the "consensus opinion" about the first diagnosis.       The diagnosis has been electronically locked-in-stone by the EHR process.   If the second doctor had gone first, a different diagnosis would have been locked-in-stone.

You have to worry about any process where the order in which people see data changes the outcome.  The order drugs are listed in a pull-down menu, for example, has a strong impact on which drug a doctor using an EHR will select.  By itself, that should be a big "WHOA." until THAT gets sorted out.