Systems Thinking Health Care
How we construct our models for understanding health care – not just what health itself is but also the institutional frameworks we use to organize health systems – defines the kinds of solutions we can derive. These models come to define what exactly is the problem we are trying to solve and how we should go about trying to build and operate health systems to meet those challenges. By leveraging a wholistic perspective systems thinking can present a whole new paradigm to how we model, manage and design health systems in response to the changing conditions of the 21st century.
Throughout history, the health equation has evolved with societal changes. Over the course of centuries, our understanding of health has evolved from the spiritual realm to being grounded in the realm of scientific materialism. Out of our newly found knowledge of the physical world that the scientific revolution brought and the new institutional paradigm of the industrial age we built the modern health systems we inherit today as over the course of the 20th century a standardized model for health systems solidified.
With the institutional framework of the nation-state, a set of centralized formal institutions coalesced as a standardized solution for managing the health of populations around the world. Under the guidance of government bureaucracies, diseases were cured and even eradicated as advances in science and the incentive structures of the free market drove incredible progressions in medicine and medical technologies. National health care plans developed to pay for health care with some countries even achieving universal health care.
But by the turn of the 21st century, our industrialized health systems are facing a new and complex set of challenges. Internally their heavy dependence upon a reductionist centralized approach in design has resulted in fractured and highly complicated systems; that are becoming overbearingly costly to operate while failing to deliver the outcomes society desires. Externally the world is changing in profound ways; the social, cultural, economic and technological environment within which we design and operate health systems is changing fast, placing requirements on those systems to adapt and evolve new structures, capabilities, and capacities.
The health equation is becoming more complex along many dimensions, in response new thinking, models and approaches to managing health systems from the local to the global are much needed; the same thinking that created the centralized health systems of today will not solve for the problems they have created and this changing context. The health systems of today are a classic illustration of both the achievements and limitations of a reductionist thinking. The analytical approach has made many advancements over the modern era, but with the ever-evolving complexity of today’s health systems linear models that focus on component parts are blinding us to the real systems-level innovations that are needed to move forward.
We focus on parts getting ever more analytical, hoping that the cure to aging or obesity is down there somewhere, in some gene or molecule and with the best of intentions we pursue that dream with billions of dollars, whilst being blinded to the networks of horizontal connections and overall environment within which human health exists. We invest billions in high-tech medical solutions and specialized doctors to use them when the solution to the patients’ problem may have just required the doctor to listen a little bit more closely.
The emergent unintended consequences of the analytical approach are everywhere to be seen; health systems are populated with people with good intentions that lead to undesired outcomes because of the structure of the system and the structures of incentives that are acting on agents in the system. Massive amounts of resources, intelligence, hard work, and aspirations go into the development and maintenance of today’s health systems while society often describes them as being “broken” how can this be?
The reductionist centralized approach only ever scales so far before starting to grind to a hold in the face of the complexity that it is not able to harness. A distributed model to health systems can go beyond that to harness that complexity, to tap into the full resources in the system. The challenge for us today is not to do things faster, more efficiently and larger than we did them before, it is to think and operate differently, to embrace the complexity of a distributed network model to health systems.
Moving to a distributed network model though requires a deep re-architecting of health systems. On the more theoretical side, we need to understand the essentials of what health systems are – how they work in the abstract – coupling this with an understanding of how our existing systems have evolved into their specific current form; really breaking ground will require a full 360 degree integrated analysis of the current context today. On the design side of the process, we need a deep understanding of the current structures to these systems and how that structure should evolve to respond to current requirements. Finally, we need to understand the new technological means that we have and how those means can be appropriately applied to realize this evolution in healthcare systems.
Systems thinking can help us to move beyond our traditional analytical reductionist thinking to health systems so as to talk about networks that cross boundaries and whole systems. To move from a world of fractured centralized systems to open platforms; shifting the locus from closed organizations to one that is centered around the individual; from arguing about the cost of service delivery to aligning incentives towards real value and outcomes; from static organizations to dynamic health networks; from reactive to preemptive; from a focus on the specific parts of the formal health system to the whole context within which health is maintained and realized.
Not only do we need new ways of thinking about health and new approaches to managing health systems but more than this we need to realize these new approaches through technology. In the coming decades’ powerful new technologies of the blockchain and advanced analytics are set to reshape virtually every aspect of society and economy, how can we use these technologies as a medium to realize new ideas and approaches, to build health systems that are qualitatively better in outcomes than the ones we inherit.
Despite trillions of dollar spent and an exponentially growing knowledge base in medicine estimates indicate that 30 percent of healthcare spending is wasted. Currently, we see dysfunctionality in healthcare systems around the world; there is wide variation in health outcomes and cost of provisioning across regions and countries but costs are rising at an unsustainable rate in many regions, outpacing GDP despite pressures by governments and payers to get them under control.1
In this context it is often recognized that we need to move towards a user-centric system; one based on value and outcomes; that better aligns incentives; that is flexible; integrated and dynamic. Our current systems due to their inherent design pull in the opposite direction, as centralization has led to siloization and inertia. We find ourselves at a point where the existing model is grinding to a halt due to its very structure and design.
Getting to this next level will require more than specific one-off interventions or simply adopting new technologies, it will require a paradigm shift in thinking and re-design according to a few basic but fundamental principles; moving from a closed system approach to an open platform approach; from a focus on patient illness and healthcare products to healthy outcomes, wellness, and end-user value; from healthcare organizations doing everything within a push model to user-generated systems within a pull model; from formal institutions to informal service networks; from preventive and piecemeal to preemptive and pervasive.
In terms of the technology infrastructure to realize this the next generation health system will not be like the national health systems of the past, they will be more like digital platforms. Data will need to move to open blockchain platforms and shift to the end-user’s possession. Health token economies will be used for people to manage their health in a decentralized fashion reducing dependency on the formal health system. Information, gamification, social networking and the design of market structures will be used to incentivize actors in the network to deliver real end-user value. These health networks will be increasingly automated through the use of smart contracts while new data sources and advanced analytics will be used to understand the full context in space and time that constitutes the wellness of people.