There are essentially two types of improvement strategies in most healthcare organizations. The first approach updates or enhances existing processes and systems. By design, this can only bring incremental improvements and scale will always be limited by the availability of key resources. The second, and more transformational strategy, is to identify and overcome the underlying structural impediments, such as taming the unwieldy organizational systems that cannot handle exponential increases in the volume of activities required to achieve better health outcomes. In other words, we need to rethink how healthcare organizations operate. From the in-take process to EMRs, from medical procedures to post-clinical care, we need to revamp the underlying technology foundation so we connect people, both patients and providers, with streamlined, smart systems and intuitive processes. We also need to access and make sense of the vast amounts of healthcare data that is often locked away in disparate systems. So what are the structural hurdles that have to be broken down to build a new type of healthcare organization? We need to address two key components.
The Guild of Knowledge—High-cost clinicians will continue to limit the expansion of healthcare “production” as long as it is not possible to substitute or augment them with other widely available or easily trainable personnel. Currently, the “guild” of highly-skilled and knowledgeable clinicians do not want to delegate their decision-making power. These professionals are not geared towards this shift in hierarchies, do not have time or energy to invest in training others, and stand behind a very strong argument that a change may negatively affect quality. In such a scenario, the only effective way to delegate healthcare responsibilities and tasks to lower cost resources is to embed clinically-proven algorithms into workflows. For example, healthcare facilities could automate the stratification of clinical problems into two categories—those that need the high-level clinical judgment of a doctor and others that can be handled by physician assistants, nurses, pharmacists, or medical assistants using a series of diagnostic and medical therapies based on algorithms. This is already happening in a very controlled manner with written protocols and checklists. However, large-scale adoption and transformation is only possible when such technologies are embedded in every process within the health system, including self-service tools for patients. With wide-scale adoption, we will see a net shift of task work from doctors to non-clinicians. This transformational change will allow doctors and other costly clinical roles to increase their capacity and manage many more patients than has traditionally been possible.
The Network—To deliver better care, there has to be better access to care, whether inside hospitals, in the community, or at home. We can achieve this by creating new provider relationships, with entities like the ACOs, or by deploying new personnel, like transition coaches whose main function is to coordinate care. These initiatives increase the number of stakeholders in a patient’s ecosystem and can complicate already-clogged processes. An easy way to understand this problem is to imagine each possible point of information exchange, whether between providers or provider and patient, as a node in a network. While more nodes in the network may appear to cumulatively provide more care, in practice, the complexity increases faster than the network can grow or expand. This is a very important principle in group collaboration that is described by Clay Shirky in his book Here Comes Everybody: The Power of Organizing Without Organizations. The figure below is borrowed from this book.
Image Credits: joelkelly.ca/blog
This superlinear increase in complexity can limit organizational effectiveness and system-wide collaboration. However, if you can shift the entire network to one multi-modal communications platform, where there is minimal cost to add participants or devices and the incremental work effort by providers is negligible, you can boost organizational effectiveness and collaboration. The last point regarding collaboration and communication is especially important because they are key factors in positive behavior or attitude change toward new information systems.
We need to tackle these two central elements of the healthcare eco-system head-on to create a new type of delivery system that is agile, yet powerful enough to solve today’s problems and satisfy tomorrow’s expectations. We need “connected healthcare” that goes beyond a single system or process and instead addresses the entire organizational environment—from the people to the systems to the data—across all facets of the care spectrum. The “production capacity” of such healthcare organizations will be exponentially larger and collaboration networks will be able to perform massive volumes of coordination without bogging down the system.