Introduction
Over 20 years ago, two separate groups of astrophysicists discovered
something unexpected at about the same time. They found that the
expansion of our universe is increasing at an accelerating pace, rather
than decelerating as was previously thought. The groups would later
share a Nobel Prize based on this discovery.1
Although this was unexpected, an increased pace of change in our world
has been evident for many centuries. We can see this ever-increasing
pace of change in our world through the innovation revolutions that had
a major impact on lifespan and quality of our lives, from the
Agricultural Revolution that took thousands of years, the Industrial
Revolution over a period of hundreds of years and the Information Age
that lasted a few decades. With the global and immediate communication
capabilities of the internet, this pace of change will only continue to
increase. We are now considered to be in the age of
networks.2
Fragmentalism – the loss of focus on “what really
matters”
With this ever-increasing pace of change, we can see the impact on the
reductionist models for our industries and organizations. Fragmantalism
has been described as an alternative term for reductionism. As the pace
of change and the complexity of our world continues to increase, a
reductionist model for an organization will lead to more fragmentation
and disconnection. This occurs through the development of more and more
department silos leading to poorer communication and more inefficiency
and waste as well as almost completely stifling innovation.
To see the negative impact of this increasing pace of change on
reductionist designed organizations, we can examine the lifespan of
Fortune 500 companies in the United States: the average lifespan was
more than 50 years in the 1950s but has decreased to less than 20 years
in the 21st century and in 2017 only 60 companies
remained in existence from the Fortune 500 list in
1955.3
Hospitals and Academic Medical Centers are no different and they may be
in the most complex and constantly changing of all organizations in our
world. But they have been relatively insulated, with massive subsidies
from government, foundations and research dollars as well as
philanthropic and investment proceeds. It was only a matter of time
before this fragmentation and disconnection would catch up with an
unsustainable business model, even in healthcare.
As I learned more about this, I came across graph published by
Woolhandler and Himmelstein shown in Figure 1. The graph reveals a many
thousand percentage growth of hospital administrators while the growth
of physicians has been minimal compare to the growth of administrators.
This fragmentation also leads to systems designed inappropriately into
the fragments of care rather than for a patient’s entire cycle of care.
For example, Electronic Medical Record (EMR) systems are designed for
the fragments of care, often with a primary purpose of documentation for
the purpose of coding and billing. By only documenting a fragment of
care, it is not possible to measure the outcomes of care for any
definable, whole patient process. This also prohibits the appropriate
data analysis that could be applied to learn how to better measure and
improve outcomes.
Ultimately, this increasing pace of change resulting in increased
fragmentation and an increase in administrative burden will predictably
lead to an unsustainable financial situation. The Commonwealth Fund is
one of many organizations that highlight the unsustainable financial
situation in healthcare. A graph demonstrating the increase in per
capita spending on healthcare for the US and many other countries is
shown in Figure 2.
Although it is well-known that the US has the highest per capita
spending on healthcare, it is not well-known that the slope of increase
of per capita spending on healthcare is nearly the same in every
country. We are all on the same unsustainable path- the US is just out
in front of every other country.
Applying Systems and Complexity Science to Real Patient
Care
For the past decade, our small abdominal wall hernia team has applied
the principles of this newer scientific paradigm, systems science, to
real patient care. Instead of testing a hypothesis using rigorous
prospective randomized clinical trials (PRCTs), we collect data from
real patient care, periodically analyze the data which provides feedback
loops to allow the clinical team to gain insight into the factors and
combinations of factors that are most correlated with good and bad
outcomes.
This can then lead to ideas to improve how we measure factors and
outcomes and generate new ideas to improve outcomes. The tools from a
systems science paradigm include principles of continuous quality
improvement (CQI) and non-linear analytics.
The reductionist paradigm relies on linear statistics to try to prove a
cause and effect relationship between a factor (drug, device, etc.) and
an outcome measure by attempting to isolate them from all other factors
and outcome measures. In systems science, the analysis and feedback
tools are meant for learning and improving whatever is measured in the
real world of patient care.