Health Systems Science- The
Third Pillar of Medicine
"Systems thinking is not big words or dynamic images but rather fearlessness amidst uncertainty."
"We live in a universe, one that is elegant, ordered & sophisticated, while unabashedly, simultaneously wicked."
"We are not cells; we are composed of them. Our bodies are acted upon...operating as social agents with oblique intentions."
"The perfect state of being would require the absolute absence of naturally occurring or socially imputed error. Fallibility comes from internal and external systems, both open social systems and closed physical systems. Human fallibility would thereby require living (not merely existing) under imperfect physical, political and organizational states."
HEALTH SYSTEMS SCIENCE (HSS)
The goal of value based care is to lower health care costs and improve outcomes. The successful “health system” requires three attributes: healthy people, superior care and moral fairness in care. But I believe that health systems science improves the acuity what is happening downstream, midstream and upstream. The linking domain of HSS is systems thinking which rests on the foundation of the “system”. There are open and closed systems. A closed system would most resemble a mechanical one or the mechanisms of the human body. On the contrary, an open system is not cut off from the environment around it. According to Bertalanffy, physicians live with the system that they are observing. But the complexity for physicians is that often the interconnected elements of a social system never stop changing and may been hidden if not declared during H&P. Medicine at the point-of care is a longitudinal struggle of H&P which account for outside social systems elements that have a hand in the health of the patient. For starters, a system is comprised of interconnecting parts that affect the integrity of the whole when the components change over time. Systems thinking is a mindset based on modelling that allows us to more realistically frame and subsequently position competing interests.
I see the world as 4 fundamental building blocks: Distinctions between and among things to structure social information; Relationships between things and ideas; Systems (Part-Whole) creation to discern meaning; and Perspectives (Point-View) to rethink systemic distinctions. The uncertainty in attaining good health is overwhelming for both patients as well as the health care system. Systems drive to the heart of dynamic social structures. Systems gives us the “what ifs”. It is an approach to understand how a whole of interrelated parts change dynamically over time. At the heart of medicine is the improvement of individual “private” lives to improve population based outcomes of the patient.
I offer the following 3 overarching objectives for a health systems science curriculum and application:
1. The meaning making of what is public health and private illness (tied to clinical care) as well as in the evaluation and experience of the patients (over undergraduate and graduate medical education)
2. The ethical conundrums encountered at the point-of-care where medical professionals, academics and stakeholders must account of outside elements that affect issues such as connected care and med/surgical care coordination as well as the ethical stance of the patient and social network.
3. The social communities, or networks, that can influence the care required by the patient (e.g. patient navigation, social support).
Beyond medical intervention, patients must navigate the spoils of health. The definition of quality of care from a population standpoint considers opportunity cost and prioritization of resources toward achieving health needs of an entire population. These definitions take into consideration three additional elements in addition to access and effectiveness discussed under quality of care from an individual standpoint. They include equity, efficiency, and cost. Equity is a subcomponent of access of care that is closely related to structure and processes of care, while cost is a subcomponent of effectiveness. Quality of Care (QOC) for a patient can be defined as the ability to access effective care on an efficient basis for optimization of health benefit/well-being. The infrastructure of medical care in developing countries is often compromised. This bears the ethical question if medical care is doing more harm in not assuring a consistent system of care to sustain improved clinical outcomes. The hard discussion must be made to discern if QOC can solely be framed as a static quality improvement activity because of medical care or as a more substantial engagement in an adaptive clinical system before and after the point-of-care. Therefore, Health Systems Science is a defining framework and so revolutionary.
Medical students need education to be become systems thinkers in the medical context. In a systems dynamics research study that I conducted with a team of systems researchers, a worldwide random sample of medical students were tested as to their success of discerning the management of body weight. Behavioral decision making according to control theory requires two things: the ability to develop an adequate model of the system (system building) and the ability to run that system over time (systems running). In the end, the study found even with simple stock and-flow systems that health professionals (including medical students) had insufficient understanding of the system. In the end, 71% of health professionals failed to understand the simple stock-and-flow of dynamic weight change and energy expenditure. (Abdel-Hamid et al.,2014) Dynamic is the key HSS concept here. Point-of-care and diagnosis is static to the examination and patient history. As this example shows there lies the potential in health systems science developed over the course of medical study as tied to basic and clinical science.
An element of point-of-care that could be served by using health systems science is understanding reimbursement such as untangling the connection of value-based care and regulations such as MACRA (Medicare Access and CHIP Reauthorization Act of 2015). Medical practices under MACRA are required to reorient both payment structures and clinical processes to improve clinical practice and deliver improved patient outcomes. In incentivizing value-based care, clinicians must discern what leverages are most meaningful to quality, resource use, clinical improvement, and advancing care information. MACRA is a Big Data push with success being ties to measures of population health management. MACRA is longitudinal and an iterative, complex process for quality control for an industry known for slow adoption of new processes. In addition, medical students report being ill-prepared for understanding both the regulation process, implementation and overall picture of what the regulation might accomplish. HHS will give the tools to understand the systemic state of the state of patients as well as the complex effect of regulations on the medical practice. The key is to not merely present MACRA as a regulatory matter relating to the point of care but also something tied to exogeneous factors that add social complexity of patient outcomes.
A second element is successful patient navigation. I offer a case study of care with the VA for a patient with PTSD. For the sake of this explanation, the actors involved in the navigation care network are the clinic (Medical Professionals), Veteran (Patient), VA Hospital (Medical Professionals, Social Services), and Domiciliary (Housing Assistance, Social Services). Note each of these agencies have unique networks imbedded in them which have its own individual complexity. The VA (Veteran Affairs) health system represents the largest integrated system in the nation. While current military are served by the Department of Defense for medical care, upon separation of duty the veteran is under the care of the VHA. The VA has is made up of 1,700 facilities which are charged with the care of over 6.3 million veterans each year. A healthy military is a strong military. A healthy military helps to ensure the best quality of life of the service members, their families as well as their communities. The proud employees of the VA have answered the noble call to serve our military. As health is a partnership across agencies and patients, the VA must place a priority on real systemic successes and lapses beyond the organizational outcomes expected to succeed. The workings of VA support and hinder continuity of care. In addition, the service member and the veteran enter a web of clinics and support services with that can be dizzying to navigate and disjointed in organization. It is imperative that the Veterans Health Administration (VHA) honestly measure the true complexity of serving its patients. A lean and nimble VA system is one that does not fear the complexity before it, but rather honestly evaluates the network of layers tying medical services and patients. Understanding and aligning the formal and informal structure of VA requires a new plan of attack, one that starts with discovering the power in looking at medical services and patients as a changing web of relationships involved in patient care.
Under the guidance of the American Medical Association, Health Systems Science is considered the "Third Pillar" of medicine along side Basic and Clinical Medicine. "Developed by the American Medical Association’s Accelerating Change in Medical Education Consortium, Health Systems Science is the first text that focuses on providing a fundamental understanding of how health care is delivered, how health care professionals work together to deliver that care, and how the health system can improve patient care and health care delivery." (https://www.ama-assn.org/health-systems-science-1st-edition).
WHY IS BEING HEALTHY SO COMPLEX?
The world is run by systems that overlap conflict and adapt to social needs over time. In dealing with the uncertainty and risk of the human condition, people seek to “control” that uncertainty (though systems can only be adapted to and not controlled).
There is nothing more uncertain for people than why they are not well. In the physical world, the perfect state would be absolute absence of error and total resilience to uncertainty. While we cling to what a perfect conception of our health can be, the margin of error between the conception and achievement of that health is tied in part to risk and uncertainty. If the uncertainty of health is framed as something that is inherent to social systems that should not be feared but harnessed, I contend that the public can confidently uncover the resilient patterns of health that make us infalliably, wholly human.
There is a difference between discredited and discreditable health realities, the seen versus the unseen. It is a part of the human experience that we are uncomfortable in the world. Some elements that marginalize and impress our lives must be worked over to figure what might be likely to happen. When uncertainty charges forth at odds with the life that we want, we neither had nor will ever enjoy pure certainty. In addition to all the unseen factors bearing down out health, there are also social, ethical and behavioral expectations that people must navigate successfully.
Health is so personal. If it is not our health that we are worried about, we worry as caregivers and concerned others. Uncertainty be damned, we want to leave this earth on our own terms, having lived a life that aligned with our providence of a “good, fulfilling life.” We want to control how we navigate and vacate this earth. Mind the gap between intentionality and what actually transpires. Comfort may be harder to conjure up if the discreditable and wicked cracks to the mandible land squarely.
PUBLIC OR PRIVATE? WHO OWNS OUR BODIES AND LIVES OUR LIVES?
Private medical issues rarely remain concealed from the public. A “private” medical issue becomes everyone else’s business for a good reason. Health must be modeled as realistically as possible, as a murky overlap of public versus private.
While a visiting scholar at the Hastings Center, I was fortunate to speak at length with Dr. Michael Gusmano, research scholar at the Hastings Center and Dr. Barry Gurland, the Director of the Morris W. Straub III Center for the Study of Quality of Life (QOL) housed at Columbia. With knocking knees, I began discussing with my desire to explore health and organizational behavior dynamically using the tenets of systems theory. I said that we reach an understanding of the state of QOL through quantifying intermediary changing in medication compliance, health literacy, and social support. This initial musing laid the foundation of my Concentric Model for Health Bound Networks in my book. I do not recall an ICD code for attendance to family barbeques or activating one’s social network for the sake of caregiving. Caregiving is just assumed to be there. You as the patient will find a way to get what you need. You will find a way to get by. Health care is not directly reimbursing for patients’ visits to Disneyland or late night trips by a helpful neighbor to the pharmacy. ICD does not directly measure our “living” but rather our quantifiable “existence” inexplicably linked to the health of our support system.
Healthy patients demand less utilization of an already expensive health care system. The domains of QOL may include daily activities and restrictions on daily life activities. But must we forget hopes, dreams, intentionality and restrictions on emotional awareness of the patient when we are explore QOL? What may be more important to improved patient outcomes may be the things that we cannot see and what we least control outside of the clinical visit, the dynamics of social support. When illness comes, the complications of this worsened health status may have devastating effects on the patient’s quality of life (QOL) and the collective lives of those around them, their “network.” According to Dr. Gurland, health care frames QOL as something a patient “should have,” not as a changing entity with heteronomy of our support networks. There must be a “truth” by a lived narrative of patients embedded in families and communities that live the experience as well. Happy patients make compliant patients. The goal of all involved in patient centered care is to have the patient experience a long (if lucky) and fruitful life. But who has the right to define what a good “life” should be for the patient and loved ones?
While autonomy is often presented as a hallmark of medical ethics, perhaps it should be viewed as a nebulous benchmark with degrees of variation. It cannot be ignored that there can be social influence from others on patients. Socially constructed autonomy differs from the vanilla version as there is an assumed outside influence on the QOL of a patient. The effect of collective autonomy is shown as the rights afforded within a self-governing network. Take the case of a family that has been stricken with ESRD (End Stage Renal Disease). There may be apathy to the perceived benefit of proper self-care and the quest for the elusive QOL that the clinicians expound as the Holy Grail. Other family members have languished on dialysis and complied at varying degrees toward “better QOL” and still died. This emotive back story could have grave consequences on compliance within the patient’s network. So what is the use of complying with physician’s directives when the network expressing discontent with the patient’s health choices? (Battle-Fisher, Application of Systems Thinking, 2015).
Patients have social networks of confidantes (nodes) of differing influence. The networks have people that come and go. This support network is an 800-pound gorilla in the examining room. This gorilla is a relative that has diabetes and complains of diabetic neuropathy while carefully sectioning the pecan pie with a surgeon’s precision. The sorority sister is a helpful node that caresses your hand as you await medical results. Patients and clinicians alike must deal with and acknowledge the bounty and dearth of social support. Best interest is the best interest of the collective. This population becomes a self-selected cohort of convenience such as a social network. By looking at socially constructed hybrid of autonomy now navigated in the public sphere, autonomous decision making becomes blurred. But I believe that this ethical discussion is necessary to understand the difficult social realities in which patients exist. “The most complex system is the one which the public has the most to lose” (Battle-Fisher, Application of Systems Thinking, 2015).
SYSTEMS DYNAMIC EXPERIMENT MENTIONED:
Abdel-Hamid, T., Ankel, F., Battle-Fisher, M., Gibson, B., Gonzalez-Parra, G., Jalali, M., Kaipainen, K., Kalupahana, N., Karanfil, O., Marathe, A., Martinson, B., McKelvey, K., Sarbadhikari, S. N., Pintauro, S., Poucheret, P., Pronk , N., Qian, Y., Sazonov, E., Oorschot, K. V., Venkitasubramanian, A. and Murphy, P. (2014). Public and health professionals’ misconceptions about the dynamics of body weight gain/loss. System Dynamics Review. 30: 58–76. doi: 10.1002/sdr.1517.
My book cited
Battle-Fisher, M. (2015). Application of Systems Thinking to Health Policy and Public Health Ethics: Public Health and Private Illness (SpringerBriefs in Public Health Ethics Series). New York: Springer. (Single-authored; Honored as Doody’s Core Title 2016)
CITATION INFORMATION FOR HEALTH SYSTEMS SCIENCE TEXT:
Softbound, 8½" x 11",
Authors: Susan E. Skochelak, Richard E. Hawkins, Luan E. Lawson, Stephanie R. Starr, Jeffrey M. Borkan, Jed D. Gonzalo
SELECT ARTICLES ABOUT HEALTH SYSTEMS SCIENCE:
"Teaching New Content in Health Systems Science" https://www.ama-assn.org/education/teaching-new-content-health-systems-science
"New 'third science' a bedrock for transforming med education" https://wire.ama-assn.org/ama-news/new-third-science-bedrock-transforming-med-ed
"Health Systems Science Curricula in Undergraduate Medical Education: Identifying and Defining a Potential Curricular Framework" http://journals.lww.com/academicmedicine/Abstract/2017/01000/Health_Systems_Science_Curricula_in_Undergraduate.34.aspx
NOTE: This narrative is taken in part from 2 of my HIPPO READS articles:
"What Scientific Gobbledygook! Systems, Uncertainty and “Known Unknowns”- http://hipporeads.com/what-scientific-gobbledygook-systems-uncertainty-and-known-unknowns/
"Chronic Illness, Caregiving and the 800-lb Gorilla Network"- http://hipporeads.com/chronic-illness-caregiving-and-the-800-pound-gorilla-network/