Sunday, March 05, 2006

Uncharted Territory and the Healthcare Crisis

Crisis, What's a Crisis?

Why is it important to understand that the changes we are experiencing in Healthcare are appropriately described as a crisis? First we must understand what a crisis is. When we use that term to describe an experience most people think of the the experience expressed as a traumatic event. It conjures up images of fear and confusion. While this can accompany any crisis the primary meaning of the term is "a critical or decisive moment". If we are experiencing a Healthcare Crisis we must see beyond the fear and confusion and act decisively during that critical moment. I would argue that it is not just one critical moment or decision but a series of them which we must engage. This will take some planning.

Kind Of Like Being a Teenager But Not.

The position I have taken on this blog is that what we are experiencing as a Healthcare Crisis is a transformation process. We are undergoing a paradigm shift in healthcare delivery. In this process we are transforming from an older, established model for delivering healthcare into an emerging, new model for delivering healthcare. In a previous post I compared it to another period of potential "crisis" in human development. That is the transition from childhood to adulthood that we call puberty and adolescence. The whole period of time can be seen as a "crisis" for the individual experiencing the transition but is in fact a series of developmental steps that are essential for human growth and maturity. What distinguishes this type of development from that seen in Healthcare is that the stages of development are anticipated and predictable. As an individual develops they can encounter problems, and while those problems may be unique to that individual, they are not necessarily considered unique to those who have already matured into adults. For the most part this developmental step is charted territory and there are plenty of experienced travelers available to guide the way. This is not necessarily so in the development of a complex adaptive system such as Healthcare.

Who Will Show The Way?

What we are missing in this current Healthcare Crisis is a map. A plan for getting us from where we are, to where we wish to be. While we lack such a map we do not lack those who think they know the way. The reactions to the crisis fall into two camps both of whom claim to have the solution. There are those who see the crisis as one problem which requires only one solution, and those that see it as many problems requiring multiple solutions. The extremes of these two are the "Single Payer, We Need a Socialized Healthcare System" camp and the "Free Market Capitalists, Let the Market Solve It" camp. They each claim to own a map that will guide us along a path that neither of them has traveled, to a place neither of them has seen. That approach may work well in a simple system moving from point A to point B, but is not particularly suited for a complex adaptive system. Kevin Dooley says in a complex adaptive system the order is "emergent as opposed to predetermined". In addition a complex adaptive system's "history is irreversible" and its "future is often unpredictable". Deciding which way to go will not be as simple or predictable as we would like to believe it is.

Where's Christopher Columbus When You Need Him?

If this is uncharted territory there is no map. So how do people travel in uncharted territory? Well there was a time when it was not uncommon to travel without a map. People didn't always arrive at the destination they anticipated but could discover something greater along the journey. Columbus sailing to the Indies and discovering the new world comes to mind. He created the map along the way using dead reckoning as his navigation tool of choice. If we have no idea what this emerging, new model for delivering healthcare is going to look like what makes us so confident we know the path that will lead us to it? I think we need a form of dead reckoning to make our way through this territory. The goal is to create a map that will lead us to a model for delivering healthcare that is far superior to the one we currently have. If this is truly a paradigm shift then that model and the path to it will look much different from the ones we have. The question is how do we create a map of this uncharted territory?

Map Making 101 for Complex Adaptive Systems

Such a map will need to employ certain features in its creation. It will need to be built bit by bit with each new change submitting to a form of natural selection. In a complex adaptive system the basic building blocks are agents which "seek to maximize some measure of goodness or fitness by evolving over time". The plan can be expected to undergo three types of change according to Kevin Dooley. "First order change, where action is taken in order to adapt the observation to the existing schema; second order change, where there is purposeful change in the schema in order to better fit observations; and third order change, where a schema survives or dies because of Darwinian survival or death of its corresponding complex adaptive system." Our attempts to fit the observations of the Healthcare Crisis into existing constructs such as "Socialized Medicine" and "Free Market Economics" may be first order changes and inadequate to deliver a sustainable long-term solution. Some other type of construct or schema may be necessary for a second order change to better fit the observations of the crisis at hand.

The Best Map Is The One That Works

From the outset we must acknowledge that it is a journey through uncharted territory. We must recognize that the journey may take longer than anticipated but will ultimately have a beginning, a middle, and an end. There are a lot of educated guesses about which direction we should take and what we will encounter along the way but nobody knows for sure. We must be very clear on what our objectives are along the way and employ a feedback system to guide course corrections as needed. Each phase of the journey will have its own set of problems that must be resolved before the journey can proceed any further. These problems must be prioritized as to their immediate importance to the journey. Some of these problems will be predictable and can be prepared for in advance. Others will need to be resolved as they are encountered. We must think of this journey as an essential step in our development as humans. We must never forget the final goal is to improve the health of ourselves, our society and our planet. We must be willing to seize the moment and make the crucial decisions before us. If that means we must improve our understanding of complex adaptive systems than that is where we begin the journey. As Francis Bacon once said, "Nature to be commanded, must be obeyed."

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