Merger of GHSU and Augusta State University in Georgia

It was recently reported in The New York Times that several pairs of colleges and universities in the University System of Georgia are being merged, including Georgia Health Sciences University (GHSU) and Augusta State University (ASU).

http://thechoice.blogs.nytimes.com/2012/01/11/georgia-university-merge/

I earned the MBA at Augusta State University years ago and am presently a student in the Master of Health Informatics degree program at GHSU. I think two valid reasons to merge institutions are the benefits of synergy and the possible savings of money. Higher education is costly and the desire to reduce costs is understandable. My guess is that the motivation of the Regents for this merger is primarily based upon an anticipation of cost savings. Synergy can be achieved through shared services and cooperation among institutions.

It seems to me that mergers are more likely to be successful if the missions of two institutions are similar. Given that educational services are increasingly being delivered virtually (online), perhaps decisions about mergers should be based upon mission statements rather than geography. And, in any case, I wonder about the hope for cost savings. The resulting complexity of merged institutions may in fact lead to more costly operations. If institutions with different missions are merged, costs may actually increase while the focus of the institutions may be diffused.

In my experiences, both Augusta State University and Georgia Health Sciences University are good and valuable institutions. ASU is more a general-purpose state university, offering a wide variety of kinds of degrees. Augusta, Georgia is certainly large enough to need and merit such an institution. GHSU is, of course, focused on medicine and the administration of health care institutions. There are a number of valuable state universities in the Georgia system similar in mission to ASU. GHSU is a more specialized institution and is already complex in its administrative structures. There is going to be a period of adjustments and transitions resulting from the merger. I wonder if in the short term the quality of health care delivery in the state of Georgia and beyond may be affected while attention is diverted to some degree from mission to adjustment at both existing institutions.

In the long run, is the ASU campus going to become medically oriented throughout its existing degree programs and research? Is GHSU going to become less focused on medicine and healthcare administration? Or will the two institutions each remain pretty much as they are but operate under a single (highly stretched) administration? For starters, there is going to be a struggle to decide who who stays and who leaves among the administrative ranks. And what will the new entity be named? Will selected programs be merged at the college and departmental levels? GHSU just went through the process of changing its name from the former name, "Medical College of Georgia." The new name is intended to emphasize the mission and focus of the University. As a citizen of Georgia my major immediate concern regarding this merger is the continued quality of medical education and the continued quality of medical care. I wonder if in fact any cost savings will be realized by this merger and if the possible synergies might have be realized through the sharing of services rather than merger.

Smarter than the average pixel?

What I understand of this TEDMED presentation by Dr. Eric Schadt is that it is not adequate to try to understand complex systems using simple linear thought (unless, of course, you are running for high political office). The part I am struggling to understand regards the idea that the causation of disease cannot be determined by studying populations of people and using statistical methods of analysis. Isn't epidemiology based on the notion that aggregate research designs can lead to insights into the causations of diseases in populations? And if an independent variable is important in the aggregate explanation for a disease or condition, isn't it likely to be important in the understanding of specific cases? It might be helpful to me to hear Dr. Schadt engage in a conversation with an epidemiologist about patterns of medical causations in individuals and populations.



It is the metaphor of the movie and the "average pixel" that I have not yet understood. Yes, there is no perfectly "average" patient. A specific instance of a disease or condition may be unique in causal origin. But I want to believe that understanding the health of populations sheds light on understanding the likely causes of instances of diseases/conditions. Patterns in complex systems are usually fractal in nature, meaning that the same patterns are evident at multiple scales. Perhaps I am trying to think too deeply about this or am simply missing some essential insight. Reader, I would welcome your comment that could shed some light.

Markets and governance

I am concerned by potentially revolutionary movements on both the right and the left side of the political spectrum in the United States. I am concerned that our system is broken and can longer able to generate rational solutions. Healthcare reform cannot be successful if transformation is impossible because of constrained resources and political failures. Those people who can cope with complexity are disadvantaged by our political system and are unlikely to win political office. I fear the resulting polarization and the social consequences.

Challenges beyond Jeopardy

IBM has an amazing history. It built its corporate culture and initial wealth building and selling mainframe computers to large bureaucratic organizations. IBM tried to make the adjustment to networks of microcomputers in the 1980s and had to shatter and reinvent its corporate culture in the process. IBM invested in Second Life apparently thinking that the next great thing might be in virtual worlds. Now it seems to be betting the store on its ability to move from the information business to the knowledge business and in so doing transform many industries including healthcare.

Let's assume for the moment that a comprehensive knowledge base of evidence-based clinical pathways has been build and that some very advanced computer like Watson has the software inference engine to make important decisions about patient care based upon the input it has instructed human medical providers to enter. And let's further assume that organizational changes have been implented in the United States that have resulted in a very high degree of medical conformance in implementing "Dr. Watson's" instructions. Would this necessarily be a good thing? What would be some of the consequences?

A Star Trek fan, I remember the episode titled Spock's Brain first broadcast September 20, 1968. Dr. McCoy is tasked with the responsibility to put Mr. Spock's stolen brain (being used to run the public works infrastructure of a city on some other planet) back in place and reconnect it to his nervous system. But the knowledge of how to do that, once known, has been lost. McCoy puts on a device known as, "the teacher" that allows him to recapture the knowledge needed to perform the work.

I cite the episode of Star Trek to suggest the if we did have a computer system like IBM's Watson loaded with evidence-based medical pathways we would in the short term advance medical knowledge but in the long run we would lose grasp of medical knowledge. Watson, as amazing as it is, does not have knowledge. It only processes patterns. The GPS unit that I sometimes use while driving seems to have a capacity for thought and I sometimes project into its voice the evidence of judgment. I sometimes image that its spoken word, "recalculating" is really its saying, "You dummy, I told you to turn back there!"

There is the knowledge that exists in individual human minds, and there is social knowledge that exists in social networks. While computers can facilitate human knowledge (both individual and social) they do not have knowledge and are not likely to gain that ability. My point is that as we become more dependent upon computer systems we risk losing "the old knowledge" that we will need to not begin to treat computers as if they have knowledge.

The risk resides not so much in the potentials of technology as in the capacity of humans to anthropomorphize computers and robots. Build an attractive robot (it does not even have to have human features) and put something like the inference engine of Watson behind it and people will begin to trust this entity that in fact has neither knowledge nor emotions. "Watson," in fact, understands nothing. Human care givers will become the interface between the technology and patients but will lack the ability to effectively judge decisions suggested (or made) by the technology. There will be no "teacher" device that one can put on to know what is represented in the computer system in forms that are less than knowledge. Computers are dumb but they have massive memories and incredibly fast processors. Computers can be networked together into massive arrays. Humans are smart but have tiny working memories, slow processing speeds and as of yet we have not created high bandwidth social networks. Clearly there is need to design more effective joint cognitive system (see book by Hollnagel and Woods) for medical and other purposes, while facing the prospect losing our knowledge of how computers are making decisions without knowledge.

Seeing Patterns in Data, Taking Actions in Life

As a university teacher I have taught on an number of campuses during my career. A few students remain in mind through the years for either having made a lasting positive impression or a lasting negative impression. I remember one student in a previous university employment who told me that as a public official her preparation for the prospect of a deadly epidemic would be to buy lots of coffins. I was at the time trying to teach her and other graduate students to use computer modeling to gain insights into dynamic complex systems so as to be able to take informed preemptive actions. In retrospect I realize that I should have been better prepared to demonstrate use of the software to my graduate students. But neither my colleagues nor my students seemed to appreciate the pedagogical use of computer simulations to help students better understand complex systems. I think now that if I had only shown students a computer simulation rather than asking them to think through the modeling of one the assignment would have been deemed acceptable. I have for years advocated that the academic field of public administration become more of a design science with ties not only to political science, management and business administration, but also to operations research. I take some comfort in the thought that Herbert Simon, if he were still with us and if he knew, would approve of my efforts, even if my efforts have on occasion contributed to the mobility of my career.

These memories were sparked this evening upon viewing the following TEDMED 2010 presentation. Jay Walker spoke of the origins of public health statistics using a Bills of Mortality book prepared during London's great plague of 1665. To me, his point is that data is the necessary basis of information that can support the knowledge needed to recognize patterns and design interventions.

If you would like to view the video directly from the YouTube site the URL is as follows.

http://www.youtube.com/watch?v=5IRsqDnPzSE

Addressing the Challenges of Multiple Chronic Diseases

This is a reflection on the article, "The Growing Burden of Chronic Disease in America" by Gerard Anderson and Jane Horvath, Public Health Reports, May-June 2004, Volune 119. The essence of the article is that a growing percentage of Americans have multiple chronic diseases; that the costs of treating people with multiple chronic diseases is high; that people with multiple chronic diseases usually see multiple physicians; and that physicians are not very successful in coordinating their efforts with one another to address the needs of specific patients. The theme here is complexity.

The human mind/body is a complex system. Physicians always take into account the complexity of multiple body systems when addressing a single medical need. But when the same body has multiple needs the complexity of interactions among the conditions drives up the complexity of trying to help the patient. And then when multiple physicians become involved (and multiple medications are prescribed by various physicians) the entire situation is likely to get out of hand. The patient is the center of the system of care but is unlikely to have the knowledge necessary to try to orchestrate the entire effort.

W. Ross Ashby introduced his Law of Requisite Variety in about 1958. The law states that if a system is to be stable the number of states of its control mechanism must be greater than or equal to the number of states in the system being controlled.

http://en.wikipedia.org/wiki/Law_of_Requisite_Variety#The_Law_of_Requisite_Variety

In the case of a patient with multiple chronic conditions, it follows from Ashby's Law of Requisite Variety that the coordinated medical care delivery system (the "control mechanism") must be at least as complex as the human body as a macro system (system of systems). Well, we are going to lose that one!

I believe there is another approach. It is root cause analysis. What becomes manifest in a patient as multiple chronic conditions may be the product of a few root causes. Stephen Wolfram has demonstrated that recursion among a very few simple rules can produce very complex fractal patterns. A chronic condition (or a combination of them) may possibly be interpreted as complex fractal patterns derived from a relatively few root causes.

http://en.wikipedia.org/wiki/Cellular_automaton

While reflecting on the article by Anderson and Horvath I am wondering if it may be possible to make clincal applications of root cause analysis in the treatment of patients with multiple chronic conditions. As it is, these authors are advocating addressing complexity with complexity, as per the insights of Ashby. Medical conditions are products of causal trees. If physicians aim too high on the causal trees they are likely to produce cascading complexities. It is the difference between the perspectives of physics and the other sciences. While others see complexity, physicists search for the simpicity from which complexity springs. If it is possible to aim closer to the roots of causal trees it may be more feasible to address the needs of patients with multiple chronic conditions more effectively.

From systems understanding to systems design

I have always been interested in analysis. As a child this was evident in multiple adventures in taking things apart in order to try to understand how they worked or why they were not working. As an adult my interest in analysis has been manifest in terms of studying object-oriented software, relational databases and service-oriented architectures. Understanding how hospitals function and why public policy often produces unintended results fits the pattern of my interests.

It is all about systems and about dynamic complexity. The basic challenge in hospitals is the existence of two competing basic needs -- the motive to serve and the motive to survive. These two needs play out in patterns of scenarios involving many stakeholders who themselves embody these two needs. The pattern is fractal. In public policy, the core problem is that stakeholders tend to feel threatened by new legislation and can usually find ways to modify their behaviors in ways not intended by those who created the legislation. Plus, our political system itself is in a dysfunctional state such that rational policy making is often not possible. Insight into why things are as they are is one thing. Learning to become a player in the existing system is another. Hoping to improve dysfunctional systems is quite another. As a child I was often frustrated by my having a greater ability to take things apart than to put them back together again. Now as an adult I hope to gain additional abilities not only to understand but to play and to possibly to help design complex systems. My hope is that the field of Public Administration becomes more of a design science, as I think Herbert Simon suggested.

Patient Advocacy and Knowledge Management

This Christmas morning I am reading a blog post by Jacqueline O'Doherty titled, Dissecting the role of a patient advocate.

http://www.hospitalimpact.org/index.php/2010/12/22/patient_advocates_guide_patients_through

She writes as if she has real power in the decision making process. It seems to me that a patient advocate is in the midst of a very complex set of participants in which there really is no centralized power. I am thinking of dynamic models of complex adaptive systems that tend over time to switch between multiple patterns called "attractors." The situation was in one attractor prior to the patient's unexpected massive stroke. Then the entire system shifted into a very different attractor. The system has a life of its own, so to speak. No one is really in charge.

Jacqueline O'Doherty writes that she called a meeting attended by every doctor and other major caregiver. She writes that this meeting allowed everyone to understand and be on the same page concerning the patient's diagnosis and prognosis. I remember "calling" such a meeting once years ago when I was a patient advocate for my father. I was only a teenager and found myself alone in a room with perhaps eight physicians and other care providers. I was his family. To the best of my ability I spoke his preferences and values when he could not speak them himself. They took time to explain the situation to me from their professional perspectives. It was quite an amazing experience.

As I think about what Ms. O'Doherty has written I realize that patient advocacy is more than knowledge management. But it seems to me that knowledge management is a major part of it. I don't think it is possible or practical to always call a meeting. Otherwise, physicians and other providers would spend most of every day sitting at a table. It is like a dance in which the music sometimes suddenly changes. It is not a square dance with a caller. I keep remembering Mary Parker Follett writing about supervision and authority. In her view, it is not about which of us leads. It is about how we respond together to what we face. But to understand how this scales up to large numbers of medical providers, insurance companies, administrators, and family members (plus the patient, of course) is quite a challenge.