House vote on the debt ceiling legislation - August 1, 2011

I watched the members of the U.S. House of Representatives vote on the debt ceiling legislation this evening and am reflecting now on the meaning of it. The scholarly explanation is that as a complex adaptive system our political system is presently stuck in a dysfunctional attractor. Assuming the U.S. Senate votes for the same language tomorrow and the President signs, I think they will have essentially kicked the can down the road a piece. I think our nation will soon lose its AAA credit rating and that all Americans will experience the equivalent of a substantial tax increase - not just the few who were saved from a return to their obligations during President Clinton's presidency. In my opinion, this bill will have more adverse financial consequences for "corporate jet owners" than a more responsible bill would have had. A more responsible bill would have prevented a probable loss in the nation's credit ratings that I think will hit every American -- not just those who are best able to buy their access to political power. I doubt that the stock markets of the world will be pleased by this legislation. My only moment of celebration this evening was the return of Representative Gabrielle Giffords. To me, she is more than a member of Congress. She is a living symbol of a great nation and of courage and survival.

Regarding the specific subject of this blog, a CNN announcer this evening made reference to future cuts affecting healthcare providers but not patients. Whatever affects providers is going to affect patients directly or indirectly.

Toward a Complex Adaptive Health Community

The "One-click Download" at this URL will display a paper titled, "The Wiki and the Blog: Toward a Complex Adaptive Intelligence Community" by D. Calvin Andrus of the Central Intelligence Agency. The paper was published in Studies in Intelligence, Volume 49, Number 3 in September of 2005.

http://papers.ssrn.com/sol3/papers.cfm?abstract_id=755904

The essence of the paper is that Web 2.0 tools including wikis and blogs can be used in organizations as effective means of knowledge sharing. The author attempts to make ties to information theory and complexity theory to say that systems (organizations) can be designed to promote the emergence of knowledge from within rather than from above. As I teach courses in Public Administration I try to help my students understand the importance of "connecting the dots," as, for example, in case work. Because of their hierarchical structures bureaucratic organizations often do not facilitate the flow of information throughout and among agencies. Networks can facilitate information flow more effectively, but there is no assurance that information will flow where it is needed without a culture that encourages sharing and some means of shaping information flows. I liken this to hydrology and landscaping. Good landscaping usually does not have to depend upon sump pumps to control the flow of water. Good landscaping "helps" water find where it "need to be" rather than controlling it by force. In organizations there needs to be a means by which people can signal to others what information they need and what information they do not need. Information flows through social networks that are shaped by personal relations as well as defined roles.

Like the CIA and other intelligence organizations, healthcare organizations are information intensive. Decisions must often be made quickly by people who may not have immediate access to all the information available within the system. The flow of vital information is shaped by organizational cultures and by traditional professional roles. Patients are sometimes seen as passive recipients of care rather than as key information resources. In fact, success or failure is largely in the hands of patients who may or may not comply with care directives. Cost containment is also larely in the hands of patients.

I believe the key word in the title of the paper by Andrus is, "toward." Intelligence agencies do not yet always "connect the dots" quickly enough. For all the virtues of emergence, it is a slow path to design. Healthcare institutions are complex adaptive communities. To the degree what we can "landscape the cultures" in which healthcare services are provided we can improve the quality of care. There are multiple kinds of barriers to information flow in healthcare organizations. Design solutions are not exclusively structural or technological. People need to think before they click on the "send to all" button. We need to become more aware of the systemic consequences of how we share (or not share) information. We need to become more aware of how attitudes, professional roles, and other aspects of culture affect informtion flow and health outcomes.

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.