Download PDF Winter Issue of The Bridge on Complex Unifiable Systems December 15, 2020 Volume 50 Issue 4 The articles in this issue are a first step toward exploring the notion of unifiability, not merely as an engineering ethos but also as a broader cultural responsibility. Reducing Systemic Vulnerabilities in US Health Care Thursday, December 17, 2020 Author: Hamilton Moses III and George Poste Health care in the United States, unlike most developed countries, has no central system for prioritization, coordination, or financing of care and services. This void has been filled by insurers and employers, spawning a host of intermediaries that direct the flow of patients, information, and payments to networks of provider organizations, supported by a parallel ecosystem of academic and corporate research innovation and global supply chains for products and services. US Health Thwarted by Complexity The US health ecosystem transcends all other sectors in the diversity of participants and the logistics to deliver highly specialized services to heterogeneous populations over their lifetimes. It is unmatched in the coalition of scientific, clinical, engineering, and computing expertise involved in innovations, many of which are subject to stringent regulation. The result is an estimated 450,000 entities that drive this complex system. Complex systems are notoriously difficult to change because they are neither entirely closed (and thus amenable to centralized command and control) nor completely open (so they are partially shielded from externally imposed change). These hybrid features explain the long history of frustrated attempts to improve the effectiveness of US approaches to care of individuals with overt disease (medical care); population-based initiatives for disease prevention and disease risk mitigation (population health); and preparedness for large-scale disasters and epidemic/pandemic infections (biosecurity). Despite America’s strength in the biomedical sciences and technologies, beginning in the 1990s a -century-long improvement in population health began to reverse. Compared to other developed countries (the G7), the United States has been the worst performer, with declining lifespan, greater mortality among those under 30, lower rates of childhood and adult vaccination, and higher rates of preventable diseases, institutionalization for chronic conditions, mental illness, drug addiction, and disabilities that prevent employment. In not a single measure of health does the United States consistently outperform other developed countries. Obstacles to Reform Deconvolution of the interdependencies that affect the performance of specific subsystems in the health -sector is necessary but not sufficient. Meaningful progress cannot occur until health is no longer viewed by policy-makers both within and outside the health sector as divorced from critical interdependencies with other systems in relentless competition for investment priorities in the national agenda (defense, infrastructure, -education, energy, agriculture, among others). Spending on health is approaching 20 percent of US GDP, with no imminent prospect of blunting cost. The accumulating shortcomings in patient- and population-centric services have the potential to adversely affect future societal resiliency, not just in economic consequences but, more insidiously, as a catalyst for channeling public dissatisfaction about the adequacy of political leaders and institutions to manage complexity, whether in health or in hyperpartisan politics, geo-political threats, climate change, and US competitiveness in advanced technology. Abrogation of free market principles combined with ineffective regulation has created a Byzantine system of opacity and information asymmetries among payers, providers, innovator companies, and supply networks about how prices are set, often without rigorous evaluation of value in improving care or controlling cost. Policy reforms to confront these market distortions are thwarted by lobbying by insurers, the professions, suppliers, and multiple private sector interests. Reform inertia is reinforced by political reluctance to explore potentially effective solutions, thus discouraging new ideas and innovations. Disagreements between those who view health care as a right versus a privilege often dampen rational political action, resulting in a narrow focus on cost control and fear of deliberate limitations of access to care, either by explicit rationing or tolerance of queues. Instabilities in complex systems arise from decays and disrepairs in adaptive evolution. When the entropy of cumulative inefficiencies and burden of external stresses reach a critical threshold affecting sufficient interacting components, resiliency is lost and instabilities cascade across the system. Whether failure manifests as a -sudden catastrophic collapse or slow sclerotic decline, the underlying etiologies are the same: multiple points of cumulative and convergent failure, with the signals of distress undetected or ignored. Individual Care vs. Population Health The covid-19 pandemic is a stark illustration of how prolonged neglect and cumulative vulnerabilities in population-centric health systems for global bio-surveillance and public health can spill over to expose myriad weaknesses across the spectrum of patient care. The pandemic revealed the consequences of imbalance in investment in public health preparedness (est. US annual cost $3–5 billion) relative to patient care ($4 trillion annually) and how the resiliency of the -latter has been compromised by reduced reserve capacity and reliance on fragile supply chains. Notwithstanding the imperative to reinvigorate international commitments to global public health as a bulwark against future pandemics, the overarching question facing the US health system is how much of the mission should be devoted to individual care versus population health, and which organizational structures best meet the distinctive needs of each? The cost of care for aging populations with multiple chronic diseases, compounded by unaddressed inequities in disease burden arising from socioeconomic disparities, is economically unsustainable. Reduction of these high-cost and personally devastating conditions will require better integration of care delivery for the ill with parallel initiatives for mitigation of the socioeconomic factors that affect disease prevention, access to care, and education about the role of lifestyle and behavior in disease risk. The latter are largely beyond the control of physicians and care providers, who have few tools to address them. Need for Large-Scale Information Systems Remedy of the looming systemic failures in health care will require the development of large-scale information systems for facile data capture, analysis, and real-time situational awareness to better detect and respond to emergent failures. Biomedicine lags other sectors such as transportation, banking, and telecommunications in adopting advanced information systems. Vast amounts of data remain inaccessible, trapped by inadequate standardization of reporting formats, database design that does not reflect clinical needs, and lack of systemwide inter-operabilities, reinforced by commercial, administrative, and cultural barriers to data sharing between institutions. US government efforts to establish electronic health records (EHRs) as a critical asset in care decisions have been protracted, fraught with expensive failure, end-user frustration, and as yet uncertain benefits on outcomes and cost savings. The core limitation in EHR design is failure to recognize that clinical decisions stem equally from tacit (intuitive) and explicit (codified) knowledge. Technology that impairs clinicians’ cognitive activities and workflow can produce unintended consequences that are not compensated by system adaptability. Belief that the entry of the Silicon Valley data -behemoths will resolve these shortcomings remains as yet unjustified. To date their efforts are largely task specific. More ambitious forays for holistic systemwide integration will be the true test of their strategic value. Conclusion Gains in health and medicine through the use of engineering and computing have been incremental, focusing on performance optimization of narrow systems largely separate from interacting complex systems. -Targeted, limited remedies have recognized value. But the scale and adverse implications of the myriad fragilities embedded in the health ecosystem demand urgent and more ambitious redesign. Interventions must occur simultaneously from outside and within the system itself. A prerequisite is clarity in defining the desired future state(s) and establishing waypoints to measure progress. Success will depend on forceful leadership from public and private sector payers, providers, and patients/consumers as well as continued academic and corporate innovation. Ultimately necessary is political will to implement sustainable change, despite the painful choices involved. Meeting this challenge will require that concepts and methods of systems engineering move beyond the predominant focus on bounded systems to examine higher-level interdependencies. The ravages of covid-19 and growing burden of -chronic illness highlight the urgency of these imperatives.  Health and health care refer here to the direct provision of clinical care to indi-viduals, including that provided by physicians, nurses, and other professionals; institutions -(hospitals, extended care, and others); and drugs, medical devices, and laboratory and information services. About the Author:Hamilton Moses is founder of the Alerion Institute, formerly partner of the Boston Consulting Group and chief physician of the Johns Hopkins Hospital and Health System. George Poste is Regents Professor, Del E. Webb Professor of Health Innovation, and chief scientist with the Complex Adaptive Systems Initiative at Arizona State University.