Robust healthcare systems

Enterprise architect, CTO, product designer at Princeton Digital Advisors
Apr. 30, 2020
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
Robust healthcare systems
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Robust healthcare systems

Editor's Notes

  1. Presentation and contents Copyright © 2020, Princeton Digital Advisors, LLC. All Rights Reserved.
  2. We’ll cover along the way: Typical health IT systems (primer) across provider, payer, patient DT has changed during the pandemic, more accurately accelerated – but not along the plan we had before – towards patient centricity What is the difference between traditional design and design for robustness and design for antifragile? One form of digital transformation would be to eliminate or reduce in-person experiences ~ making remote on par
  3. Let’s review where we are as of 30 April. A definite sense of change and a lot of questions going forward. Business and technology leaders are looking around for guidance. The next level down beyond statistics is understanding the patterns underneath. We know, for instance that… Businesses are starting from different spots – some industries had “pre-existing conditions” which were trends indicating that current business model was unsustainable. Some businesses had experiments, green shoots which could be accelerated (a plan that could be put into action) – just had not been taken seriously Some businesses have not done strategic planning and may not make it with us in the same shape. (McKinsey puts this as 18% will thrive on new business model, about same number will cease to exist) Refs: NAM – Conference Board
  4. What specifically is going on in healthcare? We’ve seen a lot of these challenges in the news and with our colleagues. Let’s take a look at what systems we’re talking about, just as a refresher.
  5. Healthcare systems are both a complex portfolio of data flows and also distributed across organizations; we will call this a complex system. Causes us as architects to look at our organizations systems in the context of changes to our partners as well. System of systems. How do organizations under stress maintain continuity when certain systems and orgs are under stress – does the whole ecosystem collapse?, image from Royal Soc. May 2019, Outbreak analytics: a developing data science for informing the response to emerging pathogens
  6. These are traditional, linear processes for emergency operations. Our business continuity planning takes a lot of preparation for known scenarios (natural disasters) and does not function well when we have a new type of occurrence (or ones we’ve only seen in particular domains at a limited impact). Most Universities for instance had NO plan to go online. Ask yourself, how good of a solution can you come up with on the fly when you do not have even a similar plan? This talk is about how to ideate better. Army - Gartner - Traditional -
  7. In healthcare specifically, we are used to fall-back, written manual procedures if WiFi goes out… a very fragile solution designed for short-term BC (assumes we have time to fix/redevelop or condition will go away quickly). Giving the two possible ends of the spectrum – one where we get information flow from our existing sources, and assume the ideas we had previously may need to be tweaked; the other where we start with the premise that even what we thought of the environment was wrong and we missed some signals, and need to look broadly for new inspiration before continuing ANYTHING from before the event Left side is ego-driven, top-down, assumes control; right side is team-driven/internally honest about limitations Left side uses existing resources to plan way out; right side is open to external advisors (outside experiences, often further afield or green shoots), requestions assumptions (in case they’ve changed) Most orgs lean towards the model on the left – risk averse going into crisis. has some good advice on looking at these two models (graphic courtesy of EA Directions.
  8. We see the same patterns in healthcare IT systems as we see at the macro level. This shows a view of different orgs being prepared at different levels We always say Don’t let a good crisis go to waste…? – what do we learn from this… Huge gap in looking around for what was succeeding and making it our own. Telemedicine may “stick” and be preferred over in-person - Elective surgery used to fund the ICU, what if ICU is 100% of business? Not funded correctly if that’s the case Delivery or packages on the curb over brick & mortar Are we ready for engaged experiences like technology consulting over Zoom?
  9. This is n organizational and systemic issue. A strategy that only works for my group ignores those nonlinear inputs from other orgs. A strategy for architecture that assumes my system is in a vacuum, ignores the fact that parts supplied from outside my control may be required and cause me to fail, even if I would scale normally. Image -
  10. We see part of the future now, but not all of it. This is therefore difficult to do traditional gap analysis with (no complete future state, no bridging patterns) Next, let’s look at complex systems starting with some theory and orientation.
  11. Complexity allows us to think of systems of systems which do not have linear responses to each other (they change around us) based on environmental stimuli Radical change of operations on continuum 5% telemedicine to 100% Facilities unusable – “meet me out back” References on complex systems: Avancier - Evolutionary architecture -
  12. In evolutionary architecture, or “adaptive” architecture, we can use a fitness function in stead of a code review, to assess how well the design undergoes change and meets the needs of the system requirements in ASR areas. This lets us go beyond microservices as a universal goodness, to understand how changes to coupling, module design and decomposition, and platform layers & boundaries affect the overall –ilities of the system. When we say replacing code reviews, we are changing from an experiential model (senior developer to junior developer) to establishing the “rules” for how decomposition will be accomplished. The developer, the DevOps engineer, and the product owner should be able to interpret these in their work product. The challenge for the architect is then how to measure the functions over time for any given significant requirement (or quality attribute).
  13. Architecture of systems came from a desire to control the outcome in a creative process – new methods reexamine this premise. Agile design moves to multi-skilled individuals working closely together to deliver faster than with specialized, distributed teams. We do not have a way yet to consistently deal with systems of systems or, in this case, a way to build resilience into systems. This again comes from a tension between the desire to control outcomes and future-proof systems. Looking at how agile plays out, we have a couple minor changes like using microservices instead of N-tier which offer the potential for some gains in certain attributes like performance or throughput but fundamentally we do a little architecture all the way through the process in an iterative way (not much different to waterfall). Agile makes a clear distinction between the short-term project and longer-term goals (architecture) by role and artefacts, usually prioritizing the project over these design aspects which become more important over time. Agile is fundamentally evolutionary design, when compared to waterfall. We acknowledge that we do not know the details of all the tasks to be done at the start of the effort, but prioritize regularly to zero in on the final work product. It is very developer led, and not very systems-of-systems aware. Evolutionary design adapts architecture to be able to consider stressors known ahead of time in the design – building the resilience in for certain very difficult to measure dimensions ahead of time. This creates initial guidance in these areas – guidelines for the team to measure against (with fitness functions) as the project proceeds. Antifragile design takes this a step further to build in resilience for changes in dimensions we may not anticipate needing ahead of time. This extends the theory we had in ATAM/FMEA. The residue is a part of a system which is left after a stressor changes. A true call to action to design differently Microservices work sometimes… no different than Open Source Look for decoupling and ability to have failure in a component (which redundancy does not mask) CAP theorem
  14. Challenge to the architect is how you get these to the whole population and not worsen the experience (digital divide, ethical issues, other conversations we’ve avoided for a long time in systems resilience) How do we leverage technology green shoots? NORA Bot - Conversa integrated healthtool and chats - Teladoc - Avizia/AmWell - & mobile app - Digital twin - for more AI – LifePod -
  15. We answer this at least at 3 different levels of thought… all of which are interdependent. For example, when would you consider it safe to go to a restaurant with your friend. Depends on your situation certainly, what the restaurant might have done (Papa Johns advertisement that no one touches the pizza with bare hands after it leaves the oven), and what national guidance might be. Would you wear a mask? Would you do that if the hospitals were full or if there were empty beds? Context matters in organic systems – what if there were a preventive shot you could take to inoculate you? Let’s take a personal example: an ER visit. If we had a system to represent this, it might be some sort of facilities, provider and patient record system. The stressors during the return to work period are dynamically changing. What if we see a rise in work absences from ambulance drivers, or an ineffectiveness in initial testing in home, or a reported process or equipment failure (which ends up to not be true), or a hacked EMR system which routes billing to a non-existent account? We may have more time than in the original crisis to spend in design, and we may have learned lessons from that previous period, so that we can actually start buying down the overall risk level (unknowns) for the next version – making it more adaptable. This broadening of stressors beyond normal modeling will be continued in later versions and will also help make our system more robust. It is part of the path then, to getting to a next stable plateau, a new normal. National level – super-organizations National or trans-national healthcare systems (interoperability, democratized access similar to Ryan White?) Organization What does the new customer journey look like? make the lessons learned in the crisis become the new digital normal (err on the side of pushing the envelope towards the new model); which things did we (or peers) have in flight that worked extremely well? look to the transformation in our own org which made it more efficient during the crisis – what did we learn? Cash flow – what do I depend on to keep the old business running (suppliers, interactions, etc. from BMC); operations can take a back seat and fill in between #1 strategy meetings; the value add in continuing these is limited as customers and partners are making decisions separately Projects - (many may be evaluated in light of 1 or 2) – some customers may be recovering themselves and no longer be interested/prioritizing these, or the projects may need re-validation of value proposition – may be obsolete work; previous projects selected as best in breed may not have same $$ value, and ones prioritized for lowest cost may have changed too Business flow changes (HR, finance, sales, creating products & services, R&D/innovation) How do I identify which talent should be shed? How do I rebuild talent? How do we communicate to all of our staff and suppliers? Is testing a “benefit” I would offer? How do I protect the communities we work in? Should I offer deals to customers who are struggling? Postpone payments or create incentives which might be free or divert cash flow to NGO’s? HR work remotely…
  16. Two things going on at once in a VUCA event: the business changing dynamically, and the system we’re trying to get out is not stable What experiments do we need to do to answer this question with a technology-based solution? For example, we have the town of Vo’ in Italy, who has been isolated and is fairly homogeneous, to know the time duration of a contained outbreak and could test an “immunity passport” within the rest of Italy. Image courtesy of NYT and WSJ (mobile app is a band plus phone app being tested in S Korea) Some questions about requirements: Who certifies workers to return? Healthcare provider (who has the test), self, state/national orgs? How do we certify that (antibody tests?) What about other controls like travel restrictions, quarantine for international visits… What is acceptable risk? How to avoid workers comp claims as employer? (what is safe workplace) What if COVID is rolling curves of infection (relapses or mini-pandemics)? Which industries will come out first? What dependencies will make this slower because we optimized SC for only certain events? Doctors do this fourth step but are not always aware themselves – Menard in New Orleans noticed a high number of flu patients coming in NO in January; did not have test for coronoavirus and miscoded them, but knoew something was different. Before we say we can’t do this, we may want to look at how test kits can actually get much more data than just symptoms (often multi-respiratory tests to identify different viruses, even unidentified ones – can cross off the list) Are we being Cassandra? Or is this easier in hindsight (i.e., only thing we have to do is put into project plans?) No, I think it’s a bit more of a call for architects to look around the fringes and bring technologies into the mainstream. The next pandemic will look different, so just solving for what is happening today is not adaptation, it is just making one aspect more robust. Not saying this is the solution or even one solution, but as we design systems, we have some technologies that may be used – with more data feeds than we’re used to, more integrations, more cross-organizational sharing (or drop-outs) – to be able to build these resilient systems.
  17. Shed fear of ambiguity over the process we’ve learned from the last way of working (we’ve learned over years through experiences, which preserve ourselves but cut off ways of thinking that modify the model). The customer is radically changing (or moving ahead) in this period and unlikely to go back to previous modes. Your organization can choose to go forward. As a personal practice of architecture, this means we do not treat the experiments as a side job (lesser) to large projects simply because they are comfortable; the experiments hold the key to adaptation and higher business value. Experimentation: Free of quarterly earnings, propose different staffing and resourcing Test & learn – truly fail, and truly learn from failure Observe interactions and customers Everything through the lens of customer value; even small changes can get 10x return (avoid big projects with 1.5X ROI – waste of capital focused on incrementally getting back to old way of work usually) Supply chain resilience has new meaning
  18. By industry, BusinessInsider - Brookings - Accenture on consumer goods - (note broadening of supply chain surveillance)