This document discusses how healthcare systems have responded to the COVID-19 pandemic. It notes how customer behaviors have changed, requiring more patient-centric and digital approaches. As complex adaptive systems, healthcare organizations have adapted in distributed ways, such as deploying telemedicine, collaborating on supply chain issues, and sharing data. Moving forward, the healthcare industry may adopt more customer-centric and digital technologies on a broader scale. Architects are encouraged to design systems using approaches like evolutionary design and antifragile architecture to enable continuous adaptation to unexpected challenges.

1. An Association for All IT Architects
Complexity and Robustness
in Healthcare Systems
Brian Loomis
Princeton Digital Advisors
Who’s leading your digital
transformation?
a) Your CIO
b) Your CTO
c) COVID19

2.  A first look at the situation of the COVID19 outbreak
 How customer behaviors have changed and patient-centricity
 How do complex, adaptive systems respond?
 And a look down the road
 What happens after COVID – has the practice of medicine changed?
 Is the customer experience a similar quality?
 What do we take away as application architects?
Overview

3.  1M+ nCOV-19 cases out of a population of 330M, not actually sure how many others may have had it or even have died from it
 Air cargo down 27% in March; truckload cargo actually up
 Major universities go entirely online; University of Chicago students protest full tuition payment for lower quality online
 Movie theaters closed; 38% surge in Netflix usage (and Hulu…)
 Airbnb down 96% in Beijing, 50% in US... changing refund policy for thousands of owners; airlines receive bailout and must fly
certain routes
 Energy sector gas spot price to sub-$40/barrel, down 50% YTD; can store North Sea but not in Oklahoma
 One third of rental payments in first week of April were not made; refinances on home mortgages accelerating, potentially with
best rates in a generation
 Restaurants revenue, normally $870b per year, down 35% in first week of March; 200% growth in online grocery app downloads,
45% growth in online grocery and Walmart orders to curbside
 35% NAM responses indicated supply chain was causing delays in manufacturing; record breaking US output at 2.4 trillion
dollars in goods produced in Q4 2019 (just a few months earlier)
 GDP prediction from 2% growth in 2020 to a 2-6% contraction. Government response has included sector bailouts, relaxing
scheduled payments; industry extends contracts, skip a payment. What do layoffs mean to disposable cash purchases?
 Stock markets in US down 16%, back up 8% already – U- or V-shaped recovery?
 Do cruise lines have a future?
Some recent facts

4.  Who’s giving the guidance?
 Inter-organization cooperation: command & control (recommendations versus directives, legal and process
agreement on the stockpile, intra-org comms between call center and hospital and HR), data sharing, supply
chain/logistics – testing? Ventilators? Morgues?, decision making and trials (assessment)
 Collaboration technology – patient-to-family, patient-to caregiver/provider (anxiety, correctness or delay in
getting results means increased effects of coronavirus), rumors… or contrary info (or agitators like people
who cough on produce at the store or Zoombombers)
 Very distributed facilities
 Change in scale to usage, and geographic diversity
 Physical facilities needed to be reconfigured or were obsolete
 Experience and expectations changing
 Technology (and healthcare) reach to all the affected population, not just current customers
 Previous experience provided in-person contact as reassurance, high-value add (maybe not so much)
 Is security an ASR?
 Internal and external business model challenges
 Cross-subsidies, referral & billing systems brittle
 Not just healthcare workers on the front lines… postal workers, fire/police, business owners, social services,
inmates, public press, nursing homes, manufacturers!
Challenges in healthcare

5.  Provider (hospital, clinic, non-profits
esp. in mental health, pharmacy)
 EMR, specialty (radiology PACS), quality
of care, scheduling and operations, supply
chain, reporting, HIPAA training &
compliance…
 Payer (insurers, benefits managers,
etc.) benefits transactions, reporting,
codes…
 Patient (self, family, community,
employer) portals, ancestry.com
 Clearinghouses & research databases (Universities
and non-profits)
 National and international organizations (Medicare,
CDC, WHO, county health departments)
Healthcare is distributed

6.  US Army FM 5-19 – Composite Risk Management
 Parallel planning from strategic to tactical
 Identify risks, assess, develop controls, implement, supervise & evaluate
 Gartner
 Define business model, identify uncertainties, assess, design, execute
 Traditional risk management
 Probability * Impact = Evaluated Risk Priority
 4-stage Crisis Management
How do organizations deal with a crisis
BUSINESS CONTINUITY PLANNING

7. ONE APPROACH – “WAR ROOM”
 Stabilize first
 Evaluate which parts “go forward” and then fix gaps
 Looks backwards first by looking at projects in flight (bias
towards learned experiences)
 Low risk (consensus based with current participants) but
also assumes threats are something we can identify and
plan for
More on decision making in crisis
ANOTHER APPROACH –
IDEATION/CREATIVE
 Take a broad look at how the environment
changed and sense trends before envisioning
the new business model with customers
 Looks forward to green shoots internally as
well as lunatic fringe externally, but runs the
risk of untrusted advisors, jeopardizing some
short-term business, and not being able to
transform in time
 Can get out of a local minimum for unknown
stressors

8.  UNPREPARED, WING IT
 On a HIMSS call, a German doctor indicated each State was having
to build their own infrastructure and reporting on COVID, which really
shows how we've traditionally done healthcare as doctor/institution-
focused doesn't make sense when medicine is becoming
patient/population centric
 GREEN SHOOTS ACCELERATED
 WiFi deployed to new hospital areas, Teams and Zoom in high
demand but facing hackers changing data and Zoombombing
 Telemedicine moved from 1% to 99% but ditched video
 Some local health departments had better plans based on similar
SARS outbreaks
 READY FOR NEW NORMAL
 South Korea already had a mobile app installed broadly to do contact
tracing
What do we observe in healthcare?
The future is already here. It's
just not evenly distributed yet.
~ William Gibson

9.  Can’t build a plan ahead of time (this was how many
looked at business continuity)
 Destructive competition – prior suppliers, friction in
engaging volunteers (read: organic adaptation) in the
organization, competing organizations
 Unknown public policy, governance – not a simple opt-in
 Communications is hard!
 Systems do not adapt, they only scale as one part of
ecosystem
 Linear design process based on decomposition implies
systems can only change so quickly once they are in
production
Why this doesn’t work for VUCA events

10.  New business models take shape
as we cross the chasm
 Customer behavior is changing,
unlikely to revert fully
 Customer-centric advances as a
new normal
 We made some half-steps with patient-
centric, consumer-centric, student-
centric
 Now we have to go further…
 What is the difference between a
COVID response and digital
transformation?
Can we work backwards from a new normal?

11. Characteristics of complex adaptive systems[1]
 Path dependent: Systems tend to be sensitive to their initial
conditions. The same force might affect systems differently.
 Systems have a history: The future behavior of a system depends
on its initial starting point and subsequent history.
 Non-linearity: React disproportionately to environmental
perturbations. Outcomes differ from those of simple systems.
 Emergence: Each system's internal dynamics affect its ability to
change in a manner that might be quite different from other systems.
 Irreducible: Irreversible process transformations cannot be reduced
back to its original state.
 Adaptive/Adaptability: Systems that are simultaneously ordered and
disordered are more adaptable and resilient.
 Operates between order and chaos: Adaptive tension emerges from
the energy differential between the system and its environment.
 Self-organizing: Systems are composed of interdependency,
interactions of its parts, and diversity in the system
[1] – Turner & Baker
What do complex systems tell us?
 Functional requirements model may be only part of
what we need to be successful
 They are often “discoverable” and have predictable
paths to implementation (“well worn path” or process
stability)
 We already use the term non-functional, quality, or
ASR’s even to catch all the other stuff, some of
which we know as important, but which are much
more difficult to describe
 Continuous adaptation as a means to survival
 Similar to Agile’s refactoring as a way to avoid “legacy
debt” and having to have requirements mostly identified
ahead of time
 Similar to the business cycle for Kodak and Fuji
 Can systems adapt and survive better in the face of
stressors?

12. “The fitness of the individual is the
probability that the individual will be
included among the group selected
as parents of the next generation”
Fitness function

13. Agile design
 Initial scope
 Platform design
 Epics / RT / roadmap
 Stories
 Sprint planning issues
 How to bake in architecture spikes
 How to balance functional &
enabler requirements
 How to measure value to the
organization in the sequencing
 Environment issues
 SAFe tries to “scale-up” agile to
deal with inter-project coordination
of value
 Continued discussion of what to do
with legacy debt and “bit rot”
Designing
Evolutionary design
 Initial architectural guidance around
ASRs
 Verification through “fitness
functions” (measurements) from CD
to test to DevOps
 Guidance should exist across
projects and align to organizational
goals
 Robust architecture issues
 How to construct a fitness
function for certain NFRs
 Continued lack of inter-project
coordination
 Difficulty in measuring / testing
in quality (stressor known
ahead of time)
Antifragile/ adaptable design
 Mindset change
 Residual analysis
 Develop initial architecture
 Describe information flows
 List large number of “stressors”
 Calculate “residues” – what survives,
regardless of likelihood of stressor
 Redesign to increase residue size
 Repeat residue analysis under broader circle
of stressors, possibly composing and
decomposing differently
 Continue to evolve architecture across
project versions
 Antifragile architecture provides
 Improved way to look at unlikely events
and ones which are non-linear
 Views new system as part of an
ecosystem
 Dynamic event response pulled into
design phase – no need to wait until
production to have a plan (or rearchitect)
 Delays decomposition of system and
traditional risk planning until after design
systemsantifragilefor with in mind

14. Some technologies we’ve piloted may become mainstream (new normal).
Low cost, apply across new parts of the portfolio:
 RPA  value in making paper or disconnected processes completely
digital (HR hiring / staff planning integrated with LinkedIn, appointment
optimization, etc.)
 AI & Bots  customer experience in giving specific, latest advice (over
static content), advice in real-time to first responders, personal advisors
 Remote video & VR  “We’ve talked about it for 20 years”
 Digital twin (simulation)  predictive modeling, contact tracing
 Interoperability standards & data sharing (health “commons”)  feeding
real-time decision-making dashboards
 ML  discovering deep data patterns for antivirus effectiveness and
contact tracing, what about unstructured OT data?
 Easy collaboration (hangouts, teams, etc.)  coordination of care, triage
remotely
Technologies to help us adapt

15.  National (not whole Earth?) level
 Organization level (CEO, CMIO, CTO,
CIO)
1. Identify the new digital
transformation scenarios
customers want
2. Focus on stabilizing short term
cash flow
3. Only lastly, assume existing
projects need to stay on track
 Personal level
 How do I get back to work? How can I
mentally get back to focus when I’m
worried about this impact?
 How do I stay safe interacting with
others? Are workplaces physically
safe?
 How do I deal with personal impact
from this (either COVID or other things
which have happened in same period
of time)
 How does my profession change?
How will we emerge from this?
 Health architecture challenges
 Geo-quarantine, with travel bans
 By demographic, older people
 Large gathering restrictions
 Test and release, flare-ups, some sort of
ID showing clear? Some sort of antibody
test? Some sort of immunity for how
long?
 People have resisted stay at home, will
get worse as pandemic walking outdoors
syndrome grows
 Police intervention? Socialized policy
 Vaccine development
timetable...Tracking by mobile phone,
specific hall passes for certain types of
trips.
 Some patients who have been on
ventilators have cognitive issues when
back (post ICU syndrome)
 Next pandemic?
* This is my conjecture only

16.  How can we get back to work?
 Requirements for a scalable system (millions of workers),
demonstrable proof of being virus free, plus an extra
requirement… what if there is a resurgence of cases?
The question you’ve all been waiting for…
FIRST PASS
• Define the
requirements
• Build a mobile app
with self-reporting
questions
• Roll it out
SECOND PASS
• Define the
requirements
• Build a mobile app
with self-reporting
questions
• Get patient profile
from central SOR
• Automate some parts
for efficiency (don’t
ask are you Male, if
you already know…)
THIRD PASS
• Build a mobile app
with self-reporting
questions
• Provide a feedback
loop from hospitals (if
the app said I was
clear, and I wasn’t…)
• Design for preplanned
stressors like
scalability through
decomposition and
testing
• Re-roll it out!
Nth PASS
• Design with residual
analysis based on
current components
and small MVPs to
see what survives
various stressors;
build parts that help
components survive
stressors observed in
reality
• Set the path for
evolving architecture
• Implement broader
triage mechanism to
detect if a new
disease is present

17.  You guessed it…
 Experimentation
 Build a habit around this
 Specifically be looking further afield, doing small $ MVP’s, and
incorporating anti-fragile planning as a co-equal in design
 The uncomfortable questions are the ones which, when answered,
lead us to adaptability
What mindset do we need to adapt?

18.  APQC guide on COVID preparedness
 Customer journey mapping in healthcare example
 HIMSS
 Royal Society on disease modelling and surveillance
 U.S. CDC site, JHU multi-sourced reporting site, Microsoft
 WaPo visualization, Moscow Times, IHME predictive model, other data sets and here
 Bill Gates 2015 talk & how Teams/remote meetings change things
 IBIS outlooks by industry & CO, social distancing impact
 Futurist
 Testing resources – BEI, NIH, Verily, CVS, Everly and strategy, Conduent
 Computational biology labs & ML
 HK/Singapore response, TraceTogether, BlueTrace.io
 Residual design & antifragile(Barry O’Reilly)
 Wuhan’s recovery
For further reading

19. An Association for All IT Architects
For further information, please direct questions to bwloomis404@gmail.com or
visit www.princetondigitaladvisors.com