Healthcare's Death Star Thinking vs. Human Centered Design

Kim BellardI missed it when it first came out, but a providential tweet from the always perceptive Steve Downs tipped me to a most interesting article from Jennifer Pahlka with the wonderful title “Death Star Thinking and Government Reform.”

The article is not directly related to healthcare, although it does include healthcare examples, but Ms. Pahlka’s central point very much applies to most efforts to reform healthcare:

The need to believe that a Death Star-style solution is at hand — that we have analyzed the plans and found the single point of failure — runs deep in our culture.

After all, who among us does not want to be the Luke Skywalker who blows up healthcare’s dysfunctional Death Star?

Of course, in reality, figuring out exactly who the evil Empire of healthcare is or what they’re using as a Death Star these days is not so easy. Nor is finding the single point of failure that we can exploit to magically make everything better.

Some see the health insurers as the Empire (or, certainly, their supposed agents the PBMs — the Darth Vaders of healthcare?). Others blame the ever-consolidating health systems, which are gobbling up fellow hospitals and any available physician practices. Pharmaceutical companies are also a popular target.

We can’t quite decide if physicians are the Imperial storm troopers who oppress us or the persecuted Jedi who may yet save us (although many — including a lot of physicians — feel that the AMA is part of the Empire). Nor can we decide if employers are the Imperial tax collectors who have all too passively allowed healthcare costs to steal our wages, or the plucky Hans Solos who are doing their best to fight the Empire.

Proposed magic bullets to fix supposed single points of failure in healthcare abound. Remove the tax preference for employment-based coverage. Give us more “skin in the game” via increased cost-sharing. Increase the number of physicians, or at least reduce the percent who are specialists. Increase integration between health professionals/facilities. Get more of us covered (or maybe not).

Improve interoperability. Make the healthcare system more digital. Use artificial intelligence (AI) and Big Data to figure out what we humans haven’t been able to. Nanotechnology or robots, even nanorobots, will save the day. Develop even more new drugs, use 3D printing, take advantage of gene splicing/editing. Exploit the microbiome’s power.

Maybe we’re looking in the wrong places and we should be focusing on social determinants of health (SDOH).

Or we could all just eat better and walk more.

A sobering new study from Ashish Jha and colleagues reminds us, though, that there probably is no such single point of failure. As other studies have attempted to do, it compares the U.S. healthcare system to other developed countries. It concludes that, aside from our high level of spending (caused by high prices and administrative costs), we’re not as bad or as unusual as many think.

It’s not that any country has fixed the single point of failure as it is that every country is also struggling to find it. Harvard Medical School professor Bruce Landon told The New York Times:

I don’t think there’s any of these countries where if you went and talked to them individually, they wouldn’t say they’re having a health care cost crisis. They’re all struggling with paying for new technology and the cost of the system.

We’re all engaging in some Death Star thinking.

Whatever the single point of failure might be, many think we need a new hero to fix it, be that Amazon, Google, Apple, or people/companies we haven’t heard of or aren’t thinking about in this space. They’ll come along to rescue us and our health care. For all those people who believe some tech company can ride in to save healthcare, Ms. Pahlka reminds us:

In fact, simply adding technology without understanding the complexity of the bureaucratic processes and how they got to be the way they are can perpetuate the problem, or even make it worse.

She also emphasizes — and this really fits healthcare — “You can’t fix the problem of a system that is based on rigid rules by specifying new rules.” We’re not going to simply legislate or regulate our way out of the mess we’ve allowed our healthcare system to get into.

Instead, she points out:

There is no “solution,” only continued storytelling that shapes a new narrative and supports a new sensibility. But it is an important, valuable agenda that will get less attention and resources than it should because it doesn’t fit the model of a “solution.”

Fixing healthcare is very much a design issue, one that requires new ways of thinking, better “storytelling,” and involvement of all impacted parties. None of that is easy nor natural for healthcare; as healthcare design guru Dr. Bon Ku said at his recent SXSW presentation: “Healthcare is the black hole of design.” (thanks to Danielle Ralic for the quote):

Dr. Ku is attacking the problem at one of the roots, during medical school, as is Clay Johnston at Dell Medical School and a short-list — too short — of other medical schools.

A new article in Harvard Business Review by Bhatti and colleagues urges that healthcare use more “human-centered design.” They studied three healthcare innovation centers, identified six common challenges, and made several recommendations for others interested in accelerating human-centered design in healthcare.

Perhaps their most important statement was a mindset:

This model isn’t just about getting greater patient feedback during the innovation process. Patients are co-designers, co-developers, and increasingly more responsible for their own and collective health outcomes.

The Empire would hate that.

If the Star Wars franchise has taught us anything, it may be that there will always be another Death Star. There will always be a would-be Empire. It is never easy to defeat the forces (small “f”!) that seek to keep us from fulfilling our destiny, even if that destiny is better health. But it also reminds us that we should never give up hope.

We didn’t design our way into our current healthcare system, but it is possible — just possible — that we can design our way out of it.