Gallery: How Complexity Science Could Help Fix Health Care
01retail-clinics
Health care is a morass, a quagmire, a slough of policy despond, but perhaps complexity science can help chart a path forward. On the day of the Supreme Court's landmark ruling, researchers from the [New England Complex Systems Institute](http://necsi.edu/) released an [eight-step prescription of network theory to America's ailing health system](http://necsi.edu/research/healthcare/healthcaresteps.html). "What makes organizations successful or unsuccessful? The underlying principle is matching scale and complexity to task," said Yaneer Bar-Yam, president of NECSI, which in earlier analyses looked at [rising food prices](http://stag-komodo.wired.com/wiredscience/2011/10/food-price-rises/), the [2008 financial crisis](http://stag-komodo.wired.com/wiredscience/2011/10/peace-boundaries/) and even the [dynamics of social violence](http://stag-komodo.wired.com/wiredscience/2011/10/peace-boundaries/). Titled "A Complex Systems Science Approach to Healthcare Costs and Quality," the white paper isn't peer-reviewed, and represents a mix of policy analysis and informed extrapolation of complex systems principles to health care. Complexity researchers might seem an odd source of health reform inspiration -- but with U.S. health care [more expensive and less effective](http://www.reuters.com/article/2011/11/23/us-usa-healthcare-oecd-idUSTRE7AM0NN20111123) than in other developed nations, inspiration from unexpected sources is most welcome. On the following pages, Wired looks at the NECSI recommendations. __Above:__ Retail Clinics -------------- One of the great shortcomings of late-20th century American health care was its emphasis on disease treatment rather than prevention. Preventive care -- such as screening people for cancer, helping them quit using tobacco, or providing flu shots -- is both common-sense and cost-effective. However, NECSI calculates that providing effective, nationwide preventive care through doctors' offices would require hiring 400,000 full-time workers. The solution: so-called retail clinics that provide simple, routine services separate from standard physician practices. There are already [more than 1,200 retail clinics in the United States](http://www.usatoday.com/news/health/healthcare/health/healthcare/story/2011-08-28/Medical-clinics-in-retail-settings-are-booming/50168796/1), many located at places like Target and Walmart, but their usefulness has been debated. NECSI calculates that a national system of retail clinics would reduce preventive costs by a factor of five. "You don't want both highly complex tasks and repetitions of simple tasks done by the same organization," Bar-Yam said. "In the health care system, that distinction is not generally made. Physicians responsible for diagnosis and treatment are also responsible for giving flu shots. They are not placed in an organization designed for efficiency." Moving certain services away from doctors and into malls may feel strange, but it's worth remembering that before the rise of specialized pharmacies, doctors were expected to mix their own medicines. *Image: [Paul Swansen](https://secure.flickr.com/photos/pswansen/5030386861/)/Flickr* *Citation: "A Complex Systems Science Approach to Healthcare Costs and Quality." By Y. Bar-Yam, S. Bar-Yam, K.Z. Bertrand, N. Cohen, A.S. Gard-Murray, H.P. Harte, and L. Leykum. June 20, 2012.*
02workgroup-competition
Workgroup Competition --------------------- An assembly-line-style retail clinic system could help with simple, routine tasks, but disease treatment and other complex jobs require a different approach. According to Bar-Yam, most proposals for improving [managed care](https://en.wikipedia.org/wiki/Managed_care) fall into two categories: top-down determinations of permitted actions, which counterproductively restrict the choices available to doctors and patients, and market-based approaches, which sound nice in principle but fall short when people lack the time and information necessary for rationally purchasing health care. There's a third option: the power of evolution. "The key issue is creating a complex system. The processes of effective care, not just a doctor but a set of people who know what to do, are a highly complex system," said Bar-Yam. "The only way that can be achieved is by evolutionary processes." Within each hospital, NECSI recommends that physicians, nurses, technicians and other care providers be divided into workgroups that are set into competition with each other, with results published monthly and creating an evolutionary dynamic. Bar-Yam drew an analogy to sports, in which the crucible of competition shapes complex systems known as teams. "They are subected, on a regular basis, to feedback. They explore alternatives and test them out. It's exactly what happens in biological evolution. Reproduction, variation, selection through competition," he said. *Image: [ReSurge International](https://secure.flickr.com/photos/interplast/3769967080/)/Flickr* *Citation: "A Complex Systems Science Approach to Healthcare Costs and Quality." By Y. Bar-Yam, S. Bar-Yam, K.Z. Bertrand, N. Cohen, A.S. Gard-Murray, H.P. Harte, and L. Leykum. June 20, 2012.*
03superdoctor-teams
Superdoctor Teams ----------------- Once workgroups are created, their personnel composition needs to be set. Bar-Yam and colleagues call for teams of physicians, each with a particular specialty, who can be considered a single "superdoctor." This is already customary in cancer treatment, with specialists in imaging, radiation therapy, chemotherapy and surgery meeting regularly to discuss patients, but isn't standard for other conditions. Patients with complex conditions that affect multiple physiological systems, such as diabetes or dementia, are often shuttled between uncoordinated specialists, causing a fragmentation in care that's both unhealthy and costly. "The advantage of the team is not just the ability to do what the individual specialists would do separately; it’s the ability to treat a wide range of conditions effectively, to make very subtle distinctions that are important for effective care, to solve the cases that are the most difficult due to the interplay of multiple causes or complications," wrote the NECSI researchers. "The capabilities of superdoctor teams will grow through being challenged, and they will learn from experience." *Citation: "A Complex Systems Science Approach to Healthcare Costs and Quality." By Y. Bar-Yam, S. Bar-Yam, K.Z. Bertrand, N. Cohen, A.S. Gard-Murray, H.P. Harte, and L. Leykum. June 20, 2012.* *Image: [Waldo Jaquith](https://secure.flickr.com/photos/waldoj/97187153/)/Flickr*
04improved-routing
Improved Routing ---------------- "A system only responds as well as its rate-limiting step," writes the NECSI team in a 21st-century update of the adage that a chain is as strong as its weakest link. In many hospitals, the rate-limiting step is intake, the time when patients are first evaluted and assigned to further care. Sometimes the intake system works, such as when a patient visits a doctor during business hours; but at night, or when a patient waits weeks for an appointment, or when receptionists are expected to make triage decisions, the gatekeeper becomes a bottleneck. The NECSI team calls for a "Super 911," a 24-hour routing service staffed by medical professionals and accessible by phone, internet and in person. "An accessible and reliable 24/7 accelerated triage mechanism -- staffed by intake specialists and augmented by an information-transfer system -- will dramatically improve our medical system’s cost-efficiency and ability," they wrote. "Wait time for care will be dramatically reduced, emergency rooms will be put to their proper use, and the burden on primary care providers will be lightened." *Image: [USDAgov](https://secure.flickr.com/photos/usdagov/6764058985/)/Flickr* *Citation: "A Complex Systems Science Approach to Healthcare Costs and Quality." By Y. Bar-Yam, S. Bar-Yam, K.Z. Bertrand, N. Cohen, A.S. Gard-Murray, H.P. Harte, and L. Leykum. June 20, 2012.*
05error-prevention
Error Prevention ---------------- In 1999, the Institute of Medicine calculated that simple, preventable medical errors annually cost $29 billion and 98,000 lives. Electronic medical records were supposed to solve much of this problem, in particular reducing mistaken drug prescriptions, but progress has been fitful. According to Bar-Yam, poorly designed electronic medical records, with ostensibly time-saving autocomplete and shortcut functions, can make errors more likely. They fail to apply the single most important error-preventing strategy of all: redundancy. Instead of trying to save time at every step, electronic records should require that every drug name and dose be repeated multiple times. "To explain, we can turn to another context where the prevention of errors is important: writing checks. Where money is involved, we are careful to make sure the information is conveyed clearly. To this end, we write the amount twice, in both words and numerals," wrote the NECSI team. "The same principle of redundancy can and should be applied to writing prescriptions." *Image: [Cult Gigolo](https://secure.flickr.com/photos/theretrogigolo/1035101292/)/Flickr* *Citation: "A Complex Systems Science Approach to Healthcare Costs and Quality." By Y. Bar-Yam, S. Bar-Yam, K.Z. Bertrand, N. Cohen, A.S. Gard-Murray, H.P. Harte, and L. Leykum. June 20, 2012.*
06disinfection-gateways
Disinfection Gateways --------------------- Infections acquired in hospitals contribute to the deaths of [99,000 Americans every year](https://www.nytimes.com/2010/02/27/business/27germ.html?_r=1&em=&adxnnl=1&adxnnlx=1267412412-yP2bfl/3pu4+g34XVmluJA). To slow their spread, hospitals have enforced strict handwashing routines, with doctors and nurses disinfecting themselves after every patient visit. This is helpful, but it's not enough. "The current focus is to reduce infection transmission at each point of contact, but handwashing doesn't address the connectivity issue," Bar-Yam said. "It makes each connection weaker, but you're still going to have a problem." The NECSI team recommends full-body, full-equipment disinfection at juncture points throughout each hospital, knocking out crucial nodes of pathogen exchange. *Image: [William Tillis](https://secure.flickr.com/photos/mc4army/4406919358/)/Flickr* *Citation: "A Complex Systems Science Approach to Healthcare Costs and Quality." By Y. Bar-Yam, S. Bar-Yam, K.Z. Bertrand, N. Cohen, A.S. Gard-Murray, H.P. Harte, and L. Leykum. June 20, 2012.*
MC 4 Army/Flickr07electronic-medical-record-research
Electronic Medical Record Research ---------------------------------- When health records are fully national, digital and anonymized, they'll be a new frontier for data analysis. With the right techniques, it should be possible to see patterns and draw correlations that couldn't be detected in any but the largest, most thorough clinical trials. Hints of this utility can be seen in the [Framingham Heart Study](http://stag-komodo.wired.com/wiredscience/2011/10/long-term-datasets/?pid=2276), which has run since 1948 and generated landmark insights into heart disease and stroke. It involved just 10,000 people, or just a small fraction of the 300 million Americans who will be covered in coming years by electronic records. In order for this to work, however, the records [need to be well-designed and standardized](http://stag-komodo.wired.com/wiredscience/2009/07/medicalrecords/). *Image: [MC 4 Army](https://secure.flickr.com/photos/mc4army/4406919358/)/Flickr* *Citation: "A Complex Systems Science Approach to Healthcare Costs and Quality." By Y. Bar-Yam, S. Bar-Yam, K.Z. Bertrand, N. Cohen, A.S. Gard-Murray, H.P. Harte, and L. Leykum. June 20, 2012.*
Alan Cleaver08cultivating-behaviors
Cultivating Behaviors --------------------- One of the more intriguing insights to come from the Framingham Heart Study is how [behaviors may spread like disease](http://www.nejm.org/doi/full/10.1056/NEJMsa066082), with conditions such as obesity moving through populations as though literally contagious. While some of that research [has been challenged](http://www.nejm.org/doi/full/10.1056/NEJMsa066082), the takeaway message remains: Individual health is embedded in larger social networks. It might not take a village to lose weight, but it certainly helps when good health is a community value. Noting the success of [Walmart's “personal sustainability projects,"](https://www.nytimes.com/2007/04/05/business/05improve.html?pagewanted=all) the NECSI team calls for similar health care initiatives in companies, organizations, cities and states. "The largest, most important scale is societal attention to one's own health," said Bar-Yam. "From a complex systems perspective, we need to figure out the natural behavior of the system that would improve that." *Image: Alan Cleaver/Flickr* *Citation: "A Complex Systems Science Approach to Healthcare Costs and Quality." By Y. Bar-Yam, S. Bar-Yam, K.Z. Bertrand, N. Cohen, A.S. Gard-Murray, H.P. Harte, and L. Leykum. June 20, 2012.*
