Scale in health care and Google

Sometimes I read a book that strikes so close to my passion that I can’t stop talking about it. I will recommend such a book to most everyone and often buy extra copies to give away to friends and colleagues (family members just tell me to go away). I found one of those books. It is In the Plex by Steven Levy. The book is a biography of Google, most of it centers on the founders and key managers who had to develop and take ownership of the growth of Google. There are a number of books that describe companies that have come from nothing to greatness, so that isn’t what makes this special. The key to this book is the notion of scale.

As I have talked with colleagues about this book I keep coming back to how the leaders of Google threw away the standards of their time to build at scale what they needed. For example, the standard in the 1990’s for servers was to buy the best you could afford to avoid having the system go down. Failure rates were kept to a minimum, as best as possible. This also meant that the servers were expensive. Google executives decided to look at it differently. They needed LOTS of servers. At a very low cost they bought parts that were rejected due to inferiority and build their own, for a fraction of the cost, adding redundancy to overcome the much higher failure rate. With this model they could scale up (or down) quickly and inexpensively to meet the demand of their product, search.

We have got to figure out how to do this in health care. yesterday I was on the phone with Matt Wojcik of GE Centricity to talk about interoperability and ICD-10. As I have many times lately, I mentioned In the Plex and we explored how an EMR search should be more like Google, building on data based on past use and a continuous reduction in time and errors. It also has to scale. As doctors engage with patients the system needs to do a better job at reducing clicks, drop down menus, and search so users can reduce non-patient care activities. At the same time doctors have to find ways to scale their own work.

For a doctor to see more patients, in the current way care is delivered, a clinic has to build more rooms, hire lots more staff, and lengthen the work day. That isn’t scale. We need to turn the work on its head to do things differently. Right now I am working on a group visit model, similar to what was done by Harvard Vanguard and Fairview Physicians (Noffsinger, E.B,, 2009). This allows scale through intense use of physician resources and increase in quality for the patient., or at least that is the idea. The data will reveal the facts.

So I recommend In the Plex. It is interesting and I learned a lot about Google and search. It is also provoking ideas about how we can scale health care so that it is meaningful to patients and meets the demand for access and quality.

A book review of Incognito

I just finished reading Incognito by David Eagleman, a book about neuroscience and social psychology. It is one of a number of books I have read recently on this topic. I was expecting it to repeat the information published by others, it surprised me by offering new insights.

What struck me about Incognito is the focus on predictive behavior. He spends the majority of the book laying out the nature versus nurture argument, and then setting it aside by not diving into an analysis of past actions. Instead he looks at what actions might occur in the future. For a health care leader the book provides intriguing questions about the role of education and patient participation.

In the book, Eagleman talks about how small pieces matter while considering the larger issues. For example, a person who has a new diagnosis such as diabetes needs to learn about the disease process and the relationship between food, exercise, and lifestyle management to successfully cope. None of the individual properties in these elements explain the emergence of the disease or its management. The combination of changes can introduce something entirely new, as Eagleman calls it “emergent properties”. Implications for health care leaders include an understanding that education needs to go beyond the basics and modifications of behavior; instead it is complex and dynamic.

When considering patient participation we understand from Eagleman that people are neither the product of biology nor the environment alone. A genetic variation creates certain probabilities and the environment can provide the adverse experiences to increase the probability of occurrence. What does this mean in patient participation? Perhaps it means that ability to participate along with willingness is part genetic and part environment. Our society tends to fault people who don’t do what science might define as necessary to prevent health crises (exercise, eat healthy, sufficient sleep, etc.). The effort necessary to accomplish these efforts varies between individuals and as health care leaders we need to look toward what is possible given the cards dealt to a person.

So where does that leave us? Eagleman has described nature and nurture in a way that brings current research forward and helps us better consider the complexity. Reductionism has us focus on the small parts, genes and chemical changes that result in personality and large system outcomes. However, the parts are not the sum of the whole and the environment can’t be ignored. Health care leaders have an important role to play in keeping the delivery of care current on research and sensitive to what we understand about humans. Eagleman has helped with that in his book Incognito. I recommend it to my colleagues.

Look to the future of health care

Recently I attended a presentation by a health care leader who talked to a large audience about the key aspects of leadership, in particular women in leadership. She mentioned having a vision for the future, building relationships, and creating balance in your life. She received a lot of nods and smiles as she spoke. I can’t disagree with her, the points she made are repeated in the literature and by consultants. However the nagging thought that crossed my mind is, this is too safe. How are we going to make the drastic changes needed in the health care industry if we play it safe. I don’t think we really know what the future holds, as described by Ronald Heifetz health care is in an adaptive challenge. We are now bringing smart phones into the health care monitoring world, and soon into diagnostics. What does this mean for the doctor working in a clinic? Does he or she have any idea what the future looks like? I doubt it.

Perhaps relationships need to be broken. Not all of them, just those that don’t serve the needs of patients and their families. In some ways it has already started. Pharmaceutical companies are self-regulating to break past relationships with doctors, those that were detrimental to patient care. I don’t think it will end here. At the same time new relationships will occur. Through technology doctors are able to serve the needs in geographic areas previously untouched. This is the beginning of new delivery of care models where patients “see” doctors who are far away, building lasting relationships to improve health.

Lastly she talked about creating balance. I don’t think we need balance; we need resiliency. Coming out of the work of many researchers, and popular in The Blue Zones, we need to fully engage with our passions. This isn’t about doing equal amounts of work and play. It is about building a structure within ourselves that can handle the bumps and challenges of what drives us.

As health care leaders we have to bring forward the latest and best research. We can’t just repeat what was said 25 years ago. It is a new world and we need the drive and passion to do the work differently and risk failure. Inspiring conversations will lead to revision of failures into new ideas and innovations. I look forward to being part of this revolution.