Revisualizing and Recoding Health Care

Two new books have me thinking about healthcare, although neither is about healthcare and, I must admit, neither of which I’ve yet read. But both appear to be full of ideas that strike me as directly relevant to the mess we call our healthcare system. 

Credit: Mengxin Li/The New York Times

The books are Atlas of the Senseable City, by Antoine Picon and Carlo Ratti, and Recoding America: Why Government Is Failing in the Digital Age and How We Can Do Better, by Jennifer Pahlka. 

Dr. Picon is a professor at The Harvard Graduate School of Design, and Professor Ratti is head of MIT’s Senseable Lab. Drawing on the Lab’s work, they write: “We hope to reveal here an urban landscape of not just spaces and objects, but also motion, connection, circulation, and experience.” I.e. dynamic maps. Traffic, weather, people’s moment-by-moment decisions all change how a city moves and works in real time.

Dr. Picon says.

These maps are a new way to apprehend the city, They’re no longer static. Maps provide a way to visualize information. They’re crucial to diagnosing problems. I think they provide a new depth…It’s a little bit like the discovery of the X-ray. You can see things within cities that were not previously accessible. You don’t see everything, but you see things you were not able to see before.

Example of dynamic map. Credit" MIT Senseable Lab

So I wondered: what would a dynamic map of our healthcare system look like? 

I’m telling you, just a map of what happens between drug companies, PBMs, health plans, pharmacies, and patients would open people’s eyes to that particular insanity in our healthcare system.  Now repeat for the millions of other ecosystems in our healthcare system.  If that kind of dynamic mapping -- showing all the complexities, bottlenecks, circuitous routes, and redundancies within the system -- wouldn’t lead to health care reform, I don’t know what would.

Knowing there is a problem isn’t enough.  Effectively acting on the problem is the key, and this is where Ms. Pahlka’s insights come in. She is the Founder and former Executive Director of Code for America, a Deputy Chief Technology Officer in the Obama Administration, and Co-Founder of U.S. Digital Response. The common thread, as discussed in her book, is that governments and other non-profit entities can use technology much more effectively. 

Jennifer Pahlka

We often blame outdated technology for how slowly, and how poorly, government often responds to problems, and there is some truth to that, but Ms. Pahlka looks deeper.  “We’ve been trying to fix this problem with more money for technology in government, more oversight and more rules," she told WBUR. "And the evidence shows that's not working. We got to take a different approach.”

The key, she believes, is less emphasis on the policy – driven by legislators or the executive branches – and more on implementation.  “They see implementation as a sort of detail that less important people should deal with," she says. "And until we change that, we're going to continue to have problems getting the outcomes we want.”

Ms. Pahlka describes how hard working employees – some call them bureaucrats – try to respond to new laws/initiatives involving technology by generating massive requests for proposals, which they then try to outsource to vendors. It doesn’t usually work well (you could ask the VA and Cerner about that).

She urges that all those people who are charged with implementation must have more say in design and requirements. To use her example, just because someone tells you to build a concrete boat, you shouldn’t necessarily just try to build a concrete boat.

 “The alternative to the status quo is pretty fundamental,” she told Nextgov/FCW. “It is moving from a structure in government… in which information and power flows one way — down — to something that is far more iterative and collaborative, where we stop conceiving of the implementers as at the bottom of a waterfall.”

She went on to say: “Product managers are able to say, ‘this has to make sense to a person.’ They're translating. They're designing the policy in a way that makes sense to a person,”  In a different interview, she quotes General Stanley McChrystal: “Don’t do what I told you to do. Do what I would do if I knew what you know on the ground.” 

How many executives, healthcare or otherwise, give their employees that freedom?  How might our healthcare system be different if everyone involved in implementation of any policy stopped to ask: does this make sense to a patient?

In an article in The Atlantic, Nicolas Bagley offers: “In other words, Pahlka’s book isn’t just about tech. It’s about the American administrative state.”  They’re both referring to government, but I’d argue that, sometimes for the better but usually for the worse, that’s what our healthcare system has become. Not a place of caring but of administration. Shame on us.

It’s easy to blame design, but Ms. Pahlka has a different perspective. She described to Justin Hendix of Tech Policy Press how some government programs are so hard to use:

Really none of this is necessary and I think sometimes, we think the system is designed to make it hard and that is obviously sometimes true, but very often, it’s simply not designed at all. We have these policies and processes and tech systems like at the EDD that have simply accreted over time and it’s not so much the difference between user-friendly design and what we would call in tech user hostile design, but more kind of the difference between any design at all and just letting it accrue and accrete. Sort of a no design.

Tell me that all doesn’t ring entirely true for our healthcare system.

She offers another important piece of advice, aimed at government but applicable to healthcare: “I mean, I like to say technology and software is something you do. It’s not something you buy. You may buy tech tools, but if you’re trying to get things done through technology, it has to be a core competency and something you actually do.” 

In 2023, in healthcare, technology has to be something you do.

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Some people fear cities are dying.  Many believe governments can’t do anything right. And everyone thinks our healthcare system is dangerously dysfunctional.  We need new ways of seeing them, as Professors Picon and Ratti are trying to do, and new ways of bringing about change, as Ms. Pahlka is recommending. If you think that’s impossible, Ms. Pahlka reminds us: “First, it's important for people to understand that we the people have created this culture.”