The Importance of Variety

04/07/2022 Compiled from lived experience Valmeek Kudesia

For 10 years I worked the late shifts in urgent care at a community health center. There I learned one of the most important lessons regarding the care of people: seek out and accommodate the "normal variety" that is the reality of peoples' lives. Not to be confused with "complexity", which suggests undesirable variation in behavior or outcomes (e.g. shoe factory makes some "size 5.5" shoes too large or too small). Rather, "normal variety" is the variation in people's need that is inherent to reality (e.g. customers actually need shoes larger or smaller than size 5.5). If the shoe factory only makes size 5.5 shoes, then most customers will feel their shoes are too large or too small. The shoe factory can spend endless resources on quality improvement for size 5.5 shoes and yet most customers will feel their shoes are too large or too small. Workers in shoe stores will try very hard to make a difference but will ultimately burn-out. Imagine the vicious cycle!

The inability to seek out and accommodate the full variety inherent to a person's life (i.e. more than pathophysiology) causes our healthcare system to:

1. Create dysfunction for the people who need care; resulting in higher risk and lower quality of care

2. Reinforce dysfunction even though the system is powered by mission-oriented highly-trained people and has many quality measures/standards

3. Misdirect the people who think they can help (e.g. well-capitalized Big Tech) and use those efforts to reinforce the dysfunction

We have many new entrants in our healthcare system (e.g. start-ups in tele/tech/real-world evidence/analytics/AI or value-based care like ACO-DIRECT or direct-contracting). This burst of interest is a precious opportunity for our healthcare system to accommodate and care for so many more people. That would be so wonderful and...humane. I am concerned that the typical misdirection from our healthcare system will steal (or is stealing) this opportunity.

Below, I share my lesson and experience in order to:

• Honor that community health center

• Show a methodology to new entrants so they can employ upstream thinking and upstream acting thereby escape the misdirection and dysfunction...and truly help

Lesson Start: Hammer and Scalpel

One memorable evening I used an 11 blade scalpel to remove a chunk of hammer head that was partially embedded in the thumb of a construction worker, "Mr Nguyen". Through a translator I learned that the head of the hammer that Mr Nguyen was holding had shattered on impact and a razor-sharp fragment embedded itself in his thumb. The heaped-up and thickened skin on his thumb told me that fragment had been lodged in his flesh for at least 3-4 weeks. When I asked about the apparent delay to seek care, Mr Nguyen explained that he chose to delay care and come to the community clinic instead of the Emergency Department near the construction site because he already "knew" the community health center; he knew how to "get what he needed" in a single visit.

He would have gotten care at the nearby ED immediately after the injury if he was confident that the providers and staff would have patience so that:

1. His whole story would be heard

2. Information would be explained slowly to him

I was very honest with him that my skills might not be sufficient for a procedure on his hand (much less his dominant hand). I would make an honest assessment and an attempt only if safe to do so. The urgent care clinic had a limited variety of scalpel blades available for use; I reasoned that an 11 scalpel blade (shaped like a narrow tall triangle and held like a pencil) was best suited for the small, precise (but not too deep) incisions that would be needed to remove the hammer fragment from the thickened surrounding skin. I'm happy to say that both he and I were successful that evening. I have always favored an 11 blade after that successful extraction (who knew an internist would have a favored scalpel?)

Mr Nguyen's experience was a dramatic example of how our healthcare system's inability to accommodate the normal variety of in a person's life restricts the appropriate interactions and use of resources. His clinical care needs likely would have been well met in the ED but language/cultural barriers made the services inaccessible to him. In other words, the ED could not accommodate the full variety of his need in order to carry out a care transaction ("meaningful interaction", not necessarily payment). People must deal with their reality on reality's terms and therefore so must their healthcare.

Lesson End: Look Upstream

This is NOT a critique of attempts to improve our healthcare system. Rather, this is calling-out the "misdirection" that tricks those good intentions. Our healthcare system accepts, accommodates, and has enormous amounts of data describing the variety of biology, anatomy, disease, and treatments. However, our healthcare system is very constrained (many reasons) in its ability to accommodate a variety of healthcare transactions (effective interactions) just like how the ATM only dispensed $20 bills. For example, reimbursement in a fee-for-service (FFS) model means that a person who only needs a short conversation and medication review to perform a successful medication refill MUST come for a "full sized synchronous" clinical encounter. Providers and staff try to figure it out yet at the same time have no concept of the true solution (just like the the cashiers).

Technology or value-based-care companies, please consider the following points in order to employ "upstream thinking" and correctly design the product or business (see guide for practical approach and be guided by the clinical identity).

Regarding Technology & Data

• • Recall that Mirroring Capabilities (value stream) is the one first stages of change upon introduction of new tech and data. Therefore, the processes and data that are available from our healthcare system to generate new hypothesis, businesses, or products are a reflection of the dysfunction .

    • Big Tech or start-ups that naively interpret these processes and data to improve care or offer new products for care will be misdirected away from the true deficit.

    • I speculate if data silos were (magically) resolved, the observations/facts available would still be of limited value because the view of reality is distorted by the dysfunction. In other words, there is a limitation on the observability of things that truly matter because the interactions where never developed that would allow those observations to be made.

    • This has enormous implication for the use of "real-world evidence" (RWE) to aid science and discovery i.e. how much of the real world of the person who is the patient is contained in EHR data vs artifacts of current system? I think RWE from the person, who is the patient, must be found elsewhere or gathered from primary data capture.

  • Platform business models always win over pipeline models. Platform models "invert the firm", which means new ideas, products come directly from the participants/users themselves; meaning the people who experience and "know" the variety inherent to reality can themselves do/make things to better help/serve themselves.

  • Platform models promote variety (yes, with some complicating factors); and only variety absorbs variety. Therefore, I think a platform model (of some sort) would be very powerful in our healthcare system.

Regarding Value Based Care

• • We must widen the variety of care transactions accommodated in order to be successful (e.g. culture change, different tech, climbing virtual-value-stream). This will allow care to reach upstream and meet the person, who is the patient, wherever and whenever the person can engage.

  • Not all variety is variation "to be solved"; rather variety is the reality that defines 1) the terms on which people (patient, provider) engage in transactions (not necessarily payment, rather meaningful interactions) and 2) social determinants of health (SDoH). Physicians are asking for help and there exist some good approaches (e.g. community health worker corps).

  • There is prior knowledge of the dimensions in which people make trade-offs to accommodate the variety of their reality.

  • We have some evidence that value-based care arrangements are associated with (what we think) are virtuous changes to acute care utilization (which is good). I think value from the point of view of the person who is the patient requires that we continue to widen our definition of value to include how we accommodate the variety in a person's life and the variety in ways satisfaction and quality of life are defined. System theory has already shown that the optimization each component of a whole will NOT result optimization of the whole

  • Very likely VBC arrangements must become familiar with a wider variety of culture change, measurements, and descriptors. The same happens in other industries that focus on outcome-based-contracting (OBC), I think the findings re "loss of control" will be applicable to healthcare.

  • Our healthcare system is not required to solve SDoH by itself. However, our system needs to accommodate the variety in SDoH and still offer health transactions (not necessarily payment, rather meaningful interactions). At the very least, variety is the state of human being e.g. people have different sized feet. Accepting a person is the same as accepting and seeing all the variety that is inherent to that person i.e. humanizing uses of data.

  • I think this lesson is a restatement that healthcare is more like a service than manufacturing; in a service the customer must 1) identify what role they are expected to play and, 2) have the preference + ability to participate accordingly. This is consistent with repeated observation that health outcomes are only 20% explained by medical options. There is prior knowledge of the dimensions that people who are customers have variety and preference.

  • Our current healthcare system has a very narrow intakes but LOTS of stuff after the intake. People circle around until they "get to fit" what intakes are available i.e. sick enough....and our best actions can inadvertently reinforce the narrow intake instead of widen it.