Stories of #TeamScience

Some challenges are so daunting and so complex that they require transdisciplinary solutions, with the healthcare transition being a good case in point. Surgery waiting lists are getting longer, healthcare staff shortages have never been more dire, and the population is aging rapidly. Rigorous changes in the healthcare sector will be needed in order to avoid even greater problems in the future, 
and while there is a way out, we will have to look beyond healthcare itself to find it, these three scientists argue. Collaboration between the tech sector, medical science and social sciences will prove essential, and applying systems thinking to today’s healthcare challenges could well be the key to a future-proof, affordable and sustainable healthcare system

This is the level at which researchers Irene Grossmann, David Abbink and Maaike Kleinsmann think about innovation in the healthcare system, focusing not on quick tech fixes but on structural changes in organisation, financing and implementation to benefit doctors and patients alike. In this story of TeamScience, they explain what they do, why their work matters and what obstacles they run into.

Systems science in practice

Finding practical applications for novel technologies is the bread and butter of the Faculty of Technology, Policy and Management, and when it comes to identifying practical applications, systems science is essential. Grossmann explains: “Approaching the world from a systems view means investigating events from multiple different perspectives. You look at the bigger picture, adopting what is known as a socio-technical approach by factoring in patient experiences, practitioners, rules and agreements, the financial side of things, and so on. We know, for example, that healthcare practitioners would save a lot of time and make fewer mistakes if they had more optimally designed digital information systems at their disposal. What’s more, everyone would benefit from a system that provides patients with insight into their medical information while automatically storing and interpreting test results. 
We look at problems differently than medical professionals are used to, Grossmann explains. “Medical research is mainly about investigating short cause-and-effect relationships, which works well for drug development. However, while the complexity of major challenges like the healthcare transition stretches far beyond a single cause-and-effect relationship, the healthcare sector is not yet accustomed to the multi-perspective ways of systems thinking.” 

For Grossman, the emergency ward at Deventer Hospital where she plies her trade as a surgeon every Friday, is an illustrative example. “Every Friday, we’re inundated with elderly patients who are too frail to stay at home and not quite sick enough to admit. We end up admitting them anyway - you never know what could happen during the weekend - and putting them through a scanner, because we can hardly leave them out in the cold. In a nutshell, healthcare has a problem. Admitting patients to the emergency ward for a full weekend costs a lot of money without solving any real problems. Even if they’re admitted, the patients still suffer. 
It’s a sad state of affairs and we should do better.” Fortunately, Grossman adds, there is a way: “Using data, you can analyse and predict how many elderly patients will need extra care, before using these insights to conceptualise a system that frees up space for them. The most straightforward solution - and people often clamour for it - is to just add more beds, but a structural, long-term solution would make much more sense. More thorough remedies, however, require scrutinising the problem from multiple angles. GPs and home care can be an important part of any future solution, but assistive technologies such as home monitoring, remote advice and special beds will certainly have a place too.”

Clashing interests

Most hospitals could do with a shift to systems thinking, Grossman explains. “Instead of simply asking how many new nurses to hire, we look at the bigger picture of rules & regulations, workplace practices, legal matters and the social domain, as well as short-term solutions to shortages. While it sounds like a prudent approach, Grossman frequently runs into obstacles. “Oftentimes, we’ll suggest a good idea only to be told: ‘We prefer doing it our own way’. Or: ‘It would be too expensive’. The most common objection? ‘It would simply take too much time!’ No one has to convince me that medical professionals love their job, but I will tell you that they don’t love change.”

And still, Grossman stresses, changes are urgently needed, including a funding overhaul. “Hospitals have launched myriad initiatives to create space by shifting patient flows, such as intermediate integrated care or enhanced specialist support for GPs. The solutions work a treat, but they end up eating into revenue to the point that hospitals struggle to stay afloat. This is just one example of the many clashing interests that complicate the transition. For me, the first step is to build a profound understanding of how healthcare funding works and what unintended effects it produces. Next, we can modify the funding system to ensure that reducing patient flows does pay off.”  

Systems education in healthcare

One of the most important steps towards a systems thinking approach is to be taken in education: STEM students need to learn how to apply systems knowledge in the context of healthcare. “The new degree programme in clinical technology has been an important first step, and we’re also working on a health track for the ‘complex systems management programme’. I’d welcome further efforts with open arms and would even go so far as to say that they are necessary. The churn rate among hospital nurses is an absurd 20%. As a university of technology, we can be part of the solution. And no, it won't make healthcare more expensive; in fact, my optimism says it will get cheaper. And I’m not the only one with a rosy outlook, even WHO has estimated that applying insights from safety science will make healthcare up to 10% cheaper, as well as making the work more appealing.”

Collaboration

Transdisciplinarity means little more than working with other disciplines, the cornerstone of this approach. “Things have been set in motion. We’re elated to have set up a long-term partnership with several hospitals, including Erasmus MC, and have already found that merging perspectives is a propellant for real change.”

“To solve our healthcare problem and save the healthcare system, we’ll need an organisational turnaround focused on the long term, which in turn requires fostering close collaboration between different areas of expertise and domains,” says Professor David Abbink. According to Abbink, today’s system is overly fragmented, both in academia and in practice. “We’ll never succeed if we keep indiscriminately throwing a bit of technology into the mix just to see what happens, only to turn to organisational change or a startup if we fail. The healthcare system can best be compared to an oil tanker, and turning around an oil tanker takes more than a haphazard approach. It’s just not how you control complex systems.” Ask Abbink, and he’ll insist that we knuckle down and come up with a solution that works. Technological research is no cure-all, but medical or organisational sciences alone won’t produce the solution either. “People like Irene, Maaike and I take a systemic perspective and harness technology in the rich context of a real, existing problem like the healthcare crisis.”  

Partnership with Erasmus MC

Abbink’s research centre, FRAIM, was set up to help tackle complex challenges. He’s a champion of long-term solutions with long-term impact, for example to solve the nursing shortage, which is a tricky issue due to the dire need for a solution and the profound hope that technology will be the remedy. “I don’t believe in labour-saving technology, because people don’t need less work. What they want is appealing work. For nurses, that means being able to take their time for patients, rather than rushing to chalk off as many as possible.”

Today’s attempts to improve healthcare prefer the buckshot approach, forgoing a sound long-term vision in favour of quick progress driven by an innovation or a robot. At Erasmus MC, Abbink gets to show the merits of his approach. “As part of convergence, the partnership between Erasmus MC, TU Delft and Erasmus University Rotterdam, we’ve set up a two-year partnership with Erasmus MC in a bid to transform healthcare with technological innovations and we have now appointed 5 post-docs.” While the two-year time-span is suboptimal, as it will naturally take more time to effect system change, it is a start. A keystone of Abbink’s approach is putting nurses front and centre. They develop the innovations, facilitated by the team of scientists (engineers, designers, social scientists) and innovators, ensuring that more attention is paid to blind spots. “It dramatically increases the odds of developing something that actually works.”

Special method of cooperation

Abbink’s novel practices have not gone unnoticed. “After just three months, the nurses came up to us: ‘This is the first time we’ve been involved in an innovation project!’ They felt heard, and all we had done was talk to them. We approach problems from a mission-driven angle, asking what attractive work will look like ten years from now.”
Still, Abbink is no stranger to resistance: “Many organisations, including healthcare organisations, are preoccupied with efficiency and accountability and prioritise measuring progress every six months, and you will never solve a challenge as daunting and complex as the healthcare crisis in just six months.”

And yet he’s optimistic: “The awareness is there: we’re getting our foot in the door. I’d compare the healthcare system to an unwieldy oil tanker. If you want to turn it around, there’s a multitude of parameters to factor in, from policy and healthcare insurers to international peers and competition. That is why I only believe in innovation that was developed the right way, which means that many different people from many different domains had to be involved. We’re not interested in a quick tech fix and instead recommend embracing systems thinking.”

Maaike Kleinsmann is glad that the gap between medical and tech researchers appears to be closing. “More and more pilot projects are demonstrating the important role of person-centred technology. As I see it, upscaling is the root problem. All too often, solutions are partial solutions at best and approaches are fragment. Scaling up promising projects therefore often proves impossible, which is why we argue that technologists and designers should play a key part in the healthcare transition. We’re also working on new degree programmes and foster collaboration with the Convergence alliance and Medical Delta.”

Kleinsmann, an industrial designer by trade, explains: “Industrial designers think about ways to link processes of social change to technological innovation. My mission is to change the way healthcare is organised with the support of technology. Because I value the person-centred approach, I put the care pathway - the journey a patient goes through - at the centre of my work. How can we optimise the way care pathways are organised? How can we empower patients to do more themselves at home? Could routine diabetes checks or post-surgery monitoring be done at home? What technology would we need? Next, you zoom out to the systems perspective and ask how this novel approach to healthcare could be organised and paid for.”

Value-driven care

Kleinsmann rejects the notion that integrating technology will make healthcare more expensive, but admits that it will reshuffle the flow of funds. “People may struggle to get to grips with the changes at first, but it is a fact that transitions reconfigure value streams. If you move healthcare to the home and give patients more control, routine checkups in the hospital will disappear. As Irene said, these checkups are an important source of revenue for hospitals, so they will have to find a way to move forward. Moreover, nurses will see their jobs change and may even have to undergo retraining. It is a complex task, but an urgent one.”

Like her fellow researchers Grossman and Abbink, Kleinsmann agrees that a new funding structure could be an important part of the solution. “Insurance companies agree, but it is still a complicated issue that the government might help solve. We should move towards what is known as value-driven care, a system in which financial incentives are based on outcomes and patient satisfaction rather than quantity alone.”

Kleinsmann also predicts that all hospitals will have a dedicated tech department, as an increase in home monitoring will require remote care centres in hospitals to analyse patient data and, consequently, “a different type of healthcare professional is needed for that.” Like Abbink, she’s no believer in technological panaceas. “Having the human, technological and business sides work together from a design perspective creates solutions that are people-oriented, technology-driven and financially feasible. We look at ways to optimise care pathways, working with teams of change managers, doctors, designers and tech experts. We should be asking: how can we cast technology in a supporting role in care pathways to actually make doctors’ lives easier and put patients in charge?”

Home monitoring

The most concrete example of home monitoring is the Box developed by Kleinsmann’s colleagues at LUMC. “We’re now working on a version off the Box that can give lifestyle advice so that patients in need of surgery can go into surgery and post-surgical rehabilitation as fit as possible.” Home monitoring generally works very well: “Patients who have to manage their body and their illness themselves, especially with chronic illnesses like diabetes, tend to learn a lot about themselves and their body. The new tool has already been implemented as part of a pilot and virtually all patients prefer it. There are plenty of successful home monitoring projects out there, but funding and scale are often key bottlenecks. It is yet another example of how the way healthcare is funded obstructs renewal and innovation, further emphasising the importance of a comprehensive approach, factoring in technological, person-centred and financial considerations.”