Transforming Healthcare with DevOps E-Book

Jeroen Mulder

• Herausgeber: Packt Publishing
• Kategorie: Fachliteratur
• Sprache: Englisch
• Veröffentlichungsjahr: 2022

Seitenzahl: 416

Beschreibung

Healthcare today faces a multitude of challenges, which can be summed up as the barriers architects and consultants face in transforming the healthcare system into a more sustainable one. This book helps you to guide that transformation step by step.
You’ll begin by understanding the need for this transformation, exploring related challenges, the possibilities of technology, and how human factors can be involved in digital transformation. The book will enable you to overcome inhibitions and plan various transformation steps using the Transformation into Sustainable Healthcare (TiSH) model and DevOps4Care. Next, you’ll use the observe, orient, decide, and act (OODA) loop as an iterative approach to address all stakeholders and adapt swiftly when situations change. Further, you’ll be able to build shared platforms that enable interaction between various stakeholders, including the technology-enabled care service teams. The final chapters will help you execute the transformation to sustainable healthcare using the knowledge you’ve gained while getting familiar with common pitfalls and learning how to avoid or mitigate them.
By the end of this DevOps book, you will have an overview of the challenges, opportunities, and directions of solutions and be on your way toward starting the transformation into sustainable healthcare.

Leseprobe

Transforming Healthcare with DevOps

A practical DevOps4Care guide to embracing the complexity of digital transformation

Jeroen Mulder

Henry Mulder

BIRMINGHAM—MUMBAI

Transforming Healthcare with DevOps

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To everyone working in healthcare, all over the world. We owe you.

– Jeroen Mulder

To the doctors, nurses, public health officials, social workers, and first responders who are protecting us from COVID-19 and guarding our health.

– Henry Mulder

Contributors

About the authors

Jeroen Mulder (born 1970) is a principal business consultant and enterprise architect with the Japanese IT services company Fujitsu and a former principal cloud architect for Philips Precision Diagnosis. He’s also a member of the city council of Emmen (the Netherlands) – the city where he was born and raised and still lives – with healthcare as a topic of special interest. Jeroen has previously written books about multi-cloud and DevOps for Packt Publishing.

I want to thank my wife, Judith, and my daughters, Rosalie and Noa, my precious family, for granting me all the space and support to spend so many hours writing – I realize that I need to seriously compensate for this time. A big thank you goes to Fujitsu, who allowed me to return to the Mothership. Lastly, I also want to thank the team at Packt for their faith and patience – especially Romy Dias, who did most of the editing once again – and for supporting us throughout this amazing journey.

Henry Mulder is a program manager for innovation with Trajectum, a care provider for intellectually disabled people needing guidance to participate safely in society, and a senior consultant at Q-Consult Zorg, a consultancy firm focused on practical change and transformations in healthcare.

He recently finished an assignment as a strategic advisor for MedMij, an interoperability governance foundation commissioned by the administrative collaboration between healthcare insurance companies and the Dutch Ministry of Health, Welfare and Sport, and a member of the NEN, the national committee on standards for health information systems.

First, my thanks to my partner, Maria, daughter, Larissa, and dog, Yara, for supporting me in writing this book. My gratitude to my colleagues at Q-Consult Zorg for being a great workplace that actively transforms healthcare for many care providers.

The communities of systems engineers (INCOSE) and system innovators (Si), for their discussions on what matters in transformation. Special thanks to the reviewers, Ray Deiotte and Gerrit Muller, for guiding us in the writing process. Finally, I want to thank all who have enlightened me with their insights.

About the reviewers

Raymond Deiotte has spent his career applying systems engineering theory and practice to the discipline of data exploitation across multiple industries. For nearly 20 years, he drove advanced decision-making automation with the application of systems of systems engineering principles and defined a taxonomy and modeling methodology to anticipate performance and behavior in the complex systems of systems. For the past 5 years, Raymond has brought those same concepts, techniques, and methodologies to US healthcare – redefining data governance, interoperability, and exploitation for clinicians and operators alike.

Gerrit Muller worked from 1980 until 1999 in the industry at Philips Healthcare and ASML. Since 1999, he has worked in research at Philips Research, the Embedded Systems Institute, and TNO in Eindhoven. He received his doctorate in 2004. In January 2008, he became a full professor of systems engineering at the University of South-Eastern Norway (USN) in Kongsberg, Norway. He continues to work at TNO in a part-time position. Since 2020, he is an INCOSE Fellow and Excellent Educator at USN. 

Table of Contents

Preface

Part 1: Introducing Digital Transformation in Healthcare

1

Understanding (the Need for) Transformation

Setting the stage for transformation

Digital twins

The urgency for transformation

Understanding demographic drivers

Understanding disruption in healthcare

Understanding the business context

Understanding the role of diagnostics and observation

Understanding the outcome on health and lifestyle

Exploring the disciplines for common understanding

Working with system engineers on health

Understanding the architecture of technology

Working with reference architecture to enable business operations

Working with communities on medical outcomes

The wicked challenge – thinking patient-centric

Summary

Further reading

2

Exploring Relevant Technologies for Healthcare

Exploring the impact of digitization

Understanding the impact of data exchange

Enabling virtual collaboration with telehealth

The outlook of participation with HeX

Introducing the ECM

Connecting the hospital to home with virtual care at scale

Working with the four treads of networked care in TiSH

Exploring the possibilities of AI, IoT, and robotics

The possibilities of AI

The possibilities of robotics

The possibilities of IoT in healthcare

Applying technology in networked care and TiSH

Learning from Amazon Care

Summary

Further reading

3

Unfolding the Complexity of Transformation

Defining complexity

Defining interaction

Defining relations

Defining systems

Exploring policies and regulations

Understanding the value of care with DevOps principles

Supporting healthcare activities

Experiencing healthcare activities

Valuing the healthcare activities

Telling about the healthcare activities

Defining value in healthcare

Understanding technology in complex systems

Understanding the role of major technology providers

Summary

Further reading

4

Including the Human Factor in Transformation

Introducing human-centric IT

Including 4Care in DevOps

Defining user stories

Human interaction on the health journey

Working with HSI

Designing human interaction

Working together in TEC teams

Data-driven decisions with OODA

Defining a new way of organizing healthcare

Implementing MEs as a disruptive model in healthcare

Human factors in the TiSH staircase

Summary

Further reading

5

Leveraging TiSH as Toolkit for Common Understanding

Starting the modeling for human-centric transformation

Defining the campaign for transformation

A leading example – Society 5.0

Transforming for people, teams, and organizations

Defining the transformation strategy

Working toward automated DevOps4Care

Using the VoC in DevOps

Summary

Further reading

Part 2: Understanding and Working with Shared Mental Models

6

Applying the Panarchy Principle

Transitioning from tread to tread

Understanding ecocycles and panarchy

Planning the ecocycles

Applying the panarchy principles to TiSH

Understanding people’s states of mind

Summary

Further reading

7

Creating New Platforms with OODA

Understanding and applying the building blocks

Reacting to health, lifestyle, and participation events with OODA

Enabling the OODA activities

Data processing on the technology platform

Applying OODA feedback loops to create transformative platforms

Explaining microservices

Reversed build of the OODA loop

Analyzing platform-driven transformation

Amazon Care

Buurtzorg

Roamler Care

Summary

8

Learning How Interaction Works in Technology-Enabled Care Teams

Defining interactions in activities

Shaping the journey for care teams and patients

Explaining the JIM

Enabling the journey with DevOps

Exploring the roles of team members and patients

Summary

Further reading

9

Working with Complex (System of) Systems

Building the Technology-Enabled Care (TEC) teams

Introducing integration in networked care teams of teams

Integrating TEC teams with patient-centric networks

IT resources

Trust

Identity management

Enabling integration in operations framework

Cross-walking integration and interoperability relations

Understanding interoperability in data domains

Integration along relations

Applying SSP, governance, and operations

Summary

Further reading

Part 3: Applying TiSH – Architecting for Transformation in Sustainable Healthcare

10

Assessments with TiSH

Understanding and defining the assessments with TiSH

Relating ambition to risk

Performing assessments

Qualities checklist for readiness

Scaling question assessment

Appreciative assessments

Maturity-driven program management

Summary

Further reading

11

Planning, Designing, and Architecting the Transformation

Defining the transformation plan

Micro-communities in the health experience ecosystem

The emergence of health experience EMCs from a patient’s view

Leveraging the power of small

Designing with TEC teams

Cooperation in digital omniversal networked care

The TEC platform for integration in the community

The quadruple aim for sustainable healthcare

Empowering transformation teams

Summary

Further reading

12

Executing the Transformation

Applying OODA to transformation – an exercise

Hierarchical or tiered OODA loops

Recognizing TiSH and DevOps4Care in actual transformations

Mitigating risks and avoiding pitfalls

Leadership

Learn

Real-life practices – stories from transformers

Gerben Krehwinkel, Treant Group, The Netherlands

Dr. Javier Asin, Surinam

Geert Quint

Pamela Girano

Defining the next steps – building transformative resources

Exploring the future of technology

Summary

Further reading

Index

Other Books You May Enjoy

Preface

The topic of transforming healthcare is not new. As early as 2014, a report to the US President was issued with the following six recommendations:

Accelerate alignment of payment systems with desired outcomesIncrease access to relevant health data and analyticsProvide technical assistance in systems engineering approachesInvolve communities in improving healthcare deliveryShare lessons learned from successful improvement effortsTrain healthcare professionals in new skills and approaches

(Refer to BETTER HEALTH CARE AND LOWER COSTS: ACCELERATING IMPROVEMENT THROUGH SYSTEMS ENGINEERING.)

Although COVID-19 has put things in motion, it is still, as the World Health Organization puts it in various publications (refer to who.int), the technology to improve the health of populations that remains largely untapped, and there is immense scope for the use of digital health solutions.

Technology is an important driver for change, but in essence, we should design and plan for personalized health and not focus on just the technology. Healthcare transformation requires more than just technology: medical staff, supporting staff, and patients including their community such as next of kin, need to embrace it. We need a methodology to bring it all together – people, organizations, and technology – by creating a common understanding.

This book presents ways to build an understanding between stakeholders and agree jointly on the way forward. The intention of this book is to make developers aware of the models to understand the complexity of healthcare so they can recognize this complexity when involved in large healthcare transformation projects. We only briefly explain what each model is about. In the Further reading section at the end of each chapter, we refer to in-depth sources.

Every chapter of this book has a specific theme, providing a comprehensive overview of the challenges, the opportunities, and the approaches to deal with them in architecture and transformation. By the end of this book, you will be able to guide the digital transformation of global healthcare. The book discusses the impact of new technologies but addresses primarily a methodology or framework for common understanding in the first place. The framework is referred to as Transformation in Sustainable Healthcare (TiSH). In addition, you will also apply Observe, Orient, Decide, Act (OODA) principles and DevOps4Care to real-world examples, step by step.

By the end of this book, you will not only understand the issues and challenges of transformation of healthcare but also possess a workable, actionable solution in the form of a roadmap.

Who this book is for

This book is written for all interested in designing, building, and providing data-driven healthcare, specifically architects, consultants, engineers, and especially healthcare practitioners who want to embrace the complexity of the digital transformation of healthcare. The book will also be interesting for digital leaders, including C-level executives. Last but not least, this book is for anyone who is on a learning path to understand the world of technological innovation combined with healthcare and wants to be a part of it.

What this book covers

Chapter 1, Understanding (the Need for) Transformation, provides a broad introduction to the book, exploring the various challenges that healthcare faces, such as an aging population and scarcity of skilled staff.

Chapter 2, Exploring Relevant Technologies for Healthcare, explores the combined possibilities of new technologies, but always from the health experience perspective.

Chapter 3, Unfolding the Complexity of Transformation, is where we learn about the policies and regulations that form guardrails in healthcare and how this affects the transformation.

Chapter 4, Including the Human Factor in Transformation, is where we learn how to prevent humans – patients and care workers – from getting lost in regulations, systems, technology, and data. We must find a balance between man and machine.

Chapter 5, Leveraging TiSH as Toolkit for Common Understanding, provides an introduction to TiSH and DevOps4Care, including the underlying models and methods.

Chapter 6, Applying the Panarchy Principle, is about community building using ecocycles to overcome inhibitions and start planning the actual transformation.

Chapter 7, Creating New Platforms with OODA, introduces and teaches you how to work with the OODA loop as a way to drive the transformation using feedback loops.

Chapter 8, Learning How Interaction Works in Technology-Enabled Care Teams, introduces the Journey Interaction Matrix (JIM), where we can follow the teams and monitor the activities throughout the health journey and interact with other teams in the ecosystem.

Chapter 9, Working with Complex (System of) Systems, is where we learn how to create a common understanding of how to integrate and transform into personal directed healthcare with the relevant solutions and systems, tread by tread in TiSH.

Chapter 10, Assessments with TiSH, is where we learn to perform assessments in healthcare, all in preparation for the transformation. For this, maturity models are introduced.

Chapter 11, Planning, Designing, and Architecting the Transformation, is where we put it all together, the concepts of TiSH and JIM, working with OODA loops, and forming the teams, and really start executing the transformation.

Chapter 12, Executing the Transformation, includes real-world examples of companies that have gone through a transformation. It ends with a big invitation to join the digital transformation of healthcare and help shape the future.

To get the most out of this book

Depending on your background prior to reading this book, we recommend you familiarize yourself with some concepts on which this book builds, such as the following:

Peter Senge’s The Fifth Discipline on systems thinking and the iceberg modelArchitectural reasoning from one of the reviewers of this book, Gerrit MullerEnterprise DevOps for Architects, by one of the authors of this book, Jeroen Mulder, published by Packt PublishingWHO’s view on digital health: https://www.who.int/health-topics/digital-health#tab=tab_1

Download the color images

We also provide a PDF file that has color images of the screenshots and diagrams used in this book. You can download it here: https://packt.link/2JSK8.

Conventions used

Tips or important notes

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Part 1: Introducing Digital Transformation in Healthcare

After reading this part, you will have a good understanding of the transformation challenges and opportunities in healthcare. This part will introduce working with Transformation in Sustainable Healthcare (TiSH) as the reference framework for transformation. This part of the book is centered around a number of themes: urgency, possibilities, complexity, human measure, and TiSH itself.

The following chapters will be covered under this section:

Chapter 1, Understanding (the Need for) TransformationChapter 2, Exploring Relevant Technologies for HealthcareChapter 3, Unfolding the Complexity of TransformationChapter 4, Including the Human Factor in TransformationChapter 5, Leveraging TiSH as Toolkit for Common Understanding

1

Understanding (the Need for) Transformation

While growing up, when things got tough, most of us ran to our mom for help and understanding. Well, as transforming healthcare can be very complicated indeed, we're also calling for our MoM, our Model of Models. She is called TiSH. We will introduce her first thing in this chapter.

Throughout this book, we remind you at the start of each chapter that MoM TiSH is always right behind you to get things in perspective.

The theme of this chapter is to set the stage for the transformation of healthcare into a far more real-time data-driven model. Why is this needed? What does it mean? How can we transform healthcare into this? And who do we involve for success?

This first chapter is a broad introduction to the book, exploring the various challenges that healthcare faces, such as an aging population and the scarcity of skilled staff. More people, with more and more treatable diseases, give an ever upward exponential trend of healthcare demand. We will learn about these challenges, how we can define the transformation with different stakeholders in the healthcare community, and who to involve to shape and drive this transformation. The most important lesson that we will learn is that it’s all about the patient and the well-being of humans.

In this chapter, we’re going to cover the following main topics:

Setting the stage for transformationThe urgency for transformationUnderstanding the role of diagnostics and observationUnderstanding the outcome on health and lifestyleExploring the disciplines for common understanding

Setting the stage for transformation

For reasons we will dive into later, we want to transform healthcare, so we need to form a team or community with the required skills and experience to embrace this topic. We want to get our heads around it.

Looking for digital changes and innovation in healthcare can be a daunting task, let alone a whole digital transformation. It’s a complex world that makes it hard to know where to begin and what to expect during a given time. We must embrace this complex world, whether we are from a medical, social, technical, consulting, or managerial discipline, and seek actionable ways to make the transformation happen.

We have to set the stage for the transformation team or community in which we will be playing our parts: on the supply side for care professionals, teams, and organizations to provision all kinds of healthcare, and on the demand side, the persons receiving treatments for their health and ever-increasing lifestyle improvements, so that they can participate in society.

Exploring this complexity, getting a common understanding across the disciplines, and knowing where to begin and how to proceed is the purpose of Transformation into Sustainable Healthcare (TiSH).

For starters, and because this model will reappear in almost every chapter, we will introduce TiSH as an acronym, name, and model. The acronym is clear, the name is to make it personal and keep everything on a human level, and the model represents a placeholder for complexity, as demonstrated in this first figure:

Figure 1.1 – The TiSH staircase for digital transformation in seven treads

The transformation objects at the foundation are People and Technology. The transformation itself is performed, tread by tread, as follows:

Learning digital Skills by individuals Enabling the Capabilities of teams with technology Ensuring enough Capacity for teams and their technology enablersProviding quality data-driven Treatments to patientsResulting in better-observed HealthPrevention via a healthier LifestyleThe best outlook to Participate in society’s activities

The lower four treads refer to the care provider’s organization to deliver treatments, and the upper four treads are about the patient and their care network to work on their Health and Lifestyle and be able to Participate.

Note that each of these treads is already happening right now in some form without much technology, standardized work, or processing. In this book, we will discuss how to improve each tread with digital transformation and accelerate the move to the highest tread in a sustainable way. Here, we mean sustainable as in the use of human, technological, and environmental resources.

Our approach is to build the digital transformation, tread by tread, by doing the right things, in the right order, and at the right pace. In other words, the right systematic approach. With this, you can ask questions regarding which tread we stand on today, which treads are our objectives in the short, medium, and long term, and what we have to do to reach the new tread. Each time, a higher tread is built on the lower treads, putting the new tread on top. It’s like building a staircase with pallets as building blocks, as represented in Figure 1.1, or rectangles with rounded upper corners. What these building blocks consist of will be revealed in the coming chapters.

The TiSH staircase forms a frame of mind to model the complexity of the transformation as a scaffold to fit knowledge, such as models and methods, into the transformation. In a way, it’s used to build a model of models for the digital transformation of healthcare.

But first, let’s start with the question of why? Why digital transformation, and why modeling?

Digital transformation is needed because of demographic, medical, technological, and especially digital advancements. We will explain the urgency of it in more detail later, where we will discuss what developments are driving these developments. Common or cross-disciplinary understanding is needed, as was already put forward in 1990 by Peter Senge in The Fifth Discipline. Here, systems thinking is the driving force realized through the shared modeling of complex developments, with a lot of disciplines working together.

In particular, it involves an combined understanding of the pillars of developing technology, business enabling, and providing care – in short, Technology, Enabling, and Care, as demonstrated in Figure 1.2:

Figure 1.2 – Common understanding between technology, enabling, and care

For this understanding, generic and cross-disciplinary models can be used. We have to look for the Goldilocks zone of models for this cross-disciplinary understanding:

Metaphors are too generic but suit initial recognitionSingle disciplinary models from their respective bodies of knowledge are too specific but are needed to detail and specify solutionsJust right are generic models with some similarity with specialized models to be used in bridging these specialized models from two or more different disciplines

This book is our contribution to describing this fabric of understanding in such a way that the reader gets a foundation and toolbox for the journey of embracing the complexity of the digital transformation of healthcare. With this contribution, we invite all disciplines to join the transformation and secure enough transformation agents and resources to make it happen on the scale required.

We started our common understanding by using metaphors such as staircases and pallets as building blocks to build a sound foundation. These metaphors are very generic with no further explanation needed. However, having a common understanding is a bit more complex, as demonstrated in the tale of the village of blind people who encounter an elephant and try to describe it. Metaphors can be easily searched on the web. If you want to know more about these metaphors, you can look for them yourself in your further reading. Try searching for the phrase “elephant metaphor.”

Additionally, cross-disciplinary generic models can be found relatively easily on the internet, as they are widely accepted by many disciplines. We will discuss how to apply them to the digital transformation process, referring to other sources for more information and further reading on the model itself or other usages.

Also, we will use some specific models to be able to bind the disciplinary bodies of knowledge. These will be explained in more detail as they form the main threads of reasoning and exploration to design jointly transformational solutions. By combining models, we get new insights to reason about and explore these solutions. Also, it helps to translate from one viewpoint or discipline to another, helping the process of common understanding.

Digital twins

Next to this modeling for common understanding of healthcare, it is useful to build a digital twin, a real-time virtual representation of real-world entities, activities, and processes. We can distinguish three of these digital twins:

The digital landscape itselfThe medical and social processes The avatar of a person

Let’s talk about the avatar, which is a digital representation of the patient. We will follow the avatar as we go through the different stages of transforming healthcare. The avatar will help us in understanding what’s in it for the patient. We cannot predict the future, but we do think that we will have a digital twin of ourselves soon: an avatar that holds all the data about our health (known as a quantified self) and tells our doctors what they need to know, a simulation of a person for clinical diagnostics based on input from, for example, scans, examinations, and medication.

This will help a clinician set precise diagnostics and define precise interventions without heavily impacting the patient. The avatar will help them to stay focused on the patient. And that’s what this book is all about: the patient or, even better, how to prevent an individual from ever becoming one.

With modeling, you can specify and quantify the healthcare in all aspects so that simulations can be designed to explore different scenarios of the transformation. Based on this, better solutions can be made.

We hope these digital twins will create feedback loops to self-direct the actions to the desired state of common understanding, sustainability, and health.

The urgency for transformation 

The first big question we ask is why a digital transformation is needed. So, before we get to the transformation and the selection of methodologies themselves and plan the transformation, first, we need to understand why we (urgently) need the transformation and what drives this transformation.

In all the rapid advancements and increasingly overwhelming scientific and technological progress, we tend to forget that, at end of the day, it’s all about humans. So, what is in it for you personally, whatever your role is? That is the question we asked ourselves when we started writing this book. From our professional roles in healthcare technology, as a patient or the next of kin of a patient, and as members of society, it’s the human factor that really counts. Therefore, this book will be 100 percent person- or people-centric, meaning that we will look at healthcare from the patient’s and caregiver’s perspectives the entire time. This is our perspective for the following assessments and quest for understanding.

On one hand, we see many great opportunities in things such as big data, machine learning, and artificial intelligence in combination with bioengineering. However, we also see the potential undesired effect on people and society. We, as people and as a society, need time to digest the new possibilities before taking well-founded decisions. The consequences can be profound.

With that in mind, first, we must put a stake in the ground and understand what drives the urgency for changing healthcare. This urgency is mainly caused by demographic drivers and disruptive economic drivers.

Understanding demographic drivers

Although certainly not complete, we will give some examples in which to understand demographic drivers:

One obvious driver is aging: we are getting older. That fact alone is already driving demand for care, in both emerging and developed economies. Figures from the United Nations show an increase in the global population by 1 billion people in 2025. That’s only 3 years from when this book was written. Of that 1 billion extra people, around 300 million will have reached the age of 65 or more. But there are more demographic factors that we need to consider. For instance, there will significant growth of the so-called middle class due to developments within countries. So, how’s that a driver for healthcare? The middle class will have greater and better access to a more luxurious lifestyle, which might lead to the occurrence of more obesity and other health problems that will burden the healthcare system. Growth is not equally divided across the planet. It’s expected that the population on the African continent will double by 2050, while the population in Europe will shrink. There’s a downside to the preceding point. With the growth of developing countries, there’s another trend that is becoming visible: the World Health Organization (WHO) calculated that, in 1990, breast cancer, diabetes, stroke, and other noncommunicable diseases (NCDs) formed 25 percent of the total amount of death and chronic illnesses in these countries. That number will rise to 80 percent by 2040 in some of the economically rising countries. Where people would likely die a century ago because of a certain disease that could not be treated, we are now able to cure a lot of these diseases due to immense scientific progress. Cancer is probably the best example here. Although it’s still life-threatening, a good number of cancers can now be treated with the prospect of good outcomes for the patient. Again, the issue is that access to cures and treatments is not evenly divided across the globe.Finally, a very important driver is the scarcity of staff in care. This is a global issue. In some countries, it has been calculated that, over the coming years, one-third of all jobs will be in healthcare, something that has been accelerated by the COVID-19 pandemic. This is not a sustainable model. To make it slightly worse, in some countries, care institutions are recruiting staff in other countries that need skilled personnel just as urgently as anywhere else, causing a “brain drain” in some parts of the world and enlarging the inequality of access to care.

The net result of all of this is that people will need complex, coordinated care for a longer period. There will be more people to take care of, and these people will live longer because we also have the capabilities to cure more diseases. On the other hand, there’s a huge risk that we can’t deliver that care because we don’t have the skilled staff to do so. This is causing the urgency to transform healthcare into a more sustainable model – a model that also allows us to scale it across the globe.

Understanding disruption in healthcare

Healthcare is already transforming, as we will discover in this section. Disruption is happening, as in almost any other industry, by highly innovative newcomers on the market. Global initiatives have been launched, disrupting traditional healthcare. We see non-healthcare industries expanding into this new market. This includes retail, wellness, and even telecom companies. They all have good business reasons for expanding into this market: healthcare is growing in the global market with tremendous opportunities. From a commercial perspective, healthcare is becoming a more and more attractive space to be in as a business.

On the other hand, we have no choice because of the increasing demand that traditional players can’t address sufficiently anymore. New entrants are leaping into the gap. It’s inevitable: a collaboration between the traditional stakeholders and new, private, commercial initiatives is required to meet the expectations of patients and clients. These patients and clients are getting used to on-demand and fast service, with the continuous improvement of products and services alongside comfort and convenience experienced with the likes of Uber, Booking.com, and other platforms. Healthcare is like any consumer market, acting with the same principles as, for instance, retail. The consumer sets the pace of innovation: on demand, ease of access, ease of use, reliability, always on, anytime, anywhere, and anyplace. This comes with a huge shift in the way healthcare must reshape its delivery model and become more agile.

At the same time, we need to control costs, so solutions need to be cost-effective. A shift to more prevention, on one hand, and more at-home care, on the other hand, are the North Stars here. Promoting wellness, a healthy lifestyle, and preventing diseases should, in the first place, benefit people and, at the same time, drive costs down – a very attractive perspective for payers and governments. Plus, the solutions are cost-effective when they are scalable. These solutions are developed once and deployed many times, preferably on a global scale.

Understanding the business context

The big change is the shift to prevention through lifestyle and behavior rather than cure. The WHO and many national government institutions have highlighted this more and more on their agenda. The COVID-19 measures on social distancing are a good example.

Therefore, a lot of new companies in healthcare are focusing on prevention by stimulating a healthy lifestyle. This is a global trend where we start to acknowledge that healthcare doesn’t start in the office of a doctor but in our personal lives and the way we take care of ourselves, for instance, with our lifestyle choices.

A well-known example is the various wearables that track movements – they monitor basic parameters such as your heart rate, sleep score, and activity points, and based on that data, provide advice for exercising. Some of these devices – think of the Apple Watch – already go the extra mile and make it possible to produce electrocardiograms (ECGs). Other apps measure an individual’s body fat percentage by using the camera on their smartphone – one of the features of the Halo View by Amazon.

Devices such as wearables and apps simply help people to maintain a healthy lifestyle. We probably all know what’s good for us and what’s not. Health is impacted by lifestyle:

InactivityUnhealthy dietsToo much alcoholSmokingNot enough sleepToo much stress

We know all of this, but apparently, it helps if someone or something helps keep us to stay alert to these factors. The biggest alert that a person could get is a serious health issue that results from an unhealthy lifestyle. Therefore, lifestyle is a very important driver in overall healthcare architecture and the transformation to more sustainable healthcare.

A sense of urgency is about pace – the pace of change. Many industries already adopted this new paradigm some time ago and started changing their business models for mainly one reason: they were forced to because of disrupting models that had been introduced into their markets.

Famous examples include Uber, which disrupted the market for taxis, and Airbnb, which did the same with traditional leisure. Are we seeing this in healthcare, too? The short answer is yes. There’s a shift happening already. In this book, we will look at some of these disrupting initiatives, for example, Amazon Care and a famous Dutch initiative called Buurtzorg that has gone international. The message of Buurtzorg is to simplify the systems and start again from the patient perspective.

Tip

Although Buurtzorg started as a Dutch initiative, the model is marketed internationally. We will refer to Buurtzorg a few times in this book, but more information can also be found at https://www.buurtzorg.com/about-us/.

Healthcare made easy, says the website of Amazon Care, promising care when the patient wants it, in the way they want it, and at the time they want it, fully focusing on the health experience. It should not be a surprise that Amazon brought this to the market. It’s derived from the guiding principle on which Jeff Bezos started Amazon: the company and its employees are obsessed with the customers of Amazon. Amazon calls this customer obsessed. In the case of Amazon Care, this becomes patient obsessed, including quality time with your team of doctors and nurse practitioners – on demand.

One other factor that makes Amazon Care and Buurtzorg great examples for this book to study is that both concepts are fully scalable and work according to agile principles. In Chapter 8, Learning How Interaction Works in Technology-Enabled Care Teams, we will learn more about these principles.

Note

A number of books have been written explaining the development and management philosophy of Amazon. Recent books include comprehensive descriptions of the working backward methodology that Amazon uses to create new services and products. This method was also used in creating Amazon Care: starting with the patient or the client, and their need, and then working backward to solutions that would address this. It’s a fundamentally different methodology of doing architecture. Although we will use Amazon Care as an example in this book, we will not go into detail about working backward.

The question is how to determine what must be done for health, when, and where. This is where diagnostics come in. Let’s get some insights into that in the next section.

Understanding the role of diagnostics and observation

The Mayo Clinic in the United States is perceived to be a lighthouse in modern healthcare, although the clinic was already founded back in the late 19th century. The American-based clinic puts tremendous effort into getting diagnostics right from the very first moment, for a lot of different reasons.

In the book Management Lessons from Mayo Clinic, founder Dr. William Mayo (1895) says: Above all things let me urge upon you the absolute necessity of careful examinations for the purpose of diagnosis. My own experience has been that the public will forgive you an error in treatment more readily than one in diagnosis, and I fully believe that more than one-half of the failures in diagnosis are due to hasty or unmethodical examinations.

Dr. Mayo figured out that an inaccurate or even wrong diagnosis would cause serious further problems to a patient and the quality of care.

Diagnostics have a decisive impact on the quality of care and patient safety by highlighting the following:

Disease prevention through early screening Discovery of any diseases at an early stage through the accurate diagnosis of early symptomsPrognosis of the course of the disease, including determining the effectiveness of treatments and medications such as antibioticsDecisions on follow-up treatments and monitoring the long-term effectiveness of those treatments

Diagnostics is aiming for improving patient care. Getting an accurate diagnosis is crucial. Getting an accurate diagnosis in a timely matter is even more crucial. Healthcare institutions are investing heavily in diagnostics. Let’s take the aforementioned Mayo Clinic as an example.

In April 2021, the clinic announced massive investments in a new platform to deliver AI-driven clinical decision support through remote monitoring. It cooperates with other companies that develop algorithms for the early detection of diseases and collect data from remote devices to support clinical decisions. These two companies – Anumana and Lucem Health – are both start-ups. This is what we will see in the future: traditional healthcare players seeking cooperation with start-ups that deliver cutting-edge technology to enhance care.

Mayo Clinic’s Platform President, Dr. John Halamka, is convinced that the upcoming technology in AI and data science will result in a breakthrough in disease detection and, with that, a better perspective for patients. However, in the statement, he added that this is not just about technology – he also stressed the importance of patient engagement and cultural changes in healthcare to make it happen (source: Healthcare IT News, April 2021).

So, diagnostics is important, but how is it driving transformation in healthcare? Getting better, faster results from diagnostics can save impactful interventions, long-term treatments, and more speedy recovery. Again, we need to keep the patient as the focus. Less impactful interventions, less need for long-term treatments, and speedy recoveries will, in the first place, benefit the patient. And, as a more than welcome side effect, it will drive the costs for healthcare down – at least that’s what economic specialists in the field expect.

With that, we are entering the field of precision diagnostics and precision medicine. A number of studies have been executed to show the cost-effectiveness of precision diagnosis and precision medicine. Precision diagnosis and precision medicine are decisive in the following ways:

Reducing the risk of treatment by trial and errorReducing the risk of over-prescriptionShortening the time before treatment is startedDecreasing the time that a patient has to spend in hospital or care institutions

The contradiction lies in the fact that precision diagnosis and precision medicine require substantial investments. However, studies from the University of Utah (source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical) show that these upfront investments can save expenditures in the long run when it comes to the execution of treatment. More importantly, the studies show that the quality of life of the patient is improving with accurate, precision diagnosis and precision medicine.

Going back to the previous section, we can see that people have already invested in smartwatches that observe their vital signs and give advice or alerts when needed. This observation and subsequent prefiltering allow for the early detection of possible health conditions but will also limit the influx of people for screening and diagnostics.

Understanding the outcome on health and lifestyle

There’s one driver that will benefit a person’s health even more, as we learned earlier, and that’s lifestyle – that is, preventing an individual from becoming a patient. We will explain this using the health experience shortened as HeX, similarly to UX for User eXperience in the DevOps world. This HeX is the first reference model we will use to understand each other.

First, we need to explain what the HeX is. It refers to the health activities of a person, varying from participating in daily life to being treated and (chronically) nursed as a patient. We use omniversal care to represent the lifetime journey through which a person, as a patient, travels in terms of required care from the cradle to the grave.

Note

We are using the word omniversal: omnidirectional and universal. This applies to all health activities from every direction at the same time.

The following diagram shows the omniversal care in the HeXagon for health experience:

Figure 1.3 – Omniversal care HeXagon to represent the Health eXperience (HeX)

The basic model is firmly patient-centric, with the activities of the person as a reference. At any given time, the person is participating in the daily life of society, conducting – more or less – prevention activities such as sports or walking, and getting regular check-ups or tests such as for colon cancer. A patient will probably visit the General Practitioner (GP). If required, further medical diagnosis is performed along with treatment such as intervention with medication, exercises, or an operation. The patient might receive either short-term or chronic nursing care. This can be for one or more diseases (co-morbidity).

The goal of any person is, implicitly or explicitly, to stay active on the upper half of the hexagon: participation, prevention, and early detection. That has a direct relation with lifestyle. Over the past few decades, medical science concluded that a healthy lifestyle is preventing a lot of commonly known diseases. An unhealthy lifestyle can lead to obesity, which, in turn, can lead to all sorts of health issues such as diabetes, cardiovascular diseases, or orthopedic problems.

Let’s get back to the demographic changes that have had an impact on global healthcare. In the first section, we discussed the rise of noncommunicable diseases in economically rising countries.

A study by Thomas J. Bollyky is a good example and reference for this topic. In his study, he relates the increase in cancers, diabetes, cardiovascular diseases, chronic respiratory illnesses, and other noncommunicable diseases in low-income countries to the increased prevalence of key modifiable behavioral risks, such as unhealthy diets and tobacco use, and reductions in the infectious diseases that disproportionately kill children and adolescents.

Worse still, these are also countries that are not well prepared to deal with these diseases because they hardly have any access to proper healthcare. However, again, it shows the major effect that lifestyle has on health.

Note

The full study, entitled Lower-Income Countries That Face The Most Rapid Shift In Noncommunicable Disease Burden Are Also The Least Prepared, is available at https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2017.0708.

The examples of Buurtzorg and Amazon Care can also be depicted in the omniversal care hexagon. The first extension of the HeX shows the principle of Buurtzorg.

The HeXagon on the right-hand side of Figure 1.3 shows how Buurtzorg is creating an inner supportive hexagon to avoid outer professional care, if possible, and rely on the local community.

Amazon Care is organizing the care ecosystem around the family of their employees to optimize participation, as shown in the following diagram:

Figure 1.4 – HeXagon of health experience showing the care ecosystem

Combining the two leads to the complete Omniversal Care HeXagon representing the patient-centric care ecosystem of self, social, and medical care. The hexagon on the right-hand side shows the complete HeX, the hexagon for health experience. Support comes from the social (the yellow or light circles) providers and medical care from (the blue or dark circles) providers.

HeX is the representation of the complete individual healthcare ecosystem. Every citizen on earth should have such an ecosystem available. So, that’s the stage on which we set our transformation challenge.

Exploring the disciplines for common understanding

We have set our challenge. Who do we need? Looking at Amazon, they utilize their platform to provide the care needed for their employees with the same rigor of customer obsession as with their logistics services.

A platform creates value by enabling interactions between two or more groups. In the case of healthcare, this is the providers, patients, and people who want to stay healthy. A platform has two major parts. One is the digital technology and the other is the community of involved people, care workers, and patients alike. Building a platform requires disciplines to build the technology and communities:

Figure 1.5 – The platform consists of technology and communities to serve at the point of care 

The two disciplines that can build this are systems engineering with a technology approach for the platform and systems innovation for the community-building approach. So, how do we involve our transformation teams in these disciplines?

Working with system engineers on health

System engineers focus on how to design, integrate, and manage complex systems over their life cycles. For a successful transformation, we have to understand how they think and work, especially in their role as architects.

Getting to a model that supports HeX means that healthcare must adopt agile, highly scalable concepts and embrace DevOps as part of the transformation. It’s a guided, agile way of developing solutions to execute this transformation. Applying this to healthcare transformation leads to something that we call DevOps4Care. This is where technology architects and consultants from medicine and healthcare enterprises closely work together to find the best solutions for the patient.

Ultimately, this book is about DevOps4Care: an agile way to create new, sustainable solutions in a speedy manner that will improve healthcare. It requires a complex transformation. In Chapter 3, Unfolding the Complexity of Transformation, we will discuss the complexity of this transformation in much more detail.

Understanding the difference between the architect and medical or business consultants requires a common reference such as we already introduced with metaphors and the book-related reference models of TiSH and HeX. In this section, we will further discuss these references and models.

Architects shape structures. They do not predict the future, although enterprise and business architects have visions of the future just as real estate architects do. What collectively binds us – or better yet, what we have in common – is that all architects and consultants come from a perspective where something is needed or desired. In business, that typically starts with business requirements, usually expressed by the consultant representing the many stakeholders. The business sees a demand, formulates requirements to address this demand, and sets these requirements as a starting point for creating architecture that, in the end, will result in a solution or a product. Healthcare isn’t different from that general principle, the only difference is that we now have a lot of medical-oriented stakeholders.

As an architect, the architecture in healthcare also is derived from the medical and business perspective. It’s the reason why all enterprise architecture models start with the business view. The Open Group Architecture Framework (TOGAF), the enterprise architecture method of The Open Group, is a good example and an industry standard for architecture. TOGAF starts reasoning from the business: what are the requirements of the business, which, in our case, is healthcare? But TOGAF is a technology perspective. We need to build an understanding of the healthcare enterprise and medicine itself.