Make it about people
“How can people be partners in their health when the system is designed to treat them like patients?”
“When there are no silent revolutions how can we know that change is happening?”
These are two of the wicked questions raised at the Healthiest State Campaign’s Health 3.0 Summit held last November in Seattle. Wicked questions unleash the imagination by highlighting a paradox that has no right or wrong answer, only better, worse and good enough solutions. The key to getting a best possible answer is to ask more and more people.
“Patient-centered healthcare” and its derivations (like the medical home model) is one set of proposed solutions to a persistent and stuck problem in health care: That people are needed to make the system work, but they’re not necessarily relevant to its function.
But, let us not confuse patient-centered healthcare with person-centered health. . Patient-centered health, at its very core, preserves and indeed strengthens the traditional medical care system. It reinforces the existing power relationships and creates the illusion of control when in fact very little changes.
Medical homes – widely celebrated as one of the most significant innovations in person-centered health – is a great example. On its own, the concept doesn’t quite get us all the way to person-centered health. At its heart, the medical home model is a technical reorganization of primary care aimed at increasing quality – not necessarily effectiveness. Except for a few medical home visionaries, there is a noticeable absence in the core belief in people that must accompany the more technical design features of the different models. Many medical homes have little to do with the actual needs of people – either doctors or patients. They don’t necessarily make health care more understandable. They don’t necessarily empower anyone to solve his or her own problems. They don’t relieve the complexity of the system. Yes, there are very important and valuable features embedded in the different models – namely that teams work more effectively (and the distinction between speed, efficiency and effectiveness is vitally important) than individuals (as an aside: that’s a revolutionary insight?). However, I find it difficult to recognize medical homes and other patient-centered care “innovations” as a revolutionary sea change in person-centered health. Why?
Well, as with most things, it comes down to control. The health care system refuses to turn over control to people. Whether it comes down to a lack of trust in people, a genuine belief that the system can and does know more about people than they know about themselves, or some other self-perpetuating myth – people are not in control. I believe there is an unspoken truth (or Mokita) in health care that the loss of control is a legitimate fear. I’m not quite sure what the big fear is … other than the fact that should person-centered health truly become a reality then there would be 300 million health systems in this country with 300 million different definitions of health and a true revolution would be underway. One in which the status quo would become the irrelevant piece, not people.
To accelerate this change the Washington Health Foundation spent significant time leading up to the Health 3.0 Summit developing and testing a set of person-centered health design principles loosely derived from Donald Norman’s “The Design of Everyday Things”. These were unveiled at and rigorously discussed during the event by a diverse set of participants:
- Dr. Vaughan Glover, president of the Canadian Association for People-Centred Health
- REAL Wellness pioneer Don Ardell
- User-interaction developers from the design consultancy frog
- Professor Julie Kientz from the University of Washington’s Human-Centered Design and Engineering Program
- Rod Falcon a health futurist from the Institute for the Future
They all agreed that with slight adjustments the six principles presented were a significant starting place for discussing the real revolution needed in health care: breaking down the context of health and making it understandable to people.
Our design principle statements:
Good person-centered health design…
- Embeds feedback loops that empower people to interact with the system as partners and individuals, not just patients (Feedback)
- Requires shared responsibility to select among a bounded set of trustworthy options, so that people’s outcomes and experiences meet their expectations (Affordance/Constraints)
- Allows people to easily understand the relationship between parts of the health system and the value that they are seeking from it (Mapping)
- Connects people and provides them with the tools to relate to others openly and freely, in ways that build from their communication needs (Networked)
- Re-shapes diverse knowledge into frameworks that people can use to improve their health and make sound personal health care decisions (Enhancement)
- Responds to the changing demands and health needs of people by providing flexible services that can adapt to emerging trends (Accessibility)
Building directly from these six principles, the Washington Health Foundation created its Health HoME concept – a vision for personal empowerment that is practical and action-based. Health HoMEs put people back in control over their health and health care decisions. They allow individuals to define for themselves the value they seek from their relationships AND extract it from a fragmented and complex system that is not designed for the loss of control.
Until health care disrupts itself out of the self-centered, self-preserving patterns that define it - all of our revolutions will remain silent. The defining characteristic of any wicked question is that you only arrive at a better answer by asking more people. Let us stop solving problems that don’t fix anything, and start asking questions. Borrowing from Ryan Jacoby at IDEO (quoted here by Ryan Sims) - questions are the new answers.