Enterprise-architecture and organisational health
My mother is a retired general-practitioner (family doctor), and still has the BMJ (British Medical Journal) delivered here each week. It’s always a useful contrast to my ‘day-job’ in enterprise-architecture, and every-now-and-then there’s a real jewel of an article there that reflects right back into my everyday work.
This morning was one of those times.
Des Spence writes a regular half-page column in the BMJ, titled ‘From the frontline‘, usually reflecting on the blunt realities of his work as a general-practitioner in Glasgow. Most articles in the BMJ are hidden away behind a paywall on their website, but fortunately Des also republishes his columns on his own weblog, and his article this week, ‘A conspiracy of anonymity‘, strikes right at the heart of much of current enterprise-architecture. His own context is the health-services, of course, but much of it reads as if it was written just for us:
…the themes of medicine are constant in time and geography. They are important but abstract, and completely ignored in medical education: doctoring is about reading people, knowing when to listen and act but also knowing when not to listen and not to act. At its core, doctoring is the willingness and requirement to accept responsibility.
If we think of enterprise-architecture as a discipline whose main responsibility and focus is the health and well-being of our organisations – especially in the longer term – then the analogy here is painfully accurate.
And yes, it gets worse:
Continuity is a broken, forgotten, rusting hulk for simple reasons. … The vast archipelago of new specialties (medical and nursing) comprises small, separate, distant islands with fiercely insular medical tribes. And despite huge expansion in consultant numbers regrettably they seem no more accessible. More resources, paradoxically, have made the problem worse.
Again, no trouble in seeing the analogy for us there. And, as in our own domains, there’s a direct link to the loss of awareness of the need for generalist disciplines to hold everything together:
Generalism has been dismissed as inferior, has been left fatally undermined, and is dying, if not already dead. Anything encountered that is outside the modern telescopic specialist training programmes results in referrals to other specialties, choking the system in needless referrals.
How often do we see this in our own practice, with specialists rarely connecting with other specialists, and no-one left to ‘join the dots’?
More, there are the same broader cultural issues that impact our own domains, too:
But we can’t blame modern medicine because it only reflects modern society, which is risk averse, unable or unwilling to accept uncertainty, and left in a paralysis of indecision.
There’s also a bleak echo of our own challenges around user-experience, customer-journey and social-business, and in getting others in the organisation to understand why such matters are important:
There has been a homeopathic dilution of medical responsibility, and patients are increasingly anonymous and faceless in the NHS [UK National Health Service]. The goal of personalised care is but a delusional myth.
To me, responsibility is the key to all of this: yet how do we support it, or create it, in a culture where the only real driver is evasion of responsibility – the relentless quest to convert as much as possible into a conveniently-invisible Somebody Else’s Problem?
I don’t have any easy answers to any of this. But at least people such as Des Spence are still asking the questions that matter here: and that’s something to hold some hope for the future, I guess?
The problem seems to be one of evolving an Enterprise Architecture of multiple Enterprise Architectures or meta-EA.
Healthcare organizes itself differently in different countries. On this side of the pond, we have the USA which is a terrible state of affairs, and then, Canada, where things are organized completely differently. It’s hard to get a straight answer as to which system is better.
The notion of a “home” doctor is, in my view, a good one. A doctor talking to a specialist seems to result in less wait time than a patient trying to book an appointment with a specialist.
Of course, when your range of options is limited to telephone , fax or e-mail, the cost of communication is higher (e.g. telephone tag, time delays between send a fax or e-mail and receiving a response).
And, the big EA hurdle is the extra effort needed to get a record of any of these transactions/outcomes into the Patient EMR.
The facts are there is no “EMR” – what we have is a bunch of EMRs, one per patient at each clinic. – if a Patient is receiving services from two or more medical professionals, each clinic/doctor has their own EMR for the patient, with a different Patient ID, with different information in each EMR. No wonder duplicate interventions are requisitioned.
My group has been building EMR software since the early 1990’s.
Very recently we acquired a Managed Care customer that built, for its member agencies, an e-clinical Hub where each intervention for a patient results in immediate seamless upload and consolidation of all information relating to the intervention at the e-Hub.
Hospitals and lab test facilities subscribe to the e-Hub with upload patient data daily to the e-Hub. The hospitals are willing participants as they now ship “results” information to one recipient only instead of previously sending results to individual clinics.
Before each new intervention, each agency clicks at a button and is able to download a consolidated clinical data for a patient and bring into their individual EMRs, whatever information they wish (structured data, plus unstructured data, including spreadsheets, images, documents and videos).
Clearly, none of this uploading/downloading would be needed if all of the agencies were using the same EMR software, but in the real world, with 1000+ EMR vendors in the marketplace, that is not likely to happen.
The system I am referring to has been in operation for only a few months. We expect it will reduce the cost of duplicative interventions and improve the quality of services rendered to Patients.
Karl – many thanks, and definitely interesting.
I’ll have to admit, though, that the point I was more aiming for above was the analogy with enterprise-architecture as a support-service for the health of organisations. To take your example, the equivalent of your software should be something like a whole-of-context repository, that enables us to keep track of the ‘clinical history and prognosis’ of each ‘patient’ (unit and sub-unit of the organisation), and also the interactions (‘epidemiology’ etc) between each of those entities individually and collectively. One of my regular rants on this blog is that such a toolset doesn’t exist for enterprise-architecture/organisational-health: the current EA toolsets each tackle only a small handful of small subsets of the need, and there’s no way at present to link them together.
So it’s the broader metaphor or analogy that I’m looking at here: for example, what kind of systems do we need to “reduce the cost of duplicative interventions and improve the quality of services rendered” to our organisations and enterprises?
I now see where our previous discussion comes from 🙂 I don’t see a family-doctor as a generalist similar to an enterprise architect because family-doctors don’t actively connects different fields together. A family doctor tries to solve the problem and if that fails the family doctor will send you to a specialist and isn’t actively involved in the rest of the process (at least that’s how it is in the Netherlands). So to me the family-doctor is more like an engineer.
For me a better analogy would be to say that an enterprise architect as a generalist should be like a professional sports coach who actively brings specialists together and actively guides the specialists (the supporting team) and the sporter or sports team all together towards a common goal. (I think that there are parallels between great sport coaches and Steve Jobs)
In the construction building world you see that with the increasing use of BIM modeling the tooling may become the generalist for the whole lifecycle of the built environment, see http://buildinginformationmanagement.wordpress.com/2012/10/01/bim-in-chains-sustainability-and-life-cycle-management-of-the-built-environment-stalled/
What we can learn from BIM is maybe that the generalist we need in business is similar to the BIM manager: a person (or a group of persons) who ensures efficient management of information processes throughout the whole cradle-to-grave time-span of an enterprise to ensure that all specialists make decisions and take actions based on the same model. And to ensure that the model itself contains active error and collision checking so that everybody knows that they can trust the model.
Or you must be lucky enough to be or find a second Steve Jobs…
@Peter: “I now see where our previous discussion comes from” – likewise! 🙂
Yes, you’re right – a key source of our difference in perspective here is likely to arise from the different roles of the family-doctor in our respective countries. In the NHS in Britain, the general-practitioner is the primary point of contact, integrator and through-life intermediary for a person’s relations with specialist medical services. The general-practitioner is “the professional sports-coach” in the sense that you describe it.
The nominal focus of the NHS is on wellness, not illness – the distinction may seem subtle, but it has huge implications for system-design and design for customer-experience and customer-journey. The real tragedy, as Des Spence points out in his article, is that that nominal focus is shifting once more towards a provider-oriented (specialist-oriented) rather than customer-oriented (patient-oriented) view, where integration breaks down and individual patients’ highly individual differences and needs are ‘simplified’ down to fit frankly wrong-headed assumptions about ‘economies of scale’ (wrong-headed because whilst the concept of ‘economies of scale’ can often provide good possibilities for cost-reduction and resource-optimisation, it has only limited validity in a context with high levels of uniqueness).
The reality is that whilst a provider-oriented model is highly ‘efficient’ and highly profitable for the provider (hence why it’s still retained in the US), it produces abysmal health-outcomes overall (as can be seen in the US, with the highest per-capita cost in the world but overall the worst health-outcomes of any ‘developed’ nation). The whole point of the NHS, way back in 1948, was to re-orient the health-system towards health-outcomes rather than private profit. Unsurprisingly, there’s been enormous pushback ever since then from the ‘provider’-side and their paid allies in government, pretty much sabotaging the system at every possible opportunity, to the point where it’s now close to breaking-point. Trust in the health-system is low, primarily because of the fragmentation that a ‘provider-orientation’ (and, for that matter, the disastrous ‘managerialisation’ that’s accompanied it) brings in its wake. There’s an urgent need to scrap large parts of the mess, strip out probably at least 90% of the managerial structures, put the specialists back where they belong – as support-services, not the centre of the system – and reinstate overall health-outcomes from the clients’ perspective as the core focus.
Almost exactly as we need to do with our large organisations, in fact. Which is where enterprise-architects, as proponents of generalism as everyone’s responsibility, come into that picture.