Moving Complex Systems Toward a Goal

I recently told several of my Mayo colleagues that I'm an outsider who has landed in a new environment where the degree of collaboration, dialog, and friendly debate is amazing.    The following a kind of guest blog, started by Dr. Michael Joyner, who is also a writer 

He wrote to a number of us

"Great paper written by chairman of bank of England in middle of financial crisis.   Pertinent to anyone interested in nudging complex systems towards a goal."   

Below are the responses:

Let’s move away from risk prediction a bit and apply these concepts to our world.  The world of innovating and translating new solutions (hugely complex and risky) in the medical care industry (more complex and regulated than even the financial industry) to treat human disease (much of it psychological/societal/evolutionary) is off the charts with risk.

I love the statement of fighting complexity with simplicity – it intrinsically feels correct - so what should our heuristics be for advancing medical care?

Modern medical innovation is complex, perhaps too complex. Regulation of modern translation of medical innovation to products is complex, almost certainly too complex. That configuration spells trouble. As you do not fight fire with fire, you do not fight complexity
with complexity. Because complexity generates uncertainty, not risk, it requires a regulatory response plan to enable innovation and translation grounded in simplicity, not complexity.

 So what is our plan and our heuristics?  My suggestion to get us started in honor of Mr. Haldane:

1)    You must move out of the harbor and get in the race in order to win (win being to develop new solutions in medical care)

a.    The race has been underway for some time, so you are behind already, so get going and move with speed

b.    A race is the best analogy – we should move quickly in just about every respect.  “Fail quickly” is a trite but true statement

c.    How many things are stuck in endless cycles of planning or less than serious (not capitalized or staffed anywhere near the need) attempts?

 2)    Almost all of your strategies, plans, predictions will turn out to be incorrect along the way, no matter how much planning you do – you will assuredly have many failures as you progress - how you respond and your ability recalibrate course and keep progressing to the goal is all that matters in terms of achieving success

a.    The good news is at this point you are at least in the race

b.    As with the best entrepreneurs, if you have not failed at least a few times you should not be trusted with anything – very easy to say  and terribly hard to live it when you are deploying capital

c.    The art in all this is determining if the failure is due to execution, if it is then you have the wrong people and should switch out the team – or vision/goal, if it is then time to go back to the harbor.  The first determination (execution) is not too hard to make but hard to execute (needing to switch out the team).

d.    Extremely hard to determine if a group or individual that has failed should be cast aside or given new resources to try again – all of history teaches us that the best folks who we celebrate as geniuses failed many times before succeeding.  Of course, fools will fail as many times as you allow them.

e.    No easy answers here other than did the group or individual at least execute well and move with efficiency and speed, that is necessary component but not sufficient

3)    You should study the strategies and successes and failures of others, but because successes and failures are the result of an enormously complex environment with variables too numerous to count, we should not study them so much or lend them credence to an extent that we “over-fit” our analysis and plan. 

a.    Successes are tainted with survivorship bias – be careful when determining why and how they were successful

b.    Failures are often due to a lack of ability to recalibrate from the inevitable setback or a poor team in charge of executing than a mistake in vision/goal

4)    You will need capital sufficient to start and recalibrate at least twice

a.    Undercapitalization is a guaranteed route to total failure

b.    Perfect Oscar Wilde quote in the article.  We often know the price of everything (salaries and the cost of a team) but the value of nothing (if not a great team staffed as required then we will surely fail, so what are we tabulating)?

5)    The humans involved in the endeavor will override everything else – need to find and bet on the best team possible

a.    All of the above will be evaluated, capitalized, planned, recalibrated and executed by a team of humans – they will determine success or failure

b.    What makes life exciting and fun is that this means complexity and unpredictability – how do we find and support the right folks?  How do we determine that the inevitable failure is the result of the vision/plan or of the humans charged with executing it?  Can we hand additional resources to the team/individual who have failed twice already?  Bill Gates, Steve Jobs and Jeff Bezos, etc. failed many times – what did others see in them to continue to provide resources?

c.    Key question for us all is how to identify and recruit the right team – from the very top to the bottom – and hold all accountable for efficient and effective progress (not success)

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The Manhattan Project is a great example of survivorship bias – we celebrate it (in a way) because it was successful.  However, that does not mean that throwing $22B and a lot of really smart people at an objective means you will succeed.  Indeed, that approach has failed more often.  It is in the intangibles – I would argue that the sheer pressure that it must succeed (because of the fear of what if we lost that race) meant the accountability and demand for speed was very large – folks got out of the harbor and recalibrated at high speed (or so I imagine).   Pretty hard to re-create that environment – hence the Haldane teaching that it is dangerous to extrapolate characteristics in a complex world

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The keys to success when moving complex systems toward a goal are:

1) Engineering problem, not a theory problem.

2) Clear definition of success.

3) Response to a real existential threat.

4) One customer.

Much of what we propose as innovation does not clearly meet any of these criteria.  Manhattan and Apollo did.  The Transcontinental railroad is another example that meets several or all of these characteristics.

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And that's what a group of wonderful colleagues debated on a Sunday morning.

Advice for Aspiring CMIOs

Recently, my colleague Steve Peters, chief medical information officer, Mayo Clinic, and I discussed our life experiences as CMIOs.  We talked about how the role has evolved along with changing technology and the transition to nearly universal adoption of electronic health records by large health centers.

 I asked Steve to share his insights on 'what makes a great CMIO in 2020' and captured his thoughts for you.

"I have thought about the 'post-EHR' CMIO as most large centers and hospitals have moved on from the initial implementation.    Here are a few thoughts:

1.       Serves as the primary physician champion for all major clinical information technology projects, including EHR implementation and information security.

2.       Assists in development of IT strategy and planning.

3.       Acts as an advocate for protection of patient privacy and the security of protected health information.

4.       Supports various regulatory compliance activities including HIPAA, Meaningful Use, and billing compliance.

5.       Represents the medical community and serves as an advocate in the promoting the use of information technology in the clinical setting.

6.       Partners with leaders in the effective adoption of information technology solutions in support of clinical care, research and education.

7.       Serves as a physician champion in the development of the electronic medical record and practice management tools.

8.       Maintains an awareness of existing and emerging technology, regulatory, and market factors that have an impact on healthcare information management.

9.       Accountable for the identification, development and execution of education, training programs, and services in the area of computer skills and competencies in the use of electronic tools for patient care, quality, resource management, and performance improvement.

10.  Going back to the 'grandfather' informatics board preparation, I found some broad texts like Biomedical Informatics (Shortliffe and Cimino) very valuable, especially for those areas in which I have less experience or expertise.   The major meetings including HIMSS (from the industry standpoint) and AMIA (more academic) are valuable.    Many areas have regional CMIO meetings to share ideas.   And read blogs."

A New Model for Sharing Insights While Protecting Privacy

Last week at JP Morgan, Mayo Clinic announced a new collaboration with nference that I would describe as "Cloud-hosted, de-identified, federated learning in which the tools are brought to the data instead of sending data to the tools"

 This Healthleaders article describes it well.

 Here's a broad overview.  Let's start with 3 containers.

 The first container is controlled by Mayo Clinic, holds identified data, and has one purpose - the development and optimization of de-identification algorithms. Selected data scientists, who are accountable to Mayo Clinic, are asked to help with algorithms via time limited, audited access to the container.   They are either Mayo staff or collaborators from outside who are trained in Mayo policies and held accountable to the same requirements as Mayo employees.    No data ever leaves this container.

 The second container is a controlled by Mayo Clinic, holds identified data, and has one purpose - running the perfected de-identification algorithms and producing a de-identified data set. That de-identified data set is moved to the third container.

 The third container is for running innovative applications brought to Mayo by partners offering unique analytics on the de-identified data. No data leaves this container, the applications are brought into it. A joint tenancy model enables the container to be run by Mayo Clinic but others to be given limited, audited use of the container to run their applications. The only thing that ever exits the container are data insights or knowledge. For example, if nference is asked a question about drug discovery, its machine learning/natural language processing software in the container can pose the question. The answer is shared but not the data used to generate the answer.

To me, this is the perfect balance of agility, innovation, and privacy protection. I've worked in many organizations and not experienced a design that has so many safeguards against  data leakage. 

We'll populate the third container with our first wave of de-identified data later this year.  I'll continue to report on our progress.

Dispatch from JP Morgan

 Although I've been attending healthcare and technology conferences for more than 40 years (yes, I attended Comdex in 1979), but until this week had never attended the JP Morgan Healthcare Conference.  The conference gathers 60,000 investors, innovators, and providers for four days to plan the next year’s path for healthcare and building relationships that will foster future innovation. I have extensive experience attending HIMSS , which has similar numbers, but only a small fraction actually attend the main the JP Morgan Healthcare Conference.  

My Mayo colleagues and I presented formally in the non-profit track but the remainder of the meetings was dedicated to side conferences in numerous hotels, restaurants, galleries, and office towers.  I'm a practical traveler who walks to most meetings but there was no way to attend 40+ meetings in 30+ locations without help. I had an amazing driver who took me to a different meeting every 30 minutes, adeptly navigating a sea of activity.

Was it worthwhile? What it consistent with my role and mission?

Yes, it was one of the most productive conferences I've attended.

In one city in one sprint of activity, I was able to meet with strategic partners, collaborators, innovators, the press, and stakeholders. I was able to have discussions about complex, technological, challenging, and controversial ideas while reading the emotion of others in the room. I was able to create new friendships and rekindle old acquaintances.  

I've often said that digital health progress depends upon technology, policy and psychology. People ask how I think about contracts and legal agreements for partnerships and collaborations. Although 100+ page documents with appropriate protections are essential, my great hope is that trust and friendships are built so that contracts are signed and never referenced again. Events like JP Morgan are foundational to that kind of relationship building.

Press communications at such events are convenient and productive. If we're going to change the world of health, we need to broadly explain what we're doing, why we're doing it, and how we're putting patients first. All major press outlets are well represented at the conference and were able to talk. I was pleased by the press coverage of the Mayo presentations. 

Finally, JP Morgan enables internal teams to bond and as we divide up the stakeholder meetings, each using our skills and expertise to greatest effect. From 6am to midnight each day we did our best to move our innovation agenda forward.

I remain energized by the optimism of the conference.

How Does a Platform Reduce Barriers to Innovation?

One of our Mayo Clinic Platform team, Emily Wampfler, recently forwarded me an overview of MIT's Platform conference

Read the Barclay's piece.   It notes that 55,000 people changed focus from product support to a platform service line orientation, remarkably enhancing business opportunities.

Few organizations in healthcare have created a Platform which connects data producers and consumers, standardizing security, enhancing reliability and accelerating agility.     What is the urgency to embrace a Platform approach to healthcare?   

 I believe a Platform strategy is the best way to reduce barriers to innovation.   What specific barriers?    I have my own opinions but also asked colleagues like Dr. Craig Monsen, CMIO of Atrius.   Our examples are not related to any single institution we've worked at (Atrius, BIDMC or Mayo) but are drawn from multiple decades of experience in healthcare.

Operational
Innovation efforts compete with staff time required for day to day activities
Innovation efforts may disrupt efforts to standardize work in an organization
Innovation efforts may not be aligned with the immediate goals and priorities of leadership

Technical
Innovation efforts may require data standards that are emerging or not yet implemented
Innovation efforts may require clarification of data use rights 
Innovation efforts may require novel IT infrastructure

Business
Innovation efforts may require significant time investment from IT, Information Security, Compliance and Legal
Innovation efforts may require new policymaking about intellectual property ownership
Innovation efforts may require clarity about unrelated business income for a 501c(3) public charity
Innovation efforts may require finalization of slowly evolving regulations (ONC information blocking rule, CMS interoperability rule)

 Legal
Innovation efforts may require re-evaluating security, privacy, conflict of interest and consent policy
Innovation efforts may require clarification about what projects are operations(as in HIPAA Treatment, Payment, Operations) versus research

What can a platform do to mitigate/eliminate these barriers?

 If senior management (Executives, Board) broadly communicates that a Platform effort will require short term additional work but the resulting standardization of technology, process, and people will simplify future work, then the organization will tolerate the extra effort and disruption.    I think of it like building a house.    Anyone who has ever done a major construction project knows about the dust, delays, and inconvenience of building.   However, when the project is done, there are decades of enjoyment to follow.

 Although data standards constantly evolve, a Platform creates a single place to get/put data using whatever technologies exist today while permitting transition to what's next when it's available.    Although EHR data extraction today may require third party tools or proprietary work arounds, once the data is flowing to a Platform then collaborators can access data via a single point of authorization and authentication  without any dependency on the EHR itself.   I've used this technique to make data available to innovators using FHIR long before FHIR was part of EHRs.   The Platform can embrace emerging standards like FHIR R4 long before such standards are native to the EHR.

 Data Use rights are a key issue and require a consensus of internal/external stakeholders.   I will detail some of the issues about Ethical Uses of data in my next post.   A Platform which serves as a single point of data input/output enables the consistent enforcement of data use policy.

 I recently worked on a project that required a novel business relationship between a 501c(3) Public Charity and an existing EHR vendor.   The business people agreed it would be unrelated business income and would be taxed.    Once a template was developed for unrelated business income arrangements, it was no longer a barrier.  Similarly, intellectual property rights covering developments made using data from a Platform require a standardized policy.   For example, is de-identified data made available for innovation at low cost with the notion that derivative intellectual property creates an ongoing revenue stream OR is the data cost initally high with the notion that derivative intellectual property is unencumbered?  A platform enables easy monitoring and execution of such arrangements

 In sum, a Platform can be an organizing framework for operational, technical, business, and legal stakeholders to create a set of standardized, templated use case variants without having to re-negotiate every new innovation project or collaboration.   In my experience, without a single enterprise approach (call it a single front door) to connecting data producers and consumers, there is unlikely to be innovation agility in healthcare.

In the first 100 days at Mayo, many stakeholders will weigh in on these issues.     I'll report on lessons learned along the way.

Week One

My new role as president of the Mayo Clinic Platform began officially on January 1, 2020.    I was selected for the role in late November and  volunteered time in December to better understand the technology, people and processes of Mayo Clinic.     What will I do in my first weeks at Mayo? 
 
Listen to my colleagues, customers, and staff.
 
I learned a valuable lesson in 1998 when I first became a CIO.   I was seeing patients on a 2pm-2am Emergency Department shift when my Motorola flip phone rang at midnight.    The conversation went something like this
 
    Caller: "Hi, this is Jim"
    Me: "Jim who"
    Caller: "Jim the CEO of the hospitals"
    Me: "Of course, how can I help"
    Caller:  "I've selected you as the next CIO and you start at 8am tomorrow.   We'll figure the rest out later"
 
At 8am I met with three advisors/mentors who agreed to guide me on my CIO journey.   Professor F. Warren McFarlan  of Harvard Business School, John F. Keane the CEO of Keane Inc , and Samuel Fleming of Decision Resources Inc.
 
I explained to them that I'd thought about the IT path forward (for 1998) overnight and we should immediately devote 100% of IT resources to embracing the web for all applications and operations.
 
They looked at me and advised that if I simply told colleagues, customers and staff what I thought they needed, I would have failed change management 101.    Instead, I needed to follow the wisdom of John Kotter and build a guiding coalition empowered by a sense of urgency to change.
 
For the next few weeks, I held listening sessions - over 300 of them.   My mentors were right.  Listening, communicating, and serving the organization based on convening/informal authority was much more potent than using formal authority to command and control.
 
At Mayo Clinic, I had over 50 meetings before I started.    I met with key Mayo partners in industry.  I've had days that started at 6am and ended at 10pm.    And I've just scratched the surface in my understanding of possible futures.
 
In my upcoming meetings I will try to answer 5 questions
 
1.  What unique assets (intellectual property, technology, people, etc.) does Mayo Clinic have?
2.  If the Mayo Clinic Platform were to offer service lines of capabilities, what should they be and who are the intended users?
3.  What economic models are most appropriate to ensure these service lines are sustainable - subscription, licensing, equity growth?
4.  What are the barriers and enablers to creating these service lines?
5.  Are there existing projects that should be halted or de-prioritized?
 
It's becoming clear to me in my conversations thus far that Mayo Clinic has an extraordinary foundation upon which the Mayo Clinic Platform can be built.
 
    30 Petabytes of clinical data
    A large collection of genomes, biological samples and pathology slides
    Numerous state of the art machine learning algorithms
    Faculty expertise
    Access to capital
    A strategic partnership with Google
    Co-development relationships with startups
    A network of affiliates that provide diverse data sources and can serve as pilot sites
    Research in collaboration with established tech companies
    A very strong business development/licensing group
    The reputation of Mayo Clinic
    Connections to innovators worldwide (Mayo opens many doors)
 
After the next several weeks of listening, we'll widely communicate a small number of initial service lines that build on this foundation and projects already in progress.    Remarkable pre-work has been done by Dr. Clark Otley, chief medical officer, who is my partner and who served as interim president of Mayo Clinic Platform and our Business Development colleagues James Rogers, Emily Wampfler, Maneesh Goyal, Andrew Danielsen and Eric Harnisch.    At the upcoming JP Morgan conference January 12-15, we'll be able to announce some of our first partnerships and strategies. 
 
The next year will be a great journey, collaboratively defining the mission, vision and values of the Platform effort, ensuring our products and services are well aligned with the goals of Mayo Clinic and the needs of many internal/external stakeholders, all while keeping the patients first.