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Systemness: The Promised Land of Medicine?

Jagmeet P. Singh, MD, MSc, DPhil

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September 03, 2021

If you’re a doc, a nurse, or an administrator working in a clinical facility, I am sure you have encountered the term "systemness." Whether you work in a hospital or private practice, "systemness" will impact your life in some form, for better or for worse. There seems to be this foreboding sense of doom and gloom as clinicians wonder how it will affect their autonomy, practice, and lives. Some call it System-mess and others System-fest; regardless, it is here to stay. Clearly a worthy goal, but execution will be critical.

Previously, growth in the healthcare world was all about mergers and acquisitions. These were typically "consolidations" of loosely held partnerships of hospitals, with institutional autonomy left in place, oftentimes at the expense of efficiency and cost-effectiveness. Not anymore. It’s not unusual these days for hospitals and practices to find themselves being asked to not just collaborate with rival institutions, but to begin operating and thinking like one "system."  

What Is Systemness?

Simply put, systemness is the creation of a "connected care stratagem" across a blend of specialty centers, community hospitals, practices, and ambulatory clinics spread over a large geographical footprint. Some may extend across state boundaries or even international terrain. Systemness often involves a collective cultural change in how hospitals, their subsidiaries, and affiliates work together by tweaking their clinical practice patterns.

The intent is for the practice patterns, workflow, technologies, data sharing, and even the deployment of staff to be seamless, allowing the varied constituents to collectively function as a single entity. The goal is to create an optimal patient experience across the entire system, while increasing patient access, improving clinical outcomes, and enhancing the overall quality of care. All of it patient-centric, of course. It’s a big ask, especially while trying to maintain robust financial margins in an already fiercely competitive environment.

Will Systemness Result in a Loss of Autonomy?

Systemness requires a level of integration that creates distinct pressure points among several stakeholders. This discomfiture could be felt by the practicing clinicians, technicians, ancillary support, or administrative staff, depending on the specific request of the strategic initiative. To enable the system to function and provide the highest-value care at the population level (which is the goal of systemness), powerful leadership must underscore the priorities, break down the organizational silos, and do away with the skepticism of rival institutions.

A big barrier is the perceived loss of autonomy: the replacement of independence with inter-dependence. This could be at the individual or the institutional level. To get this right, the top-down command chain needs to be explicit about their role. The governance structure, the autonomy within it, along with the balance of power between the different components of the system need to be well-defined. There must be no ambiguity, with little to no room for either stepping on toes or passing the buck. The concern about the individual practitioner’s loss of autonomy needs to be addressed head-on in a non-threatening way and supported by data and kindness. Incentives that prioritize the system agenda, over the local or personal one, should be encouraged.

Some systemness changes are straightforward, such as streamlining business functions and supply chain efficiencies to lower costs and improve quality and patient access. But when the system seeks to standardize clinical practice patterns (reducing inter-physician practice variation) to improve care quality, that’s when individual autonomy begins to be threatened.

We physicians develop and hone our skills over decades of practice and are understandably averse to being told to change elements of our practice overnight. It is undermining to be told what drugs, devices, and therapeutics to use, or to practice medicine in an algorithmic manner.

Physicians and institutions often subscribe to the notion that they are unique. Our individuality is threatened by the demand for uniformity, but data can help inform this change. Prescriptive systemwide approaches need to be backed by evidence that they improve clinical outcomes. When the patient is placed at the center, and the data confirms that, then even the most cynical among us will be convinced.

Changes From the Ground Up

The DNA of the organization need not change, unless deeply faulty to begin with. But instead, every individual within the system needs to work in harmony. This will require the engagement of the rank-and-file staff at every level. Good leadership and a well-articulated vision helps -- but the movement must start within every unit, each section, then expand to the division, departmental level, and ultimately across all components of the system.

Clinical leadership, with appropriate representation of the workforce and frontline staff within the broader system, is imperative. However lofty and inspiring the vision may be, the implementation needs to be iterative with continuous, individualized, and collective messaging to every stakeholder. The mission and vision in its clearest form needs to be etched into the DNA of the system.

Technology, too, can provide a helping hand. Digital connectivity being the interstitial fluid holding all the organelles within this organism together. The world of sensors, at home-testing, artificial intelligence weaved into care-pathways will help offload the mundane repetitive tasks asked of the frontline staff while enhancing patient-centric care delivery. Continuous predictive and actionable analytics will help organizations stay on course.

Is There a Grand Finale?

Systemness is a continuous process. The healthcare system is never static, ever evolving to the changing times. Consider how much healthcare changed during the current pandemic, when systems across the country had to demonstrate an agility and nimbleness like never before. We need to reverse-engineer the lessons learnt and hardwire them into the DNA of the organization. Developing a common culture, a sense of togetherness, and a systemwide plan with regular transparent discussion of metrics and targets needs to become part of the daily work ethos.

Systemness carries the promise of refining care delivery and the patient experience to enhance clinical outcomes and improve the health of our communities at lower costs. But this will be a long, perilous journey, loaded with political landmines and conflicting priorities. It is a worthy goal. Diversity in opinion is important, but at the end of the day, there is a need for one "collective" voice.

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About Dr Jagmeet Singh
Jag Singh is a physician, scientist, and professor at Harvard. He is passionate about social issues, leadership, digital health, and medical innovations. You can follow him on Twitter @JagSinghMD

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