A little more than two years ago, separated by three months, my wife and I were blessed with the arrival of two grandsons. They have enriched our lives immeasurably, and as I watched one of them playing recently, I found myself thinking about the second law of thermodynamics and the concept of entropy. Simply defined, entropy is nature’s inexorable march toward chaos.
A toddler is a perfect illustration of entropy. Make an orderly stack of blocks in the vicinity of a small child and wait a moment or two. The natural order of things is to move from organized to disorganized – from structured to unstructured. Creating order from chaos takes energy. It’s physics.
Entropy manifests itself in the health care system in a number of ways. An inordinate amount of energy (and resources) are expended in an effort to bring order to a largely disorganized delivery system. Electronic medical records, sophisticated communications infrastructure, complex organizational designs and emerging health systems all strive to “manage care across the continuum,” an ambitious term that has become the mantra of health care providers.
Yet in spite of such well-meaning and well-funded efforts, entropy rears its head, most notably in the experiences of patients suffering from advanced chronic illnesses or in the midst of complex episodes of care. The fragmented nature of the multispecialty services delivered to those patients fails to address a number of unmet needs, most of which have less to do with biochemistry and more to do with psychosocial and logistical support.
In the course of spending much of a year with a national task force of health care professionals devoted to caring for patients with advanced chronic illness, I had an epiphany. It is the complexity of being chronically ill, not the complexity of the illness itself, that compromises the quality of the patient's life and our delivery system was not designed to bring order to that chaos. We have mastered the science of treating the disease, but we have largely failed to remedy (or have even exacerbated) the patients’ anxiety and frustration that arises from the complexity of being seriously ill. In January 2015, we created a YouTube video, "Doing Well by Doing Good: The Chronic Disease Medical Home,” which encapsulates the challenges faced by the chronically ill in the traditional health care delivery system.
The delivery of health care is not immune from the laws of physics. Facing the complexity of living with multiple chronic diseases as well as overwhelming psychosocial challenges, the lives of chronically ill patients are trying to come apart. Meeting the unmet needs of this vulnerable patient cohort requires fundamental changes in virtually everything that we do. The system was never organized to address the gaping holes that now exist in chronic and complex episodes. Fixing the problems is not a matter of tweaking existing processes. It requires bold new thinking.
