Healthcare systems not as machines but living organisms.

(Analyzing Healthcare as a Complex Adaptive System (CAS)
One of my fellow students at OHSU turned me on to CAS, and I’ve been researching it in my spare time. It really strikes a cord with me, and I am curious to develop a pragmatic understanding of it. I plan to summarize this in a paper.  I would be very curious to hear from others in this area.

So here’s my summer reading list:

A quick note of explanation:

There have been numerous attempts to change healthcare. Examples include the difficulty implementing an EMR at a small clinic or at the national level. Why do these attempts routinely fail?  CAS posits that a healthcare system  encompasses multi-relational agents that change and learn.  This is unlike the more typical analysis of the system as a machine, with standard parts and processes.  Merely bolting on new parts, or replacing old ones will not do.  One needs a broader view of the system, and a way to work within its deeply dynamic culture(s).  CAS tries to provide this.

I’ve currently read the following.  They are available on the Internet: (Forgive the improper citation formatting.)


Quick read and definition of CAS.

Healthcare Organizations as adaptive systems
j Begun, B Zimmerman, K Dooley
Advances in Health Care Organization Theory 2003, pp 253-288

Nice introduction to CAS, its history, and Healthcare.

A Complex Adaptive Systems (CAS) Approach to Public Policy Decision Making
Society for Chaos Theory in Psychology in the Life Sciences
August, 1998
Glenda H. Eoyang

Although not strictly about healthcare, more in-depth about CAS style management and how it is supposed to work.

Health Care as a Complex Adaptive System: Implications for Design and Management
William B. Rouse
Volume 38, Number 1 – Spring 2008

Use CAS to help give value.  Management with incentives. Suggested matrices.  Good article and a quick read.

Healthcare Organizations as Complex Adaptive Systems
Sean Park, MA Candidate
University of Toronto
Jagger Smith, MHA Candidate
University of Ottawa

Nice explanations, especially Complicated Vs Complex.  Some management tips.

Complex Adaptive System Behavior and Healthcare Expenditures: Evidence and Implications.
Rupper R; AcademyHealth. Meeting (2004 : San Diego, Calif.).
Abstr AcademyHealth Meet. 2004; 21: abstract no. 1517.

Attempts to prove that Healthcare has at least one attribute of CAS.

Clinical Quality Needs Complex Adaptive Systems and Machine Learning
Stephen Marslanda and Iain Buchana,

Only 5 pages and mostly about machine learning.  Some info on healthcare.

Finally, I’m in almost done reading the book, “Edgeware: insights from complexity science for health care leaders” by Brenda Zimmerman, CreateSpace 1998.  You’ll have to purchase this one, or get it though your library.  It’s quite good. Lots of examples on how to use CAS.

I’ll be digging up more Internet available information as well.

About John

Interested in how information intersects daily life, technology, and art. Collaboration specialist, working in social and collaborative media. Biomedical Informaticist, focusing on patient/patient, patient/provider communication.
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7 Responses to Healthcare systems not as machines but living organisms.

  1. Elena says:

    I suggest to read “Discipline and Punish” Michele Foucault

  2. John says:

    Wow, thanks Elena. It’s been years since I’ve read Foucault…basically excerpts from “Discipline and Punishment” as well as parts of “The History of Sexuality”. I’ll need to revisit that one!

    (BA Philosophy UCSC)

  3. Ricardo Garcia says:

    Hello John.

    I am a masters student in Lisbon – Portugal, and im interested in evidence of Vertical Integrated care as Complex Adaptive Systems.

    I can´t get acces to this pdf:
    Complex Adaptive System Behavior and Healthcare Expenditures: Evidence and Implications.

    Is it possible that you send it to me?
    Congratulations about your site.


  4. John says:

    Hi Ricardo,

    Sounds like a great topic!

    I searched around and do not have a pdf of that paper. (I may have had access to it when I was a student via the medical library.) Unfortunately, I am no able to find it on the Academy Health site, although maybe it is there somewhere.

    Best of luck with your studies.

  5. Ebenezer says:

    I work in an OR in a large city hospital; in 2005 I was introduced to the CAS paradigm by a book called “Crossing the Quality Chasm” by the Institutes of Medicine. It had an appendix by Paul Plsek, who is a consultant to the industry, on CAS.

    I found the subject so fruitful that after some reading I started my own website, which I would invite anyone to visit. It has some applications of CAS that I am trying to develop and present.

    Ironically, the book “Crossing the Quality Chasm”, which was trying to address healthcare quality issues (especially medical error) didn’t really apply the ‘principles of CAS’, in my view. They ended up with a complicated and expensive ‘solution’, which was ignored. Surprise, surprise.

  6. John says:

    Thank you very much for dropping this note and link back to your site. I’m just starting on all of this. Looks like a lot of great content, and I’ll need to follow up. Fascinating subject.

    As you know, “Crossing the Quality Chasm” was/is a major text in medical informatics. Putting together CAS principles so that they take advantage of CAS my be the feat.

  7. Ebenezer says:

    It has been years since I’ve read the book, but it would be interesting to revisit it at some point.

    Regarding your comment on “Putting together CAS principles so that they take advantage of CAS may be the feat”… yes, I agree. There is an interesting program called “The Game of Life”, in which some simple rules give rise to varied behavior (‘adaptive’) over time.

    I use that game/computer simulateion as a metaphor for finding the “right rules”. The book “Crossing the Quality Chasm” ended up with 10 rules, which is too many. There really should be just two rules, I think: one looking out at the society of which ‘healthcare’ finds itself a part, and the second an inward ‘maintaining homeostasis’ kind of rule. One to maintain balance and coherence. All other rules should ideally be subsumed under a “rule tree”, and support the “Great Commandments”. At least that is my current thinking.

    Anyway, the trick is to have simple rules, not complex ones, AND to have the ‘right’ simple rules.

    To see the “Game of Life” simulation, see here

    for example/

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