HJAR May/Jun 2024

CHANGING THE CARE: OBESITY and underlying mental health perturbations such as anxiety or depression, all need to be addressed by a more holistic model of primary care to achieve the types of health outcomes that our patients deserve. None of those vari- ables can be sufficiently impacted without a cohesive multi-disciplinary care team working together to solve problems by applying their respective domain knowledge to the problem to be solved. In other words, it takes a behav- ioral therapist and/or health coach working to improve self-efficacy, sort through the chal- lenges of adverse childhood trauma, perform motivational interviewing, engage in behavior- al modification therapy, manage emotional eat- ing tendencies, and achieve PHQ9 and GAD7 scores < 5 to indicate remission of depression and anxiety. Since Type 2 diabetes is typically a disease characterized by high levels of insulin resistance, and since insulin resistance is in turn highly correlated with rates of central obesity, the holistic solution for Type 2 diabetes doesn’t stop at just achieving adequate glycemic con- trol. It also focuses on reducing body mass in- dex and waist circumference to improve meta- bolic parameters of disease. Again, the only hard part here is in overcoming the operational constraints and barriers that stand in the way, such as existing payment models, entrenched provider mindsets and behaviors, and the limi- tations of modern clinical research. Just like achieving > 90% rate of diabetes control is easy, achieving > 15 to 20% reduction in a person’s weight is not difficult, but doing it reliably and reproducibly requires a high performing clinical care team organized as a clinical microsystem. Minimally viable products, ecosystems, and the clinical microsystem In his book, The Lean Startup , author Eric Ries describes the “build-measure-learn” feedback loop of how to execute the strategy of a start- up company’s vision. He describes how startup businesses typically have a true north desti- nation in mind: creating a thriving and world- changing business. To achieve that vision, these startups employ a strategy, which includes their business model, product road map, points of view about partners and competitors, and ideas about what their customers both want and need. Their product is the end result of that strategy. In healthcare, what should our true north vision or product be? I would posit that it is better health . What else would it be? Tradi- tional health systems need to ask themselves if they have internal alignment around a cohesive vision where their entire focus is on improving the health of their customers, whether their strategy is designed to execute that strategy, and whether they are succeeding in achieving a product/vision of better health. Following through with this line of thinking, I would con- tend that healthcare’s current performance in managing these recent epidemics of pediatric and adult obesity means that most traditional health system strategies are failing miserably at product development, or at least a prod- uct that achieves our vision of better health. The lean startup method asks people to start measuring their productivity differently. The goal of any startup is to figure out the right thing to build — the thing customers want most and are most willing to pay for — as quickly as pos- sible. In other words, “the Lean Startup method is a new way of looking at the development of innovative new products that emphasizes fast iteration and customer insight, a huge vision, and great ambition, all at the same time.” Only through rapidly cycling iterations of building, measuring, learning, and improving can we hope to discover all the relevant variables that influence our outcomes or can we learn how to favorably impact those outcomes to achieve a desired set of results. In healthcare, and in treating the disease of obesity, it will require the development of a minimally viable ecosystem or clinical microsystem to engage in that build- measure-learn, and improve, feedback loop. One of my former professors, Ron Adner, PhD, wrote a book called Winning the Right Game: How to Disrupt, Defend, and Deliver in a Changing World . In that book, he tells the story of how Kodak won its hard-fought battle to become a digital printing company. Unfor- tunately for Kodak, they won the wrong game, and even though they successfully navigated the management of technology disruption, what they missed entirely was the dynamic of ecosystem disruption, which altered the very foundation of their core value creation. They became the best digital printing business in the world, only to be disrupted by something they never dreamed possible, the displace- ment of printed photos by digital viewing on phones, tablets, and laptops. Traditional health systems — as opposed to systems that deliver health — are trying to win the wrong game and “... as we progress through the stages of knowledge for a given chronic condition, be it diabetes or obesity, the ultimate path is one that will require approaches to problem solving that utilize a combination of research, scientific discovery, clinical trials, and expert opinion, but also rapidly iterative and recursive loops of process improvement where we are holding ourselves rigidly accountable for a given outcomes measure .”