Health Systems Science, 2nd edition, Elsevier
Writers: Victoria Stagg Elliott, MA; Jeffrey Borkan, MD, PhD; Jed Gonzalo, MD, MSc; Maya Hammoud, MD, MBA; Luan Lawson, MD, MAEd; and Stephanie Starr, MD
Health systems science has emerged as the third pillar of medical education along with the basic and clinical sciences. Elsevier released the 2nd edition of the Health Systems Science textbook at the end of May 2020, which includes a science fiction story (Chapter 17) describing an imaginary pandemic. This chapter, entitled Looking Ahead: the Dynamic Nature of Health Systems Science, Future Trends, and the Role of Learners as Change Agents, was written prior to the emergence of COVID-19 and explored the future of health systems science. The science fiction story depicts a team of medical students using their knowledge of health systems science to assist with the containment of an outbreak of a fictional vaccine-preventable infectious disease at an undetermined future time and place.
The COVID-19 pandemic has underscored the need for all medical students, health professions trainees, physicians, and other health professionals to achieve competency in health systems science alongside the basic and clinical sciences. Health systems science is defined as the understanding of how care is delivered, how health care professionals work together to deliver that care, and how the health system can improve patient care and health care delivery. It provides a holistic framework for previously underappreciated and underrepresented concepts such as leadership, teamwork, patient safety, structural and social determinants of health, population health, systems thinking, and others that are emerging as critical to addressing this pandemic. An understanding of these concepts, how they are connected to each other, and how they are tightly linked to the basic and clinical sciences allows every health professional, clinical team, and health system to utilize the basic and clinical sciences to more effectively care for patients and the populations they serve.
The pandemic and some of the early failures in the response were partly due to insufficient attention to and ownership of health systems science and its lessons. For example, basic and clinical sciences helped physicians, other health professionals, and scientists around the world understand what is currently known about SARS-CoV2 transmission and how to best deploy personal protective equipment (PPE) to minimize infections among clinical teams caring for COVID-19 patients. COVID-19 has spread throughout the U.S. in part as a result of inadequate systems thinking (implications of an interconnected and vulnerable supply chain) and failure of the health system and society to prioritize and address the structural and social determinants of health (such as housing and poverty) as the per capita rates of infection among vulnerable populations rise.
Gratefully, there have been many successes in addressing the COVID-19 pandemic. Many of these successes illustrate the importance of understanding and applying health systems science concepts.
Population and Public Health
Never has there been a more critical need to integrate and unify traditional health care and public health. The nation will not be able to adequately respond to this pandemic and decrease the risk for similar pandemics in the future without embracing the need for population health.1,2 For example, a physician may need to reach out to high-risk patients to discuss additional preventive steps they should consider. Virtual visits may be needed to address non-COVID-19 health issues for patients at high risk of mortality or severe morbidity. Physicians and other health care professionals treating patients infected with COVID-19 must identify ways to prevent spread to others and work with public health entities working to contain this pandemic.
Leadership
In mid-March when the response to this pandemic was accelerating in the U.S., the Association of American Medical Colleges issued guidance strongly suggesting that medical students not be involved in direct patient contact activities.3 This did not stop medical students from using their leadership skills to create opportunities to make a meaningful impact. Medical students formed the COVID-19 Student Service Corps in order to increase the capacity of health professional students to engage in service-learning to address the needs of health systems and communities. This effort started at Columbia Medical School and spread nationally.4 Medical students at Harvard Medical School formed the National Student Response Network linking medical and other health profession students to opportunities to deliver personal protective equipment, trace contacts, and deliver food to the elderly.5 Medical students organized themselves and others to deliver food to vulnerable populations, staff public health call centers, assist with COVID-19 related research, help with patient intake, create morale-boosting goodie bags for health care personnel, and take care of the children of physicians and other health care professionals. There are too many examples to cite and list.
Patient safety
In the early days of the pandemic there were efforts to keep COVID-19 patients separate from other patients in health care facilities in order to reduce spread and maintain patient safety. These efforts continue, although it has become clear that every patient in a health care facility is a potential COVID-19 patient, whether or not they have tested positive. Patient safety strategies must be used to help reduce iatrogenic infections and maintain health system capacity.6 Many patients are being screened by phone before scheduled outpatient visits, and those with potential COVID-19 symptoms are seen at a separate location and/or during specific hours to minimize exposure to asymptomatic patients, families, and staff.
Teamwork
COVID-19 is straining the health system, providing a new urgency for health care professionals to work well in teams. This outbreak will not be stopped by a single hero, but by thousands of heroic teams working well together.7,8 Teams are being formed across disciplines and medical specialties to care for COVID-19 patients, especially those in special circumstances such as pregnancy.9 Teams are being formed across facilities that have not traditionally worked closely together such as those in primary, community, acute, and long-term care settings. The concept of “essential workers” has underscored the importance of others outside of health care on the COVID-19 team, from supermarket clerks to cell-phone tower maintenance staff. Good teamwork can also mean that some clinicians may have to provide care outside their usual practice, forcing rapid learning and adaptation to additional systems.10,11
Clinical informatics
The vast majority of the U.S. health system has access to some form of an EHR12, and these computer systems have become vital outbreak management tools. A full understanding of what an EHR can do has allowed them to be used to develop scripted triaging, electronic check-in, standard ordering and documentation, secure messaging, real-time data analytics, and telemedicine capabilities. Clinical informatics has also allowed those responding to the pandemic to adjust the EHR as needed in response to new information and changing conditions13 and has underscored the need for ever greater connectivity, effective communication, and actionable data.
Structural and social determinants of health
An understanding of the structural and social determinants of health has also emerged as critical to controlling this pandemic because the impact of COVID-19 is hugely inequitable. Across the country, minorities are disproportionately infected and dying from COVID-19, including patients who are black, Latinx, and Native American.14,15 In April 2020, the Navajo Nation had the third highest per capita cases of COVID-19, behind New York and New Jersey.16 The structural, social, and economic factors that contribute to health inequities are not new, but the COVID-19 pandemic highlights the acute need to address them in order to decrease the risk of infection and illness for the U.S.17,18,19
Systems Thinking
Systems thinking, the bedrock of all health systems science domains, is critical for those working at every level of this crisis to understand and influence the spread of infection and its numerous consequences across a community.20 Systems thinking allows those working to end this pandemic to know when to lead and when to follow, how to connect with multiple levels of the health system and different types of professionals throughout the health system in order to implement patient safety protocols, how to connect the right people into the right teams, how to utilize clinical informatics to the fullest potential, and how to quantify the impact of the structural and social determinants of health and how to best address them, when possible.
This list is not exhaustive, but it does demonstrate how those who know and apply the domains of health systems science can improve the response to this pandemic now and other emerging health threats in the future.
Access Chapter 17 for free: Looking Ahead: The Dynamic Nature of Health Systems Science, Future Trends, and the Role of Learners as Change Agents
References:
The first edition of the Health Systems Science textbook, published in December 2016, provided a groundbreaking framework for this nascent discipline. The second edition, published May 2020, builds on the first with updated material, additional exercises, insightful sidebars from experts on the ground, and new chapters on systems thinking, health care structure and processes, and ethics and legal issues.
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