Cybernetic Applications and Health-Care

Julien Libbrecht

Motivations

-Increasing needs and costs of health-care and health care systems in the future

-Increasing difficulties on behalf of health-care workers intheir relation with patients: complexification and differentiation of relations, stress, burn-out, early exit,…

-Increasing demands in performance of the workers, the institutions and the system on macro-scale

Why cybernetics?

-Art and science of regulation and control

-Health-care is regulation of health-condition of patientsand regulation of systems

-Applicability of cybernetics in a broad range of domains: economy, sociology, biology: many activities in almostevery branch of science and life.

-Cybernetics: art of managing relationships (also by quantification)

Tree different elementsCommon terms

-Two players: patient and care provider (in the mostsimple form)

-Tree elements as basic system: Patient (D), care provider (R) and outcome (E)

-One desired outcome: patient’s health or health-stabilisation (idealised expectation)

Tree elementsCybernetic terms (Ashby)

Patient: disturbance or variety inducerAmount of different problems

Care provider: regulatorAmount of different responses

Outcome: amount of different results

Conceiving variety

-Each element has variety of a certain amount

-The amount of variety depends of both the element and theobserver of the element (we must be aware of the trap of thedetached observer: he does not exist)

-One’s variety is determined, it can be measured

-Measuring variety is the beginning of knowing it

-Knowing it is the beginning of handling it

Conceiving variety

-Variety reflects a state of a element at a certain moment

-The element will always be composed of parts or components that can change in function of time

-This element will be called a vector

-The components of the vector can have different values

-Change of the vector always means change of values

Variety and constraint

-Variety and constraint are intimately interlinked

-Variety without constraint is not conceivable

- Constraint sets a limit on variety and enables us to handlethe world

- Constraint makes things predictable

- Constraints are the rules for every transformation

Transformation

-Transformation is always the action of an operator onan operand with transform as result

-Transformation can be closed or open

In theory, every transformation on an unlimited numberof operands can result in an unlimited number of transformsIn practice, a transformation operates under certain rulesor constraints, e.g. the transformation of the embryo intoa foetus will occur under certain constraints

Transformation-A transformation can be single valued or multiple valued:

Single: when each operand will be transformed in onetransformMultiple: when each operand will be transformed in manytransforms

-A transformation can be single valued and one-one, when eachoperand corresponds with a different transform

-In all other cases they will be of the many-one type

-Another type of transformation (the most frequent one) is theidentical transformation

FormalisationsOpen, single-valued, one-one

A B C

T B C D

T1 C D E

T2 D E F

FormalisationsClosed, single-valued, one-one

A B C

T1 D A B

T2 D D A

T3 D D D

Formalisations

Ph Ps Em

Ph

(T1)

1 0 0

Ps

(T2)

1 1 0

Ps

(T3)

1 1 1

Variety and health-care

-Every patient is a vector with different possible values

-Every patient can have an infinite number of values

-Every care provider is a vector which can take a limited numberof values

-The variety of the outcome is the different possible values the outcome can take.

-The table T is the system (unit, hospital,…) which provides theoutcome.

Confronting variety Vo Vd/Vr

Int Ps Soc

Ph H

Psy H

Soc H

Em C

Re C

Agr C

R

D T

E

The Law of Requisite Variety

-Only increasing variety of R can force down the variety of outcomes

-To force down the variety of outcomes, the variety in R must increase

Vo >or = Vd / Vr

-Only variety can destroy variety

-If we want the outcomes to take one value, the variety of R must be at last equal to that of D.

Variety of patients and care providers

-How to control the patient’s variety?

-The variety of patient needs is in most cases larger than the variety of care providers.

-The classic way of confronting variety of patient needs is toenlarge the variety of the care providers so that

Vd = Vr or

Vo = 0

The art of Regulation

-Care providers are in se regulators who transform patientneeds in one outcome: stabilisation, health,…

-The aim of cybernetic approaches consists in investigating the ways in which this regulation can be reached in the most effective way

-The most effective way to do this begins with acceptingthe law of requisite variety and to investigate the ways oforganising care taking into account the law.

Requisite varietyThe Art of Regulation

16st Ph Ps

Ph 1 0

Psy 0 1

Em 0 0

Env 0 0

What’s regulation?

-Regulation is the way the regulator follows to transformthe input of D into a certain range of desired outcomes.

-The only way for the regulator to do this is to fully take into account the variety of D.

-Without respect of the law, the regulator fails in his mission:suffering and decline of the whole system are the result.

Regulating health-problems

Three questions – three answers :

-Confronting patient’s problems = defining the set of problems

- When the patient’s problems are known, define the target: result

- How can we transform the problems in the target: desired Outcome?

Defining the problems (D)

R ? ?

D

Ph

Psy

Em

Re

So

Agr

Vd = 64 (possible states) = log2 = 5.17

Defining problems (D)

-Different aspects as components of one problem or vector

-Each component can have two possible values (0-1)

-Variety of the D-vector = 64 different states

-Describing patient’s problems = result of an interaction process

-Defining patient’s problems = first important step in delimitingvariety on the input of the system T (blocking).

Defining outcome1 = pos. Outcome (target)

R Int-chir Psy

D

Ph 1

Psy 1

Em

Soc

Rel

AgrVo = or > D / R

Defining Outcome (E)

-Limiting outcome = enlarging R

-If outcome is limited to 1 value (1), Vr must be = Vd.

-Health-care is idealistic because it claims a limited set of outcomes

-Health care providers must be precise in formulating outcomeand results.

Possible solutionsIncrease Vr

-Vr = Vd

-Certain components of R becomes multi-functional: increasingthe competence of certain components of R.

-Increase the competence of R .

-R ‘s possibilities aren’t illimited

- Paradoxical with spcialisation

Decreasing D

-Division of D in different components

-Block Vd = selection in variety of components of DPatient information: what can the patient expect?

-Sequentialisation of the transformation: stochastic problemtransformation of components

-Transform certain components of D in components of RImplication of patients in the treatment.

-Clustering of different components

Increasing Vo

-Non-limiting the possible outcomes: compound target

-Non-defining the target

-Defining the possibile outcomes in function of Vr

The Anatomy of Health-CareFive Functions

or Systems

5

4

3

2

1

Beer S. Brain of the firm, Whiley, 1981

5 systems or functions

System 1: operational level-activity-regulation-registration

System 2: metasystem subsuming all system one – coordinationby information

System 3: information transmitter – coordination by regulation algodonometer – stabilisator/inhibitor

System 4: big switch – modeling

System 5: decision-making.

Division of workFrom opposition to collaboration

Preliminary condition: patient and care-provider must be consideredas one unity. Switch from applicatif to process-care (2th cybernetics).

Autonomic activitiesSystem 1: patient – CPSystem 2: CPSystem 3: CP

Management activitiesSystem 4: patientSystem 5: patient - CP

Managing variety

-System 1: patient too assumes a regulation function.Enhance patients capabilities:

Increase Vr

-System 5: Define the target and objectives, evaluate and plan.

Increase VoDecrease Vd

Cross-matching LRV and Managing HC-model

Objective: manage care trought the interaction betweenPatient and CP in one system

Increase Vr:

-patient becomes a regulator too in collaboration with CP-regulation becomes auto-regulation-transformation becomes auto-transformation

Cross-matching LRV and Managing HC-model

Decrease Vd:

• Defining variety of D through negociation (interaction)• Defining limits on variety

Increase Vo:

• Defining objectives as possible outcomes• Defining targets in a step by step method