eHealth Isn’t Rocket Science…But Maybe it Should Be

For those of us in the eHealth area and working in Ontario, these are dark days. While the opportunities for electronic tools can make a substantial different to patient care, health promotion, and health innovation are greater than ever, the events surrounding eHealth Ontario, it’s former CEO, its governance, and its outputs have made eHealth a bad word in many circles. When a term that could stand for innovation, quality, accessibility and efficiency is equated with $25K speeches and Choco Bites, we’ve got problems.

But as Andre Picard wrote in the Globe and Mail, it wasn’t about the Choco Bites. The eHealth ‘boondoggle’ is about most everything, but what it was supposed to do. It became about the technology and not about designing a system to support the health and wellbeing of the public and the delivery of care by professionals. But when it became about the technology, we relied on well-worn and inefficient means of building it because people thought it was too important and too big not to trust to the ‘experts’. The problem is, the experts in this system are designing things to make money as their first priority, not health. The result? Large, inefficient systems that are technology first and people second, meaning they don’t do the job.

It is understandable that people might feel a little overwhelmed trying to imagine how a computer system could connect all the myriad paper records together to provide timely, accurate and secure information to physicians and care providers all across a large province like Ontario. It may be this very feeling that has inspired the decisions to pursue such outlandishly expensive electronic solutions that, to date, appear to have little value for dollar.

We’ve seen this before. The Canadian Firearms Registry was one example. So have been the examples of various database programs to support child welfare programs and track paroled sexual offenders. More often than not, these become big expenses with outcomes that are less than stellar.

Building databases is complicated, but it isn’t rocket science. Maybe it should be.

In the Shadow of the Moon is a remarkable documentary that looks at the race to the moon as told by the only men who had ever stepped foot on it. What stood out for me in that film was how, with some inspiration, determination, and resources, the U.S. was able to mobilize its talent to go from rockets that blew up on the launch pad to sending men to the moon multiple times to win the Space Race. This was a feat of innovation that was staggering. 40 years later, the Ansari X-Prize was awarded to the first team “to build and launch a spacecraft capable of carrying three people to 100 kilometers above the earth’s surface, twice within two weeks.” It set off a new phase in commercial space flight. Just as Charles Lindberg won the Orteig Prize, which initiated transcontinental air flight, the X-Prize has initiated a new industry. Yet, at the end of all that, we remember the people and the amazing things they did much more than the technologies they used to get there.

Maybe we need the X-Prize for eHealth. What if we enabled the power of collective thinking, self-organization, and the motivation that comes from winning a prestigious prize? What new ideas would we come up? How much money would we save? The X-Prize was $10M and kick-started a $300M nascent market for commercial space travel. eHealth Ontario has spent more that $650M and achieved little.

Bring on the rocket scientists, our health system apparently needs them.

The limits to individual action

I’m writing this from a Starbucks. With free wireless Internet, decent cafe Americanos and fast breakfast foods that are both reasonably healthy, tasty and not too expensive, its one of the few chains I look for when I’m in need of a place to sit down when a comparable locally-flavoured establishment isn’t available. As someone who both works long (and often early) hours and travels a lot, places that offer decent food and drink and productivity space are valued above almost anything.  When you don’t have time to shop for healthy foods for home and have to eat out it can take a real toll on your health.

I bring with me a travel tumbler, reusable bags and even portable chopsticks to eat with. I buy local and responsibly whenever possible, and when eating at home I aim to buy items with little packaging and, what packaging there is gets recycled with the food waste organics separated and composted in biodegradable bags. When I took the David Suzuki Foundation challenge I got high marks. All is well– right? No. And that’s why climate change and protecting our environment is truly a grand challenge that requires a systems approach. Grand challenge problems refer to exceptionally difficult tasks that stretch the limits of any one group to be able to address them. They are the complex problems that have no single source or simple solution.

No matter what I’ve done to address climate change and help the environment, I am only making a small difference. I’ve been reminded by that because of one product: The Starbucks Vivanno.

This morning my wife and I had a Starbucks Vivanno — a fruit smoothie that is reasonably healthy and pretty decent food option if you’re pressed for time and want some low-fat protein — which is no easy task at the best of time, particularly if you don’t eat meat. If you’ve watched people make these things, they are messy and they are designed for a disposable cup – one that is outside of the regular size cups that a person brings around with them, making it difficult to use the reuasble cup option. This leaves us with a lot of options: 1) Take the disposable cup and make more waste, 2) find a very large cup and bring that around, adding bulk to your bag, 3) don’t drink smoothies at all and either not eat or eat something unhealthy.

Thinking about this a little further, one realizes how tied up layers upon layers of issues are in this drink.

> Why aren’t there other food choices available? (this speaks to the market, to innovation, to location — an easy thing to overlook when you live in downtown Toronto)

>Why am I so busy that I can’t make a decent healthy meal at home? (issues: work demands; social expectations; lack of funding for university research requiring me to work long hours; the expectations of my employer, employees, students and colleagues — requiring me to work long hours; my personality; availability of healthy foods in local grocery stores; ability to cook something I want to eat and meets my nutritional needs)

>Why can’t stores serve drinks in reusables? (issues: cost, breakage, theft, no proper recycling options, people’s busy schedules and need to ‘take away’, no exchange program for containers)

>Why can’t we just get better travel mugs? (issues: our bags are already making us look like sherpas with laptops, pens, books, workout gear, batteries and so forth; they cost a lot for a good one — or you buy a cheap one and add more waste when it breaks, market, etcc.)

These are just four questions with lots of issues — there are many more that you can probably think of. I write this from downtown Toronto, Canada. There are more than 20 other Starbucks locations within a 30 minute walk from my current location and dozens of other coffee shops, pastry places and food outlets to choose from. In some ways, this is really a luxurious problem to have. What about places where you have to drive to get somewhere? What about rural communities where one or two shops is all you have? Yes, the cultural standards will change in each place, but the more I look at this the easier it is to see how I can become the David Suzuki poster boy and still make only a dent on the environment without considering these myriad other issues that influence how a simple product (a cup) becomes a complex issue.

Ideology-Free Food Systems Change

Food is one of my great passions. It’s nice to have one that just happens to overlap with a basic need for survival and is a topic that is perhaps the single most powerful lever for social change in the world. We all have to eat and when we can’t eat, or consume enough, or eat food that’s appropriate to our culture or taste sensibilities our quality of life suffers greatly.  Since devoting more of my energies to food systems as part of research I’ve found myself reading a LOT about food: where and how it is grown, it’s environmental footprint, and it’s health effects on individuals and the world around us. Needless to say, there is a lot to read. There are those that look at what to eat like Michael Pollan’s Omnivore’s Dilemma & Marion Nestle’s What to Eat. Both authors have penned books on the politics of food as well such as Nestle’s Food Politics and Pollan’s In Defence of Food. Add to that the books on the food system as a whole such as Raj Patel’s Stuffed and Starved and Paul Roberts The End of Food and you’ve got a lot on your bookshelf.

Most of this reading does not paint our current Western food system in such good light.

Then there are books like the 100 mile diet by Alisa Smith & J.B. MacKinnon or Animal, Vegetable, Miracle by Barbara Kingsolver chronicle the real challenges of living life of local eating. I liked them both because they didn’t paint an unrealistic picture of what is involved in growing and eating in a manner that reflects (in places like Canada and the United States at least) a largely bygone era of food production.

I have found these books useful, interesting and (mostly) enjoyable to read. My consciousness around what I eat and my role in the food has expanded greatly since diving into this issue. I grew up in Southern Alberta and spent a lot of time in the country growing up, including visiting farms. It is a (literally) dirty business for hard-working people and a vocation that few non-farmers truly understand. It is for that reason that the themes of the books above can easily skate over perspectives that don’t gel well with with their central thesis (namely, that our current food system is unsustainable, perhaps inhumane, and not helpful to people — including farmers). And while I agree with all three of these statements, putting on my systems thinking cap and viewing the problem from that perspective has me cautious in wholeheartedly recommending that we abandon our current system. It is this critical perspective that drew me to an essay by farmer Blake Hurst that tries to put these recommendation into the perspective of the farmer and modern agrifood. Although the article is in the right-wing, business-first journal of the American Enterprise Institute I found it quite balanced and congruent with the conversations I’ve had with farmers over the past few years as I’ve become much more professionally engaged with the agrifood sector.

What I found interesting in Hurst’s article was how it burst a lot of the myths around farming that have been set up by many advocates of organic, small-scale farming that use the books I mentioned at the beginning as their defence. Hurst writes:

I’m dozing, as I often do on airplanes, but the guy behind me has been broadcasting nonstop for nearly three hours. I finally admit defeat and start some serious eavesdropping. He’s talking about food, damning farming, particularly livestock farming, compensating for his lack of knowledge with volume. I’m so tired of people who wouldn’t visit a doctor who used a stethoscope instead of an MRI demanding that farmers like me use 1930s technology to raise food…But now we have to listen to self-appointed experts on airplanes frightening their seatmates about the profession I have practiced for more than 30 years. I’d had enough. I turned around and politely told the lecturer that he ought not believe everything he reads. He quieted and asked me what kind of farming I do. I told him, and when he asked if I used organic farming, I said no, and left it at that. I didn’t answer with the first thought that came to mind, which is simply this: I deal in the real world, not superstitions, and unless the consumer absolutely forces my hand, I am about as likely to adopt organic methods as the Wall Street Journal is to publish their next edition by setting the type by hand.

It is here that I saw congruence and the levers for systems change: “unless the consumer absolutely forces my hand“. Indeed, if systems change is to come it must come from the bottom as much as the top, but do so in a manner that acknowledges the realities that Hurst outlines. I once spent almost two hours talking with Alisa Smith and J.B. MacKinnon about their book on the 100 mile diet. I’ve also met Marion Nestle and spoken to her about these challenges. Both parties were passionate advocates, but neither were zealots or ideologues. Yet, ideological rants are what is coming out loud and clear from those who are against conventional farming. This was loud and clear when the U.K. Food Standards Agency published their study showing that organics were no more nutrient rich as conventionally grown food (see my earlier post). The news and the web are full of criticisms of it, driven (presumably) by an ideology that simply see the report as an attack, rather than a reflection of science.

Diversity of perspective is an essential ingredient for healthy systems change. Hurst’s article motivated me to write this because I think he has a valuable thing to say. While many might favour organics and small scale farming for the reasons I’ve cited earlier, the truth is that there are some things that conventional farmers do now that isn’t incongruent with this perspective and that perhaps ideology should be put into the backseat. As Peter Senge and others have outlined, we need to have all groups at the table to develop our systems change strategy and this won’t happen through attacking the others, only through listening. Maybe through being present with others, listening to their perspective, and developing a strategy based less on ideology and more on collaboration will be successful in getting the healthy food system we want.

Wikipedia and the Limits of Co-Creation(?)

This week my eye caught a blog post from New Scientist magazine speculating that Wikipedia might be heading for a fall. When I saw Fast Company add to the argument, it seemed that there was more than just passing interest in the research that spawned the article.  Wikipedia, the most widely used encyclopedic source in the world, has become the go-to place for people interested in both mainstream and obscure facts. In my view, it has become to information repositories what Google has become to the search; namely the first place people go when they need something specific.

Yet, Wikipedia is slowly losing its momentum. As Jim Giles reports, there is research from the Palo Alto Research Center in California (the once Xerox PARC for those who know about the early innovation in computing, design and systems there for many years) suggesting that : “The number of articles added per month flattened out at 60,000 in 2006 and has since declined by around a third. They also found that the number of edits made every month and the number of active editors both stopped growing the following year, flattening out at around 5.5 million and 750,000 respectively.”

The article speaks to the problems that Wikipedia is having with maintaining control and how it is limiting co-creation in some small, but persistent ways by exercising more editorial control over content and thereby reducing the number of words that were generated by members in total over those generated by Wikipedia editors. To some, the answer might be “so, what?”. Maybe this is a good thing that there is more control over the content, particularly given its wide interest? Although this has merit, there is a risk that by creating a content system that is more tightly controlled that Wikipedia is limiting the very power of self-organization and community building that made it so popular in the first place.

Co-creation is about developing a partnership between creators to truly collaborate on the text. This need not be equal in terms of time and energy — there is always some who are far more enthusiastic about a topic than others and will therefore take a larger role in writing — but that partnership needs to exist. Perhaps Wikipedia leaders need to get back to revisiting the very concepts that made them successful. The beauty of the wiki — and a popular one like Wikipedia — is that it:

1) provides a critical mass of engaged users;

2) encourages a diversity of voices participating in the conversation;

3) provides opportunities for expertise to be shared and leveraged;

4) offers a coordinating mechanism to bring together this diversity keeping the system closer to the ‘edge of chaos’ ;

5) promotes self-organization;

6) which increases the likelihood that new ideas will emerge from the collaborations.

These are all hallmarks of strong, creative, and (mostly) effective communities and fits very well with the lessons learned from complexity science and systems thinking. It also is what has made them so popular and widely used. Perhaps the leadership at Wikipedia has forgotten that.

Asking the Right Question / Adding to the Organics Debate

Another interesting note of argument to the growing chorus of voices on the organics and health issue coming from New Scientist magazine writer Jim Giles. In his article the quote I like most is this one: “It’s not about whether organic food is good or a sham,” says Jules Pretty, an agricultural scientist at the University of Essex in Colchester, UK. “That’s the wrong question. We should be asking how we can make all of agriculture more sustainable.”

Asking the right question is an important thing to stop and consider. So often the debates in science go off into different directions without stopping to ask whether the science is answering the right (or the most important) question. This makes me think back to the presidential address by Pat O’Neill at the Canadian Psychological Association’s annual meeting a few years ago. Pat is a community psychologist and someone who’s work I’ve long admired. For those not familiar with the field, community psychology was formed largely out of the frustration of psychologists working in clinical settings who were trying to ‘treat’ psychological problems at an individual level when the problems were less about the individual, but much more about the environment that they live in. This is what we often refer to as the social determinants of health (and wellbeing). For community psychologists, asking whether or not a person had the resources to cope with the problems was the wrong (or less productive) question to ask. Why were these problems there in the first place? What was their causes? And how could psychological knowledge contribute to alleviating those problems and changing the systems that sustain them?

Anyway, what Pat argued in his presidential address is for some re-consideration of the questions that psychologists ask. He argued (quite well) that much of the knowledge we have is constrained by the questions we’ve asked. One of the reasons we don’t have the data to address the big problems is that we haven’t asked the questions (in research terms) that address these problems.

Asking whether organics is equivalent to conventional food is a worthy question from a scientific standpoint and from a nutritional science perspective. But whether that is the question that we ought to base our food choices and food policy on is quite another.

The Organic – Health debate

This week the health blogosphere, newswires and cocktail party circuits were buzzing over the report from the report for the U.K. Food Standards Agency that came to the conclusion that organic food offered no more nutrients than ‘conventionally’ produced foodstuffs. (I find it strange to call the way we mass-produce food conventional, particularly when you think that most of what we eat today didn’t exist 50 years ago and the stuff that did exist is now produced in a way that is so foreign to the way its been done for the thousands of years before that calling it conventional is about as realistic as calling one of those ‘meal replacement‘ products a meal…but I digress — for an interesting take on this go see Food Inc. in theatres).

This finding didn’t surprise me at all. There isn’t any particular reason why ‘conventionally’ grown food should be any less nutrient rich than organics. But as Marion Nestle writes, that misses the point. It’s the same case that I’ve been making in my social circles the past few days as people talk about organics and how this has them reconsidering things. It shouldn’t — unless physical health is the only reason why you eat something. And I would argue that there are many good reasons to eat organics that have just as much to do with health, but do so in a way that goes beyond nutrients.

Organics are much more friendly to the planet for starters. The problems with birds & wildlife, and environmental degradation due to pesticides has been well-documented.

Pesticides are also highly toxic to those who are administering them — very often low educated, non-protected workers and their families – despite efforts to reduce this.

Organics also provide a vehicle for supporting local farmers, which brings added environmental and economic benefits.

All of these things produce health in our community. These are the social determinants of health of the food system and not just the nutrient portion of it. And there is much reason to believe that these social and environmental determinants play as big of a role in our health as anything we gain from nutrients.

Health is indeed a complex system both physically, socially, and as a concept in its own right. Viewing the link between organics and physical health (vis nutrients) as straightforward (and one that some organic supporters are doing through their critique of the report) reduces this complexity and potentially does the organics movement more harm than good. My suggestion would be to look at all the other benefits that organics can confer and focus on that.

This doesn’t mean the door is closed and that more research shouldn’t be done, but I think a lot of people will be happy enough knowing that the organic food they eat is doing the planet good, animals good and their local economies good and that is healthy in its own right.

Doing important things

Last night I attended the closing session of the 27th annual Systems Dynamics Society conference in Albuquerque, New Mexico featuring organizational change leader Peter Senge. Although I had planned to go to the talk originally, I was getting a little drained from all the learning and non-stop activity since arriving on Saturday and thought I’d go to Santa Fe for the day. Santa Fe is beautiful and has more art galleries than any city in the U.S. (so I am told) and is also the home of the world’s premiere think tank on complexity science, the Santa Fe Institute.

However, ‘fate intervened’ and every single car was rented in the city. We also got a wicked thunderstorm in the afternoon. Somehow, things worked out to keep me in town and I am so glad I was here. The talk — a conversation really — was truly inspiring. It wasn’t because of any particular oratory that Peter or the other conversants delivered or its brilliance in delivery (although it was enjoyable to be a part of). It was how it tapped into what I might call the soul of systems thinking and modeling. Systems dynamics modeling is a pretty esoteric field to those not familiar with it. Few people jump up and down at the thought of a model being created. It feels academic, perhaps because it sometimes is.

Yet, they offer us a powerful way to converse, particularly when they are developed in a participatory way. They provide a means to help people see the bigger picture and collaborate on some of the big problems in life, the problems that we NEED to work on if our species is to survive and indeed, if many of the other species on the planet will survive. Climate change was indeed one of the big issues under discussion, not only because it is something that systems dynamics is actively involved in, but because it is one of the grand challenges that we as a society need to bring systems science to so desperately.

The bottom line is that we need to create the space to reflect in our work. That’s what I hoped this blog would achieve for me. But its something we don’t do much of, and for the young professors and students in the audience there was some real concern about how to do this when it is so rarely valued by our environments, yet ironically is one of the tools that creates more value in our work than anything.

It was a special evening and I came away with some wonderful quotes that I scribbled in my notebook that I wanted to share:

“You only have so much time on this earth. Why would you spend your days doing anything but the most important thing you can do?” — Jay Forrester

“Climate change is a symptom; how we live is the problem. If want change, we need to focus on the problem” – Peter Senge

” The gift of climate change is that we all have to work together, otherwise it is unsolvable” — Peter Senge

“It is only through reflection that we escape our history”

Indeed, some words to reflect upon.

Obesity the new tobacco?

This week the widely-cited peer-reviewed journal, Health Affairs, published a paper looking at the link between obesity and the costs to the U.S. health system. The paper, based on research conducted by the Centers for Disease Control, suggests that obesity could cost the system close to $150 billion dollars in the coming years if not put in check. Obesity is a fascinating area of study for many reasons and one of them is that it elicits such visceral reactions from different groups. Like tobacco, there are sides that are considered to be ‘good’ (public health) and ‘bad’ (fast food industry) by some.

But unlike tobacco, which has a clear industry that produces its product behind it, obesity is not as clear cut. As NYU professor of public health and nutrition and well-known author Marion Nestle writes, there are other groups that are challenging the CDC data. In her recent blog post, Nestle points to groups like the American Council on Science and Health that have come out strongly against data linking obesity and health problems. Nestle raises the question about where their funding comes from. Just like tobacco has a lot of groups that it sponsors to lobby and support on behalf of policies that are friendly to it – including funding “science” to support claims.

I am not an obesity expert, but I do an increasingly large amount of my work within the food system and bring over a decade of experience in tobacco control. What I see between the two areas is looking a lot alike.

If these numbers are correct, it is most likely another sign that a major campaign is about to be declared on obsesity, just like it was with tobacco. If so (and there is lots to suggest that it is already underway), it will be interesting to see if we get the same patterns of action that we had in tobacco like:

1. Faux science groups funded by those that create the very products under scrutiny claiming that the current research is flawed;

2. On the other side, an ‘obesity’ industry that becomes empowered but also resistant to new perspectives;

3. Stigmatization of those that are obese;

4. Major systems change in the way products are regulated

These are just some of the possible options. But I think that there may be some interesting parallels to note as this moves forward.

Censemaking

Censemaking is intended to serve as a creative outlet to express ideas about Complexity science, E-health, Networks, Systems thinking, and Evaluation (CENSE — get it?). This is the environment that I have chosen to immerse myself in as a person and a professional. Now certainly, the idea of living systems might make sense to some — but evaluation? e-Health? Why are they connected? Well, it has a lot to do with my vocation: a professor of public health at the Dalla Lana School of Public Health at the University of Toronto. Through a long and windy road I’ve come to believe that we’re at a nexus of unprecedented opportunity and danger and that the linear mindset that has served us for so long and brought us the technological and social marvels we have today is pushing up against a wall. Climate change, chronic and infectious diseases, food security, mass migration, and globalization are just some of the ‘wicked problems’ that will only be solved by many people working together, self-organizing, and being creative. Indeed, the ‘C’ in CENSE is really a placeholder for a lot of things: creativity, collaboration, complexity, convergence, conservation… All of these things are essential for us to continue to have the life of relative comfort that comes from the plenty that those of us in places like Canada have come to enjoy.

But not all of us — even in Canada — are so well off. It’s easy to put a head in the sand and ignore the realities experienced by our First Nations peoples, new immigrants, and those billions who live on less than $2 a day worldwide. It is easy to forget that while I have access to an abundance of fresh water, clean air, medical care, safe and abundant food supplies, and educational opportunities, I am in the minority. I have been given a lot of opportunity to do well, and I’ve created a lot of opportunities too. The point of this blog isn’t to talk about how good or bad things are, but to imagine how we can collectively create a glocal (global+local) system of support and care that enables the world to have opportunities like I’ve had in a manner that is sustainable and just.

A tall order? Yes. But why live a life nestled on the ground when you can also reach for the stars?

Blogging is tough. I am an avid microblogger on Twitter (@cdnorman), but a long form blog is something that I’ve been wanting to commit to for some time. After much debate about what platform to use, I’ve decided to start Censemaking here, now and hopefully for the years to come. Watch this space for ideas, insights, ramblings and musings about the issues that intertwine to reflect the reality of my personal and professional life. You’ll see a lot on technology — information tools to communicate, share and collaborate. There will also be a lot on public engagement and learning. I am an educator, so you’ll see some things on that. I’m also a foodie and believe that transforming our food system — from its production to its packaging and transportation to its marketing, consumption and through to its disposal — is the issue that will define the 21st century (along with water, which I relate to it). So you’ll see a lot on that. And, I’m a public health professor, so there will be musings on topics like disease, health promotion, tobacco control, obesity and many other things that are relevant to the health of populations.

I hope that whoever you are, you enjoy my blog.

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