By J. Raymond Geis, MD

The Cheesecake Factory restaurant model represents our best prospect for reliable, high quality, affordable medicine.Up to now we’ve let health care systems provide us with the equivalent of greasy-spoon fare at four-star prices, and the results have been ruinous. So says Atul Gawande in a recent New Yorker article ‘Big Med’ which is generating discussion throughout the US healthcare community.

Big Med will arrive throughout the US, no matter what happens with the election. As the CEO of my main hospital says, “This train has left the station.” Healthcare is behind other industries in this change, just as it lags in informatics.

Healthcare is a cottage system, like restaurants and retail business used to be. Dale Compton and Proctor Reid of the National Academy of Engineering describe a cottage industry as many components operating as independent agencies. No single entity is in charge, and no cost objectives, efficiency standards, or safety goals exist for the overall system. They also note one cannot optimize a large, complex system by optimizing its individual parts, because that does not account for interactions among those parts.

Healthcare even has cottages within cottages. Each subcomponent is independent. Within a hospital the radiology IT department often acts as an independent cottage to optimize its own quality and productivity outside plans for the larger entity.

Medicine is also, however, what engineers call a complex adaptive system. That means it isn’t as straightforward as, say, the restaurant industry. A complex adaptive system’s behavior is often unpredictable, and no one is “in charge.” System behavior is more easily influenced than controlled.

Medical imaging is moving towards Big Med. This will require a whole new world of imaging informatics. Not only must imaging informaticists implement software to manage and measure quality, and standardize and optimize workflow. This software must do more than improve tasks in our own imaging cottage; it should be part of the bigger picture of health information technology. In future posts over the next two years I’ll explore how imaging informatics will evolve. We won’t control it, but if done correctly we will surely influence it for the benefit of all.