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22 ISE Magazine | www.iise.org/ISEmagazine I health systems Well, if you ask me ... By William "Ike" Eisenhauer I have written here over the last few years about the different challenges in healthcare engineering and the sheer complexity of healthcare. I have la- mented (verging on complaining) about the issues and called readers to face challenges that can lead to dramat- ic improvements. However, I haven't written down how to design a public healthcare system. With this, my last column, I lay my cards on the table. Here from the vantage point of a systems engineer is my vision for public healthcare of the future. This design focuses on a publicly funded healthcare system running parallel to autonomous private healthcare. My objective is to best align and integrate the pooled public resources used at all government levels serving the public. The primary issues of misalignment and disintegration, and the source of gross inefficiencies, come from how every level of public healthcare tries to be all things to all people. That needs to stop. It confuses the public, allows things to become disconnected, wastes vast amounts of money and duplicates efforts. With that goal in mind, we can carve up the functions that our public system needs to handle, segmenting domains between federal, state, county and city government levels (adapt to your specific country designations). Federal: The federal level, due to its sheer size and economy of scale, ne- gotiates pharmaceutical acquisition, es- tablishes large distribution centers and networks and oversees end-of-life care. The federal government is responsible for long-term nursing and assisted care facilities. Most governments already place the federal government in the po- sition of managing elder care and senior pensions, so they are in the best posi- tion to use those resources and under- stand that segmentation. State: The state/provincial level is tasked with two key portions, trauma center development and mental health facilities. These are both resource in- tensive facilities that must be geograph- ically located to best serve their func- tion. Consolidation at this level allows proper oversight and assurance that re- sources can be managed appropriately without getting into intrastate conflicts surrounding these critical areas. The ability of the state to accommodate the professional resources necessary in these areas is also important. County: This level is charged with the maternity/delivery/neonatal phase of life for both mother and child, which cannot be properly managed at the state level because multiple patient visits mean the resources must be geographi- cally available. Along a similar line of thought, the county also is responsible for outpatient/chronic disease manage- ment, i.e., diabetes, COPD, high blood pressure, etc. At this point, patients are assigned a primary registered nurse, not a medical doctor. The RN care man- ager is trained and, if necessary, works with the transition to a federal long- term program. City: This level is charged with sporadic, short-term immediate issues. Urgent care, emergency care (with po- tential transport to state-run trauma centers), well care annual check- ups, pharmaceutical distribution, etc. At this level patients are as- signed a primary RN, similar to the county one. But this RN oversees many more patients with lower complexity until they are transferred to a county primary RN for more complex cases. My idea is to consolidate resources, stop duplicating efforts and focus on the strengths of each coordination level. There it is. It is not perfect and needs fleshing out, and I am sure I have over- looked some issues, but it is now out there, hopefully a seed to start discus- sions. I hope to keep the march to- ward the perfect system going. I wish all health systems engineers the best in your journeys – the world needs you. William "Ike" Eise hauer is a gi eer- i g professor at Portla d State U iversity. His i terests are i tegrati g e gi eeri g a d healthcare professio als to i crease the value of health systems a d adva ci g e gi eeri g scie ce to address healthcare delivery chal- le ges. He ca e reached at wde@pdx.edu. Every level of public healthcare tries to be all things to all people.