Mind to Market

Tuesday, August 10, 2010

Top Down or Bottom Up?

If systems are thought of as having a vertical structure, building them would proceed from one end to the other; either start at the top and work down or start at the bottom and work up. An iterative approach may require multiple end to end swipes but they would most likely proceed in the same end-to-end fashion.

Consider a large construction project, such as a bridge. A vision of the completed bridge, and its connections to a road or rail system, would exist before the first bulldozer rolled. This is a classic example of a top-down project. And the planning stage is not even really the top of the system; consider the budgets, laws, regulations, and standards that must be in place even before the initial plans are drawn up.

The bottom-up approach usually starts at the level of implementation; the construction site, an empty lot. Solutions are implemented quickly and meet immediate needs, i.e. a shed, mobile home to fill a need for shelter. These solutions, by their nature, may not take system wide impacts into consideration and may in fact create issues with other parts of the system; where's the bathroom? This is not to say that these types of solutions are not valuable; the key is knowing when a bottom-up approach can be taken and when a more top-down solution is necessary.

One frustration we all have with top-down designs is that they tend toward the one-size-fits-all approach; the designers cannot anticipate all possible scenarios in which the designs will be implemented. We may be familiar with some examples of this such as Medicare reimbursements incentivizing unnecessary treatments, government programs intended to encourage home ownership bringing down entire economies. Top-down approaches, left unmanaged, are prone to abuse simply because they cannot predict what the future will bring.

The recently enacted HITECH Meaningful Use criteria constitute a top-down edict instituted by the government to the healthcare industry: if healthcare providers and hospitals comply with the edict then they will receive incentive payments, if not they will be penalized. The problem is that these rules have taken the focus from providers and hospitals directing their own information technology strategy to one that is focused on meeting needs that may not directly benefit the providers and hospitals. There is an assumption that the end result will be to the benefit of all stakeholders, but that won't be known for many years and in the meantime the costs, only partly defrayed by incentive payments, will be borne by the providers and hospitals.

Can a transformation, such as that being attempted by the U.S. healthcare industry, be accomplished through a bottom-up process? In fact bottom-up processes are in continuous practice, solving short and long term issues. To expect a bottom-up process to come up with a national infrastructure, in a well established industry, would be quite extraordinary.

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