The Case of the Pulse Oximeter

We now know of these devices from our collective COVID haze, but also our piercing memories of recognition that the healthcare system was not designed for all.

For those who struggle with understanding structural racism and how it shows up in everyday experiences - consider the case of the pulse oximeter, which does not work as well on folks with darker skin tones, it generates false positives, and fails to predict accurately.

Even worse, the news about the pulse oximeter is still not well-known within the medical community.

From a recent STAT article describing the measures the FDA is taking to fix the problem points to this reality:

a Black patient with COPD, said he has many physicians due to multiple health issues but “none of them except my African American primary care physician had ever heard of this problem. That’s a big, big problem.”

How do we think about radically and rapidly shifting the healthcare system to "fix this problem" that is so structural?

Let's use a favorite frame from an OG system thinker, Donella Meadows, whose leverage points of places within a complex system identify where a small shift in one thing can produce big changes in everything.

How would we correct the problem of pulse oximeter accuracy issues according to Meadows' hierarchy of leverage points, from least to highest impact:

12. Constants, Parameters, Numbers (Weakest Leverage)

• Labeling Changes: Adjusting device labels to inform users about potential inaccuracies for darker skin can be seen as changing parameters to influence system behavior.

11. The Sizes of Buffers and Other Stabilizing Stocks

• Availability of Alternative Monitoring Methods: Medical device innovators - accelerate your better oximeters!

10. The Structure of Material Stocks and Flows

• Distribution and Recall of Devices: Managing the flow of pulse oximeters into and out of the market, especially concerning the recall of devices that are particularly problematic or inaccurate for darker-skinned patients. This includes how devices are produced, distributed, replaced, or recalled based on their performance and accuracy across all skin tones.

9. The Lengths of Delays, Relative to the Rate of System Change

• Educating Clinicians: Reducing the delay in awareness and knowledge transfer regarding pulse oximeter inaccuracies can help the healthcare system adapt more quickly to these findings.

8. The Strength of Negative Feedback Loops

• Consumer Awareness: Healthcare activists demand more rigorous and accelerated methods that are acting as a feedback mechanism to manufacturers to improve device accuracy.

7. The Gain Around Driving Positive Feedback Loops

• Transparency and Data Sharing: Utilizing federated learning and edge AI technologies, enhance the positive feedback loop of innovation and improvement in device accuracy by fostering collaborative research efforts.

6. The Structure of Information Flows

• Enhanced Testing Protocols: Modifying how information about skin tone is measured and incorporated into testing changes the flow of information within the system of device approval and monitoring.

5. The Rules of the System (Incentives, Punishments, Constraints)

• Regulatory Oversight and Proposals for Recall: Implementing stricter regulations and the potential for recalls introduces new rules that directly impact how manufacturers design and test their products.

4. The Power to Add, Change, Evolve, or Self-Organize System Structure

• Research and Studies: Conducting comprehensive studies to understand device performance across skin tones can lead to significant structural changes in how devices are developed and tested.

3. The Goals of the System

• Health Equity: While not universally accepted, many stakeholders are attempting to shift the overarching goal of the healthcare system is to ensure health equity by providing equitable, effective, and culturally competent care tailored to meet the diverse needs of all individuals.

2. The Mindset or Paradigm Out of Which the System Arises

• From individual to equity: Shifting from a reactive, one-size-fits-all healthcare model to a proactive, personalized approach that emphasizes inclusivity, accessibility, and equity for every individual.

1. The Power to Transcend Paradigms (Strongest Leverage)

• Collaborative well-being: This paradigm shift in healthcare reflects a transformation in the very essence of how we perceive and design health systems. It's a move towards creating environments and practices that inherently shape our well-being by acknowledging that the structures around us—technological, social, and environmental—actively participate in crafting our health outcomes. In this new model, healthcare doesn't merely respond to illness but anticipates and nurtures health, recognizing the interconnectedness of individuals with their communities and environments.

What lever would you choose next?