Fast Forward: A Blueprint for the Future from the Institute of Medicine.

LAST YEAR THE INSTITUTE of Medicine created a national buzz when its Committee on the Quality of Health Care in America released its first report, To Err Is Human: Building a Safer Health System. [1] The authors concluded that both systemic problems in the delivery of health care and the way we respond to medical errors create a system in which there are few incentives for improving patient safety. These errors lead to tens of thousands of unnecessary deaths and hundreds of thousands of injuries to patients each year. The report made headlines and forced responses from health organizations at many levels--and its impact on accreditation and health care organizations is ongoing.

On March 1, 2001 the same IOM committee released Crossing the Quality Chasm: A New Health System for the 21st Century. [2] This 300-page report may not be a headline grabber, but it proposes sweeping changes in the way health care is organized and delivered in the United States. (Unless otherwise indicated, all quotes are from this IOM report.) Many of the issues it raises are critical ones for physician executives.

The need for change

Crossing the Quality Chasm opens with: "The American health care delivery system is in need of fundamental change." "Health care today harms too frequently and routinely fails to deliver its potential benefits." "Quality problems are everywhere, affecting many patients. Between the health care we have and the care we could have lies not just a gap, but a chasm." "(T)his report is a call for action to improve the American health care delivery system as whole, in all its quality dimensions for all Americans."

Readers of The Physician Executive will see themselves characterized:

"Despite the efforts of many talented leaders and dedicated professionals, the last quarter of the 20th Century might best be described as the 'era of Brownian motion in health care.' Mergers, acquisitions, and affiliations have been commonplace within the health plan, hospital, and physician practice sectors. Yet all this organizational turmoil has resulted in little change in the way health care is delivered. Some of the new arrangements have failed following disappointing results. Leaders of health care institutions are under extraordinary pressure, trying on the one hand to strategically reposition their organizations for the future, and on the other hand to respond to today's challenges, such as reductions in third-party payments, shortfalls in nurse staffing and growing numbers of uninsured patients seeking uncompensated care."

Never let it be said that no one understands your plight!

The shift to chronic care

Over the past several decades the health care needs of Americans have shifted from acute care to care for chronic conditions. And yet our training, infrastructure, payment structure, and thinking continue to emphasize and reward treating acute illness more than managing chronic conditions.

The committee notes that the most effective approach to chronic illness includes access to the entire medical record for each patient, coordination of treatment between various health care providers, and simplicity of system use for both the practitioner and the patient. Little of this exists in our medical world.

A key point of the report is "Trying harder will not work. Changing systems of care will." Crossing the Quality Chasm is a call to change what we are doing to make health care better for us all; it is not an indictment but rather a recommendation to do things differently. "Health care has safety and quality problems because it relies on outmoded systems of work. Poor designs set the workforce up to fail, regardless of how hard they try. If we want safer, higher-quality care, we will need to have redesigned systems of care, including the use of information technology to support clinical and administrative processes.

Six aims for a new health system

The IOM report proposes six aims for our 21st Century health care system. The system we should strive for needs to be:

1. Safe--avoiding injuries to patients from the care that is intended to help them.

2. Effective--providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively).

3. Patient-centered--providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

4. Timely--reducing waits and sometimes harmful delays for both those who receive and those who give care.

5. Efficient--avoiding waste, including waste of equipment, supplies, ideas, and energy.

6. Equitable--providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status.

Such a system, the IOM notes, would not only be better for patients, it would also benefit clinicians. It will require a collaborative effort involving the federal and state legislatures, governmental agencies at all levels, private health care organizations, insurers, foundations, and provider organizations. No one sector can carry this burden alone, and no sector can consider itself exempt.

Ten rules

The report presents ten rules that outline a "new paradigm for health care delivery." These rules are the way in which the six aims of care might be implemented and would obligate private and public purchasers, health care organizations, clinicians, and patients to work together:

1. Care is based on continuous healing relationships. Health care is responsive at all times and through multiple channels.

2. Care is customized based on patient needs and values.

3. The patient is the source of control. The health system should be able to accommodate differences in patient preferences.

4. Knowledge is shared and there is a free flow of information.

5. Evidence-based decision-making directs care.

6. Safety is a system property.

7. Information is transparent. The system should make information available to patients and their families, including information on the system's performance on safety, evidence-based practice, and patient satisfaction.

8. Anticipation of needs is a priority. The system should anticipate patient needs rather than simply react to events.

9. Efforts are made toward a continuous decrease in waste.

10. Cooperation among clinicians is the norm.

These rules are a tall order! How can we put them into action? The IOM report outlines a methodology to move us into a world where these rules could apply, This effort will require large amounts of time, effort, and money.

Implementing change

To get things moving in the direction of the new paradigm, the IOM recommends focusing our health care resources more tightly on the care processes for common conditions that afflict the greatest number of patients. This is the "biggest bang for a buck" approach. "By focusing attention on a limited number of common conditions, the committee believes it will be possible to make sizable improvements in the quality of care received by many individuals within the coming decade."

The top 15 conditions are:

1. Cancer

2. Diabetes

3. Emphysema 

4. High cholesterol 

5. HIV/AIDS 

6. Hypertension

7. Ischemic heart attack

8. Stroke

9. Arthritis

10. Asthma

11. Gall bladder disease

12. Stomach ulcers

13. Back problems

14. Alzheimer's disease and other dementias

15. Depression and anxiety disorders 

"(T)hese conditions represent an excellent starting point for efforts to better define optimum care or best practices, and to design care processes to meet patient needs." "Redirecting the health care industry toward the implementation of well-designed care processes for priority conditions will require significant resources." The committee calls on governmental agencies, private organizations, and charitable foundations to focus on these conditions over others as a way of gaining benefit for the maximum number of patients in the coming years.

Six challenges

The committee recognizes six challenges that must be overcome to successfully implement the new health care paradigm:

1. The process of health care itself must be redesigned to more effectively serve the needs of the chronically ill.

2. All members of the health care team, as well as patients, must utilize information technology effectively.

3. We must develop methods to manage the growing medical knowledge base.

4. Organizations must coordinate care across patient conditions, services, and settings over time.

5. The effectiveness of teams must be continuously advanced.

6. Performance must be improved by incorporating outcome measurements into daily work.

None of this will be easy. To make these changes, the environment of care must change. Ultimately this is what the report advocates: an environmental restructuring of health care in the United States.

Information technology

"Health care delivery has been relatively untouched by the revolution in information technology that has been transforming nearly every other aspect of society." "Although growth in clinical knowledge and technology has been profound, many health care settings lack basic computer systems to provide clinical information or support clinical decision making." The committee does note: "An important constraint is that consumers and policy makers share concerns about the privacy and confidentiality of these data" [patient medical records].

Nevertheless, the report asserts:

"In the absence of a national commitment and financial support to build a national health information infrastructure, the committee believes that progress on quality improvement will be painfully slow." The final goal is clear: "This commitment should lead to the elimination of most handwritten clinical data by the end of the decade."

Payment policies

Particularly with regard to the treatment of chronic conditions and ongoing quality improvement the committee states, "Current payment methods do not adequately encourage or support the provision of quality health care. Although payment is not the only factor that influences provider and patient behavior, it is an important one." Private and public purchasers of health care will need to "examine their current payment methods to remove barriers that impede quality improvement, and to build in stronger incentives for quality enhancement."

A better payment policy would:

* Provide fair payment for good clinical management.

* Provide the opportunity for providers to share in the benefits of quality improvement.

* Provide the opportunity for consumers and purchasers to recognize quality differences in health care and direct their decisions accordingly.

* Align financial incentives with the implementation of care processes based on best practices and achieving better patient outcomes.

* Reduce the fragmentation of care.

The report does not pick one form of payment as better than others. Problems are perceived with both fee-for-service and capitated models of payment. Some form of "blended payments for priority conditions" is proposed.

Preparing the workforce

Who will staff this new paradigm of health care? "A major challenge in transitioning to the health care of the 21st Century envisioned by the committee is preparing the workforce to acquire new skills and adopt new ways of relating to patients and each other." This change must be a three-pronged effort:

1. Redesign how health professionals are trained.

2. Modify the ways in which health professionals are regulated to increase flexibility in scope-of-practice and innovation.

3. Examine how the liability system can constructively support changes in care delivery while remaining part of an overall approach to accountability for health care professionals and organizations.

The report's strengths and weaknesses

The report's emphasis on the needs of chronic care must be applauded. When medical students look at the payment for an hour of time doing a procedure in the operating room compared to an hour trying to untangle the health needs of a complicated Medicare patient with multiple system illnesses, the students vote with their feet. After all, they have big education expenses to pay off. We should not expect students and young physicians to choose specialties that emphasize chronic care until the differentials in pay are more nearly equalized.

The focus on the team approach is also important. Modern medicine is seldom a solo behavior anymore. Training increasingly emphasizes the utility of the team approach to properly equip tomorrow's doctors and nurses. The committee calls for increasing flexibility in scope of practice issues; this is an area of turf battles and jealousy, which is not easily laid to rest.

The call for information technology is also critical. One can establish a line of credit with an ATM in almost any part of the world in less than one minute. This is much faster than your doctor can obtain your medical records at your own hospital's emergency department. No paradigm for the 21st Century of medicine can ignore how woefully behind medicine has fallen with regard to how we handle information. Without effective IT, evidence-based decision-making will remain a distant dream.

Utopian

Undoubtedly, the members of the committee have considerable real world experience with implementing change in complex human systems. Nevertheless, much of this report seems to assume a nearly utopian vision in which all the players will behave altruistically on behalf of "the greater good." One could only wish this were true! Unfortunately, health care workers at all levels are human. Some of the more utopian aspects of this report will need the leavening of reality. Let us not forget that "utopia" means "nowhere" in Latin.

The Top 15

Several areas of the report will cause glee or anger in the health care community, depending on whose ox is being gored. The 15 priority health conditions are a case in point. If you are a cancer researcher or clinician, you cannot help being pleased that cancer is number one on the list. This will seem only right, natural, and fair. If, on the other hand, you are the parent of a child with cystic fibrosis, the list is going to seem terribly wrong. (As a pediatrician, I can't help but note that, except for asthma almost none of the Top 15 is very important to children's health. From my perspective, this is just one more time that the needs of the elderly [i.e., "voters"] are pushed ahead of the needs of our youth [i.e., "non-voters"].)

Will it be easy to get governmental and private funding to focus more exclusively on the Top 15? I doubt it. What happens when a new disease (the next AIDS) comes along and knocks someone's special problem off the most-favored list? The political ramifications are staggering. As much as it makes sense to spend the most of our money on the health problems that affect the largest number of people, there are going to be many "special conditions" clamoring for an exception.

Acute care versus chronic care

I applaud the concept of enhancing the way we pay for health care to emphasize the best care of chronic conditions over time. However, there are many professionals who chose their careers based on the current payment model. Generations of physicians have been trained in the acute care model and have chosen careers that emphasize acute care because that is where the best living can be made. We have seen the anger and professional infighting that has accompanied changes in Medicare payment schemes. Would any of us think that this sort of infighting wouldn't accompany even larger changes in payment methodology? Our move toward a new paradigm must anticipate resistance and sabotage from many whose situation will be diminished.

Patient-centered care

It certainly sounds nice (and even politically correct) to urge that health care must become "patient-centered--providing care that is respectful of and responsive to individual preferences, needs, and values and ensuring that patient values guide all clinical decisions." I hope that this patient-centered approach describes the majority of my efforts as a clinician over the last 25 years, but I can't claim that all my efforts have been so noble.

What if the patient is wrong? Are we obliged to accept patient preferences when someone demands an antibiotic prescription for every cold? How about treating colon cancer with coffee enemas? How does evidence-based decision-making square with that patient preference? For better or for worse western medicine has thrown in its lot with science. We cannot turn our backs on science whenever our patients prefer some other way of viewing the world.

These sorts of problems are not merely theoretical constructs; they are the reality that clinicians face every day. How respectful should you be to someone's ideas if the ideas are crazy? Every doctor and nurse can rattle off a long list of examples where the patient's preferences, needs, and values were not just inconvenient but downright dangerous. This report is correct in identifying patient-centered care as one area of concern. We should do everything we can to accommodate our patients' needs and desires. I just don't know if any of us can accommodate some patients' desires without deviating severely from good medical care.

I hope I do not get branded as a curmudgeon or an inflexible thinker saying this, but the committee has touched on a growing issue. Today's patient is bombarded with medical information on TV, in magazines, on the Internet, and from family and friends in a way that previous generations never faced. Some of this information is good and some is awful. Our patients ultimately need a well-trained professional to help them sort out the wheat from the chaff. They need a doctor they can trust to steer them toward good personal health care decisions. In the best of all possible future paradigms, this sort of doctor-patient relationship will become the norm.

If this IOM report gets us moving in a direction in which the best doctor-patient relationship can flourish, I say hooray. If we wander too close to "the customer is always right," regardless of the science of the matter, I am worried.

Information technology

Finally, let us consider the committee's recommendations regarding information technology. "Personal health information must accompany patients as they transition from home to clinical office setting to hospital to nursing home and back." Sounds great! This is what we all could hope for, but what about HIPAA? Many observers wonder how we will even be able to legally fax a prescription to a pharmacy next year as the HIPAA regulations come into play. HIPAA is based on important concerns about protecting sensitive patient information in a world where disseminating private data is only a mouse-click away. How we will balance these two conflicting imperatives remains to be seen.

Moreover, our patients may well be ready to accept some loss of privacy in order to gain a better functioning health care system. Privacy lawyer Robert Blair said, "The public is fairly pessimistic about privacy--a lot of folks may think their privacy is already gone." [3] This aspect of the new paradigm may vex us all the most.

An important report

It is easy to take potshots at the work of others; that is not my purpose here. Overall, Crossing the Chasm: A New Health System for the 21st Century points us in a good direction. Somebody needs to set proper goals for our profession and industry. This report is an excellent starting point.

Health care executives will need to be conversant with the details of the IOM report. It establishes targets and a lexicon that will be a part of the ongoing effort to redirect our industry. Like it or not, this report has set the table for our discussion of the future of medicine. Let us appreciate the Herculean nature of the committee's task and accept the report as a basis of further development of our health care system. This report is a good starting place for our journey into 21st Century medicine..

Earl (Trey) R. Washburn, MD, FAAP, is an Administrative Physician at El Dorado Pediatric Medical Group, Inc., in Placerville, California .

Note

This synopsis of the major points in Crossing the Chasm: A New Health System for the 21st Century can only provide an overview or flavor of the committee's recommendations. Interested readers are encouraged to obtain the report and analyze it further. You can read the report online for free or purchase it for $35.96 at www.iom.edu.

References

(1.) Kohn, L., Corrigan, J., Donaldson, M., Editors: Committee on Quality of Health Care in America, To Err is Human: Building a Safer Health System, Institute of Medicine, 2000, ISBN: 0-309-06837-1.

(2.) Committee on Quality of Health Care in America, Crossing the Chasm: A New Health System for the 21st Century, Institute of Medicine, 2001, ISBN: 0-309-07280-8.

(3.) Reaves, J., "Ooops! Medical Privacy Rules Aren't Written in Stone After All," Time, March 6, 2001.

* Restructuring the U.S. Health Care System

* Institute of Medicine's Recommendations

* New Paradigm for Health Care Delivery

* 21st Century Health Care

* Improving Health Care Quality

* Shift from Acute Care to Chronic Care

* 15 Priority Conditions

A newly released report from the Institute of Medicine outlines an ambitious program for changing the direction of U.S. health care. Crossing the Quality Chasm: A New Health System for the 21 st Century recommends switching health system priorities from predominantly acute care treatment to focusing on chronic medical conditions. The report also recognizes 15 conditions that it says should take priority for funding and support from all health care agencies. Evidence-based medicine must be fostered and the entire fabric of medical care must become more patient-centered. The IOM report proposes six aims for our 21st Century health care system. The system we should strive for needs to be: (1) safe; (2) effective; (3) patient-centered; (4) timely; (5) efficient; and (6) equitable. This article looks at some of the IOM recommendations and analyzes their strengths and weaknesses. Ultimately, the report advocates an environmental restructuring of health care in the United States.

What is the Institute of Medicine?

The Institute of Medicine (IOM) is part of the National Academy of Sciences (NAS), a unique creation of the federal government. The Academy of Sciences was chartered by Congress to be an advisor to the federal government on scientific and technological matters. The IOM is one of the associated organizations that operate under the aegis of the NAS.

Both the NAS and the IOM are private, non-governmental organizations that do not receive direct federal appropriations for their work. Studies undertaken for the government by the IOM are usually funded out of appropriations made to various federal agencies. Most of the studies done are at the request of federal agencies.

The IOM is an independent agency that uses unpaid, expert volunteers to author most of its reports. Each report goes through a rigorous and formal peer review process. Because the IOM is not a governmental organization, its experts and committees have greater latitude to conduct inquiry and study. Most IOM committees operate by consensus, and the process designed to reach consensus depends on scientific evidence and its implications. Where the published data are insufficient to support a conclusion, the committee may use its collective knowledge to argue for conclusions.