On Sep. 6, the Institute of Medicine (IOM), one of the United States National Academies, and a leading non-governmental organization in the healthcare policy arena, released a report entitled “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” The report was produced by a committee of 18 volunteer healthcare industry leaders, including such luminaries as Helen Darling, president of the National Business Group on Health; George Halvorson, chairman and CEO of Kaiser Permanente, Mark D. Smith (the committee’s chair), president and CEO of the California HealthCare Foundation, and Brent James, chief quality officer at Intermountain Health Care, and supported by nine IOM staff members.
That committee, the Committee on the Learning Health Care System in America, has produced a 382-page report, with 10 core recommendations for action to create what the report’s editors—Mark Smith, Robert Saunders, Leigh Stuckhardt, and J. Michael McGinnis—call a vision of a new healthcare system: “a learning healthcare system that links personal and population data, to researchers and practitioners, dramatically enhancing the knowledge base on effectiveness of interventions and providing real-time guidance for superior care in treating and preventing illness.” The editors added that “A healthcare system that gains from continuous learning is a system that can provide Americans with superior care at lower cost.”
Reflecting on both the gains that have been made in healthcare delivery performance since the publication of the groundbreaking IOM report “To Err Is Human: Building a Safer Health System” in 1999, and its follow-up report “Crossing the Quality Chasm,” published in 2001, as well as the obstacles that remain in improving patient safety, care quality, cost-effectiveness, and efficiency, the report’s authors and the committee offer the following 10 core recommendations:
> The digital infrastructure: Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.
> The data utility: Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.
> Clinical decision support: Accelerate integration of the best clinical knowledge into care decisions.
> Patient-centered care: Involve patients and families in decisions regarding health and healthcare, tailored to fit their preferences.
> Community links: Promote community-clinical partnerships and services aimed at managing and improving health at the community level.
> Care continuity: improve coordination and communication with and across organizations.
> Optimized operations: Continuously improve healthcare operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.
> Financial incentives: Structure payment to reward continuous learning and improvement in the provision of best care at lower cost.
> Performance transparency: Increase transparency on healthcare system performance.
> Broad leadership: Expand commitment to the goals of a continuously learning healthcare system.
Importantly, the report’s authors and the committee note, “Given the interconnected nature of the problems to be solved, it will be important to take the actions identified above in concert.” For example, they note, “To elevate the quantity of evidence available to inform clinical decisions, for example, it is necessary to increase the supply of evidence by expanding the clinical research base; make the evidence easily accessible by embedding it in clinical technological tools, such as clinical decision support; encourage use of the evidence through appropriate payment, contracting, and regulatory policies and cultural factors; and assess progress toward the goal using reliable metrics and appropriate transparency.” And, they add, “The absence of any one of these factors will substantially limit overall improvement.”
In other words, the committee and the report’s authors agree, a combination of continuous performance improvement, continuously increasing evidence-based care supports, care coordination, continuous improvements in operational efficiency, and the creation of cultures of continuous learning, all supported and facilitated by significant investment in the information systems needed to create this change, will be required.
The implications for healthcare leaders and healthcare IT leaders are obvious, and most importantly, this IOM report acknowledges the interconnectedness of all the issues involved.
To sort through some of those issues, HCI Editor-in-Chief Mark Hagland spoke with Paul Tang, M.D., a committee member, regarding the implications for healthcare IT leaders. Tang is vice president and chief innovation and technology officer at the Palo Alto Medical Foundation, a multispecialty group in Palo Alto, California, that takes care of 800,000 patients in a service area just south of San Francisco. Below are excerpts from that interview.
To begin with, what seems particularly important about this report is that the committee is recommending a broad range of continuous improvements to be tackled in concert, including patient safety and care quality improvement, efficiency improvement and performance improvement, care coordination, provider-community connectedness, and strategic information technology implementation and leveraging. Is that a correct summation of the broadest goals in the report?
Yes, you got it absolutely right. This is why we started out two decades ago doing this; we didn’t have the same context that we do today, but even back in the 1980s, we saw where our system was headed. For one thing, with all the advances in medicine, in the literature, and in everything else, doctors simply can’t keep up. And the result could be that people wouldn’t get optimal care, even while what we’re doing for people is bankrupting this country. So then obviously, we had to ask what we could do about it. And so we really focused on a couple of things: making things available in terms of knowledge, and then capturing that knowledge in ways that everyone could take advantage of it.
With regard to the 10 core recommendations [above], you can put them in three buckets. One, we’ve got to create a data and knowledge foundation, a digital foundation. Second, we’ve got to apply that to each and every patient and to the community at large; and third, we’ve got to apply this information to the right policies.
And what are the implications? Fortunately, we had this thing called HITECH [the Health Information Technology for Economic and Clinical Health Act] that has given us a lot of the tools, and particularly the meaningful use objectives. So the broad objectives of meaningful use are very well aligned with the goals of this report. For example, in the first group of recommendations, we have clinical decision support as a key component of that group.
And we’re moving towards a major emphasis on this infrastructure, a big piece of which is the electronic health record [EHR], of course. Because you have to capture all this information on the front line, and you can’t do that without an EHR. And in order to engage patients, not only should patients be able to access information, they should be able to contribute information—thus, the need for patient portals.
Paul Tang, M.D.
Can you comment on the Stage 2 final rule requirement for patient engagement through patient access to and downloading of information, and the pushback on the part of the Centers for Medicare & Medicaid Services (CMS) and Office of the National Coordinator for Health Information Technology (ONC), against providers’ request for the elimination of that requirement?
Just to put that 10 percent now five percent requirement, into context, 73 percent of our patients at Palo Alto Medical Foundation are online with us. And in today’s world, 5 percent is very achievable throughout the country. Now, 73 percent may not be achievable throughout the country, but that statistic [the 5 percent requirement] just shows what can be done. And the biggest progress takes place when physicians personally encourage their patients to get online with them; and the most common opportunity is during the patient visit. And it’s very easy for me to say to a patient when I’m giving them their lab result, would you get online? And it’s natural for them to say, yes, sure. And the thing is, patients really love this stuff, and get a lot out of it. And just having their information online encourages them towards healthy behaviors. So it’s really a try-it-you’ll-like-it technology, both on the patient and physician side. And you do have to have a little kickstart, but it’s very worthwhile.
The pioneering organizations in this country have all committed to continuous performance improvement and continuous learning, as recommended in the report. What are your thoughts on that?
Well, the pioneering organizations in performance have all long ago committed to investing in the information technology needed to support their work, and invested their own money, long before HITECH. Unfortunately, when you talk about the folks whose organizations haven’t achieved that continuous learning state, it’s because they haven’t achieved the infrastructure they’ve needed. The pioneering organizations’ leaders spent the money, ahead of the curve, on the infrastructure, and then moved ahead and improved; that’s why we have that divide between types of organizations. And that’s where HITECH comes in.
Do you think that we’ve reached a turning point of awareness in our industry now, with regard to healthcare leaders’ realization of the need to engage in concerted, coordinated performance improvement?
Yes, I do. We’re reaching that tipping point on health IT now because of HITECH. But also, everyone is in touch and regularly uses a computer in their lives now, and is accessing information and knowledge. So the cultures are being transformed for us because of the instant availability of data and information. And computing mobility is pushing us over that point.
In the context of the report and everything we’ve discussed here, what should CIOs and CMIOs and their teams be doing right now? What are your personal recommendations?
We talked a lot about the digital infrastructure in our report, so, first, get the EHRs and patient portals in place; because that is key to implementing a lot of the recommendations. So the EHR and PHR [personal health record] are the foundation. Get the clinicians and patients to use them. And if you do a great job with meaningful use, you’ll be on your way to leveraging the tools. Meanwhile, the additional element that’s not in meaningful use is leadership. We’ve got to make sure that leaders understand how to use the tools and get the most out of them. So accelerate what you’re doing with the IT infrastructure, and really work at the culture of continuous improvement.