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Representative terms from entire chapter:
tire health
cE cA
Quality poems a/e eve'~yw1?e'~e, affecting Nay patients. Between the
health care we have and the care we cor'/cl have lies '?otj'~st a gap' b''t
chasm.—Crossing the Q''ality Chasm: A New Health Systen?for the 21st
cel?hiry, 2001
THE 2~.~Y ~~.~M
Recent years leave brought to national attention a troubling fact: tire
U.S. health care delivery system does not provide
consistent, l~igh-quality meclical care to all peo-
ple all of tire time. Crossing the Q~'ali~ Chasm: A
ee.~e U.SO heallb (are
delivery system doe`s n<~t
New Health System for the 21st Century (2001~ calls provide ~~)n~i8~t' highs
for a sweeping reclesig~ of tire entire delivery
system. Modifying the current system Camelot do
the job, because its inherently poor design sets
up health care worI
[~.~IP'S!rt~ 111~<' I~{,/~~!~. Cart IDA lS~St,~S IN ~<,4!7~
/tivingw~th / \ \
/ Illness/ / \ \
Disability / \ Gettir~g Better \
Chronic / \ Acute Care
Care / \
V
A I
\
Coping with ~
End of Life \
\ Palliative
Ware
\ Cross
fff`~4~1 C~-~- Drt~`S17~.~l AND in :,4~3,48~.\
ity of the nation's Stealth care burclen ant! resource use. Several of the
areas, such as tire need for coordination among clinicians and institutions
in patient caret cut across specific conditions and I~ealtl~ care settings.
Collective actions in these priority areas could Whelp transformer tire entire
heath care system. As steps are taken to improve care, it will be vital to
measure their impact regularly, using stancIarclizeci methods treat permit
comparisons. Over time, new priority areas may need to be identified,
using the criteria anti selection process spelled out in tire report.
The Quality Chasm report also stresses Bleat transforming tire health care
delivery system will ~ equire transforming how pl~ysiciat~s, nurses, pl~arma-
cists. and other health professionals are educated. Hedit/? professior?s
Educations: A Bric/ge to Quaker (2003) provides a blueprint for cage.
Educators should develop curricula ant! programs for undergraduate,
graduate, Alice continuing education to erasure Cleat clinicians achieve profi-
ciency in five core areas: providing patient-oriente~i care; working, in inter-
disciplinary teams; practicing eviclence-based medicine; applying quality
improvement approaches; and using information technologies.
Organizations witty oversight responsibilities including accreclitatio~,
licensure, and certification groups also should! adopt mechanisms to
ensure that students Alice worl~ing professionals develop and ~nai'~tain pro-
ficiency in blase areas. Among Oliver recomn~endations, tire report calls
for changes to training programs, for research to improve educational
practices and iclentify what clinicians si~ouIc! be taught to improve patient
care, for public reporting relater] to health pi ofessio~s education to better
Overlap of Gore £ompetencies for
Health Professionals
_~'Empl~y
_, F ~Y;de
1~ r ~
~f~4l~r(~ I-- 3' CKI11~AL i.~St 'ES bier BALM
coo~cli~ate ant! integrate across their multiple roles, ant! for active leacle~-
ship across clisciplines to improve health professions education.
REr'(~G 'at bYS'.~M
Given their lcey role in training stealth professionals, conducting
~esearcl~ treat advances health, and treating tire neediest of patients, aca-
demic healths centers can leas] efforts to improve healths care. ACaC]el??iC
Heat Centers: Leaching Change in the 21st Century (2003) offers a comprel~e~-
sive plan for flow acaclemic stealth centers (AHCs) si~ouIc! reform their own
operations, proposes public policy actions speeded to ensure that AHCs
catty out reforms ant! describes flow AHCs can serve as ~nociels to guicle
change for health care delivery, education, and research. Among priority
needs, AHCs should take the lead in redesigning the content and methods
of healths professions education (and Congress sI~ouIc! create a declicatect
Academic -I cente's
pals ~ ~ these d ~~e
areas can be steadily t~-
itt'red ai3d Ads tiff the
cent(~10S must Step forward
nice the r,0tit-~n Ad
'improved healthy.
fund to support such innovation) and they
sI~ouic! design and assess new organizational
structures and team approaches for patient care
(and government agencies organizations that
pay for health care ant! founclations sl~ouIc! sup-
port demonstration projects to evaluate these
approaches). AHCs also should increase their
emphasis on clinical stealth services and preven-
tion reseal cl1 in of cler to answer questions about
tire clinical electiveness and cost effectiveness
of both current practices and emerging technologies ant! funnel s of heatth-
r elated ~ esearch especially at the federal level should enhance ant! foster
collaboration across departments professional schnooks ant! institutions.
AHCs must set clear goals so tight progress in these diverse areas can be
steadily ~nonitorecl, and leaders of tire centers must step fo'warcl to guide
else nations towa'd improved health.
In many fields conducting demonstration projects often proves of
great benefit in determining tile best ways to r each desired goals. For this
reason tire Department of Health ant! Human Services asker! the IOM to
identify possible demonstration projects focused on improving health care
that could be concluctect in tire near term ant! treat might yielc] models for
broad reforms of tire overall clelivery system within a few years. Fostering
Rapic! Acivances in Health Care: Leaming from System Demonstrations (2003)
describes a carefully crafted set of projects that I~oic! promise of breaking
new ground ant! potentially could improve stealth save dollars or both.
[~ ~~' C~ i~- Drtit~i S]rSILl\f AND pERF-~fANCE ~Al'ARILI'TIE-S
TO projects fall into five basic categories: chronic care; primary care; tire
information and communications technology infiastructure; state health
insurance, and meclical liability. Taken together; the projects acIciress criti-
cal elements of proposed strategies for systen~-wide I~ealtl~ care reforest.
All or nearly all of tire projects will involve public and pri-
vate partnerships amuck collaborative efforts, ant! witty tire
exception of the u',insu'-ed demonstration, they are
expecter! to r equire modest ceases in stealth care
expenditures beyond initial upfront investment. As witty
all de~nonstratio~s, these projects should be viewer! as
experiments and should be carefully evaluated to deter-
~i'~e wl~etl~e~- acid to wheat extent they achieve
intenclec! outcomes.
Proposals for improving tl~e quality, safety, and effca-
cy of tire healtl1 care system typically place considerable
emphasis Ott cleveloping and implementing electronic I~ealtl~ record (EHR)
systems. Although an increasing number of health care organizations
already use such systems, most providers continue to write orders for serv-
ices and maintain patient records on leaper, ant! most also practice without
con~puter-assisted decisions supports, sot as prompts to check a diabetic
patie~t's blooc! glucose or alerts that inclicate drug interactions. As part of
a ~~atio~al effort to encourage tire acloptior, of computer-basec! heat
records, the Department of Healths and Human Services asked the IOM for
Whelp in establishing what characteristics EHR systems should possess to be
most useful. Key Capabilities of a'~ Electronic Health Recorc! System (2003) iclen-
tifies a set of ei51lt core functions bleat EHRs sixfold be capable of perform-
ing-. Tire functions were selected off tire basis of their ability to improve
patient safety, support effective care, assist ilk tire management of chronic
diseases, acid improve efficiency. Tipsy all protect patient privacy and co'~-
fidentiality, acid Riley comply witty established standarcIs for security, stor-
age, and exchange of data. Having a common understanding about key
functions will enable health care orga~izatio~s to more easily compare tile
EHR systems treat are currently available, guide venclors in builcling new
systems witty enhanced capabilities, Whelp accreditation organizations in
certifying systems treat are ready for adoption, and may guicle tire federal
govern net as it considers ways to stimulate care providers to
invest in EHR.
~5
\Rj~; EVE Fr77 a 7~: [R/~f ~~ /\ ~~?
~ help in determining whether the nation is making progress in
improving the deUve[y of heakl1 care, Congress has malldsted the Agency
far Heakhcare Research and QuaUty to prepare an annual report on quah-
~ ~ends, with the first resort dated far 2003. The a~enCv asked tile 1O~
~ . . ~ ~
. . . . ~ . , . , ~ . .
to develop ~ ViSiOll of the design slid contents of this lCpOli. to
Me Thong/ Geoff ~~ Quaky flora (2001) off ~ broad Framework far
assessing quaff of health care describes specific examples of the types of
pleasures that should be included and suggests how to obtain such data
most efficiently; and provides advice on how to reach intended audiences
with Ulis intimation. Although its primary audience is intended to be pol-
i~ makers and 1leald1 care leaders at tile national and state levels, the
report also should be Of interest to the public clinicians, researchers, pur-
chasers of health care, and other individuals alla groups concerned with
Avid
Children with h~4hreatening conditions and their Memoirs too open
d to receive competent, compassionate, and consistent health care that
meets their physical, emotional, alla spiritual needs. Amen ~~'d~" fife:
If~proy~'l~ ~~/f~f~e gild End- Boor CAfid~n Ovid Miff fee {2003)
Flucent~1 Cord
Membranes
Con~enita1 (2~)
Anomalies \
(1 Z~) ~ \
CompUcations
of Pregnancy
(2~)
Short
Gestation
(8~)
Heart Disease
/ (2~)
Unintentional
\ attunes
~ (22~)
~ 1
SITS
(5~)
Respirator
Distress
(2~)
mu:
Cancer
(4~)
Homicide and
Suicide
(8~)
Other
(33~)
PercenLage of Ill ChUdhood Oeaths by Age Croup q999t SOURCE: Men Children
O7e: /mprov7/l~ ~///af;ve and End- Care fair Ct;7dren and Weir Made, 2002,
Rage 4
,.,
ut-At74 ~ cow- Drtit~ir bars IT,\] ANo pr~ ogMANGE CAI3ASItI~S
concluc:les that the nation must do more to cleliver effective ant! appropri-
ate care ilk these tragic situations It provides a set of worIcing principles
treat characterize I~igI~-quality palliative, encI-of-life, ant! bereavement care,
and suggests a broacI-~'asec! strategy for making such care widely available.
Incleeci, good care aIreacly is possible but current methods of organizing
ant] fina~ci'~g complicate tile provision and coo~clination of services, ant!
sometimes ever, requite families to choose between curative oil life-pro-
longing care acid palliative services, particularly hospice care. Inadequate
scientific knowledge also impedes efforts to deliver effective care and
clesig~ supportive public policies, and tire ~ eport calls for expanded
researcl~ to fill current data gaps. Expanded eclucational efforts are needed
as well to provide all physicians, nurses, anti otIler I~ealtI1 professionals
witty basic competence in palliative, end-of-life, and bereavement calve, and
to provide specialists ant! others who routinely treat children with life-
threatening conclitions with acIvanced competence in tidiest types of care.
ASSESSING 60~T ~~-~ ] Pi
TI1e government's six major health care programs
serve some 100 million people (1irectly anti significantly
influence flow tire private sector provides care to mil-
lions more. In response to a request from Congress, tire
IOM analyzer! flow well tI~ese programs: Medicare;
MedicaicI; tire State CI1ilcIren's Health Insurance Program;
the Veterans HeaitI~ A
I3y~,'y~r:~ '7~< Ft,'~7~ ~E CRI116~AL ~~S IN BEAT COW
Tire gove~nment's main programs for providing casts befits Alice eligi-
bility for medical benefits to people witty disabilities the Social Security
Disability Insurance programed and the Supplemental Security Incense pro-
gran~ leave experiences! unexpectecIly rapid growths cluring the past two
decades. For guidance on managing these p~-o~,rams, tire Social Security
Administration (SSA) turned to the Institute of Medicine. The Dynamics of
Disability: Measuring and Monitoring Disability for Social Security Programs
(2002) offers a comprehensive set of recomn~enclations. Since clisability is
a cynic process treat can fluctuate in breadth amuck severity act oss tire life
counsel the SSA should clevelop a monitoring systemic to continually gate
information ill a variety of areas. This system would provicle the agency
Title data needed to respond to a variety of policy and planning issues,
such as cleanses in the size, distribution, and characteristics of the work-
ing populations wilds disabilities; demographic trends, fluctuations ilk labor
markets, and changes in economic conditions; needs of minority and spe-
cial populations witty disabilities; and tire impacts of legislative, ~egulato-
ry7 and judicial actions on disability programs. The SSA also desperately
needs to develop a systematic lo~g-term research program to address
growing demands on its disability programs and to provide tire basis foil
improving l~ow it maces decisions about program eligibility.
Strengti~eni~g research efforts, within the agency and thorough extran~ural
programs, will require a major i'~fusio~ of new resources, in terns of both
dollars and recruitment of qualified r esearcI~e~-s.
1
/
Difference
Discrimination:
Biases, Stereotyping,
\ and Uncertainty
Clinical Appropriateness
and Need
Patient Preferences
The Operation of
Healthcare Systems and
Legal and Regulatory
Climate
Disparity
1
Difierence, Disparities, and Discrimination: Populations with Equal Access to Health
Cal-e. SOURCE: Unequal Treatment: Confronting Racial and Ethnic Disparities in
Health Care 2002, page 3 3
HE-AL71! ~ ilRE DELIVERY Sprig ITM AIVD Pair C,*~)AR~S
COT DISPARITIE:S IN WRAITH chip
It is well established that members of racial ant! ethnic minority go oups
in tire Unitec! States experience a lower quality of I~ealtl~ services, inclucI-
in', even routine meclical procedu~ es, titan clo Finite people. Unequal
Treatment: Confronting Racial and Ethnic Disparities in Health Care (2002)
reviews tire extent of such disparities, explores factors treat cause totem,
ant! suggests policies and practices to ensure treat all people receive the
same level of care. Among its recommenciatio~s, efforts are needed to
make health care providers, insurance companies, policy-makers, apace
members of the public more aware of tI~ese disparities; to encourage
heat care providers and health plaits to adopt evidence-basec! guiclelines
for malting decisions about which procedures to orcler or pay for; to inte-
~g-rate cross-cultural education into tire training of all Stealth professionals;
and to recruit and train more minority health professionals, In adttition,
public education programs should be stepped up to ensure that minority
patients know how to access care ant! participate in treatment decisions.
Guiclance for increasing tire representation of racial and etI~nic n~i~or-
ity groups in the health professions is offered in an earlier IOM report. The
Right Twig to Do, The Smart Thing to Do: Enhancing Diversity in the Health
Professions (2001) summarizes the proceedings of a major symposium
organized its conjunction witty the American Associations of Medical
Colleges and tire Association of Acaclemic Healths Centers. The report dis-
cusses bar r iers to recruiting ant! traipsing, underrep~esented minority stu-
clents anti proposes steps fot overcoming these obstacles. Efforts will be
Hispanic
25%
Asian/Pacif~c
Islander
10%
American lndTan
1%
-
-
/
\
Black \
14%
White
50%
U.S. Population Aged 1 6~G4, Year 2050 (percentages). SOURCE: The Right Thing to
Do, The Smart Thing to Do: Enhancing Diversity in Health Profession: Summary of the
Symposium on Diversity in Health Professions in Honor of Herbert ~ Dickens, M.D.,
2001, page 2.
-or ]~E I4~ CP]~(A] [~S Or ~HEAI7~
neeclec! at all stages of the academic pipeline, beginning with programs to
help minority students perform better ill science Alice mathematics ill grade
school and high school. Promising stuclents Insist be encouraged to pursue
tidiest fielcIs during undergraduate acid professional training, ant! tI~ey'~ust
be provided with a variety of tools and support to ensure their success.
Eclucational institutions and health professional organizations can Whelp
smooths the academic pathway, especially at the undergraduate level, by
training career advise's in else pal ticular needs of minor ity stuclents acid by
rewarclinb faculty for serving as stucle'~t mentors. Motif unclergracluate and
professional scl~ools also face Able cl~alle~ge of developing ad~nissio~s poli-
cies that address tire neec! for racial anct ethic diversity Simile keeping in
nice r ecent shrifts ilk legislative anti judicial positions r egarcting affirmative
actions. New strategies anc! mecI~a'~is~ns are neeclec! as well for overcoming
tire financial constraints that too often have preventer! underrepresented
minority stucle~ts from pursuing careers in tire health professions.
HELPING TFiE UNINSt)~D
Over else years, tire IOM leas issued numerous reports focused on else
nation's approach to health insurance coverage. One problem Blat remains
particularly challenging is the large number of people who clo not have
Stealth insurance. In 2000, tire IOM establisI~ec' tire Committee on the
Consequences of Uninsurance, witty support from tire
Robert Woof! Johnson Foundation, to consicler what lack
of coverage means not only for tire more titan 40 million
people wire go without, but also for their families and
communities, for health care organizations, acid for tire
larger society The commitree's Clark is to criticaliv
review and synthesize the extensive but diffuse policy
and clinical reseal literature and to communicate its
findings and recommel1datiolls to policy-lllakers and tI1e
general public.
~ — Cry J
TI1e committee has issued five of its six scI1eduled
reports, eacI1 rigorously examining different aspects of the problem. TI1e
breadth and analytic deptI1 of tI1ese reports has helped to expand policy
discussions beyond a moral imperative for insurance coverage. Key find-
iligS from tire reports include flee following:
~ Coverage Matters: l'~sura`~ce and Health Care (2001) concludes treat
many more people are regularly or periodically wninsurecl than widely
believed. An estimated one out of seven people goes without coverage for
BALM (,\~E ~~Y 51~M i\~Vl) pERI<~E :,`~['ARILfrHE~.\
a year or snore at some point in life, and many more go without coverage
for shorter periods, sometimes on a r ecurring basis. More titan 80 percent
of tire uninsured live in families in whicI~ at least one person works, and
roughly 80 percent of tire uninsured are U.S. citizens. More titan tire state
of tire economy, the rising cost of health care services and insurance pre-
miun~s, combined with a I~ocigepodge of government policies, unclermilles
the affordability of health insurance.
· Care Without Cvveroge: Too Little, Too Late (2002J finals that won Ici~g-
age aclults who are uninsured tend to be sicker and clie earlier titan insured
adults. Tire uninsured are significantly less lithely to receive needed health
care, i~cluciing preventative services and care for chronic conditions. Tire
health benefits of insurance are strongest widen coverage is continuous
rattler than sporadic, and broad-based strategies to foste'- coverage across
the entire uninsured population are more likely to improve health out-
co~nes than are "rescue" programs aimec! primarily at people Gino already
are seriously ill.
· HenitI~ Insu/ once Is a Family Matter (2002) concludes that families with-
out health insurance risk not only tI~eir health
. . An est~t~£! t~ out t~{
but also their economic v~ab~ty. Incleeci, the
physical, emotional, and financial well-being of
all members of a family may be adversely affect-
ed if any November lacks coverage. In families
Seven pe(~plle goes will
COVC(~C [of ~ year OF more
at some point in ~tife~e
~ ~ ~ ~ — ~ A 18 ~ ~
where someone is uninsured, both parents and children are less likely to
get timely Seattle set vices. Uninsurec! child en r eceive fewer services,
including important preventative services (such as routine checkups) that
can leave beneficial long-teTtT~ effects. Most uninsured families clo not leave
sufficient funcIs to purchase health insurance independently, as the cost of
premiums is too l~igl~.
· A Sharerl Destiny: Community Effects of Insurance (2003) describes
spillover effects that go far beyond any given uninsured pea son or family.
In communities wI~ere many people lacI; coverage or tI~eir numbers are ris-
ing rapicIly, health often suffers among insurer! people as well as among
tire uninsured. A variety of factors play a role. Communities that must
devote incT eased public fiuncis to caring for tire uninsured often resoTt to
cutting back on other meclical services aimed at the general population
including cli'~ic-based primary care, specialty I~ealtl~ services, ant! I~ospital-
based care, particularly emergency medical services anti trauma care. Also,
since uninsured people generally are more likely to cIevelop comTnuT~icable
diseases (and less likely to be fully vaccinated against Lucia cliseases), they
may Chasten tire spreac! of infections throughout tire community.
INH)~NI/~! 7~E ~~ CkI11g:~AL I.~S IN BALM
· ~ 1~4-~% {~ ~~
_ ~~.~.~.~ ~ ~.~.~.~ ~~ ~~ ~~'
~ ..
r~ 17 pO:j~ ~
~ I COW,) {A
~ t.~,'~<',
6']~ ~ ~ .0''>.'J
}iced O.,~';~'o
pit (.) ~."~.j
or Am
~) ,5 2~'&
DE ~ O.£~
MD ~ ~ 6?O, S.
D c.; ~ ~ .9 -..o
Po.~.~' Of Stotc
~ : Ur16~
I!~ CARI~ DELITIRN! SV~SITi\] ,4~:) PERF-~]ANCE CAT3ARILI7~S
(lancer ranks second only to Impart clisease as tile At ion's leading cause
of deaths. Yet many types of cancers can be prevented or at least cletected
early enough to make effective treatment possible by caging flow peo-
ple behave. F''lfilli'~g the Potentin! of Cancer Prevention ails Early Detection
(2003J examines tire extent to which tile burden of cancer can ire reducer!
by promoting behavior al changes and outlines a national strategy to
achieve sucks gains. In orcler to save tile most lives, Call care providers,
health plans, insurers, employers, policy-~nakers, and researchers should
be conce~t'ati'~g their resources off Whelping people to stop snowing, mai~-
tain a beastly weight and diet, exercise regularly, keep alcohol consump-
tio'~ at low to moderate levels, and get screened for- breast, cervical, and
colorectal cancer. A 19 percent clecline in the rate at which new cancer
cases occur and a 29 percent clecline in the rate of cancer Beatles could be
acl~ievecl by the year 2015, if efforts to help people change behaviors that
put them at risk are stepped up ant! if those people maintain their new
tttestyies. ~ his WOUld equate to the prevention of approxin~ately 100,000
cancer cases and 60,000 cancer Beatles each year. These behavioral changes
~ . ~ . t ~ 1 ~
80 -
70 -
o
::
Q
o
Q
Q) 50-
o
o
o
o
a)
Q
a)
60 -
40 -
30
20
10 -
_
O- 1
1930 1 940
Luna and Bronchus ~
Her
. .. .
. . .
.....
. . .
.... .......
Stomach
.; ~ / \
J
J
~ ~ . .. ~ ..
Colon and
rectum Prostate
\ \
_'
~ ~ Am ~ ~
fit
; Leukemia
,,.. ~ ..,
- I! ,,
Pancreas
............................. ~;: _
1 1 1
1950 1960 1970
1980 1 990
Age-ad lusted Cancer Death Rates,* for Males by Site, U.S. 1930-1 997.*Per 100,000, age-
adjusted to the 197() standard population. NOTE: Due to changes in ICD coding, numer-
ator information has changed over time. Rates for cancers of the liver, lung and bronchus,
and colon and recount are affected by these coding changes. Data obtained from U.S.
Mortality Public Use Data Tapes 1960-1968, U.S. Mortality Volumes 1930-1959, National
Center for Health Statistics, Centers for Disease Control and Prevention, 2~)()(). SOURCE
Fulfilling the Potential of Cancer Prevention and Early Detection, 2003, page 19.
(.~3
[PNE;~/lI[.~(r 1~E F(f1-~L~~ 6~71~L ~~ IN -ANEW
may help to alleviate, in particula'; the disproportionate burclen of cancer
borne by members of certain racial and Bionic minority groups. The l~en-
efits of promoting such behaviors also may extend beyonc! cancer to car-
diovascular disease ant! clial~etes as well.
Breast cancer strikes '~ore titan 180,000 women, ant! kills more titan
40,000 women, ilk tire Uniter! States Tacit yeas: Early detection of invasive
tumors currently is tire best hope for reducing this disease burden—and X-
ray man~mograpl~y screening is the mainstay for early detection. But this
method leas its limits, ant! researchers are pursuing a range of new
approaches. Ma~nn~ograpl~y and Beyond: Developing Technologies for the Early
Detection of Breast Cancer (2001) icie~tifies promising technologies ant!
explores their merits and drawbacI`s. Among tire technologies are modified
versions of conventional mammography treat use computer programs to
spot suspicious areas ant] alternative ~netI~ods of detec-
tion such as magnetic resonance imaging and biocl~emi-
cal testing of breast fluids. Tire report also details ways
to improve tire development process. Actions include
increasing government support for research on cancer
Makers or biological characteristics associated with
breast cancer; ensuring titan federal regulations regard-
ing approval of detection devices are consistent arid as
uncomplicated as possible; and developing snore co'~-
prel~ensive and coordinated insurance mechanisms to
cover screening tests. To Whelp r educe Else toll fir breast
cancer as improved technologies make timid way into
general use there remains a need to reacts many more women with screen-
ing efforts. Tire report recomn~e'~ds several steps to optimize tire use of
proven technologies currently available sucks as expanding federal screen-
ing programs to include women without insurance arid determining
whether there is (or soon will be) a shortage of radiologists trained in
. .
Breast Imaging.
455~' ~MM(~ATIt:~N ~~£~E
Imn~unization offers a ~ iffily effective means of preventin serious ill-
'~esses and Readies in cI~ildre'~ and adults. But tire nations system for
financing immunization services leas developed gaps. In 2000 the IOM
issued a report tI,at focused attention on Else uncertainties arid instability
of the public health infrastructure that supports i~nmunizatio'~ programs
Calling the Shots: l~nmunization Finance Policies and Practices proposed sever-
~ . .
-Arm c-~r fir S~rS]~M i'`N~ Pr~-~3~E ~AI3ARIl l~
al strategies to acicIress these concerns and to provicle an aclequate fund-
ing level for immunization infrastructure. To help catalyze reforms, tire
Centers for Disease Control and Prevention asker! the IOM to undertake a
special effort to foster discussions among tire various public and private
groups who participate directly or indirectly in the immunization system.
In response, tire IOM Ibid a series of four workshops designed to
increase awareness of tire conclusions and recommendations of Calling the
Shots; built! consensus for initiatives to redesign tire infrastructure of tire
immunization system, measure its performance, and finance its opera-
tions; acid identify unresolved public health and Stealth finance issues a
concerns at flee regional, state, and local levels Cleat require further atten-
tion from public ant! private policy-mal~ers. Reports leave now been pub-
lisheci on each of the workshops. Highlights of tire reports' which carry the
general title Setting the Course: A Strategic Visions for Im~nu'~ization, include
the following:
· Part 1: Sunny ofthe Chicago Workshop (2002) e~npl~asizes tire need
for collaborative strategies to engage tire healths care, business, and gov-
ern~nent sectors in iclentifyillg OppO1 "unities to achieve public ilealtI~
im~nunizatio~ goals. Efforts are neecled to encourage private health plans
and case providers to assume responsibility for ensuring treat large nun~-
bers of children and adults receive needed immunizations within the com-
munities Alley serve. New approaches tIlat use inforn~a-
tion resources efficiently and reduce reliance Ott public
funcling will be r equired to meet persistent and r outine
immunization needs.
~ Part 2: Summary oft/e Austin Workshop (2002) rein-
forces tire importance of collaboration, consultation, and
partnership efforts across levels of government ant!
between tire public ant] private sector: For Texas, in par-
ticula~; efforts to improve vaccination rates, wl~icI~ are
among the lowest in tire nation, are Amperes by many
obstacles, inclucling tire state's increasing births rate acid
national shortages of some vaccines. Legislative action
presents one strategy for noosing al~eacl. For example, tire state night
change its guiclelines to automatically place cl~ilciren on the immunization
registry (unless they opt out of participating). Healths agencies anal pi ofes-
sional groups also can establish incentives to encourage more care
providers to participate ilk immunization programs.
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and Prevent
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Coverage
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Six Roles ot the National ltntnunizatiot~ System. SOURCE: Setting the Course: A
Strategic Vision for Immunization--Part 3: Summary of the Los Angeles Workshop,
2()()3, page 14.
· Part 3: Summary of the Los Angeles Workshop (2003) finds that although
state and local efforts to aid clinics and care providers have boosted im~u-
nization coverage levels to tire national average, p~-oblen~s loom on the
horizon. California's economic clow'~turn is expected to mean reductions in
state and local funding for immunization services, and taxis dilemma is
compounclec! by the high cost of new vaccines and the increasing cost of
older vaccines. Tile high cost of vaccines also results in serious financial
risk for many private providers who clepenci on reimbursements to cover
their vaccine purchases To address such concerns, it will ire necessary to
explore public policy tools that can air! in creating incentives for the pro-
cluction ant] distributions of vaccines. Leadership also is neecled within tire
public health community to ensure that immunization issues remain visi-
ble anal receive adequate attention.
· Part 4: Summary of the Washington, D.C., Workshop (2003) describes
strategies to preserve and support traclitional public health efforts Such as
~ 1 , ~ ~ ~ ~ _ ~ ~ ~ _ ~ _ _ _
outreach, education, ant! monitoring and surve~ianceJ while also ~neetmg
flew cle~nands associated witty delivering a I~igI~e~ p~-oportio~ of vaccines ifs
tl~e private I~ealtl~ sector: Tire shift in immunization service settings leas
created new stresses ant! tensions over tire appropriate roles of public
health departments and the manner in which those roles should be
financecI. One particular ciifB~culty facing bile public healths system is n~ain-
taining vigilance even widen visible signs of infectious disease outbreaks
[~ arm C-ARE I S)rS'1~M ,41\S~ PERT-~3~A~JAN(,! C,4~3AR~F~rIE~S
are not apparent. Developing a plan to determine flow the costs of immu-
nizations efforts sI~ouIct be allocated across tire federal, state, and private
health agencies also remains a significant challenge.
The IOM also leas examiner! problems in flow vaccines are purchased
ant! distributes! in tire stealth care system. Vaccine manufacture is not prof-
itable foil pharmaceutical companies widen compared to drugs wield broad
markets, such as tire class of statins titan prevent heart disease. At the same
time, new vaccines are expensive, ant! mucks of the burden for their pur-
cI~ase falls on governments at the federal and state level. Financing Vaccines
ill the 21st Century: Assuring Access ancIAvailability (2003) calls for fundamen-
tal changes to the system user! by the government to buy ant! distribute
vaccines. Tire principle recommendation is treat current government pro-
`~rams for purchasing vaccines be replacer! with a new government-funded
insurance n~andate and voucher plan for vaccines that are approved by tire
Advisory Committee on Immunization Practices (ACIP), which is the body
Fiat recommends vaccines. The mandate wouIc! require all public and pri-
vate health plans to include vaccine benefits, coupled with vouchers for
uninsured children acid aclults. The r ole of tire federal government would
be to reimburse plans ant! healths care providers for the costs of timid vac-
cine purchases. The report also recommences changes in tire composition
of tire ACIP and in tire procedures it uses for making decisions about vac-
cines, in orde' to better clefine its mission.
PCOM!j~G RE PORTS
Improving Quality of Care. To Err Is Human: Building a Safer Health Systen?,
ala IOM study issued in 2000, established that protecting patients from
accidental injury cluring meclical treatment is a critical first step in improv-
ing quality of care. Among its recommendations, tire report called for
developing i~nprovec] systems for reporting patient safety cIata. At the
request of tire Department of Healths and Suntan Services, tire IOM is con-
clucting a stucly to develop a cletailec! plan to facilitate the generation of
standards for the collection, coding, and classification of data Ol1 patient
safety. It is expected that the standards will ~naxi~nize the usefulness of
information derived fiom tile data collected, and in particular will enable
comparisons to be made across reporting systems and over tine.
~ ~ .
Another study is under way to identify I
lAl~;~A'lI`~(r WE Farm ~~ CKI11~AL [~,~? IN HE-,4~7YI!
reduce costs and streamline tire delivery of healths care have lect to signifi-
cant changes in tile workplace. In other industries, such significant
changes often leave been accompanied by increased safety problems, but
few studies leave addressed taxis issue in health care settings. Topics to be
covered in the study inclucle the nature of the work performer! by nurses
ant! nursing assistants, including sucks factors as workload ant! woricing
hours; the effects of pressures to work quickly with numerous interrup-
tions; tire effects of having to work witty poorly designee! processes or
processes that are not stanclarclized; and tire impact of social, physical, and
other barriers to effective communications among else care team. Tl~e
study report will propose changes in nurses' working conditions Fiat
potentially can enhance patient safety.
U.S. consumers are increasingly using complementary and alternative
medicines (CAMs), rattler titan relying solely on conventional therapies.
With taxis increased use comes the need for scientific investigation to
determine flow wiclely CAMs are being user! and whether tizzy are effective
ant! safe. Tire IOM is contracting sucks a stucly. The objectives are to deter-
n~ine which CAM s are ilk widespread use ant! what populations are using
them; to critically assess tile risI
OCR for page 99
i~f~Ai77-i CARI`- MY 517~Ti\] AiVD PLYkI.-~3Rf\1A,\~E ~A['ASIl-~.S
A variety of new technologies inclucling crevices software programs
and drugs loops promise for detecting breast cancer at an early stage widen
it is most treatable. But tire pathway for taking a promising technology to
tire clinic where it can be user] to Imp patients is fraught witty hurdles.
The IOM is conducting a stucly to determine Silica of the existing and
evolving approaches Voice tile greatest }promise for improving tire early
detection and diagnosis of breast cancel; ant} to identify technological
financial and regulatory obstacles that are limiting timid fume- clevelop-
ment. Strategies will be iclentified to accelerate the flow of targeted flew
approaches into clinical practice.
Financing anc! Delivery of HIV Care. The Ryan White Comprehensive AIDS
Resources Emergency (CARE) Act provides meclical treatment ant] support
services for uninsured or t~r~derinst~rec! people living witty HIV clisease.
Widen the act was reauthorized in 2000 Congress directed the ION to
stucly various aspects of its operation, particularly in the areas of data gatl~-
ering and evaluations. Among issues lading acIciressed, tire study will deter-
mine whether tire HIV surveillance system of each state reports HIV cases
in a manner that provides adequate information on else number of such
cases and their demographic characteristics. Also being examiner! is the
availability acid utility of health outcomes measures foil HIV primary care
and support t services, and tire extent to which that information can be used
to measure the quality of funded services. Taxis information, along witty
otiose study findings, will be useful in planning programs and allocating
resources at local and national levels.
In reauthorizing the Ryan White Care Act, Congress also directec! the
IOM to study more broadly tire public financing and delivery of HIV servic-
es. As tire HIV/AIDS epidemic has growls, titers has been a substantial
increase ilk tire number and size of }public programs that provide care for
people living with HlY, but the current system of public funcling still results
in inequities in access to care. Tire study will acIcIress such issues as tire
financing, and stealth clelivery challenges posed to HIV I~ealti, centers at tire
local, state, and national levels; ~netI~ocIs for reclucing tile barriers tIlat peo-
ple sometimes face in obtaining quality HIV heath services; ant! tire role of
tire private insurance it ustry is assuring appropriate access to HIV care
ant! treatment tI~ougI~out the entire course of HIV disease. The study
report will propose a policy fia~nework acid ~ecommenciatio~s that will
improve the continuity, equity, ant! efficiency of the systems that provide
HlV care.
~c,,'
Selected Recommendations for Human Security
and Bioterro~rism
The Role of Technology in Countering Terrorism: Ensure production and distribu-
tion of known treatments and preventatives for pathogens. Develops effective treat-
ments and preventive measures for known pathogens for which current responses
are unavailable arid for Potential emerging pathogens. Deploy known technologies
and standards for allowing emergency responders to reliably communicate Witi1
each others Develop new and better technologies le.g., protective gear, sensors,
and communications) for emergency responders. Ensure that trusted spokespersons
will be able to inform the public promptly and witty technical authority whenever
the technical aspects of an emergency are dominant in the pt~b~ic's concerns.
(Making the Nation Safer: The Role of Science anc! Technology in Countering
Terrorism, 2002)
Focus on Vaccines: iOM recommends that better ways to administer vaccines
should be developecI. Also, the Department of Defense should strengthen systems
for detecting health problems that might occur months or years after the receipt of
any vaccine, including the anthrax vaccine Future monitoring of adverse health
effects should continue to include separate analyses of data for men and women.
And finally, the Department of Defense should speed up its research to develop an
improved vaccine. (The Anthrax Vaccine: Is It Safe? Does It Work?, 2002)
Reducing the Psychological Consequences of Terrorism: The Department of
Health and Human Services should develop evicience-based techniques, training,
awl education in psychological first aid to address all hazards and all members of
society before, during, and after a terrorism event in order to limit the psychologi-
ca~ consequences of terrorism. DHHS Loud also develop public Stealth surveillance
for pre- and post-event factors relevant to addressing tire psychological conse-
quences of terrorism and develop n~et~ods of applying the findings through appro-
priate interventions for groups of special interest. Academic health centers, profes-
siona~ associations and societies for mental Stealth professionals, and state boards of
education should ensure the education and training of Yenta health care providers,
including community- and school-based mental Stealth care providers to respond to
the psychological aftermath of terrorism, and should ensure the education and train-
ing of relevant health professionals. DRIPS and the Department of l~omelanA
Security should analyze federal, state, and local preparedness for terrorism to ensure
that the nation's public ~ health infrastructure is prepared to adequately respond to
psychological consequences.~(Preparing for the Psychological Consequences of
:Terrorism: A Publics Healths Strategy, 2003)
