BUILDING A BETTER DELIVERY SYSTEM

A New Engineering/Health Care Partnership

Proctor P. Reid, W. Dale Compton, Jerome H. Grossman, and Gary Fanjiang, Editors


NATIONAL ACADEMY OF ENGINEERING AND INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Building a Better Delivery System: A New Engineering/Health Care Partnership BUILDING A BETTER DELIVERY SYSTEM A New Engineering/Health Care Partnership Proctor P. Reid, W. Dale Compton, Jerome H. Grossman, and Gary Fanjiang, Editors NATIONAL ACADEMY OF ENGINEERING AND INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Building a Better Delivery System: A New Engineering/Health Care Partnership THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Science, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this project was provided by the National Science Foundation (Award No. DMI-0222041), the Robert Wood Johnson Foundation (Grant No. 044640), and the National Institutes of Health (Contract No. N01-OD-4-2139, Task Order No. 111). Any opinions, findings, and conclusions or recommendations expressed in this report are those of the National Academy of Engineering/Institute of Medicine Committee on Engineering and the Health Care System and do not necessarily reflect the views of the funding organizations, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. government. International Standard Book Number 0-309-09643-X Copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (888) 624-8373 or (202) 334-3313 (in the Washington metropolitan area); online at http://www.nap.edu. Copyright 2005 by the National Academies. All rights reserved. Printed in the United States of America

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Building a Better Delivery System: A New Engineering/Health Care Partnership THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Building a Better Delivery System: A New Engineering/Health Care Partnership COMMITTEE ON ENGINEERING AND THE HEALTH CARE SYSTEM W. DALE COMPTON (NAE), co-chair, Purdue University, West Lafayette, Indiana JEROME H. GROSSMAN (IOM), co-chair, John F. Kennedy School of Government, Harvard University, Cambridge, Massachusetts REBECCA M. BERGMAN, Medtronic Inc., Minneapolis, Minnesota JOHN R. BIRGE, University of Chicago, Chicago, Illinois DENIS CORTESE, Mayo Clinic, Rochester, Minnesota ROBERT S. DITTUS, Vanderbilt University and Veterans Administration Tennessee Valley Healthcare System, Nashville, Tennessee G. SCOTT GAZELLE, MGH Institute for Technology Assessment, Boston, Massachusetts CAROL HARADEN, Institute for Healthcare Improvement, Cambridge, Massachusetts RICHARD MIGLIORI, United Resource Networks, Golden Valley, Minnesota WOODROW MYERS (IOM), WellPoint, Thousand Oaks, California WILLIAM P. PIERSKALLA, Anderson Graduate School of Management, University of California, Los Angeles STEPHEN M. SHORTELL (IOM), School of Public Health and Haas School of Business, University of California, Berkeley KENSALL D. WISE (NAE), University of Michigan, Ann Arbor DAVID D. WOODS, Ohio State University, Columbus Project Staff PROCTOR P. REID, Study Director and Director, Program Office, National Academy of Engineering JANET M. CORRIGAN, Senior Board Director for Health Services, Institute of Medicine CAROL R. ARENBERG, Editor, National Academy of Engineering PHILIP ASPDEN, Senior Program Officer, Board on Health Services, Institute of Medicine GARY FANJIANG, Fellow, National Academy of Engineering PENELOPE J. GIBBS, Program Associate, Program Office, National Academy of Engineering JAMES PHIMISTER, J. Herbert Hollomon Fellow, National Academy of Engineering AMANDA SARATA, Intern, National Academy of Engineering

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Building a Better Delivery System: A New Engineering/Health Care Partnership Preface In 2000 and 2001, the Institute of Medicine (IOM) issued two reports, To Err Is Human and Crossing the Quality Chasm, documenting a glaring divergence between the rush of progress in medical science and the deterioration of health care delivery. The first report included an estimate that systems failures in health care delivery (i.e., poorly designed or “broken” care processes) were responsible for at least 98,000 deaths each year. The second report revealed a wide “chasm” between the quality of care the health system should be capable of delivering today, given the astounding advances in medical science and technology in the past half-century, and the quality of care most Americans receive. Documenting deep crises related to the safety, efficacy, efficiency, and patient-centeredness of health care in America, Crossing the Quality Chasm set forth a vision for a transformed health care system and challenged system stakeholders to take bold actions to bring about that transformation. In response to this challenge, the National Academy of Engineering (NAE) and IOM, with support from the National Science Foundation, Robert Wood Johnson Foundation, National Institutes of Health, and the NAE Fund, initiated a project in 2002 to (1) identify engineering applications that could contribute significantly to improvements in health care delivery in the short, medium, and long terms; (2) assess factors that would facilitate or impede the deployment of these applications; and (3) identify areas of research in engineering and other fields that could contribute to rapid improvements in performance. This report, Building a Better Delivery System, is the culmination of the joint NAE/IOM study. The report builds on a growing realization within the health care community of the critical role information/ communications technologies, systems engineering tools, and related organizational innovations must play in addressing the interrelated quality and productivity crises facing the health care system. The report provides a framework for change and an action plan for a systems approach to health care delivery based on a partnership between engineers, health care professionals, and health care managers. The goal of the plan is to transform the U.S. health care sector from an underperforming conglomerate of independent entities (individual practitioners, small group practices, clinics, hospitals, pharmacies, community health centers, etc.) into a high-performance “system” in which participating units recognize their interdependence and the implications and repercussions of their actions on the system as a whole. The report describes opportunities and challenges to using systems engineering, information technologies, and other tools to advance a twenty-first century system capable of delivering safe, effective, timely, patient-centered, efficient, equitable health care—a system that embodies the six “quality aims” envisioned in Crossing the Quality Chasm. The committee co-chairs are grateful to the members of the committee, not only for their knowledge, expertise, and commitment to change, but also for their participation in wide-ranging discussions on various aspects of this complex topic. Their collegiality and openness to ideas from many directions enabled the committee as a whole to overcome some of the very communications and cultural barriers described in the report and reach consensus on key recommendations. We also thank the outside experts who contributed their time and efforts to the success of this project, and the NAE and IOM staff for their research, editorial, and administrative support. W. Dale Compton, co-chair Committee on Engineering and the Health Care System Jerome H. Grossman, co-chair Committee on Engineering and the Health Care System

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Building a Better Delivery System: A New Engineering/Health Care Partnership Acknowledgment of Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise in accordance with procedures approved by the National Research Council Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for reviewing this report: David E. Daniel, University of Texas Paul Griner, Emeritus, University of Rochester School of Medicine and Dentistry John D. Halamka, CareGroup Health System Angela Barron McBride, Indiana University School of Nursing James C. McGroddy, IBM Corporation (ret.) John M. Mulvey, Princeton University Robert M. Nerem, Georgia Institute of Technology Don M. Nielsen, American Hospital Association Vinod K. Sahney, Henry Ford Health System Edward J. Sondik, National Center for Health Statistics Paul C. Tang, Palo Alto Medical Foundation Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Don E. Detmer, American Medical Informatics Association, and Charles E. Phelps, University of Rochester, appointed by the National Research Council Report Review Committee, who was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Building a Better Delivery System: A New Engineering/Health Care Partnership Contents EXECUTIVE SUMMARY   1 PART I:   CONSENSUS REPORT     1   A NEW PARTNERSHIP BETWEEN SYSTEMS ENGINEERING AND HEALTH CARE   11      The Paradox of American Health Care,   11      Interconnected Crises in U.S. Health Care,   11      Proximate Causes of Health Care Crises,   12      The Role of Engineering in the Transformation of Health Care,   14      The Engineering/Health Care Partnership,   15      Structure of the Report,   16      References,   16 2   A FRAMEWORK FOR A SYSTEMS APPROACH TO HEALTH CARE DELIVERY   19      A Four-Level Model of the Health Care System,   19      A Systems View of Health Care,   22      The Role of Information and Communications Technology,   24      References,   24 3   THE TOOLS OF SYSTEMS ENGINEERING   27      The Need for Good Data,   28      Systems-Design Tools,   28      Systems-Analysis Tools,   35      Systems-Control Tools,   45      Applying Systems Tools to Health Care Delivery,   52      Barriers to Implementation,   55      Findings,   56      Recommendations,   57      Conclusion,   57      References,   58

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Building a Better Delivery System: A New Engineering/Health Care Partnership 4   INFORMATION AND COMMUNICATIONS SYSTEMS: THE BACKBONE OF THE HEALTH CARE DELIVERY SYSTEM   63      The Centrality of Information to Health Care Delivery,   63      From Electronic Medical Records to a National Health Information Infrastructure,   64      Foundations of a National Health Information Infrastructure,   67      Communications Technologies,   72      Microelectronic Systems and Emerging Modes of Communication,   75      Conclusion,   78      References,   79 5   A STRATEGY TO ACCELERATE CHANGE   83      Educational Barriers to Change,   83      A Platform for Interdisciplinary Research, Education, and Outreach,   84      Call to Action,   89      References,   89 PART II:   WORKSHOP PRESENTATIONS         FRAMING THE HEALTH CARE CHALLENGE         Crossing the Quality Chasm, Janet Corrigan   95     Bridging the Quality Chasm, David Lawrence   99     Envisioning the Future, Jeff Goldsmith   103     Improving Health and Health Care, Lewis G. Sandy   105     Engineering and the Health Care System, Richard J. Coffey   107     Engineering and the Health Care Organization, Vinod K. Sahney   113     EQUIPPING THE PATIENT AND THE CARE TEAM         Evidence-Based Medicine, Brian Haynes   117     The Context of Care and the Patient Care Team: The Safety Attitudes Questionnaire, J. Bryan Sexton, Eric J. Thomas, and Peter Pronovost   119     Engineering the Patient and Family into the Patient Care Team, David Gustafson   125     Connecting Patients, Providers, and Payers, John D. Halamka   129     New Paradigms for Working and Learning, Richard Bohmer   133     Designing Caregiver- and Patient-Centered Health Care Systems, H. Kent Bowen   135     ENGINEERING TOOLS AND PROCEDURES FOR MEETING THE CHALLENGES         Systems Engineering: Opportunities for Health Care, Jennifer K. Ryan   141     Supply-Chain Management and Health Care Delivery: Pursuing a System-Level Understanding, Reha Uzsoy   143     The Human Factor in Health Care Systems Design, Kim J. Vicente   147

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Building a Better Delivery System: A New Engineering/Health Care Partnership     Changing Health Care Delivery Enterprises, Seth Bonder   149     Transforming Current Hospital Design: Engineering Concepts Applied to the Patient Care Team and Hospital Design, Ann Hendrich   153     Discrete-Event Simulation Modeling of the Content, Processes, and Structures of Health Care, Robert S. Dittus   157     Measuring and Reporting on Health Care Quality, Dana Gelb Safran   163     Archimedes: An Analytical Tool for Improving the Quality and Efficiency of Health Care, David M. Eddy and Leonard Schlessinger   167     Applying Financial Engineering to the Health Services Industry, John M. Mulvey   173     Engineering Tools and Methods in the Delivery of Cancer Care Services, Molla S. Donaldson   177     Patient Trajectory Risk Management, Charles Denham   183     Deploying Resources for an Idealized Office Practice: Access, Interactions, Reliability, and Vitality, Thomas W. Nolan   187     INFORMATION TECHNOLOGY FOR CLINICAL APPLICATIONS AND MICROSYSTEMS         Engineering and the System Environment, Paul C. Tang   191     Challenges in Informatics, William W. Stead   193     A National Standard for Medication Use, David Classen   195     Obstacles to the Implementation and Acceptance of Electronic Medical Record Systems, Paul D. Clayton   199     Automation of the Clinical Practice: Cost-Effective and Efficient Health Care, Prince K. Zachariah   205     The eICU® Solution: A Technology-Enabled Care Paradigm for ICU Performance, Michael J. Breslow   209     Wireless Biomonitoring for Health Care, Thomas F. Budinger   215     Rehabilitation Redefined, Mindy L. Aisen   221     Evaluating the Potential of New Technologies, Carolyn M. Clancy   223     BARRIERS AND INCENTIVES TO CHANGE         Political Barriers to Change, Nancy-Ann DeParle   227     Lessons from Financial Services, Ralph Kimball   231     Can Purchasers Leverage Engineering Principles to Improve Health Care?, Arnold Milstein   233     Shibboleths in Modeling Public Policy, Richard P. O’Neill   235     Matching and Allocation in Medicine and Health Care, Alvin E. Roth   237

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Building a Better Delivery System: A New Engineering/Health Care Partnership APPENDIXES     A   Agenda for First Workshop   243 B   Participants in First Workshop   245 C   Agenda for Second Workshop   249 D   Participants in Second Workshop   251 E   Agenda for Third Workshop   253 F   Participants in Third Workshop   255 G   Biographical Information   259