2
Foundation Stones in the Common Ground

The first goal of the workshop was to consider elements of the stakeholder capacity to foster progress toward a learning healthcare system. Discussing these elements was key to progress, because health care in the United States is composed of diverse, sometimes competing, interests that imperfectly relate to each other under the assumption that they will collaborate around common interests to achieve common goals. Indeed, any system’s long-term viability is predicated on the ability of its disparate stakeholders to find ways to work together productively. Stakeholder cooperation was a driving force behind the workshop, Leadership Commitments to Improve Value in Health Care, and an imperative for the development of a learning healthcare system.

As an initial step toward broader understanding of stakeholder capacities, individuals identified from each Roundtable sector—patients, healthcare professionals, healthcare delivery organizations, clinical investigators, healthcare product developers, regulators, insurers, employers and employees, and information technology experts—were asked to develop an authored background paper that outlined the nature of each sector’s activities relevant to evidence generation and application, as well as the primary opportunities for individual and collective work to drive progress toward the Roundtable’s goal of ensuring that by 2020, 90 percent of clinical decisions are supported by accurate, timely, and up-to-date clinical information.

These papers were made available in advance of the workshop, and key elements were presented at the workshop as a way to share the rich perspectives of each sector, as well as to develop a sense of the intersecting



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2 Foundation Stones in the Common Ground The first goal of the workshop was to consider elements of the stake- holder capacity to foster progress toward a learning healthcare system. Discussing these elements was key to progress, because health care in the United States is composed of diverse, sometimes competing, interests that imperfectly relate to each other under the assumption that they will col- laborate around common interests to achieve common goals. Indeed, any system’s long-term viability is predicated on the ability of its disparate stakeholders to find ways to work together productively. Stakeholder coop- eration was a driving force behind the workshop, Leadership Commitments to Improve Value in Health Care, and an imperative for the development of a learning healthcare system. As an initial step toward broader understanding of stakeholder capacities, individuals identified from each Roundtable sector—patients, healthcare professionals, healthcare delivery organizations, clinical investi- gators, healthcare product developers, regulators, insurers, employers and employees, and information technology experts—were asked to develop an authored background paper that outlined the nature of each sector’s activities relevant to evidence generation and application, as well as the primary opportunities for individual and collective work to drive progress toward the Roundtable’s goal of ensuring that by 2020, 90 percent of clinical decisions are supported by accurate, timely, and up-to-date clinical information. These papers were made available in advance of the workshop, and key elements were presented at the workshop as a way to share the rich perspectives of each sector, as well as to develop a sense of the intersecting 9

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0 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE interests and potential alignments among the sectors. Indeed, stakeholders present at the workshop came to the discussion committed to explor- ing opportunities to work together, and the resulting exchange of ideas was both frank and constructive. In the 2 days of dialogue, participants acknowledged areas of contention as well as those around which they had substantive agreement. Throughout the workshop, participants noted the unique nature of these discussions, and their importance was underscored by the emergence of opportunities for sectors to work together not only in areas in which they have a common purpose but also in those in which uncertainty exists or more discussion was needed to broker a greater level of agreement among them. True to the spirit of the meeting, the greater part of the discussion focused on finding areas in which participants might work to effect the improvements necessary to accelerate progress. This chapter summarizes portions of the workshop discussions focused on elements essential for concrete and sustained system change. Over the course of the discussions, participants emphasized certain elements: trust, commitment to evidence- driven care, embedding learning into the culture of health care, development of a common focal point and a trusted source of evidence, and stakeholder leadership. A consistent understanding and commitment to these “founda- tion stones” among the various sectors of the healthcare system would constitute an important starting point for progress. BUILDING TRUST: TRANSPARENCY AND VALUE As noted throughout the workshop and this publication, participants felt there are ample opportunities for increased collaboration, ranging from the development of national research priorities to streamlining policies and procedures that affect the whole healthcare system (e.g., financial incentives and reimbursement). Discussions also revealed the tensions and even mis- trust that pervade the healthcare system—between patients and providers, providers and insurers, insurers and manufacturers, manufacturers and regulators, and so forth—and have historically impeded progress. In these instances, trust—or a belief in the reliability, truth, or ability of other stakeholders—has been compromised by doubts about motivations or per- ceived conflicts of interest. This context poses a significant barrier to the emerging vision for health care as a system that is guided by evidence, is broadly interactive, and is continuously evolving and improving. Oppor- tunities to work together constructively are possible only if a higher level of trust among stakeholders is established, and without evidence, trust is at risk. The presumption of this workshop, and of the Roundtable, is that increased opportunities for cross-sector conversations will help break down misperceptions and encourage a new degree of honesty and candor within

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 FOUNDATION STONES IN THE COMMON GROUND and among sectors. Priorities in this respect include increasing system trans- parency and defining a shared value proposition for health care. Transparency As a prerequisite for progress, participants emphasized the need to embrace an ethos whereby processes, decisions, policies, and practices are established and carried out more in public than in private, with greater openness and accountability. Achieving the vision of the Roundtable will require stakeholders to make concessions. The risks and benefits of possible approaches must be articulated clearly so that each sector can weigh the merits and the relative trade-offs. A starting point suggested for the creation of greater transparency was the establishment of principles for the interpretation and use of clinical evidence. Individuals in a number of different sectors make these judgments to provide actionable information to decision makers at all levels: patients, physicians, providers, employers, and policy makers. However, despite the broad impact of coverage decisions or guideline development, there is often little transparency in how information is gathered, synthesized, or weighted in making decisions; as a result, there is little accountability. Participants felt that the increased transparency of these processes not only would pro- vide a needed context for decision makers but also would help clarify what types of information are most helpful for decision making, essentially, what constitutes consistent, accurate, usable, and meaningful evidence. Transparency is particularly needed in areas in which stakeholder responsibilities and obligations overlap. In addition to the interpretation and use of evidence, these areas include regulatory decision making, market- ing practices, and data collection and governance. Also important are instances in which financial transactions occur, including general funding structures and payment practices. Establishing, clarifying, and publicizing principles, or rules of the road, will be vitally important, and collaboration among stakeholders is needed to determine the principles and areas of focus that will bring greater openness to health care. Value Increased transparency ensures a shared understanding of important processes, and perhaps no element has greater need for shared perspective than the notion of value in health care. Although commenters pointed to the centrality and importance of realizing value from health care, differ- ent stakeholders evaluated this value in different ways. Depending on the perspective and circumstances, value might mean reduced death or dis- ease, better function, less pain, a better sense of well-being, fewer hospital

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2 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE days, or lower costs. As a result, the healthcare system is often structured to deliver value as defined by different sectors, and these definitions are potentially at cross-purposes. It will be increasingly important to design a common approach to the delivery of value-driven healthcare services. To provide a better sense of common purpose and goals, workshop partici- pants suggested that a multistakeholder effort is needed to drive clarity and consensus on common principles and elements of value in health care. SHARED COMMITMENT TO EVIDENCE-DRIVEN CARE The sectoral background papers cataloged a growing number of efforts within each sector to improve the development and application of evidence and identified a large set of overlapping priorities among stakeholders, providing an important and encouraging basis for discussion. There was an overarching interest in embedding evidence throughout the healthcare system, and participants discussed the importance of a shared commitment among all stakeholders to evidence-driven care to facilitate the identifica- tion and use of untapped resources in various sectors that could promote dramatic systemwide improvements. For example, as one of its fundamental functions—and belying the many gaps in evidence available to support current care—the U.S. health- care system captures important knowledge that could be used to provide insights into healthcare practices. Healthcare clinics, laboratories, offices, and organizations across the country collect important information on a daily basis. Both a commitment to sharing information developed during the routine delivery of health care to improve the understanding of what works and for whom and a commitment to developing new capabilities to generate evidence that cannot be acquired from routinely collected data are needed. Similar examples were cited for application and dissemination of the evidence, reinforcing the notion that each sector has much to contribute to the transformation of health care. The collective expertise, resources, and experiences in health care are needed to broaden access to clinical decision support systems and electronic health records, bring clinical research closer to clinical practice, improve the quality and accessibility of healthcare data, and create decision support systems that produce actionable information with the end user in mind. Likewise, each sector can help structure the healthcare environment to offer incentives for and reward activities that support a system that consistently applies evidence and captures the results for improvement. In each of these areas, participants believed that the col- lective commitment of all sectors to evidence-driven health care holds the potential to create transformative innovation and progress.

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 FOUNDATION STONES IN THE COMMON GROUND BUILDING LEARNING INTO THE CULTURE OF HEALTH CARE Throughout the workshop, it was emphasized that to manage com- plexity, organizations must emphasize a culture of teamwork, adaptability, synchrony, and tracking and measurement oriented toward continual learning and improvement. Health care has become increasingly complex, resulting in hyperspecialization, the fragmentation of knowledge and care, unnecessary variations in practice patterns, and the slow diffusion of best practices. Despite the increasing sophistication of decision support tech- nology and its ability to provide knowledge when needed and despite the availability of tools that help orchestrate team-based approaches to health care, little priority has been placed on integrating these technologies and tools into the process of providing health care. Enhancing the focus of health professions training on the dynamic nature of evidence, how to track and apply it, and how to contribute to its development will require both a different approach by schools of health professionals and a shift to a culture that values and emphasizes the importance of ongoing training or lifelong learning. Concomitant with educational efforts should be the acceleration of advances in health information technology and the incorporation of those advances into the healthcare setting. Technology can be an important tool that supports a culture of learning—for example, creating learning networks to improve the way in which evidence is shared. Other oppor- tunities for the use of technology include enabling data aggregation and utilization, delivering evidence to the point of care, and expanding research capacities. In these efforts, a focus on frontline providers is necessary to ensure that healthcare professionals take full and appropriate advantage of the best available evidence when they provide care. Accelerating the translation of clinical research into practice will require the organizations that represent providers to address matters of professional education, credentialing, and licensure. However, other sectors that develop evidence and support its use will also have to make the needs of healthcare professionals more central to their work. For example, clinicians may require tools that help them understand how to best access and use evidence in their decision-making processes or why they should spend their time on what might appear to be mostly an operational or administrative function. For physicians and patients to truly engage in a learning healthcare system, they need to under- stand how they might benefit from it. Accordingly, patients need to become more involved in their own care, including their involvement in both the development and the use of evidence.

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 LEADERSHIP COMMITMENTS TO IMPROVE VALUE IN HEALTH CARE COMMON FOCAL POINT AND TRUSTED SOURCE The fragmented nature of evidence development compromises its accuracy and efficiency and can result in guidance that is conflicting, of limited relevance, or out of date. Too much information of varying quality is now available. Some workshop participants believed that coordinated efforts in evidence development might be much more productive and that some process or repository might be needed to coordinate data collection and access to those data. In particular, most participants and working groups who addressed this issue supported the establishment of a national entity—a trusted, independent source that engages all stakeholders—that could serve to identify gaps; set priorities; establish standards; and other- wise guide the development, interpretation, and dissemination of evi- dence on clinical effectiveness. To most stakeholders, the lack of clinical effectiveness information represents a “missing link” in the healthcare system, and various ways to create the needed capacity were proposed. The funding, organization, and governance suggested by participants for the proposed coordinating capacity varied, and several basic functions were proposed for the entity: agenda-setting for the generation of evi- dence; coordination of the development and interpretation of comparative effectiveness research; and dissemination of knowledge to all stakeholders and beyond, including the public. This entity could foster cross-sector collaboration in the development and distribution of evidence and could help both standardize and synthesize evidence-based knowledge at the national level. Other participants suggested that the entity could serve as a clearinghouse to ensure the ongoing and widespread sharing of evidence generated in the field. It could spark and support collaboration among stakeholders. Importantly, it could also serve to communicate advances in the development of evidence. STAKEHOLDER LEADERSHIP FOR CHANGE It was generally acknowledged that the ultimate driver of widespread support for evidence-driven care will be strong leadership within and among the various healthcare sectors that can articulate the tangible impact of broad improvements in healthcare decisions on patients, providers, and society. Although the representatives of various sectors recognized the potential of evidence-based practice to drive dramatic improvements in patient health and to guide the necessary transformation of the nation’s healthcare system, they indicated a strong need to make a better case. Some individuals still see evidence-based medicine either as “cookbook medicine” that restricts the use of provider judgment or as a way to ration or limit patient access to care. In creating a case to strengthen intrasectoral support

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 FOUNDATION STONES IN THE COMMON GROUND for change, efforts can also be made to improve the demand for evidence more broadly, particularly by purchasers, consumers, hospital and other industry boards, and regulators. It was felt that the public deserves to know how improvements in the generation and application of evidence-based medicine might translate to their own care. Ways to better illustrate the impact of evidence-driven care are important to improved communications. Participants asked for collaboration in documenting the consequences of care based on too little evidence and the potential benefits of having the right evidence in hand for real-world decision making. Participants pro- vided a collection of compelling examples viewed as means of improving the understanding of and demand for evidence-based care and stakeholder activation. They also suggested that efforts are needed to more effectively convey the central concepts that medical evidence is dynamic, that evidence- based medicine is knowing what the evidence suggests is best for any given patient at any given time, and that health care is a joint patient-provider partnership.

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