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Summary
The fundamental notion of the learning healthcare system—continuous
improvement in effectiveness, efficiency, safety, and quality—is rooted in
principles that medicine shares with engineering. In particular, the fields
of systems engineering, industrial engineering, and operations research
have long experience in the systematic design, analysis, and improvement
of complex systems, notably in such large sectors as the airline and auto-
mobile industries. Working cooperatively with the National Academy of
Engineering (NAE), the Institute of Medicine (IOM) organized Engineering
a Learning Healthcare System: A Look at the Future to bring together lead-
ers from the fields of health care and engineering to identify particularly
promising areas for application of engineering principles to the design of
more effective and efficient health care—a learning healthcare system. This
report presents the summary of the meeting’s discussions.
Currently, the organization, management, and delivery of health care
in the United States falls short of delivering quality health care reliably,
consistently, and affordably. As health care continues to increase in scope
and complexity, so will the challenges to efficiency. In part, the capacity to
address these challenges will depend on the ability to develop information
about the relative effectiveness of interventions in a fashion that is more
timely and practical than is typically the case for individually designed
prospective studies, such as randomized clinical trials. It will also depend
on the ability to design delivery systems in which the dynamics at the com-
ponent interfaces are much more efficient. In both cases, the adaptation of
engineering principles to facilitate continuous learning will be key.
1
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2 ENGINEERING A LEARNING HEALTHCARE SYSTEM
The goal of a learning healthcare system is to deliver the best care
every time, and to learn and improve with each care experience. This goal
is attainable only through system-wide changes of the sort that have been
successfully undertaken in certain activities of the manufacturing sectors.
In these cases significant benefits have been realized through organization-
wide transformations guided by principles of systems and process engineer-
ing and the practices of structured data feedback for process improvement.
Data collection and monitoring are increasingly important components of
health care, but much remains to be done in their application for continu-
ous improvement. Engineering sciences associated with system design could
contribute to a learning healthcare system that applies the best-known
evidence, encourages continuous learning, and allows for knowledge gen-
eration as a natural by-product of patient care delivery. A fully functional
system of this sort would advance quality; improve patient and provider
safety, in turn delivering increasing value to consumers; and ensure that the
care that is delivered is centered on the best outcome for each patient.
With these issues in focus, Engineering a Learning Healthcare System:
A Look at the Future was organized by the National Academies to take
stock of lessons from engineering that might be applicable to health, to
investigate examples of efforts completed or under way in that respect, and
to examine prospects for increasing the level of interdisciplinary, coopera-
tive activity. The workshop was one of a series of workshops sponsored by
the IOM Roundtable on Value & Science-Driven Health Care (then, the
Roundtable on Evidence-Based Medicine) and focused on the development
of a learning healthcare system. Because the workshop aimed to identify
learning opportunities from health care, and teaching opportunities from
engineering, it was structured both to review already well-established ex-
amples of activities in which engineering principles—in particular, systems
engineering—have been adapted for use in healthcare settings, as well as to
encourage discussion of additional opportunities and approaches to foster-
ing ongoing progress in communication between the two fields.
An overview of the premises of the workshop identified by the work-
shop planning committee is found in Box S-1. Throughout the meeting’s
discussions, frequent mention was made of the cross-relevance of the con-
cepts, and participants observed that even some of the terminology and
reference points were similar—e.g., the discussions of Harold W. Sorenson
and William W. Stead who addressed, respectively, how to engage health
as a complex system, and approaches to adjusting to a more complex clini-
cal decision environment. Case studies illustrated achievements in health
care that have drawn upon systems engineering, and breakout sessions
challenged workshop participants to identify opportunities and actions for
generating additional value in health care through application of engineer-
ing concepts. Neither the case studies nor the breakout sessions yielded
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SUMMARY
BOX S-1
Workshop Premises
• ealth care is substantially underperforming on most dimensions: effective-
H
ness, appropriateness, safety, cost, efficiency, and value.
• ncreasing complexity in health care is likely to accentuate current problems
I
unless reform efforts go beyond financing to foster significant changes in the
culture, practice, and delivery of health care.
• xtensive administrative and clinical data collected in healthcare settings are
E
largely unused for new insights on the effectiveness of healthcare interventions
and systems of care.
• f the effectiveness of health care is to keep pace with the opportunity of di-
I
agnostic and treatment innovation, system design and information technology
must be structured to ensure application of the best evidence, continuous
learning, and research insights generated as a natural by-product of the care
process.
• ngineering principles are at the core of a learning healthcare system—one
E
structured to keep the patient constantly in focus, while continuously improving
quality, safety, knowledge, and value in health care.
• mpressive transformations have occurred through systems and process en-
I
gineering in service and manufacturing sectors—e.g., banking, airline safety,
automobile manufacturing.
• espite the obvious differences that exist in the dynamics of mechanical vs.
D
biological and social systems, the current challenges in health care necessitate
an entirely fresh view of the organization, structure, and function of the delivery
and monitoring processes in health care.
• aking on the challenges in health care offers the engineering sciences an op-
T
portunity to test, learn, and refine approaches to understanding and improving
innovation in complex adaptive systems.
breakthrough insights, but that fact itself is testament to the need for more
systematic engagement of terms, education, and opportunities for jointly
targeted projects.
THE ROUNDTABLE AND THE LEARNING HEALTHCARE SYSTEM
Convened in 2006 under the auspices of the IOM, the Roundtable
on Value & Science-Driven Health Care provides a trusted setting for
healthcare stakeholders—patients, employers, manufacturers, payers, policy
makers, providers, and researchers—to discuss strategies to improve the ef-
fectiveness and efficiency of the nation’s healthcare system. The Roundtable
is therefore aimed at exploring ways in which health care may be improved
through the systematic and routine capture and analysis of clinical data for
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ENGINEERING A LEARNING HEALTHCARE SYSTEM
point-of-care learning, the seamless application of insights to improve the
effectiveness and efficiency of care processes, and the outcomes and value
optimized for each patient and the system as a whole. It has devoted sub-
stantial attention to prospects and strategies for substantially expanded use
of clinical data, with careful attention to security and privacy protection,
as a basic resource for the generation of new knowledge.
Roundtable participants established a goal that, by the year 2020,
90 percent of clinical decisions will be supported by accurate, timely, and
up-to-date clinical information, and will reflect the best aailable eidence
(IOM Roundtable on Evidence-Based Medicine, 2005). Members are com-
mitted to identifying, prioritizing, and addressing opportunities through
ongoing public–private initiatives, including convening the Learning Health
System series of workshops and resulting publications. To date, the work-
shop series has included
The Learning Healthcare System (July 2006)
•
J
udging the Evidence: Standards for Determining Clinical Effective-
•
ness (February 2007)
L
eadership Commitments to Improve Value in Healthcare: Finding
•
Common Ground (July 2007)
R
edesigning the Clinical Effectiveness Research Paradigm: Innova-
•
tion and Practice-Based Approaches (December 2007)
C
linical Data as the Basic Staple of Health Learning: Creating and
•
Protecting a Public Good (February 2008)
E
ngineering a Learning Healthcare System: A Look at the Future
•
(April 2008)
L
earning What Works: Infrastructure Required for Comparative
•
Effectiveness Research (July 2008)
V
alue in Health Care: Accounting for Cost, Quality, Safety, Out-
•
comes, and Innovation (November 2008)
T
he Healthcare Imperative: Lowering Costs and Improving Out-
•
comes (May, July, September, and December 2009)
• Patients Charting the Course: Citizen Engagement and the Learn-
ing Health System (April 2010)
• Digital Infrastructure for the Learning Health System: The Founda-
tion for Continuous Improvement in Health and Health Care (July,
September, and October 2010)
Engineering a Learning Healthcare System: A Look at the Future was
the sixth workshop in the Learning Health System series, and this chapter
briefly summarizes the presentations, discussions, and recurring themes.
The first day of the workshop provided insights into potential synergies
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SUMMARY
between engineering disciplines and healthcare challenges (Chapter 1) and
guided the audience through some of the processes by which engineering
deals with systems complexity (Chapter 2). The afternoon sessions on the
first day lent insight into the complexities of health care (Chapter 3) and
the mechanisms through which other industries have addressed complexity
(Chapter 4). The second day’s presentations identified opportunities for
systems improvement followed by a breakout session, and it concluded
with observations on systems change (Chapter 5 and Berwick, Chapter 1,
p. 53) and a discussion on opportunities to align policies with leadership
opportunities. Chapter 6 explores the next steps for aligning policies with
leadership opportunities and summarizes the common themes and issues for
the Roundtable’s attention. The workshop agenda, biographical sketches of
participants, and a list of attendees can be found in the appendixes.
COMMON THEMES
The presentations and discussions within the workshop highlighted
multiple opportunities for applying engineering principles in the establish-
ment of a learning healthcare system. The presentations and discussions
also provided insight into engineering approaches to systems complexity
and identified critical areas that need attention in health care. Throughout
the 2 days of the workshop, a set of common themes emerged as recurring
elements of the discussion (Box S-2).
T
he system’s processes must be centered on the right target—the
•
patient. Patient-centered care was defined in the 2001 IOM report
Crossing the Quality Chasm as providing care that is respectful of
and responsive to individual patient preferences, needs, and values
and ensuring that patient values guide all clinical decisions (IOM,
2001). However, health care is by nature highly complex, involving
multiple participants and parallel activities that sometimes take on
a character of their own, independent of patient needs or desires.
Throughout several sessions, workshop participants emphasized
the need to ensure that processes support patients—and that pa-
tients are not forced into processes. Patient needs and perspectives
must be at the center of all process design, technology application,
and clinician engagement.
S
ystem excellence is created by the reliable deliery of established
•
best practice. Identifying and embedding practices that work best,
and developing the system processes to ensure their delivery every
time, help to define excellence in system performance and to fo-
cus the system on delivering the best possible care for patients. In
health care, establishing practices from the best available evidence
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ENGINEERING A LEARNING HEALTHCARE SYSTEM
and building them as routines into practice patterns, as well as de-
veloping systems to document results and update best practices as
the evidence evolves, will integrate some of the best elements from
the engineering disciplines into healthcare issues. Participants often
cited the need for better integration of development and commu-
nication of best practices in healthcare systems, as well as the need
for process systems to track healthcare details and outcomes, with
feedback for practice refinement and better patient outcomes.
C
omplexity compels reasoned allowance for tailored adjustments.
•
Established routines may need circumstance-specific adjustments
related to differences in the appropriateness of established health-
care regimens for various individuals, variations in caregiver skill,
and the evolving nature of the science base—or all three. Mass
customization and other engineering practices can help assure a
consistency that can accelerate the recognition of the need for
tailoring and delivering the most appropriate care—with the best
prospects for improved outcomes—for the patient. Participants
pointed to the need for the development of a system of care flex-
ible enough to incorporate these considerations and to leverage the
lessons learned from their employment in a process of continuous
learning.
BOX S-2
Workshop Common Themes
• The system’s processes must be centered on the right target—the patient.
• System excellence is created by the reliable delivery of established best
practice.
• Complexity compels reasoned allowance for tailored adjustments.
• Learning is a non-linear process.
• Emphasize interdependence and tend to the process interfaces.
• Teamwork and cross-checks trump command and control.
• Performance, transparency, and feedback serve as the engine for
improvement.
• Expect errors in the performance of individuals but perfection in the perfor-
mance of systems.
• Align rewards on key elements of continuous improvement.
• Education and research can facilitate understanding and partnerships between
engineering and the health professions.
• Foster a leadership culture, language, and style that reinforce teamwork and
results.
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SUMMARY
earning is a non-linear process. The focus on an established hier-
L
•
archy of scientific evidence as a basis for evaluation and decision
making cannot fully accommodate the fact that much of the sound
learning in complex systems occurs in local and individual settings.
Participants cited the need to bridge the gap between dependence
on formal trials, such as randomized clinical trials, and the experi-
ence of local improvement in order to speed learning and avoid
impractical costs.
mphasize interdependence and tend to the process interfaces. A
E
•
system is most vulnerable at links between critical processes. In
health care, attention to the nature of relationships and hand-offs
between elements of the patient care and administrative processes
is therefore vital and a crucial component of focusing the process
on the patient experience and improving outcomes.
eamwork and cross-checks trump command and control. Espe-
T
•
cially in systems designed to guarantee safety, system performance
that is effective and efficient requires careful coordination and
teamwork as well as a culture that encourages parity among all
those with established responsibilities. During the workshop, sev-
eral examples were cited of other industries that have used systems
design and social engineering to better integrate and strengthen
their systems processes with great improvements in efficiency and
safety.
P
erformance, transparency, and feedback sere as the engine for
•
improement. Continuous learning and improvement in patient
care requires transparency in processes and outcomes as well as
the ability to capture feedback and make adjustments.
E
xpect errors in the performance of indiiduals, but perfection in
•
the performance of systems. Human error is inevitable in any sys-
tem and should be assumed. On the other hand, safeguards and de-
signed redundancies can deliver perfection in system performance.
Mapping processes and embedding prompts, cross-checks, and
information loops can assure best outcomes and allow human ca-
pacity to focus on what can not be programmed—compassion and
individual patient needs. Several workshop presentations shared
success stories and lessons learned from other industries, such as
the automotive and airline industries, that have effectively incor-
porated this strategy.
A
lign rewards on the key elements of continuous improement.
•
Incentives, standards, and measurement requirements can serve as
powerful change agents. Therefore, it is vital that they be carefully
considered and directed to the targets most important to improv-
ing the patient and provider experiences. Participants noted that it
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8 ENGINEERING A LEARNING HEALTHCARE SYSTEM
is vital that incentives be carefully considered and directed to the
targets most important to improving the efficiency, effectiveness,
and safety of the system—and ultimately patient outcomes—as well
as taking into consideration the patient and provider experiences.
E
ducation and research can facilitate understanding and partner-
•
ships between engineering and the health professions. The relevance
of systems engineering principles to health care and the impressive
transformation brought to other industries speaks to the merits
of developing common vocabularies, concepts, and ongoing joint
education and research activities that help generate stronger ques-
tions and solutions. Workshop participants pointed to the dearth of
training opportunities bridging these two professions and spoke of
the need to encourage greater collaborative work between them.
F
oster a leadership culture, language, and style that reinforce team-
•
work and results. Positive leadership cultures foster and celebrate
consensus goals, teamwork, multidisciplinary efforts, transparency,
and continuous monitoring and improvement. In citing examples
of successful learning systems, participants highlighted the need for
a supportive and integrated leadership.
PRESENTATION AND DISCUSSION SUMMARIES
The workshop opened with keynote addresses outlining the current
challenges faced in health care and suggesting pathways by which engi-
neering principles might improve the way care is delivered. Sessions that
followed examined how engineering disciplines engage system complexity,
explored some of the impediments and failures in health care that engineer-
ing might help ameliorate, and presented case studies of successful transfor-
mations via applied systems engineering. Further sessions looked in depth
at the value that could be derived from systemic change in the healthcare
system, at specific types of change that would create the greatest value, and
at the entities and actions that might best facilitate change.
Engineering a Learning Healthcare System
Opening the workshop and providing context for the meeting were
Brent C. James, executive director of the Institute for Health Care Delivery
Research at Intermountain Healthcare, and W. Dale Compton, the Lillian
Gilbreth Distinguished Professor (Emeritus) of Industrial Engineering at
Purdue University. In his keynote on the second day, Donald M. Berwick,
then president and chief executive officer (CEO) of the Institute for Health-
care Improvement, offered an overview of some of the key factors in ini-
tiating health system change. Together, the speakers addressed the central
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9
SUMMARY
systemic shortfalls and challenges in health care today, reflecting on the
changes needed and how systems engineering might help foster a healthcare
system that delivers care that we know works, and that learns from the
care delivered.
Learning Opportunities for Health Care
As the first keynote speaker, James suggested that the healthcare indus-
try is experiencing the results of a disconnect between the rapid expansion
of knowledge and the traditional cultural and organizational constructs of
modern medicine. This incongruity has created a system that has certain
strengths, such as excellent rescue care, but also has many weaknesses,
including inadequate primary and preventive care, spiraling costs, and inef-
ficient and ineffective care delivery.
James identified several current weaknesses in the care delivery sys-
tem as opportunities for improvement, including high levels of variation
in services and outcomes, with often inverse associations between service
intensity and outcomes; increasing rates of inappropriate care, where the
risk to the patient outweighs potential benefits; unacceptable rates of care
associated with adverse outcomes; inconsistent application of evidence; and
significant waste within the system, leading to increased prices and limited
access to care.
Although the healthcare industry continues to develop solutions at vari-
ous loci in the system, James stressed the importance of additional stron-
ger and more sustained gains that might be achieved through engineering
approaches to system redesign. Opportunities include efforts to improve
the protocols and predictability of care delivered, the implementation of
team-based processes, structured engagement of care complexity, and active
management of knowledge and learning. Perhaps most important over the
long term, James said, is designing health care to be fully coordinated and
interconnected as a key to the future effectiveness of American medicine.
Teaching Opportunities from Engineering
Framing the range of possible responses to the identified healthcare
challenges from the engineering field, Compton discussed some of the op-
portunities available in making changes to a large system such as health
care. He identified two particular areas where engineering can help: the or-
ganization of the delivery system and its structure. Compton suggested that
appreciation of the engineering tool set can begin by clarifying several main
elements, including healthcare system objectives, performance parameters,
and existing control points within the system. Compton also provided rel-
evant examples of quality and process improvement from large commercial
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10 ENGINEERING A LEARNING HEALTHCARE SYSTEM
product industries, including Ford Motor Company and Toyota, and sug-
gested that they have relevance to current challenges facing the healthcare
system. In particular, he posited that engineering principles that support
continuous improvement by leveraging data, and empowering all members
of the organization to communicate and participate, hold much promise for
the movement toward a learning healthcare system.
In the long term, Compton said, medical and engineering professionals
will need to work together much better to create common vocabulary and
understanding. Specific solutions offered during his presentation included
multidisciplinary involvement in research, tool development and applica-
tion, and the generation and implementation of new interdisciplinary edu-
cational models for both medical and engineering professions (NAE/IOM,
2005).
Obserations on Initiating Systems Change in Health Care
Citing the general areas of technique, culture, training, and economics,
Berwick offered an assessment of the major challenges to the successful ap-
plication of systems thinking to health care, stemming fundamentally from
its basic design. That is, improvement will require fundamental changes to
the system, not simply “trying harder.”
Berwick outlined seven major deficiencies that must be overcome to
truly wed medicine and systems knowledge: (1) a lack of emphasis on co-
ordination and interdependence in the current practice of medicine; (2) the
lack of a patient-centered approach to the care process; (3) the lack of ap-
preciation of the power of dynamic learning and local adaptation; (4) a lack
of knowledge about, or action to counteract, waste within the system; (5)
the absence of a platform for interdisciplinary research and collaboration
between health care and systems engineering; (6) the absence of systems
thinking in the current process of healthcare providers’ professional devel-
opment; and (7) the lack of incentives or levers for the vast institutional
rearrangement necessary to achieve the potential offered in the application
of systems science to the healthcare system.
Drawing on examples, Berwick both identified the challenges and set
the stage for discussion of how systems engineering principles could succeed
in drawing improvement from the intersection of health care and systems
thinking.
Engaging Complex Systems Through Engineering Concepts
The meeting’s first panel discussion addressed how various engineering
disciplines—including systems engineering, industrial engineering, opera-
tions research, human factors engineering, financial engineering, and risk
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11
SUMMARY
analysis—deal with system complexity and how these approaches might
inform and improve health care. Speakers provided examples of past suc-
cesses in other industries and offered analyses about what can be learned
from the contrasts.
Systems Engineering Perspecties
William B. Rouse, executive director of the Tennenbaum Institute at
the Georgia Institute of Technology, provided perspectives and principles
related to systems engineering approaches to complex problems, including
health care. He emphasized that engineering builds on scientific findings and
works to identify ways to redesign and provide for better system controls.
As a starting point, Rouse emphasized the importance of a common
understanding between the healthcare and engineering vocabularies. In
elaborating, he reviewed a number of engineering concepts that have ap-
plicability to health care. One class of concepts concerns the operation
of a system, including measurement, defining and measuring the state of
a system; feedback, comparing desired and actual outcome states of the
system; and control, influencing system input to correct for differences be-
tween the desired and actual states. A second class of concepts concerns the
creation of a system to achieve objectives of interest. The elements of this
class include analysis, understanding input–output relationships, including
uncertainties; synthesis, configuring input–output relationships to achieve
objectives; design, integrating input–output relationships; production, cre-
ating systems that embody desired relationships; and sustainment, creating
mechanisms to ensure the achievement of future objectives. He then went
on to show how engineers use mathematical modeling to analyze the phe-
nomena of spiraling healthcare costs caused by technological innovation,
noting multiple opportunities for increased system efficiency.
Engineering Systems Analysis Tools
Operations research (OR) uses aspects of the scientific method to help
frame, formulate, and solve difficult operations problems involving people
and technology. Richard C. Larson, the Mitsui Professor of Engineering
Systems and Civil and Environmental Engineering and director of the Cen-
ter for Engineering Systems Fundamentals at the Massachusetts Institute
of Technology, described the evolution of OR and provided several models
of its applications in health care. Strongly systems oriented, OR has been
used successfully to improve aspects of performance in healthcare settings
and therefore has value and potential in developing learning healthcare
systems.
Larson described how OR was used to advance cancer therapeutics
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1 ENGINEERING A LEARNING HEALTHCARE SYSTEM
ment and feedback. He described some important lessons associated with
data-driven analysis and decision making for identifying opportunities and
motivating change. The UPHS experience with workflow redesign and
role restructuring, based in part on integrated IT, facilitated the identifica-
tion of goals and improvement in performance. Muller discussed UPHS’s
approaches to engaging physicians, management, and staff in systems im-
provement initiatives as a testament to the possibility of gaining efficiency
yields in an overwhelmingly complex American healthcare system through
incremental changes at individual institutions.
Information Knowledge and Deelopment
As the nation’s healthcare system moves toward increasingly integrated
information systems, it will be important to support information exchange
and knowledge management while evaluating and improving the quality
and value of healthcare practices. Eugene C. Nelson, professor in the Dart-
mouth Institute for Health Policy and Clinical Practice at Dartmouth Medi-
cal School and director of quality administration at Dartmouth–Hitchcock
Medical Center, presented a case study, based on the Dartmouth–Hitchcock
Spine Center’s work, that illustrated the principles and methods of feed-
forward, which builds feedback from past experiences into the future design
and improvement of the system. Such an approach serves to increase the
efficiency of patient care as well as to generate and manage new informa-
tion about individual patients and entire patient populations.
In his presentation, Nelson outlined how the Spine Center’s system
focuses on the critical function of patient-reported data embedded into the
process of healthcare delivery, including some of the complexities associated
with developing patient-centered, feed-forward data systems. In particular,
he highlighted the challenges stemming from embedding decision-support
evidence into the care delivery process, and he advocated “collaboratories”
in which professionally organized networks for both care and care research
could develop sustainable feed-forward data systems.
Case Studies in Transformation Through Systems Engineering
Several workshop case studies illustrated the successful application of
systems engineering in various circumstances and sectors.
Airline Safety
The aviation industry has successfully integrated engineering solutions
that transformed safety outcomes. John J. Nance, founding member of
the National Patient Safety Foundation, discussed the possibilities sug-
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1
SUMMARY
gested by the aviation industry’s experience. Nance summarized elements
of aviation’s use of engineering principles, including critical feedback sys-
tems associated with detecting and managing mechanical problems and the
notion of “exquisite redundancy.” The airlines built a system around the
assumptions that humans are imperfect and that systems can be structured
to correct—and even anticipate—human errors through training programs,
procedure standardization, and variable minimization. He described the
need for healthcare systems to plan for and expect failure in every aspect as
well as the need for acceptance of these realities operationally and cultur-
ally. The wide scope and variety of engineering experiences adopted in avia-
tion could be directly applicable to health care, legitimizing and inculcating
known best practices, eliminating the need to reinvent every procedure, and
providing operational buffers against human fallibility in order to allow for
safer care delivery systems, Nance said.
Alcoa’s Reorientation
Innovations designed and implemented by organizations can advance
the frontiers of business operations. Earnest J. Edwards, senior vice presi-
dent and controller (retired) of Alcoa, Inc., and now the vice chair of Mar-
tha Jefferson Health Service, offered what he called the five basic truths of
organizational innovation: (1) high quality in tandem with low cost creates
high efficiency, (2) informed decision making originates in effective systems,
(3) change agents are solution-oriented, (4) strategic planning is preferred
over historical reporting, and (5) vital business partners leverage their roles
to make strategic decisions.
Edwards described successful applications of cycle-time reduction in the
financial closing process in a leading company (Alcoa), a major government
agency (the U.S. Treasury), and a community hospital (Martha Jefferson
Health Service) that all achieved their goals through the application of five
key strategies: (1) expecting high value, (2) effectively using information,
(3) becoming solution oriented, (4) focusing on planning the future, and (5)
becoming vital business partners with expanded roles in strategic decisions.
In addition to streamlining financial functions, projects to reduce financial
closing cycles at each of these companies provided more timely information
for business decision making, served as an example of how to make major
improvements to a routine process, and were a major motivating force for
the staff of the organizations. Health care could benefit by adopting similar
programs, he suggested.
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18 ENGINEERING A LEARNING HEALTHCARE SYSTEM
Veterans Health Affairs
The veterans healthcare system, managed by the Veterans Health Ad-
ministration in the U.S. Department of Veterans Affairs (VA), is the larg-
est integrated healthcare system in the United States. As recently as the
1990s, the VA system was widely criticized for providing fragmented and
disjointed care that was expensive, difficult to access, and insensitive to in-
dividual needs. Kenneth W. Kizer, chair of Medsphere Systems Corporation,
described the radical re-engineering of VA health care that was launched in
1995, a program aimed at creating a continuum of consistent, predictable,
high-quality, patient-centered care. The effort was based on specific inter-
related and overlapping strategic goals: (1) create an accountable manage-
ment structure and control system, (2) integrate and coordinate services
across the continuum of care, (3) improve and standardize the quality of
care, (4) modernize information management, and (5) align the system’s
finances with desired outcomes.
The effect of the reform was transformative. In recent years, the Veter-
ans Health Administration has been hailed as providing the best health care
in the United States and is held out as an exemplary model of high-quality,
low-cost (i.e., high value) health care. Kizer reviewed some of the systemic
changes integral to the transformation and some of the improvements in
performance. Examples include decentralizing operational decision making
and instituting both the computerized patient record system and the veter-
ans equitable resource allocation methodology. He declared that relatively
simple interventions can be implemented and hold promise for the reform
of health care.
Ascension Health
Ascension Health is the largest not-for-profit healthcare delivery system
in the United States, the largest Catholic healthcare system, and the third
largest healthcare system overall (after the VA and the Hospital Corpora-
tion of America). David B. Pryor, the system’s chief medical officer, detailed
Ascension Health’s “Call to Action,” a reform effort established in October
2002 that focused on three goals: health care that works, health care that
is safe, and health care that leaves no one behind.
During the presentation, Pryor focused on the steps taken to improve
safety related to hospital mortality, adverse drug events, Joint Commission
National Patient Safety Goals, nosocomial infections, falls and fall injuries,
pressure ulcers, perinatal safety, and surgical complications, with the goal
of no preventable injuries or deaths. Those steps addressed challenges in
culture, infrastructure, the business case, standardization, and staff col-
laboration. Strategies were derived for each challenge and implemented
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19
SUMMARY
with great success. Pryor offered several crucial factors that contributed to
this success, including a clear focus with accountable goals, transparency in
results reporting, addressing all challenge areas, and a deep organizational
commitment across all levels of leadership with mutual accountability.
Fostering Systems Change to Drive Continuous Learning in Health Care
The IOM workshop publication The Learning Healthcare System
(2007) identified several common characteristics of a learning healthcare
organization, including a culture that emphasizes transparency and learn-
ing through continuous feedback loops, care as a seamless team process,
best practices that are embedded in system design, information systems that
reliably deliver evidence and capture results, and results that are captured
and used as feedback to improve the level of practice and the state of the
science. Each speaker addressed what feedback and performance improve-
ment look like and how impediments can be turned into enablers.
Learning, Team, and Patient-Oriented Culture
In manufacturing, heavy industry, high-tech services, aviation, the mili-
tary, and elsewhere, a small number of organizations will be innovative
leaders. These innovators may use similar science and technology to meet
the needs of a similar customer base, depend on the same group of suppli-
ers, hire from the same labor pools, and be subject to the same regulations
as other organizations in their fields, but they deliver far more value, often
with less effort and at a lower cost. These “rabbits” gain and sustain leader-
ship by managing their systems of work in markedly different ways.
Steven J. Spear, senior lecturer at the Massachusetts Institute of Tech-
nology and a senior fellow at the Institute for Healthcare Improvement,
described several such “rabbits,” including Toyota and Southwest Airlines.
He pointed out that healthcare organizations can and have learned from
these types of companies, with impressive improvements in efficacy, effi-
ciency, safety, and quality of care. Spear proposed that delivering better care
to more people at lower costs and with less effort is achievable by adopting
elements of “clinical evidence” from other organizations. He emphasized
that these transformations require an approach of process reform rather
than managing individual functions and also need continuous, dynamic
monitoring and management.
Knowledge Deelopment, Access, and Use
In addition to requiring education and research agendas, knowledge
management for clinical decision support (CDS) also requires a policy
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20 ENGINEERING A LEARNING HEALTHCARE SYSTEM
framework. Donald E. Detmer, then president and CEO of the American
Medical Informatics Association (AMIA) and professor of medical educa-
tion at the University of Virginia, asserted that we do not have the appro-
priate policy infrastructure to support some of these goals. Drawing from
the AMIA CDS Roadmap for National Action, Detmer proposed several
policy solutions. The AMIA recommends a three-pillar structure of timely
availability of quality knowledge, high adoption and effective use, and
continuous improvement of knowledge and methods. He noted that this
roadmap was used by the U.S. Department of Health and Human Services
to identify priorities for CDS development, including achieving measurable
progress toward performance goals for healthcare quality improvement,
exploring private–public partnerships to facilitate collaboration, and ac-
celerating development and employment through federal programs and
collaborations.
Technology Management
For health care, technology management is a growing issue that con-
tinues to require significant attention. Because a large portion of the recent
growth in healthcare expenditures is a direct outcome of technology devel-
opment, many look to technology as an opportunity to streamline processes
and reduce costs. Stephen J. Swensen, director of quality at the Mayo
Clinic and professor of radiology in the Mayo Clinic College of Medicine,
presented several perspectives on the issue of technology management in
U.S. health care.
Swensen outlined four primary elements of healthcare technology man-
agement. First, policies—particularly those policies that create incentives,
such as payment—can be central motivators of activities and performance.
The appropriateness and reliability of technology offer opportunities in
terms of managing the appropriate use and ensuring the high reliability of
the technologies applied. Effective diffusion of best practices and safety nets
is crucial for efficient and effective technology management, as it allows
for the optimization of technology use. Finally, social engineering strate-
gies, including transparency, team-work training, horizontal infrastructure,
and cross-functional team-based simulations, can contribute to moving an
organization toward integrated care coordination in which decisions are
made with an organizational perspective. In conclusion, Swensen noted
that, in order to reach technology management goals and provide reliable
patient care, the healthcare industry must foster systems changes to drive
continuous learning.
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SUMMARY
Information Systems Organization and Management
Simulation can help accelerate progress. Over the past decade, numer-
ous healthcare delivery organizations have implemented clinical informa-
tion systems in order to improve the quality and safety of patient care.
Recent studies have suggested that, despite considerable investment in these
systems, many organizations have failed in these efforts. David C. Classen,
chief medical officer of First Consulting Group and an associate professor
of medicine at the University of Utah, explored current approaches to evalu-
ating clinical information systems and detailed a new simulation tool that
has been developed and used by healthcare organizations to evaluate the
effectiveness of these systems in improving the safety of care. He described
several strategies for evaluating the computerized physician order entry
system, one of the ways that hospitals work toward safe medication man-
agement. These strategies included electronic health record (EHR) product
certification as well as approaches by the National Quality Forum and the
Leapfrog Group that employ simulation. Classen noted that the widespread
use of simulation in these instances holds great promise for the evaluation
of clinical information systems.
Capturing More Value in Health Care
During a breakout session, participants assembled in small groups
to discuss the engineering approach likely to yield the greatest return in
health, the amount of enhanced effectiveness and efficiency that might be
anticipated, and what actions might facilitate change. The main points of
their discussions were reported back to the entire group.
In response to the question of how much more value (health returned
for dollars invested) could be obtained through application of systems
engineering principles in health care, respondents felt that the definition of
value was problematic as it depends on the stakeholder in question. In con-
trast, other small groups reported that based on some workshop estimates,
suggesting that 50 percent of the current system resources were wasted, it
was reasonable to assume that a doubling of value ought to be attainable
through systematic changes, including realignment of payment incentives,
health IT, and better systems integration.
When asked to identify where the greatest value could be returned,
participants listed a number of different areas. Among these were health IT,
for better systemic coordination and informed decision making; education
reform, for the necessary cultural changes within professions and greater
interdisciplinary exposure and training; realignment of incentives to pro-
mote best practices; greater emphasis on collaboration; better integration of
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22 ENGINEERING A LEARNING HEALTHCARE SYSTEM
systems; adoption of processes that lead to use and evaluation; and adop-
tion and implementation of process technologies.
Responding to the question of which actions could do the most to
facilitate the needed changes, participants elaborated on some of the areas
mentioned previously. Participants noted that the approach to reform was
important and should start with easy, manageable issues and progress
to broader, more difficult reforms. This two-tiered approach would al-
low for demonstrations of the potential for improvement and would thus
provide the opportunity to get greater buy-in from stakeholders. Several
groups mentioned the need to encourage a more collaborative approach to
the care process that would involve multidisciplinary groups. Participants
mentioned the need for changes in the current culture in order to allow
for more integrated care, including reforms to the models of education for
healthcare providers.
Changes in the availability, implementation, and application of EHRs
and health IT were discussed as ways to better communicate best practices,
to allow for improved analysis of process and outcomes data that can be
fed back and used to improve the system, and to create better continuity of
care. In order to achieve this, however, interfaces between technology and
users need to be redesigned to allow for ease of use and seamless integra-
tion into the care process. Use of data from health IT systems to model
and optimize care processes was discussed as a natural application of sys-
tems engineering to health care, as was the idea of combining healthcare
economics models with process engineering models to get a better grasp
on measuring value. Participants also discussed the need for collaboration
between process engineering and medical professional organizations and
other groups concerning issues of education, nomenclature, and develop-
ment of best practices and core performance measures.
Finally, several groups mentioned the need to better define value in
the context of a learning healthcare system and from the perspective of
all of the stakeholders involved. This would make possible the creation
of processes that allow for the measurement of value and its inclusion in
decision-making processes.
Next Steps: Aligning Policies with Leadership Opportunities
A concluding panel discussion on aligning policies with leadership
opportunities was held with five leaders from key settings in health care
reflecting on their visions for changes in practice, policy, and culture. Con-
tributing members of the panel discussion were Denis A. Cortese of the
Mayo Clinic, Paul F. Conlon of Trinity Health, Mary Jane Koren of The
Commonwealth Fund, Louise L. Liang of Kaiser Permanente, and Douglas
W. Lowery-North of Emory University.
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SUMMARY
Several of the themes mentioned previously were raised again and
expanded upon during the question-and-answer session with the panel-
ists. Cortese, for example, shared his experiences with the achievement of
interoperable systems for radiology, pointing out that it was driven by de-
mands from the radiology professional groups. There was also discussion of
the need for consideration of interoperability on the part of manufacturers
in their business models as well as the need for agreement on requirements
on the part of potential IT systems users in order to allow for the emergence
of a unified market.
The need for a patient-centered approach was a common theme in pan-
elists’ comments. This included the use of market segmentation strategies
(e.g., mass customization) to allow for the identification and individualized
targeting of different groups as well as for the consideration of patient
preferences in treatment and care coordination strategies.
The need for the development of value standards that factor in out-
comes, safety, and cost was discussed. Panelists suggested the development
of such standards for the five most common diseases as a potential first
step and emphasized the need for transparency in this and all development
processes.
One of the panelists proposed a human resources–focused approach
to initiating reform. It would be aimed at encouraging the training of new
professionals in both health care and systems engineering, as well as col-
laboration across those fields, and it could incentivize participation with
such strategies as debt relief for new trainees.
Finally, panelists voiced an overarching concern about potential sup-
port for the work that is needed to reengineer the healthcare system and
hence the importance of reforming financial incentives throughout the
system.
AREAS FOR INNOVATION AND COLLABORATIVE ACTION
Presentations and discussions during the workshop offered insights into
the opportunities for Roundtable members to consider along with possible
follow-up actions for ongoing multistakeholder involvement to advance the
integration of engineering sciences into healthcare systems improvement.
Areas mentioned as possibilities include the following:
1. Clarify terms: The ability of healthcare professionals to draw upon
relevant and helpful engineering principles for system improve-
ment could be facilitated by a better mutual understanding of
the terminology. A collaborative effort by the IOM and the NAE
could create a targeted glossary and develop potentially bridging
terminology for use as appropriate.
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2. Identify best practices: Three areas of systems orientation are par-
ticularly important to improving the efficiency and effectiveness of
health care: (1) focusing the system elements more directly on the
key outcome—the patient experience; (2) ensuring transparency in
the performance of the system and its players and components; and
(3) establishing a culture that emphasizes teamwork, consistency,
and excellence. Progress could be accelerated by identifying and
disseminating examples of best practices from health care and from
engineering on each of these dimensions.
3. Explore health professions education change: In the face of a
rapidly changing environment in health care—the expansion of
diagnostic and treatment options, much greater knowledge avail-
able, movement beyond the point at which any one individual can
personally hold all the information necessary, and IT that opens
new capabilities—changes to the education of health professionals
can advance caregiver skills in knowledge navigation, teamwork,
patient–provider partnership, and process awareness.
4. Adance the science of payment for alue: With cost increases
in health care consistently outstripping gains in performance by
most measures, progress toward counteracting this trend could be
achieved with a stronger focus on ways to enhance both health and
economic returns from healthcare investments. This could include
work in the areas of understanding, measuring, and providing in-
centives for value in health care.
5. Explore fostering the deelopment of a science of waste assessment
and engagement: Similarly, and directly related, an exploration of
the elements of inefficiency in health care, how to define and mea-
sure waste, and how to mobilize responses to eliminating waste
could contribute to increasing value within healthcare systems.
6. Support the deelopment of a robust health IT system: The de-
velopment of a health IT system, designed with systems-related
continuous improvement principles in mind, must lie at the core of
an efficient, effective learning system. Beginning with challenges to
EHR adoption, much work remains in order to achieve a system
that allows for continuous learning; permits data sharing, includ-
ing the construction of databases; employs consistent standards;
and addresses privacy and security concerns. Health IT is a natural
place for collaborative work between engineers and caregivers,
beginning with better resolution of barriers to the achievement of
such a system through the employment of both expert lenses.
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SUMMARY
REFERENCES
IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the
21st century. Washington, DC: National Academy Press.
_____. 2007. The learning healthcare system. Washington, DC: The National Academies
Press.
IOM Roundtable on Evidence-Based Medicine. 2005. Roundtable on Eidence-Based Medi-
cine charter and ision statement. Washington, DC: The National Academies Press.
NAE (National Academy of Engineering)/IOM. 2005. Building a better deliery system: A
new engineering/health care partnership, edited by P. P. Reid. W. D. Compton, J. H.
Grossman, and G. Fanjiang. Washington, DC: The National Academies Press.
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