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6
Next Steps:
Aligning Policies with
Leadership Opportunities
INTRODUCTION
Appropriate to the title of the workshop, Engineering a Learning
Healthcare System: A Look at the Future, the final session was devoted to
exploring critical policy areas that must be engaged in order to advance en-
gineering approaches to transformational changes in health care, including
those that might trigger “disruptive innovations.” Five panelists provided
context and policy recommendations, drawing from widely varying experi-
ences in academic medical centers, community hospitals, integrated care de-
livery organizations, ambulatory clinics, and skilled nursing facilities: Paul
F. Conlon, senior vice president for Clinical Quality and Patient Safety at
Trinity Health; Denis A. Cortese, president and chief executive officer of the
Mayo Clinic; Mary Jane Koren, assistant vice president of The Common-
wealth Fund; Louise L. Liang, senior vice president of quality and clinical
systems support for Kaiser Foundation Health Plan and Kaiser Foundation
Hospitals; and Douglas W. Lowery-North, vice chair of clinical operations
at Emory Healthcare Department of Emergency Medicine.
Each panelist offered brief reflections on his or her vision for changes in
practice, policy, and culture. Recurring themes included the need for deliv-
ery of best practices, both clinical and administrative; process standardiza-
tion and improvement at care interfaces; and leveraging human capital.
21
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22 ENGINEERING A LEARNING HEALTHCARE SYSTEM
PROCESS STANDARDIZATION AND IMPROVEMENT
Interfaces
A key element of the panel’s discussion was the notion of interfaces
between engineers and providers, and among multiple processes. Cortese
discussed the importance of medical school admissions selection criteria to
ensure that medical education and training include fundamental engineering
concepts. He provided the Mayo medical school as an example of a medi-
cal school where the size will not increase until the training program adds
incrementally to historical practices. American health care is not lacking for
resources, Conlon said. Those resources are probably abundant, but they
suffer from poor distribution and use. He spoke of the importance of the
intersection of engineering with health care in helping to build an under-
standing of the systems we use for creating the product that at this point is
so rife with inefficiency and waste.
Lowery-North also highlighted the gap in uptake of healthcare en-
gineers. He attributed it to language differences between medicine and
health care. Fortifying the interface between health care and engineering
will provide additional perspectives on the opportunities in health care
for accelerated improvement. Cortese said that healthcare educators need
to ensure there is a basic understanding of systems engineering in their
programs and that their students, the future healthcare practitioners, need
to understand how to handle data, turn it into information, and turn that
information into knowledge, as well as effective communication tools.
Cortese also indicated that engineering schools can play an important role
in integrating health information training into engineering curriculums and
master’s and postgraduate programs through relationships developed with
academic medical centers. The Regenstrief Institute at Purdue has one such
program; other examples can be found at Georgia Tech, the University of
Wisconsin, and North Carolina State.
Systems Improvement
The roles of the federal government and the private sector could be
to create multidisciplinary centers to address issues of quality, value, and
waste. Such centers could link the work of researchers, practitioners, edu-
cators, and engineers, and could include both basic and applied research,
according to Cortese. The centers could demonstrate and disseminate tools,
technologies, and knowledge, and they could perhaps identify a federal
agency to take a lead role. Perhaps the government and private sources
could ensure stable and adequate funding. Such an approach could help
overcome barriers to the application of systems engineering, information
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technologies (ITs), and communication technologies, and it could play an
important role in educating students. Public education would also have a
role. If health care is to be improved through engineering, the government
has to work to improve public education.
Reflecting on the intersection of engineering and healthcare delivery
and on the kind of policies needed to help increase value, Conlon proposed
using technology to hardwire some best clinical practices. For example, if
a patient anywhere in a system is identified as being at risk for ulcers or
falling, the act of entering that information in the electronic health record
(EHR) could trigger a set of evidence-based nursing orders designed to
mitigate against those risks. Individual nurses would have the opportunity
to modify those orders as appropriate. Using technology to facilitate co-
ordination of care is vitally important, yet Conlon expressed concern over
the debate with IT vendors about whether they are implementing the right
information in the right systems for the changes needed.
Liang addressed the measurements, measuring systems, and metrics
used by large health plans and purchasers to identify process measures, all
of them driven by claims data. Such data are available, Liang noted, but the
measures only feed current activities instead of encouraging better outcomes
or processes. Data collection is time intensive, Liang noted, and she urged
an examination of the benefits provided vs. the burden created in achieving
those benefits. Cortese added another layer by challenging the Joint Com-
mission to completely change the way it does business and instead become
a conduit for sharing information—a reporting center that could encourage
the learning process throughout health care.
Another basic challenge to system improvement is the adoption of
health IT. For example, nursing homes have not been at the technological
forefront in terms of IT, Koren said. Although the homes are starting to use
IT, it is a disruptive innovation, and too many of them see it as something
that you buy, you plug in, and then you teach somebody to press the but-
ton. Few vendors engage the possibilities of IT as a change management
tool. Therefore, Koren said, we need to think about teaching nursing homes
how to do things like process mapping and workflow design and to use
those tools to optimal advantage. And because doctors often do not like to
go to nursing homes, more effective ways are needed to use telehealth and
telemonitoring tools to ensure that patients get the best medical care even
at those times when a physician is not present.
Delivery of Value
Koren also highlighted some opportunities for skilled nursing care fa-
cilities to increase the value derived from services. She urged the audience
to consider the best ways to design facilities, employing engineering systems
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2 ENGINEERING A LEARNING HEALTHCARE SYSTEM
insights that support caring for a frail, usually older population. Cortese
followed up on this line of thinking by advocating that the federal govern-
ment simply pay for value, a policy proposal that has gained significant
traction as offering an alternative to reimbursement. Liang discussed the
idea of generating value through the creation and use of medical knowl-
edge, and she noted the significant workshop conversation about the barrier
of financial incentives. Right now the healthcare system pays for activity
and, as expected, activity is the result. However, value, quality, service, and
better outcomes should be the focus of reimbursement.
For full attainment of the value potential, Liang said that better use of
informatics is needed, and this means that the federal government needs to
do more to address in a straightforward fashion the privacy concerns of
institutions and patients that arise from the use of information for clini-
cal knowledge generation. In light of the recent challenges experienced by
other institutions, she said, legitimate privacy concerns need to be clarified
in order to allow and support full leverage of the significant information
becoming available to the healthcare community.
LEVERAGING PEOPLE FOR HEALTHCARE IMPROVEMENT
Culture and the Learning Process
Culture is generally the most important barrier to change, Cortese ob-
served, and this is especially true with health care. Lowery-North cautioned
against losing the component of human systems engineering when evaluat-
ing engineering approaches to culture change. Organizational composition,
diffusion of innovation, and change management strategies are areas in
which health care continues to lag behind other sectors, Lowery-North said,
and this is probably why it has been so difficult to effect change. The phar-
maceutical sales industry can offer insight into how to change physician
behavior, panelists said. Examining the experiences of that group of people
may offer some lessons about how to change the behaviors of physicians,
who in practice may have little, if any, incentive to change. Cortese noted
that one facet of necessary cultural change is found in the current emphasis
on research and even teaching over patient care. In academic centers, most
often the motivator is research; many academic medical centers exist be-
cause of research. If someone has full funding, they get a tenured position;
if they lose funding, they are often required to dedicate more time to teach-
ing. In the face of such concerns, it is unfortunately the case that medical
care is totally secondary. Rather than separate the two, Cortese said, what
is important is to draw research and patient care closer together so that
every patient experience becomes a learning opportunity.
Conlon identified the omnipresent measurement culture, monitoring
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the effectiveness of the healthcare system and identifying opportunities for
improvement, as a barrier to change, explaining that the growing burden
of data capture is potentially beginning to exceed the value of information.
That is a problem because nurses and physicians spend too much time
marking off checklists in order to be able to prove, for example, that ACE
inhibitors or beta-blockers were used properly. This is a great opportunity
to automate that data capture—and correspondingly shift the culture—so
that practitioners can devote more of their time directly to patient care.
Conlon noted that EHR implementation is about more than simply
documenting health information in EHRs; it can serve as a catalyst to re-
ally transform how we deliver care. The records provide the opportunity
to actually look at processes of care and to redesign them. Liang also of-
fered a word of caution by citing the work of Ronald Heifetz, who wrote
Leadership Without Easy Answers: “One of the most common leader-
ship mistakes is expecting technical solution to solve adaptive problems”
(Heifetz, 1994).
Liang also argued that cultural challenges are a major issue everywhere,
even in the Kaiser Permanente system in which physicians and nurses are
more aligned than perhaps anywhere else. The fact remains that the fun-
damental guild or craftsman culture of healthcare professionals is still a
significant problem, Liang said. For Kaiser, the biggest factor enabling that
culture change has been the availability of transparent, specific data that
are comparable across the organization and which allow different loca-
tions of care to see what is possible in other parts of the organization and
what is possible in terms of national benchmarking—as well as where their
individual performances stand. That information needs to be made avail-
able, but it also needs to be combined with good evidence about the right
pathway and with contextual knowledge about how the clinic next door
does so much better. Such context is not necessarily found in the data; the
data say where to go look, where to have the conversations about exactly
what someone is doing that could offer lessons to others.
Occasionally it takes people time to accept the data. There are times
when some physicians and departments have to go through a dialogue of
“The data [are] wrong, my patients are sicker, you just don’t understand,”
but eventually they come to accept the system. Kaiser has seen a huge de-
crease in its variation and a large improvement overall, Liang said, based
fundamentally on the availability of the data to identify issues and help peo-
ple grapple with the fact that, at the moment, everything is not possible.
Communicating With and Engaging Patients
Communication was a central point of discussion in the final session of
the workshop. Three primary communication themes arose: (1) interoper-
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2 ENGINEERING A LEARNING HEALTHCARE SYSTEM
ability of systems in order to facilitate communication, (2) communication
between care team members, and (3) enlisting the patient in support of
knowledge development.
Noting the lack of portability of patient records among care settings,
patients, and providers, Conlon discussed the predominance of incompat-
ible software that effectively precludes information sharing. There is a great
policy opportunity for consistency in the interoperability of these systems
and in the exchange of the information associated with them. Conlon also
urged the adoption of policies that enable information to follow patients
and to exist in a form that can be easily shared and transferred, regardless
of location. Liang added that the federal government should set interoper-
ability standards, particularly in areas that hold outstanding promise, such
as home monitoring and other similar medical devices, as well as standards
that will help give all patients the right to take their medical records with
them. Right now these records can be provided in print, on a compact disc,
or on a memory stick, but that is still a far cry from what it should be.
Lowery-North emphasized that developing interoperability standards will
be critical. A favorable factor is that physician practitioners are gradually
migrating to larger group settings, which are more likely to adopt informa-
tion systems that have interoperability standards because they are more
likely to have been created with a systems engineering approach in mind.
Another area with policy implications is the team nature of health care;
however, we are not teaching people to work in teams, according to Koren.
Educational policy is needed to make sure that we have people who are
skilled and working in an interdisciplinary or multidisciplinary manner.
Moving doctors into such teams is an innate problem because, for example,
doctors typically don’t like to go to nursing homes. These teams are largely
led by nurses, with paraprofessionals working at the bottom. An issue,
therefore, is how we can integrate those paraprofessionals into that team.
We need engineering to help us think about how to bring workers into that
team and effectively listen to the knowledge being generated at the front
lines of care. How do we best use that knowledge to make the system better
and more responsive to what people want?
Finally, it was noted that if patients are to become more engaged in
the research process, several rules will have to change. Privacy remains a
barrier to knowledge generation from patient data, yet the concerns are
largely perceptual in nature. Research is an opportunity to shift the culture
in health care through getting people to understand that research in the
name of patient care improvement is legitimate, publishable, hypothesis-
testing research.
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RECURRING THEMES FOR ROUNDTABLE ATTENTION
The presentations and discussions within the workshop zeroed in on a
number of specific ideas and themes concerning the best ways to use engi-
neering to improve healthcare delivery. In addition, they provided a variety
of insights into engineering approaches to dealing with systems complexity
and identified critical areas needing attention in health care. The recurring
themes of discussion throughout the 2 days of the workshop are sum-
marized below. While perhaps intuitively obvious—hence the reason for
their recurrence—they were nonetheless noted as worthy of attention and
engagement by the Roundtable members.
T
he system’s processes must be centered on the right target—the
•
patient. Patient-centered care was defined in the 2001 Institute of
Medicine (IOM) report Crossing the Quality Chasm as providing
care that is respectful of and responsive to individual patient prefer-
ences, 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 activi-
ties 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 patients 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
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 the development and com-
munication of best practices in healthcare systems, as well as the
need for process systems to track care 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-
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28 ENGINEERING A LEARNING HEALTHCARE SYSTEM
care regimens for various individuals, variations in caregiver skill,
the evolving nature of the science base—or all three. Mass custom-
ization and other engineering practices can help assure a consis-
tency 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 flexible enough to
incorporate these considerations and to leverage the lessons learned
from their employment in a process of continuous learning.
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 controlled trials, and the ex-
perience 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, perfection in the
•
performance of systems. Human error is inevitable in any system,
and should be assumed. On the other hand, safeguards and de-
signed redundancies can deliver perfection in system performance.
Mapping processes, embedding prompts, cross-checks, and infor-
mation loops can assure best outcomes and allow human capac-
ity to focus on what can not be programmed—compassion and
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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
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.
AREAS FOR INNOVATION AND COLLABORATIVE ACTION
Presentations and discussions during the workshop offered insight into
the opportunities for Roundtable members to consider possible follow-up
actions for ongoing multi-stakeholder involvement to advance the integra-
tion of engineering sciences into healthcare systems improvement.
Discussions during the breakout sessions provided the opportunity for
workshop attendees, in both the health and engineering fields, to engage
with each other and identify novel opportunities for innovative work that
might yield breakthroughs that capture more value in health care. Par-
ticipants felt that the opportunities were great for various engineering ap-
proaches to streamline processes and improve efficiency, but they struggled
with the ambiguity of the definition of value in health care. The result was
that they largely referred back to themes covered in the workshop pre-
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280 ENGINEERING A LEARNING HEALTHCARE SYSTEM
sentations and summarized elsewhere in this summary. This suggests that
there is still much work to do in laying a foundation at the intersection of
engineering and health care if drilling down with greater specificity is to
add substantially to value.
That said, workshop participants identified several areas for collabora-
tive work that merit follow-up. With particular emphasis on the need for
ongoing means of communication and collaboration that will bring better
perspective and nurtured understanding from the two fields, areas men-
tioned for possible Roundtable follow-up 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 National
Academy of Engineering could create a targeted glossary and de-
velop potentially bridging terminology for use as appropriate.
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 rap-
idly changing environment in health care—expanding diagnostic
and treatment options, much greater knowledge available, move-
ment beyond the point at which any one individual can person-
ally 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-
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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 such
a system that allows for continuous learning; permits data shar-
ing, including 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.
As healthcare and engineering professionals consider these areas for
collaboration and innovation, it is important to emphasize that the focus
of all the engineering applications to health care discussed in the workshop
was, ultimately, improving patient outcomes. The reforms that were dis-
cussed are all focused on to bringing the right care to the right person at
the right time at the right price. The essential questions are straightforward:
Can it work? Will it work—for this patient, in this setting? Do the benefits
outweigh any harms? Do the benefits justify the costs? Do the reforms offer
important advantages over existing alternatives?
If full advantage is to be taken of this potential, much work remains to
bridge the gaps between the professions of health care and engineering. As
the problems within healthcare systems become increasingly better defined,
the opportunity increases for true collaborative approaches that go beyond
joint acknowledgment and parallel approaches. This workshop, while lim-
ited by the chosen areas of emphasis and the specific backgrounds of the
participants, identified a number of important prospects for advancing the
discussion and sharing of ideas as a more frequent and routine activity.
Better coordination, collaboration, public–private partnerships, and
priority setting are central challenges for the U.S. healthcare system. The
discussions summarized in this report highlight engineering’s potential con-
tribution to progress toward the Roundtable membership’s concept of a
learning health system with a stated 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 available evidence.
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282 ENGINEERING A LEARNING HEALTHCARE SYSTEM
REFERENCE
Heifetz, R. A. 1994. Leadership without easy answers. Cambridge, MA: Belknap Press of
Harvard University Press.
IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health systems for the
21st century. Washington, DC: National Academy Press.
