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THE LEARNING HEALTH SYSTEM SERIES
ROUNDTABLE ON VALUE & SCIENCE-DRIVEN HEALTH CARE
ENGINEERING A LEARNING
HEALTHCARE SYSTEM
A Look at the Future
Workshop Summary
Claudia Grossmann, W. Alexander Goolsby, LeighAnne Olsen,
and J. Michael McGinnis
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Govern-
ing Board of the National Research Council, whose members are drawn from the
councils of the National Academy of Sciences, the National Academy of Engineer-
ing, and the Institute of Medicine.
This project was supported by the Agency for Healthcare Research and Quality,
America’s Health Insurance Plans, AstraZeneca, Blue Shield of California Foun-
dation, Burroughs Wellcome Fund, California Health Care Foundation, Centers
for Medicare & Medicaid Services, Charina Endowment Fund, Department of
Veterans Affairs, Food and Drug Administration, Johnson & Johnson, Gordon
and Betty Moore Foundation, National Institutes of Health, the Peter G. Peterson
Foundation, sanofi-aventis, and Stryker. Any opinions, findings, conclusions, or
recommendations expressed in this publication are those of the author(s) and do
not necessarily reflect the view of the organizations or agencies that provided sup-
port for this project.
International Standard Book Number-13: 0-978-0-309-12064-7
International Standard Book Number-10: 0-309-12064-0
Additional copies of this report are available from The National Academies Press,
500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or
(202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.
edu.
For more information about the Institute of Medicine, visit the IOM home page
at: www.iom.edu.
Copyright 2011 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost
all cultures and religions since the beginning of recorded history. The serpent ad-
opted as a logotype by the Institute of Medicine is a relief carving from ancient
Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2011. Engineering a learning
healthcare system: A look at the future: Workshop summary. Washington, DC: The
National Academies Press.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific and engineering research, dedicated to
the furtherance of science and technology and to their use for the general welfare.
Upon the authority of the charter granted to it by the Congress in 1863, the Acad-
emy has a mandate that requires it to advise the federal government on scientific
and technical matters. Dr. Ralph J. Cicerone is president of the National Academy
of Sciences.
The National Academy of Engineering was established in 1964, under the charter
of the National Academy of Sciences, as a parallel organization of outstanding en-
gineers. It is autonomous in its administration and in the selection of its members,
sharing with the National Academy of Sciences the responsibility for advising the
federal government. The National Academy of Engineering also sponsors engineer-
ing programs aimed at meeting national needs, encourages education and research,
and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi-
dent of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of
Sciences to secure the services of eminent members of appropriate professions in
the examination of policy matters pertaining to the health of the public. The Insti-
tute acts under the responsibility given to the National Academy of Sciences by its
congressional charter to be an adviser to the federal government and, upon its own
initiative, to identify issues of medical care, research, and education. Dr. Harvey V.
Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sci-
ences in 1916 to associate the broad community of science and technology with the
Academy’s purposes of furthering knowledge and advising the federal government.
Functioning in accordance with general policies determined by the Academy, the
Council has become the principal operating agency of both the National Academy
of Sciences and the National Academy of Engineering in providing services to the
government, the public, and the scientific and engineering communities. The Coun-
cil is administered jointly by both Academies and the Institute of Medicine. Dr.
Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of
the National Research Council.
www.national-academies.org
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This workshop summary is dedicated to Jerome H. Grossman, M.D.,
a long-time member, friend, and leader in the work of the National
Academies. Bridging by nature and by profession, Jerry Grossman
sered as the liaison between the Institute of Medicine and the Na-
tional Academy of Engineering and was a key motiator and intellec-
tual compass for this workshop and its focus on bringing the insights
of engineering principles to the benefit of the complex and ital actii-
ties of health care. He passed away suddenly on April 1, 2008.
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ROUNDTABLE ON VALUE & SCIENCE-DRIVEN HEALTH CARE*
Denis A. Cortese (Chair), Emeritus President and Chief Executive Officer,
Mayo Clinic; Foundation Professor, ASU
Donald Berwick, Administrator, Centers for Medicare & Medicaid
Services (ex officio)
David Blumenthal, National Coordinator, Office of the National
Coordinator for Health IT (ex officio)
Bruce G. Bodaken, Chairman, President, and Chief Executive Officer,
Blue Shield of California
David R. Brennan, Chief Executive Officer, AstraZeneca PLC
Paul Chew, Chief Science Officer and CMO, sanofi-aventis U.S., Inc.
Carolyn M. Clancy, Director, Agency for Healthcare Research and
Quality (ex officio)
Michael J. Critelli, Former Executive Chairman, Pitney Bowes, Inc.
Helen Darling, President, National Business Group on Health
Thomas R. Frieden, Director, Centers for Disease Control and Prevention
(designee: Chesley Richards) (ex officio)
Gary L. Gottlieb, President and CEO, Partners HealthCare System
James A. Guest, President, Consumers Union
George C. Halvorson, Chairman and Chief Executive Officer, Kaiser
Permanente
Margaret A. Hamburg, Commissioner, Food and Drug Administration
(ex officio)
Carmen Hooker Odom, President, Milbank Memorial Fund Board
Ardis Hoven, Board Chair, American Medical Association
Brent James, Chief Quality Officer and Executive Director, Institute for
Health Care Delivery Research, Intermountain Healthcare
Michael M. E. Johns, Chancellor, Emory University
Craig Jones, Director, Vermont Blueprint for Health
Cato T. Laurencin, Vice President for Health Affairs, Dean of the School
of Medicine, University of Connecticut
Stephen P. MacMillan, President and Chief Executive Officer, Stryker
Mark B. McClellan, Director, Engelberg Center for Healthcare Reform,
The Brookings Institution
Sheri S. McCoy, Worldwide Chairman, Johnson & Johnson
Pharmaceuticals Group
Elizabeth G. Nabel, President, Brigham and Women’s Hospital
* Formerly the Roundtable on Evidence-Based Medicine, Institute of Medicine forums and
roundtables do not issue, review, or approve individual documents. The responsibility for the
published workshop summary rests with the workshop rapporteurs and the institution.
ii
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Mary D. Naylor, Professor and Director of Center for Transitions in
Health, University of Pennsylvania
Peter Neupert, Corporate Vice President, Health Solutions Group,
Microsoft Corporation
William D. Novelli, Former CEO, AARP; Professor, Georgetown
University
Jonathan B. Perlin, Chief Medical Officer and President, Clinical Services,
HCA, Inc.
Robert A. Petzel, Under Secretary, Veterans Health Administration (ex
officio)
Richard Platt, Professor and Chair, Harvard Medical School and Harvard
Pilgrim Health Care
John C. Rother, Group Executive Officer, AARP
John W. Rowe, Professor, Mailman School of Public Health, Columbia
University
Susan Shurin, Acting Director, National Heart, Lung, and Blood Institute
(ex officio)
Mark D. Smith, President and CEO, California HealthCare Foundation
George P. Taylor, Assistant Secretary for Health Affairs (Acting),
Department of Defense (designee: Michael Dinneen) (ex officio)
Reed D. Tuckson, Executive VP and Chief of Medical Affairs,
UnitedHealth Group
Frances M. Visco, President, National Breast Cancer Coalition
Workshop Planning Committee
William B. Rouse (Chair), Georgia Institute of Technology
Jerome H. Grossman, Harvard University
Brent C. James, Intermountain Healthcare, Inc.
Helen S. Kim, Gordon and Betty Moore Foundation
Cato T. Laurencin, University of Virginia
The Honorable Paul H. O’Neill, Value Capture, LLC
Roundtable and National Academy of Engineering Staff
Christie Bell, Financial Associate
Katharine Bothner, Senior Program Assistant (through July 2008)
Patrick Burke, Financial Associate (through December 2009)
Andrea Cohen, Financial Associate (through December 2008)
W. Alexander Goolsby, Program Officer (through September 2008)
Claudia Grossmann, Program Officer
Kiran Gupta, Mirzayan Fellow (through May 2009)
J. Michael McGinnis, Senior Scholar and Executive Director
iii
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LeighAnne Olsen, Program Officer (through July 2010)
Daniel O’Neill, Research Associate (through January 2009)
Stephen Pelletier, Consultant
Laura Penny, Consultant
Brian Powers, Senior Program Assistant
Proctor Reid, Director, National Academy of Engineering Program Office
Valerie Rohrbach, Program Assistant
Julia Sanders, Program Assistant
Robert Saunders, Program Officer
Ruth Strommen, Intern (through August 2009)
Leigh Stuckhardt, Program Associate
Kate Vasconi, Senior Program Assistant (through January 2011)
Pierre L. Young, Program Officer (through May 2010)
Catherine Zweig, Senior Program Assistant (through June 2010)
ix
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Reviewers
This report has been reviewed in draft form by individuals chosen
for their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid
and critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional
standards for objectivity, evidence, and responsiveness to the study charge.
The review comments and draft manuscript remain confidential to protect
the integrity of the deliberative process. We wish to thank the following
individuals for their review of this report:
Arthur Garson, University of Virginia
C. David Naylor, University of Toronto
David Pryor, Ascension Health
Ronald Rardin, University of Arkansas
Harold W. Sorenson, University of California, San Diego
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the final draft
of the report before its release. The review of this report was overseen by
Patricia F. Brennan, University of Wisconsin, Madison. Appointed by the
Institute of Medicine, she was responsible for making certain that an in-
dependent examination of this report was carried out in accordance with
institutional procedures and that all review comments were carefully con-
sidered. Responsibility for the final content of this report rests entirely with
the authoring committee and the institution.
xi
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Foreword
The nation turns to the National Academies for sound advice on is-
sues related to science, technology, and health. Accordingly, the Institute
of Medicine (IOM), as the healthcare arm of the National Academies, is
the advisor to the nation on matters of health and medicine. Similarly, the
National Academy of Engineering (NAE) serves as the nation’s preeminent
advisor on matters of engineering and technology. Improving our nation’s
healthcare system is a challenge which, because of its scale and complex-
ity, requires a creative approach and input from many different fields of
expertise.
This publication summarizes presentations and discussions at Engineer-
ing a Learning Healthcare System: A Look at the Future, a meeting spon-
sored by the IOM’s Roundtable on Value & Science-Driven Health Care
(formerly the Roundtable on Evidence-Based Medicine) in cooperation with
the NAE. The IOM Roundtable provides a neutral forum for engaging in
key health issues through collaborative discussion, with a focus on improv-
ing evidence generation and its application in health care. The Roundtable
membership has developed the concept of a learning health system with the
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.
Building on previous work done by the IOM and NAE in this area,
including production of the report Building a Better Deliery System: A
New Engineering/Health Care Partnership, the workshop convened leading
engineering practitioners, health professionals, and scholars to explore how
the field might learn from and apply systems engineering principles in the
x
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xi FOREWORD
design of a learning healthcare system, one that embeds real-time learning
for continuous improvement in the quality, safety, and efficiency of care,
while generating new knowledge and evidence about what works best.
The following pages summarize the workshop discussions during which
participants explored barriers to care delivery, lessons in transformation
from other organizations, and harnessing the technical talent of the en-
gineering field to inform the development of necessary decision support,
feedback mechanisms, and infrastructure. Throughout the workshop, par-
ticipants emphasized that health care is substantially underperforming on
many dimensions and that significant opportunity remains for the system
to learn and to develop into one that yields the best results and the high-
est value. Among the most important of these opportunities are the re-
alignment of incentives to compel continuous improvement, fostering a
leadership culture that reinforces teamwork, enhancing opportunities for
sustained learning and research from different perspectives, accounting for
human error but requiring perfection in system performance, and, most im-
portantly, centering the system’s processes on the major consideration—the
patient experience. The engagement of diverse perspectives, including those
of engineering and healthcare professionals, will be essential to designing
such a system.
We would like to offer our thanks to the Roundtable members for the
leadership that they bring to these important issues; to the members of the
workshop planning committee, especially its chair, NAE member William B.
Rouse, for the invaluable insight and guidance provided; to the Roundtable
and NAE staff for their skill and dedication in coordinating and facilitat-
ing the activities; and, importantly, to the sponsors who make this work
possible: Agency for Healthcare Research and Quality, America’s Health
Insurance Plans, AstraZeneca, Blue Shield of California Foundation, Bur-
roughs Wellcome Fund, California Health Care Foundation, Centers for
Medicare & Medicaid Services, Charina Endowment Fund, Department
of Veterans Affairs, Food and Drug Administration, Johnson & Johnson,
Gordon and Betty Moore Foundation, National Institutes of Health, the
Peter G. Peterson Foundation, sanofi-aventis, and Stryker.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
Charles M. Vest, Ph.D.
President, National Academy of Engineering
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Preface
Engineering a Learning Healthcare System: A Look at the Future fo-
cuses on current major healthcare system challenges and what the field of
engineering has to offer in the redesign of the system toward one of continu-
ous improvement—a learning healthcare system. The Institute of Medicine’s
(IOM’s) Roundtable on Value & Science-Driven Health Care (formerly the
Roundtable on Evidence-Based Medicine) envisions that such a system will
be the product of collaboration across major healthcare stakeholders and
could draw significant benefits from insights from the field of engineering.
Thus this workshop is a product of a collaboration between the IOM and
the National Academy of Engineering (NAE) and investigates the interfaces
and synergies between the engineering and medical sciences. The workshop
convened experts to identify and discuss issues related to healthcare system
improvement and how lessons learned from engineering might inform cur-
rent thinking about the different components of healthcare delivery, from
research and knowledge generation to clinical care at the bedside.
The Roundtable has outlined important crosscutting issues in health-
care system transformation through the Learning Health System set of
workshops. These provide a framework for working toward the Round-
table’s goal that by the year 2020, 90 percent of clinical decisions will
reflect and be supported by accurate, timely, and up-to-date evidence. A
reworking of the current healthcare delivery system to one that ensures
that the right patient receives the right care at the right time is essential to
this transformation, and insights from the systems engineering field, such
as those discussed during these 2 days, will be crucial in making progress
toward that goal.
xii
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xiii PREFACE
Workshop presentations and discussions surveyed the potential for
greater interaction between the disciplines of medicine and engineering.
Presentations covered various opportunities for learning on the part of
health care as well as teaching opportunities for engineering fields. Partici-
pants heard accounts of how engineering engages complex systems, such as
health care; case studies of how systems engineering has transformed other
industries and sectors; and ways in which the application of engineering
principles can foster changes toward continuous learning in health care.
Presentations and discussions also identified current healthcare system com-
plexities, impediments, and failures; identified opportunities for capturing
more value in health care; and considered ideas about how to initiate the
necessary systems changes and align policies and leadership opportunities
with them.
Numerous themes emerged over the course of the 2-day workshop,
and they centered on the issue of how to transform the current healthcare
system into one that learns throughout the continuum of care. These themes
included the need to center the system’s processes on the right target—the
patient experience, the notion that system excellence is created by the reli-
able delivery of established best practices, the idea that complexity compels
reasoned allowance for tailored adjustments, the need to emphasize interde-
pendence of different components and to address the interfaces of the differ-
ent components, the importance of communication through teamwork, the
need for cross-checking, transparency and feedback as engines for system
improvement, the acknowledgment and management of human error, the
alignment of rewards to foster continuous improvement, the enhancement
of opportunities for sustained learning and research from different perspec-
tives, and the need to foster a leadership culture that reinforces teamwork
and results.
In addition to these themes, a number of cross-sector follow-up actions
were identified that may be pursued by the Roundtable. These actions may
include further collaboration between the IOM Roundtable and the NAE
to clarify terminology in order to prompt healthcare professionals to draw
more naturally upon relevant and helpful engineering principles for system
improvement. Actions may also include greater focus on identifying and
disseminating best practices in order to improve patient outcomes; explor-
ing the possibility of changing the education of health professionals to
advance skills in knowledge navigation, teamwork, patient–provider part-
nerships, and process awareness; advancing the notion of paying for value;
and exploring the elements of inefficiency in health care and developing a
science of waste assessment and how to mobilize resources to eliminate it.
We would like to acknowledge those individuals and organizations
that donated their valuable time toward the development of this workshop
summary. In particular, we acknowledge the contributors to this volume
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xix
PREFACE
for their presence at the workshop and their efforts to further develop their
presentations into the manuscripts contained in this publication. We would
also like to acknowledge those who provided counsel by serving on the
planning committee for this workshop, including William B. Rouse (Chair)
(Georgia Institute of Technology), the late Jerome H. Grossman (Harvard
University), Brent C. James (Intermountain Health Care, Inc.), Helen S.
Kim (Gordon and Betty Moore Foundation), Cato T. Laurencin (University
of Virginia), and the Honorable Paul H. O’Neill (Value Capture, LLC).*
Although not a formal member of the planning committee, Proctor Reid
of the NAE contributed to the planning and execution of the workshop.
Roundtable staff, including Katharine Bothner, Kiran Gupta, W. Alexander
Goolsby, LeighAnne Olsen, Daniel O’Neill, Ruth Strommen, and Catherine
Zweig, helped to translate the workshop proceedings and discussion into
this workshop summary. Stephen Pelletier also contributed substantially
to publication development. We would also like to thank Lara Andersen,
Greta Gorman, Jackie Turner, Michele de la Menardiere, Vilija Teel, and
Bronwyn Schrecker for helping to coordinate the various aspects of review,
production, and publication. This book is dedicated to the memory of Jerry
Grossman, who was a stellar planning committee member, with lifelong
dedication to and leadership in the bridging of medicine and engineering.
Engineering a Learning Healthcare System: A Look at the Future of-
fers important insights to the field of medicine from the field of engineering
concerning the development of a learning healthcare system. It also pro-
vides an example of how collaboration across diverse disciplines can lead
to vast improvements in healthcare delivery. The hope is that, by making
major stakeholders more aware of the importance of the delivery system,
it will prompt the development of strategies for applying the insights from
this workshop to health system improvements and that these strategies will
ultimately transform the current healthcare system into one that smoothly
operates to both generate and apply evidence to improve the health of
Americans.
Denis A. Cortese
Chair, Roundtable on Value & Science-Driven Health Care
J. Michael McGinnis
Executie Director, Roundtable on Value & Science-
Driven Health Care
* Institute of Medicine planning committees are solely responsible for organizing the work-
shop, identifying topics, and choosing speakers. The responsibility for the published workshop
summary rests with the workshop rapporteurs and the institution.
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Contents
SUMMARY 1
1 ENGINEERING A LEARNING HEALTHCARE SYSTEM 27
Introduction, 27
Learning Opportunities for Health Care, 31
Brent C. James
Teaching Opportunities from Engineering: Learning by Example, 46
W. Dale Compton
Observations on Initiating Systems Change in Health Care:
Challenges to Overcome, 53
Donald M. Berwick
2 ENGAGING COMPLEX SYSTEMS THROUGH
ENGINEERING CONCEPTS 63
Introduction, 63
Can We Afford Technological Innovation in Health Care?, 65
William B. Rouse
Operations Research for the Operating Room and Much More!, 75
Richard C. Larson
On Designing an Integrated and Adaptive Healthcare System, 79
James M. Tien and Pascal J. Goldschmidt
Engaging Complex Systems Through Engineering Concepts:
A Methodology for Engineering Complex Systems, 104
Harold W. Sorenson
xxi
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xxii CONTENTS
3 HEALTHCARE SYSTEM COMPLEXITIES,
IMPEDIMENTS, AND FAILURES 117
Introduction, 117
Healthcare Culture in the United States, 120
William W. Stead
Diagnostic and Treatment Technologies, 125
Rita F. Redberg
A Look at the Future of Clinical Data Systems and Clinical
Decision Support, 130
Michael D. Chase
Care Coordination and Linkage, 136
Amy L. Deutschendorf
Transforming Hospitals Through Reform of the Care Process, 143
Ralph W. Muller
A Perspective on Patient-Centric, Feed-Forward
“Collaboratories,” 149
Eugene C. Nelson, Elliott S. Fisher, and James N. Weinstein
4 CASE STUDIES IN TRANSFORMATION THROUGH
SYSTEMS ENGINEERING 171
Introduction, 171
Airline Safety, 173
John J. Nance
Alcoa’s Reorientation: Streamlining the Financial Close Process, 182
Earnest J. Edwards
Veterans Health Affairs: Transforming the Veterans Health
Administration, 188
Kenneth W. Kizer
The Clinical Transformation of Ascension Health, 208
Daid B. Pryor, Ann Hendrich, Sanford F. Tolchin, Robert J.
Henkel, James K. Beckmann, Jr., and Anthony R. Tersigni
5 FOSTERING SYSTEMS CHANGE TO DRIVE CONTINUOUS
LEARNING IN HEALTH CARE 237
Introduction, 237
Chasing the Rabbit: What Healthcare Organizations Can Learn from
the World’s Greatest Organizations, 239
Steen J. Spear
Knowledge Management for Clinical Care, 245
Donald E. Detmer
Technology Management, 250
Stephen J. Swensen and James Dilling
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xxiii
CONTENTS
A Learning System for Implementation of Electronic
Health Records, 255
Daid C. Classen, Jane B. Metzger, and Emily Welebob
Breakout Session: Capturing More Value in Health Care, 260
6 NEXT STEPS: ALIGNING POLICIES WITH LEADERSHIP
OPPORTUNITIES 271
Introduction, 271
Process Standardization and Improvement, 272
Leveraging People for Healthcare Improvement, 274
Recurring Themes for Roundtable Attention, 277
Areas for Innovation and Collaborative Action, 279
APPENDIXES
A Workshop Agenda 285
B Biographical Sketches of Participants 291
C Workshop Attendee List 307
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