4
Increase Effectiveness and Efficiency of the U.S. Health Care System

No matter how much costs and decision making are shifted to consumers, they cannot succeed unless providers and health plans have to compete on results and the right information and advice are available.

Porter and Teisberg (2006)

RECOMMENDATION 3

Increase Effectiveness and Efficiency of the U.S. Health Care System

The secretary should accelerate the establishment of a collaborative, robust system for evaluating the health care system that would incorporate existing department and external research, stimulate new studies as needed, synthesize findings, and provide actionable feedback for policy makers, purchasers, payers, providers, health care professionals, and the public.

  1. The secretary should work with Congress to establish a capability for assessing the comparative value—including clinical and cost-effectivenessof medical interventions and procedures, preventive and treatment technologies, and methods of organizing and delivering care. The assessment of comparative value should begin by leveraging department-wide data sources in conjunction with supportive evidence from providers, payers, and health researchers.1

1

The committee did not reach consensus on recommendation 3a. Although the majority of the committee supports the language of the recommendation, David Beier, J.D., Senior Vice President of Global Government and Corporate Affairs, Amgen; Kathleen Buto, M.P.A., Vice President, Health Policy, Johnson & Johnson; and Myrl Weinberg, C.A.E., President, National Health Council, did not agree with the majority’s view and provided



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 87
4 Increase Effectiveness and Efficiency of the U.S. Health Care System No matter how much costs and decision making are shifted to consumers, they cannot succeed unless providers and health plans have to compete on results and the right information and advice are available. Porter and Teisberg (2006) RECOMMENDATION 3 Increase Effectiveness and Efficiency of the U.S. Health Care System The secretary should accelerate the establishment of a collabora- tive, robust system for evaluating the health care system that would incorporate existing department and external research, stimulate new studies as needed, synthesize findings, and provide actionable feedback for policy makers, purchasers, payers, providers, health care professionals, and the public. The secretary should work with Congress to es- a. tablish a capability for assessing the comparative value—including clinical and cost-effectiveness— of medical interventions and procedures, preven- tive and treatment technologies, and methods of organizing and delivering care. The assessment of comparative value should begin by leveraging department-wide data sources in conjunction with supportive evidence from providers, payers, and health researchers. 1 1 The committee did not reach consensus on recommendation 3a. Although the majority of the committee supports the language of the recommendation, David Beier, J.D., Senior Vice President of Global Government and Corporate Affairs, Amgen; Kathleen Buto, M.P.A., Vice President, Health Policy, Johnson & Johnson; and Myrl Weinberg, C.A.E., President, National Health Council, did not agree with the majority’s view and provided 87

OCR for page 87
88 HHS IN THE 21ST CENTURY b. The secretary should work with Congress to en- sure that the department’s programs and reim- bursement policies are outcomes-based, reflecting best available evidence of value and creating in- centives for adoption of best practices, including integration of care, in order to improve quality and efficiency. c. The department should collaborate with state and local public health agencies and community-based organizations, as both sources and users of prac- tical program guidance. d. The department should provide authoritative, plain-language, and current evidence-based infor- mation to the public regarding prevention and treatment options. e. To assess the health of the American people and overall health system performance accurately, the department needs current data from the nation’s health system. To facilitate collection of these data, the department should actively promote the universal adoption of electronic information capa- bilities—including health information exchange and electronic medical, personal health records— for administrative and clinical purposes. HHS’S ROLE IN A VALUE-BASED SYSTEM Medicare and Medicaid exert powerful influence on the U.S. health care system beyond the impact of the large dollars they expend. Because their rules and coverage decisions often are adopted by private payers, these two public programs—although limited to covering specific popu- lation groups—affect the entire health care system and all Americans. Also, some of their reimbursement strategies—especially those support- ing traditional fee-for-service care—have inadvertently contributed to the rapid growth in health care costs. As the Institute of Medicine (IOM) committee considered its charge to examine how the Department of Health and Human Services (HHS) could be more effective in “advanc- dissenting opinions, which can be found in Appendix F. They were unable to agree on a common statement.

OCR for page 87
89 INCREASE EFFECTIVENESS AND EFFICIENCY OF THE U.S. HEALTH CARE SYSTEM ing the health of the nation,” it saw an important potential role for the Centers for Medicare and Medicaid Services (CMS) in providing leader- ship on issues of evidence-based care and creating a value-driven sys- tem—arguably the most promising current approach to the problems of rapidly rising health care costs and shortfalls in quality. KNOWING WHAT WORKS: ESTABLISHING VALUE IN HEALTH CARE An IOM committee has recommended a multipart national program to identify which diagnostic, treatment, and prevention services really work and under what conditions (IOM, 2008). 2 This work originates from recognition that many health care practices need closer scrutiny. On one hand, patients often do not receive services that are known to be ef- fective and appropriate. 3 On the other, new technologies or certain pat- terns of care may be adopted without knowing whether they are the most effective. Evidence is compelling that Americans receive a substantial amount of care that is inappropriate. Two decades of studies by a team of Dart- mouth College researchers have shown large differences from one geo- graphic area to another in care patterns, such as the frequency with which patients receive certain surgical operations or are admitted to intensive care units (ICUs). These differences are not associated with characteris- tics of the patients themselves but attributable almost entirely to differ- ences in the way local doctors practice and the supply of clinical resources—hospital beds, ICUs, high-tech equipment, and specialist phy- 2 Legislation on this topic is currently pending in the 110th Congress, including the Comparative Effectiveness Research Act of 2008 (S. 3408, introduced August 2008), which would establish a nonprofit corporation, the Health Care Comparative Effective- ness Research Institute; the Children’s Health and Medicare Protection Act (H.R. 3162, Sec. 904, passed the House August 2007), which would establish a Center for Compara- tive Effectiveness Research within the Agency for Healthcare Research and Quality (AHRQ); and the Enhanced Health Care Value for All Act (H.R. 2184, introduced May 2007), which charges a Comparative Effectiveness Advisory Board, led by the director of AHRQ, to determine whether one or more AHRQ-sponsored federally funded research and development centers should be created to conduct and review comparative effective- ness research within two years of the act’s passage. 3 An often-cited study showed that, in general, Americans receive only about 55 percent of the care recommended for their condition or situation (McGlynn et al., 2003).

OCR for page 87
90 HHS IN THE 21ST CENTURY sicians. For example, for the average patient in Miami, Medicare spends about two and a half times the amount it spends for the average patient in Minneapolis (Wennberg et al., 1999), even after adjusting for age, illness severity, and comorbidities; in recent years, Medicare spent an average of almost $60,000 on New Jersey patients in the last 24 months of their lives, but only half that amount on similar patients in North Dakota (Wennberg et al., 2008). At the same time, effective preventive services, such as mammography or pneumonia vaccinations, are underutilized in both high- and low-cost geographic areas (Wennberg et al., 1999). Ironically, a greater intensity of services does not necessarily mean that patients fare better. Sometimes, they fare worse. Mortality rates for patients with the same personal characteristics and the same disease are often higher in locales where more health care services are routinely provided (Wennberg et al., 2008). Significant resources could be saved throughout the health system if the least efficient providers mimicked the practices of the most efficient (Antos and Rivlin, 2007). If all patients nationwide had the kind and in- tensity of care that patients receive in the least-intensive, most conserva- tive settings (notably Mayo Clinic in Rochester, Minnesota, and Intermountain Healthcare in Salt Lake City), Medicare—and perhaps other—spending could be reduced by about 30 percent (Wennberg et al., 2002). There may always be patients who do benefit more from an inten- sive approach, but the costs of paying for extra care for these few would be more than balanced by reducing the intensity of services for the larger number who receive too much care (Wennberg et al., 2008). Figure 4-1 presents state-level data showing what Medicare spends, on average, per beneficiary, compared to how the quality of care for beneficiaries is rated in that state. Each dot represents a state, and the figure clearly shows the absence of a relationship between spending and quality. If the two were related, low-spending states would be clustered in the lower left of the figure and higher-spending states would rise on the quality scale. Instead, beneficiaries in some states on the low end of the spending scale receive high-quality care, whereas beneficiaries in some states on the high end of the spending scale receive low-quality care. In fact, the state with the highest-quality care is at the low-cost end, with annual costs of about $6,000 per beneficiary, whereas the two states where care is most expensive (close to $9,000 per year) have among the lowest quality ratings.

OCR for page 87
91 INCREASE EFFECTIVENESS AND EFFICIENCY OF THE U.S. HEALTH CARE SYSTEM FIGURE 4-1 Relationship between quality of care and Medicare spending, by state (2004). NOTES: The composite measure of the quality of care, based on Medicare bene- ficiaries in the fee-for-service program who were hospitalized in 2004, conveys the percentage who received recommended care for myocardial infarction, heart failure, or pneumonia. Spending figures are average amounts for each state. SOURCE: Congressional Budget Office (Orszag, 2008), based on data from CMS and AHRQ’s National Healthcare Quality Report, 2005. Even in the nation’s “best” hospitals—those that are integrated aca- demic medical centers and members of the Council of Teaching Hospi- tals and Health Systems—costs of care vary markedly. Figure 4-2 shows that among 93 such hospitals, the cost of care for Medicare patients with specific chronic diseases ranges from about $24,000 to almost $92,000 in the last two years of life—nearly a four-fold difference. Again, this sug- gests that changing physician and hospital practice patterns could drasti- cally reduce costs and still mirror the care found among the nation’s leading hospitals.

OCR for page 87
92 HHS IN THE 21ST CENTURY 100,000 90,000 Medicare spending for hospitalizations and inpatient physician services per decedent 80,000 70,000 60,000 50,000 40,000 30,000 20,000 FIGURE 4-2 Medicare spending for hospitalizations and inpatient physician services per decedent in the last two years of life among patients with at least one of nine chronic conditions receiving most of their care from selected Coun- cil of Teaching Hospitals (COTHs) integrated academic medical centers (deaths occurring 2001–2005). NOTE: The 18 hospitals on U.S. News & World Report’s Honor Roll for 2007 are noted in the lighter shade of gray. SOURCE: Wennberg et al. (2008). Patient outcomes are affected by the clinical content of care, as well as by whether care is integrated and how it is organized, delivered, and paid for. “Integrated care” is guided by a plan that takes into account the individual’s personal needs and goals, and reflects patient preferences after being informed of the benefits, risks, and availability of alternative treatments. Integrated care is coordinated across all providers and set- tings over time, is culturally and linguistically appropriate, and uses in-

OCR for page 87
93 INCREASE EFFECTIVENESS AND EFFICIENCY OF THE U.S. HEALTH CARE SYSTEM teractive electronic medical and personal health records. The organiza- tion and delivery of care relates to whether it is provided in private of- fices or multispecialty group practice, financed through fee-for-service or under managed care or an alternative payment method, is provided prin- cipally by primary care physicians or specialists, with or without partici- pation of nurse practitioners, physician assistants, nutritionists, health educators, or other health professionals. The way care is paid for pro- foundly affects outcomes. Fee-for-service payment systems give provid- ers financial incentives to do more tests, procedures, and treatments, in order to maximize income. Just as there may be no “one best way” to organize a large federal department, it is likely that there is no “one best way” to provide health care, and that different approaches may work best in different circumstances. Analyses of all these factors clearly are beyond the capacity of indi- vidual physicians or hospitals. Nor are insurers or payers likely to invest in such analyses if they will benefit competitors equally. Also, none of these entities is likely to commission significant new research to fill in any gaps in understanding. Government should provide significant na- tional leadership, through support for a variety of intra-agency and cross- agency efforts, to describe more effective health care. The astronomical cost of Medicare and Medicaid is a powerful incentive to do so. 4 Related Recommendation The secretary should work with Congress to es- a. tablish a capability for assessing the comparative value—including clinical and cost-effectiveness— of medical interventions and procedures, preven- tive and treatment technologies, and methods of 4 The Centers for Medicare and Medicaid Services projects that by 2017, national health expenditures will double to more than $4 trillion annually. With the leading edge of the baby boom generation beginning to become eligible for Medicare in 2011, that program would more than double its 2006 size, to reach $884 billion, as would Medicaid, reaching a projected $402 billion. In total, government sources alone would be responsi- ble for $2 trillion of the national health bill (Keehan et al., 2008).

OCR for page 87
94 HHS IN THE 21ST CENTURY organizing and delivering care. The assessment of comparative value should begin by leveraging department-wide data sources in conjunction with supportive evidence from providers, payers, and health researchers. 5 EMPLOYING EVIDENCE FOR IMPROVED OUTCOMES Better coordination is needed to leverage the comprehensive data collected by the CMS, Food and Drug Administration (FDA), National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and other government agencies, as well as the data collected by nongovernmental payers, providers, and researchers. Improved coordina- tion would allow existing data to be used more effectively in assessing the value (costs and benefits) of health services. Consideration also must be given to the methodological limitations of studies. For example, study designs such as randomized controlled trials and observational studies provide valuable population-level information but do not always provide definitive direction for care at the individual patient level. Despite these limitations, best available evidence can be used to inform policy deci- sions and the development of clinical guidelines. This can result in a bet- ter understanding of which policies produce improved outcomes and fewer unnecessary costs—ultimately increasing the value of the health care system. Assessing the comparative clinical and cost-effectiveness of different health services and organizational and delivery arrangements need not create a rigid system that limits choices for patients, providers, and health systems. Indeed, the particular situations of individual patients and communities always have to be taken into account in making decisions about clinical care and organization of services. 6 (See Box 4-1 for a brief description of “value” in health care.) 5 The committee did not reach consensus on recommendation 3a. Although the majority of the committee supports the language of the recommendation, David Beier, J.D., Senior Vice President of Global Government and Corporate Affairs, Amgen; Kathleen Buto, M.P.A., Vice President, Health Policy, Johnson & Johnson; and Myrl Weinberg, C.A.E., President, National Health Council, did not agree with the majority’s view and provided dissenting opinions, which can be found in Appendix F. They were unable to agree on a common statement. 6 For patients, this means consideration not just of their clinical situation, but also of their unique preferences, concerns, and expectations that are brought to a clinical encoun- ter and that must be integrated into clinical decisions if the patient is to be well served.

OCR for page 87
95 INCREASE EFFECTIVENESS AND EFFICIENCY OF THE U.S. HEALTH CARE SYSTEM BOX 4-1 Value in Health Care Patient value … is the compass that must guide the strategic and operational choices of every provider group, hospital, clinic, and physician practice Porter and Teisberg (2006) IOM Roundtable on Evidence-Based Medicine’s Definition of Value: ...Value in health care is expressed as the physical health and sense of well-being achieved relative to the cost. This means getting the right care at the right time to the right patient for the right price.... Value in health care ... depends on vantage point and circumstance. Perceived value will vary accord- ing to one’s view as a patient, caregiver, family member, neighbor, community leader, employer, health care manager, innovator, or policy official. Sometimes the determination of value is complicated by the fact that a benefit received is the result of a cost shared or borne elsewhere. This is typi- cal of activities in which there is advantage or necessity to arrange for pooling of resources to make it possible for groups of people to benefit. . . . In these cases, the gain is considered from two perspectives: the individual gain for one person’s investment and the social gain from the collective investment. Value from pooled arrangements is expressed as the aggregate gains relative to the aggregate costs. Rewarding caregivers who deliver high-value care . . . should be a central goal of incentives embedded in health care financing. Accomplishing this aim will require analytic tools and capacity beyond those currently available, in- cluding development of the capacity to study relative safety and effectiveness; to inform, assess, and integrate patient preferences; to better characterize and target groups at particular risk; to understand and balance the various elements of cost; to fashion the principles needed to ensure an appropriate balance between an individual’s value proposition and that of the aggregate for a population; to systematically track the results of health care interven- tions; and to identify the system elements most conducive to high-value health care (IOM Roundtable on Evidence-Based Medicine, 2008). To this committee, research related to establishing value creates actionable information about the relative benefits and costs of preventive and treatment technologies, procedures, and methods of organizing, delivering, and paying for services. Assessments of value should include measures of both individ- ual and societal costs and benefits (quality of life, productivity) and would be useful to policy makers, payers, purchasers, providers, health care profes- sionals, and the public. This preeminence of value in comparing professionals and providers (indi- vidual physicians, hospitals, and the like) applies equally to comparisons of medical treatments used in treating a disease, of alternative preventive measures, or varying organizational structures for care. As Porter and Teis- berg (2006) conclude, “If value for patients truly governed every provider choice, the health outcomes per dollar expended in the U.S. health care sys- tem would improve dramatically.”

OCR for page 87
96 HHS IN THE 21ST CENTURY Better evidence on comparative effectiveness must be a priority, but we also need to acknowledge the challenges in obtaining timely, patient- relevant evidence. For example, patients currently receive recommended, effective treatments only about half of the time (McGlynn et al., 2003). Thus far, having evidence on what works has not resulted in closing the substantial gaps between evidence development and its application at the bedside; one study estimates that 17 years pass before published research is translated into practice (Balas and Boren, 2000). We must find new, more effective ways to move the results of research into clinical practice. Undertaking assessments of the value of services to treat specific diseases could be accomplished by an existing government agency, a newly formed one, a quasi-government organization, or some type of public-private partnership (CBO, 2007). The effort should leverage cur- rent private and public agency research efforts, such as those of the Agency for Healthcare Research and Quality (AHRQ), which already supports some studies comparing technologies and styles of medical practice, and for which the committee recommends a larger budget in recommendation 2. There are many management choices regarding gov- ernance and oversight, but the first step is to support research on “what works” as the best hope for improving quality and efficiency in the near future and certainly an important component of long-term system reform. AHRQ is working closely with other units of HHS to fulfill the goals of HHS Secretary Leavitt’s Value-Driven Health Care Initiative. This initiative requires federal agencies that administer or support health in- surance programs to provide information on the cost and quality of health care and collaborate on strategies to do the following: • Connect data throughout the system, by adopting interoperable health information technologies and strategies. • Measure and make available information on the quality and costs of health care services. • Align incentives so that payers, providers, and patients benefit when care delivery is focused on achieving the best value of health care at the lowest cost. Medicare and Medicaid officials (and those of other government payment programs) should use the results of comparative effectiveness studies to inform, but not dictate, their coverage decisions. CMS leader- ship will positively influence other payers to gravitate to evidence-based practices, and payers can create incentives for health care providers and

OCR for page 87
97 INCREASE EFFECTIVENESS AND EFFICIENCY OF THE U.S. HEALTH CARE SYSTEM professionals to adopt evidence-based practices, as well. In such a poten- tially contentious arena, the analyses that support coverage decisions must be absolutely independent, methodologically sound, and perfectly transparent. Although information is rarely perfect and controversies may arise, in the long run it seems fundamental that payers should reward care for which there is evidence of value and discourage care that is either too costly for the benefit received or too low in benefit, regardless of cost. At present, the science is far from able to translate this general principle into care decisions for individual patients with their unique needs; nor would an absolute application of general rules to individual cases be ethically acceptable. To take full advantage of the findings from effectiveness research, CMS reimbursement practices will have to change. With new and better information from these analyses, CMS should be able to focus on creat- ing value in the system, by developing a range of policy incentives for • better management of high-cost chronic illnesses, including pro- active management by providers and self-management by pa- tients (practices discouraged by some current reimbursement policies); • use of primary, versus specialist, care; • reduced geographic variation in care patterns; • better integration of care, through, for example, establishment of a medical home or similar mechanism for assuring continuous, accessible, comprehensive, and coordinated care; and • more efficient practices, generally, including adoption of elec- tronic information exchange and clinical records. Comparative effectiveness research, like any sharp tool, needs to be used carefully. It does not provide the answer to every question. Most thought leaders acknowledge that it can reduce uncertainty, but there will rarely be black-and-white choices that can guide coverage decisions. In other words, when it comes to care for individual patients, we must ac- cept a gray area. However, this type of research would provide informa- tion that patients and physicians need to make choices that offer them the greatest value, as they define it. The committee believes strongly that the department’s activities must rest on a strong science base, that it should foster ongoing learning

OCR for page 87
98 HHS IN THE 21ST CENTURY of many types, and that it needs more effective ways to assess its per- formance, for accountability purposes. Comparative effectiveness analy- ses fit nicely into this overall learning theme—for both the department and our health system as a whole. Related Recommendation b. The secretary should work with Congress to en- sure that the department’s programs and reim- bursement policies are outcomes-based, reflecting best available evidence of value and creating in- centives for adoption of best practices, including integration of care, in order to improve quality and efficiency. The department has strong relationships with state and local govern- ment entities that deliver services and manage programs, and with com- munity-based organizations that are grantees. These groups, too, should align their services with the comparative effectiveness study results, in order to increase system value at the community level. If these entities had appropriate electronic links to the federal government, they could provide real-time feedback to program administrators regarding the func- tioning of grant and contract programs and their effects on the popula- tions served. Related Recommendation The department should collaborate with state and c. local public health agencies and community-based organizations, as both sources and users of prac- tical program guidance. PUBLIC INFORMATION The era when Americans were passive recipients of health services and physicians were unquestioned authorities is fast fading—in part be- cause of societal trends and patients’ own desires, influenced by new

OCR for page 87
99 INCREASE EFFECTIVENESS AND EFFICIENCY OF THE U.S. HEALTH CARE SYSTEM information technologies, and in part because of trends in the health care system itself. An uneasy shift in terminology often defines patients as “consum- ers.” They certainly act like consumers when they take advantage of self- help medical volumes at the local bookstore; access information about their symptoms, conditions, or treatments on the Internet; participate in online “chats” about symptoms and therapies; and join support groups. Health topics are among the most popular on the web: WebMD, the most often-consulted health site, averages 17.3 million unique users per month, according to web marketing analysts (comSource, 2008). This collection of resources of varying reliability is obviously filling a need, but people should have guidance to locate easy-to-understand and imme- diately accessible information from authoritative sources as well. Several government-sponsored websites aim to direct people toward those more reliable sources. 7 At the same time, changes in health care delivery push Americans toward becoming better informed about their health, medical treatments, and ways of navigating the health care system. Outpatient surgery and faster hospital discharges send patients home needing significant atten- tion and infection control; an increasing number of home care technolo- gies—heart disease monitoring, diabetes and asthma management, kidney dialysis, analgesia pumps, and many others—require greater knowledge of both the disease and how to work with sophisticated equipment; home-based hospice teaches families to handle emergencies and to manage pain and symptoms; parents of children with severe dis- abilities learn to deal with respirators and feeding tubes, and to watch for early signs of impending crises. Families dealing with elderly members aging in place are presented with a constellation of care choices and decisions, sometimes having to be made for a loved one no longer capable of participating in health- related decisions. For these families, it is essential that they have confi- dence in the choice they make on behalf of their loved one and the ade- quacy of the information on which it is based. In hospitals, the trend toward larger patient rooms with accommodation for family members is facilitating instruction of families about follow-up care and even encour- aging some patient care by family members. 7 See, for example, http://www.health.gov; http://nnlm.gov/hip/; and http://www. cancer.gov/cancertopics/factsheet/information/internet.

OCR for page 87
100 HHS IN THE 21ST CENTURY Americans have long held substantial personal responsibility for pre- venting disease and injury—obtaining immunizations and checkups, eat- ing properly, driving safely, exercising, not smoking—but today, they are becoming increasingly responsible for carrying out their treatments, too—well beyond taking medications and returning to the doctor every six months. In general, greater involvement in one’s own care is a positive trend. Extensive research has shown that involving patients effectively in deci- sion making increases their knowledge of their choices, gives them a re- alistic understanding of what to expect, and helps them be comfortable with the choice made. For example, when patients were given appropri- ate help in deciding whether to have major elective surgery, about 25 percent fewer chose the more invasive surgical option, with no adverse effects on health outcomes or satisfaction with care. Further, when pa- tients are involved in decision making, some evidence suggests they tend to choose lower-cost options and have better results (O’Connor et al., 2007). In weighing treatment options, Americans must be able to easily find unbiased, accurate, and up-to-date information that describes in plain language the pros and cons of available treatments. Also, with trends to- ward reduced insurance coverage and higher out-of-pocket payments, this information should include an indication of costs, as well. Public education efforts may also be necessary to demonstrate that “more ex- pensive” is not necessarily better, and is sometimes worse. Related Recommendation d. The department should provide authoritative, plain-language, and current evidence-based infor- mation to the public regarding prevention and treatment options. FULFILL THE PROMISE OF HEALTH INFORMATION TECHNOLOGY Among the many potential benefits of increased use of health infor- mation technology are several that relate directly to the committee’s rec- ommendation regarding increased health care system effectiveness and

OCR for page 87
101 INCREASE EFFECTIVENESS AND EFFICIENCY OF THE U.S. HEALTH CARE SYSTEM efficiency. The use of health information technology can improve the continuity and integration of care the committee espouses, by facilitating exchanges of information when a patient is referred from one physician to another, goes to a different hospital, fills prescriptions at different pharmacies, seeks care while traveling, or obtains health-supporting ser- vices from social workers, mental health specialists, or other health care professionals. Such technology would make health care more accessible for pa- tients if more physician offices allowed patients to schedule appoint- ments and obtain test results online, send their physician e-mail queries, receive electronic reminders, and provide helpful clinical information. Early efforts to facilitate the exchange of health information, so that health professionals and patients can access electronically all necessary information at the point of care, should be strengthened to improve pa- tient safety, improve the quality of care, and reduce the costs of missing information and duplicated services. Yet adoption of electronic records at the physician-office level has been slow—in 2006, only 29 percent of physicians reported using any type of electronic medical record in their office-based practices (Hing et al., 2007)—mostly because of high infra- structure costs, uncertainty about which system to buy, the need for train- ing and integration with other office systems, concerns about patient privacy, and the lack of incentives to do so. Although only a small proportion of medical records are fully elec- tronic today, many important elements of medical care exist in electronic form—insurance status; claims for services; pharmacy, laboratory, and other reports—that can give insights into the operations of the health care system. In the future, systems that allow selective information exchange, while maintaining patient privacy, will eventually provide the databases for systematic review and synthesis of the clinical effectiveness and cost- effectiveness of various treatments and help establish their relative value. The results can be used to create “rapid learning” for providers and pay- ers, enable large-scale national research projects with robust results in shorter time frames, facilitate technology assessment, and monitor and improve system performance overall (Etheredge, 2007). Electronic dis- tribution of the findings from these analyses, in forms suitable for differ- ent audiences—health care professionals, payers, and the public—would fill current information gaps. HHS has identified many of the previously cited benefits for patients of expanded use of health information technology as well as predicting

OCR for page 87
102 HHS IN THE 21ST CENTURY that it would make care more accessible, increase administrative effi- ciencies, and decrease paperwork. Health information technology can produce many public health benefits, as well, enabling • early detection of outbreaks of infectious diseases or bioterror- ism and tracking short- and long-term effects of exposures to en- vironmental hazards, • improved monitoring and proactive management of chronic dis- ease patterns, • more coordinated care for clients of publicly funded clinics, and • identifying adverse events once drugs are in real-world use. In the IOM’s widely referenced report on achieving health care qual- ity, Crossing the Quality Chasm, the authors say that achievement of every one of the health care attributes they describe as essential to quality care—that it be safe, effective, patient-centered, timely, efficient, and equitable—would be aided by improved information technology (IOM, 2001). However, financial and technical assistance may be necessary to help small physician practices and safety-net providers adopt these sys- tems. Progress has been slow in many areas: standards development, pri- vate physician adoption, achieving interoperability across systems and within institutions, and achieving confidentiality—areas in which gov- ernment carrots (financial incentives) and sticks (penalties) could move the field forward more quickly, such as those set forth in the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. This act provides phased incentive payments for doctors who begin e-prescribing, and eventually, penalties for those who don’t comply. Health information technology is a tool that can facilitate change. However, it cannot create change. The potential benefits of health infor- mation technology, in terms of quality and cost-effectiveness, cannot be realized without substantial changes in the organizational arrangements of the health system. Otherwise, the new information capacity will only perpetuate and further institutionalize the built-in problems we have to- day (Diamond and Shirky, 2008). Having available timely electronic data from both the public and the private sectors will enable the secretary to provide Congress and the American people with a more complete picture of the state of Americans’ health, unmet needs, the costs and effectiveness of health

OCR for page 87
103 INCREASE EFFECTIVENESS AND EFFICIENCY OF THE U.S. HEALTH CARE SYSTEM services, and opportunities for improvement. Used appropriately, it will facilitate the greater accountability this IOM committee recommends (see Chapter 6). Related Recommendation To assess the health of the American people and e. overall health system performance accurately, the department needs current data from the nation’s health system. To facilitate collection of these data, the department should actively promote the universal adoption of electronic information capa- bilities—including health information exchange and electronic medical, personal health records— for administrative and clinical purposes. REFERENCES Antos, J., and A. Rivlin. 2007. Slowing the growth of health spending: We need mixed strategies, and we need to start now. In Opportunity 08: Independent ideas for America’s next president. Edited by M. O’Hanlon. Washington, DC: Brookings Institution. Pp. 303-320. Balas, E., and S. Boren. 2000. Managing clinical knowledge for health care im- provement. In Yearbook of medical informatics. Bethesda, MD: National Li- brary of Medicine. Pp. 65-70. CBO (Congressional Budget Office). 2007. Research on the comparative effec- tiveness of medical treatments: Issues and options for an expanded federal role. Washington, DC: Congress of the United States. comSource. 2008. Online health information category grows at rate four times faster than total Internet. http://www.comscore.com/press/release.asp? press=2436 (accessed November 17, 2008). Diamond, C. C., and C. Shirky. 2008. Health information technology: A few years of magical thinking? Health Affairs 27(5):w383-w390. Etheredge, L. 2007. A rapid-learning health system. Health Affairs 26:w107- w118. Hing, E. S., C. W. Burt, and D. A. Woodwell. 2007. Electronic medical record use by office-based physicians and their practices: United States, 2006. At- lanta, GA: National Center for Health Statistics. IOM (Institute of Medicine). 2001. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

OCR for page 87
104 HHS IN THE 21ST CENTURY IOM. 2008. Knowing what works in health care: A roadmap for the nation. Washington, DC: The National Academies Press. IOM Roundtable on Evidence-Based Medicine. 2008. Learning healthcare sys- tem concepts, v. 2008. Washington, DC: The National Academies Press. Keehan, S., A. Sisko, C. Truffer, S. Smith, C. Cowan, J. Poisal, and M. K. Clemens. 2008. Health spending projections through 2017: The baby-boom generation is coming to Medicare. Health Affairs 27(2):w145-w155. McGlynn, E., S. Asch, J. Adams, J. Keesey, J. Hicks, A. DeCristofaro, and E. Kerr. 2003. The quality of health care delivered to adults in the United States. New England Journal of Medicine 348:2635-2645. O’Connor, A. M., J. E. Wennberg, F. Legare, H. A. Llewellyn-Thomas, B. W. Moulton, K. R. Sepucha, A. G. Sodano, and J. S. King. 2007. Toward the “tip- ping point”: Decision aids and informed patient choice. Health Affairs 26(3):716-725. Orszag, P. 2008. Increasing the value of federal spending on health care. Wash- ington, DC: CBO. Porter, M., and E. Teisberg. 2006. Redefining health care: Creating value-based competition on results. Boston, MA: Harvard Business School Press. Wennberg, J., J. D. Birkmeyer, K. K. Bronner, T. A. Bubolz, D. E. Campbell, E. S. Fisher, G. T. O’Connor, J. F. Poage, S. M. Sharp, J. S. Skinner, T. A. Stukel, and D. E. Wennberg. 1999. The quality of medical care in the United States: A report on the Medicare program. Hanover, NH: Dartmouth Atlas of Health Care. Wennberg, J. E., E. S. Fisher, and J. S. Skinner. 2002. Geography and the debate over Medicare reform. Health Affairs Suppl Web Exclusives: w96-w114. Wennberg, J., E. Fisher, D. Goodman, and J. Skinner. 2008. Tracking the care of patients with severe chronic illness. Hanover, NH: Dartmouth Atlas of Health Care.