10

Actions for Continuous Learning, Best Care, and Lower Costs

Implementing the actions delineated in Chapters 6-9 and achieving the vision of continuous learning and improvement for the health care system will depend on broad leadership by the complex network of decentralized and loosely associated individuals and organizations that make up the current system. Given the complexity of the system and the interconnectedness of its various sectors, no one sector acting alone can bring about the scope and scale of transformative change necessary to develop a system that continuously learns and improves. Each stakeholder brings different strengths, skills, needs, and expertise to the task of improving the system; faces unique challenges; and is accountable for different aspects of the system’s success. Hence, collaboration among individuals and organizations in a given stakeholder group, as well as between stakeholders, will be necessary to produce effective and sustainable change. This chapter summarizes the recommendations presented in Chapters 6 through 9 and then describes the roles of the various stakeholders in the system in implementing these recommendations.

ACHIEVING THE VISION

Based on the findings and conclusions identified in the course of its work, the committee recommends specific actions, supported by the material presented in Chapters 6-9, that will accelerate progress toward continuous learning, best care, and lower costs. The committee’s recommendations are collected below, grouped into three categories as summarized in Box 10-1: foundational elements, care improvement targets, and a supportive



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10 Actions for Continuous Learning, Best Care, and Lower Costs Implementing the actions delineated in Chapters 6-9 and achieving the vision of continuous learning and improvement for the health care system will depend on broad leadership by the complex network of decentralized and loosely associated individuals and organizations that make up the cur- rent system. Given the complexity of the system and the interconnected- ness of its various sectors, no one sector acting alone can bring about the scope and scale of transformative change necessary to develop a system that continuously learns and improves. Each stakeholder brings different strengths, skills, needs, and expertise to the task of improving the system; faces unique challenges; and is accountable for different aspects of the sys- tem’s success. Hence, collaboration among individuals and organizations in a given stakeholder group, as well as between stakeholders, will be neces- sary to produce effective and sustainable change. This chapter summarizes the recommendations presented in Chapters 6 through 9 and then describes the roles of the various stakeholders in the system in implementing these recommendations. ACHIEVING THE VISION Based on the findings and conclusions identified in the course of its work, the committee recommends specific actions, supported by the mate- rial presented in Chapters 6-9, that will accelerate progress toward continu- ous learning, best care, and lower costs. The committee’s recommendations are collected below, grouped into three categories as summarized in Box 10-1: foundational elements, care improvement targets, and a supportive 281

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282 BEST CARE AT LOWER COST BOX 10-1 Categories of the Committee’s Recommendations Foundational Elements Recommendation 1: The digital infrastructure. Improve the capacity to cap- ture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge. Recommendation 2: The data utility. Streamline and revise research regu- lations to improve care, promote the capture of clinical data, and generate knowledge. Care Improvement Targets Recommendation 3: Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions. Recommendation 4: Patient-centered care. Involve patients and families in decisions regarding health and health care, tailored to fit their preferences. Recommendation 5: Community links. Promote community-clinical partner- ships and services aimed at managing and improving health at the community level. Recommendation 6: Care continuity. Improve coordination and communica- tion within and across organizations. Recommendation 7: Optimized operations. Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health. Supportive Policy Environment Recommendation 8: Financial incentives. Structure payment to reward con- tinuous learning and improvement in the provision of best care at lower cost. Recommendation 9: Performance transparency. Increase transparency on health care system performance. Recommendation 10: Broad leadership. Expand commitment to the goals of a continuously learning health care system. policy environment. Also identified are the stakeholders whose engage- ment is necessary for the implementation of each recommendation. Each recommendation describes the core improvement aim for the area, fol- lowed by specific strategies representing initial steps stakeholders should take in acting on the recommendation. Additional activities will have to be undertaken by numerous stakeholder groups to sustain and advance the continuous improvement required.

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ACTIONS FOR CONTINUOUS LEARNING, BEST CARE, AND LOWER COSTS 283 Foundational Elements Recommendation 1: The Digital Infrastructure I mprove the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the genera- tion of new knowledge. Data generated in the course of care delivery should be digitally collected, compiled, and protected as a reliable and accessible resource for care management, process improvement, public health, and the generation of new knowledge. Strategies for progress toward this goal: • Health care delivery organizations and clinicians should fully and effectively employ digital systems that capture patient care expe- riences reliably and consistently, and implement standards and practices that advance the interoperability of data systems. • The National Coordinator for Health Information Technology, digital technology developers, and standards organizations should ensure that the digital infrastructure captures and delivers the core data elements and interoperability needed to support better care, system improvement, and the generation of new knowledge. • Payers, health care delivery organizations, and medical product companies should contribute data to research and analytic consor- tia to support expanded use of care data to generate new insights. • Patients should participate in the development of a robust data util- ity; use new clinical communication tools, such as personal portals, for self-management and care activities; and be involved in building new knowledge, such as through patient-reported outcomes and other knowledge processes. • The Secretary of Health and Human Services should encourage the development of distributed data research networks and expand the availability of departmental health data resources for translation into accessible knowledge that can be used for improving care, lowering costs, and enhancing public health. • Research funding agencies and organizations, such as the Na- tional Institutes of Health, the Agency for Healthcare Research and Quality, the Veterans Health Administration, the Department of Defense, and the Patient-Centered Outcomes Research Institute, should promote research designs and methods that draw naturally on existing care processes and that also support ongoing quality improvement efforts.

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284 BEST CARE AT LOWER COST Recommendation 2: The Data Utility  treamline and revise research regulations to improve care, promote the S capture of clinical data, and generate knowledge. Regulatory agencies should clarify and improve regulations governing the collection and use of clinical data to ensure patient privacy but also the seamless use of clinical data for better care coordination and management, improved care, and knowledge enhancement. Strategies for progress toward this goal: • The Secretary of Health and Human Services should accelerate and expand the review of the Health Insurance Portability and Accountability Act (HIPAA) and institutional review board (IRB) policies with respect to actual or perceived regulatory impediments to the protected use of clinical data, and clarify regulations and their interpretation to support the use of clinical data as a resource for advancing science and care improvement. • Patient and consumer groups, clinicians, professional specialty societies, health care delivery organizations, voluntary organiza- tions, researchers, and grantmakers should develop strategies and outreach to improve understanding of the benefits and importance of accelerating the use of clinical data to improve care and health outcomes. Care Improvement Targets Recommendation 3: Clinical Decision Support  ccelerate integration of the best clinical knowledge into care decisions. A Decision support tools and knowledge management systems should be routine features of health care delivery to ensure that decisions made by clinicians and patients are informed by current best evidence. Strategies for progress toward this goal: • Clinicians and health care organizations should adopt tools that deliver reliable, current clinical knowledge to the point of care, and organizations should adopt incentives that encourage the use of these tools. • Research organizations, advocacy organizations, professional spe- cialty societies, and care delivery organizations should facilitate the

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ACTIONS FOR CONTINUOUS LEARNING, BEST CARE, AND LOWER COSTS 285 development, accessibility, and use of evidence-based and harmo- nized clinical practice guidelines. • Public and private payers should promote the adoption of decision support tools, knowledge management systems, and evidence-based clinical practice guidelines by structuring payment and contracting policies to reward effective, evidence-based care that improves patient health. • Health professional education programs should teach new methods for accessing, managing, and applying evidence; engaging in life- long learning; understanding human behavior and social science; and delivering safe care in an interdisciplinary environment. • Research funding agencies and organizations should promote re- search into the barriers and systematic challenges to the dissemina- tion and use of evidence at the point of care, and support research to develop strategies and methods that can improve the usefulness and accessibility of patient outcome data and scientific evidence for clinicians and patients. Recommendation 4: Patient-Centered Care  nvolve patients and families in decisions regarding health and health I care, tailored to fit their preferences. Patients and families should be given the opportunity to be fully engaged participants at all levels, in- cluding individual care decisions, health system learning and improve- ment activities, and community-based interventions to promote health. Strategies for progress toward this goal: • Patients and families should expect to be offered full participation in their own care and health and encouraged to partner, according to their preference, with clinicians in fulfilling those expectations. • Clinicians should employ high-quality, reliable tools and skills for informed shared decision making with patients and families, tai- lored to clinical needs, patient goals, social circumstances, and the degree of control patients prefer. • Health care delivery organizations, including programs operated by the Department of Defense, the Veterans Health Administration, and Health Resources and Services Administration, should moni- tor and assess patient perspectives and use the insights thus gained to improve care processes; establish patient portals to facilitate data sharing and communication among clinicians, patients, and families; and make high-quality, reliable tools available for shared decision making with patients at different levels of health literacy.

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286 BEST CARE AT LOWER COST • The Agency for Healthcare Research and Quality, partnering with the Centers for Medicare & Medicaid Services, other payers, and stakeholder organizations, should support the development and testing of an accurate and reliable core set of measures of patient- centeredness for consistent use across the health care system. • The Centers for Medicare & Medicaid Services and other public and private payers should promote and measure patient-centered care through payment models, contracting policies, and public reporting programs. • Digital technology developers and health product innovators should develop tools to assist individuals in managing their health and health care, in addition to providing patient supports in new forms of communities. Recommendation 5: Community Links  romote community-clinical partnerships and services aimed at man- P aging and improving health at the community level. Care delivery and community-based organizations and agencies should partner with each other to develop cooperative strategies for the design, implementa- tion, and accountability of services aimed at improving individual and population health. Strategies for progress toward this goal: • Health care delivery organizations and clinicians should partner with community-based organizations and public health agencies to leverage and coordinate prevention, health promotion, and c ­ ommunity-based interventions to improve health outcomes, includ- ing strategies related to the assessment and use of web-based tools. • Public and private payers should incorporate population health improvement into their health care payment and contracting poli- cies and accountability measures. • Health economists, health service researchers, professional spe- cialty societies, and measure development organizations should continue to improve measures that can readily be applied to assess performance on both individual and population health. Recommendation 6: Care Continuity  mprove coordination and communication within and across organi- I zations. Payers should structure payment and contracting to reward

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ACTIONS FOR CONTINUOUS LEARNING, BEST CARE, AND LOWER COSTS 287 effective communication and coordination between and among mem- bers of a patient’s care team. Strategies for progress toward this goal: • Health care delivery organizations and clinicians, partnering with patients, families, and community organizations, should develop coordination and transition processes, data sharing capabilities, and communication tools to ensure safe, seamless patient care. • Health economists, health service researchers, professional specialty societies, and measure development organizations should develop and test metrics with which to monitor and evaluate the effective- ness of care transitions in improving patient health outcomes. • Public and private payers should promote effective care transitions that improve patient health through their payment and contracting policies. Recommendation 7: Optimized Operations C  ontinuously improve health care operations to reduce waste, stream- line care delivery, and focus on activities that improve patient health. Care delivery organizations should apply systems engineering tools and process improvement methods to improve operations and care delivery processes. Strategies for progress toward this goal: • Health care delivery organizations should utilize systems engineer- ing tools and process improvement methods to eliminate inefficien- cies, remove unnecessary burdens on clinicians and staff, enhance patient experience, and improve patient health outcomes. • The Centers for Medicare & Medicaid Services, the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, quality improvement organizations, and process improvement leaders should develop a learning consortium aimed at accelerating training, technical assistance, and the collection and validation of lessons learned about ways to transform the ef- fectiveness and efficiency of care through continuous improvement programs and initiatives.

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288 BEST CARE AT LOWER COST Supportive Policy Environment Recommendation 8: Financial Incentives  tructure payment to reward continuous learning and improvement in S the provision of best care at lower cost. Payers should structure pay- ment models, contracting policies, and benefit designs to reward care that is effective and efficient and continuously learns and improves. Strategies for progress toward this goal: • Public and private payers should reward continuous learning and improvement through outcome- and value-oriented payment models, contracting policies, and benefit designs. Payment models should adequately incentivize and support high-quality team-based care focused on the needs and goals of patients and families. • Health care delivery organizations should reward continuous learning and improvement through the use of internal practice incentives. • Health economists, health service researchers, professional spe- cialty societies, and measure development organizations should partner with public and private payers to develop and evaluate metrics, payment models, contracting policies, and benefit designs that reward high-value care that improves health outcomes. Recommendation 9: Performance Transparency  ncrease transparency on health care system performance. Health care I delivery organizations, clinicians, and payers should increase the avail- ability of information on the quality, prices and cost, and outcomes of care to help inform care decisions and guide improvement efforts. Strategies for progress toward this goal: • Health care delivery organizations should collect and expand the availability of information on the safety, quality, prices and cost, and health outcomes of care. • Professional specialty societies should encourage transparency on the quality, value, and outcomes of the care provided by their members. • Public and private payers should promote transparency in quality, value, and outcomes to aid plan members in their care decision making.

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ACTIONS FOR CONTINUOUS LEARNING, BEST CARE, AND LOWER COSTS 289 • Consumer and patient organizations should disseminate this infor- mation to facilitate discussion, informed decision making, and care improvement. Recommendation 10: Broad Leadership  xpand commitment to the goals of a continuously learning health care E system. Continuous learning and improvement should be a core and constant priority for all participants in health care—patients, families, clinicians, care leaders, and those involved in supporting their work. Strategies for progress toward this goal: • Health care delivery organizations should develop organizational cultures that support and encourage continuous improvement, the use of best practices, transparency, open communication, staff em- powerment, coordination, teamwork, and mutual respect and align rewards accordingly. • Leaders of these organizations should define, disseminate, support, and commit to a vision of continuous improvement; focus atten- tion, training, and resources on continuous learning; and build an operational model that incentivizes continuous improvement and ensures its sustainability. • Governing boards of health care delivery organizations should sup- port and actively participate in fostering a culture of continuous improvement, request continuous feedback on the progress being made toward the adoption of such a culture, and align leadership incentive structures accordingly. • Clinical professional specialty societies, health professional edu- cation programs, health professions specialty boards, licensing boards, and accreditation organizations should incorporate basic concepts and specialized applications of continuous learning and improvement into health professions education; continuing educa- tion; and licensing, certification, and accreditation requirements. Given the interconnected nature of the problems to be solved, it will be important to take the actions identified above in concert. To elevate the quantity of evidence available to inform clinical decisions, for example, it is necessary to increase the supply of evidence by expanding the clinical re- search base; make the evidence easily accessible by embedding it in clinical technological tools, such as clinical decision support; encourage use of the evidence through appropriate payment, contracting, and regulatory poli- cies and cultural factors; and assess progress toward the goal using reliable

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290 BEST CARE AT LOWER COST metrics and appropriate transparency. The absence of any one of these fac- tors will substantially limit overall improvement. To guide success, progress on the recommendations in this report should be monitored continuously. Implementing the actions detailed above and achieving the vision of continuous learning and improvement will depend on the exercise of broad leadership by the complex network of decentralized and loosely associated individuals and organizations that make up the health care system. Given the complexity of the system and the interconnectedness of its different actors and sectors, no one actor or sector alone can bring about the scope and scale of transformative change necessary to develop a system that con- tinuously learns and improves. Each stakeholder brings different strengths, skills, needs, and expertise to the task of improving the system, faces unique challenges, and is accountable for different aspects of the system’s success. There is a distinct need for collaboration between and among stakeholders to produce effective and sustainable change. PATIENTS, CONSUMERS, CAREGIVERS, COMMUNITIES, AND THE PUBLIC Roles in Learning As the focus of health care, patients are central to the success of improvement initiatives. Any large-scale change will require the partici- pation of patients as partners, with the system building trust on every dimension. Patients can motivate continuous improvement by setting high expectations for their care in terms of quality, value, and use of scientific evidence and by selecting health care services, clinicians, health care organizations, and plans that meet those expectations. Patients also can promote learning and improvement by engaging in their own care; sharing decision making with their clinicians; and, with the help of their caregiv- ers, directly applying evidence to their self-care and self-management on an ongoing basis. As their needs progress, patients can seek effective and efficient services that align most closely with their goals. Challenges to Learning There are several impediments to patients and the broader public play- ing a central role in improving the health care system. Notably, the culture of health care often does not encourage or support shared decision making. Even when patients are encouraged to play a role in decisions about their care, they often lack understandable, reliable information—from evidence on the efficacy of different treatment options to information on the quality of different providers and health care organizations—that is customized to

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ACTIONS FOR CONTINUOUS LEARNING, BEST CARE, AND LOWER COSTS 291 their needs, preferences, and health goals. In addition, health care needs to be tailored to a patient’s health literacy, as people have different abilities to obtain, comprehend, and use health information to make care decisions (Brach et al., 2012). In addition, there are challenges to measuring patient empowerment and patient-centered care. Without accurate and reliable measures, it is difficult to determine whether initiatives aimed at achieving greater patient empowerment are successful or to reward clinicians and health care orga- nizations that provide patient-centered care. Several organizations, such as the National Quality Forum (NQF) and the National Committee for Quality Assurance (NCQA), have begun to address this need with respect to defining and measuring aspects of health care performance that relate to patient-centered care. Once measurement has been accomplished, moreover, there are further challenges in communicating this information to patients in an understandable and relevant format such that it can easily be applied to care decisions. These challenges are beginning to be addressed by several public reporting initiatives, including national initiatives such as Hospital Compare and regional initiatives such as Minnesota Community Measure- ment and the Wisconsin Collaborative for Healthcare Quality, which have begun to incorporate patient experience metrics into their public reporting efforts. Opportunities While the challenges described above are considerable, several oppor- tunities exist for increasing patient involvement in the health care system. Organizations have implemented new methods for gathering patient feed- back, from patient advisory councils to surveys; clinicians have introduced new communication and shared decision-making processes; and insurers have begun to account for patient-centeredness in payment. Further, health information technology offers new ways for patients and providers to com- municate, and new mobile devices and sensors allow patients to monitor their conditions continuously. Leveraging these opportunities will increase patient involvement in improving health care. Next Steps To help achieve a learning health care system, patients will need to play the following roles: • Engage actively in their own care and health and, where appropri- ate, that of family members and loved ones through approaches that include questioning, education and lifelong learning, the use

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302 BEST CARE AT LOWER COST for Healthcare Research and Quality (AHRQ), the National Institutes of Health (NIH), and PCORI. Challenges to Learning This stakeholder group faces several challenges as it works to build knowledge. The financial resources for research and development are lim- ited as a result of economic and budgetary constraints. Further, public awareness of and participation in the clinical research enterprise has re- cently decreased, with fewer individuals expressing interest in participat- ing in clinical trials (Woolley and Propst, 2005). Investigators also have expressed concern about the ability to share data and glean insights from clinical data because of the current regulatory framework (IOM, 2009a). Results of previous surveys of health researchers suggest that the current formulation and interpretation of privacy rules have increased the cost and time to conduct research, that different institutional interpretations of the Health Insurance Portability and Accountability Act (HIPAA) and associ- ated regulations have impeded collaboration, and that the rules have made it difficult to recruit subjects (Association of Academic Health Centers, 2008; Greene et al., 2006; IOM, 2009a; Ness, 2007). Transforming the research enterprise will require new efforts to build trust among patients and the public. Building this trust will in turn require increasing confidence in the results of clinical research, being open and hon- est about the risks and benefits of this type of research, and ensuring con- fidence in the privacy and security safeguards for health data. Technically, new approaches are needed to reduce the expense and effort of conducting the research, to improve the applicability of its results to clinical decisions, and to identify smaller effects and effects on different populations. Finally, this sector will need to consider how to accelerate the transla- tion of evidence into practice using technological and nontechnological tools, accounting for the factors that affect the dissemination of initiatives in the health care system. The products of the nation’s clinical data utility and research enterprise are useless unless they are disseminated and put into practice. Yet current systems that generate new clinical knowledge and those that implement such knowledge are largely disconnected and poorly coordinated. Although many effective, evidence-based practices, therapeu- tics, and interventions are developed every year, only some become widely used in a meaningful way. Overcoming this obstacle will require a focus on the dissemination and translation of research, new partnerships between clinical and health service researchers and clinicians in implementing re- search results, and additional research into the dissemination and diffusion of scientific evidence in the system.

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ACTIONS FOR CONTINUOUS LEARNING, BEST CARE, AND LOWER COSTS 303 Opportunities New efforts to increase the knowledge base on clinical effectiveness, such as PCORI, along with the work of existing research agencies, such as NIH and AHRQ, will help broaden the scope of the clinical research that is undertaken. Further, many research organizations have initiated high-­ rofile efforts to improve the quality and efficiency of clinical trials, p including initiatives at NIH and the Food and Drug Administration’s Clini- cal Trials Transformation Initiative. Based on these efforts and the work of academic research leaders, new types of research trials have been developed, such as pragmatic clinical trials, delayed design trials, and cluster random- ized controlled trials (see Chapter 6 for a description of these types of trials) (Campbell et al., 2007; Eldridge et al., 2008; Tunis et al., 2003, 2010). Ad- vanced statistical methods, including Bayesian analysis, allow for adaptive research designs that can learn as a research study advances, making studies more flexible (Chow and Chang, 2008). These new methods are designed to reduce the expense and effort of conducting research, to improve the applicability of research results to clinical decisions, to improve the abil- ity to identify smaller effects, and to offer an alternative when traditional methods are not feasible. In addition to new research methods, advances in statistical analysis, simulation, and modeling now supplement traditional methods for con- ducting trials. Given that even the most tightly controlled trials show a distribution of patient responses to a given treatment or intervention, new statistical techniques can help segment results for different populations. Further, new Bayesian techniques for data analysis can disentangle the ef- fects of different clinical interventions on overall population health (Berry et al., 2006). With the growth in computational power, newly developed models can replicate physiological pathways and disease states (Eddy and Schlessinger, 2003; Stern et al., 2008). These models can then be used to simulate clinical trials and individualize clinical guidelines according to a patient’s particular situation and biology, which can improve health status while reducing costs (Eddy et al., 2011). As computational power increases, the potential applications of these simulation and modeling tools will con- tinue to advance. In addition, novel technologies allow for new means of collecting health care data directly from patients. Enabled by advances in mobile technologies and informatics, patients and consumers now have the ability to be involved in collecting and sharing data on their personal condition. This vision is being realized through biobanks operated by disease-specific organizations, in addition to social networking sites. Examples of social networking sites that aim to promote patient participation in research in- clude PatientsLikeMe®, Love/Avon Army of Women, and Facebook health

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304 BEST CARE AT LOWER COST groups. While these patient-initiated approaches face challenges, especially related to bias in self-reporting, data quality, and protection against dis- crimination, their prevalence can only be expected to increase. Next Steps To help achieve a learning health care system, health researchers need to play the following roles: • Actively engage with care communities to advance understanding of clinical research and clinical trials and thereby enhance balanced consideration of and enrollment in clinical trials. • Develop and implement new methods for conducting clinical re- search that overcome the limitations of the traditional research enterprise. • Partner with patients to build trust in the clinical research enterprise. • Optimize, through formal and informal structures, the linkages among basic research, clinical research, public health, and care de- livery through such means as technology, communities of learning, and cross-industry collaboration. • Engage in efforts to advance publication and learning as a result of quality improvement efforts. • Advance the science of dissemination and implementation, with a focus on practical strategies for expanding the diffusion of clinical research. DIGITAL TECHNOLOGY DEVELOPERS Roles in Learning Digital technology developers have emerged to meet the growing de- mand to capture, store, retrieve, and share information in virtually every aspect of health care. The range of newly digitalized services is remarkable, encompassing products that assist in scheduling and billing, claims process- ing and payment, supply and equipment inventory maintenance, individual patient records, medication prescribing and tracking, decision support sys- tems, postmarket product monitoring, and disease and treatment registries. Fundamentally, the work of this sector focuses on improving the access of patients and health care providers to reliable, high-quality evidence; en- hancing patient-provider communication and interaction; seamlessly and continuously capturing measures of patient health at ever finer levels of granularity; promoting operational effectiveness and efficiency; improving

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ACTIONS FOR CONTINUOUS LEARNING, BEST CARE, AND LOWER COSTS 305 the ability to manage and analyze large quantities of data; and improving research on clinical effectiveness and quality of care. Challenges to Learning Digital technology developers face multiple challenges to increasing the digital resources for health care. One of the greatest challenges is the need to develop standards that foster data sharing and data quality. For example, sharing of electronic health records is impeded by the fact that a variety of such systems are in use, each of which stores data using different methods and in different formats. Overcoming these challenges will require technological solutions, such as interoperability strategies; methods for highlighting the quality of the data; and ways to identify the data’s source, context, and provenance. In addition, given the complex and demanding nature of modern health care practice, it is necessary to ensure that these tools can be seamlessly integrated into providers’ daily workflow without causing disruptions in their clinical routine. Opportunities An opportunity to promote the adoption of health information tech- nologies was recently provided by the Health Information Technology for Economic and Clinical Health (HITECH) Act, part of the American Re- covery and Reinvestment Act. This legislation formalized the Office of the National Coordinator for Health Information Technology in the Depart- ment of Health and Human Services and provided substantial financial in- centives for health care providers and hospitals to adopt and use electronic health records. Resources devoted to those programs include $2 billion for programs by the National Coordinator, as well as almost $30 billion in Medicare and Medicaid incentive payments to physicians and hospitals (Blumenthal, 2009; Buntin et al., 2010). Notably, the act encourages not only the adoption but also the meaningful use of such record systems. The criteria for incentive eligibility in the first stage of meaningful use were released by CMS on July 13, 2010. The aim of this stage was to capture clinical data in a standardized format within electronic health records and make the data accessible to authorized users (Blumenthal and Tavenner, 2010). Subsequent stages of meaningful use are currently under develop- ment. They will focus on the secure exchange of health information for care coordination and will drive more advanced uses of health information technology systems (Buntin et al., 2010).

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306 BEST CARE AT LOWER COST Next Steps To help achieve a learning health care system, digital technology devel- opers need to play the following roles: • Ensure that electronic health record systems and other digital tech- nologies capture and deliver the core data elements needed to sup- port knowledge generation. • Partner with patients, the delivery system, insurers, researchers, innovators, regulators, and other stakeholders. • Collaborate in the development of core datasets for different dis- eases and conditions to support clinical care, improvement, and research. • Develop tools that assist individuals in managing their health and health care and that provide opportunities for building communi- ties to support patient efforts. • Consider interoperability and integration in clinical workflows in designing digital health systems. HEALTH PRODUCT INNOVATORS AND REGULATORS Roles in Learning By conducting clinical research and developing innovative new treat- ments and interventions, health product innovators play a pivotal role in a learning health care system. In 2010, the biopharmaceutical segment of the market conducted research and development for more than 3,000 products in development (Pharmaceutical Research and Manufacturers of America, 2011). Regulators, including the Food and Drug Administration, play an important role as well in several aspects of the health care system, from the introduction of medical products to surveillance of existing products. Challenges to Learning As with other research sectors, these stakeholders face challenges in generating new clinical evidence. The current research paradigm often requires substantial investments of money and time to answer important questions, limiting the amount of research that can be conducted to answer important questions and develop new products. The research enterprise is especially challenged in understanding how different treatments affect patients in everyday settings and in distinguishing the effects of a treat- ment in different population groups. Regulators similarly face challenges

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ACTIONS FOR CONTINUOUS LEARNING, BEST CARE, AND LOWER COSTS 307 in providing a regulatory framework that ensures safety and effectiveness throughout a product’s life cycle (IOM, 2009b, 2011a,c). Opportunities Health product innovators and regulators will be affected by new developments in the design of health plan benefits, such as the coverage with evidence development designs noted above that provide payment for interventions while evidence on their efficacy continues to be generated. Further, the digital infrastructure will provide new opportunities to gather postmarket surveillance data and identify potential adverse reactions, as well as unexpected indications for a therapy. Finally, the development of new research methods will allow for more granular assessments of a prod- uct’s effectiveness, including the patient populations that benefit (or do not), allowing for more effective use of the product. The industry has an opportunity to build on its productive partnerships in clinical effectiveness research to further advance the capacities of the field. Developments in digital technology allow for new linkages between health product innovators and regulators. Given their interest in the safety and effectiveness of pharmaceuticals, devices, and other products, regula- tors collect and analyze substantial amounts of data to evaluate whether a product is safe and effective for its indicated use. For the health care system to continuously learn and improve, health care knowledge must continu- ously be generated. On the regulatory level, evidence on a product’s effec- tiveness needs to be updated after the product’s introduction. One initiative aimed at addressing this concern is the Food and Drug Administration’s Sentinel Initiative, which is focused on building a national electronic system to monitor the safety of drugs. A related pilot initiative is the Mini-Sentinel network, whose mission is to learn about the barriers and challenges to establishing this type of large-scale product safety monitoring system. Next Steps To help achieve a learning health care system, health product innova- tors and regulators need to play the following roles: • Build a learning system across the industry, anchored in ethical practice, that allows for the most effective public-private partner- ships, learning, and diffusion of innovation. • Probe the unique systems, processes, and needs of high-quality, high-value health care, and conduct applied research on innovative approaches to meeting those needs.

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308 BEST CARE AT LOWER COST • Partner with the health care organizations in the communities in which they and their employees live to address identified opportu- nities for improvement. • Develop tools that assist individuals in managing their health and health care. GOVERNANCE Roles in Learning All governance groups, from boards of health care organizations to governmental bodies, need to be actively involved in promoting a learning health care system. The leadership of these groups, often in collaborative forms, will be necessary to motivate the actions required to create a learn- ing health care system. Hospital and health care delivery system boards have a crucial role in guiding their organizations toward continuous learning and improve- ment. Boards are responsible for the quality of care provided, the financial health and reputation of the organization, oversight of the organization’s executives, and formulation of the organization’s mission (Belmont et al., 2011; Conway, 2008). Better outcomes are associated with organizations in which the board spends time on health care quality concepts, sets a quality agenda, formally monitors quality performance metrics, interacts with staff on strategy, and rewards executive leadership based on measured quality and safety goals (IHI, 2007; Jiang et al., 2009; Vaughn et al., 2006). Challenges to Learning As stated earlier, many institutions still struggle to implement sustain- able, transformational system changes. The challenges range from health care payment incentives that encourage greater use of health care services to an organizational culture opposed to large-scale change. There also is a need to diffuse the lessons learned by pioneer organizations more broadly, so that the whole system can benefit from the knowledge gained through the initiatives of individual organizations. Opportunities As noted earlier, many industries have developed new methods for improving safety, reliability, quality, and value. These methods hold great promise. Encouraging and rewarding their application in health care orga- nizations is an important task of governing bodies.

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ACTIONS FOR CONTINUOUS LEARNING, BEST CARE, AND LOWER COSTS 309 Furthermore, health care organizations have the opportunity to incor- porate and promote learning throughout their governance structures, from governing boards to professional governance bodies. The professional gov- ernance bodies, such as a hospital’s medical committee, generally monitor clinical practice patterns and review professional standards, allowing for an opportunity to promote evidence-based practices and highlighting areas within the organization that achieve high performance. Other committees and governance structures in the organization have similar opportunities to encourage continuous improvement from all the organization’s employees. Next Steps To help achieve a learning health care system, governing bodies need to play the following roles: • Embrace a culture of continuous improvement, with a focus on sharing and learning within and across systems. • Set bold mission-driven aims for clinical, financial, service, and ex- perience outcomes against a frank assessment of the current reality. • Affirm the primary role of health care organizations in serving their communities by working to improve the care experience, popula- tion health, and the value of care. • Establish vibrant collaboratives, with clear aims and expectations for improvement across the care continuum, connecting commu- nity, health care delivery, public health, regulatory, employer, in- surer, education, and other key stakeholders. THE CHALLENGE Missed opportunities for better health care have real human and eco- nomic impacts. If the care in every state were of the quality delivered by the highest-performing state, an estimated 75,000 fewer deaths would have occurred across the country in 2005 (McCarthy et al., 2009; Schoenbaum et al., 2011). Current waste in health care diverts resources from productive uses—estimates suggest almost $750 billion in opportunity costs in 2009 that could be used for improving care on many dimensions (IOM, 2010). It is only through shared commitments, in alignment with a supportive policy environment, that the opportunities offered by science and information technology can be captured. The nation’s health and economic futures— best care at lower cost—depend on the ability to steward the evolution of a continuously learning health care system.

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310 BEST CARE AT LOWER COST REFERENCES AAMC (Association of American Medical Colleges). 2011. Behavioral and social science foundations for future physicians. Washington, DC: AAMC. Association of Academic Health Centers. 2008. HIPAA creating barriers to research and dis- covery: HIPAA problems widespread and unresolved since 2003. http://www.aahcdc.org/ policy/reddot/AAHC_HIPAA_Creating_Barriers.pdf (accessed June 9, 2011). Auerbach, D. I., and A. L. Kellermann. 2011. A decade of health care cost growth has wiped out real income gains for an average US family. Health Affairs 30(9):1630-1636. Belmont, E., C. C. Haltom, D. A. Hastings, R. G. Homchick, L. Morris, J. Taitsman, B. M. Peters, R. L. Nagele, B. Schermer, and K. C. Peisert. 2011. A new quality compass: Hos- pital boards’ increased role under the Affordable Care Act. Health Affairs (Millwood) 30(7):1282-1289. Berry, D. A., L. Inoue, Y. Shen, J. Venier, D. Cohen, M. Bondy, R. Theriault, and M. F. Munsell. 2006. Modeling the impact of treatment and screening on U.S. breast cancer mortality: A Bayesian approach. Journal of the National Cancer Institute Monographs (36):30-36. Blumenthal, D. 2009. Stimulating the adoption of health information technology. New Eng- land Journal of Medicine 360(15):1477-1479. Blumenthal, D., and M. Tavenner. 2010. The “meaningful use” regulation for electronic health records. New England Journal of Medicine 363(6):501-504. Bovbjerg, R. R., and R. A. Berenson. 2012. The value of clinical practice guidelines as mal- practice “safe harbors.” Washington, DC: Urban Institute. Brach, C., B. Dreyer, P. Schyve, L. M. Hernandez, C. Baur, A. J. Lemerise, and R. Parker. 2012. Attributes of a health literate organization. Discussion Paper, Institute of Medicine, Washington, DC. http://iom.edu/~/media/Files/Perspectives-Files/2012/Discussion-Papers/ BPH_Ten_HLit_Attributes.pdf (accessed August 31, 2012). Buntin, M. B., S. H. Jain, and D. Blumenthal. 2010. Health information technology: Laying the infrastructure for national health reform. Health Affairs (Millwood) 29(6):1214-1219. Campbell, M. J., A. Donner, and N. Klar. 2007. Developments in cluster randomized trials and statistics in medicine. Statistics in Medicine 26(1):2-19. Cassel, C. K., and J. A. Guest. 2012. Choosing wisely: Helping physicians and patients make smart decisions about their care. Journal of the American Medical Association 307(17):1801-1802. Chow, S. C., and M. Chang. 2008. Adaptive design methods in clinical trials—a review. Or- phanet Journal of Rare Diseases 3:11. Conway, J. 2008. Getting boards on board: Engaging governing boards in quality and safety. Joint Commission Journal on Quality and Patient Safety 34(4):214-220. DeNavas-Walt, C., B. D. Proctor, and J. C. Smith. 2011. Income, poverty, and health insurance coverage in the United States: 2010. Washington, DC: U.S. Census Bureau. Eddy, D. M., and L. Schlessinger. 2003. Archimedes: A trial-validated model of diabetes. Diabetes Care 26(11):3093-3101. Eddy, D. M., J. Adler, B. Patterson, D. Lucas, K. A. Smith, and M. Morris. 2011. Individual- ized guidelines: The potential for increasing quality and reducing costs. Annals of Internal Medicine 154(9):627-634. Eldridge, S., D. Ashby, C. Bennett, M. Wakelin, and G. Feder. 2008. Internal and external validity of cluster randomised trials: Systematic review of recent trials. British Medical Journal 336(7649):876-880. Ferris, T. G., C. Vogeli, J. Marder, C. S. Sennett, and E. G. Campbell. 2007. Physician spe- cialty societies and the development of physician performance measures. Health Affairs (Millwood) 26(6):1712-1719.

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ACTIONS FOR CONTINUOUS LEARNING, BEST CARE, AND LOWER COSTS 311 Good Stewardship Working Group. 2011. The “top 5” lists in primary care: Meeting the responsibility of professionalism. Archives of Internal Medicine 171(15):1385-1390. Greene, S. M., A. M. Geiger, E. L. Harris, A. Altschuler, L. Nekhlyudov, M. B. Barton, S. J. Rolnick, J. G. Elmore, and S. Fletcher. 2006. Impact of IRB requirements on a multicenter survey of prophylactic mastectomy outcomes. Annals of Epidemiology 16(4):275-278. HRSA (Health Resources and Services Administration). 2008. The physician workforce: Pro- jections and research into current issues affecting supply and demand. Washington, DC: U.S. Department of Health and Human Services. IHI (Institute for Healthcare Improvement). 2007. Protecting 5 million lives from harm. Get- ting started kit: Governance leadership “boards on board.” http://www.longwoods.com/ product/download/code/19364 (accessed August 31, 2012). IOM (Institute of Medicine). 2003. Health professions education: A bridge to quality. Wash- ington, DC: The National Academies Press. IOM. 2009a. Beyond the HIPAA privacy rule: Enhancing privacy, improving health through research. Washington, DC: The National Academies Press. IOM. 2009b. Leadership commitments to improve value in health care: Finding common ground: Workshop summary. Washington, DC: The National Academies Press. IOM. 2010. The healthcare imperative: Lowering costs and improving outcomes: Workshop series summary. Washington, DC: The National Academies Press. IOM. 2011a. Building a national framework for the establishment of regulatory science for drug development: Workshop summary. Washington, DC: The National Academies Press. IOM. 2011b. The future of nursing: Leading change, advancing health. Washington, DC: The National Academies Press. IOM. 2011c. Medical devices and the public’s health: The FDA 510(k) clearance process at 35 years. Washington, DC: The National Academies Press. Jiang, H. J., C. Lockee, K. Bass, and I. Fraser. 2009. Board oversight of quality: Any differ- ences in process of care and mortality? Journal of Healthcare Management 54(1):15-29. Kaiser Family Foundation and Health Research & Educational Trust. 2011. Employer health benefits: 2011 annual survey. Menlo Park, CA: Kaiser Family Foundation and Health Research & Educational Trust. Kocher, R., and N. R. Sahni. 2011. Hospitals’ race to employ physicians—the logic behind a money-losing proposition. New England Journal of Medicine 364(19):1790-1793. Lucian Leape Institute Roundtable on Reforming Medical Education. 2010. Unmet needs: Teaching physicians to provide safe patient care. Boston, MA: National Patient Safety Foundation. McCarthy, D., S. How, C. Schoen, J. Cantor, and D. Belloff. 2009. Aiming higher: Results from a state scorecard on health system performance. New York: Commonwealth Fund Commission on a High Performance Health System. Ness, R. B. 2007. Influence of the HIPAA privacy rule on health research. Journal of the American Medical Association 298(18):2164-2170. Pham, H. H., D. Schrag, A. S. O’Malley, B. Wu, and P. B. Bach. 2007. Care patterns in Medi- care and their implications for pay for performance. New England Journal of Medicine 356(11):1130-1139. Pharmaceutical Research and Manufacturers of America. 2011. Pharmaceutical industry profile 2011. Washington, DC: Pharmaceutical Research and Manufacturers of America. Schoenbaum, S. C., C. Schoen, J. L. Nicholson, and J. C. Cantor. 2011. Mortality amenable to health care in the United States: The roles of demographics and health systems per- formance. Journal of Public Health Policy 32(4):407-429.

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312 BEST CARE AT LOWER COST Staiger, D. O., D. I. Auerbach, and P. I. Buerhaus. 2009. Comparison of physician work- force estimates and supply projections. Journal of the American Medical Association 302(15):1674-1680. Stern, M., K. Williams, D. Eddy, and R. Kahn. 2008. Validation of prediction of diabetes by the Archimedes model and comparison with other predicting models. Diabetes Care 31(8):1670-1671. Tunis, S. R., D. B. Stryer, and C. M. Clancy. 2003. Practical clinical trials: Increasing the value of clinical research for decision making in clinical and health policy. Journal of the American Medical Association 290(12):1624-1632. Tunis, S. R., J. Benner, and M. McClellan. 2010. Comparative effectiveness research: Pol- icy context, methods development and research infrastructure. Statistics in Medicine 29(19):1963-1976. U.S. Bureau of Labor Statistics. 2011. Occupational employment statistics: Occupational profiles (May 2011 estimates). http://www.bls.gov/oes/current/oes_stru.htm#29-0000 (ac- cessed May 15, 2012). Vaughn, T., M. Koepke, E. Kroch, W. Lehrman, S. Sinha, and S. Levey. 2006. Engagement of leadership in quality improvement initiatives: Executive quality improvement survey results. Journal of Patient Safety 2(1). Washington, A. E., and S. H. Lipstein. 2011. The Patient-Centered Outcomes Research Institute—promoting better information, decisions, and health. New England Journal of Medicine 365(15):e31. Woolley, M., and S. M. Propst. 2005. Public attitudes and perceptions about health-related research. Journal of the American Medical Association 294(11):1380-1384.