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BEST CARE AT LOWER COST
The Path to Continuously Learning
Health Care in America
Committee on the Learning Health Care System in America
Mark Smith, Robert Saunders, Leigh Stuckhardt, and J. Michael cGinnis,
M
Editors
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing
Board of the National Research Council, whose members are drawn from the councils
of the National Academy of Sciences, the National Academy of Engineering, and the
Institute of Medicine. The members of the committee responsible for the report were
chosen for their special competences and with regard for appropriate balance.
Support for this report was provided by the Blue Shield of California Foundation; the
Charina Endowment Fund; and the Robert Wood Johnson Foundation. Any opinions,
findings, conclusions, or recommendations expressed in this publication are those of the
author(s) and do not necessarily reflect the view of the organizations or agencies that
provided support for this project.
Library of Congress Cataloging-in-Publication Data
Best care at lower cost : the path to continuously learning health care in
America / Committee on the Learning Health Care System in America, The
Institute of Medicine ; Mark Smith ... [et al.], editors.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-309-26073-2 (hardcover) — ISBN 978-0-309-26074-9 (pdf)
I. Smith, Mark D., M.D. II. Institute of Medicine (U.S.). Committee on the
Learning Health Care System in America.
[DNLM: 1. Delivery of Health Care—economics—United States. 2. Costs and
Cost Analysis—United States. 3. Efficiency, Organizational—economics—
United States. 4. Quality of Health Care—economics—United States. W 84 AA1]
368.38′200973—dc23
2012040484
Additional copies of this report are available from the National Academies Press, 500
Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313;
http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at:
www.iom.edu.
Copyright 2013 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all
cultures and religions since the beginning of recorded history. The serpent adopted as a
logotype by the Institute of Medicine is a relief carving from ancient Greece, now held
by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2013. Best care at lower cost: The
path to continuously learning health care in America. Washington, DC: The National
Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
Advising the Nation. Improving Health.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific and engineering research, dedicated to
the furtherance of science and technology and to their use for the general welfare.
Upon the authority of the charter granted to it by the Congress in 1863, the Acad-
emy has a mandate that requires it to advise the federal government on scientific
and technical matters. Dr. Ralph J. Cicerone is president of the National Academy
of Sciences.
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federal government. The National Academy of Engineering also sponsors engineer-
ing programs aimed at meeting national needs, encourages education and research,
and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi-
dent of the National Academy of Engineering.
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Sciences to secure the services of eminent members of appropriate professions in
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tute acts under the responsibility given to the National Academy of Sciences by its
congressional charter to be an adviser to the federal government and, upon its own
initiative, to identify issues of medical care, research, and education. Dr. Harvey V.
Fineberg is president of the Institute of Medicine.
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in 1916 to associate the broad community of science and technology with the
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Functioning in accordance with general policies determined by the Academy, the
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C
ouncil is administered jointly by both Academies and the Institute of Medicine.
Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively,
of the National Research Council.
www.national-academies.org
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COMMITTEE ON THE LEARNING HEALTH
CARE SYSTEM IN AMERICA
MARK D. SMITH (Chair), President and Chief Executive Officer,
California HealthCare Foundation, Oakland
JAMES P. BAGIAN, Professor of Engineering Practice, University of
Michigan, Ann Arbor
ANTHONY S. BRYK, President, Carnegie Foundation for the
Advancement of Teaching, Stanford, CA
GAIL H. CASSELL, Former Vice President, Scientific Affairs, Eli Lilly and
Company, Carmel, IN
JAMES B. CONWAY, Senior Fellow, Institute for Healthcare
Improvement, Boston, MA
HELEN B. DARLING, President, National Business Group on Health,
Washington, DC
T. BRUCE FERGUSON, JR., Professor and Inaugural Chairman,
Department of Cardiovascular Sciences, East Carolina University,
Greenville, NC
GINGER L. GRAHAM, Former President and Chief Executive Officer,
Amylin Pharmaceuticals, and Former Group Chairman, Guidant
Corporation, Boulder, CO
GEORGE C. HALVORSON, Chairman and Chief Executive Officer,
Kaiser Permanente, Oakland, CA
BRENT C. JAMES, Chief Quality Officer, Intermountain Health Care,
Inc., Salt Lake City, UT
CRAIG A. JONES, Director, Vermont Blueprint for Health, Burlington
GARY S. KAPLAN, Chairman and Chief Executive Officer, Virginia
Mason Health System, Seattle, WA
ARTHUR A. LEVIN, Director, Center for Medical Consumers,
New York, NY
EUGENE LITVAK, President and Chief Executive Officer, Institute for
Healthcare Optimization, Newton, MA
DAVID O. MELTZER, Director, Center for Health and the Social
Sciences, University of Chicago, IL
MARY D. NAYLOR, Director, NewCourtland Center for Transitions and
Health, University of Pennsylvania School of Nursing, Philadelphia
RITA F. REDBERG, Professor of Medicine, University of California,
San Francisco
PAUL C. TANG, Vice President and Chief Innovation and Technology
Officer, Palo Alto Medical Foundation, and Consulting Associate
Professor of Medicine, Stanford University, Palo Alto, CA
v
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IOM Staff
ROBERT SAUNDERS, Study Director
LEIGH STUCKHARDT, Program Associate
JULIA C. SANDERS, Senior Program Assistant
BRIAN W. POWERS, Senior Program Assistant (through July 2012)
VALERIE ROHRBACH, Senior Program Assistant
CLAUDIA GROSSMAN, Senior Program Officer
ISABELLE VON KOHORN, Program Officer
BARRET ZIMMERMANN, Program Assistant
J. MICHAEL McGINNIS, Senior Scholar
Consultants
RONA BRIERE, Briere Associates, Inc.
ALISA DECATUR, Briere Associates, Inc.
vi
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Reviewers
This report has been reviewed in draft form by individuals chosen
for their diverse perspectives and technical expertise, in accordance with
procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid
and critical comments that will assist the institution in making its published
report as sound as possible and to ensure that the report meets institutional
standards for objectivity, evidence, and responsiveness to the study charge.
The review comments and draft manuscript remain confidential to protect
the integrity of the deliberative process. We wish to thank the following
individuals for their review of this report:
WYLIE BURKE, Professor and Chair, Department of Bioethics and
Humanities, University of Washington, Seattle
MICHAEL CHERNEW, Professor of Health Care Policy, Harvard
Medical School, Boston, MA
JANET CORRIGAN, Former President and Chief Executive Officer,
National Quality Forum, Washington, DC
JOHN HALAMKA, Chief Information Officer, CareGroup Health
System, Boston, MA
GEORGE ISHAM, Medical Director and Chief Health Officer,
HealthPartners, Inc., Bloomington, MN
STEPHEN KIMMEL, Professor of Medicine, University of
Pennsylvania School of Medicine, Philadelphia
ALLEN S. LICHTER, Chief Executive Officer, American Society of
Clinical Oncology, Alexandria, VA
vii
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viii REVIEWERS
ANGELA BARRON McBRIDE, Distinguished Professor and
University Dean Emerita, Indiana University School of Nursing,
Lafayette
MARK McCLELLAN, Director, Engelberg Center for Health Care
Reform, The Brookings Institution, Washington, DC
LYN PAGET, Director of Policy and Outreach, Informed Medical
Decisions Foundation, Boston, MA
LEWIS SANDY, Senior Vice President, Clinical Advancement,
UnitedHealth Group, Minnetonka, MN
EDWARD H. SHORTLIFFE, Scholar in Residence, New York
Academy of Medicine, New York
STEVEN SPEAR, Senior Lecturer, Engineering Systems Division,
Massachusetts Institute of Technology, Cambridge
JOHN TOUSSAINT, Chief Executive Officer, ThedaCare Center for
Healthcare Value, Appleton, WI
YULUN WANG, Chairman and Chief Executive Officer, InTouch
Health, Goleta, CA
DIANA ZUCKERMAN, President, National Research Center for
Women & Families, Washington, DC
Although the reviewers listed above provided many constructive com-
ments and suggestions, they were not asked to endorse the report’s conclu-
sions or recommendations, nor did they see the final draft of the report
before its release. The review of this report was overseen by coordinator
Robert S. Galvin, Chief Executive Officer, Equity Healthcare, The Blackstone
Group, New York, NY, and monitor Emmett B. Keeler, rofessor of Health
P
Services, Pardee RAND Graduate School, University of California, Los
Angeles, School of Public Health, Santa Monica, CA. Appointed by the
National Research Council and Institute of Medicine, they were responsible
for making certain that an independent examination of this report was
carried out in accordance with institutional procedures and that all review
comments were carefully considered. Responsibility for the final content of
this report rests entirely with the authoring committee and the institution.
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Foreword
Best Care at Lower Cost: The Path to Continuously Learning Health
Care in America presents a vision of what is possible if the nation ap-
plies the resources and tools at hand by marshaling science, information
technology, incentives, and care culture to transform the effectiveness and
efficiency of care—to produce high-quality health care that continuously
learns to be better.
More than a decade since the Institute of Medicine’s (IOM’s) To Err
Is Human: Building a Safer Health System was published, the U.S. health
care system continues to fall far short of its potential. Although To Err Is
Human and other IOM reports, including the Crossing the Quality Chasm
series, have helped spark numerous efforts to improve practices, persistent
health care underperformance and high costs highlight the considerable
challenge of bringing isolated successes to scale. The nation has yet to see
the broad improvements in safety, accessibility, quality, or efficiency that
the American people need and deserve.
Leaders from every sector that bears on health have a part to play in
realizing such broad improvements. Recognizing the need for cross-sector
collaboration, in 2006 the IOM organized the Roundtable on Value &
Science-Driven Health Care. The Roundtable convenes leaders from across
the health care system—including representatives of patients and consumers,
providers, manufacturers, payers, research, and policy—to help make con-
tinuous improvement in performance an intrinsic part of U.S. health care.
Under the guidance of its membership, the Roundtable has developed
and articulated a vision of this new system—a learning health care system
that links personal and population data to researchers and practitioners,
ix
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x FOREWORD
dramatically enhancing the knowledge base on effectiveness of interven-
tions and providing real-time guidance for superior care in treating and
preventing illness. A health care system that gains from continuous learning
is a system that can provide Americans with superior care at lower cost.
The IOM Committee on the Learning Health Care System in America
was convened to explore and advance this vision of continuously learn-
ing health care. The committee’s report describes the key challenges faced
by the health care system today—the mounting complexity of modern
medicine, the rising cost of care, and the limited return on investment—and
outlines how to harness new technologies, innovations, and approaches to
overcome these challenges.
Importantly, the report demonstrates how a health care system that de-
livers the best care at lower cost is not only necessary, but also possible. The
committee has articulated detailed strategies for incorporating continuous
learning and improvement into all facets of health care. The report recog-
nizes the multifaceted and integrative nature of the needed transformation
and outlines the multiple and concerted actions necessary across all sectors
to achieve that transformation. No one individual, organization, or sector
alone can effect the scope and scale of transformative change necessary
for a true learning system. Rather, leadership from all sectors working in
concert will be required.
I would like to express my gratitude to the committee and staff who
produced this report that sets forth a vision for a successful, sustainable
health care system—one that continuously learns and improves. The in-
sights, ideas, and recommendations offered here point the way to building
a superior health care system for all Americans.
Harvey V. Fineberg, M.D., Ph.D.
President, Institute of Medicine
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Preface
The tragic life of Dr. Ignaz Semmelweis offers an example of the chal-
lenges faced in building a truly learning health care system. The Hungarian
physician observed that simply washing hands could drastically reduce high
rates of maternal death during childbirth. But since he could not prove
a connection between hand washing and the spread of infection, he was
ridiculed and ignored. Hounded out of his profession, he died in a mental
hospital. More than 165 years later, half of clinicians still do not regularly
wash their hands before seeing patients.
The challenges today are in some ways that straightforward, and in
many other ways significantly more complex. Narrow-minded rejection of
scientific evidence is rarely encountered today in medicine, yet the American
health care system imposes significant institutional, economic, and peda-
gogic barriers to learning and adapting.
For more than a decade, reports of the Institute of Medicine (IOM)
have focused attention on a persistent set of problems within the Ameri-
can health care system that urgently need to be addressed, including poor
quality; lax safety; high cost; questionable value; and the maldistribution
of care based on income, race, and ethnicity. Each report has called for
substantive transformation of the nation’s health care system. Many have
pointed out a disturbing paradox: the coexistence of overtreatment and
undertreatment. The committee that authored this report found a similar
situation: learning and adoption that are maddeningly slow—as with hand
washing—coexisting with overly rapid adoption of some new techniques,
devices, and drugs, with harmful results.
xi
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xii PREFACE
Exemplary efforts under way across the nation are working on these
problems. Indeed, some members of this committee come from organiza-
tions that are pacesetters in continuous learning. But the pace of change
is too slow, and adoption is too spotty; the system is not evolving quickly
enough. The system needs to learn more rapidly, digest what does and does
not work, and spread that knowledge in ways that can be broadly adapted
and adopted. This report offers a roadmap for accomplishing this vision to
benefit patients and society.
The committee identified two reasons for the above problems that grow
more urgent every year. One is the increasingly unmanageable complexity
of the science of health care. During the past half-century, there has been an
explosion of biomedical and clinical knowledge, with even more dazzling
clinical capabilities just over the horizon. However, the systems by which
health care providers are trained, deployed, paid, and updated cannot use-
fully digest this deluge of information. Second is the ever-escalating cost of
care, which is widely acknowledged to be wasteful and unsustainable. Un-
less ways are found to provide more efficient, lower-cost health care, more
and more Americans will lose coverage of and access to care.
The committee also believes that opportunities exist for attacking these
problems—opportunities that did not exist even a decade ago.
• Vast computational power (with associated sophistication of infor-
mation technology) has become affordable and widely available.
This capability makes it possible to harvest useful information
from actual patient care (as opposed to one-time studies), some-
thing that previously was impossible.
• Connectivity allows that power to be accessed in real time virtually
anywhere by professionals and patients, permitting unprecedented
diffusion of information cheaply, quickly, and on demand.
• Progress in human and organizational capabilities and management
science can improve the reliability and efficiency of care, permitting
more scientific deployment of human and technical resources to
match the complexity of systems and institutions.
• Increasing empowerment of patients unleashes the potential for
their participation, in concert with clinicians, in the prevention and
treatment of disease—tasks that increasingly depend on personal
behavior change.
The committee recognizes that individual physicians, nurses, techni-
cians, pharmacists, and others involved in patient care work diligently to
provide high-quality, compassionate care to their patients. The problem is
not that they are not working hard enough; it is that the system does not
adequately support them in their work. The system lags in adjusting to new
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PREFACE xiii
discoveries, disseminating data in real time, organizing and coordinating
the enormous volume of research and recommendations, and providing
incentives for choosing the smartest route to health, not just the newest,
shiniest—and often most expensive—tool. These broader issues prevent cli-
nicians from providing the best care to their patients and limit their ability
to continuously learn and improve.
In completing its work, the committee solicited the views of more than
200 individuals, representing clinicians, patients, health care delivery lead-
ers, clinical researchers, professional societies, life science industries, infor-
mation technology developers, and government agencies. The information
gleaned from these individuals enabled the committee to better understand
the challenges to learning and improvement, as well as to learn from the
experiences of those who have successfully incorporated learning and im-
provement into their regular work. In addition, the IOM staff provided
excellent research, analysis, and writing support for this project and assisted
the committee in its deliberative process.
Given the imperatives and opportunities outlined above, this is the right
time for the vision proposed in this report to be realized. Developing a con-
tinuously learning health care system is critical for the future of health care,
as well as for the future physical and financial health of the nation. There
is no simple path forward; rather, actions need to be taken by every stake-
holder if this vision is to become a reality. Such concerted action will enable
the nation’s health care system to evolve to one that continuously learns
and improves, finally providing Americans with the best care at lower cost.
Mark D. Smith, Chair
Committee on the Learning Health Care System in America
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Acknowledgments
Best Care at Lower Cost: The Path to Continuously Learning Health
Care for America reflects the contributions of many people. The committee
would like to acknowledge and express strong appreciation to those who
so generously participated in the development of this report.
First, we would like to thank the sponsors of this project, the Blue
Shield of California Foundation, the Charina Endowment Fund, and the
Robert Wood Johnson Foundation, for their financial support.
The committee would also like to thank Lynn Etheredge for his assis-
tance with this effort. He was a member of the committee from January 1,
2011, until August 2, 2011, and his contributions to the committee’s early
thinking are very much appreciated.
The committee’s deliberations were informed by presentations and dis-
cussions at four meetings held between January 2011 and January 2012.
Additional input was sought from numerous outside stakeholders, and we
would like to thank the 137 organizations and individuals who provided
their input on committee directives.
A number of Institute of Medicine (IOM) staff played instrumental
roles in coordinating the committee meetings and the preparation of this
report, including Leigh Stuckhardt, Julia Sanders, Claudia Grossmann,
Brian Powers, Valerie Rohrbach, and Isabelle Von Kohorn. The committee
would also like to thank Lauren Tobias, Laura Harbold DeStefano, and
Sarah Ziegenhorn for helping to coordinate the various aspects of report
review, production, and publication. Committee consultant Rona Briere,
Briere Associates, Inc., made indispensable contributions to the report pro-
duction and publication processes. Additionally, we would like to thank
xv
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xvi ACKNOWLEDGMENTS
both Column Five Media and LeAnn Locher for their contributions to the
graphic portrayal and cover of this report. The committee would especially
like to thank Robert Saunders, study director, for his overall guidance and
support. Finally, we would like to acknowledge the guidance and contri-
butions of Michael McGinnis, IOM senior scholar, throughout the study
process.
America has the potential to realize a transformative learning health
care system that could revolutionize the way care is delivered and under-
stood. While great strides have already been made with new policy, sturdy
dedication and engagement will continue to be instrumental as health care
delivery in the United States is restructured. We look forward to building
upon the ideas that have emerged in this report and achieving a learning
health care system.
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Contents
Abstract 1
Summary 5
The Imperatives, 8
The Vision, 17
The Path, 19
Actions for Continuous Learning, Best Care, and Lower Costs, 28
Achieving the Vision, 36
References, 38
PART I: THE IMPERATIVES
1 Introduction and Overview 47
The Need for a Continuously Learning Health Care System, 49
Study Context, 50
Statement of Task, Scope, and Methods, 57
Organization of the Report, 59
References, 60
2 Imperative: Managing Rapidly Increasing Complexity 63
Clinical Complexity, 64
Administrative Complexity, 79
References, 83
xvii
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xviii CONTENTS
3 Imperative: Achieving Greater Value in Health Care 91
Unacceptable Outcomes, 92
Unsustainable Costs, 99
Consequences of Inaction, 105
References, 105
4 Imperative: Capturing Opportunities from Technology,
Industry, and Policy 111
The Digital Infrastructure: Computing, the Internet,
and Mobile Technologies, 112
Lessons in Continuous Improvement from Other Industries, 117
Opportunities from a Changing Health Policy Landscape, 121
References, 126
PART II: THE VISION
5 A Continuously Learning Health Care System 133
Definition, 136
Characteristics, 136
The Path to a Continuously Learning Health Care System, 143
References, 144
PART III: THE PATH
6 Generating and Applying Knowledge in Real Time 149
Need for a New Approach to Knowledge Generation, 150
Emerging Capacities, Methods, and Approaches, 157
Creation of the Data Utility, 159
The Learning Bridge: From Knowledge to Practice, 167
People, Patients, and Consumers as Active Stakeholders, 173
Framework for Achieving the Vision, 175
References, 179
7 Engaging Patients, Families, and Communities 189
Centering Care on People’s Needs and Preferences, 191
Engaging Patients as Active Participants in Their Care, 196
Integrating Health Care and the Health of the Community, 206
Framework for Achieving the Vision, 214
References, 217
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CONTENTS xix
8 Achieving and Rewarding High-Value Care 227
Obstacles to High-Value Care, 228
Measurement of Results and Value, 232
Strategies for Achieving Transparency, 234
The Path to a System That Pays for Continuous Improvement, 239
Framework for Achieving the Vision, 245
References, 247
9 Creating a New Culture of Care 255
Organizational Leadership for Care Transformation, 257
Teaming, Partnership, and Continuity, 261
Consistency, Reliability, and Transparency of Results, 263
Alignment of Incentives Within and Across Organizations, 271
Framework for Achieving the Vision, 273
References, 275
10 Actions for Continuous Learning, Best Care, and Lower Costs 281
Achieving the Vision, 281
Patients, Consumers, Caregivers, Communities, and the Public, 290
Clinicians and Their Teachers, 292
Professional Specialty Societies, 294
Delivery System Leaders, 296
Health Insurers, 298
Employers, 300
Health Researchers, 301
Digital Technology Developers, 304
Health Product Innovators and Regulators, 306
Governance, 308
The Challenge, 309
References, 310
APPENDIXES
A Glossary 313
B A CEO Checklist for High-Value Care 315
C ACA Provisions with Implications for a Learning Health Care
System 389
D Biosketches of Committee Members and Staff 401
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