Engineering a Learning Healthcare System A Look at the Future: Workshop Summary (2011) / Chapter Skim
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3 Healthcare System Complexities, Impediments, and Failures
3 Healthcare System Complexities, Impediments, and Failures
Pages 117-170
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From page 117... ...
Stead, chief information officer of Vanderbilt University Medical Center, described the current healthcare environment as being characterized by competition, misaligned incentives, and inherent distrust among stakeholders. Throughout health care, Stead sees competing cultures at loggerheads -- as exemplified by the tensions among consum 11
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From page 118... ...
As health care has become more complex, the lag in the sophistication of data applications in evidence generation has become more acute. Engineering principles, Chase suggested, could help those in charge of health care manage various complex processes and increase the use of data for clinical decision support.
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From page 119... ...
Deutschendorf suggested a number of other changes, including more clarification, definition, and distinctions between acute patient care and ambulatory care; better management of consumer expectations; and increased communication and collaboration between caregiving team members. Because models of care need to be based more firmly on evidence, she proposed that rigorous research be conducted to determine which care delivery models can yield appropriate safety outcomes and the highest possible quality outcomes.
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From page 120... ...
As the health professions and other stakeholders realize that they cannot escape disruptive change, we will have a once-in-a-century chance to test better approaches to health care. Building on these observations, this paper contrasts the current healthcare culture with a future culture in which care is delivered through systems approaches.
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From page 121... ...
The culture of the health professions is influenced by the way decisions are made. The reasoning of health professionals, because they are experts, takes place through the recognition of patterns.
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From page 122... ...
Health professionals do their best to deliver exceptional care despite the "system." Time is the most limited resource. The combination of these internal roots and external pressures has led the culture of the health professions to become one in which circumstances that conflict with quality health care are accepted.
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From page 123... ...
They are forced to change health plans regularly as employers and government seek to control costs. A Medicare beneficiary sees a median of two primary care providers and five specialists per year, and Medicare beneficiaries with multiple chronic diseases see up to 16 health professionals (Pham, 2007)
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From page 124... ...
In the process of shifting toward this vision or other possible futures, health professionals must strive to preserve the best of the current culture. Most people engaged in health care are passionate about what they are do TABLE 3-1 Comparison of Current and Possible Future Healthcare Cultures Current Culture Future Culture • Layer fix on fix from outside • Improve from the inside out • Trust oneself; provide care despite the • Know one's limits; trust the system and system one's team • Care safe for the masses • Right care for the individual • Manage episodes of care • Care for populations and the patient as a whole • Expert-mediated use of evidence • Systematic use of evidence • Each patient is an experiment with • Each patient is a data point in a n=1 population • Learn in disciplinary silos • Learn in teams • Learn by applying science through • Learn from simulation and outcomes practice • Pay for piece work and process steps • Pay for coordination and outcomes
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From page 125... ...
It was difficult to be criticized for ordering too many tests as one could also be criticized for omitting a potentially useful test. All of the incentives in medical training lean toward ordering more tests, and how the additional information improves patient care receives little consideration.
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From page 126... ...
This point is best illustrated by randomized controlled trials. The current healthcare system does not emphasize the need for evidence of benefit before widespread diffusion of new technology.
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From page 127... ...
Defensive medicine, such as ordering a specific test because of concern about being sued, is always mentioned as a driver of healthcare costs in relation to technology advances. Patient demand for the use of new technologies has also increased.
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From page 128... ...
collaborated on draft text that could be used for local CCTA coverage decisions, based on the ACC and ACR consensus concerning indications for use of the technology. Just a few months after the Medicare coverage meeting in which the evidence was found to be insufficient, all 50 states had included CCTA in Medicare coverage by local decisions (Redberg, 2007)
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From page 129... ...
More randomized controlled trials -- which will require more funding -- is in order, as is the development of more observational data. It is important that these data be gathered, analyzed, and incorporated into practice guidelines and reimbursement.
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From page 130... ...
A LOOK AT THE FUTURE OF CLINICAL DATA SYSTEMS AND CLINICAL DECISION SUPPORT Michael D Chase, M.D., Kaiser Permanente Colorado To date, health care in the United States has not fully leveraged the available clinical data to improve the health outcomes of individuals and populations.
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From page 131... ...
The barriers to synthesizing and using information to support enhanced care delivery can be viewed in terms of four broad categories: people and culture, process, data and technology, and the healthcare environment. Challenges from the people standpoint include the prevailing culture of health care with its hierarchical, often physician-centric, and slow-to-evolve team-based approach to care.
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From page 132... ...
Another way of framing this point is to ask, "What sorts of information do the patient, the clinician, and the healthcare team need to meet their agreed-upon healthcare goals? " A review of clinical decision support published in 2005 in the British Medical Journal concluded that "clinical decision support systems have shown great promise for reducing medical errors and improving patient care.
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From page 133... ...
In approaching clinical decision support, one needs to think broadly across the care team members, including the patient; across the continuum of care; and across the tools and systems available. Some decision support opportunities include • eference information and guidance -- clinical evidence sources and r guidelines, • irect-to-patient clinical decision support -- availability of d information, • eleant data presentation -- attention to the human–computer r interface, • ocumentation forms and templates -- integration into the workflow, d • rder entry facilitator -- integration of decision support at order o entry, • rotocol and pathway support -- a way to facilitate the care p process, • reactie alert and reminders -- used judiciously, and • se of clinical data -- clinical registries to support the planned care u model.
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From page 134... ...
Decision support can also be embedded in the pharmacy information system, thereby using the pharmacist as another team member in the care delivery process. Finally, the enhanced system uses clinical registries, which apply data from the EMR as well as other clinical systems.
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From page 135... ...
Also of interest is that the organization has seen a financial return because fewer patients with cardiovascular disease require rehospitalization or further cardiac interventions. The development of the KPCO Cardiac Rehabilitation and Clinical Pharmacy Cardiac Risk Service addressed and overcame many of the barriers in the areas of people and culture, process, data and technology, and the healthcare environment that were reviewed earlier, resulting in superior clinical outcomes.
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From page 136... ...
The proliferation of new medical information and technologies, increased regulatory oversight, an aging population, and heightened consumer awareness and expectations are all affecting the ability to provide coherent care for patients. The dismantling of traditional care delivery models as a result of cost constraints in the early 1990s has also contributed to the disorganization, fragmentation, and discontinuity of patient care.
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From page 137... ...
Although some new patient care delivery models were proposed that centered care on patients and families, most were more closely related to industrial approaches geared to achieving efficiencies affecting the bottom line. Untested models were implemented without evidence of improved clinical quality outcomes, effective care delivery systems were frequently dismantled, and unskilled workers were substituted for professional staff.
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From page 138... ...
Although these objectives are significantly different from those of just 20 years ago, patient care delivery processes have not changed dramatically, even as the increased severity of illness demands significant transformation. As noted, it is not uncommon for a quarter of a large academic hospital's patients to have a length of stay of 24 hours or less.
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From page 139... ...
. An example is the increase in redundant pneumococcal vaccinations for hospital inpatients as acute care facilities attempt to comply with Joint Commission Core Measures.
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From page 140... ...
Patient care planning is unidimensional and uncoordinated as a result of poor communication among providers, patients, and families and across levels of care. Hand-offs between providers, from shift to shift and across transitions, are insufficient and frequently result
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From page 141... ...
New structures and processes must be built to support these elements. Strategies must be implemented that support frequent, real-time, mul TABLE 3-2 Patient Care Delivery Transition Old Approach New Approach • Focus is on the high-risk patient • Focus is on all patients • Episodic acute care is the priority • Continuity of care across the care continuum is the priority • Healthcare professionals work in • Collaboration among healthcare team isolation members is required • Care planning is conceptual • Care planning is aggressive and results oriented, and prevention is important • Provider infrastructure is fragmented, • Provider infrastructure is fully integrated and information systems are not integrated
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From page 142... ...
. Even the simple approach of having all members of provider teams take part in daily multidisciplinary rounds with all patients can improve patient care planning, expedite care delivery, and reduce fragmentation.
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From page 143... ...
To accomplish the overarching and major systemic changes in patient care delivery required to achieve true improvements in quality and safety, certain healthcare traditions must be addressed. These traditions exist in all disciplines and in each patient care environment.
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From page 144... ...
Often the tendency within the hospital is to blame the finance office, which sends the bill, but in fact the bill generated is the result of a multistep process that commences before the patient is even provided care. As shown in Figure 3-1, the typical hospital billing process is complex, and breakdowns can and do occur at many points.
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From page 145... ...
The process and system changes implemented also yielded productivity improvements equivalent to 20 staff. Access to Physicians A second transformation effort at UPHS focused on increasing patient access to physicians.
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From page 146... ...
Rescheduling patients after a cancellation required a great deal of extra work. To tackle such service and efficiency issues, UPHS evaluated the full continuum of its care process, including access and scheduling of appointments, availability, patient flow during and after the visit, and follow-up.
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From page 147... ...
Sharing comparative data with physicians, most of whom strive to be among the best, has spurred internal competition to achieve and demonstrate improvement. Inpatient Stays As is the case with many acute care hospitals in the country, occupancy rates at UPHS are very high, with patients occupying 90 percent or more of the hospitals' beds on average.
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From page 148... ...
To advance patient care processes inside the hospital, it was critical to track the key steps in the patient journey from admission to discharge, sharing information in real time with all caregivers. • edesign workflows and restructure roles, integrating information R technology.
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From page 149... ...
Efforts to redesign the care processes at UPHS were inte grated into the overall management plan of the organization. For example, all UPHS administrators, including the CEO, academic department chairs, and every member of senior management, have related goals that are written into their individual and team plans.
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From page 150... ...
As suggested by the above quotation from Weinstein, a basic premise is that the intelligent design of health information systems can unite clinical practice with clinical research and contribute powerfully to a learning healthcare system, with everyone learning from his or her own practice base. The Nature of the Problem This section begins with a case study (fictitious name, but based on a real situation)
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From page 151... ...
This case represents a common situation: the presence of disconnected, partial, non-patient-centric data and information on the patient's health status and how it has evolved over time, plus limited information on prior healthcare experiences and the associated treatments and outcomes. This state of affairs is bad for patient care, bad for practice-based learning and improvement (a core competency of today's physician)
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From page 152... ...
challenge is to keep the data connected to the individual patient and to the population of patients as they travel through the healthcare system. For example, during an illness patients receive services from different sites, such as primary care, specialty care, home health care, a community hospital, or an academic medical center.
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From page 153... ...
Satisfaction of need, monitoring, assessment of outputs Feed Forward Acute Care Management Initial Chronic Care Enrollment Orient ation Work Up Management Assignment Plan for Care Preventative Care Management People with healthcare People with needs met healthcare needs Palliative Care Functional Health Status Functional Health Status Feedback Clinical Biological Expectations Clinical Status Biological Satisfaction Status Against Costs Need Costs Customer knowledge, including knowledge of customer's life while not in direct contac t with healthcare system FIGURE 3-4 Feed-forward and feedback in the context of a general clinical F3 -4.eps microsystem. SOURCE: Eugene C
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From page 154... ...
The clinician completes the assessment based on the patient's medical history, a physical examination, and diagnostic tests, all of which contribute to a patient-centric plan of care. The patient care plan will include a blend of services -- preventive, acute, chronic, and palliative -- based on the patient's current needs and preferences and on the success of the care plan at producing desired outcomes efficiently.
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From page 155... ...
This common situation poses several daunting challenges to the design of health information systems that contribute to patient care, research, and education while delivering the best possible results in the most efficient manner. The data challenges can be summarized by the phrase "embed, feed forward, generate, and cascade." Again referring to Figure 3-5, which portrays the healthcare system by blending "horizontally linked clinical microsystems" with "vertically organized healthcare delivery systems," we can see that there are three fundamental challenges to the design of high-utility healthcare information systems:
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From page 156... ...
• enerate accurate data from the care process to be used for clinical G program improvement, biomedical research, health professional education, and transparent public reporting on health outcomes and costs of care. The core assumption is that in the design of high-utility EHRs it is not enough to have standardized nomenclature for the essential elements of care (tests, diagnoses, procedures, medications, and so forth)
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From page 157... ...
. The value compass approach suggests that the quality of patient care outcomes can be measured by focusing on three domains -- clinical, functional, and satisfaction against need -- whereas the costs of care can be captured in a fourth domain, which is measured by determining the direct costs of providing care to patients and the indirect social costs patients incur by being ill or injured and receiving care.
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From page 158... ...
Part of the plan for what would come to be called the Dartmouth Spine Center was to build a real-time, feed-forward information environment, using the clinical value compass framework, that would actively contribute to better patient care, better research, and a better learning environment. This information environment was built for primary and subspecialty care, all delivered and integrated within the same home, addressing a multidimensional set of clinical problems with an interdisciplinary, patient-centered approach and incorporating patients' values and preferences.
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From page 159... ...
When patients come to the Spine Center, they complete a computerized survey before seeing a clinician or clinical team, and their health status and expectations are recorded. That information feeds into the assessment.
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From page 160... ...
The Spine Center case provides a proof of principle for the patient Shared Feed Forward Decision Sub-Acute Making Care Management Functional Interdisciplinar y Restoration Patient Program Assessment Enrollment Orient ation Assignment Preventative Care People with People with Management healthcare needs healthcare needs met Feedback Disenrollment Functional Functional Health Status Health Status National Biological Spine Expectations Satisfaction National Status Clinical Network Against Spine Biological Survey Network Need Costs Status Database Costs FIGURE 3-7 Spine Center process for a-7.eps F3 feed-forward and feedback information system. SOURCE: Eugene C
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From page 161... ...
He did not know that the Spine Center had been designed based on his own research concerning how the world's best-in-class service organizations worked to bring quality and value to customers at the point of service, but he was moved to write a letter to the local newspaper about the wonderful care he had just received from the center. He praised the center for using innovative information technology to focus on the patient's individual and unique health state, to elicit the patient's expectations for care outcomes and explore all treatment options, to help patients make wise treatment decisions based on medical evidence and personal preferences, and to work smoothly with a full interdisciplinary team without having to go from clinic to clinic and experience frustrating waits and delays.
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From page 162... ...
12 ENGINEERING A LEARNING HEALTHCARE SYSTEM Functional Status Clinical Status Patient Perceived Outcomes Benefits History & Symptoms 3-12 a, b Mostly bitmapped
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From page 163... ...
• atient-centric -- The individual patient's health status, health risks, P decisions based on preferences and values, perceptions of good care and good outcomes, and costs of care are at the forefront of all that is done (IOM, 2001)
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From page 164... ...
Some of the key characteristics of healthcare collaboratories would be • atient-centric and focused on relevant dimensions of health out p comes for any given population of patients; • rofessionally organized to fit into the flow of health care for p the purpose of improving care while contributing to research and education; • ased on feed-forward methods to follow patients over time as b their healthcare experience evolves and to better match patients' changing health status with an evidence-based preference-sensitive plan of care; and • ependent on feedback methods to track health risks, health status, d diagnoses, and treatments associated with health outcomes and costs and to analyze results at multiple levels of the system (patient, micro, meso, macro, community, and region)
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From page 165... ...
, as well as the Karolinska Institute and the Swedish Rheumatoid Arthritis Registry. However, there are other research networks and communities of practice that have some collaboratory features, including the Cystic Fibrosis Foundation and cystic fibrosis centers in the United States; the Vermont Oxford Project and neonatal intensive care units in North America and Europe; the Autism Program at Geisinger Health System; the Northern New England Cardiovascular Group and cardiovascular programs in Maine, New Hampshire, and Vermont; and the Clinical Program Model at Intermountain Health Care (James and Lazar, 2007)
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From page 166... ...
These forces include communities of professional practice combining patient care and health research, the funding of research by the NIH through the new CTSA approach, the formation of regional health information organizations across the country, the emergence of new scientific paradigms that recognize complexity and the value of multiple research methods, and demands for better quality and value that are measured and transparent. An excellent example of these forces coming together can be seen in the new National Quality Forum (NQF)
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From page 167... ...
Second, patient-centric health risks, health status, and health outcomes are an essential component of any comprehensive approach for improving health care and studying health outcomes. Third, it will be essential to design feed-forward information systems to accomplish the tripartite aim of improving healthcare outcomes, advancing biomedical research, and enhancing health professional learning.
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From page 168... ...
2005. Improving clinical practice using clinical decision support systems: A systematic review of trials to identify features critical to success.
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From page 169... ...
nonopera tive treatment for lumbar disk herniation: The Spine Patient Outcomes Research Trial (SPORT) : A randomized trial.
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