Engineering a Learning Healthcare System A Look at the Future: Workshop Summary (2011) / Chapter Skim
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1 Engineering a Learning Healthcare System
1 Engineering a Learning Healthcare System
Pages 27-62
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The Engineering a Learning Healthcare System: A Look at the Future workshop drew together participants from healthcare and engineering disciplines to identify challenges in health care, including effectiveness, safety, and efficiency, that might benefit from a systems engineering perspective. With the baseline assumption that reform efforts must extend beyond finance to remedy the growing complexities in health care.
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The first presentation, "Learning Opportunities for Health Care" was by Brent C James, executive director of the Institute for Health Care Delivery Research and vice president of medical research and continuing medical education at Intermountain Healthcare.
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James began by discussing the historical evolution of the modern structure of healthcare delivery. He outlined five areas where care delivery currently falls short of its theoretic potential, touched briefly on the reasons for that failure, and then reflected on emerging solutions, emerging frameworks, and challenges that create a context for work on improving health care.
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Although communication has many dimensions that vary among organizations, Compton asserted that engineers and healthcare professionals have considerable work to do in creating a common understanding of problems and opportunities. A cadre consisting of both engineering and medical professionals is needed to tackle some of health care's more intractable problems, working in the near term on problem solving and in the longer term on more fundamental systems design.
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The healing professions have always been central to human society. Humanity's earliest written records refer to clinical practice.
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Clinical leaders refined the licensing laws, produced a new definition of medical professionalism, and used the resulting tools to hold the profession as a whole uniformly accountable to a much higher level of demonstrated knowledge, skills, and ethical conduct. Finally, clinical leaders created a new organizational structure for care delivery.
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. Life expectancy gains due to advances in public health plateaued in the decade following the end of World War II.
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The evidence is clear: modern health professionals now routinely offer treatments that would have appeared miraculous to any previous generation. Aim Defines the System Given these achievements, it is worth reflecting on what is known about the factors most important in determining a person's total health -- that is, how long and how well one lives.
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im defines the system." Relative to health spending, what are the aims of healthcare delivery? The current national healthcare debate implicitly assumes, without examination, that the primary aim of healthcare delivery is "total health" -- how long and how well we live.
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(Szilagyi, 1965) 4 High touch care leads to patient satisfaction with the healthcare delivery system.
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system from the perspective of total health and patient satisfaction. This advantage appears to be attributable to healthier behaviors, better public health, and easily accessible primary care.
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health care delivery falls short of its theoretical potential. The shortcomings represent significant opportunities for improvement.
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U.S. healthcare delivery misses by wide margins on both sides of the target of effective, beneficial care, which probably explains why inappropriate care does not account for geographic variation in care.
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Collision Between the Craft of Medicine and Clinical Uncertainty The same body of research that documents the ways in which healthcare delivery falls short of its theoretical potential also points to a likely cause: a head-on collision of two factors inherent in current approaches to health care. The first factor is practice based on the craft of medicine -- the idea that physicians, nurses, and other health professionals should act as standalone experts who draw on a massive personal knowledge base gained from formal education and practice experience and who honor an ethical trust that places a patient's healthcare needs above any other end.
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He reports that within 3 to 4 years of initial board certification, both generalist and subspecialist internists (cognitive physicians) begin to show "substantive declines in gen eral medical knowledge." He estimates that to maintain current knowledge, a general internist would need to read about 20 articles a day, 365 days a
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The third element is continued reliance on subjectie recall as a foundation for clinical decision making. The expert mind reaches conclusions by breaking a problem down into subproblems, pattern matching within each subproblem, and then summarizing results back into a synthetic whole.
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Variation in how physicians subconsciously select and prioritize factors could directly contribute to geographic variation in care delivery patterns overall. Early Solutions, Emerging Frameworks, and Refined Challenges When the inherent complexity of modern medicine and the limitations of the human mind collide with the craft of medicine, the result is wide variation, high rates of inappropriate care, unacceptable rates of care associated with injury and death, a striking inability to apply well-established proven therapies consistently and broadly, and huge amounts of waste.
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It allows a physician to focus on a handful of critical factors for each individual patient because the rest of the care delivery process is reliable through standardization and measurement. Shared baselines have produced dramatic improvement in many care processes in Intermountain.
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Medical professionals could benefit from the counsel and shared learning of our engineering colleagues. As we shift from a craft-based to a profession-based practice, the idea of care delivered by a team -- an organized system of care delivery, as opposed to a loose conglomeration of poorly coordinated parts -- presents a number of challenges.
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This paper focuses on some of the successful approaches used by organizations and suggests that the healthcare delivery system might consider undertaking similar attempts to better serve its customers. Any large organization faces many challenges, some organizational and others related to human behavior.
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In thinking about the steps that might prove pertinent to changing the healthcare delivery system, it is helpful to draw on experience from another industry. Although there are many differences between the operation of a large, diverse, global manufacturing company and the healthcare enterprise, some of the experiences of the former may be useful.
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8 ENGINEERING A LEARNING HEALTHCARE SYSTEM There were no real incentives. After all, our principal competitor was just across town, and they had the same problems with product quality as Ford.
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Of the many aspects of continuous improvement, four are particularly relevant to this discussion. First, how does one tell if improvements are occurring?
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Yet without these data, it is difficult to use the engineering tools that can determine optimal flow. A second aspect of continuous improvement focuses on participation by all involved.
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The healthcare delivery system does not yet have the sort of comprehensive information technology system it needs. Some relevant bills were recently considered in Congress.
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Collaboration is needed to help people understand what healthcare professionals and engineers can accomplish together in the proper environment. For a large, diverse, diffuse system to learn and change requires the involvement of all people at all levels, starting with a committed CEO.
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Finally, the successes achieved by individual teams need to be demonstrated to others. It will not be easy for the healthcare delivery system to learn and change.
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A variation on this saying with a more positive tone is, "Aim creates a system." One of the serious barriers to wedding engineering, sciences, and health care lies outside these fields; it is the absence of aim. A country that cannot make a clear decision that its health care will be safe, or efficient, or effective, or patient centered, or timely, or equitable will not achieve those aims.
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It is a habit of payment systems to pay for interactions but not for coordination, as evidenced by the institutional boundaries that exist. I am engaged in a great debate right now in one of the committees on which I serve concerning whether hospitals' mortality rates should include deaths that occur beyond the hospital walls.
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Rather, when done properly, it drives costs down. The third challenge is the need to recognize the importance of nonlinearities and the alue of dynamic learning and of local adaptation as scientific learning progresses.
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There is a chasm between, on the one hand, pragmatic engineering sciences (which are very sensitive to nonlinearities) and local learning and system improvement methods and, on the other hand, the current hegemonic hierarchies of evaluation of clinical procedures.
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My career benefited enormously from leaders at Harvard -- Howard Hiatt the first among them -- who built a platform for the intersection of quantitative analysis methods and healthcare delivery. That platform was the foundation of my own career.
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It is not at all clear that upon emerging from that exploration, there would be a need for hospitals or offices or insurers or professions in anything close to their current forms. Some caution against this kind of grandiose thinking about redesign, but it may be that the science would lead there, that system redesign -- not political or financing rearrangement -- would be the true manifestation of what should be called healthcare reform.
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Health Affairs 21(2)
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Health Affairs 26(6)
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