To Improve Human Health A History of the Institute of Medicine (1998) / Chapter Skim
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7 The Institute of Medicine at Twenty Five
7 The Institute of Medicine at Twenty Five
Pages 249-276
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From page 249... ...
and Bruce VIadeck at the Health Care Financing Administration (HCFA)
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From page 250... ...
For example, a project on the implications of regional health care data bases for health policy fell into the bailiwick of the Division of Health Care Services, still headed by Karl Yordy, who had come to the TOM in the era of John Hogness and would remain until his retirement in October 1993. Roger Bulger, another old IOM hand
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From page 251... ...
To minimize the harm and maximize the benefits, the steering committee recommended that employers "not be permitted to require receipt of an individual's data from a health database organization as a condition of employment or the receipt of benefits" but suggested that "health database or~aniza ~ · ~ ~ · ~ · ~ talons snout release non-person-~ctent~anie ciata upon request to other entities once those data are in analyzable form."2 Another project from the Division of Health Care Services came from a congressional mandate that the Institute of Medicine study whether there was a need for more nurses in hospitals and nursing homes in order to improve the quality of patient care and reduce work-related injuries and stress among nurses. Nursing professional associations and special interest groups, concerned about changes in health care settings made to promote efficiency and reduce costs, supplied the impetus for the study.
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From page 252... ...
Hospitals and nursing homes, for their part, should carefully screen applicants for patient care positions filled by nurse assistants to make sure they had no past history of patient abuse.3 Both of these studies exemplified the traditional TOM role of appointing an expert pane] to help in the process of setting standards of medical practice and administration and to identify topics that required more research.
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From page 253... ...
The committee, heacled by Paul Torrens of UCLA's School of Public Health, proposed banning tobacco products from public vending machines as well as a ban on the free distribution of tobacco products at public events or through the mail. At the heart of the committee's strategy to prevent young people from starting to smoke was a mass media campaign that would include explicit antitobacco advertisements on commercial television stations.
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From page 254... ...
In other years, the award went to Robert Ball, the former Social Securitv commissioner and resident scholar at the Institute of Medicine, and Julius Richmond, President Carter's Surgeon General and "pro tem" head of the Institute of Medicine between Donald Fredrickson and David Hamburg. Like other Institute of Medicine components, the staff of the Division of Health Promotion and Disease Prevention spent most of its time not on convening or honorific functions but on the conduct of actual studies, such as the one begun in 1992 on Agent Orange.
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From page 255... ...
This finding failed to settle the dispute, however, because most of the evidence the committee assembled came from studies of people exposed to dioxin or herbicides in occupational and environmental settings, rather than during the Vietnam War. In fact, the committee knew that most Vietnam veterans had lower levels of exposure to herbicides than did the subjects of the other studies, but the exact level of exposure of Vietnam veterans remained unknown.
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From page 256... ...
Such conflicts were unavoidable, because the TOM was removed from the subject under study the defense and chemical industries- but not from the business of medical research. If the Agent Orange study exemplified the work of the Division of Health Promotion and Disease Prevention in the public service mode, the unintended pregnancy study, another project of this division in the Shine era, illustrated its public education mode.
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From page 257... ...
For the medically indigent, it supported using Medicaid to cover contraceptive services for two years following childbirth, and it recommended the provision of federal, state, and local funding for "comprehensive contraceptive services, especially for those low-income women and adolescents who face major financial barriers in securing such care." The funding recommendations made it clear that the report was a call for birth control, a traditional item on the liberal political agenda, but with the new rationale of protecting the wellbeing of children and families by reducing unintended pregnancy, a
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From page 258... ...
The report on unintended pregnancy showed how the Institute of Medicine maintained its independence from partisan politics yet remained engaged in contemporary issues. · ~, · ~· ~ Although the report Involved a close reacting or social statistics and other forms of hard data, it also contained philosophical assumptions for example, on the moral validity of birth control- that went largely unexamined.
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From page 259... ...
to receive early alerts on significant microbial threats.~4 Emerging Infections, therefore, showed how the best TOM projects combined science and public health policy. For Assessing Genetic Risks, a project of the Division of Health Sciences Policy that was completed in 1994, the TOM assembled the nation's leading experts, including University of Washington geneticist Arno MotuIsky, to anticipate another problem on the boundary between science and social policy.
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From page 260... ...
In 1994, for example, the Division of Health Sciences Policy produced a report on Women and Health Research that considered the ethical and legal issues involved in including women in clinical studies. The report started with broad general principles, for example, that "volunteers for clinical studies should be offered the opportunity to participate without regard to gender, race, ethnicity, or age" and then considered some of the problems unique to women.
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From page 261... ...
\~hen the TOM issued a report of this type, it often called for a program of public education. In the case of sexually transmitted diseases, for example, the report urged that the mass media "accept advertisements and sponsor public service messages that promote condom use." Such a strategy was consistent with recommendations that the IOM had developed to respond to the AIDS · .
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From page 262... ...
A different sort of Food and Nutrition Board publication, Nutrition During Pregnancy anct Lactation, was a handbook intended for health care practitioners who worked with pregnant or lactating women. The handbook detailed simple steps and procedures that the practitioner could take to ensure that women received proper nutrition through pregnancy and the early stages of motherhood.
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From page 263... ...
As a means of determining the lOM's goals, he led the organization in strategic planning activities that resulted in a mission statement and action plan approved by the IOM Council in November 1993.24 This plan produced useful results in the form of a decrease in the time needed to complete a study, an increase in the number of studies with quick turnaround, a greater emphasis on the dissemination of study results, and the creation of a special focus on health care quality as an TOMwide initiative. Encouraged and aware that an increase in endowment made it possible to raise the TOM to a new level, Shine initiated a similar process in 1997 in which he and his staff consulted with a broad array of TOM members, foundation officials, association executives, and health reporters on the organization's strengths and weaknesses.
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From page 264... ...
More ambitious strategies to reach objectives included holding briefings for all health-related federal agencies at least every two years in order to meet the goal of providing "timely and evidence-based analysis and advice on matters related to health." The plan also contained quite specific ideas on improving the dissemination process, for example, by maintaining a "listserv" that brought news of the TOM to congressional staffers by way of e-mai! and extending the basic listserv approach, developed by Roger Herdman, a former Office of Technology Assessment director and an TOM senior scholar, to foundation officials.29 Through these strategic planning exercises, Kenneth Shine put his stamp on the organization.
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From page 265... ...
Influencing the Health Security Plan required expertise in, among other fields, health care economics. Although economists such as Stuart Altman, Gail Wilensky, and Rashi Fein served important functions in the TOM, they were less prominent within the organization than were physicians from academic medical centers.
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From page 266... ...
On the other hand, it offered all the advice it could and even lent direct aid, for example, by sending the Robert Wood Johnson Foundation Fellows in Health Care Policy to work with the White House Task Force on Health Care Reform. In January 1993, Shine gave HilIary Clinton and Donna Shalala an TOM white paper on health care reform that consisted of a compendium of previous TOM proposals.
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From page 267... ...
The project produced a 1997 statement, issued under the signature of the presidents of the NAS's three central organizations, on "Focusing on Quality in a Changing Health Care System"; a series of special newsletters; and a number of TOM reports. As part of the initiative, the TOM also convened a National Roundtable on Health Care Quality.34 Unlike the subject of national health insurance, in which the Institute of Medicine was one voice among many, the TOM acquired a form of collective expertise on matters related to quality of care and spoke with considerable authority on the issue.
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The present name invited confusion between the independent Institute of Medicine and the governmental National Institutes of Health. On an international level, the name baffled foreign authorities, who could not understand why the United States chose to call its academy an institute.
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From page 269... ...
When it came time for the new Institute of Medicine to consider major issues related to public health and access to medical care, however, John Hogness, the first TOM president, found it difficult to initiate large-scale projects of the sort McDermott favored. Part of the reason was that the Nixon administration did not want to cede the political action on questions such as national health insurance to an organization whose political affiliation had yet to be tested.
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From page 270... ...
In the interim, before the TOM developed a large program of studies, it resembled nothing so much as an honorary organization of the sort that would have been more congenial to Irvine Page than Walsh McDermott. The highlight of the early Institute of Medicine was the annual meeting, a gathering with a great deal of intellectual content that yielded important papers on health policy but was a social occasion nonetheless.
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From page 271... ...
Major changes occurred in health care financing patterns during the Reagan years, and the TOM played little or no role in them.
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From page 272... ...
The authors of the Sproull report collected a great deal of seemingly damning information about the TOM its lack of purpose, its uncertain place among organizations concerned with health policy, its lack of energy in raising money and seeking new projects, and its inability to issue decisive reports in a reasonable amount of time. Early in 1985, however, the National Academy of Sciences rejected the major conclusion of the Sproull report that the lOM be converted into the National Academy of Medicine and its research functions moved to the National Research Council.
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As a result, the TOM remained close to AIDS policy even when the action shifted to the Presidential Commission. In the AIDS initiatives, the TOM came the closest to realizing Walsh McDermott's vision of a socially engaged organization tackling the toughest public health problems of its era.
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From page 274... ...
Public education took such forms as the Food and Nutrition Board's report on diet and chronic illness and the TOM report on bereavement or an even less high-profile report, such as the one on pain and disability. The Institute's convening functions represented a more private form of education.
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17. Institute of Medicine, Women and Health Research: Ethical and Legal Issues of Including Women in Clinical Studies (Washington, D.C.: National Academy Press, 1994)
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25. "IOM Strategic Planning Activity, Conference Call with Foundation Officials," June 25, 1997, Shine Files.
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