INTEGRATING RESEARCH
AND PRACTICE
Health System Leaders Working Toward High-Value Care
Workshop Summary
Joe Alper and Claudia Grossmann, Rapporteurs
Roundtable on Value & Science-Driven Health Care
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, D.C.
THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The workshop that is the subject of this workshop summary 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.
This activity was supported by an unnumbered agreement between the National Academy of Sciences and the Patient-Centered Outcomes Research Institute (PCORI). The views presented in this publication do not necessarily reflect the views of the organizations or agencies that provided support for the activity.
International Standard Book Number-13: 978-0-309-31201-1
International Standard Book Number-10: 0-309-31201-9
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Copyright 2015 by the National Academy of Sciences. All rights reserved.
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Suggested citation: IOM (Institute of Medicine). 2015. Integrating research and practice: Health system leaders working toward high-value care: Workshop summary. Washington, DC: The National Academies Press.
“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
Advising the Nation. Improving Health.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
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 Academy 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.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. C. D. Mote, Jr., is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute 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. Victor J. Dzau is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. C. D. Mote, Jr., are chair and vice chair, respectively, of the National Research Council.
PLANNING COMMITTEE ON INTEGRATING
RESEARCH AND PRACTICE: HEALTH SYSTEM LEADERS
WORKING TOWARD HIGH-VALUE CARE1
ERIC B. LARSON (Chair), Vice President for Research, Group Health
RAYMOND J. BAXTER, Senior Vice President, Community Benefit Research and Health Policy, Kaiser Permanente
BARBARA E. BIERER, Senior Vice President, Research, Brigham and Women’s Hospital
MARY K. BRAINERD, President and Chief Executive Officer, HealthPartners
MEIGHAN GIRGUS, Chief Mission Officer, American Heart Association
REGINA HOLLIDAY, Artist and Patient Data Activist
BRENT JAMES, Executive Director, Institute for Health Care Delivery Research, Intermountain Healthcare
UMA R. KOTAGAL, Senior Vice President, Quality, Safety and Transformation, Cincinnati Children’s Hospital Medical Center
DAVID LABBY, Chief Medical Officer, Health Share of Oregon
JONATHAN B. PERLIN, President, Clinical Services, Chief Medical Office, Hospital Corporation of America
LEWIS G. SANDY, Executive Vice President, Clinical Advancement, UnitedHealth Group
JOE V. SELBY, Executive Director, Patient-Centered Outcomes Research Institute
JONATHAN N. TOBIN, President and Chief Executive Officer, Clinical Directors Network, Inc., and Co-Director for Community Engaged Research, Rockefeller University Center for Clinical and Translational Science
P. JON WHITE, Director, Health Information Technology, Agency for Healthcare Research and Quality
IOM Staff
CLAUDIA GROSSMANN, Senior Program Officer
ELIZABETH JOHNSTON, Senior Program Assistant
KATHERINE BURNS, Senior Program Assistant
DIEDTRA HENDERSON, Program Officer
MELINDA MORIN, Senior Program Officer
_____________
1 Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution.
ELIZABETH ROBINSON, Associate Program Officer
SOPHIE YANG, Senior Program Assistant (until December 2014)
J. MICHAEL McGINNIS, Senior Scholar, Executive Director, Roundtable on Value & Science-Driven Health Care
Consultant
JOE ALPER, Consulting Writer
ROUNDTABLE ON VALUE & SCIENCE-DRIVEN HEALTH CARE1
MARK B. McCLELLAN (Chair), Senior Fellow, The Brookings Institution
RAYMOND J. BAXTER, Senior Vice President, Kaiser Permanente
PAUL BLEICHER, Chief Executive Officer, Optum Labs
DAVID BLUMENTHAL, President, The Commonwealth Fund
BRUCE G. BODAKEN, Former Chairman and Chief Executive Officer, Blue Shield of California
PAUL CHEW, Chief Science Officer and Chief Medical Officer, Sanofi U.S.
CAROLYN CLANCY, Interim Under Secretary for Health, U.S. Department of Veterans Affairs (Ex Officio)
FRANCIS COLLINS, Director, National Institutes of Health (Ex Officio) (designee: Kathy Hudson)
HELEN DARLING, Strategic Advisor, National Business Group on Health
KAREN B. DESALVO, National Coordinator, Office of the National Coordinator for Health Information Technology (Ex Officio)
SUSAN DEVORE, Chief Executive Officer, Premier, Inc.
JUDITH FAULKNER, Founder and Chief Executive Officer, Epic Health Systems
JOSEPH F. FIFER, President and Chief Executive Officer, Healthcare Financial Management Association
THOMAS R. FRIEDEN, Director, Centers for Disease Control and Prevention (Ex Officio) (designee: Chesley Richards)
PATRICIA A. GABOW, Former Chief Executive Officer, Denver Health
ATUL GAWANDE, General and Endocrine Surgeon, Brigham and Women’s Hospital
GARY L. GOTTLIEB, President and Chief Executive Officer, Partners HealthCare System, Inc.
JAMES A. GUEST, President and Chief Executive Officer, Consumers Union
MARGARET A. HAMBURG, Commissioner, U.S. Food and Drug Administration (Ex Officio) (designee: Peter Lurie)
JAMES HEYWOOD, Co-Founder and Chairman, PatientsLikeMe
RALPH I. HORWITZ, Senior Vice President, Clinical Evaluation Sciences, GlaxoSmithKline
PAUL HUDSON, Executive Vice President, AstraZeneca
_____________
1 Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution.
BRENT C. JAMES, Chief Quality Officer, Intermountain Healthcare
CRAIG A. JONES, Director, Vermont Blueprint for Health
GARY KAPLAN, Chairman and Chief Executive Officer, Virginia Mason Health System
DARRELL G. KIRCH, President and Chief Executive Officer, Association of American Medical Colleges
RICHARD C. LARSON, Professor, Massachusetts Institute of Technology
PETER LONG, President and Chief Executive Officer, Blue Shield of California Foundation
JAMES L. MADARA, Chief Executive Officer, American Medical Association
MARY D. NAYLOR, Director, NewCourtland Center, University of Pennsylvania
WILLIAM D. NOVELLI, Professor, Georgetown University; Co-Chair, Coalition to Transform Advanced Care
SAM R. NUSSBAUM, Chief Medical Officer, WellPoint, Inc.
JONATHAN B. PERLIN, President, Clinical and Physician Services, Hospital Corporation of America
RICHARD PLATT, Chair, Population Medicine, Harvard Medical School
MICHAEL ROSENBLATT, Executive Vice President and Chief Medical Officer, Merck & Co.
JOHN W. ROWE, Former Chairman and Chief Executive Officer, Aetna; Professor, Columbia University
LEONARD D. SCHAEFFER, Judge Robert Maclay Widney Chair and Professor, University of Southern California Sol Price School of Public Policy
JOE V. SELBY, Executive Director, Patient-Centered Outcomes Research Institute
MARK D. SMITH, Founding President and Chief Executive Officer, California HealthCare Foundation
GLENN D. STEELE, President and Chief Executive Officer, Geisinger Health System
JENNIFER TAUBERT, President, Janssen North America, Johnson & Johnson
MARILYN TAVENNER, Administrator, Centers for Medicare & Medicaid Services (Ex Officio) (designee: Patrick Conway)
REED V. TUCKSON, Former Executive Vice President, UnitedHealth Group; Managing Director, Tuckson Health
RICHARD J. UMBDENSTOCK, President and Chief Executive Officer, American Hospital Association
MARY WAKEFIELD, Administrator, Health Resources and Services Administration (Ex Officio)
DEBRA B. WHITMAN, Executive Vice President, Policy and International, AARP
JONATHAN WOODSON, Assistant Secretary for Health Affairs, U.S. Department of Defense (Ex Officio)
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Institute of Medicine
Roundtable on Value & Science-Driven Health Care
Charter and Vision Statement
Vision: Our vision is for the development of a continuously learning health system in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the care process, patients and families active participants in all elements, and new knowledge captured as an integral by-product of the care experience.
Goal: By the year 2020, 90 percent of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence. We believe that this presents a tangible focus for progress toward our vision, that Americans ought to expect at least this level of performance, that it should be feasible with existing resources and emerging tools, and that measures can be developed to track and stimulate progress.
Context: As unprecedented developments in the diagnosis, treatment, and long-term management of disease bring Americans closer than ever to the promise of personalized health care, we are faced with similarly unprecedented challenges to identify and deliver the care most appropriate for individual needs and conditions. Care that is important is often not delivered. Care that is delivered is often not important. In part, this is due to our failure to apply the evidence that we have about the medical care that is most effective—a failure related to shortfalls in provider knowledge and accountability, inadequate care coordination and support, lack of insurance, poorly aligned payment incentives, and misplaced patient expectations. Increasingly, it is also a result of our limited capacity for timely generation of evidence on the relative effectiveness, efficiency, and safety of available and emerging interventions. Improving the value of the return on our health care investment is a vital imperative that will require much greater capacity to evaluate high-priority clinical interventions, stronger links between clinical research and practice, and reorientation of the incentives to apply new insights. We must quicken our efforts to position evidence development and application as natural outgrowths of clinical care to foster health care that learns.
Approach: The Institute of Medicine Roundtable on Value & Science-Driven Health Care serves as a forum to facilitate the collaborative assessment and action around issues central to achieving the vision and goal stated. The challenges are myriad and include issues that must be addressed to improve evidence development, evidence application, and the capacity to advance progress on both dimensions. To address these challenges, as leaders in their fields, Roundtable members work with their colleagues to identify the issues not being adequately addressed, the nature of the barriers and possible solutions, and the priorities for action and marshal the resources of the sectors represented on the Roundtable to work for sustained public-private cooperation for change. Activities include collaborative exploration of new and expedited approaches to assessing the effectiveness of diagnostic and treatment interventions, better use of the patient care experience to generate evidence on the effectiveness and efficiency of care, identification of assessment priorities, and communication strategies to enhance
provider and patient understanding and support for interventions proven to work best and deliver value in health care.
Core concepts and principles: For the purpose of the Roundtable activities, we define science-driven health care broadly to mean that, to the greatest extent possible, the decisions that shape the health and health care of Americans—by patients, providers, payers, and policy makers alike—will be grounded in a reliable evidence base, will account appropriately for individual variation in patient needs, and will support the generation of new insights on clinical effectiveness. Evidence is generally considered to be information from clinical experience that has met some established test of validity, and the appropriate standard is determined according to the requirements of the intervention and clinical circumstance. Processes that involve the development and use of evidence should be accessible and transparent to all stakeholders.
A common commitment to certain principles and priorities guides the activities of the Roundtable and its members, including the commitment to the right health care for each person; putting the best evidence into practice; establishing the effectiveness, efficiency, and safety of the medical care delivered; building constant measurement into our health care investments; the establishment of health care data as a public good; shared responsibility distributed equitably across stakeholders, both public and private; collaborative stakeholder involvement in priority setting; transparency in the execution of activities and reporting of results; and subjugation of individual political or stakeholder perspectives in favor of the common good.
Reviewers
This workshop summary 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 workshop summary as sound as possible and to ensure that the workshop summary 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 process. We wish to thank the following individuals for their review of this workshop summary:
Robert M. Califf, Duke University Medical Center
Rainu Kaushal, Weill Cornell Medical College
Michael Johns, University of Michigan Health System
Although the reviewers listed above have provided many constructive comments and suggestions, they did not see the final draft of the workshop summary before its release. The review of this workshop summary was overseen by Stephen Shortell, University of California, Berkeley, School of Public Health. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this workshop summary was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this workshop summary rests entirely with the rapporteurs and the institution.
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Contents
Scope and Objectives of the Workshops
The Roundtable on Value & Science-Driven Health Care
2 CONTINUOUS LEARNING AND IMPROVEMENT IN HEALTH CARE
Patient Outcomes Research to Advance Learning (PORTAL) Network
New York City Clinical Data Research Network
3 CONTINUOUSLY LEARNING HEALTH CARE: THE VALUE PROPOSITION
Is the Time Right for Continuously Learning Health Care?
Increasing Efficiency and Eliminating Waste
Improving Our Ability to Choose Wisely
4 INTEGRATING CLINICAL RESEARCH AND PRACTICE: EXAMPLES
Embedded Research at Group Health
Research and Practice in a Safety Net System
5 CREATING THE CONDITIONS FOR SUSTAINABILITY
The Learning Health Care System
Evaluation and Improvement of Care Delivery
Improving Care for Me and Patients Like Me
Leveraging Data for Improvement
6 ADDRESSING ISSUES OF REGULATORY OVERSIGHT
An Ethical Framework for Learning Health Systems
Approaches to Dealing with Oversight Challenges
7 GOVERNANCE THAT ACCELERATES PROGRESS AND SUSTAINABILITY
Aligning Research with Institutional Goals
Data Sharing in a Competitive Environment
Governing Interinstitutional Research
8 FOSTERING THE WELL-PREPARED STAKEHOLDER CULTURE
Creating a Culture of Learning
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ABIM | American Board of Internal Medicine |
ACO | accountable care organization |
AHRQ | Agency for Healthcare Research and Quality |
CDC | Centers for Disease Control and Prevention |
CDRN | clinical data research network |
CEO | chief executive officer |
CER | comparative effectiveness research |
CMS | Centers for Medicare & Medicaid Services |
EHR | electronic health record |
FDA | U.S. Food and Drug Administration |
GHRI | Group Health Research Institute |
HCA | Hospital Corporation of America |
HHS | U.S. Department of Health and Human Services |
HIPAA | Health Insurance Portability and Accountability Act |
ICU | intensive care unit |
IOM | Institute of Medicine |
IRB | institutional review board |
MRSA | methicillin-resistant Staphylococcus aureus |
NIH | National Institutes of Health |
OHRP | Office for Human Research Protections |
ONC | Office of the National Coordinator for Health Information Technology |
PCMH | patient-centered medical home |
PCORI | Patient-Centered Outcomes Research Institute |
PCORnet | National Patient-Centered Clinical Research Network |
PORTAL | Patient Outcomes Research to Advance Learning |
PPRN | patient-powered research network |
RCT | randomized controlled trial |
REDUCE | Randomized Evaluation of Decolonization vs. Universal Clearance to Eliminate |
UCSF | University of California, San Francisco |
VA | U.S. Department of Veterans Affairs |
VHA | Veterans Health Administration |