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The future of the present health care system is bleak, according to a new government study. If the industry is to succeed, the system needs to be completely redesigned — with information technology playing a major role. The report, "Crossing the Quality Chasm: A New Health System for the 21st Century," is a follow-up to the Institute of Medicine (IOM) of the National Academies’ controversial 1999 report that addressed medical errors, "To Err Is Human: Building a Safer Health System."
Medical errors are just a symptom of a dysfunctional health care system, says the committee that wrote the report. America’s health system is a tangled, highly fragmented web that often wastes resources by providing unnecessary services and duplicating efforts, leaving unaccountable gaps in care and failing to build on the strengths of all health professionals, the new report declares.
The report lists six aims for improving the health care system and calls for immediate action to improve care over the next decade. It also provides what it calls 10 "simple" rules to guide the 21st-century health care system as well as 13 recommendations to make health care "safe, effective, patient-centered, timely, efficient and equitable."
"The system is failing because it is poorly designed," says William C. Richardson, committee chairman and president of the W.K. Kellogg Foundation of Battle Creek, MI. "For even the most common conditions, such as breast cancer and diabetes, there are very few programs that use multidisciplinary teams to provide comprehensive services to patients. For too many patients, the health care system is a maze, and many do not receive the services from which they would likely benefit."
The committee was charged with coming up with a design for the 21st-century health care system, explains Paul Plsek, president of Paul E. Plsek & Associates of Roswell, GA. Plsek, who gives consultations on innovation and improvement for complex organizations, advised the committee. After a couple of meetings and some attempts to make clarifications, the committee found itself reconstructing the Clinton health care plan with boxes and arrows, Plsek says. "They decided that that kind of mechanistic design wasn’t going to work."
He met with committee members more than a year ago to discuss the science of complex adaptive systems (CAS). CASs are composed of agents that are constantly organizing and reorganizing into ever-increasing complexity on the basis of a few simple rules. As complexity increases, new structures and behaviors emerge. "A system as complex as health care needs to evolve," Plsek says. "It can’t be designed in a mechanistic sense."
Attempts to design systems that are organic in nature have been failures in the past, he explains. "There are some classic stories from ecology and botany of people trying to recreate prairie land by trying to landscape it with wild plants. It’s a dismal failure. Botanists realized they have to let some things grow and see what happens. They can water, fertilize, cut some things back, but in the end a prairie has to grow itself. They couldn’t design it."
The same is true for the health care system, he adds. "It’s going to have to grow itself. It’s gotten to the state of complexity that it is in by evolution, not by anyone’s design." Plsek has written an appendix to the report that describes an approach to large-system redesign using simple rules and other concepts from the science of CAS.
The time to consider a different approach to the health care system may be now, he says. "There is a growing sense of awareness and frustration that we have tried several structural fixes to health care." At times, the industry thought managed care, capitation, and integrated delivery systems would provide fixes. "We’ve had enough rounds of people trying what they think were obvious, quick solutions. I think the frustration has grown that there are more people who are willing to say, We should approach this in a completely different way.’"
The report encourages teamwork among health care workers and makes much greater use of information technology. Advances in technology are sorely needed, the report says. "Patient information typically is dispersed in a collection of paper records, which often are poorly organized, illegible, and not easy to retrieve, making it nearly impossible to manage various chronic illnesses that require frequent monitoring and ongoing patient support."
It is amazing how much information is still on paper and is not easily accessible, Plsek says. "There needs to be a major revolution in information systems in health care organizations."
The IOM committee agrees. A nationwide effort is needed to build a technology-based information infrastructure that would lead to the elimination of most handwritten clinical data within the next 10 years, the committee says. The committee recognizes that many payment, policy, and legal issues stand in the way of technological innovation. Still, the use of automated medication order entry systems can reduce errors in prescribing and dosing drugs, and computerized reminders can help both patients and clinicians identify needed services, the report says.
Some innovations are already taking place, Plsek says, including electronic medical records and the use of Palm Pilots for order entry. "Those innovations will accelerate over the next five years," he predicts.
Organizations have begun receiving incentives to innovate with information technology, Plsek says. One example is a $20.9 million initiative, "Pursuing Perfection: Raising the Bar for Health Care Performance," that the Robert Wood Johnson Foundation in Princeton, NJ, is offering hospitals and physician organizations for pursuing ways to dramatically improve patient outcomes.
The IOM report also recommends that a $1 billion innovation fund be established. "If that comes into play, it will certainly spur some new approaches," Plsek says.
Some organizations are taking the report to heart, he adds. "There are already a number of organizations that tend to be on the leading edge that are beginning to access the report," he says. "I get calls from people wanting to talk more about it. I think there will be some early adopters and innovators who have already been thinking in some of these new directions and [about these] new rules."
The big question is how people will embrace the changes suggested in the report, Plsek says. "Certainly there are things that pull in the opposite direction. The strong legislation around patient privacy and confidentiality would tend to pull in the direction that’s opposite of what the report says."
For example, the "simple" rules offered in the report call for transparency of information as opposed to secrecy. "I think there are some dynamic tensions in the system," Plsek says. "How do we make sure that information about care is available when needed and where needed without compromising the confidentiality of the patient? That is a paradox that remains to be resolved."