How can healthcare be changed for the better

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This cycle essentially mimics the steps of the scientific method, but is adapted for action-oriented learning. Once your plan is underway, be sure to communicate with your team and with your organization at large.

Share milestones both large and small as well as setbacks. Congratulate those who have contributed and made an impact on your progress. Your plan is more likely to succeed when staff are engaged. Certain websites such as Patient Care Link allow consumers and healthcare industry workers to view hospital data and trends. Research online and in the literature, and reach out to see if you can learn from their quality improvement programs.

Most organizations are open to sharing this information for the greater good of patients. In its annual report to Congress , the Agency for Healthcare Research and Quality AHRQ reported promising improvements in healthcare quality as a result of improvement efforts nationwide.

Some of their findings included lower patient death rates, higher vaccination rates, and improved patient-provider communication. Still, according to AHRQ, quality problems persist, such as variation in services, underuse, overuse or misuse of services, and disparities in quality—making healthcare quality improvement efforts all the more important.

For more information about healthcare quality improvement and an in-depth update on the state of healthcare quality in the US, read our article entitled An Update on United States Healthcare Quality Improvement Efforts. For an overview of successful improvement efforts, read an essay published in Health Affairs entitled Improving Quality and Safety. Harvard T. To learn more about this opportunity, click here. Escalating costs have drawn attention to the need for quality improvement in US health care.

According to the Institute for Healthcare Improvement IHI , healthcare should be: Safe: Avoid injuries to patients from the care that is intended to help them. Effective: Match care to science; avoid overuse of ineffective care and underuse of effective care. Patient-Centered: Honor the individual and respect choice.

Timely: Reduce waiting for both patients and those who give care. Efficient: Reduce waste. The first of these reports, To Err Is Human, estimated that as many as 98, patients die in any given year from medical errors that occur in hospitals and established ensuring patient safety a critical first step in improving quality of health care.

A year later, a follow-on report, Crossing the Quality Chasm , focused on the delivery system as a whole and issued a call to action to improve system performance in the six dimensions of quality—to ensure safe, effective, patient-centered, timely, efficient, and equitable care.

Expanding the evidence base to support quality medical care for each patient poses an ongoing challenge to healthcare improvement, and to contend with this issue, in , the IOM convened the Roundtable on Evidence-Based Medicine.

Over the last 2 years, the Roundtable has explored, through its series of meetings and workshops on the learning health-care system, the key opportunities and challenges to establishing evidence as the linchpin of the healthcare enterprise.

Collectively, the Roundtable seeks the development of a healthcare system that is designed to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care. Roundtable activities focus on accelerating the development of a learning healthcare system; expanding the capacity to generate evidence on medical care that is the most effective and produces the greatest value; and improving public understanding of the nature, importance, and dynamic character of medical evidence.

The IOM convenes annual meetings dedicated to the examination of topical and critical issues in health care and health policy. The meeting was structured to provide an overview of some of the key issues and challenges as well as to present some of the primary opportunities for progress that have emerged from the work of the Roundtable.

The chapters in this publication provide important perspectives on the changing nature of health care: from the forces driving the need for better medical evidence and the many new challenges confronting patients and providers to opportunities to transform the speed and reliability of new medical evidence and enable an evidence-based healthcare system.

To provide context for these discussions, comments were provided by the meeting co-chairs Mark B. McClellan and Elizabeth G. Nabel and by session moderators Denis A. Cortese, Michael M. Johns, John W. Rowe, and John K. A summary of these perspectives follows. Two core challenges are facing health care and health policy in the 21st century. Healthcare costs are rising and not sustainable, and a tremendous, largely untapped potential exists for much better health through better, more targeted treatments.

In principle, better evidence will result in higher confidence about what works for every patient in the healthcare system. This is a precondition to achieving what health care should be about in the 21st century—care that is based on solid evidence about what will work in particular patients. With the advent of electronic medical records EMRs , clinical data registries, and other new forms of electronic data, care is becoming rich with information that can reveal patterns of disease mechanisms and markers of risks and benefits.

These data also hold promise for instilling a greater confidence in health care than currently exists for a system that offers widely varying medical practices, with possible consequences for outcomes and definite consequences for costs.

In addition, even treatments effective for some may not be beneficial for others and may carry significant risks. With the cost of health care rising along with its benefits, creating an evidence-based system will be critical to achieving the promise of personalized medicine in which treatments are more effectively targeted to those that benefit, an achievement well worth its cost.

Although there has been progress toward this goal, attaining such a system remains a distant prospect. Better disease models and evidence relevant to the treatment of individual patients is lacking, despite publications and news stories that seem to suggest otherwise.

Also, much of the current data are not from traditional randomized controlled trials RCTs , creating a dilemma about the relevance of EBM in clinical practice. Some practitioners believe that if evidence is developed using traditional RCTs, it may not be reflective of the complexities of populations and the delivery settings in real-world practice.

For example, even if different practice methods appear to have a similar effect in an overall population, this may not be the case for different subgroups or different types of patients within that population. The key elements that should inform strategies for change are contained within these pages. As Michael E. Porter notes in Chapter 7 , while simple steps such as price controls or restrictions on access to control costs might seem useful on the surface, they have failed in the past.

Instead, a new vision is needed, marked by effective evidence and targeted treatments that account for the diverse characteristics—findings, histories, validated biomarkers, and preferences—of the various patient groups in this country. With the complement of secure EMRs, access to these patient and population characteristics will bring relevant evidence to healthcare decision making.

This will, in turn, lead to better results and higher value. Clearly, there will be challenges along the way to gather the evidence necessary for the backbone of this type of healthcare system: data must be consistent; low-cost alternatives to RCTs must be agreed upon; electronic systems should be integrated; and sophisticated longitudinal databases, such as provider-led clinical registries, should be supported.

In addition to studying the discrete interventions of particular drugs or particular modalities in treatments, the performance of healthcare systems themselves should be addressed. The variations in care discussed by Elliott S. Fisher in Chapter 2 must be aligned.

Also, costs will increase and value will be compromised if patients receive care from a number of different providers who do not collaborate effectively.

To study these delivery system issues in real-world practices, traditional approaches such as RCTs will not be effective. Policy challenges must also be addressed. As George C. Halvorson acknowledges in Chapter 6 , small shifts in the system will not create fundamental change. Value and outcomes cannot be achieved by micromanaging practices, but rather by providing support for better care at a lower cost.

Rewarding better quality and lower costs will give healthcare professionals the opportunity to deliver quality care and still make ends meet. This includes changing reimbursements to focus on higher value. Making these changes will provide an opportunity for patients to become more involved, and not simply through cost sharing.

Many opportunities exist for people with chronic diseases to improve their own health, since most care is actually self-care. In our traditional insurance system, these individuals do not always have the opportunity to make choices that can save money. However, recent reforms have begun to allow chronically ill patients in this country to control the services they receive. For example, the tiered benefits in Medicare allow beneficiaries to save money by switching to generic drugs—one of the main reasons that Part D in Medicare is less expensive than projected.

There are a number of programs being implemented around this concept of shared savings, in which healthcare professionals working together reap savings when they document better outcomes at a lower cost.

However those savings are accomplished—through system redesign, information technology IT , or remote monitoring systems—they are a step toward a bundled reimbursement approach that focuses on the effective outcomes in our healthcare system while promoting better care for everyone in it. Clearly, the technical and policy challenges of fulfilling the vision of EBM are great.

In spite of these challenges, the promise of EBM has put it at the forefront of policy making. The Food and Drug Administration is working to implement major new reforms, including plans for a public-private partnership to support a post-marketing surveillance system to gather data on drug risks and benefits. Also, Congress is considering proposals for a major initiative to support the generation of comparative effectiveness information about healthcare interventions.

In addition to work by the federal government, the practice of EBM will require numerous public- and private-sector strategies and collaborations. Needed are new approaches to the evaluation and adoption of medical best practices, new methods for drawing appropriate conclusions from vastly expanded data resources, and new approaches for using evidence to improve care and reduce health costs.

The process will not be easy, but unlike previous times, there are now widespread calls from healthcare leaders for the reforms needed to develop a system that delivers efficient and effective care. The IOM has the opportunity to catalyze that change. Healthcare reform will be one of the top domestic issues of the political agenda in the next presidential election, making our focus on EBM and the changing nature of health care very timely.

The roles and responsibilities of all healthcare stakeholders are undergoing transformative change and—whether we approach reform as providers, payers, researchers, health product developers, or consumers—there is much to learn from all who are involved in these collaborative discussions about how to contend with the rapid changes in the healthcare system. Healthcare providers, whether involved in delivering or reimbursing care, face a unique set of challenges as care is increasingly informed by and organized around rapidly evolving evidence.

Developing better approaches to reimbursement and other mechanisms that support the delivery of quality care are at the forefront for all providers, and many pilot projects are already under way. A key consideration, as illustrated throughout this report, is the strong influence of local cultures on practice patterns. They can prevent the infiltration of evidence-based decision making, but they can also lead to great innovation to support the application and development of evidence.

The papers by William W. Stead and George C. Halvorson in Chapters 4 and 6 discuss lessons learned from their efforts to harness electronic health record EHR systems for improved application of evidence in practice and improved capacity for research and discovery, respectively.

However, these local solutions may need restructuring to succeed at a national level. There has been considerable advocacy for sharing best practices nationwide, but it may be necessary to set goals and work backwards to align the systems. For consumers, access to care is a priority but an additional, emerging challenge will be to ensure that incentives for research and care are properly aligned to support care focused on individual patient needs, circumstances, and preferences.

The very nature of patient-physician relationships is also undergoing a rapid change as healthcare data are increasingly captured and made available in various forms through IT.

Patients will be presented with more health information from a variety of sources and, increasingly, they will be pivotal in making decisions about their own health care.

As we are reminded by Peter M. Neupert in Chapter 5 , most of health care is self-care and much of the care delivered throughout this country is family-based. Family health managers and the availability of secure personal health records will be critical to informing and providing increasingly individualized patient care.

EBM will also impact researchers. Methodologies to generate evidence are evolving and need to be continually defined and adapted. EHRs will provide the opportunity to quickly gather large amounts of data from real-world practice and produce evidence in real time, but how these data can be used appropriately and effectively will be a major challenge for researchers and practitioners.

Clearly, developing evidence that draws from and informs real-world care practices is a science, and improved methods for modeling and analyzing work processes and decision management are needed. This may require restructuring of the way we fund research. Federal agencies, such as the National Institutes of Health, the Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Department of Defense, the Veterans Health Administration, the Centers for Disease Control and Prevention, and others, will be essential components of this dialogue and can demonstrate leadership by partnering across agencies, as well as with others in the private sector.

There is no doubt that the work to transform our healthcare system will be challenging. Many healthcare leaders have been working on improving the system for decades; but we all need to get on with finding a solution now. In the United States the cost of health insurance is rising faster than wages at a rate that is not sustainable, but the quality of care—measured in outcomes, safety, and service—is much lower than it should be.

Especially in comparison to other countries, the value of medical care in the United States is low but even among individual states of the United States the variability in the value of health care delivered is dramatic.

Only 10 percent of the states provide high-value care on average, and the value of care in the United States on a whole is well below what should be expected. Given the current approach to health care, however, these shortfalls are not surprising. Across the healthcare system, competition and rewards are not based on value, and there are scant incentives for patients to seek—or for professionals to provide—high-quality, cost-effective health care.

In reality there is no true healthcare system. There never has been a conscientious attempt to design and maintain a system that would create value. We now have an opportunity to take the steps to develop a vision, create a strategy, and specify goals for a true system of health care in the United States. Yet what should a healthcare system do? In sum, a healthcare system should improve the quality of life and aim to keep people as well as possible, while ensuring that healthcare expenditures are affordable for both individuals and the nation.

In essence, a reformed healthcare system should provide individuals with high-value health and health care. As outlined in Chapters 2 and 3 , these forces include rising and unsustainable costs, wide variations in the quality and cost of health care delivered across the United States, and the complexity of care introduced by the emerging insights from genetic research and the diversity of new health products.

Many of the issues discussed throughout this publication are important for moving forward with needed healthcare system reform, but my focus is on key considerations for providers and, to some degree, patients.

Most pressing in this respect is an improved understanding of what constitutes good evidence of effective care and outcomes. For a profession that adopted the scientific method about a century ago, there is alarmingly little evidence for the effectiveness of much of what is taught and practiced today.

To get to an evidence-based, value-driven health system we have to align all of our professional educational programs to teach new systems and capabilities.

Introduction to key concepts in EBM should begin, at the very least, at the college level. In addition, the dissemination and incorporation of new knowledge into practice must be accelerated so that it does not require a decade or more for the average provider to adopt new knowledge and skills. As more and better evidence is developed, effective processes and IT systems are needed to ensure that healthcare practice utilizes best evidence.

These systems should also have feedback loops to continuously improve on the evidence. Systems must be interoperable and scalable and must also incorporate the patient into the decision-making and care provision processes. To be effective, systems must include the proper rewards, incentives, and financing for providers, as well as the means to pay for required processes and IT systems and innovations.

The general public will need education and support to be able to use the copious medical information becoming available, as well as to gain an appreciation for information that is backed by solid evidence. Practitioners need to work with the public to help ensure that we find the right health-care solutions for individual patients. The complexity of clinical evidence is daunting even for experienced, trained professionals who diagnose and treat disease; but it is far more challenging to the non-expert.

Reducing this complexity is key to empowering patients—not only as better informed consumers of health care, but also as active partners in improving health outcomes. In addition, the right kinds of professional support should be made available to patients, whether through health coaches or other sorts of new professionals who can support and educate patients on the best evidence-based processes for health care and healing.

It is clear that we are still at a rudimentary level of conceptualization and implementation of an evidence-based, value-driven healthcare system and that we still have a long way to go. Finding ways in which patients and providers can be proactive in catalyzing and implementing the needed changes is essential. A learning healthcare system is defined as one in which the usual and customary activities associated with the production, distribution, utilization, and financing of healthcare services result in the simultaneous development and capture of data that are essential to the monitoring and evaluation of health care delivered.

A wide variety of information is contained in these data including, but not necessarily limited to, patient characteristics e. Through efficient organization and analysis, and provision of findings at the point of care, these data are a rich resource for informed decision making.

Two general categories of decisions require an expanded evidence base. The first category includes the use of drugs, devices, and procedures. The second category concerns the management of care itself, including the organization of care, IT, types and effectiveness of providers, and clinical pathways.

Both categories require not only effectiveness information but also comparative effectiveness information, including cost or value. As emphasized in Chapter 2 , attention is needed on the evaluation of drugs, devices, and procedures, as well as on systems of care and the healthcare professionals that are involved in the provision of the care.

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