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Health Care System Needs Overhaul, IOM Report Says

Cheryl A. Thompson

The U.S. health care system falls far short in routinely delivering its potential benefits to patients, leaving a chasm between reality and possibility, says an Institute of Medicine (IOM) committee in a report released last week. Efforts to overhaul the system over the next decade should start immediately, the committee recommended, spurred by an as yet unbudgeted $1 billion "innovation fund" from Congress.

In "Crossing the Quality Chasm: A New Health System for the 21st Century," the IOM Committee on Quality of Health Care in America takes up where its 1999 report, "To Err Is Human: Building a Safer Health System," left off. That first report, said committee chair William C. Richardson, was "only a small part of the unfolding story of quality in American health care—the tip of the iceberg." The new report discusses "the rest of the iceberg," he said.

Under the current system of health care in this country, the report said, not only do thousands of people die each year from medical error, health professionals provide unnecessary services, duplicate one another’s efforts, and do not necessarily make decisions on the basis of scientific evidence. This waste of resources mounts up, leading to gaps in care. As with "To Err Is Human," the committee laid blame on the system, not practitioners.

Five-part strategy for quality care. The committee was formed in 1998 to develop a strategy that, over the ensuing 10 years, would lead to substantial improvements in the quality of health care. In this latest report, the committee offered its five-part strategy for changing the health care system.

1. Commit to making significant improvement in six areas integral to high-quality care. Every health care institution, practitioner, purchaser, and regulator must strongly commit to making care (1) safe, (2) effective, (3) patient centered, (4) timely, (5) efficient, and (6) equitable. To significantly improve in these six areas, the committee said, new systems and approaches to delivering care will be needed. Innovation at the local level should be nurtured.

2. Adopt a new set of principles to guide the redesign of care processes. The new health care system, the committee said, must have as its highest priority attention to patients’ needs. To guide clinicians’ relationships with patients, the committee proposed that clinicians and health care organizations follow 10 rules.

One, use "continuous healing relationships"—whether over the Internet, by telephone, or through some other means in order to supplement face-to-face visits.

Two, customize care on the basis of patients’ needs and values. The system should enable clinicians to meet the most common types of needs yet respond to an individual patient’s choices and preferences.

Three, give patients control over their care. Patients should receive the information necessary for making a decision and have the opportunity to exercise as much control as they want over a decision that affects them.

Four, share clinical knowledge and medical information with patients.

Five, make clinical decisions on the basis of the best scientific evidence.

Six, make the system as safe as possible for patients. This rule reiterates the message of "To Err Is Human."

Seven, make information available to patients so that they can make informed decisions when selecting a health plan, hospital, clinical practice, or treatment.

Eight, anticipate patients’ needs rather than react to them.

Nine, do not waste resources or patient time.

Ten, cooperate more so that clinicians appropriately exchange information and coordinate care.

3. Develop evidence-based approaches to care for common conditions. Some 15 to 25 conditions, nearly all chronic, account for most of the health care services currently provided to patients, the committee said. Therefore, the federal Agency for Healthcare Research and Quality should identify the most common, or "priority," conditions, and health care organizations, clinicians, and purchasers should organize evidence-based care processes for these conditions. Also, Congress should appropriate $1 billion over three to five years to a "Health Care Quality Innovation Fund" that would fund projects seeking to improve the six areas integral to high-quality care or produce substantial improvements in the quality of care provided to patients with the priority conditions.

4. Create organizational processes that will support changes in the delivery of care. Changes must be supported by better organizational processes, the committee said, specifically pointing to information technology, care teams, and performance and outcome measurements. Information technology holds great potential for supporting changes in care, but problems with data exchange hinder many projects and consume financial resources, the committee said. Although the public sector should take the lead in funding these changes, private-sector foundations, purchasers, and health care organizations should also invest. Organizations must encourage clinicians to enlist the help of other health care professionals as appropriate.

5. Change the health care environment to one that fosters and rewards improvement. The committee called on purchasers, regulators, health professions, educational institutions, and the Department of Health and Human Services (HHS) to create an infrastructure that will support evidence-based practice, facilitate the use of information technology, align payment incentives, and prepare the work force to better serve patients. Specifically, the HHS secretary should oversee the establishment and maintenance of a comprehensive program that makes scientific evidence more useful and accessible to clinicians and patients. Through cooperation between the public and private sectors, information technology should advance in the coming years so that, by 2009, little clinical data is handwritten. Payment methods must encourage high-quality care rather than impede local innovations and penalize clinicians and health care organizations, the committee said. To prepare the work force for the changes that will occur, the committee recommended that health care profession leaders meet to develop strategies for restructuring clinical education and assess the implications for credentialing programs, funding, and sponsorship of educational programs.

Reactions. The American Hospital Association (AHA) greeted the IOM report with reservation. While agreeing with the committee that the health care system should continue to focus on the six areas identified as integral to high-quality care, AHA cautioned that the system overhaul envisioned in the report will not come easily. All stakeholders, including the government and insurers, must commit to funding research and taking advantage of new technology and avoid duplicating their efforts and setting unrealistic timelines, AHA said.

Four major physician groups—the American Academy of Family Physicians, American College of Physicians-American Society of Internal Medicine, American College of Surgeons, and American Medical Association—supported the IOM committee’s call for action, particularly on the part of Congress and federal agencies. Congress should enact legislation that would encourage physicians to work toward correcting "potential system problems that undermine quality" yet ensure protection from penalties for speaking up, the groups said in a joint statement.

The National Patient Safety Foundation affirmed the committee’s call for multidisciplinary care teams and higher levels of safety for patients and urged quick action in translating concepts into actual system improvements.