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Interdisciplinary Health Care Can Cross 'Quality Chasm,' Experts Say

Donna Young

The Institute of Medicine (IOM) last year suggested that health care in the United States was in need of major reform and should shift its focus from treating acute illnesses to providing evidence-based, interdisciplinary care for patients with common chronic conditions, such as heart disease, diabetes, asthma, and arthritis.

In Crossing the Quality Chasm, IOM stated that, before change can occur, health care education programs must redesign the way professionals are trained.

IOM’s Board of Health Care Services invited physicians, nurses, pharmacists, other health care professionals, and education and policy experts to a two-day summit held in Washington, D.C., in June to discuss strategies for restructuring health care curriculum and training at universities and colleges and in continuing-education programs. The institute plans to release a report later this year that includes operational plans developed by summit participants. A task force overseeing the project is scheduled to meet in September, an IOM spokeswoman said.

University of Arizona College of Pharmacy Dean J. Lyle Bootman, the only pharmacist member of IOM’s Board of Health Care Services, said that people look to educational institutions and academic health centers to retool the health care system "because that is where all practitioners are born."

But, he added, those institutions are sometimes the most difficult places in which to implement change because they are "steeped in culture and tradition."

"They’ve been training the way they have been training for 100 years," Bootman said. "We don’t need to change the entire culture, but we need a commitment of leadership to [IOM’s] principles. Everyone needs to get behind the desire [for change]."

Pharmacists and pharmacy organizations, Bootman said, have been discussing the need for an interdisciplinary approach to patient care for more than 30 years.

"We have been sort of waiting for medicine and others to come to the table," he said. "To physicians, interdisciplinary health care means that the internist talks to the pediatrician, or the internist talks to the oncologist, not that they talk to the nurses or the pharmacists."

Bootman said he was excited to see "very high-level elite" physicians, nurses, and pharmacists at the IOM summit "getting behind this, stamping their desire, and making the commitment" to support changes in the education of health care professionals.

One difficulty faced by some pharmacy schools in trying to implement an interdisciplinary training approach is the lack of an associated medical or nursing school on the same campus or an academic hospital in close proximity.

"That’s a major issue that I’ve brought up" to IOM, Bootman said.

Of the 126 academic medical centers in the United States, less than 30 have a pharmacy school on the same campus, noted Bootman.

"That is going to require some strategic planning and thought on the part of organized pharmacy," he said. Pharmacy needs to ensure that physicians do not graduate and residents do not complete a medical residency program without working in some way with pharmacists.

For instance, Bootman said, Samford University in Birmingham, Alabama, has McWhorter School of Pharmacy and a nursing school on the campus but not a medical school. But just a short distance away at the University of Alabama at Birmingham, there is a medical school. The University of Alabama does not necessarily need to have a pharmacy school, he said, but does need to have a relationship with one.

Many medical schools want to involve pharmacists and pharmacy students in medical residency programs, Bootman said. Professional pharmacy associations, he said, need to "give some serious thought" about how to ensure that pharmacy residents engage in programs linked with medical residencies; nursing, nutritionist, and physical therapist education; and other health care training programs.

"But if we had to choose two, [they] would be nursing and medicine," he added.

Also, the hospital and health-system community must commit to fostering interdisciplinary, collaborative treatment, Bootman said. Otherwise, newly trained professionals will revert to practicing in ways that are not patient centered. "Transitioning is very key," he said.

Accrediting organizations for health care continuing-education programs should modify them to include interdisciplinary training, Bootman added. A "radical thought," he said, would be for physicians, pharmacists, and nurses to complete a certain number of hours per year of collaborative training.

Congress and state legislators must work with the health care community to change legislation to give pharmacists provider status under Medicare, Bootman said. The Centers for Medicare & Medicaid Services and other regulatory agencies must also develop and fund more demonstration projects of collaborative care reimbursement models, he added.

Information technology is also an important element to restructuring the health care system to meet patient care needs, Bootman said.

Health care professionals need a common database to access and share patient information, he said, and the ability to communicate electronically with patients and other practitioners. Many hospitals and clinics, he added, are not yet connected to the Internet. "Much of that will have to be driven by the consumer being the center of all of that activity."

Patients, Bootman said, must be willing participants in health care reform.

The IOM report, he said, "recognizes that there’s a third [of the patient population] who are eagerly awaiting to get involved; a third that, will say, tell me what to do, and I’ll get involved; and a third that don’t want anything to do with it." The least-involved patients, he said, could be the major cost drivers.

Changing health care education’s curriculum to include interdisciplinary care, informatics, and evidence-based training will require significant monetary investments from educational institutions, government, corporations, and the public, Bootman said.