Best Care at Lower Cost

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Best Care at Lower Cost - The Path to Continuously Learning Health Care in America

Best Care at Lower Cost [1] is a report on health care quality published by the Institute of Medicine (IOM) in September, 2012. It builds on prior landmark reports issued by the IOM like To Err is Human [2], Crossing the Quality Chasm [3] and Unequal Treatment [4] and offers a list of recommendations to improve health care in America. This report, as many of the prior IOM reports, identifies biomedical and health informatics as a key component of the future of health care in the U.S. and its largely based on the idea of building a continuously learning, adaptive health care system around a digital health information infrastructure.


Background

Health care in America has experienced a huge explosion in knowledge and technology in the last few decades, but despite this it falls short on quality, outcomes, cost and equity. Part of the problem are the inefficiencies in the system that result in waste and harm to the patients. These shortcomings are especially notorious when comparing healthcare to other industries. The banking industry, for instance, is largely based on electronic financial records that are updated in real time, and the automobile companies are capable of producing thousands of vehicles that are standardized in their core, with reliable safety and efficiency, while customized at the margins to meet the customers needs. Health care could learn from these industries how to become consistently reliable but at the same time be able to systematically and seamlessly improve.


The Adaptive Systems

The adaptive system is a system that learns, with the aid of new tools, how to improve and better manage problems in real time. The vast computational power available today along with the current organizational capabilities and the recognition of the central role of collaborative health care teams in the delivery of effective care offers opportunities to build such a system that were not available just a few years ago.


The Role of Health Informatics

The IOM recognizes the value of collecting and analyzing the data generated by health care encounters in order to capture results, improve processes and generate new knowledge. The report acknowledges the efforts of the Department of Health and Human Services effort to increase the digital capacity of the health care system, but it also encourages it to develop data research networks and expand the access to health care data to improve care, lower costs and enhance public health. In essence, not only improve the data infrastructure but also the data utility. This will require, according to the report, a revision of the current rules and regulations in order to improve the access and use of such data while safeguarding patient privacy. The report alludes to the importance of continuously updated clinical decision support tools and knowledge management systems to ensure that decisions made during routine health care delivery are made with the best evidence at the point of care.


Patient-Centeredness and Payment Models

Best Care at Lower Cost also highlights the importance of involving patients in their own health and encourages public and private health care payers to measure and promote patient-centeredness. It also encourages the involvement of communities and advocacy groups in the huge undertaking of transforming health care into an adaptive, continuously learning system.

In regards to the payment models, the IOM recommends moving away from the current fee-for-service payment model and adopting a value- and outcome-oriented model that provides the best care at a lower cost.


Leadership, Organizational Culture and Incentives

The IOM recognizes in Best Care at Lower Cost the importance of broad leadership at all levels to undertake the fundamental changes needed in the health care system. It encourages health care organizations to foster cultures that encourage improvement, the use of best practices, transparency, open communication, staff empowerment, care coordination, teamwork and mutual respect. The IOM also recommends the alignment of incentives accordingly to promote this change.


Recommendations

Recommendation 1: The Digital Infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.

Recommendation 2: The Data Utility. Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.

Recommendation 3: Clinical Decision Support. Accelerate integration of the best clinical knowledge into care decisions. Decision support tools and knowledge management systems should be routine features of healthcare delivery to ensure that decisions made by clinicians and patients are informed by current best evidence.

Recommendation 4: Patient-Centered Care. Involve patients and families in decisions regarding health and health care, tailored to fit their preferences.

Recommendation 5: Community Links. Promote community-clinical partnerships and services aimed at managing and improving health at the community level.

Recommendation 6: Care Continuity. Improve coordination and communication within and across organizations.

Recommendation 7: Optimized Operations. Continuously improve healthcare operations to reduce waste, streamline care delivery, and focus on activities that improve patient health by applying systems engineering tools and process improvement methods

Recommendation 8: Financial Incentives. Structure payments to reward continuous learning and improvement in the provision of best care at lower cost through outcome- and value-oriented payment models and improvement incentives.

Recommendation 9: Performance Transparency. Increase transparency on health care system performance to help inform care decisions and guide improvement efforts.

Recommendation 10: Broad Leadership. Expand commitment to the goals of a continuously learning health care system. Healthcare delivery organizations should develop organizational cultures that support and encourage continuous improvement, the use of best practices, transparency, open communication, staff empowerment, coordination, teamwork, and mutual respect and align rewards accordingly.


Submitted by L. N. Sanchez-Pinto, MD


References

1. Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. National Academies Press, 2012.

2. Institute of Medicine. To err is human. Building a safer health system. Washington. National Academies Press, 1999.

3. Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. National Academies Press, 2001.

4. Institute of Medicine. Unequal treatment: Confronting racial and ethnic disparities in health care. National Academy Press, 2003.