Best Care at Lower Cost The Path to Continuously Learning Health Care in America (2013) / Chapter Skim
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Pages 5-44
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Yet, American health care is falling short on basic dimensions of quality, outcomes, costs, and equity. Available knowledge is too rarely applied to improve the care experience, and information generated by the care experience is too rarely gathered to improve the knowledge available.
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convened the Committee on the Learning Health Care System in America to explore
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Over the past 6 years, 11 workshop summaries have been produced, exploring various aspects of the challenges and opportunities in health care today, with a particular focus on the foundational elements of a learning health system. Meeting the challenges discussed at those workshops has taken on great urgency as a result of two overarching imperatives: • to manage the health care system's ever-increasing complexity, and • to curb ever-escalating costs.
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Additionally, new opportunities emerging from technology, industry, and policy can be leveraged to help mold the system into one characterized by continuous learning and improvement. In this context, the committee identified three imperatives for achieving a continuously learning health care system that provides the best care at lower cost: (1)
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health care system now is characterized by more to do, more to know, and more to manage than at any time in history. As one quantification of this increase, the vol ume of the biomedical and clinical knowledge base has rapidly expanded, with research publications having risen from more than 200,000 per year in 1970 to more than 750,000 in 2010 (see Figure S-1)
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. Managing these multiple conditions requires a holistic approach, because the use of various clinical practice guidelines developed for single diseases may have adverse effects (Boyd et al., 2005a; Parekh and Barton, 2010; Tinetti et al., 2004)
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. One study found that in a single year, a typical primary care physician coordinated with an average of 229 other physicians in 117 different practices just for Medicare patients (Pham et al., 2009)
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Estimates vary on waste and excess health care costs, but they are large. The IOM workshop summary The Healthcare Imperative: Lowering Costs and Improving Outcomes contains estimates of excess costs in six domains: unnecessary services, services inefficiently delivered, prices that are too high, excess administrative costs, missed prevention opportunities, and medical fraud (IOM, 2010)
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Estimate of Category Sources Excess Costs Unnecessary Services • Overuse -- beyond evidence- $210 billion established levels • Discretionary use beyond benchmarks • Unnecessary choice of higher-cost services Inefficiently Delivered • Mistakes -- errors, preventable $130 billion Services complications • Care fragmentation • Unnecessary use of higher-cost providers • Operational inefficiencies at care delivery sites Excess Administrative • Insurance paperwork costs beyond $190 billion Costs benchmarks • Insurers' administrative inefficiencies • Inefficiencies due to care documentation requirements Prices That Are Too High • Service prices beyond competitive $105 billion benchmarks • Product prices beyond competitive benchmarks Missed Prevention • Primary prevention $55 billion Opportunities • Secondary prevention • Tertiary prevention Fraud • All sources -- payers, clinicians, $75 billion patients SOURCE: Adapted with permission from IOM, 2010.
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. 3 The average premiums for a single worker were calculated using the Kaiser Family Foundation's 2009 Employer Health Benefits survey, with the size of the civilian labor force drawn from Bureau of Labor Statistics estimates for 2009 (Kaiser Family Foundation and Health Research & Educational Trust, 2009; U.S.
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. Projections are for 90 percent of office-based physicians to have access to fully operational electronic health records by 2019, up from 34 percent in 2011 (Congressional Budget Office, 2009; Hsiao et al., 2011)
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Across the United States, moreover, there is growing momentum to implement novel partnerships and collaborations to test delivery system innovations aimed at high-value, high-quality health care. In many settings, stakeholders at all levels -- federal, state, and local governments; public and private insurers; health care delivery organizations; employers; patients and consumers; and others -- are working together with the shared objectives of controlling health care costs and improving health care quality.
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. The convergence of these novel partnerships, a changing health care landscape, and investments in knowledge infrastructure has created a unique opportunity to achieve continuously learning health care.
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Patient-Clinician Partnerships Engaged, empowered patients -- A learning health care system is anchored on patient needs and perspectives and promotes the inclusion of patients, families, and other caregivers as vital members of the continuously learning care team. Incentives Incentives aligned for value -- A learning health care system has incentives actively aligned to encourage continuous improvement, identify and reduce waste, and reward high-value care.
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THE PATH The path to achieving the vision of a learning health care system entails generating and using real-time knowledge to improve outcomes; engaging patients, families, and communities; achieving and rewarding high-value care; and creating a new culture of care. Generating and Using Real-Time Knowledge to Improve Outcomes Although unprecedented and increasing levels of information are available in journals, guidelines, and other sources, patients and clinicians often
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. Given the increasing number of new medical treatments and technologies, the complexity of managing multiple chronic diseases, and the growing personalization of treatments and diagnostics, the challenge is to produce and deliver practical evidence that clinicians and patients can apply to clinical questions.
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. Conclusion: Growing computational capabilities to generate, com municate, and apply new knowledge create the potential to build a clinical data infrastructure to support continuous learning and improvement in health care.
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Technological tools, such as decision support tools that can be broadly embedded in electronic health records, hold promise for improving the application of evidence. One study found that digital decision support tools helped clinicians apply clinical guidelines, improving health outcomes for diabetics by 15 percent (Cebul et al., 2011)
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These opportunities include improving communications outside of traditional clinical visits by providing new venues for care; assisting patients in managing their own health; and explaining options for shared clinical decisions, a capability that highlights health professionals' need to assume new roles in partnering with patients in the use of reliable online sources of health information (Brach et al., 2012)
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Most determinants of the health status of individuals and populations lie not in health care -- medical care accounts for only 10 to 20 percent of overall health prospects -- but in such factors as behavior, social circumstances, and environment. Thus, close clinical-community coordination is required to protect and improve health (McGinnis et al., 2002)
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However, most of these models tend to pay clinicians and health care organizations without a specific focus on patient health and value, which has contributed to waste and inefficiency. One study found, on average, only a 4.3 percent correlation between the quality of care delivered and the price of the medical service, with higher prices often being associated with lower quality (Office of the Attorney General of Massachusetts, 2011)
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The culture of health care is central to promoting learning at every level. Continuous improvement requires systematic problem solving, the application of systems engineering techniques, operational models that encourage and reward sustained quality and improved patient outcomes, transparency on cost and outcomes, and strong leadership with a vision devoted to improving health care processes.
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Further, an organization's commitment to teaming, partnership, and continuity is fundamental in fostering a culture of continuous learning and improvement. In a large, multifacility integrated health system, for example, an intervention that focused on teamwork training, coaching, and communication skills saw an 18 percent reduction in annual mortality among participating facilities, with adverse events continuing to decrease, versus only a 7 percent reduction among nonparticipating facilities (Neily et al., 2010, 2011)
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ACTIONS FOR CONTINUOUS LEARNING, BEST CARE, AND LOWER COSTS Based on the findings and conclusions derived in the course of its work, the committee offers recommendations for specific actions that would accelerate progress toward continuous learning, best care, and lower costs. As displayed in Box S-1, these recommendations can be grouped into three categories: foundational elements, care improvement targets, and a supportive policy environment.
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Recommendation 10: Broad leadership. Expand commitment to the goals of a continuously learning health care system.
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• Patient and consumer groups, clinicians, professional specialty societies, health care delivery organizations, voluntary organiza tions, researchers, and grantmakers should develop strategies and outreach to improve understanding of the benefits and importance of accelerating the use of clinical data to improve care and health outcomes.
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Strategies for progress toward this goal: • Clinicians and health care organizations should adopt tools that deliver reliable, current clinical knowledge to the point of care, and organizations should adopt incentives that encourage the use of these tools. • Research organizations, advocacy organizations, professional spe cialty societies, and care delivery organizations should facilitate the development, accessibility, and use of evidence-based and harmo nized clinical practice guidelines.
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• The Centers for Medicare & Medicaid Services and other public and private payers should promote and measure patient-centered care through payment models, contracting policies, and public reporting programs. • Digital technology developers and health product innovators should develop tools to assist individuals in managing their health and health care, in addition to providing patient supports in new forms of communities.
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• Health economists, health service researchers, professional specialty societies, and measure development organizations should develop and test metrics with which to monitor and evaluate the effective ness of care transitions in improving patient health outcomes. • Public and private payers should promote effective care transitions that improve patient health through their payment and contracting policies.
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• Health care delivery organizations should reward continuous learning and improvement through the use of internal practice incentives. • Health economists, health service researchers, professional spe cialty societies, and measure development organizations should partner with public and private payers to develop and evaluate metrics, payment models, contracting policies, and benefit designs that reward high-value care that improves health outcomes.
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Recommendation 10: Broad Leadership xpand commitment to the goals of a continuously learning health care E system. Continuous learning and improvement should be a core and constant priority for all participants in health care -- patients, families, clinicians, care leaders, and those involved in supporting their work.
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ACHIEVING THE VISION Implementing the actions detailed above and achieving the vision of continuous learning and improvement will depend on the exercise of broad leadership by the complex network of decentralized and loosely associated individuals and organizations that make up the health care system. Given the complexity of the system and the interconnectedness of its different actors and sectors, no one actor or sector alone can bring about the scope and scale of transformative change necessary to develop a system that continuously learns and improves.
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Similarly, employers can support efforts to improve quality and value by using their purchasing power to drive improvement efforts through contracts with providers and insurers, the design of benefit plans, and the provision of incentives and information for employees. Digital technology developers, health product innovators, and regulators are additional stakeholders that need to be engaged in achieving the vision of a learning health care system.
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The nation's health and economic futures -- best care at lower cost -- depend on the ability to steward the evolution of a continuously learning health care system. REFERENCES Anderson, G
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2005a. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases.
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Washing ton, DC: Congressional Budget Office. Congressional Budget Office.
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2010. The healthcare imperative: Lowering costs and improving outcomes: Workshop series summary, Learning health system series.
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Washington, DC: Congressional Budget Office.
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Health Affairs (Millwood)
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2009. Scientific evidence underlying the ACC/AHA clinical practice guidelines.
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