A review of the 2012 report from the Institute of Medicine

Julie Balch Samora, MD, PhD, MPH, and David B. Bumpass, MD

More than a decade after the Institute of Medicine (IOM) published To Err Is Human: Building a Safer Health System, underperformance, inefficiency, and exorbitant costs continue in the U.S. healthcare system. Although biomedical knowledge, innovations in therapies and surgical procedures, and management of chronic conditions have substantially advanced, American health care has failed to significantly improve in many areas. There are shortcomings in each of the six aims for quality care (safety, effectiveness, efficiency, equity, timeliness, and patient-centeredness) identified in the 2001 IOM report Crossing the Quality Chasm.

Last year, the IOM convened the Committee on the Learning Health Care System in America to identify current challenges and propose solutions to improving the healthcare system. Their 381-page report, Best Care at Lower Cost: The Path to Continuously Learning Health Care in America, describes the complexity of modern medicine, the costs of care, and the limited return on investment.

The specific aim of the report was to identify how the effectiveness and efficiency of the present healthcare system could be transformed through tools and incentives to create a healthcare system characterized by continuous learning and improvement. This report outlines how to harness new technologies, innovations, and approaches to overcome the many challenges in the U.S. healthcare system.

The first section of the report explores ‘the imperatives,’ the second segment outlines ‘the vision,’ and the third part expounds ‘the path.’ The committee identified the following three imperatives for achieving a continuously learning healthcare system:

• Managing rapidly increasing complexity
• Achieving greater value in health care
• Capturing opportunities from technology, industry, and policy

The vision is based on the belief that a learning healthcare system can be achieved, one in which “science and informatics, patient-clinician partnerships, incentives, and culture are aligned to promote and enable continuous and real-time improvement in both the effectiveness and efficiency of care.” The path to achieving this vision 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.”

The need for transparency
The report explores the need for transparency of process, outcome, price, and cost information. It recommends that healthcare organizations and professional specialty societies, such as AAOS, collect and expand the availability of information on the safety, quality, price, and health outcomes of care, so as to help inform care decisions and guide improvement efforts. Furthermore, it argues that public and private payers should promote transparency to aid members with decision-making.

Data demonstrate that transparency can lead to improved performance. For example, when public reporting of pneumonia care measures was instituted, compliance rates rose from 72 percent to 95 percent over 8 years. Another initiative indicated that coupling financial incentives with assistance to clinicians in monitoring their practice patterns against those of others decreased spending growth by 2 percent per quarter while improving overall care quality.

Data were also presented that outline the excessive costs of health care in this country. For example, healthcare costs for the Department of Defense alone are more than $50 billion a year (or approximately 10 percent of its budget), and Medicaid expenditures consume almost 20 percent of state budgets. For the public, the cost of health care is consuming more of each paycheck and rising higher than any increases in pay. In the past decade, the average income for a family of four rose by 30 percent, while the family’s healthcare costs increased by 76 percent.

Knowledge transmission
The report also addressed the issue of knowledge transmission, arguing that traditional systems for disseminating new knowledge (ie, the ways healthcare providers are educated, deployed, rewarded, and updated) can no longer keep pace with scientific and technologic advances—and may be harmful to patients. For example, it took 13 years after the first positive clinical trial for most experts to recommend thrombolytic drugs for treatment of myocardial infarction.

In orthopaedics, a relevant section is the need for research to address clinical questions. The authors note that nearly half of clinical guideline recommendations in all of medicine are based on expert opinion, case studies, or standards of care as opposed to clinical trials, indicating that much knowledge is lacking. This can be readily seen in orthopaedics, with many AAOS clinical practice guidelines having moderate or limited strength and inconclusive evidence.

The adoption of beneficial innovative medicines, technology, devices, and techniques must be balanced, however; overly rapid adoption may lead to harmful results, illustrated by a case history involving a metal-on-metal hip implant. The authors argue that the availability of an appropriate digital infrastructure such as a universal electronic medical record, clinical data to compare effectiveness and efficiency of various interventions, and registries to identify side effects and safety issues could have prevented this situation. It calls for more data, monitoring, and analysis to evaluate, disseminate, and implement health information and technology.

Coordinated care
Health care is often poorly coordinated across different settings and providers. In one survey, roughly 25 percent of patients noted that a test had to be repeated because the results from another provider had not been shared—a situation that frequently occurs in orthopaedics with radiographs or magnetic resonance imaging scans.

Because approximately 75 million Americans have more than one chronic condition, coordination among multiple specialists and therapies is necessary to avoid miscommunication, misdiagnosis, potentially conflicting interventions, and dangerous drug interactions. Mobile technologies and electronic health records have the potential to improve the capture and sharing of health data.

The federal office of the National Coordinator for Health Information Technology, information technology developers, and standard-setting organizations should ensure that these systems are robust and interoperable. Clinicians and care organizations should fully adopt these technologies, and patients should be encouraged to use tools, such as personal health information portals, to actively engage in their care.

Payment models
Another section of the report focuses on developing payment models, contracting policies, and benefit designs to reward effective, efficient care. Payment models should provide adequate incentives and support for high-quality, team-based care focused on the needs and goals of patients and families. Health economists, health service researchers, professional specialty 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. The AAOS is currently working toward developing appropriate quality metrics within orthopaedics.

Recommendations
The report concludes with the following ten recommendations for improvement:

• Improve the digital infrastructure
• Streamline data utility
• Accelerate integration of the best clinical knowledge
• Include patients and their families in the decision-making process
• Promote community–clinical partnerships
• Improve coordination among organizations
• Optimize operations to reduce waste
• Structure payment to reward continuous learning and improvement
• Increase transparency on performance
• Promote broad leadership that is committed to sustaining a continuously learning healthcare system.

Best Care at Lower Cost: The Path to Continuously Learning Health Care in America is a call to action to guide the many different stakeholders in medicine toward common goals. It urges the application of all possible resources and tools and the utilization of science, information technology, and incentives to transform the effectiveness and efficiency of care.

It outlines detailed strategies for incorporating continuous learning and improvement in all aspects of health care, recognizing that no one individual or organization can effect the needed change to enhance the healthcare system. In the end, the nation’s health and economic future depends on our ability to steward the evolution of a continuously learning healthcare system.

Best Care at Lower Cost: The Path to Continuously Learning Health Care in America can be read online for free. See the online version of this article for a link to download the report.

Julie Balch Samora, MD, PhD, MPH, and David B. Bumpass, MD, are the 2012–2013 AAOS Washington Health Policy Fellows.

Editor’s Note: Policy Timeout is a series on advocacy issues written by AAOS Washington Health Policy Fellows.