The new IOM report: Will it change your practice?

It paints a grim picture of the health care system. But will the lofty solutions it offers up actually work?

By Mark Crane
Senior Editor

"America's health system is a tangled, highly fragmented web that often wastes resources by providing unnecessary services and duplicating efforts, leaving unaccountable gaps in care. . . . Reorganization and reform are urgently needed to fix what is now a disjointed and inefficient system."

So say the authors of the latest report from the Institute of Medicine. But Crossing the Quality Chasm is not only a stinging indictment; the report also contains a laundry list of ambitious goals for fixing the mess. Among them are pleas for Congress to appropriate $1 billion for an "innovation fund" to help subsidize an overhaul of the system.

In its 335-page book, the IOM, part of the National Academy of Sciences, calls for new vigor in improving care for common chronic conditions, such as heart disease, diabetes, and asthma. It encourages greater coordination and communication among health care workers, more reliance on evidence-based medicine and guidelines, more emphasis on electronic records, e-mail between doctors and patients, and automated medication order-entry systems that can reduce errors. By employing information technology, the IOM envisions the elimination of most handwritten clinical data within the next 10 years.

"Our top priority is for all physicians and public officials to accept the report's aims and overall agenda," says Donald M. Berwick, a pediatrics professor at Harvard Medical School and president and CEO of the Institute for Healthcare Improvement. Berwick was one of the report's authors.

The IOM's goals are lofty, but are they realistic? Officially, reaction from most medical and health policy leaders has been positive if unenthusiastic. They applaud the report for providing a blueprint for change and a good starting point in a discussion of how to revamp a system that frustrates everyone.

Privately, however, some are disappointed with what they call vague generalities and the lack of real impact, especially coming on the heels of the controversial IOM report on patient safety. That study found that more people die from medical mistakes each year than from motor vehicle accidents, breast cancer, or AIDS.

"Ho hum," says one health policy observer who asked not to be identified. "The report is an oversimplified statement of the obvious. You can't really oppose anything it said. Sure, things would be better if only we spent more money, had better communication, used technology more, etc. But who didn't already know that? This report doesn't break any new ground."

Berwick disagrees: "This report is far more sweeping than the one on safety. The details are there in the fine print. We establish strong links to literature and best practices. There's a wealth of information for office-based physicians to use. But they have to follow the links in detail.

"The report is necessarily vague in complex areas we know less about, such as overall health policy, organizational systems, and the regulatory climate," he continues. "We're not providing the definitive solution, because that would be unrealistic. We've identified where we need to see greater experimentation. It would be neither useful nor possible for us to specify in detail the design of 21st-century health care delivery systems."

The IOM recognizes that there are many obstacles to achieving its goals, but hopes that the report will spur debate and action. That's a good bet: Given the IOM's prestige, it's likely that the report's basic concepts will be taken seriously on Capitol Hill and at major health institutions.

Here are some of the report's top recommendations:

Treat chronic conditions better. The federal Agency for Healthcare Research and Quality should identify 15 or more common health conditions, most of them chronic. Then, health professionals, hospitals, plans, and purchasers should develop strategies to improve care for each of these priority conditions. "These ailments typically require care involving a variety of clinicians and health care settings, over extended periods of time," says the IOM. "Yet physician groups, hospitals, and health care organizations work so independently from one another that they frequently provide care without the benefit of complete information about the patients' conditions, medical histories, or treatment received in other settings."

Promote evidence-based medicine. The IOM laments the tremendous variability in practice for many chronic conditions, and urges changes in payment methods to eliminate these variations. "Care should not vary illogically from clinician to clinician or from place to place," declares the IOM.

The Department of Health and Human Services should be given the responsibility and resources to make scientific evidence more accessible to clinicians and patients. The goal is to have ongoing analysis of medical evidence, delineation of specific practice guidelines, and identification of best practices.

Use information technology. "Health care delivery has been relatively untouched by the revolution in information technology that has been transforming nearly every other aspect of society," declares the IOM report. As an example, the report cites the small fraction of physicians who offer e-mail interaction with their patients.

"Many patients could have their needs met more quickly and at lower cost if they had the option of communicating with clinicians through e-mail," says the IOM. "The use of automated medication order-entry systems can reduce errors in prescribing and dosing drugs, and computerized reminders can help both patients and clinicians identify needed services." The report concedes that this may be impossible under current laws and given current payment arrangements.

Reform payment policies. The current system is replete with payment policies that work against the efforts of clinicians. Fee-for-service raises concerns about overutilization; capitation and per-case payment systems raise concerns about rationing.

The IOM wants private and public purchasers to examine their payment methods to remove barriers that currently impede quality improvement, and to build in stronger incentives for quality enhancement. These purchasers should then pursue a vigorous program of "pilot testing" and evaluating different options. The Centers for Medicare & Medicaid Services (formerly HCFA) and the Agency for Healthcare Research and Quality should identify and evaluate various options to accomplish this goal.

New approaches could include "blended methods of payment for providers, multiyear contracts, payment modifications to encourage the use of electronic interaction among clinicians and between clinicians and patients, risk adjustment, bundled payments for priority conditions, and alternative approaches for addressing the capital investments needed to improve quality."

Consider modifying liability rules. The IOM recognizes that "innovations in care can contribute to increased threats of litigation because, by definition, innovation implies a change from previous practice, and medical advances are often imperfect when first applied in clinical practices."

As examples, the IOM cites the use of care teams or communication by e-mail instead of a face-to-face meeting with the doctor. "Such changes can be disorienting to patients if not well understood, and in the short run, could create new hazards and risks of litigation," says the IOM.

Also, liability concerns can affect "the willingness of physicians and other clinicians to share information about areas in which quality improvement is needed if they believe the information may subsequently be used against them." The report favors peer review protection of data used inside health care organizations.

It's still unclear how courts will incorporate clinical evidence and clinical practice guidelines into legal decision-making. "To date, clinical practice guidelines have had little effect on litigation," the report states.

The IOM favors greater study of alternative approaches to liability, such as enterprise liability (where the health plan would be legally responsible, rather than an individual clinician) or no-fault compensation. These methods could produce a legal environment more conducive to uncovering and resolving quality problems.

The full text of the IOM report is available at the National Academy Press Web site at www.nap.edu/books/0309072808/html .

 

Mark Crane. The new IOM report: Will it change your practice?. Medical Economics 2001;15:32.