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Moving to the Next Stage:Quality and Efficiency Improvement Jerome H. Grossman, MD Director Health Care Delivery Policy Program Harvard University JFK School of Government Presentation to Mayo Clinic January 22, 2004
Scanning the Environment - Costs • Increasing at steep rate • Increased uninsured – increased middle class concern • Employers pass increasing cost to employees • Employers pass increase onto retirees – not new employees • Government passes increase onto retirees and states (Medicaid) • Medicare Bill includes medical savings account • The beginning of health 401(k) • Employers/govt. decreasing responsibility for health insurance
Quality • Quality focus dominates media and legislation • However progress stays in neutral • Scattered successes balanced by new revelations of error • Strategy shifting from projects to “systems thinking” • Lack of transparency and safety oversight becoming larger issue • Finance has SEC • Civil Air Transport has FAA • Health has JCAHO – malpractice (mainly self-regulation)
Implications • Transition coming • From professional determined public good (civil right) • To market-based service industry • Tightly integrated orgs. like Mayo have first mover advantage • Have been working together on quality, information systems and service since inception (most intensely in the past decade) • High level “Brand” remains quality measure • “but” . . . There is a new challenge coming!
Productivity • Why is medicine a special case? • Up to now, many actors, little data, many outcomes • Advances in medical information and economic methods (for service industry) make research possible • KEY RESULT: • Integrates Costs andQuality
For Example • Clinical Condition • “Input” • Arthritis of Hip • with surgery • without surgery • mild • moderate • severe • Quality • “Output” • Technical • Functional • Trust • Service Medical Surgical Rehab All Resources ($) Used
Research Projects at Harvard • Studying the History of Treatment Innovation • Acute medical - AMI • Chronic medical • Diabetes • Pediatric asthma • Congestive heart failure • Surgical – minimally invasive surgery • Preventive – colon cancer screening
An Engineering Agenda to Help Realize the IOM Vision • Two Major Interconnected Opportunity Sets for Engineering and Medicine • Information and information/communication technologies and associated research to advance connectivity, information flow, coordination. • System design, analysis and control tools & associated research to advance understanding of processes and system interactions; and improve/optimize dimensions of system performance in face of constraints.
Information and Information/Communication Technologies • Information and information/communication technologies and associated research to advance: • Connectivity • Information flow • Coordination
Systems Design and Implementation • System design, analysis and control tools and associated research to: • Advance understanding of processes and system interactions • Improve/optimize dimensions of system performance in face of constraints
Health Care System Quality Process • Patient Inputs • Severity • Comorbidities • Age/Sex • Socioeconomic Status • Compliance • Genetics • Expectations • Attitude • Patient Outcomes • Mortality • Morbidity • Functional Status • Quality of Life • Cost of Care • Satisfaction Infrastructure Source: Jim Naessens, Thesis Work
Integration of Multiple Subsystems PCP Triage Lab Surgery Admitting ICU ED Nursing Library Patient Ed. Post-OP Specialist
For Example ←FROM: Computerized Physician Order Entry ----Process Distribution ←TO: Computer Aided Design (CAD) ----Computer Aided Manufacture (CAM) DESIGN AUTOMATED PROCESS MANAGEMENT Orders What First? What Next? What to Do When When to Interfere Due to Delay (Historical Data) Design Send Message to “Delay Factor” Evidence Based Medicine Caretaker “Alters” Process Reset Process Personal Habits
Solving the Simultaneous Equations Government Consumers Employers Consumer Aggregators Insurers/Risk & Disease Management Delivery Aggregators Regulation Safety (FED, FAA) Transparency (SEC) • Productivity • Better • Cheaper • Faster Practices Hospitals Drugs Integrated Systems