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Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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7
Healthcare Delivery Organizations

Coordinator


Robert M. Crane, Kaiser Permanente Institute for Health Policy


Other Contributors


Madhulika Agarwal, Veterans Health Administration; Denis Cortese, Mayo Clinic; Benjamin Druss, Emory University; Kate Meyers, Kaiser Permanente Institute for Health Policy, Jonathan Perlin, HCA, Inc.; Richard Platt, Harvard Medical School and Harvard Pilgrim Health Care; Laura Tollen, Kaiser Permanente Institute for Health Policy

SECTOR OVERVIEW

This chapter focuses on healthcare delivery organizations and is limited to two major entities: (1) integrated delivery systems (IDSs) and large physician groups and (2) hospitals. The discussion excludes physicians in solo and small group practices because such practices are too small to provide the organizational infrastructure that is the focus of this sector. However, it should be noted that physicians in solo or small group practices (2 to 10 physicians) make up fully 99 percent of office-based physician practices and that 89 percent of the physicians in the United States are in solo or small group practices (Hing and Burt, 2007).

Without major changes in clinical practice by these physicians, no amount of change by the more organized delivery sector will enable achievement of the Roundtable’s goal (smaller clinical practices are addressed in Chapter 5, which describes the healthcare professional sector). Despite the number of nonorganized physicians, however, healthcare delivery organizations play a critical role because of their ability to drive practice trends, set standards, and influence smaller practices by sharing information, resources, and guidelines. A key to achieving the Roundtable’s goal will be to improve the organizational infrastructure for physicians who are currently non-

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×

organized and/or in small groups, and healthcare delivery organizations can play an important role in facilitating that improvement.

The task in this chapter is to describe how healthcare delivery organizations can enable the generation and use of evidence. “Evidence” itself is a murky concept, and there has been much debate over what type of information qualifies as evidence for the purpose of “evidence-based medicine.” Most experts agree that the results of randomized controlled trials (RCTs) would qualify as evidence, but there is less agreement about the validity of other types of information, such as observational research and expert opinion and consensus. For the most part, the means of the “generation of evidence” in this chapter excludes expert opinion and refers mainly to more formal types of research and observational analysis (such as the analysis of large datasets created as part of the usual delivery of care), whether or not the findings are published in peer-reviewed journals. Also included is evidence generated by mathematical modeling techniques. When the “use of evidence” or the “dissemination of evidence” is addressed in this chapter, the origins of such information are not specified but are assumed to come from sound research rather than from accepted standards of community practice. For further discussion of the definition of “evidence,” see the charter statement for the Institute of Medicine’s (IOM’s) Roundtable on Evidence-Based Medicine (IOM Roundtable on Evidence-Based Medicine, 2006).

To answer the question of how healthcare delivery organizations can enable the generation and use of evidence, semistructured interviews were conducted with sector members and other experts from relevant organizations.1 Over the course of these interviews, two general themes emerged: (1) significant data aggregation is critical, and information technology is fundamental to such aggregation; and (2) healthcare organizations need to have a culture of using everyday healthcare delivery as a learning tool and a means of generating evidence.

Data Aggregation and Information Technology

Without information technology to enable the aggregation of data across settings and time, the practice of evidence-based medicine becomes nearly impossible. Data aggregation can take place at the level of a single delivery organization by using a comprehensive electronic health record (EHR), or it can take place at the level of an external third party, such as a payer, that can combine claims data from multiple providers. An example of the former is Kaiser Permanente’s implementation of KP HealthConnect, a system that integrates the electronic medical record with appointments,

1

For a list of interviewees see below references.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×

registration, and billing, linking facilities and providing physicians and patients with online access to clinical information 24 hours per day (Kaiser Permanente, 2007a). Another example is the Veterans Health Information Systems and Technology Architecture (VistA), which integrates patient records and administrative data to provide real-time data access across more than 150 healthcare facilities and 800 clinics throughout the United States and in several U.S. territories. Examples of multiorganization systems include the Cancer Research Network, sponsored by the National Cancer Institute and the HMO Research Network, and the American Medical Group Association’s collaborative database of 1.5 million patient records. All of these systems have in common not just the ability to aggregate data but also the analytic capacity to organize and retrieve data in useful ways.

Culture of Continuous Learning

The interviewees agreed that there simply are not enough RCTs to keep up with the ever-advancing onslaught of new technologies, procedures, drugs, and so forth in medical care (let alone the already established technologies for which evidence to support their use may or may not be available). Such trials are costly and time intensive, and their results may not be generalizable to patient populations not included in the study, rendering RCTs unrealistic as the only acceptable standard of evidence generation for the majority of medical practices. Some experts have also noted that the peer-review process for publication of RCTs is narrow: typically, only a handful of reviewers, selected by the journal, examine a research study and its findings before it is deemed publishable. It is only after publication, when the study has already, arguably, become “evidence,” that a broad array of experts can examine it and test its findings against their own experience in real-world situations. Furthermore, the amount of evidence available to support each and every medical decision will increase exponentially in the coming years and decades as massive amounts of information become available from the fields of genomics and proteomics. Organizations need to learn to make continuous use of their own observational data and, in the words of Lynn Etheredge (2007), become “rapid-learning health systems” as they face a learning curve that becomes continually steeper. Rapid-learning health systems are those that can combine the clinical experiences of their patients (and, possibly, the experiences of other organizations’ patients) in a searchable database that can be used for research. Such organizations view every patient encounter as adding to the collective knowledge of the group and as a means to test a hypothesis so that others in the group can benefit from the knowledge that is generated.

Although this chapter focuses on physician group practices and hospitals separately, it is important to emphasize that both types of organizations

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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will provide the greatest value to the field of evidence-based medicine by cooperating with other organizations within the larger delivery system. For example, data obtained from inpatient settings alone can be misleading, as patients receive care in many settings. Research into what works must take into account the fact that critical follow-up care after hospitalization takes place in the community. This follow-up care can have a huge impact on whether or not the care provided in the hospital can be considered effective. As a result, evidence about hospital-based care is not entirely separable from evidence about physician organizations. IDSs that are fully integrated and that combine inpatient and outpatient care delivery are particularly well positioned to track the delivery of care across settings.

The following sections of this chapter present an overview of the specific practices that healthcare delivery organizations use to generate and use evidence in clinical decision making. The chapter also provides a description of the challenges and a set of opportunities. At the outset, however, it is important to recognize the distance between the status quo and the goal of the IOM’s Roundtable on Evidence-Based Medicine. Reaching the goal of having 90 percent of clinical decisions being evidence based by 2020 will not be easy. Healthcare delivery organizations know how to generate data; but data are not the same as usable information, and the availability of usable information does not guarantee its use. Furthermore, the generation of evidence is not without cost. Although the current practices, challenges, and recommendations are a useful start, overcoming the gaps in data, information, and the will to change must not be underestimated. Reaching the Roundtable’s goal by 2020 will take more than tinkering around the edges of the healthcare delivery system. Rather, it will take fundamental restructuring and rethinking by all stakeholders, as was recommended by the IOM in its 2001 report Crossing the Quality Chasm (Institute of Medicine, 2001).

Current Practices

As noted above, this chapter addresses two major classes of healthcare delivery organizations: (1) IDSs and large physician groups and (2) hospitals. A simple description of each of these subsectors is warranted.

Integrated Delivery Systems and Large Physician Group Practices

As described by Enthoven and Tollen (2005), IDSs are organizations built on the core of a large, multispecialty medical group practice, often with links to hospitals, laboratories, pharmacies, and other facilities and often with a sizable amount of revenue based on per capita prepayment. Examples of IDSs include delivery organizations that also have an insurance function, such as Kaiser Permanente and Group Health Cooperative. Also included in

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×

this category, although it is not technically an insurer, is the Veterans Health Administration (VHA), which delivers extensive healthcare services and also purchases (finances) services that are not available within the organization.

This chapter also discusses large public and private physician group practices, which may or may not have links to a specific health plan. Many of the nation’s largest and most well-known private multispecialty physician groups, including the Cleveland Clinic and the Mayo Clinic, are members of the Council of Accountable Physician Practices, which seeks to foster the development and recognition of accountable physician practices as a model for transforming the American healthcare system (Council of Accountable Physician Practices, 2007).2 Other groups that represent IDSs and large physician group practices include the American Medical Group Association and the Alliance of Community Health Plans (Alliance of Community Health Plans, 2007; American Medical Group Association, 2007). Many publicly funded community clinics also function similarly to large multi-specialty physician groups.

Because there is no generally agreed-upon definition of an IDS, it is difficult to provide an exact count of the number of IDSs in existence today. More readily available, however, are data on medical groups, and as noted above, the core of an IDS is a large, multispecialty medical group, whether it is public or private.

According to the U.S. Department of Health and Human Services (HHS), in 2003-2004 (the most recent year for which complete data are available), there were 311,200 office-based physicians in the United States practicing in 161,200 medical practices (Hing and Burt, 2007). As previously noted, physicians in solo or small group practices (2 to 10 physicians) make up fully 99 percent of the physicians in office-based physician practices and 89 percent of the physicians in the United States. Therefore, physicians who are the focus of this sector—those in larger groups—constitute only 1 percent of practices and 11 percent of physicians. Nearly 79 percent of physicians are in solo practice or single-specialty groups, whereas only 21 percent are in multispecialty groups. Although the percentage of physicians in large or multispecialty groups, or both, seems small, these physicians do care for a significant percentage of the U.S. population. For example, the members of the American Medical Group Association care for more than 50 million Americans (American Medical Group Association, 2007).

Hospitals

Hospitals and hospital systems comprise another important part of the healthcare delivery organizations sector. As stand-alone entities or

2

For a list of Council of Accountable Physician Practices members, see www.amga.org/CAPP.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×

as part of healthcare systems or networks, public and private hospitals account for about 30 percent of the expenditures on health care in the United States (California HealthCare Foundation, 2006). The following data on hospitals are from the American Hospital Association (2007). There are nearly 5,800 hospitals in the United States, most of which are classified as community hospitals (nonfederal, short-term general, and other specialty hospitals, such as cancer centers or orthopedic specialty centers, including academic medical centers, fit these criteria). More than 80 percent of community hospitals are not for profit or public (state and local).

About 2,700 community hospitals are part of a “system,” defined by the American Hospital Association as “a multihospital or a diversified single hospital system. A multihospital system is two or more hospitals owned, leased, sponsored, or managed under contract by a central organization. Single, freestanding hospitals may be categorized as a system by bringing into membership three or more and at least 25 percent of their owned or leased nonhospital preacute or postacute healthcare organizations.” About 1,400 community hospitals are part of a “network,” defined by the American Hospital Association as “a group of hospitals, physicians, other providers, insurers and/or community agencies that work together to coordinate and deliver a broad spectrum of services to their community.” By these definitions, systems and networks are not mutually exclusive: an entity can be classified as both part of a system and part of a network (American Hospital Association, 2007).

As defined by the National Association of Public Hospitals and Health Systems (2006), safety net hospitals “include healthcare providers owned and operated by cities, counties, states, universities, non-profit organizations, or other entities” that have “a common … mission of providing health care to all, regardless of ability to pay.” In addition to inpatient care, many safety net hospitals also deliver outpatient care. On average, the 100 members of the National Association of Public Hospitals and Health Systems take care of the individuals involved in more than 400,000 ambulatory care visits per year, or approximately 36 percent of outpatient visits in the safety net.

Hospitals and hospital systems are clearly not a homogeneous group, and their differences have bearing on their current and future roles in promoting the goals of the IOM’s Roundtable on Evidence-Based Medicine. Although the definition is not comprehensive, use of the following definitions is one useful way to parse hospitals and hospital systems when their role in the generation and use of evidence is considered: (1) integrated hospital systems comprise hospitals that are closely integrated with multi-specialty medical groups (such as the Mayo Clinic and Kaiser Permanente), (2) academic medical centers are integrated with medical schools, and

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×

(3) nonprofit or for-profit community hospitals may or may not have affiliations with other hospitals or a network. The VHA hospitals represent a fourth category, as they combine aspects of the first two categories provided above. Another way to categorize hospitals is by the organizations that they choose to represent them at the national level, such as the American Hospital Association, the Federation of American Hospitals, and the National Association of Public Hospitals and Health Systems. Each broad category of hospitals has different types of incentives and infrastructures for the generation and use of evidence, which will be discussed in more detail in subsequent sections of this chapter.

ACTIVITY CATEGORIES

Many experts believe that healthcare delivery organizations, including hospitals, are better positioned than physicians in solo and small group practices to generate and use evidence in clinical decision making (Casalino et al., 2003a; Crosson, 2005; Enthoven and Tollen, 2005). Ultimately, they accomplish this by developing evidence-based practice guidelines and making them available to providers at the point of care. According to Berwick and Jain (2004), doing this requires a number of support systems that can “(1) find the science, (2) embed the science in sound standards of practice, (3) make the relevant knowledge available to clinicians and patients at the point of care and at the time of care, and (4) track performance and improve it continually.” They also note that in creating such systems, “prepaid group practices are at the forefront.” That statement can be expanded to include not just prepaid group practices but also large IDSs, large physician group practices (prepaid or not), and sophisticated hospitals.

How do healthcare delivery organizations develop the four systems described by Berwick and Jain? On the basis of the responses from the interviews, the primary mechanisms that these organizations use are described below.

Information Technology

As noted earlier, the aggregation of data across care settings and time is critical to the generation of evidence, and large delivery organizations have an advantage in this area for three reasons: (1) they have a sufficient patient base to support the meaningful (statistically relevant) aggregation of data; (2) they are more likely to have the resources required to implement and maintain the electronic data systems that are necessary for data aggregation and the provision of real-time decision support to clinicians; and (3) in the case of integrated systems, they have access to data from the many settings in which patients receive care.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×

According to Jha and colleagues (2006), although there is no universally accepted definition of the EHR, “consensus is emerging that electronic documentation of providers’ notes, electronic viewing of laboratory and radiology results, and electronic prescribing are key components of an EHR.” These tools facilitate the use of evidence-based practice because they provide clinicians with decision support (in the form of reminders, order sets, and templates) and current practice guidelines at the point of care.3 However, it is not necessary for all of these elements to be in place for a healthcare delivery organization to benefit from electronic data capture. Disease registries can also provide an important platform for conducting research and implementing evidence-based care by providing information about every patient in a provider’s population with a given condition.

Although the use of EHRs is on the rise, only about 25 percent of physicians use them, and among office-based physicians, that number is closer to 19 percent (Jha et al., 2006). Large physician group practices and IDSs have been leaders in implementing EHRs (Halvorson, 2004). In fact, the predominant factor affecting the use of information technology is practice size (Audet et al., 2004). Audet and colleagues (2004) found that 87 percent of physicians in large group practices but only 36 percent of physicians in solo practice have access to electronic test results. Other information technologies follow a similar pattern. Physicians in large group practices are more likely than solo practitioners to use EHRs, receive electronic drug alerts, and use e-mail to communicate with colleagues and patients (Audet et al., 2004).

Evidence on the use of EHRs in the inpatient setting is lacking. One systematic review of surveys on the adoption of EHRs found that the only higher-quality studies in the inpatient setting focused exclusively on computerized physician order entry (CPOE), or electronic prescribing, which is just one component of an EHR. That review concluded that just 5 percent of hospitals use CPOE and that no high-quality estimate of inpatient EHR use could be made (Jha et al., 2006). Another study that used some of the same source data on CPOE that Jha and colleagues (2006) used found that investment in this technology was more likely in government (nonfederal, in the study of Cutler [2005]) and teaching hospitals than in other types of hospitals, with for-profit hospitals being the least likely, and that larger hospitals were more likely than others to invest in CPOE (Cutler, 2005).

As with integrated systems and large physician group practices, hospital investment in information technology supports the generation and

3

It should be noted, however, that if the guidelines available through the EHR are not themselves evidence based, the EHR will do little to improve practice. The EHR is only a tool to convey information; other processes must be in place to ensure that the information is evidence based.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×

use of evidence. Given the limited use of EHRs in hospitals at present, this potential is far from being realized. Different types of hospitals may have various incentives and capabilities to implement EHRs. Integrated hospital systems likely have the greatest capacity and incentive to invest in EHRs because of the economies of scale and the purchasing power of a larger system and because of their ability to share best practices about implementing the technology. Prepaid integrated hospital systems may have additional capacities and incentives to invest in these technologies because of global budgets. Academic medical centers may have incentives to create such systems to remain on the cutting edge and to enable better research and training, but they would typically not enjoy the same incentives as the prepaid integrated systems. Other nonprofit and for-profit community hospitals typically have less of a capability or incentive to purchase and implement large-scale information systems because of an inability to spread costs over their smaller institutions.

In a practice or hospital setting not supported by information technology, providers must rely on their memories to keep up with best practices. This is a nearly impossible task when one considers that the results of 10,000 RCTs are published each year (Chassin, 1998). According to David Eddy (1999), a leader in the field of evidence-based medicine, “The complexity of modern medicine exceeds the inherent limitations of the unaided human mind.” However, having an EHR does not guarantee support for evidence-based practice. The structure—and, therein, the utility—of the data repository is important in determining how much providers can learn in real time. Issues that play a role in maximizing the usefulness of electronic data include which data are captured in the clinical information system, which data are captured as free-text notes that may not be searchable versus which data are captured as defined fields that are searchable, and whether individual data systems are connected to one another to give a comprehensive picture of a patient’s clinical situation across practice settings.

Significant Research Capacity

The large patient populations that healthcare delivery organizations serve provide a foundation for conducting research to support evidence-based guidelines. According to Fink and Greenlick (2004), before the 1950s, little was known about the use of health services by noninstitutionalized populations. At about that time, the emergence of several IDSs as a source of care for large populations provided an unprecedented opportunity for research across the full spectrum of care. Some of the pioneering IDSs that established research centers include Kaiser Permanente, the HIP Health Plan of New York, and the VHA.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×

Today, Kaiser Permanente’s eight research centers together comprise one of the largest nonacademic research institutions in the United States (Kaiser Permanente, 2007b). Similar to the Kaiser and HIP research programs, the Mayo Clinic’s Department of Health Services Research also evolved out of large-scale epidemiological projects, including the Olmsted County project, the medical information (medical records, laboratory test and radiological examination results, and tissue specimens) from which the Mayo Clinic has retained for more than 50 years. This information has been the basis of many large-scale observational studies that have led to the development of new knowledge, supporting the Mayo Clinic’s clinical practice, education programs, and research.

The VHA also has an expansive national research program, with studies being conducted at more than 100 medical centers on topics that include mental illness, long-term care, traumatic injury, and special populations, such as female veterans. VHA research has made direct contributions to current clinical practices for hypertension, posttraumatic stress disorder, diabetes, and other chronic diseases. The VHA has established a unique program, the Quality Enhancement Research Initiative, whose mission is to bring researchers into partnership with healthcare system leaders to ensure that the care provided is based on the most current scientific evidence, thereby bringing scientific discovery from the bedside to the bench and then back to the bedside (Francis and Perlin, 2006). In collaborating with external, academic research institutions, the VHA can serve as a model for other healthcare system-based research organizations.

In addition to these system-specific research centers, many healthcare delivery organizations have joined together in various networks to pool research data and capabilities. Examples include the HMO Research Network and the Cancer Research Network.4 All of these research institutions can provide important insight into evidence-based practice.

Systematic Use of External Resources

In addition to generating their own research, another means by which healthcare delivery organizations gather evidence for clinical decision making is by availing themselves of external resources. Many healthcare delivery organizations have standing internal technology assessment committees or

4

Members of the HMO Research Network include seven regions of Kaiser Permanente, HealthPartners Research Foundation, Group Health Cooperative, Harvard Pilgrim Health Care, Henry Ford Health System-Health Alliance Plan, Lovelace Clinic Foundation, Meyers Primary Care Institute, Fallon Community Health Plan, Fallon Foundation and the University of Massachusetts Medical School, Scott and White Health System, Geisinger Health System, and Marshfield Clinic Research Foundation. See www.hmoresearchnetwork.org. For information on the Cancer Research Network, see http://crn.cancer.gov/.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×

pharmacy and therapeutics committees whose purposes are to assess all available information on new procedures, devices, and drugs and determine what should be used in practice and how. These committees rely on the internal analysis both of the data and the medical literature and of information from external organizations that provide independent research and analysis, including the Blue Cross Blue Shield Association’s Technology Evaluation Center, Hayes, Inc., UpToDate, ECRI Institute, the Evidence-Based Practice Centers sponsored by the Agency for Healthcare Research and Quality, the Cochrane Collaboration, and the Center for Evidence-Based Policy at the Oregon Health and Science University (Agency for Healthcare Research and Quality, 2007; BlueCross BlueShield Association, 2000; Cochrane Collaboration, 2007; ECRI Institute, 2007; Hayes, Inc., 2007; Oregon Health and Science University, 2007; UpToDate, 2007).

Quality Measurement and Reporting

Critical to the successful implementation of evidence-based practice guidelines is a system of accountability to ensure that the guidelines are being used. One of the ways that healthcare delivery organizations do this is through systematic quality measurement. Because of their size and organizational capacity, such organizations are more likely than smaller practices to have in place quality measurement systems whose capabilities go beyond those required for accreditation. Reporting on the results of the Community Tracking Study survey, Casalino and colleagues (2003b) found that the advantages of medical groups of at least moderate size are their ability to create organized processes to proactively improve care, serve as units of analysis for which statistically reliable and valid measurements of quality can be made, and monitor clinical performance and implement clinical protocols.

Hospitals, too, can implement performance measurement and reporting systems within their institutions to help physicians understand how their performance on particular evidence-based quality measures compares with that of their peers. Quality measurement can be used as an internal means of monitoring performance, or it can be tied to financial incentives, as in pay-for-performance programs. If it is done correctly, pay-for-performance can help accelerate the adoption of evidence-based medicine, but to do so, such schemes must reward adherence to evidence-based practice rather than simply reporting on processes.

Culture and Leadership

An intangible but important element of improving the use of evidence-based clinical decision making is the organizational culture and leadership.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×

Physicians and other clinicians must be comfortable with the notion that there is in fact a best practice that may not be their own current practice. This way of thinking can be in conflict with physicians’ training, in which they are taught to be self-reliant, independent thinkers. For some, the use of guidelines may feel like “cookbook medicine” and may be viewed with suspicion. In an essay on group responsibility in medicine, Crosson and colleagues (2004) note, “It was not so long ago that physicians held a God-like sway over the healthcare universe. After all, it was a universe that consisted, for the most part, of tens of thousands of highly personalized, independent solo practices, each tending to the healthcare needs of hundreds of individual patients, one at a time. Within that intimate relationship between physician and patient, the physician held all the knowledge, all the power, all the authority.”

Today, medicine has become so highly complex that individual physicians can no longer hold all the knowledge that is relevant to their practice, and they must rely on others—colleagues and organizational structures—to help them do this. This is best accomplished within an organizational culture and with strong leadership that emphasize the use of evidence-based medicine, collaboration, and group responsibility for a population of patients rather than the outmoded model of one patient and one provider.

Human Factors Principles

Organizations that provide a physical space for the delivery of care can establish systems within their institutions that support medical staff in doing the right thing for the right patient at the right time. Systems that address human factors build evidence-based and safety principles into the design of buildings, technology, and the workflow. Examples include medication management tools (to avoid the prescription of incorrect doses or the contraindicated use of medications) and establishing standard codes among different hospitals in the same area to reduce errors when staff work in more than one facility. Hospitals can also identify what processes are needed to address quality gaps and to bundle those processes, making it the standard of care for patients with given circumstances to receive that bundle of interventions, which are supported by tools such as standing orders, protocols, and care team training. The VHA Center for Patient Safety offers an outstanding example of a systemwide safety program that is predominantly electronic in nature and that produces aggregate data for performance improvement activities and incident avoidance.

Case Studies

The following case studies illustrate the ways in which healthcare delivery organizations have incorporated the practices described above

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×

to support the use of evidence-based medicine. Each organization uses a combination of the techniques described, as no single practice is sufficient to achieve the type of culture change needed to reorient an organization toward evidence-based decision making.

Kaiser Permanente Care Management Institute

As the nation’s largest nonprofit health plan and largest nonfederal integrated healthcare delivery system, Kaiser Permanente cares for 8.7 million members in eight geographic regions. One of Kaiser Permanente’s assets in improving the generation and use of evidence is the Care Management Institute (CMI), which works to improve health outcomes through the identification, implementation, and evaluation of nationally consistent evidence-based population care management programs. Focusing on some of the most common and costly chronic diseases (e.g., diabetes, asthma, depression, hypertension, and chronic pain) as well as on the unique needs of specific populations, such as older adults, CMI acts as a central hub for the development of evidence-based guidelines, models of care, and common measurement systems for use across Kaiser Permanente.

CMI’s guiding philosophy is “making the right thing easier to do.” With collaboration among 55 staff members, work groups of clinicians, and other experts and with the use of regional implementation and measurement counterparts, its specific streams of work include creating and sharing knowledge about successful clinical approaches, designing and collecting empirical measurement and modeling projections to inform decision making, identifying and diffusing successful practices and innovations, and creating and supporting systems that enhance health care.

One example of CMI’s work focuses on decreasing the risk of cardiovascular events among people with diabetes and coronary artery disease. There is compelling clinical evidence that a combination of three medications, aspirin, lisinopril, and lovastatin (ALL), can reduce the risk of heart attack, stroke, and death in patients over 55 year of age with diabetes and in patients with coronary artery disease by more than 70 percent. CMI’s ALL initiative tracks regional performance on ALL use and facilitates the sharing of successful practices to increase the rate of use of this combination of medications in the target population. These practices include programs for mailed prescriptions, group visits, phone consultations with pharmacists, electronic reminders for physicians, tools for panel management support, patient coaching outside of the office, and the involvement of the entire healthcare team. From 2002 to 2005, the proportions of members with coronary artery disease and those over age 55 years with diabetes who took the ALL medications increased from 49 to 67 percent (personal communication, Michelle Wong, Kaiser Permanente Care Management Institute, 2007).

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
×
Safety Net Clinics

Community clinics are an integral part of the safety net, with more than 1,000 health centers serving an estimated 14.8 million patients in 2006 (personal communication, D. Geolot, Center of Quality, and colleagues, Health Resources and Services Administration, U.S. Department of Health and Human Services, 2007). Driven by a mission of serving the underserved, safety net clinics engage in a number of practices aimed at improving the quality of care on the basis of a general evidence-based approach. These safety net clinics and health centers use a range of technologies to help support evidence-based practice, including practice management tools, registries, care management systems, and EHRs that integrate these different functions and more. At present, only about 8 percent of health centers have full EHRs, but the majority of those that do not are actively considering investing in EHR systems and doing research to make informed choices so that they may select the system that best meets their needs.

Safety net clinics were early adopters of the notion of evidence-based practice and quality improvement processes, as demonstrated by a partnership with the Institute for Healthcare Improvement to form Health Disparities Collaboratives, which began in 1998. This evidence-based systems change initiative is, at its core, a quality improvement effort based on known quality deficiencies in the treatment of chronic diseases and cancer and in the prevention of these diseases. It focuses on the translation of evidence into practice by identifying the optimal ways to deliver the right care and applies evidence-based criteria to clinical, operational, and fiscal components. It is explicitly an evidence-based practice framework applied to all components of delivery of care, using national clinical experts, national management experts, and national experts in systems change. More than 90 percent of health centers participated in the collaboratives in 2007. Through this process, health centers have adopted the use of the same terminology and models for quality improvement, enabling the more rapid communication and dissemination of successful practices.

The collaboratives focused on improving processes of care and succeeded in this regard. One evaluation found that the centers participating in the collaboratives had significantly greater improvement than external and internal control centers in certain measures of prevention, screening, disease treatment, and monitoring, including “a 21 percent increase in foot examinations for patients with diabetes, … a 14 percent increase in the use of anti-inflammatory medication for asthma, and a 16 percent increase in the assessment of glycated hemoglobin” (Landon et al., 2007). However, the same evaluation showed no improvement in any of the intermediate clinical outcomes assessed to date. Given that finding, safety net clinics are now looking at ways to integrate more monitoring of outcomes

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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through the development of core measures. Although the collaboratives have mainly focused on ways of “pushing” evidence to clinicians and translating evidence into practice, plans for future work emphasize the “pull” for evidence-based care by the use of more standardized quality measures across the program in areas where the evidence is strong. This measurement will enable the identification of model programs that can be disseminated elsewhere and can provide centers with information on comparable patient populations.

Veterans Health Administration

As the largest public IDS in the United States, the VHA annually serves 5.3 million patients at nearly 1,400 sites of care (Kupersmith et al., 2007). Although its patients are older, sicker, and poorer than the general U.S. population, the VHA’s performance surpasses that of other health systems on standardized quality measures (Asch et al., 2004). The transformation of the VHA was enabled by the adoption of evidence-based practice guidelines and quality measures; a renewed focus on the safety of vulnerable groups of people, such as individuals with mental or chronic illnesses; and the development of a performance management system that held senior managers accountable for evidence-based quality measures (Jha et al., 2003).

All of this work was supported by the creation of a comprehensive EHR, now known as VistA, which includes a suite of more than 100 applications supporting clinical, financial, and administrative functions. Access to VistA was made possible through a user interface known as the computerized patient record system (CPRS). With VistA/CPRS, providers can securely access patient information at the point of care, update a patient’s medical history, place orders, and review test results and drug prescriptions. Because VistA also stores medical images such as x-rays and photographs directly in the patient record, clinicians have access to all of the information that they need for diagnosis and treatment. As of December 2005, VistA systems contained 779 million clinical documents, more than 1.5 billion orders, and 425 million images.

Many clinicians initially resisted the use of the EHR. Convincing them otherwise took several approaches. The most important approach was involving clinicians at the onset. This meant working to ensure the usability and integration of the EHR system with clinical processes. Local and national supports were created. Local “superusers” were designated to champion the project; and a national Veterans Electronic Health University facilitated collaboration among the local, regional, and national sponsors of the EHR rollout. National performance measures and the gradual withdrawal of paper records made the use of EHR an inescapable reality. Finally, the economic costs to clinicians were blunted by a salaried environ-

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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ment, and other benefits (such as reductions in time wasted searching for paper records) also emerged. Over time, staff came to view VistA/CPRS as indispensable for good clinical care (Brown et al., 2003).

VistA/CPRS allows clinicians to access and generate clinical information about their individual patients, but additional steps are needed to yield insights into population health. Structured clinical data in the EHR can be aggregated within specialized databases, providing a rich source of data for VHA administrators and health services researchers. Additionally, unstructured text data, such as clinicians’ notes, can be reviewed and abstracted electronically from a central location. This is of particular benefit to researchers: VHA multisite clinical trials and observational studies are facilitated by immediate 100 percent chart availability.

The greatest advantage of EHRs in the VHA is their ability to influence the behavior of patients, clinicians, and the system itself. For instance, the VHA’s diabetes registry has been used to construct performance profiles for administrators, clinical managers, and clinicians. These profiles included comparisons of facilities and identified the proportion of veterans with substantial elevations in their hemoglobin HbA1c and cholesterol levels and blood pressure. Patient lists also facilitated follow-up with high-risk patients. The EHR system also allows the consideration of options that can be used to intensify therapy in response to that risk level (such as starting or increasing the dose of a cholesterol-lowering medication when the patient’s low-density lipid cholesterol level is elevated). This approach credits clinicians with providing optimal treatment and informs them about what might be required to improve care (Kerr et al., 2003).

The VHA has been an EHR innovator, developing from the ground up a clinically rich system that has become so integrated into the delivery of care and the conduct of research that one cannot imagine a veterans’ health system without it. However, many factors in addition to the EHR contributed to the VHA’s quality transformation, including a culture with academicians-clinicians who value quality, scientific evidence, and account-ability; the presence of embedded researchers who are active clinicians, managers, policy makers, and the developers of VistA/CPRS; and a research infrastructure that can be applied to this topic (Greenfield and Kaplan, 2004; Perlin, 2006).

Mayo Clinic

The Mayo Clinic has a long and distinguished history as a leader in the provision of high-quality health care and as a learning organization through its use of core strategies of integrated medical practice, education, and research, all underpinned by the provision of information in an accurate, timely, and reliable manner. The Mayo Clinic’s culture is centered on

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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the notions of systems engineering. The organization has included a formal focus on systems engineering through its Department of Systems and Procedures since 1947. Several specific actions taken in recent years demonstrate the Mayo Clinic’s efforts to provide quality and high-value care using evidence-based decisions and distributing evidence at the point of care. Building on their existing EHR, Mayo Clinic staff members are developing the Enterprise Learning System (ELS), which distributes clinical knowledge and patient-specific triggers to physicians in a timely way. Future plans for the ELS include the ability to provide continuing medical education as just-in-time learning when an individual accesses specific information in the ELS. In addition, the Mayo Clinic is building an Enterprise Information Technology Data Trust for all patient-related data that will improve its efforts to modify old information and to generate new knowledge. Several components of the Mayo Clinic’s organizational structure also support the generation and use of evidence. For example, the Mayo Clinic has an enterprise-wide Quality Academy, through which the organization is taking significant steps to improve transparency, both internally and externally. In addition, it has a Department of Health Sciences Research that supports quality efforts and generates knowledge about clinically related questions.

Institute for Clinical Systems Improvement

In an impressive example of a virtual system working to improve the use of evidence-based medicine, 11 competing hospital systems (operating a combined total of 26 hospitals in southeastern Minnesota) created the Safest in America program. Members of the group work toward the ideal of being the safest in America by sharing data, exchanging information, implementing best practices, and implementing community standardization where appropriate. Safest in America is facilitated by the Institute for Clinical Systems Improvement, an independent, nonprofit organization that facilitates collaboration on healthcare quality improvement by medical groups, hospitals, and health plans in the state of Minnesota and in adjacent areas of surrounding states. Founded in 1993 by HealthPartners Medical Group, the Mayo Clinic, and Park Nicollet Health Services, the Institute for Clinical Systems Improvement today has 62 members and is funded by all six health plans in Minnesota. The medical groups and hospital systems combined represent more than 7,600 physicians (Institute for Clinical Systems Improvement, 2007).

Safest in America hospitals have put competition aside to collectively set goals for the prevention of ventilator-associated pneumonia, the implementation of rapid response teams, reductions in the incidence of hyper- and hypoglycemia, and other patient safety issues. A key value of Safest in America has been its ability to facilitate community-wide standardization,

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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when appropriate. For example, one of Safest in America’s first projects in 2000 was a community-wide ban on the use of nine unsafe prescription abbreviations. In recent years, hospitals implemented a standard safe-site surgery protocol to verify the surgical site, patient, and procedure. This year, Safest in America hospitals will implement a standard protocol to prevent the retention of unintended foreign objects in the patient’s body during surgical procedures.

Archimedes

Evidence-based medicine is often thought of as syntheses of data points from clinical trials or other sources that can be used to determine the best course of action for a particular patient population. Mathematical modeling goes beyond this paradigm to include projections about what would likely happen (as opposed to what has happened in past studies) to certain types of patients in certain scenarios on the basis of what is already known from existing clinical trials or other data. The Archimedes model, developed by David Eddy and Len Schlessinger, creates a virtual reality that is able to simulate a series of events for specific patient populations. In the model, “all the important objects and events in the real world have corresponding objects and events in the model’s world. When a simulation is run, the objects interact and events occur as they would in the real world. [The model] has virtual people with virtual physiologies who get virtual diseases, go to virtual doctors, get virtual tests and treatments and have virtual outcomes” (Archimedes-Kaiser Permanente, 2007). The model can focus on simulated patients, doctors, offices, tests, equipment, or treatments in the areas of diabetes, coronary artery disease, congestive heart failure, asthma, stroke, hypertension, dyslipidemia, and obesity, with the potential for other conditions to be added in the future. The model has been validated against existing real-world clinical trials by simulating the different components of those trials and comparing the results of the simulation to the results of the actual trial itself (Archimedes-Kaiser Permanente, 2007). The model enables experimentation with different interventions or different assumptions about patient characteristics or care processes and has the ability to explore the impacts of these variations on outcomes of interest.

The Archimedes model can use existing clinical evidence to support care protocols, and it can also generate new evidence. The model uses existing evidence and data from clinical trials, large-scale surveys and datasets, health risk appraisals, and, once they are available, EHRs to represent real populations in its virtual world. It generates evidence by testing a variety of interventions or alternatives. For example, as described by Eddy (Eddy, 2007), the objective of a model like Archimedes is to create a virtual world that

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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can be used to help analyze physiological processes; design guidelines, performance measures, and the “what-to-do” parts of disease management programs; design the “how-to-do-it” parts of disease management programs, case management protocols, and continuous quality improvement (CQI) projects; forecast logistics, utilization, costs, and cost-effectiveness; set clinical priorities and design strategic goals; prioritize or combine performance measures; analyze the effects of multiple diseases (co-morbidities), syndromes that affect multiple organ systems, drugs that have multiple effects, and combinations of drugs; address questions of timing, such as screening, frequency of follow-up visits, or how long a medication should be tried before the dose is changed; and help design and predict clinical trials.

Eddy and Schlessinger developed the Archimedes model with major support from Kaiser Permanente, and the model is now available to all researchers and healthcare delivery organizations. For example, the American Diabetes Association has partnered with Archimedes to create a World Wide Web–based consumer-focused tool called Diabetes PhD (American Diabetes Association, 2007). The tool allows consumers to enter personal information about their health history and to explore the effects of a variety of interventions, including losing weight, stopping smoking, and taking certain medications. Diabetes PhD creates a personalized results overview for each patient that shows the patient’s current risk for diabetes, heart attack, stroke, kidney failure, and foot and eye complications. By changing the variables in the profile, such as smoking cessation or weight loss, patients can see how these changes will affect their future health.

Challenges

Although healthcare delivery organizations have made strides in improving the development and use of evidence in clinical decision making, there are many challenges to reaching the Roundtable’s goal of having 90 percent of clinical decisions being evidence based by 2020. Among healthcare delivery organizations, hospitals may face special constraints as institutions with various levels of control or influence over the practices of the physicians who care for patients in their facilities. Ultimately, hospitals will be most successful at achieving improvement in the evidence-based delivery of care when they are able to collaborate with their physicians to identify gaps and potential solutions.

The interviewees identified the primary challenges for organizations in implementing evidence-based decision making. The following sections describe these challenges.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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The Information Technology Gap

Information technology generally and EHRs specifically are critical to the improved use of evidence in clinical decision making. Although many healthcare delivery organizations are ahead of the curve in implementing this technology, the majority of providers lag far behind. Only one-fourth of the physicians in the United States use an EHR, and only 5 percent of the hospitals use electronic prescribing tools (Jha et al., 2006). The likelihood that these tools will be used increases with practice size (Audet et al., 2004; Burt and Sisk, 2005). Significant expansions in the availability and use of information technology will be necessary to bridge this digital divide and to reach the Roundtable’s goal of having 90 percent of clinical decisions be evidence based by 2020. It is also critical that expansions in the use of information technology be strongly rooted in the concept of interoperability so that various systems can “talk” to one another. Interoperability will ensure that all providers have systems that meet their needs and will also allow patients to travel from one delivery system to another without a loss of their medical information.

Restrictions on Support of Technology

Given the important role that information technology plays in the generation and use of evidence, hospitals would be better equipped to improve the quality of care that they provide if their affiliated physicians had access to EHRs. However, hospitals are challenged in their ability to support affiliated physicians’ purchase of information technology by the federal Stark laws. These rules originally banned hospitals from funding such technology, and although the Centers for Medicare and Medicaid Services established “safe harbors” in August 2006, many hospitals are proceeding cautiously, as unresolved issues remain (Serb, 2007). For many hospitals, these safe harbors do not appear to be safe enough, so the investment in and the adoption of information technology by affiliated physician groups is progressing slowly. However, a recent Internal Revenue Service determination clarified that hospital subsidies for physicians’ costs for HHS-approved information technology will not jeopardize the tax-exempt status of nonprofit hospitals (Lerner, 2007). This determination may remove one of the barriers to hospital subsidization of information technology for physicians, at least in the nonprofit sector.

The Inferential Gap

Much of the clinical evidence available today (which largely comes from RCTs) fails to meet the needs of its end users. Research on strictly

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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defined populations may not be directly applicable to the populations of aging individuals and individuals with comorbid conditions who clinicians see in their offices every day. Walter Stewart and colleagues from the Geisinger Health System have referred to this problem as the “inferential gap” or “the gap between the paucity of what is proved to be effective for selected groups of patients versus the infinitely complex clinical decisions required for individual patients” (Stewart et al., 2007). Stewart and colleagues believe that EHRs will help narrow this large gap by accelerating the creation of evidence relevant to everyday practice needs and facilitating the real-time use of knowledge in practice. They envision a future state similar to that which was described earlier as a rapid-learning healthcare system (Etheredge, 2007).

The Science of Behavior Change

Experts in the field of evidence-based medicine have put a great deal of effort into understanding and improving the generation of evidence and making it available to clinicians. Equally important is the issue of changing clinicians’ and patients’ behavior when they are provided with sound, convenient, and relevant information. With respect to physicians, a landmark study by the RAND Corporation starkly illustrated this problem, finding that patients receive the recommended care only about 50 percent of the time (McGlynn et al., 2003). How can the use of the available recommendations and information be ensured?

The best methods of changing physician behavior are not yet known. Research has shown that the provision of didactic continuing medical education courses is not effective in changing behavior, and more participatory forms of continuing medical education (e.g., rounds) are only slightly more effective. Other possible means of changing physician behavior include pay-for-performance programs and the use of information technology, academic detailing, and even peer pressure in the form of quality measurement and internal reporting at the individual physician level. More research is required to determine which methods are the most effective. There are similar issues with respect to patients. Although some evidence provides information about the tools and shared decision-making practices that are most effective in motivating patients to adopt healthy behaviors, physicians do not necessarily know that these tools are available, nor do they know how to use them.

Financial Incentives

One of the most important potential barriers to the use of evidence-based practice is the predominant fee-for-service (FFS) payment system.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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Under the FFS system, providers and hospitals are rewarded for taking actions: doing procedures, prescribing drugs, performing tests, and so forth. This type of payment system may encourage the application of evidence in determining a course of care when the evidence calls for doing more. However, the best evidence sometimes calls for not doing something or for taking a more conservative course of action. In such cases, the payment system can discourage the use of best practices. In addition, the FFS payment system causes physicians to ask the wrong questions in evaluating adherence to best practices. Physicians ask, “Did the patient survive the bypass surgery?” rather than, “Could the patient’s bypass surgery have been avoided?” FFS system incentives to do more may stand in the way of evidence-based practices that call for more streamlined or less invasive care paths or the use of low-tech interventions to improve quality (such as the use of better hygiene practices in clinical encounters).

Leadership Practices

As noted earlier, the key to the improved use of evidence in decision making is a culture of group responsibility and an appreciation for the fact that no single physician can keep track of all relevant best practices in his or her head. These intangibles require strong physician leadership, which is often lacking in organizations compelled to respond to financial imperatives. The critical importance of evidence-based decision making does not yet seem to be on the radar screen of the majority of physician and hospital leaders, although the tipping point may be near.

Followership Practices

Although greater leadership is needed to advance the practice of evidence-based medicine, rank-and-file practitioners also need a more thorough understanding of the concept. Many experts interviewed for this statement believe that outside of highly academic and elite health and medical policy circles, there is little discussion of the implications of evidence for clinical decision making or understanding that much of current practice is not, in fact, evidence based. Healthcare providers need to become much more acculturated to this concept and willing to recast professional norms so that they align more with evidence than with autonomy.

Privacy Rules

Current privacy expectations, mores, and fears of misuse can lead to the zealous protection of medical information. To a certain extent, laws that do not go far enough in terms of prohibiting the misuse of personal health

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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information (e.g., for insurance rating and employability) can have a chilling effect on the use of deidentified health information as a public utility for understanding and improving healthcare services and delivery. In addition, deidentified data often lack sufficient detail to allow the tracking of outcomes and the establishment of linkages across data systems (for example, without a date of birth or social security number, it is not possible to check the National Death Index to determine mortality for a specific patient). The Health Insurance Portability and Accountability Act (HIPAA) was developed more than a decade ago, before the establishment of the current notions of learning healthcare organizations. It may be time to revisit the HIPAA privacy requirements to allow the improved and more rapid use of patient information to support research and quality improvement.

Multiple Payers and Reporting Requirements

As noted above, quality measurement and reporting are means by which large healthcare delivery organizations can improve their use of evidence-based decision making. However, large providers are often subject to multiple and conflicting reporting demands from different payers. Each payer’s reporting requirements divert resources and attention from another’s, creating barriers to organizations’ ability to focus on a critical (and manageable) set of evidence-based practices.

Physician Supply and Resources

The practice of evidence-based medicine can be time intensive for physicians. Some experts argue that it will require much more than the usual 15-minute office visit to ensure that 90 percent of clinical decisions are evidence based. Anecdotal evidence suggests that physicians in primary care are already overwhelmed with the number of protocols and best practices that they must fit into brief office visits, and the field is not even close to having 90 percent of clinical practice being supported by evidence. If office visit times (or inpatient visits) need to be lengthened to accommodate a greater reliance on evidence for decision making, will the country need more physicians and more beds? Can non-visit-based types of care (phone, e-mail, etc.) or care in nontraditional settings help offset any additional time that physicians may wish to spend with patients in their offices or in the hospital?

Special Challenges for the Safety Net

In addition to the challenges described above, safety net providers may face other difficulties in improving the use of evidence-based decision making because of resource constraints. Many safety net organizations are

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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highly committed to the principles of evidence-based quality improvement. More than 80 percent of the health centers that receive funding from the Bureau of Primary Health Care participate in a Health Disparities Collaborative for quality improvement in chronic diseases, cancer, and prevention. Many public hospitals are closely affiliated with academic medical centers and partner with them on the development of evidence through clinical research and the use of evidence through care protocols. Some clinic practices are also large and multispecialty, but a lack of resources can make it difficult to devote staff and expertise to seeking out the available evidence and embedding it into best practices. A lack of resources can also make referrals to specialists difficult, even when the best evidence clearly calls for it. In addition, the multiple comorbidities and poor socioeconomic condition of many individuals who comprise the safety net patient population add to the problem of the inferential gap described earlier.

Special Challenges for Hospitals

As noted above, hospitals will be most effective in increasing the use of evidence-based decision making when they can influence the behavior of physicians who practice within their walls. The interviewees identified two major challenges to this.


Adversarial hospital-physician relationships Relationships between hospitals and medical staff have evolved over the last few decades. According to Berenson and colleagues (2007), traditionally, physicians “have been relatively independent of hospitals and have used them as ‘workshops’ in which to carry out their professional services.” Since the 1990s, greater competition between physicians and hospitals has emerged in some areas of the country, with reports of greater strain in hospital-physician relations in 2005 than in 2000-2001 (Berenson et al., 2007). This tension limits the amount of leverage that hospitals have to compel physicians to generate and use evidence in their delivery of care. There may be differences in this potential leverage among different types of physicians and hospitals. For example, hospitals may hold more sway with specialist physicians who are directly employed by or contracted as a group with the hospital, such as hospitalists, intensivists, radiologists, anesthesiologists, and emergency physicians, due to their more explicit employer-employee relationships. Integrated hospital systems have the most potential to influence medical staff, as they can provide direct financial incentives to physicians to adhere to evidence-based practices and protocols and are better able to measure the rate of adherence and to compare the performance of physicians with those of other physicians within the system. Some academic medical centers are moving toward establishing participation in evidence-based medicine

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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activities as part of their contracts with new physicians but may have less of an opportunity to influence their more senior physicians. In many community hospitals, relationships with physicians are more adversarial, and hospitals have less leverage.


Difficulty of sanctions Even when evidence-based practices and protocols can be instituted within hospitals, the financial interdependence between hospitals and physicians, as well as their intertwined professional networks, may make it difficult for hospitals to enforce guidelines and issue sanctions against noncompliant physicians. Furthermore, few options for managing noncompliance exist. The use of blunt instruments, such as revoking hospital privileges or malpractice insurance coverage, are drastic approaches to punishing undesired behavior and can be used only in rare circumstances in which there is absolutely no doubt about the right care. Otherwise, further deterioration in relationships between hospitals and physicians will occur.

LEADERSHIP COMMITMENTS AND INITIATIVES

The experts interviewed for this chapter described the following opportunities for improved evidence-based decision making.

Create a Focal Point for the Development and Dissemination of Evidence

There is a need for national agenda setting and coordination of the generation and communication of evidence. As noted earlier, there is a gap between the evidence available and the evidence needed for everyday decision making. Currently, no single entity in the healthcare system serves as a focal point for determining where the most urgent evidence gaps lie and deciding how limited research dollars should be spent to fill those gaps. Such a focal point, presumably, an entity publicly charged with coordinating the generation and communication of evidence, would determine where the most urgent evidence gaps lie, support comparative effectiveness analysis of treatments, and provide information to physicians and patients. To maximize its effectiveness, the entity should be inclusive of a broad range of stakeholders; have adequate resources to accomplish the goal of the IOM’s Roundtable on Evidenced-Based Medicine; and be transparent about the methods, the processes, and the priorities for study.

Support Information Technology and Identify Strategies to Eliminate the Digital Divide

To improve the generation and use of evidence, more healthcare delivery organizations must implement fully operational EHRs with decision sup-

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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port capabilities. Structured correctly, such systems can provide useful information based on real-time clinical care, enabling organizations to be rapid-learning systems that use observable data to create evidence on what works (Etheredge, 2007). Too few physicians currently have access to this technology, and the digital divide is even greater for hospitals. Policies that support provider adoption of EHRs should be encouraged.

Improve Leadership Training

Tomorrow’s leaders of complex healthcare organizations must become conversant in the concepts of evidence-based medicine and committed to establishing a culture of continuous learning. According to the IOM (Institute of Medicine, 2005), the healthcare industry has neglected to use engineering strategies and technologies that have revolutionized quality, productivity, and performance in many other industries. Remedying this problem, essentially undoing the learning that health care is delivered one patient at a time, will require the training of clinician leaders in new fields, such as systems and industrial engineering and the management of organizational change. Leaders need to be reoriented to view healthcare organizations as having a collective responsibility for groups of patients. Today, most leaders of healthcare organizations come from a medical or business background. Neither of these disciplines yet consistently incorporates the concepts of systems engineering and group responsibility that are foundational to the use of evidence-based medicine.

Improve Clinician Training

Leaders are not the only actors in healthcare organizations who need to become more familiar with the concepts of evidence-based medicine. Frontline clinicians (both physicians and other healthcare professionals) delivering care on a daily basis need to have ongoing training in the use of evidence in decision making. The continuing medical education system is one mechanism for bringing this content to clinicians, although its effectiveness is questionable, as noted above. Another idea is to incorporate training in evidence-based medicine into requirements for board certification in the medical specialties. By incorporating evidence-based medicine concepts into medical training, a demand for this style of practice is created among clinicians, so that when they leave school and practice in the community, they will expect to have the organizational support that they need to practice in this way.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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Engage and Leverage Boards of Directors

To ensure that evidence-based practice is a priority for healthcare delivery organizations, boards of directors should be educated about the principles of evidence and make evidence-based practice a stated goal of the organization. Two levers for influencing boards include framing evidence-based care as a mechanism for fulfilling the organization’s mission or “contract with the community” and as part of their fiduciary duty to deliver effective, efficient care. A more limited role for hospital boards could be to make participation in evidence-based practice a condition of hospital privileges, but this is complicated, as discussed above.

Increase Patient Demand for Evidence-Based Medicine

Although increasing physician demand for evidence-based practice is important, so, too, is creating consumer or patient demand. If patients know what evidence-based medicine is and understand the organizational structures that must support it, they may be more likely to demand this style of practice from their clinicians. Today, it would most likely come as a surprise to the majority of patients that some of their care is not evidence based. One means of improving consumers’ understanding is to incorporate basic concepts of health literacy into the health education that students receive in middle and high school. Such training would need to be reinforced for adults through media outreach and public information campaigns. Another means of creating consumer demand for evidence-based medicine is to design insurance benefit packages that require smaller amounts of cost-sharing for evidence-based care than for other types of care.5 The science of evidence-based medicine may not yet allow this to happen on a broad scale, but as the science develops, so, too, can consumer incentives.

Link Performance Standards to Use of Evidence

Healthcare delivery organizations can and must identify standards of care and measure individual physicians’ performance against them. Such standards can be used internally for quality improvement, or they can be reported to external entities, where they may become the basis for payment differentials (see “Restructure Financial Incentives” below). Organizations can identify standards of care, measure an individual physician’s performance, and report back to enable physicians to compare their performance

5

For more on the concept of evidence-based benefit design, see the work of the Employers-Employees Sector of the IOM Roundtable on Evidence-Based Medicine in Chapter 12.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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with that of their peers. The use of peer pressure as an incentive can be even more effective than the use of financial incentives. When financial incentives are used, they should focus on paying for value and outcomes and not just for performance on process measures. Work by organizations such as the National Committee for Quality Assurance and the Leapfrog Group to standardize performance measures should incorporate concepts of evidence-based decision making.

Restructure Financial Incentives

The FFS payment system creates incentives to provide care and services which may or may not be based on evidence-based care. Value-based purchasing initiatives built on foundations of comparative effectiveness research have the potential to correct this problem. As discussed above, pay-for-performance and capitation, types of value-based purchasing, can be important tools if they are structured correctly. However, capitation alone does not encourage the use of evidence-based medicine when the evidence calls for doing more (or more expensive) treatments.

Enable Passive Generation of Evidence

Even without EHRs, healthcare delivery organizations routinely collect a variety of patient care data that could be aggregated by a common entity, such as a payer (e.g., the Centers for Medicare and Medicaid Services, which has claims data from the vast majority of hospitals and physicians). This would add to the ability to use real-time data to learn about best care and would help to bridge the inferential gap that occurs when published research findings are based on data for very narrowly defined populations.

Encourage “Systemness

Hospitals and physicians that are parts of systems have a greater ability and more incentives to invest in information technology and to share information on evidence-based care guidelines. Improved collaboration among hospitals and medical staffs, in a variety of organizational forms, will allow the more effective capture and use of evidence. In different geographic areas, different models of hospital-physician collaboration or integration will work better than others, and “systemness” can be either real or virtual. For example, regional health information organizations, which share patient data among the providers in a community, are types of virtual organizations that may prove to be a bridge to improved systemness without full organizational integration.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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Invest in Understanding the Drivers of Behavior Change

Further research is needed to determine which methods work best in changing clinicians’ and patients’ behavior. A large body of literature in the disciplines of sociology and psychology, as well as health services research, has explored this question. Ideas and experts from these fields must be integrated more fully into discussions of evidence-based medicine to ensure the use of the most effective means of translating evidence into practice.

Advocate for Changes to HIPAA

As noted above, the patient privacy provisions of HIPAA have had a chilling effect on the use of large datasets of patient information, even when that information is deidentified. Greater flexibility in the use of patient information for research and quality improvement is needed, provided that the patients’ information is not put at risk of being revealed for other purposes. The IOM is conducting a study, entitled Health Research and the Privacy of Health Information—The HIPAA Privacy Rule, that can serve as a foundation for revisiting HIPAA in light of the need for the improved generation and use of evidence in the everyday delivery of care (Institute of Medicine, 2007). In addition, the high visibility of consumer messages about the right to privacy may have inadvertently created a culture in which consumers do not expect and are not willing to permit data about themselves to be used for any purpose. More accurate and nuanced messages need to be created for consumers.

Improve Collaboration Among End Users

As described above in the case studies, many healthcare delivery organizations have processes in place to review internal and external evidence, create clinical guidelines, and translate them into practice. This effort is essential to provide safe, high-quality care but requires significant resources. Today, a sufficient cadre of highly capable entities perform evidence translation, and it may be unnecessary to internally and individually create the capacity. Rather, evidence-based knowledge products (reviews and practice guidelines) can be created jointly by use of a cooperative mechanism.

Optimize Human Resources

Hospitals and large physician group practices can create infrastructures that fully utilize the expertise that they have within the medical staff. By supporting information exchange and consultation among physicians around emergent or complex medical needs, such as rapid response teams

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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that bring critical care experts to a patient’s bedside within minutes of being called, hospitals can increase best practices and improve outcomes. Similarly, physician organizations, such as the Mayo Clinic, have improved diabetes care by providing the primary care physicians at the clinic in Rochester, Minnesota, virtual consultations with endocrinologists through e-mail. The endocrinologists review an abstract of the EHR and provide performance-triggered suggestions with supporting evidence to the clinicians and their families.

NEXT STEPS

Although all of the opportunities described above are important for improving evidence-based decision making, several key initiatives that have the potential to transform the way in which the healthcare delivery organization sector generates and uses evidence have been identified.

Create a National Entity to Develop and Disseminate Evidence

As noted earlier, there is a need for national agenda setting and coordination of the generation and communication of evidence. An increased and focused investment is also needed. Many large healthcare delivery organizations already do this work independently. National coordination and prioritization would allow the sector as a whole to eliminate redundancy and make better use of the resources devoted to evidence generation.

First Step

The most important first step for healthcare delivery organizations in creating a national entity for the development and dissemination of evidence is to advocate for this change with policy makers and other stakeholders. Policy makers must be educated about the need for such an entity and encouraged to authorize and establish funding for it. Because of their high visibility and significant clinical expertise, sector members must play a central role in efforts to design and advocate for the agenda-setting entity. Such work may include active communication of the work of the IOM’s Roundtable on Evidence-Based Medicine.

Cross-Sector Collaboration

A number of other healthcare sectors are advocating for the entity described here. Rather than working alone or at cross-purposes with these sectors, healthcare delivery organizations should work with the organizations already active in this area as they develop a vision and legislation to

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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authorize the entity. Some of the organizations taking a lead in this area include America’s Health Insurance Plans, the BlueCross BlueShield Association, the Health Industry Forum, and AcademyHealth. These existing efforts could benefit from the clinical and research expertise of the large healthcare delivery organizations.

Support the Adoption and Use of Information Technology

The broader implementation of EHRs across the entire healthcare delivery organization sector will both support the delivery of care and create rapid-learning organizations. The digitization of healthcare delivery through the use of the EHR is one of the most important changes that can be made to improve care and support learning. Large delivery organizations, in addition to leading this change, can also help smaller physician groups learn about EHRs by providing technical assistance and sharing their expertise through the establishment of learning networks. Unless all (or nearly all) healthcare providers can connect and share information electronically, there will continue to be a significant amount of information lost and missed opportunities for learning. It is therefore critical that the digital divide be closed. Healthcare delivery organizations can play a leadership role in making this happen.

First Steps

One of the major barriers to the widespread adoption of EHRs is a lack of standardization of the data produced by clinical information systems. The federal government is in the best position to convene stakeholders to establish these needed standards and to enforce adherence to the standards, once they are established. However, as noted above, healthcare delivery organizations are leaders in the implementation of EHRs and therefore have a wealth of expertise that can and should be brought to bear on efforts to create interoperability and other information technology standards. This sector can also be a leader in establishing learning networks of organizations that have implemented EHRs to disseminate knowledge to all providers, both organized and nonorganized.

Cross-Sector Collaboration

The federal government is leading the way in standard setting for health information technology interoperability. In 2005, HHS announced the formation of the American Health Information Community (AHIC), which will provide input and recommendations to HHS on how to make health records digital and interoperable and ensure that the privacy and

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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security of those records are protected (U.S. Department of Health and Human Services, 2007). Initially, HHS appointed 16 members, including a few representing healthcare delivery organizations, to the AHIC commission. Plans are now being made to transition AHIC to an independent and sustainable public–private partnership by fall 2008. Because of their expertise with these systems and their significant financial investments in them, healthcare delivery organizations should take every opportunity to participate in this and other processes that support standardization. Healthcare delivery organizations should also continue to collaborate with the federal government in this area by participating in various Medicare demonstration projects to test and measure the effect of program changes on the adoption and use of healthcare information technology (primarily in the FFS delivery system).

Improve Understanding of and Support for Evidence-Based Care

The concept of evidence-based medicine and its potential to drastically improve quality need to be communicated broadly to the public in much the same way as the concept of medical errors and the opportunities to make health care safer were communicated when the IOM published To Err Is Human in 1999 (Institute of Medicine, 1999). Many of the opportunities identified above call for educating key stakeholders (clinical leaders, rank-and-file clinicians, boards of directors of healthcare delivery organizations, and patients-consumers) about the need for the improved use of evidence-based decision making and outlining some potential strategies for doing so. As these strategies make clear, there is no single way to reach all of these audiences with messages about evidence-based care; multiple channels will need to be used. As entities with many opportunities to reach both patients and providers, healthcare delivery organizations have a unique opportunity to develop and deliver messages about the importance of evidence-based care to these audiences.

First Steps

Although the strategies for reaching the main stakeholders differ, the healthcare delivery organizations sector has unique access to all of these groups and therefore a unique potential to influence them. As a first step toward improving the understanding of and support for evidence-based care, healthcare delivery organizations should work collaboratively to develop the messages, materials, or curricula to be used with key audiences and then work independently to influence their own boards, clinical leaders, clinicians, and patients. To make such an education part of the culture of medicine and the delivery of care and to influence the public in a more

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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meaningful way, longer-term strategies involving the efforts and resources of multiple sectors (including the media) will be necessary.

Cross-Sector Collaboration

Collaboration across healthcare sectors and beyond will be critical to improving the understanding of and support for evidence-based care. For example, the healthcare professions education sector and professional societies and associations will need to play active roles in efforts to change the training of clinicians (and clinician leaders). The consumer sector will need to collaborate with healthcare delivery organizations, insurers, and others outside of traditional healthcare circles (including the broader public education sector) to include information on evidence-based care in health education, in public awareness campaigns, and through health insurance benefit design. There may be a role for an entity such as the IOM to organize and facilitate this work, given the cross-sector collaboration required.

Link Measures of Evidence-Based Care to Performance Standards and Incentives

Performance measurements and incentives need to be structured to encourage the use of evidence-based care. Healthcare delivery organizations can play an important role in this work by identifying care standards based on the evidence and structuring incentives (such as payment differentials) to reward value and outcomes. This can help place a focus on the most important standards and narrow the range of different requirements from different payers. A lack of consistent pay-for-performance expectations has been shown to reduce the impacts of these programs.

First Steps

Healthcare delivery organizations should review their existing performance measures and care standards to assess the extent to which they are already evidence based. Measures and standards that are evidence based should be prioritized, and those that are not should be considered for adaptation or elimination. In addition, healthcare delivery organizations should examine their existing internal payment incentives (such as provider bonuses) to ensure that they are paying for evidence-based care.

Cross-Sector Collaboration

A number of sectors will need to be involved in efforts to align performance measurement and incentives with evidence-based care. For example,

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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as noted earlier, organizations such as the National Committee for Quality Assurance and the Leapfrog Group can set the standard for creating performance measures based on evidence, and purchasers can adopt more consistent evidence-based standards. The Agency for Healthcare Research and Quality should also play a role in this work. Although healthcare delivery organizations can serve as subject matter experts and learning laboratories for testing measurement and incentive approaches, the national entities described above are in a better position to standardize measures and approaches to providing incentives across organizations. In addition, employers and large public purchasers should play a central role in creating value-based purchasing initiatives (such as pay for performance) that align incentives for medical care to adhere to the evidence.

Conclusion

The healthcare delivery organizations sector plays a central role in efforts to improve the use of evidence-based care. As entities that organize and employ physicians and other clinicians, deliver care to patients, and, in some cases, conduct research, sector members have opportunities to influence the generation and use of evidence through many channels. Because sector members are organized and can act purposefully as goal-setting institutions, they may have a greater ability than nonorganized providers to influence the transformational initiatives outlined above.

Momentum is building nationally to improve the use of evidence-based care, and now is the time for healthcare delivery organizations to take action to assist in this effort. Change will not come overnight, nor will it come from only one sector. Reasonable goals for the healthcare delivery organizations sector in the next 3 to 5 years include working with others to accomplish the following: enact authorizing legislation for a national entity to develop and disseminate evidence, develop widely accepted standards for information technology interoperability, begin a public outreach and awareness campaign about evidence-based medicine, and standardize and streamline quality measurement and incentive programs to focus resources on a defined set of evidence-based practices.

Sector members can also provide leadership in efforts to improve the use of evidence-based care by modeling what works for nonorganized providers. To date, as examined in the case studies presented earlier in this chapter, many healthcare delivery organizations are already active in this arena. By providing models of effective generation and use of the evidence, healthcare delivery organizations can help nonorganized providers better understand the quality benefits of integration and organization, which could ultimately encourage the spread of evidence-based care.

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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INTERVIEWEES

The interviewees included Madhulika Agarwal, Chief Patient Care Services Officer, Veterans Health Administration; Ahmed Calvo, Medical Advisor, Center for Quality, Health Resources and Services Administration; Denis Cortese, President and Chief Executive Officer, Mayo Clinic; Roscoe Dandy, Office of Minority Health and Health Disparities, Health Resources and Services Administration; Carolyn Days-Mustille, Codirector, Kaiser Permanente Care Management Institute; Benjamin Druss, Rosalynn Carter Chair in Mental Health and Associate Professor of Health Policy and Management, Rollins School of Public Health, Emory University; Kay Felix-Aaron, Director, Office of Quality Data, Center for Quality, Health Resources and Services Administration; Nancy Foster, Vice President for Quality and Patient Safety, American Hospital Association; Denise Geolot,

Suggested Citation:"7 Healthcare Delivery Organizations." Institute of Medicine. 2009. Leadership Commitments to Improve Value in Health Care: Finding Common Ground: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11982.
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Director, Center for Quality, Health Resources and Services Administration; Steve Mayfield, Director, American Hospital Association Quality Center; Gregg Meyer, Medical Director, Massachusetts General Physician Organization (MGPO) and Senior Vice President for Quality and Patient Safety, Massachusetts General Hospital and MGPO; Lynnette Nilan, Office of Patient Care Services, U.S. Department of Veterans Affairs; Jonathan Perlin, Chief Medical Officer and President, Clinical Services, HCA, Inc.; Richard Platt, Professor and Chair, Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care; Paul Wallace, Medical Director for Health and Productivity Management Programs, The Permanente Federation; Deborah Willis-Fillinger, Senior Medical Advisor, Center for Quality, Health Resources and Services Administration; and Scott Young, Codirector, Kaiser Permanente Care Management Institute.

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This volume reports on discussions among multiple stakeholders about ways they might help transform health care in the United States. The U.S. healthcare system consists of a complex network of decentralized and loosely associated organizations, services, relationships, and participants. Each of the healthcare system's component sectors--patients, healthcare professionals, healthcare delivery organizations, healthcare product developers, clinical investigators and evaluators, regulators, insurers, employers and employees, and individuals involved in information technology--conducts activities that support a common goal: to improve patient health and wellbeing. Implicit in this goal is the commitment of each stakeholder group to contribute to the evidence base for health care, that is, to assist with the development and application of information about the efficacy, safety, effectiveness, value, and appropriateness of the health care delivered.

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