Paying attention to how elements of the system mingle is crucial for improving quality, says the man who spearheaded the latest Institute of Medicine study.
Since America's $1.4 trillion health care "system" is hardly systematic, an important question to ask when trying to improve the quality of care in such a sprawling enterprise is, "What do we do first?" George J. Isham, MD, the chairman, and his colleagues on the committee that produced the Institute of Medicine's latest report, Priority Areas for National Action: Transforming Health Care Quality, provide a 20-part answer to that question. The report recommends focusing quality-improvement efforts on that number of priority areas. The goal: reducing the gap between how medicine should be practiced, based on the best available evidence, and how it is practiced.
A focus on quality is also a large part of Isham's day job as medical director and chief health officer for HealthPartners, which provides HMO and other health coverage to more than 660,000 Minnesotans.
Isham, a longtime member of this publication's editorial advisory board, represents HealthPartners as a board member of the Institute for Clinical Systems Integration, a collaborative of Twin Cities medical groups that is designing clinical guidelines and putting them into practice. He is cochairman of the National Committee on Quality Assurance's committee on performance measurement, which oversees HEDIS, the Health Employer Data and Information Set. He is also a member of the board of directors of the Minnesota Health Data Institute, a public-private partnership to produce health care quality information for Minnesota.
Before his current position, Isham was medical director of MedCenters Health Plan in Minneapolis. Isham holds a master's of science in preventive medicine/administrative medicine from the University of Wisconsin Madison. After receiving his medical degree from the University of Illinois, he completed his internship and residency in internal medicine at the University of Wisconsin Hospital and Clinics in Madison. Isham recently spoke about the latest IOM report and HealthPartners' quality-improvement efforts with Senior Contributing Editor Patrick Mullen.
MANAGED CARE: How does the latest Institute of Medicine report, Priority Areas for National Action: Transforming Health Care Quality, carry on the work begun with the two previous IOM reports, To Err is Human and Crossing the Quality Chasm?
GEORGE J. ISHAM, MD: This report lays out a blueprint for addressing some of the problems raised in the first two IOM reports. That blueprint included an important recommendation that the Agency for Healthcare Research and Quality (AHRQ) identify at least 15 priority conditions that would serve as the starting point for transforming quality in the country. Acting on that recommendation, the agency asked the Institute of Medicine to convene a panel of experts, which the committee represents.
MC: What was the goal in choosing 20 priority areas?
ISHAM: The purpose is not primarily to draw attention to the priority areas themselves, but rather to use these 20 areas to see that changes occur and the health care system is transformed, so it benefits thousands of conditions, not just the first 20.
MC: How did the committee decide which conditions to include on its priority list?
ISHAM: The committee identified three criteria for selection: impact, improvability, and inclusiveness. Impact looks at the burden and scope of the problem, improvability looks at whether there is a gap between known best practices and current practices that can be closed, and inclusiveness measures whether the set as a whole represents a good starting point for transforming care. Does the set address all age groups, as well as various types and settings of care? We looked at hundreds of conditions and a number of other data sets. A number of things are not on that list that could be.
MC: What went wrong with health care delivery in this country that led to so many areas in which patients don't receive fairly simple care that can prevent serious problems down the road? It is well known that people with diabetes should have regular vision screenings and foot exams, but a majority don't receive them. What happened?
ISHAM: That gets to the underlying issues raised in the Crossing the Quality Chasm report out of which this effort flowed. That report clearly identified the need to develop underlying systems that close those gaps. We have good science, we know what to do, and yet we almost consistently fall short of actually delivering needed care. The culture of health care is uniquely backward in that it doesn't use information technology and training and coordinating techniques that other sectors of the American economy use. This is why we consistently fall short.
MC: Why is health care uniquely backward?
ISHAM: I'm not so sure it's anybody's fault, and I'll leave it to historians to figure out why health care is or isn't behind the curve. All I know is that it's not where it needs to be and we need to address these areas in a much more effective way if we're going to close these gaps. We need to make information systems more widely available to help caregivers do the right thing at the right time when a person shows up for care. That includes making sure that automated medical records systems are available, that data flow freely from inpatient to outpatient settings, that information is coordinated so that care can be coordinated across settings. People who work in the health care system seeing patients must be trained to work together and must know what resources are available.
MC: How will progress in putting the report's recommendations into action be measured?
ISHAM: The federal government intends to include these priority areas in the national quality report. The first edition of that report, due this spring, won't fully reflect these 20 conditions, but I expect that subsequent editions will monitor how we're doing with regard to most if not all of them. Second, we'd like to see AHRQ continue to monitor and if necessary modify the priority list over the coming years. As far as other elements of government, another recent IOM report, Leadership by Example, helps different elements of government understand how they can work together in terms of common definition of priorities, metrics, and measurements. The government also has a role in terms of how Medicare works on quality improvement. On the private side, I am very encouraged by the positive response the report has received from organizations and groups across the country. They recognize that these are important priorities and plan to incorporate them into their quality-improvement activities. Hospital groups, ambulatory groups, health care plans, and a host of other health care organizations will look at this priority list to see how it can stimulate the development of information systems, practical management approaches, and training activities. Third, IOM has a grant for a conference later in the year to develop strategies for implementing improvements in these 20 areas.
MC: Obesity is one of the priority areas in the IOM report. While it ties into several of the more distinct medical conditions like hypertension, stroke, and heart health, obesity moves beyond traditional concepts of medical care and into public health and changing behavior. How should managed care plans address what is, if you'll pardon the pun, an enormous national problem?
ISHAM: Obesity is an emerging priority area and a very important public health issue, and an increasingly recognized health care issue because of the link to chronic disease. Any health system that wants to be effective in preventing chronic disease or dealing with its consequences has to be concerned about obesity. In addition to the wider public health and social challenges, we as health care providers must be able to respond to people who ask us for help with a weight problem through better nutrition and more exercise. Surgical approaches have known complications but can work for people who are very obese. Other approaches — using drugs or counseling to change behavior — are maturing but need further development. Still, the lack of more effective approaches is a frustrating area for health care providers, and that's why it's an emerging area.
MC: How does HealthPartners try to deal with obesity in its members?
ISHAM: We make sure that the surgical approaches are covered through our health benefit plan. We look very critically at emerging pharmacological approaches. We provide a lot of support through our Center for Health Promotion for telephone counseling and weight-management programs. We have an effective program called 10,000 Steps that encourages people to exercise through walking.
MC: Another priority area is self-management/health literacy. Has the Internet helped or hindered the way toward better-informed
ISHAM: Overall, putting more information in people's hands is a very healthy trend. Whether coping with obesity or any of the other priorities, people need to be equipped to deal effectively with the issue themselves. Health literacy involves people understanding what they must do in order to help themselves and us having the ability to convey that information to people effectively. Certainly people come to us with more information than they used to, and we are concerned that the information they have represents well-researched evidence-based approaches. There's no question that there are lot of myths and poorly researched approaches out in the general discussion. We're very interested in people having information and asking questions of their physicians, even though responding to those questions can add to the burden of physicians' schedules. We need to encourage a dialogue between patients and physicians about how individuals can deal with their health conditions.
MC: HealthPartners is part of the Institute for Clinical Systems Improvement. What is the institute and how is it working to reduce medical errors and improve patient safety?
ISHAM: The institute is a collaborative effort that represents 34 provider organizations and more than 5,300 physicians in Minnesota. Most importantly, it includes the leadership of all the clinical groups in the state. The purpose is to engage clinicians, doctors, nurses, and others in the work of improving the quality of care. We start by defining processes of care by reading the literature together and developing written guidelines. Medical groups then do the bulk of the work by forming work teams and collaborative efforts to actually improve care, using guideposts, measurements, technical training, and other assistance from the institute.
MC: Has the institute focused on any of the 20 priority areas identified in the IOM report?
ISHAM: The institute has developed 50 guidelines, so there is significant overlap. The guidelines, along with guideline-impact studies, process-improvement reports, and technology-assessment reports, are published on the web at «http://icsi.org.
MC: HealthPartners is developing a Center for Clinical Simulation and Patient Safety. How will the center change the way health professionals are trained? What do you hope the center will achieve?
ISHAM: First, the idea of using simulations in training is obviously not original to us. Simulators have long helped pilots. They learn how to respond in a controlled and safe environment, then analyze results and figure out the best approaches to take in the event of real emergencies. The idea of a clinical simulation center is similar. We set up exam rooms with patient simulators that allow clinicians to practice procedures in response to emergencies and other serious life-threatening situations. We then analyze and evaluate performance in a learning session afterwards. People acquire needed skills in an environment where we can know they've mastered them. It's quite different from the tradition of on-the-job apprenticeship in less controlled settings that has been the norm in health care. We plan to train individuals to acquire skills in inpatient and outpatient settings and procedures. We also expect to train teams of professionals from different disciplines that don't customarily train together, like nurses and doctors and technicians. The center will be operational this spring.
MC: How can payment be used as an incentive to improve quality and reduce medical errors?
ISHAM: Working with the Institute for Healthcare Improvement and the Commonwealth Fund, HealthPartners conducted case studies of diabetes patients that examined issues connecting payment to quality. That research will appear later this year in Health Affairs. More locally, we're trying to figure out how to pay for and reward nontraditional patient contact like e-mail care and phone care. It's a tough issue because it is a change from how care has customarily been paid for. We've also focused a fair amount of money on paying bonuses to achieve certain clinical objectives in specific areas such as diabetes and tobacco dependence, both of which are on the IOM priority list. Because of how payment moves in the whole system, it is hard for one participant in an economic system to decide to do a payment differently. Customers need to demand changes. The first step toward paying for quality involves establishing a dialog with our key business partners — purchasers and clinics — on how to proceed.
MC: As you reflect on the course that the managed care industry took in the 1990s, do some of the quality problems facing the system today reflect a lack of focus amid the battles between plans and physicians over utilization review and other cost-control tools? Was too much attention paid to the financial rather than clinical side of health care?
ISHAM: I don't think so. The quality movement definitely evolved during the '90s. Look at the work of such people as Don Berwick at the Institute for Healthcare Improvement in pushing quality-improvement techniques, or Lucian Leape's work at Harvard on safety and reducing medical errors. The Institute of Medicine reports have also had a strong influence. Research on improving quality has been ongoing. From the managed care plan perspective, many of the issues and public debates around quality that occurred during the '90s showed us that some older conceptualizations of how to change qualities didn't work and were not acceptable to the public. Those debates set the table for the managed care constituency to be ready to support and try new approaches. I see these as evolutionary streams that have moved us in this direction. I would like to have seen us get there 20 years earlier, but here we are in 2003.
MC: In the effort to improve quality, what would constitute success? Will our grandchildren be working on the same objectives?
ISHAM: No. We'll see baseline data developed in the first two of a series of quality reports from the AHRQ. I'm hopeful that they'll show steady and definite improvement in the 20 priority areas over time. That's one way to measure success. Second, as time goes on and people begin to marshal efforts to improve care in the 20 areas, I expect the medical literature will reflect dramatic improvement in these identified areas. The third way to look at success is the development and widespread application of system enhancements that will improve quality: better-coordinated care, better information systems, better training for health professionals, and a more cohesive sense of team among health professionals. In all these areas, we'll have to figure out how to measure and document first the baseline and then the improvements. Some particularly smart researcher in the future will provide the analysis to demonstrate how these systems benefit not only the 20 conditions, but also many other chronic and ambulatory conditions.
MC: Thank you.