Moments ago, the Institute of Medicine (IOM) of the National Academies released what promises to become a landmark study — Best Care at Lower Cost: The Path to Continuously Learning Health Care in America — comprehensively laying the foundation for a learning health care system that links personal and population data to researchers, practitioners, and patients, thereby “dramatically enhancing the knowledge base on effectiveness of interventions and providing real-time guidance for superior care in treating and preventing illness.” The report presents “a vision of what is possible if the nation applies the resources and tools at hand by marshaling science, information technology, incentives, and care culture to transform effectiveness and efficacy of care.”

What’s most interesting about the report is the significant emphasis that’s placed upon computer science throughout:

“Advances in computing, information science, and connectivity can improve patient-clinician communication, point-of-care guidance, the capture of experience, population surveillance, planning and evaluation, and the generation of real-time knowledge — features of a continuously learning health care system.”

Indeed, at least 8 of the 10 recommendations specified in the report clearly require foundational advances in computing (following the link):

• Recommendation 1: The Digital Infrastructure: Improve the capacity of to capture clinical, care delivery process, and financial data for better care, system improvement, and the generation of new knowledge.
• Recommendation 2: The Data Utility: Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.
• Recommendation 3: Clinical Decision Support: Accelerate integration of the best clinical knowledge into care decisions.
• Recommendation 4: Patient-Centered Care: Involve patients and families in decisions regarding health and health care, tailored to fit their preferences.
• Recommendation 5: Community Links: Promote community-clinical partnerships and services aimed at managing and improving health at the community level.
• Recommendation 6: Care Continuity: Improve coordination and communication within and across organizations.
• Recommendation 7: Optimized Operations: Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient care.
• Recommendation 9: Performance Transparency: Increase transparency on health care system performance.

The report begins by defining the central challenge in health care today:

Health care in America presents a fundamental paradox. The past 50 years have seen an explosion in biomedical knowledge, dramatic innovation in therapies and surgical procedures, and management of conditions that previously were fatal, with ever more exciting clinical capabilities on the horizon. Yet American health care is falling short on basic dimensions of quality, outcomes, costs, and equity. Available knowledge is too rarely applied to improve the care experience, and information generated by the care experience is too rarely gathered to improve the knowledge available. The traditional systems for transmitting new knowledge — the ways clinicians are educated, deployed, rewarded, and updated — can no longer keep pace with scientific advances. If unaddressed, the current shortfalls in the performance of the nation’s health care system will deepen on both quality and cost dimensions, challenging the well-being of Americans now and potentially far into the future…

 

The committee recognizes that individual physicians, nurses, technicians, pharmacists, and others involved in patient care work diligently to provide high-quality, compassionate care to their patients. The problem is not that they are not working hard enough; it is that the system does not adequately support them in their work. The system lags in adjusting to new discoveries, disseminating data in real time, organizing and coordinating the enormous volume of research and recommendations, and providing incentives for choosing the smartest route to health, not just the newest, shiniest — and often most expensive — tool. These broader issues prevent clinicians from providing the best care to their patients and limit their ability to continuously learn and improve.

It references the myriad ways in which computing has transformed other industries —

Consider the impact on American services if other industries routinely operated in the same manner as many aspects of health care:

 

• If banking were like health care, automated teller machine (ATM) transactions would take not seconds but perhaps days or longer as a result of unavailable or misplaced records.

• If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination.

• If shopping were like health care, product prices would not be posted, and the price charged would vary widely within the same store, depending on the source of payment.

• If automobile manufacturing were like health care, warranties for cars that require manufacturers to pay for defects would not exist. As a result, few factories would seek to monitor and improve production line performance and product quality.

• If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not to perform one at all.

— and describes similar transformative potential in health care:

The point is not that health care can or should function in precisely the same way as all other sectors of people’s lives — each is very different from the others, and every industry has room for improvement. Yet if some of the transferable best practices from banking, construction, retailing, automobile manufacturing, flight safety, public utilities, and personal services were adopted as standard best practices in health care, the nation could see patient care in which

 

• records were immediately updated and available for use by patients;

• care delivered was care proven reliable at the core and tailored at the margins;

• patient and family needs and preferences were a central part of the decision process;

• all team members were fully informed in real time about each other’s activities;

• prices and total costs were fully transparent to all participants;

• payment incentives were structured to reward outcomes and value, not volume;

• errors were promptly identified and corrected; and

• results were routinely captured and used for continuous improvement.

So how do we get there?

Meeting the challenges discussed at those workshops has taken on great urgency as a result of two overarching imperatives:

 

• to manage the health care system’s ever-increasing complexity, and

• to curb ever-escalating costs.

 

The convergence of these imperatives makes the status quo untenable. At the same time, however, opportunities exist to address these problems — opportunities that did not exist even a decade ago:

 

• Vast computational power (with associated sophistication of information technology) has become affordable and widely available. This capability makes it possible to harvest useful information from actual patient care (as opposed to one-time studies), something that previously was impossible.

• Connectivity that allows that vast computational power to be accessed in real time virtually anywhere by professionals and patients, permitting unprecedented diffusion of information cheaply, quickly, and on demand.

• Progress in human and organizational capabilities and management science can improve the reliability and efficiency of care, permitting more scientific deployment of human and technical resources to match the complexity of systems and institutions.

• The recognition that effective care must be delivered by collaborations between teams of clinicians and patients, each playing a vital role in the care process. Increasing empowerment of patients unleashes the potential for their participation, in concert with clinicians, in the prevention and treatment of disease — tasks that increasingly depend on personal behavior change.

Even more explicitly:

As noted earlier, new opportunities exist to address the challenges outlined above. Just as the information revolution has transformed many other fields, growing stores of data and computational abilities hold the same promise for improving clinical research, clinical practice, and clinical decision making. In the past three decades, for example, computer processing speed has grown by 60 percent a year on average, while the capacity to share information over telecommunications networks has risen by an average of 30 percent a year (Hilbert and López, 2011). These advances in computing and connectivity have the potential to improve health care by expanding the reach of knowledge, increasing access to clinical information when and where needed, and assisting patients and providers in managing chronic diseases. Studies also have found that using such electronic systems can improve safety — one study reported a 41 percent reduction in potential adverse drug events following the implementation of a computerized patient management system (computerized physician order entry, or CPOE), while another estimated that overall medication error rates dropped by 81 percent (Bates et al., 1998, 1999; Potts et al., 2004). Projections are for 90 percent of office-based physicians to have access to fully operational electronic health records by 2019, up from 34 percent in 2011 (Congressional Budget Office, 2009; Hsiao et al., 2011). Since these capacities are relatively early in their development in the health care arena, there is substantial room for progress as they are implemented in the field. However, multiple nontechnological developments, such as supportive care processes, governance, and patient and public engagement, will be necessary if these technologies are to reach their full potential.

The study seems well worth a quick read this morning.

(Contributed by Erwin Gianchandani, CCC Director)