By Christopher Guadagnino, Ph.D.

Published April 2001

• React to this article in the Discussion Forum.

Lonnie Bristow, M.D., is former president of the American Medical Association and a member of the Institute of Medicine’s Committee on Health Care Quality in America.

PND: What problems did the committee’s latest report address?

LRB: The Committee on Health Care Quality in America was created two and a half years ago and given the charge of devising a strategy to achieve a substantial improvement in the quality of care in America. The committee’s first report concerned patient safety, and the report that came out this March was called, "Crossing the Quality Chasm: A New Health Care System for the 21st Century." Both reports identify that the problems either with safety or the overall quality of care in America lies with the systems of care that we give to Americans. That’s terribly important. When we say systems, we’re talking about the organization or integration of the various factors that produce a particular outcome or product. Health care as it rendered in America frequently was organized in a fashion that was for a different time, not for the 21st century. Accordingly, many of the problems that we see with health care are due to faulty or flawed organization of those various factors that we use to produce an outcome in patients. That’s marvelous news because it means that it’s not really about incompetent physicians or nurses, or uncaring hospitals. In fact, the final report states very clearly that we are not going to achieve substantial improvement in the quality of care by simply exhorting those particular players to work harder to make the quality of care better. They can’t. They literally cannot, unless we reorganize the way we integrate the various factors that are used in producing the product of health care. This is good news because it means we can stop beating up on each other and begin to look at the systems of care that we use, some of which were developed hundreds of years ago, for example, the way we write prescriptions. It’s not important to keep secret what your prescriptions are. In fact, every physician or caregiver worth their salt wants patients to know about the care that they’re receiving because patients really are an important part in ensuring that the care that’s given actually works.

PND: What specific defects in the current health care system are identified by the committee’s recent report?

LRB: At the end of the report there’s an appendix that contains 73 references from peer reviewed literature over the last seven years that document our shortfalls in immunization rates, mammography screening rates, the use of colonoscopy and other screening approaches for cancer. They demonstrate the extraordinarily spotty application of the best practices for treating asthma, hypertension, and the list goes on. After reviewing those documents, I was forced to conclude that the committee is absolutely right: the quality of care as rendered in America is not what we desire it to be. Frequently it is excellent, but not everyone has access to that excellent care. And it’s not a matter of whether or not they have insurance. Frequently, individuals who are well-insured and well-educated still do not get the best quality care that we depend on.

It’s a good news, bad news, good news story. The first good news is that we have all these marvelous tools at our disposal, and knowledge is being accumulated in logarithmic increments. The bad news is that it’s overwhelming and most individuals cannot keep up with it without some substantial assistance. Fifty years ago when medical students studied pharmacology, there were substantially less than 500 medications to learn about. Today there are over 10,000. It’s physically impossible for any one individual to learn all of that and keep up to date with the barrage of knowledge. Fifty years ago, we had the first randomized clinical trial. Today we have 10,000 a year being recorded in the literature. Fifty years ago, there were probably no more than 100 medical journals in English. Today there are thousands of peer reviewed journals. There’s no way the average clinician can hope to keep up with what’s the absolute best way to treat a diabetic who happens to have peripheral vascular disease and is also experiencing hypertension, because the knowledge base continues to expand.

PND: Isn’t Continuing Medical Education equipped to fill in those knowledge gaps?

LRB: CME can’t possibly keep up with it. That’s our problem. The good news is that it’s not because that doctor isn’t trying hard enough. He or she is. They’re tap dancing as fast as they can. We need better systems to process that information and make it available to them when they need it. You don’t need to know everything that’s in all those clinical trials, but when you are faced with that diabetic who has peripheral vascular disease and hypertension, that’s when you need to know the information about that particular set of circumstances.

The second good news is that substantial assistance, in the form of information technology in particular, is coming on-line, but that process has not been organized well. That’s what the IOM committee is saying: that we must get on with the business of reorganizing the macro system of how we educate individuals, how we make sure the stream of new knowledge is funneled to those who are in the front lines. One of the studies on health care quality shows that, on average, it takes 17 years for definitive knowledge that’s derived at the bench to actually reach the front-line of clinical practice. Even then, the application is not remotely as good as we’d like to pat ourselves on the back and think it is.

PND: What guiding principles for change did the report offer?

LRB: The report says that we need to take all the major players—the various professions, the hospitals, the pharmaceutical industry, those who pay for care, and those who create social policy—and bring them together to agree upon a core goal: to continuously reduce illness, injury and disability within the American public and to continuously improve the health and functional capability of people of the United States. If we can all organize around that core goal, the report says that we should utilize six specific aims to get us progressively closer to that goal. Those aims are, first, to make sure that care is safe. People should be able to rely upon the fact that, wherever they go to get their health care, that system will not harm them. The initial report by the committee at the end of 1999 indicated that there are significant numbers of individuals who are harmed by the systems of care that they receive, including the fact that somewhere between 44,000 and 98,000 Americans actually die each year as a result of injuries received, many of which are preventable. Secondly, care should be effective. It should have been shown to be the most effective by using evidence-based care. Third, it should be patient-centered. Too often we find that health care has been organized, not for the convenience of patients, but for the convenience of other parties. Hospitals have to work in shifts. Hospitals normally don’t do elective surgery on weekends. That’s because of how the hospital is organized. We are saying that all care should be organized around the concerns of patients and it should be sensitive to their preferences. Fourth, it should be timely. Around the country, patients frequently have to wait to get their care. Seeing a doctor two hours after the time of a scheduled appointment is not uncommon, even with the physician’s office staff doing their level best to try to process the traffic of patients. Fifth, it should be efficient. Anytime we give a person care that’s either inappropriate or ineffective, then that person is going to have to have additional care, the right care, to address the problem they originally presented. That’s wasteful and inefficient. There’s a substantial amount of such waste built into the systems of care that we have now and they can be made much more efficient. And lastly, it should be equitable. All Americans should have access to care of high quality regardless of their personal circumstances.

PND: What concrete proposals does the report have for institutionalizing these goals?

LRB: This report should be viewed as a road map. It is not a blueprint. A road map tells you where you are, identifies where you want to go and what you will have to go through in order to get there. Time and experience will help us decide which of various approaches actually is the best. The report lays out six major strategies for getting us from where we are to where we want to be. The first is that there needs to be a national report to Congress and to the president on the status of quality of health care in America, done annually by the Secretary of Health and Human Services. Second, the report promulgates ten "golden rules" to guide innovation, such as customizing care based on patient needs and values, giving patients unfettered access to their own medical information, using evidence-based decision-making, anticipating patient needs rather than reacting to them, decreasing waste of resources or patient time, and ensuring cooperation among clinicians and institutions. The third strategy addresses the fact that the majority of the $1.1 trillion spent on health care in this nation each year is spent on chronic care—illnesses that don’t go away and that have to be managed. Because of that, at least 15 priority chronic care conditions should be identified and targeted by the Agency for Health Care Research and Quality to develop the best and most efficient ways of treating them. The fourth strategy is to acknowledge that it will cost money to gear up for the information technology that has to be used. We’ve said that a billion dollars should be appropriated for this purpose by the Congress over the next three to five years to be spent on pilot programs that have the ability to improve quality of care using those six aims or improve the quality of care among those fifteen priority conditions that I mentioned. These pilot research projects should be transferable and transportable to other parts of the broad community, not simply to that one locality. The fifth strategy is to have the Dept. of Health and Human Services sponsor research to develop an infrastructure to extract what is the best evidence that we can bring to bear on treatment approaches for a given set of clinical factors and to make it more easily accessible for those who are in the trenches. Part of that is going to require information technology development, such as putting information into a palm pilot and having it organized in a format in that will be easily utilized by caregivers in the field. The sixth strategy is that there must be a supportive environment created in several areas: payment, education, reliability of treatment and information technology. As we improve quality we need to make sure the incentives are aligned. Hospitals must find ways to make sure that they are not actually punished by the payment system for doing good.

PND: Is it realistic to expect to find commonality of incentives between the seemingly incommensurate financial interests of payors and providers?

LRB: That goes back to the need for all of the interested players to come together and agree on a core goal for the nation to substantially reduce the illness, injury and disability within the American public and to continuously improve the health and functional capability of Americans. I don’t think it’s beyond achievement if we have national goals and make a national effort. If you look over those 73 references in the report’s appendix, you realize we’ve got a serious problem here. The American public deserves to have the best kind of care, while doctors, nurses and hospitals want to give the best kind of care. I believe we can do it as a nation. The question is going to be whether we’ll have the leadership to accomplish that.

PND: Do you think the free market is equipped to accomplish these goals?

LRB: The free market is anxious to help. The Leapfrog Group formed in response to the medical errors report of the IOM, in which a number of the largest corporations in America came together and said, "This is fine, we support it, and in fact we are going to restructure the insurance programs that we have so as to reward those hospitals that are attempting publicly to meet the principles that we articulate as far as improved safety." There’s a huge role, however, for the public sector, meaning government, and we had a distinct advantage when we brought forward the medical errors report because the President of the United States read the report, understood the report, and had it evaluated by agencies within the administration, which came back and said, "As painful as it is, Mr. President, everything that they’ve said is correct." And he had the courage to say, "I want the changes that have been recommended implemented within all governmental entities." So, the Department of Defense and the Veterans Administration are moving already with implementation based on the safety report. That kind of leadership is what’s going to be needed now. We need to have, frankly, someone very high in government willing to take on the job of saying, "Improved quality of care to the level that we can achieve is something the American people deserve." We will have to have that kind of visionary leadership and I’m hoping we will. Without it, I don’t see how this can realistically be accomplished within this decade. All of these changes will ultimately occur. It may take us 50 or 60 years and it won’t be as well constructed because it will happen in a happenstance fashion. In the meantime, there are going to be millions of people getting less than the quality of care they should and, unfortunately, that adds to morbidity and disability.