What System?

The health care system can hardly be called a system. Rather it is a dizzying array of highly decentralized sectors. Although the size of physician groups is growing, 37 percent of practicing physicians are still in solo or two-person practices (Center for Studying Health System Change, 2002). The health plan sector is turning away from structures that can facilitate integration and coordination, with the market share of health maintenance organizations (HMOs) falling and preferred provider organizations (PPOs) becoming more popular (Kaiser Family Foundation and Health Research and Educational Trust, 2002). And even though the hospital sector has been consolidating in many markets—of the 5,000 community hospitals, more than 3,500 belong to some network or system—most of these arrangements are focused on administrative rather than clinical integration (American Hospital Association, 2000; Lesser and Ginsburg, 2000). As Ken Shine, former president of the Institute of Medicine (IOM), attested at the summit:

We operate our health care system like a cottage industry, big, big cottages with state-of-the-art technologies to care for patients, but infrastructure which is totally inadequate, systems which don’t talk to each other (Shine, 2002).

The absence of systems, or poorly designed systems, and the resulting lack of integration are apparent across sectors, as well as within individual health care organizations. Such systems can harm patients or fail to deliver what patients need. A previous IOM report makes abundantly clear that the inability to apply knowledge about human factors in systems design and the failure to incorporate well-acknowledged safety principles into health care (such as standardizing and simplifying equipment, supplies, and processes) are key contributors to the unpardonably high number of medical errors that occur (Institute of Medicine, 2000).

Mary Naylor, School of Nursing, University of Pennsylvania, a panelist at the summit, echoed this reality:

We have both a culture and organization of care that separate our care into distinct systems—hospitals, home care, skilled nursing facilities—with little formal communication, relationships, or collaboration between and among those settings….And providers don’t necessarily see that they’re responsible for what happens to people as they move from one level of care to another. We don’t pay a lot of attention to issues of quality assessment, particularly in those difficult hand-offs or transitions from one level of care to another (Naylor, 2002).

The Quality Chasm report also stresses that a redesigned system is predicated on interdisciplinary teams. In the current system, however, health professionals work together, but display little of the coordination and collaboration that would characterize an interdisciplinary team. Many factors, including differing professional and personal perspectives and values, role competition and turf issues, lack of a common language among the professions, variations in professional socialization processes, differing accreditation and licensure regulations, payment systems, and existing hierarchies, have decreased the system’s ability to function, causing defined roles to predominate over meeting patients’ needs. The hierarchy in which physicians dominate and the emphasis on assuming individual responsibility for decision making result in a reliance on personal accountability and a failure to solicit the contributions of others who could bring added insight and relevant information, whatever their formal credentials (Helmreich, 2000; Institute of Medicine, 2001a).

The resulting lack of continuity and coordination of care, miscommunication, redundant and wasteful processes, and excess costs have resulted in patient suffering (Institute of Medicine, 2001a; Larson, 1999). Patients and families commonly report that caregivers appear not to coordinate their work or even to know what each other are doing. Patients spend a great deal of time consulting with an endless stream of physicians, nurses, therapists, social workers, home care workers, nutritionists, pharmacists, and other specialists, who too often are ignorant of past medical histories, medications, or treatment plans and therefore work at cross purposes. When patients are moved from one setting to another—for example, from hospital to rehabilitation center to home—fragmentation of care results in overlapping or conflicting treatment that is costly and confusing and, worst of all, detrimental to the patient. In a recent survey, 85 percent of physicians surveyed stated that one or more adverse outcomes result from uncoordinated care, and more than half suggested that a lack of coordination is usually the cause of patients receiving contradictory health information from providers (Partnership for Solutions, 2002b).

Poor Accommodation of Patients’ Needs

Americans are living longer, in part as a consequence of advances in medical science, technology, and health care delivery. As the population ages, there will be more patients with chronic conditions. In 2000, about 13 percent of the population (35 million Americans) were over age 65; this proportion is expected to rise to 20 percent (70 million) by 2030 (National Center for Health Statistics, 2002). An estimated 125 million Americans already have one or more chronic conditions, and more than half of these people have multiple such conditions (Wu and Green, 2000).

Moreover, although the majority of disease burden and health care resources is related to the treatment of chronic conditions, the nation’s health care system is organized and oriented largely to provide acute care and is inadequate in meeting the needs of the chronically ill (Wagner et al., 2001). As William Richardson, Kellogg Foundation, noted in his remarks at the summit, “There are few clinical programs that can provide the full complement of services needed by people with heart disease, diabetes, asthma, or other common chronic conditions (Richardson, 2002).

Studies show that effective treatment of chronic conditions needs to be continuous across settings and types of providers. Clinicians need to collaborate with each other and with patients to develop joint care plans with agreed-upon goals, targets, and implementation steps. Such care should support patient self-management and encompass regular clinician follow-up, both face-to-face and through electronic means (DeBusk et al., 1994; Von Korff et al., 1997; Wagner et al., 2001; Wagner et al., 1996). Clinicians practicing in such an environment need to be effective members of an interdisciplinary team, provide care that is patient-centered, and be proficient in informatics applications.

A recent survey underscored issues faced by the chronically ill, with about three of every four respondents reporting difficulty in obtaining medical care. Specifically, 72 percent had experienced difficulty in obtaining care from a primary care physician, 79 percent from a medical specialist, and 74 percent from providers of drug therapy (Partnership for Solutions, 2002b). This same survey indicated that, as a result of the lack of coordination, the chronically ill were receiving spotty or contradictory information and facing avoidable complications. At the summit, Mary Naylor described a typical real-life example of the lack of coordination for the chronically ill:

A 75-year old woman…had a number of chronic conditions: osteoporosis, hypertension, diabetes, and heart failure, and… was admitted to a hospital as a result of a fall…and fracture…. We followed her…from hospital admission, through one month’s time, and she was the subject of about 20 major providers. That does not include the numbers of ancillary personnel and other support people involved in her care. While hospitalized, she interacted with an orthopedic surgeon and his team, a cardiologist, an endocrinologist, a primary care nurse, a physical therapist based in the hospital, and a social worker who helped facilitate her discharge to a skilled nursing facility. At that point, the hand-off was to a physician in the skilled nursing facility, a physical therapist, an occupational therapist, and a variety of other providers. Within 2 weeks’ time, she was returned home to home care follow-up by the Visiting Nurse’s Association, and had a nurse, occupational therapist, and physical therapist engage with her in care in the home.

Her care was characterized by poor communication….Very little attention [was paid] to her preferences or the preferences of her family members in decision making about what care [she should receive] and what site she should go to, and what the plan of care should be at each of those sites. There was very poor transfer of information from one site to the other; in fact, critical pieces of her care plan were not communicated from the hospital to the nursing home, resulting in an emergency room visit within a couple of days of discharge to the skilled nursing facility. And there was no point person, no broker of care, no one there advocating for her, for her family, and coordinating this entire experience, all of which took place in a very short period of time (Naylor, 2002).

America’s increasing chronic care needs also highlight the importance of health professionals being better prepared in prevention and health promotion. It has been estimated that approximately 40 percent of all deaths are caused by behavior patterns that could be modified (McGinnis et al., 2002). Prevention is also key in dealing with the nation’s emerging infections, both those that occur naturally and those that are intentionally introduced. Since the events of September 11, 2001, and the anthrax attacks that followed, the once seemingly remote threat of a bioterrorist attack in the United States has now become plausible. The ability of health care professionals to apply population-based prevention strategies and activate the public health system is crucial to an effective response to such incidents. In a recent survey of health professionals, however, only a quarter of respondents said they felt prepared to respond to a bioterrorist event (Chen et al., 2002).

In addition to the need for the health system to be more responsive to those with chronic conditions and more focused on prevention, the system has not done a good job in accommodating the diverse cultural needs and varying preferences of racial and ethnic groups. A recent IOM report that reviews a large body of research concludes that racial and ethnic minorities tend to receive lower-quality care than Caucasians, even when one accounts for differences in insurance status, income, age, and severity of condition (Institute of Medicine, 2002). The IOM committee that prepared that report outlined steps needed to close this gap, including preparing health professionals to be competent in providing care that is culturally sensitive (Institute of Medicine, 2002). There is added urgency to address such inequities given that ethnic/racial minorities are predicted to comprise a majority of the U.S. population by 2050 (U.S. Census Bureau, 2002).

Inability to Assimilate the Increasingly Complex Science Base

Over the last 50 years, there has been a steady increase in funding for biomedical research that has resulted in extraordinary advances in clinical knowledge and technology. From a start of about $300 in 1887, the National Institutes of Health (NIH) has been appropriated nearly $23.4 billion for 2002 (National Institutes of Health, 2002), while investment on the part of pharmaceutical firms has risen from $13.5 billion to $24 billion between 1993 and 1999 (Pharmaceutical Research and Manufacturers of America, 2000). Likewise, research and development in the medical device industry, funded largely by private dollars, totaled $8.9 billion in 1998 (The Lewin Group, 2000). Results of all this investment include a doubling of the average number of new drugs approved each year since the 1980s (The Henry J. Kaiser Family Foundation, 2000) and exponential growth in the number of clinical trials from about 500 a year in the 1970s to more than 10,000 a year today (Chassin, 1998). There are no signs that this growth is going to abate any time soon—nor would we want that to happen.

Traditionally, it has been assumed that health professionals are able to diagnose and treat, evaluate new tests and procedures, and develop clinical practice guidelines, all using the training initially received from their academic education and ongoing practice experience. This assumption is no longer valid, with human memory becoming increasingly unreliable in keeping pace with the ever-expanding knowledge base on effective care and its use in health care settings. For clinicians, just staying abreast of advances, let alone obtaining active training in or experience with new techniques and approaches, can be a daunting task. As David Eddy, a prominent quality expert, has said, the “complexity of modern medicine exceeds the inherent limitations of the unaided human mind” (Millenson, 1997:75). Although no practitioner needs to absorb the results of 10,000 clinical trials that span many areas of specialty, rapid expansion of knowledge is occurring even within specific areas. For example, as William Richardson noted at the summit, the number of randomized controlled trials on diabetes published over the last 30 years increased from about 5 to more than 150 per year.

Few professionals are prepared to cope with the continuously expanding knowledge and technology base, and supports to help clinicians access and apply this knowledge base to practice are not widely available. Such supports would include providing relevant information in an accessible format at the point of care. However, the literature is “replete with evidence of the failure to provide care consistent with well established guidelines for common chronic conditions” (Institute of Medicine, 2001a: 28). And the lag between the discovery of more effective forms of treatment and their incorporation into routine patient care is, on average, 17 years (Balas, 2001). Obviously, the health system needs to do better in this regard.

As William Richardson asked summit participants, “If we can’t keep up now, how will we respond to the extraordinary advances that will emerge during this new century?” (Richardson, 2002). These advances include, among others, the use of genomics to diagnose and eventually treat disease; engineering discoveries such as miniaturization and robotics; and the application of advanced epidemiological knowledge, especially as it relates to bioterrorism, to large populations and databases (Institute of Medicine, 2001a).

Slow Adoption of Information Technology

Information technology is poised to bring about a significant transformation in the nation’s health system, with the Internet serving as a major agent of change. The Quality Chasm report stresses that the automation of clinical, financial, and administrative transactions is essential to improving quality, preventing errors, enhancing consumer confidence in the health system, and improving efficiency (Institute of Medicine, 2001b). That report and others, as well as the plenary address at the summit by William Richardson, identify key areas in which a communications and information technology infrastructure could contribute greatly to enhancing the health care system (Institute of Medicine, 2001a; National Research Council, 2000). These potential contributions include enhancing clinical decision making by making real-time data available, increasing communication among providers and with patients through such approaches as remote medical consultations, collecting and aggregating clinical information and evidence into accessible information databases, facilitating patient access to reliable health information, and reducing medical errors.

Despite the range of areas in which communications and information technology could make a substantial contribution to enhancing health care access, quality, and service while reducing costs, the industry has been slow to invest in and embrace such technology. And while industries do differ in their degree of capital intensiveness, the differences in information technology investment are striking. For example, in 1996 the health care industry spent only $543 per worker on information technology, as compared with $12,666 per worker spent by securities brokers. Further, health care ranked 38^th among 53 industries surveyed in terms of information technology investment (U.S. Department of Commerce, 2000).

Consequently, health care delivery has not been touched to the same degree by the revolution that has been transforming nearly every other aspect of society (Institute of Medicine, 2001a). Most clinical information is still stored in a collection of poorly organized and often illegible paper records (Staggers et al., 2001; Hagland, 2001). Few patients have e-mail access to their caregivers. Indeed, most payment to providers is based on face-to-face visits, and clinicians cannot get paid for the kinds of alternative communication that information technology offers and patients desire. Most patients do not benefit from even the simplest decision aids, such as patient reminder systems. Finally, an unacceptable number of medical errors occur because there are few information systems in place to process and check the vast amount of clinical data that flows through the system (Godin et al., 1999). In short, existing systems typically do not collect and store the right information; are not sufficiently automated or computerized; are not integrated or linked to each other; and lack the hardware, software, and data entry support necessary for retrieval and analysis of information.

One impediment to the greater use of communications and information technology is the absence of national standards for the capture, storage, communication, processing, and presentation of health information (Work Group on Computerization of Patient Records, 2000). Another is privacy and data security issues. Regulatory requirements governing e-mail use with patients, such as the Health Insurance Portability and Accountability Act, designed to help guarantee the privacy and confidentiality of patient medical records, will help somewhat in this regard. However, the Quality Chasm report emphasizes that in the absence of a national commitment and financial support for building a national health information infrastructure, progress in this area will be painfully slow.

Failure to Address Growing Consumerism Among Patients

There has been a growing consumerism in health care, exemplified by increases in access to health information on the Internet and other media (Calabretta, 2002; Frosch and Kaplan, 1999; Gerteis et al., 1993; Mansell et al., 2000; Mazur and Hickam, 1997). Largely as a result of the Internet, patients and their families are now better educated and informed about their health care. As a consequence, some patients want to be able to make their own decisions about diagnosis and treatment, bringing their own information and values to bear, with the expectation that, together with their health care providers, they will manage their illness or disease (Benbassat et al., 1998). In one survey, only 16 percent had sought health information via the Internet (Tu, 2003). While in another, 76 percent of respondents said they had searched the Internet for health information (Taylor, 2002). In that survey, 83 percent of respondents said they would like the results of their laboratory tests to be available online, and 69 percent expressed their desire for online charts for use in monitoring their chronic conditions over time. An annual Harris Interactive Survey spanning 1998–2002 shows a steady rise in adults who sometimes look for health information online. One survey showed that individuals span the education and income spectrum (Taylor, 2002) while another showed that higher educated individuals are more likely to search the Internet for health information (Tu, 2003).

Many patients, however, have expressed frustration with their inability to participate in decision making, to obtain the information they need, to be heard, and to participate in systems of care that are responsive to their and their families’ and caregivers’ needs and values (Partnership for Solutions, 2002a). Studies have demonstrated substantial shortcomings among health professionals in understanding and communicating with patients (Laine and Davidoff, 1996; Meryn, 1998; Stewart et al., 1999), as well as in their ability to provide adequate information for informed decision making (Braddock et al., 1999). An early important study revealed that in 69 percent of visits, physicians did not allow patients to complete their opening statement of symptoms and concerns, interrupting after a mean time of 18 seconds. Patients were given the opportunity to state their full list of concerns in only 23 percent of visits (Beckman and Frankel, 1984). A later study on the same topic revealed similar results, with failure to obtain the patient’s complete agenda resulting in late-arising concerns and missed opportunities to collect potentially valuable information (Marvel et al., 1999).

At the summit, Myrl Weinberg, National Health Council, attested to the problems from a patient’s perspective:

What are the complementary alternatives, treatments, over-the-counter kinds of treatments that people are taking that [are] never asked about? So often, no one ever asks. And if people are asked… they don’t understand the question, and they think they’re not taking any other prescription drugs and that’s the end of it.…Some of the studies are showing that the reason people pay billions of dollars for complementary alternative products through health food stores is because they feel a sense of shared values; that there’s a holistic approach for some of these other health care providers or treatments. And they feel more comfortable there than they do any longer with individuals in the more traditional health care systems….It’s not often the health care provider says, “Gee, I can’t know it all, there’s no way, there are other great educational sources, and here are some places you can go or Web sites that you can trust, to find out more about your condition so that we can discuss it when you’re here (Weinberg, 2002).”

Workforce Shortages and Discontent

Health care has always been subject to trends in oversupply and undersupply of various health professionals, but the current shortage of nurses is different, with many experts saying it will not be resolved quickly (Buerhaus, 2000). In the year 2000, the nursing shortage was estimated at 6 percent, with 1.89 million full-time registered nurses in the workforce and demand projected at 2 million. If trends continue, the shortage is predicted to skyrocket to 29 percent by 2020 (Health Resources and Services Administration, 2002). Fully 75 percent of all current vacancies at hospitals are for nurses (American Hospital Association, 2001). Though enrollments in entry-level baccalaureate programs in nursing increased in fall 2001, ending a 6-year period of decline, the number of students in the educational pipeline is still insufficient to meet the projected demand for the million new nurses needed over the next 10 years (American Association of Colleges of Nursing, 2002). These problems are exacerbated by an increasing shortage of nursing faculty. According to the American Association of Colleges of Nursing (AACN), of more than 9,000 faculty at AACN-member nursing schools, only slightly more than 50 percent have a doctorate, and there is a large decrease in the number of nursing students with a master’s degree who are pursuing academic careers (Berlin and Sechrist, 2002).

Nurses also are increasingly dissatisfied once they are on the job. A 2001 survey reveals that 40 percent of nurses working in hospitals are dissatisfied with their jobs, and 1 of 3 hospital nurses under the age of 30 is planning to leave his or her current job in the next year (Aiken et al., 2001). Sources of dissatisfaction include working conditions, such as inadequate staffing and higher use of less-skilled workers; heavy workloads; increases in overtime; a lack of sufficient support staff; and inadequacy of wages (U.S. General Accounting Office, 2001).

The nursing shortage and dissatisfaction of registered nurses with their work environments have taken a toll. An increasing number of studies have shown that patient safety issues and adverse health outcomes result, including patient deaths, as well as increased stress (physical and psychological), burnout, and frustration among health professionals (Aiken et al., 2002; Blegen et al., 1998; Buerhaus, 2000; Flood and Diers, 1998; Kovner and Gergen, 1998; Lichtig et al., 1999; Sochalski, 2002). The shortages have resulted in fragmentation of care, with fewer opportunities for one-on-one contact between patients and health professionals.

Shortages in pharmacy are also pressing and have been characterized as “dynamic,” with demand for pharmacy services increasing in recent years despite a steady growth in supply (Department of Health and Human Service, 2000; Knapp and Livesey, 2002). The shortage is attributable to a number of factors, including patients’ increased use of medications; expansion of pharmacists’ traditional roles to include patient education, counseling, and medication management; limited use of technology and pharmacy technicians, as well as poor work design; and greater numbers of female pharmacists, who work fewer hours than their male counterparts (Cooksey et al., 2002). There are conflicting reports on whether the shortage will be long term (Cooksey et al., 2002; Bureau of Labor Statistics. Pharmacists, 2000; Knapp, 1999).

While experts disagree about whether there is a shortage of physicians (Cooper, 2002; Cooper et al., 2002), physicians are increasingly dissatisfied with their work life. Of some 1,900 recently surveyed physicians, 27 percent anticipated leaving their practices within 2 years, with 29 percent of those being aged 34 or younger (Pathman et al., 2002). In another survey, 31 percent expressed worry that they were “burning out” as physicians (Shearer and Toedt, 2001). In Massachusetts, substantial numbers of physicians surveyed were planning to leave the state, change careers, or retire early as a result of the current practice environment (Massachusetts Medical Society Online, 2001).

While there are shortages of some health professionals, there is an increasing number of professionals in other disciplines now joining the ranks who are redefining care delivery. Nurse practitioners, certified nurse midwives, physician assistants, optometrists, podiatrists, and nurse anesthetists have all increased in number significantly in recent years (Cooper et al., 1998), though poor national data hamper accurate tabulations (Phillips et al., 2002). Regardless, such professionals’ responsibilities are increasingly overlapping with or complementing those of physicians and nurses. This situation is resulting in tremendous friction among the professions over practice control and compensation (Phillips et al., 2002), some of which gets played out in legislative battles over scope of practice.