Growing Complexity of Science and Technology

Health care today is characterized by more to know, more to manage, more to watch, more to do, and more people involved in doing it than at any time in the nation's history. Our current methods of organizing and delivering care are unable to meet the expectations of patients and their families because the science and technologies involved in health care—the knowledge, skills, care interventions, devices, and drugs—have advanced more rapidly than our ability to deliver them safely, effectively, and efficiently (The Robert Wood Johnson Foundation, 1996).

For more than five decades, investments in biomedical research have increased steadily, resulting in an extraordinary expansion of medical knowledge and technology (Blumenthal, 1994). Between 1994 and 1999, the budget of the National Institutes of Health increased from $10.9 to $15.6 billion (National Institutes of Health, 2000), while the investment of pharmaceutical firms in research and development increased from about $13.5 to $24 billion (Pharmaceutical Research and Manufacturers of America, 2000). Spending on research and development in the medical device industry, most of which comes from private sources, totaled $8.9 billion in 1998 (The Lewin Group, 2000).

As suggested earlier, quality problems do not generally stem from a lack of knowledge, training, or effort by health professionals. Today, no one clinician can retain all the information necessary for sound, evidence-based practice. No unaided human being can read, recall, and act effectively on the volume of clinically relevant scientific literature. Since the results of the first randomized controlled trial were published more than 50 years ago (Cochrane, 1972; Daniels and Hill, 1952), health care practitioners have been increasingly inundated with information about what does and does not work to produce good outcomes in health care. Over the last 30 years, the increase in such trials has been staggering—from just over 100 to nearly 10,000 annually. The first 5 years of this 30-year period accounts for only 1 percent of all the articles in the medical literature, while the last 5 years accounts for almost half (49 percent) (Chassin, 1998), and there is no indication that this rate is slowing. Studies on the effectiveness of medical practice have also become increasingly sophisticated, involving complex issues of patient selection and statistical procedures.

As the knowledge base has expanded, so too has the number of drugs, medical devices, and other technological supports. For example, the average number of new drugs approved per year has doubled since the early 1980s, from 19 to 38 (The Henry J.Kaiser Family Foundation, 2000). Between 1990 and 1999, 311 new drugs were approved by the U.S. Food and Drug Administration (U.S. Food and Drug Administration, 2000). The cost of pharmaceuticals is the most rapidly growing component of health care expenditures. As clinical science continues to advance, the challenge of managing the use of existing and new pharmaceuticals and health technologies will intensify.

Without substantial changes in the ways health care is delivered, the problems resulting from the growing complexity of health care science and technologies are unlikely to abate; in fact, they will increase. For example, work being done in genomics offers significant promise for disease diagnosis and, eventually, treatment. Engineering advances in miniaturization will place diagnostic, monitoring, and treatment tools directly into the hands of patients as science improves and costs are reduced. And the application of epidemiological knowledge to large populations and databases will enable us to understand more and more about the dynamics of wellness and disease.

Increase in Chronic Conditions

One of the consequences of advances in medical science and technology is that people are now living longer. Although health care is by no means the only factor that affects morbidity and mortality, innovations in medical science and technology have contributed greatly to increases in life expectancy. The average American born today can expect to live more than 76 years (National Center for Health Statistics, 2000). Roughly 1 additional year has been added to life expectancy every 5 years since 1965.

Because of changing mortality patterns, those age 65 and over constitute an increasingly large number and proportion of the U.S. population. Today, this age group accounts for approximately 1 in 8 persons, or 13 percent of the population (National Center for Health Statistics, 1999). In 2030, when the large baby boom cohort has entered old age, 1 in 5 persons (20 percent) is expected to be in this age group. These demographic changes have important implications for the organization of the health care delivery system, but we have yet to address them in any serious way. One consequence of the aging of the population is an increase in the incidence and prevalence of chronic conditions.

Chronic conditions, defined as illnesses that last longer than 3 months and are not self-limiting, are now the leading cause of illness, disability, and death in this country, and affect almost half of the U.S. population (Hoffman et al., 1996). About 100 million Americans have one or more chronic conditions, and this number is estimated to grow to 134 million by 2020 (The Robert Wood Johnson Foundation, 1996). About 1 in 6 Americans is limited in daily activities in some way as a result of a chronic condition (The Robert Wood Johnson Foundation, 1996). Disabling chronic conditions affect all age groups; about two-thirds of those with such conditions are under age 65.

The majority of health care resources are now devoted to the treatment of chronic disease. In 1990, the direct medical costs for persons with chronic conditions was $425 billion, nearly 70 percent of all personal health care expenditures (The Robert Wood Johnson Foundation, 1996). The indirect costs—lost productivity due to premature death or inability to work—added another $234 billion to this figure.

Providing state-of-the-art health care to a population in which chronic conditions predominate is complicated by the fact that many of those afflicted have comorbid conditions. About 44 percent of those with a chronic illness have more than one such condition, and the likelihood of having two or more chronic conditions increases steadily with age. In 1987, annual medical costs per person were more than twice as high for those with one chronic condition ($1,829) as compared with those with acute conditions only ($817) (The Robert Wood Johnson Foundation, 1996). Annual medical costs per person increase much more for those with more than one chronic condition ($4,672).

Unlike much acute episodic care, effective care of the chronically ill is a collaborative process, involving the definition of clinical problems in terms that both patients and providers understand; joint development of a care plan with goals, targets, and implementation strategies; provision of self-management training and support services; and active, sustained follow-up using visits, telephone calls, e-mail, and Web-based monitoring and decision support programs (Von Korff et al., 1997). Much of the care provided to the chronically ill is given by patients and their families. Activities performed range from the provision of basic support care to active monitoring and management (e.g., self blood glucose monitoring by diabetics, use of peak flow meters by asthmatics). Although some degree of collaborative management is essential to achieve desired outcomes for many chronic conditions, patients vary a great deal in the amount of information they want to receive on their condition and their desire to participate in treatment decisions (Strull et al., 1984). Nonetheless, the collaboration involved in much of the care provided to the chronically ill adds another layer of complexity to the delivery of health care to this growing segment of the population.

Poorly Organized Delivery System

The current health care delivery system is highly decentralized. In a survey of physicians practicing in community settings, nearly 40 percent were in one-physician practices, and more than four of five practiced in settings with fewer than ten physicians (American Medical Association, 1998). Hospital consolidation is occurring in many markets; of the more than 5,000 community hospitals, 3,556 belong to some form of network or system (American Hospital Association, 2000). The formation of physician organizations is occurring much more slowly, however (Kohn, 2000).

The prevailing model of health care delivery is complicated, comprising layers of processes and handoffs that patients and families find bewildering and clinicians view as wasteful. Patients in a 1996 Picker Survey reported that the health care system is a “nightmare to navigate”—that it feels less like a system than a confusing, expensive, unreliable, and often impersonal disarray (Picker Institute and American Hospital Association, 1996). Care delivery processes are often overly complex, requiring steps and handoffs that slow down the care process and decrease rather than improve safety. These processes waste resources; leave unaccountable gaps in coverage; result in the loss of information; and fail to build on the strengths of all health professionals involved to ensure that care is timely, safe, and appropriate.

In a population increasingly afflicted by chronic conditions, the health care delivery system is poorly organized to provide care to those with such conditions. In a review of the literature on chronic care, Wagner et al. (1996) identified five elements required to improve patient outcomes for the chronically ill:

• Evidence-based, planned care. The literature is replete with evidence of the failure to provide care consistent with well-established guidelines for common chronic conditions such as hypertension (Stockwell et al., 1994), asthma (Legorreta et al., 1998; Starfield et al., 1994), and diabetes (Kenny et al., 1993). Successful chronic care programs tend to be ones that incorporate guidelines and protocols explicitly into practice.
• Reorganization of practices to meet the needs of patients who require more time, a broad array of resources, and closer follow-up. Such reorganization generally involves the delivery of care through a multidisciplinary team, the careful allocation of tasks among the team members, and the ongoing management of patient contact (appointments, follow-up) (Wagner et al., 1996).
• Systematic attention to patients' need for information and behavioral change. A review of 400 articles, randomized trials, and observational studies of self-management support interventions (Center for Advancement of Health, 1996), revealed substantial evidence that programs providing counseling, education, information feedback, and other supports to patients with common chronic conditions are associated with improved outcomes (Brown, 1990; DeBusk et al., 1994; Mullen et al., 1987).
• Ready access to necessary clinical expertise. Specialized clinical knowledge and expertise are important to improved outcomes. Evidence suggests that there are numerous ways to enhance access to such knowledge and expertise, including education of patients and primary care providers (Inui et al., 1976; Sawicki et al., 1993; Soumerai and Avorn, 1990), referrals to specialists, various consultation processes (e.g., teleconferencing, hot line to specialists) (Vinicor et al., 1987), collaborative care models whereby primary care providers and specialists practice together (Katon et al., 1995; McCulloch et al., 1994), and computer decision support systems (Barton and Schoenbaum, 1990; Litzelman et al., 1993; McDonald et al., 1988).
• Supportive information systems. Patient registries have been used effectively in many settings to issue reminders for preventive care and necessary follow-up, and to provide feedback to the provider practice on patient compliance and service use (Glanz and Scholl, 1982; Johnston et al., 1994; Macharia et al., 1992; Mugford et al., 1991; Stason et al., 1994). Mechanisms for sharing clinical and other information among all members of the care team, ranging from patient-carried medical records (Dickey and Petitti, 1992; Turner et al., 1990) to automated patient records, can also improve care.

Thus the American health care system does not have well-organized programs to provide the full complement of services needed by people with such chronic conditions as heart disease, cancer, diabetes, and asthma. Nor do we have mechanisms to coordinate the full range of services needed by those with multiple serious illnesses. And our current health system has only a rudimentary ability to collect and share patient information.

A growing body of evidence for some procedures and conditions suggests that higher volume is associated with better outcomes (Hewitt, 2000). We know little about the underlying factors that produce this relationship (e.g., more effective care processes, better processes for incorporating knowledge into practice, provider skill, effective multidisciplinary team, access to specialized resources). But the results are consistent with the conclusion that the growing complexity of health care necessitates more sophisticated and carefully designed care processes.

The application of engineering concepts to the design of care processes is a critical first step in improving patient safety. Yet few health care organizations have applied the lessons learned by other high-risk industries that have led to very low rates of injury. These lessons include organized approaches to collecting data on errors and analyzing their causes, minimizing reliance on human memory, and standardizing routine aspects of care processes (Chassin, 1998; Institute of Medicine, 2000). Patient safety emerges from systems that are skillfully designed to prevent harm (Cook, 1998). Although many, often simple, steps could be taken now and without great cost, knowledge about such actions has neither been disseminated among health care institutions nor widely implemented, probably because there are often no real penalties for failing to do so and no real rewards for effective improvements. Although Americans have come to expect high-technology care, they do not demand safety and reliability with the same insistence.

For the most part, health care organizations are only beginning to apply information technology to manage and improve patient care. A great deal of medical information is stored on paper. Communication among clinicians and with patients does not generally make use of the Internet or other contemporary information technology. Hospitals and physician groups operate independently of one another, often providing care without the benefit of complete information on the patient's condition or medical history, services provided in other settings, or medications prescribed by other providers.

Our attempts to deliver today's technologies with today's medical production capabilities are the medical equivalent of manufacturing microprocessors in a vacuum tube factory. The costs of waste, poor quality, and inefficiency are enormous. If the current delivery system is unable to utilize today's technologies effectively, it will be even less able to carry the weight of tomorrow's technologies and an aging population, raising the specter of even more variability in quality, more errors, less responsiveness, and greater costs associated with waste and poor quality.

The challenge before us is to move from today's highly decentralized, cottage industry to one that is capable of providing primary and preventive care, caring for the chronically ill, and coping with acute and catastrophic events. To meet this challenge, there must be a commitment to organizing services around common patient needs and applying information technology and engineering concepts to the design of care processes.

Constraints on Exploiting the Revolution in Information Technology

The advent of the Internet and the World Wide Web has placed us on the threshold of a change that is reshaping virtually all aspects of society, including health care delivery. The Internet supports a rising tide of consumerism, with greater demands for information and convenience in all areas of commerce. And Internet services are becoming cheaper and easier to access.

Four of ten U.S. households had Internet access as of August 2000 (U.S. Department of Commerce, 2000), and it is predicted that 90 percent will have access by 2010 or before (Rosenberg, 1999). Large increases in Internet access have occurred among most groups of Americans, regardless of income, education, race or ethnicity, location, age, or gender (U.S. Department of Commerce, 2000). Nonetheless, a “digital divide” remains, especially for the disabled and for African Americans and Hispanics.

Large numbers of patients are turning to the Internet for health care information and advice. An estimated 70 million Americans seek health information online (Cain et al., 2000). It is estimated that there are 10,000 or more health-related Web sites (Benton Foundation, 1999), allowing consumers to search for information on specific diseases and treatments, evaluate health plans and clinicians, pose questions to care providers, manage chronic conditions, participate in discussion groups, assess existing health risks, and purchase health-related products (National Research Council, 2000). There is however, much variability in the accuracy and completeness of health information found on the Web (Biermann et al., 1999).

The effect of these trends on health care will be a fundamental transformation in the ways services are organized and delivered and clinicians and patients interact. Individuals are making many of their own decisions about diagnosis and treatment. Increasingly, they are also bringing information to their physicians to obtain help in interpreting or judging its value for themselves.

To better understand how information technology can contribute to improving quality, the Committee on the Quality of Health Care in America held a workshop in September 1999 at which participants identified five key areas in which information technology could contribute to an improved health care delivery system:

• Access to the medical knowledge-base. Through use of the Web, it should be possible to help both providers and consumers gain better access to clinical evidence.
• Computer-aided decision support systems. Embedding knowledge in tools and training clinicians to use those tools to augment their own skills and experience can facilitate the consistent application of the expanding science base to patient care.
• Collection and sharing of clinical information. The automation of patient-specific clinical information is essential for many types of computer-aided decision support systems. Automation of clinical data offers the potential to improve coordination of care across clinicians and settings, which is critical to the effective management of chronic conditions.
• Reduction in errors. Information technology can contribute to a reduction in errors by standardizing and automating certain decisions and by aiding in the identification of possible errors, such as potential adverse drug interactions, before they occur.
• Enhanced patient and clinician communication. Information technology can change the way individuals receive care and interact with their clinicians. Instead of a $65 office visit and a half-day off work, a 2-minute e-mail communication could meet many patients' needs more responsively and at lower cost. Similarly, patients would be able to go online and obtain test results, inform their clinicians about how they are doing, send pictures and data, participate in interactive care management services, receive after-care instructions, and participate in support groups. Appropriately structured e-mail communication between patient and provider could also permit continuous monitoring of clinical conditions, especially for patients with chronic conditions that require self-management.

A recent report by the National Research Council of The National Academies, Networking Health, also concludes that “the Internet has great potential to improve Americans' health by enhancing communications and improving access to information for care providers, patients, health plan administrators, public health officials, biomedical researchers, and other health professionals” (National Research Council, 2000). In recent years, some applications have become commonplace, such as online searching for health information by patients and providers. Others, such as remote and virtual surgery and simulations of surgical procedures, are in early stages of development.

Although opportunities to improve access, quality, and service abound, the health care industry has been slow to invest in information technology. In 1996, the industry spent only $543 per worker on information technology, compared, for example, with $12,666 spent by securities brokers, and ranked 38th out of 53 industries surveyed (U.S. Department of Commerce, 1999). In a recent survey of 30 health plans, it was found that all had established Web sites to allow patients to obtain certain types of information and interact with the organization (e.g., online provider directory, search formulary, ability to query member services or file a complaint), and about one-half had the capability to conduct some types of transactions online (e.g., enrollment, referral processing, claims submission) (First Consulting Group, 2000). But none had automated entire service functions, such as online medical management, which would require significant changes in business strategy, involve many employees and/or partners, and entail sizable capital investments.

There are many technical, organizational, behavioral, and public policy challenges to greater use of information technology. Technical challenges include ensuring the security of personally identifiable information; making persistent, reliable broadband connectivity available to many locations, including rural clinics and patients' homes; establishing processes for authentication of the source and recipient of information; and making tools available for locating information of interest and for determining the quality of retrieved information (National Research Council, 2000).

Over the long run, however, organizational challenges may play the greatest role in constraining the adoption of various types of Internet applications. The diverse and highly decentralized structure of the health care industry, as discussed above, makes the business models for new applications complex and difficult, resulting in slow adoption of even highly successful pioneering applications. Efforts to introduce new applications also encounter resistance from health care professionals for a variety of reasons, including uncertainties about how such applications will alter relationships among and between clinicians, patients, and health care organizations (National Research Council, 2000).

Numerous public policy, payment, and legal issues also must be resolved. Many applications in the public health arena (e.g., videoconferencing during emergency situations, collection of information from local and state public health departments, incident reporting and disease surveillance) are within technical reach at relatively low cost, but are not widely used because of a lack of targeted public-sector funding and organizational barriers (e.g., shortage of adequately trained personnel). Fee-for-service payment, the most common method of payment for physicians, does not compensate clinicians for time spent on e-mail communication. State-based professional licensing requirements and restrictions on practice have stymied widespread use of other applications, such as remote medical consultations. Online access to and transfer of clinical information has also been slow to evolve, in part because of concerns about privacy and confidentiality. Chapter 7 reviews in greater detail the use of information technology to improve the quality of health care and some of the barriers to its more widespread adoption.