The other shoe--a size 17EEE steel-toed workboot--finally dropped on the quality of care in the healthcare industry.
Last week in Washington, the Institute of Medicine released its long-awaited blueprint for transforming America's failing healthcare industry. Although the goal is laudable, many healthcare practitioners are questioning where the resources will come from.
The 335-page Crossing the Quality Chasm: A New Health System for the 21st Century is the second and final report of the IOM's Committee on Quality of Health Care in America. It follows To Err is Human, a widely referenced report on medical errors published in late 1999.
The new report is sharply critical of the nation's healthcare delivery system, which it says is "plagued by a serious quality gap." The report calls for eliminating handwritten clinical information by 2010 and refocusing the healthcare system on treating chronic illness.
"We need to reinvent the system, and the committee is proposing nothing less than that," said Committee Chairman William Richardson, president and chief executive officer of the W.K. Kellogg Foundation in Battle Creek, Mich.
Underscoring the politely affirming response of industry groups-including the American Hospital Association and the American Medical Association-were some skepticism and concern about implementing the IOM's 10-year vision for American healthcare delivery.
A written statement from AHA President Richard Davidson agreed with the IOM's findings but added, "Some caution is needed to ensure that we avoid duplication of effort, set realistic timelines and clearly recognize the resources needed to successfully implement those ideas."
AMA President Randolph Smoak Jr., M.D., said his group welcomes the IOM's call for improving the healthcare system, and physicians have long worked to bring about some of the changes identified in the report. But, Smoak added, "there comes a point where, as hard as they try, there is a barrier beyond which they can't overcome alone."
Money will be a significant issue in transforming the system, hospital and physician leaders agreed.
The IOM recommends that Congress create a $1 billion "innovation fund." Carrying a much higher price tag is the call to upgrade the information technology of healthcare delivery systems around the country.
"It seems difficult to believe these issues are not going to be inflationary in healthcare; it is just going to cost more to do all this," said committee member Gail Warden, president and CEO of Henry Ford Health System in Detroit and 1995 chairman of the AHA Board of Trustees.
"Funding is clearly going to be critical to bring about the type of change the IOM is talking about," said Carmela Coyle, AHA senior vice president of policy.
Despite the best work of diligent and competent professionals in the industry, according to the report, flaws in the system are to blame for shortcomings in disseminating medical research, using information technology, paying for innovative healthcare and adequately preparing the healthcare workforce.
Although To Err is Human shocked the industry and the general public with an estimate that as many as 98,000 Americans are killed by hospital medical errors annually, the new report lacks headline-grabbing statistics. Its simple message is that healthcare quality is inexcusably poor-as documented in 70 professional journals in the past decade-and this is how the nation's leading experts propose to fix it.
The first report caught the healthcare industry off-guard, prompting several quality-improvement projects to be announced in the weeks after its release. This time, the industry knew the report was coming and softened the public relations blow with a number of quality-improvement announcements in the two weeks before its release (See box, p. 5).
Crossing the Quality Chasm doesn't prescribe a single best approach for recrafting the health system, such as integrated delivery systems or capitated networks. Instead, it asks healthcare providers, payers and consumers to commit to six "aims": Make healthcare safe, effective, patient-centered, timely, efficient and equitable.
"If you want to consider To Err is Human as the wake-up call, this report is the call to action," said Steven Shortell, a member of a subcommittee that worked on the report and a professor of health policy and management at the University of California-Berkeley.
The document delegated about half of its 13 recommendations to HHS and its agencies HCFA and the Agency for Health Research and Quality. Yet much of the burden of implementing the changes during the next decade will fall on those who provide, pay for and consume healthcare.
Richardson said he hopes the report will "mobilize local communities," prompting a dialogue in which health system trustees, administrators, physicians and patients examine the extent to which their local healthcare delivery is meeting the ideals set forth in the report.
But again, a lack of funding may stymie local efforts.
"What we need is a Hill-Burton program for healthcare information technology and the other things we need to provide 21st century healthcare," Kenneth Kizer, M.D., president and CEO of the Washington-based National Quality Forum, said, referring to the federal government's program that funded the construction of hospitals from 1946 to 1975.
Neither Congress nor President Bush's proposed budget for 2002 have offered the $1 billion innovation fund or a larger pot of money for rebuilding the system.
"Any contribution the federal government makes to this effort should complement the work that is already under way," said Sen. James Jeffords (R-Vt.), chairman of the Senate Health and Education Committee.
Jeffords said his committee anticipates introducing patient-safety legislation this spring. "I believe an important contribution Congress can make is to look at the issue of translating research into practice," he added.
It takes an average of 17 years for new medical knowledge to be incorporated into practice, and even then application is uneven.
Richardson described today's reimbursement system as "toxic...in terms of improving quality of care." The report cites examples of physicians being economically penalized for providing innovative healthcare for which the system is not set up to pay.
"We can't expect to see major progress in quality of care if they lose money every time they provide care," said committee member Molly Joel Coye, M.D, president of the Health Technology Center in San Francisco.
Warden called on payers to avoid healthcare organizations where quality "is not what it should be." He pointed to the efforts of Leapfrog Group, an organization of Fortune 500 companies that in November 2000 announced plans to incorporate specific quality principles into the purchase of healthcare for employees.
Critical to improving information technology is the development of a common platform for IT. "Most of the pieces don't talk to each other," Coye said. The report stops short of calling for fully electronic medical records but said sizable benefits can be obtained by more automation of data, such as medication orders.
Among the recommendations are that HHS make scientific evidence more accessible and useful to providers and patients; that HCFA and the AHRQ research ways to better align payment methods with quality improvement goals; and that the AHRQ study how regulatory and legal systems should be changed to create an improved healthcare delivery system.
The report also calls for the HHS secretary to report annually to Congress and the president on the quality of healthcare in America. Later this month, another IOM committee is set to provide the AHRQ with a framework for establishing what will become an annual report on the quality of healthcare in the U.S. The first report is due in 2003.
The IOM's full report is available at http: //www.nas.edu on the Web.