A fledgling Institute of Medicine report is looking for strong shoulders to land on. Authors of Crossing the Quality Chasm: A New Health System for the 21st Century and industry experts differ on who should and will supply the leadership and money to transform the American healthcare system as outlined in the report, but they all agree healthcare is in turmoil.
The report, issued March 1 and the second from the IOM in two years, was specific in its call for the federal government to step forward but vague in awarding responsibility to others. Those receiving barely a mention were traditional healthcare watchdogs-the Joint Commission on the Accreditation of Healthcare Organizations and the National Committee on Quality Assurance.
The report asks Congress for a $1 billion "innovation fund" for pilot projects to advance a vision of a new healthcare system. But industry experts agree that even more money will be needed to achieve the report's mandate of revamping health information technology across the country.
Also crucial is for individuals and organizations to step forward to guide the integration of what is a rigidly segmented industry.
"I would say that leadership is the key matter," said report co-author Donald Berwick, M.D., president and chief executive officer of the Institute for Healthcare Improvement in Boston.
A week after the IOM report's release, the role of Congress, specifically whether it will cough up the $1 billion to get things rolling, is unclear.
"There is discussion about what could be done, but no conclusion about which way to do it," said Joseph Karpinski, Senate Health and Education Committee communications director.
Some maintain that the designation of federal money for the innovation fund and for new health information systems-a possible rebirth of the federal Hill-Burton program, which funded hospital construction from 1946 to 1975-is imminent.
JCAHO President Dennis O'Leary, M.D., said funding for these issues was "getting up on the radar screen" of the Bush administration. O'Leary called congressional leadership on priorities of the IOM report a "linchpin issue" for achieving those goals.
Report co-author Molly Joel Coye, M.D., president of the San Francisco-based Health Technology Center, said it is "not unreasonable to hope for commitment (for the innovation fund) in this budget cycle of Congress."
There is "genuine interest on the Hill in providing dollars to providers for information technology," said Thomas Nickels, the American Hospital Association's senior vice president of federal relations. Nickels stipulated that interest is there if IOM's priorities are banded with hospital IT needs to comply with patient-privacy regulations in the Health Insurance Portability and Accountability Act of 1996. Those regulations are on hold.
Other sources doubt whether money for the report's priorities is likely to come from Congress or even whether the money is critical to moving forward. "I'm not sure the government is ready to pony up the money," said Margaret O'Kane, president of the NCQA. "It just feels like we are always waiting for someone to come and bail us out rather than taking the reins as an industry."
"If we are going to see anything emerge here, it is going to be at the community level," Berwick said.
The report's call to action is far-reaching, and it details specific tasks. For example, it calls on HHS' Agency for Healthcare Research and Quality to identify at least 15 chronic health conditions; to convene workshops to address coordination-of-care and IT challenges; and to conduct research on aligning payment methods with quality-improvement goals.
The private, not-for-profit National Quality Forum is charged with working with HHS to improve accessibility of scientific evidence for providers and patients.
But few beyond Congress and select federal agencies are tapped to carry the ball.
The report, which cites 70 publications documenting that "millions of Americans fail to receive effective care," does not give specific roles to the JCAHO and the NCQA. The 50-year-old JCAHO's mission includes "to continuously improve the safety and quality of care to the public" through its accreditation program. The 10-year-old NCQA has a mission "to evaluate and report on the quality of the nation's managed-care organizations."
Report authors said the omission was intentional. "The committee decided not to go into detail about the specifics of what should be measured and by whom," said Janet Corrigan, M.D., who directed the IOM study.
O'Leary said he was fine with the JCAHO's not factoring more prominently into the report. "Once you start talking about roles for individual players, it is a little bit hard to stop."
JCAHO and NCQA spokesmen said the organizations support the report and are eager to play critical roles in making the vision a reality during the next 10 years.
O'Kane expressed concern that the second report did not seem to be engaging the public to the extent that the IOM's alarming 1999 report did. That report estimated that 98,000 people die annually from hospital medical errors. "I am not sure that it is creating leverage the way the patient- safety report did," O'Kane said.
Berwick said Chasm has generated fewer responses than To Err is Human, but he maintained that the latest report eventually would lead to a more meaningful dialogue about what should change in healthcare. "I guess if the patient-safety report was jazz, this is classical."