Moving to the Next Stage: Quality and Efficiency Improvement Jerome H. Grossman, MD Director Health Care Delivery Policy Program Harvard University JFK School of Government Presentation to Mayo Clinic January 22, 2004

Scanning the Environment - Costs Increasing at steep rate Increased uninsured – increased middle class concern Employers pass increasing cost to employees Employers pass increase onto retirees – not new employees Government passes increase onto retirees and states (Medicaid) Medicare Bill includes medical savings account The beginning of health 401(k) Employers/govt. decreasing responsibility for health insurance

Quality Quality focus dominates media and legislation However progress stays in neutral - Scattered successes balanced by new revelations of error Strategy shifting from projects to “systems thinking” Lack of transparency and safety oversight becoming larger issue - Finance has SEC - Civil Air Transport has FAA - Health has JCAHO – malpractice (mainly self-regulation)

Implications Transition coming - From professional determined public good (civil right) - To market-based service industry Tightly integrated orgs. like Mayo have first mover advantage - Have been working together on quality, information systems and service since inception (most intensely in the past decade) - High level “Brand” remains quality measure “but”... There is a new challenge coming!

Productivity Why is medicine a special case? Up to now, many actors, little data, many outcomes Advances in medical information and economic methods (for service industry) make research possible KEY RESULT: Integrates Costs and Quality

For Example Clinical Condition “Input” Arthritis of Hip - with surgery - without surgery mild moderate severe Clinical Condition “Input” Arthritis of Hip - with surgery - without surgery mild moderate severe Quality “Output” - Technical - Functional - Trust - Service Quality “Output” - Technical - Functional - Trust - Service MedicalSurgicalRehab All Resources ($) Used

Research Projects at Harvard Studying the History of Treatment Innovation Acute medical - AMI Chronic medical -Diabetes -Pediatric asthma -Congestive heart failure Surgical – minimally invasive surgery Preventive – colon cancer screening

An Engineering Agenda to Help Realize the IOM Vision Two Major Interconnected Opportunity Sets for Engineering and Medicine 1.Information and information/communication technologies and associated research to advance connectivity, information flow, coordination. 2.System design, analysis and control tools & associated research to advance understanding of processes and system interactions; and improve/optimize dimensions of system performance in face of constraints.

Information and Information/Communication Technologies Information and information/communication technologies and associated research to advance: Connectivity Information flow Coordination

For Example

Data Monitoring

Wireless Endoscopy

Biomonitoring Techniques

Systems Design and Implementation System design, analysis and control tools and associated research to: Advance understanding of processes and system interactions Improve/optimize dimensions of system performance in face of constraints

Health Care System Quality Protocols Procedures Best Practices Safety Service Timely Credentialing EMR Staffing Facilities Volume Integrated Practice CPOE Educational Environment Teamwork Innovation Patient-Centered Systems Engineering Infrastructure Process Patient Outcomes Mortality Morbidity Functional Status Quality of Life Cost of Care Satisfaction Patient Inputs Severity Comorbidities Age/Sex Socioeconomic Status Compliance Genetics Expectations Attitude Source: Jim Naessens, Thesis Work

Integration of Multiple Subsystems PCP ED Admitting Surgery Lab Triage Patient Ed. Patient Ed. Library Specialist ICU Nursing Post-OP

For Example (Historical Data) Design Personal Habits Evidence Based Medicine What to Do When When to Interfere Due to Delay Caretaker “Alters” Process ←FROM: Computerized Physician Order Entry ----Process Distribution ←TO: Computer Aided Design (CAD) ----Computer Aided Manufacture (CAM) Reset Process Send Message to “Delay Factor” DESIGNAUTOMATED PROCESS MANAGEMENT OrdersWhat First?What Next?

Solving the Simultaneous Equations Consumer Aggregators Insurers/Risk & Disease Management Delivery Aggregators Regulation Safety (FED, FAA) Transparency (SEC) Productivity Better Cheaper Faster Practices Hospitals Drugs Integrated Systems GovernmentConsumersEmployers