Nearly five years ago, the Institute of Medicine (IOM) released its seminal report, Crossing the Quality Chasm, which noted that “between the health care we now have and the health care we could have lies not just a gap, but a chasm,” and recommended sweeping changes in the delivery system to achieve better results. More recently, the IOM joined with the National Academy of Engineering (NAE) to examine how the health care delivery system—the complex system that it is—could embrace systems engineering to deliver safe, effective, timely, patient-centered, efficient and equitable care.
A committee of 14 engineers and health care professionals met over a two-year period to examine engineering applications and tools that could improve health care delivery over the short and long term. Their work, funded in part by the Robert Wood Johnson Foundation, is outlined in the report Building a Better Delivery System: A New Engineering/Health Care Partnership, available from the National Academies Press. Jerome Grossman, M.D., served as co-chairman of the committee with his colleague, W. Dale Compton, Ph.D., distinguished professor of engineering, Purdue University, West Lafayette, Ind.
Q: American medicine is considered by many to be cutting edge in practice and research. How and why have we fallen behind in the quality and productivity arenas?
A: During the 1990s, we thought managed care was the answer to our health care woes. We believed managed care would both control costs and improve quality. Therefore, we didn't really have any reason to engage in looking at inefficiencies in the delivery system. Health care inflation was running between 0 and 1 percent, and we were lulled into believing that we had solved the problem.
Managed Care resulted in one-time efficiency gains but didn't lay the solid foundation for sustained improvement.
As we entered the new millennium, health costs began to spiral again. The IOM report, Crossing the Quality Chasm, shed light on the real quality problems in the health care system. They included poor safety, inefficiency, and questions with reference to effectiveness. The Chasm report contrasted recent dismal performance of health care delivery with impressive quality and efficiency/productivity gains in other sectors of the economy, much more intense and effective use of information technology, systems engineering, and associated organizational innovations. In 2004 the Brookings Institute illuminated gains in productivity and efficiency in the manufacturing and more importantly in service industries. Those sectors employed systems engineering that made health care look that much more behind in contrast. In the past, there was really very little incentive to look at the business of how we deliver health care. Today, health care understands that it needs to catch up—and effective widespread use of systems engineering and information technology are critical to closing the gap.
Q: We've heard a good deal about how IT could be applied to improve health care delivery, how would systems engineering help and where does it fit in?
A: There is a great deal of complexity to health care delivery. The system includes different kinds of personnel working in a variety of settings using many resources and generating and using multiple flows of information. Health care has historically managed this complexity through a professional silo model and subspecialization. The division of labor—whether one is a physician, nurse or lab technician—is rigid, and personnel are licensed and accredited according to their silo within the system. Subspecialization divided the multiple streams of information among different physician specialties, each one of which was responsible for managing a particular kind of information related to the patient. As a result, health care has ended up with hundreds of silos and many, many scattered efforts at improving quality and efficiency. Those of us in medicine are embarrassed and chagrined, and concede that we can't not apply systems engineering to make things better. When we talk about systems engineering, we mean system design and analysis recognizes that mathematical/analytical tools are used in the design in order to achieve specific objectives such as efficiency, quality, safety, etc. Mathematical/analytical tools are used in the analysis to improve the operation of an existing system and its constituent subsystems or elements. For example, human factors engineering would be very helpful in designing the next generation of physician electronic medical records as well as patient personal health records.
Q: What health care systems are at the forefront of using systems engineering?
A: Three providers come to mind: the Veterans Health Administration, Kaiser Permanente and the Mayo Clinic. The first two are alike in that they have salaried physicians and are combined vertically as both payer and provider. The Mayo Clinic has been a health care pioneer since 1911 when the Mayo brothers recognized the importance of developing one medical record that could follow the patient and had the clinic and its information system designed to accomplish this. Some 85 years later Mayo Clinic took another step forward with digital radiology and the automated medical record—and found that physicians could see more patients per day and provide higher quality care because all the information they needed was at their fingertips. In addition, with this automation, Mayo saved 152 FTEs [full-time equivalents] over a 12-month period.
Q: What fields should health care look to for examples of innovative systems engineering success stories?
A: It is worth examining the changes in the financial services industry. With the advent of the automated teller machine (ATM) and, more recently, online banking, the industry has made accessing services much more convenient for the consumer. At the same time, they have achieved cost savings with the introduction of these forms of “self-care.” The consumer no longer has to stand in front of a teller to do the banking. The airline industry is also a good model. They, too, have taken steps to allow consumers to conduct their business 24/7—book flights, check the status of flights and print boarding passes. And like health care, safety is a big issue for the industry. With human factors and error analysis, the industry has increased the number of miles flown—and miles flown safely every year. The logistics industry, Federal Express in particular, is yet another model. Their ability to track the status of packages in transit—as they are handed off from site to site—as well as final outcomes is impeccable. And, again, consumers can do it themselves. Dropped hand-offs are a big problem in health care. Understanding who is doing what, how they are doing it and how best to pull all the pieces together is the real forté of systems engineering.
Q: At the heart of your recommendations is the need for a national health information infrastructure. What is this and why is it so important?
A: There are many systems engineering tools ripe for widespread application in Health Care Delivery at the patient-care team levels that could have a profound impact on quality and productivity that do not require significant investments in IT to take advantage of them. However an information infrastructure would provide a standard vocabulary and standards of interoperability for data and communication within the health care industry. We do not have that now. So if health care providers in one setting want to send data on a patient to another setting, either they can not do it electronically or the data get there and the second system can not read it. It should also provide a platform for use of more information-intensive systems analysis, design and control tools, as well as a backbone for next generation information systems. The banking industry, for example, was able to create an infrastructure that supports ATMs. You can go to an ATM almost anywhere and access your account because the banks agreed to standards. The federal government needs to be involved in the effort to create a health information infrastructure—because we are looking for national standards—but a working group of private-sector health care providers and health information organizations will soon be is already looking into the development of a prototype to demonstrate that it is possible to do it among 20 or so provider groups that serve 50 million enrollees.
Q: According to the NAE/IOM report, what kind of new partnership is necessary to transform the health care delivery system and what is the ultimate goal of this partnership?
A: Now is an opportune moment to bring together the disciplines of engineering and health care. To address the complexities of health care in the United States—to take health care delivery from thousands and thousands of professionals, practices and providers functioning independently to a true system where all the parts work interdependently—requires the expertise and thought processes of both disciplines. A clear starting point for such a partnership is interdisciplinary research and education. In fact, the NAE/IOM committee has recommended that the federal government, in partnership with the private sector, universities, federal laboratories and state governments, create multidisciplinary research centers at institutions of higher learning that bring together researchers, practitioners, educators and students from fields of engineering, health care, social and behavioral science and other disciplines to tackle health care's quality and productivity issues.
Recommendations from the NAO/IOM Study
The key recommendations that emerged from the NAE/IOM study, Building a Better Delivery System: A New Engineering/Health Care Partnership, regarding the use of systems engineering tools to improve the quality and productivity of the U.S. health care delivery system include the following:
- Private insurers, large employers and public payers, including the Federal Center for Medicare & Medicaid Services and state Medicaid programs should provide more incentives for health care providers to use systems-engineering tools to improve the quality of care and the efficiency of care delivery.
- Public- and private-sector organizations that use or promote systems-engineering tools in health care delivery should coordinate and expand their dissemination efforts and integrate them into existing regulatory and accreditation frameworks.
- A Web site operated by the National Institutes of Health Library of Medicine should promote the use and diffusion of systems-engineering tools in health care delivery by providing patients and clinicians with information about the tools and access to them.
- Health care providers should begin to use the systems-engineering tools that already are available rather than wait for the development of a full complement of tools.
- Federal agencies that support research and health care improvement should increase their support for research to advance the application and utility of systems engineering in health care delivery.
- Under its 10-year plan, the U.S. Department of Health and Human Services should continue to develop a national health information infrastructure, which would include standardized technologies, applications, systems, values, and laws that support individual and public health and health care.
- The public and private sector should support research in a variety of areas, including communications technology system interfaces; voice-recognition systems; software that improves interoperability among systems; secure, multiagent databases; and measurement of the impact of communications systems on health care quality and productivity.
- To build a partnership between engineering and health care—and create an environment in which students and professionals from these fields interact and collaborate—the federal government, in partnership with state governments, universities and federal laboratories, should establish geographically distributed multidisciplinary centers at institutions of higher learning that focus on research, dissemination of new knowledge and education of professionals who are expert in systems engineering for health care delivery.
- Education and training to support systems engineering for health care delivery should include coursework on systems-engineering tools, communications technologies and systems approaches to health care delivery for health care professionals; the integration of health care issues into engineering and MBA curricula; and the development of new fellowship programs in health care, engineering and management supported by the public and private sectors.