Best Care at Lower Cost The Path to Continuously Learning Health Care in America THE NATIONAL ACADEMIES PRESS Copyright © National Academy of Sciences. All rights reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America Best Care at Lower Cost The Path to Continuously Learning Health Care in America Committee on the Learning Health Care System in America Mark Smith, Robert Saunders, Leigh Stuckhardt, J. Michael McGinnis, Editors Copyright © National Academy of Sciences. All rights reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. Support for this report was provided by the Blue Shield of California Foundation; the Charina Endowment Fund; and the Robert Wood Johnson Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313 http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2012 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2012. Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press. 978-0-309-26073-2 International Standard Book Number Copyright © National Academy of Sciences. All rights reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America Copyright © National Academy of Sciences. All rights reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org Copyright © National Academy of Sciences. All rights reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America v COMMITTEE ON THE LEARNING HEALTH CARE SYSTEM IN AMERICA MARK D. SMITH (Chair), President and Chief Executive Officer, California HealthCare Foundation, Oakland JAMES P. BAGIAN, Professor of Engineering Practice, University of Michigan, Ann Arbor ANTHONY BRYK, President, Carnegie Foundation for the Advancement of Teaching, Stanford, CA GAIL H. CASSELL, Former Vice President, Scientific Affairs, Eli Lilly and Company, Carmel, IN JAMES B. CONWAY, Senior Fellow, Institute for Healthcare Improvement, Boston, MA HELEN B. DARLING, President, National Business Group on Health, Washington, DC T. BRUCE FERGUSON, Professor and Inaugural Chairman, Department of Cardiovascular Sciences, East Carolina University, Greenville, NC GINGER L. GRAHAM, Former President and Chief Executive Officer, Amylin Pharmaceuticals, and Former Group Chairman, Guidant Corporation, Boulder, CO GEORGE C. HALVORSON, Chairman and Chief Executive Officer, Kaiser Permanente, Oakland, CA BRENT JAMES, Chief Quality Officer, Intermountain Health Care, Inc., Salt Lake City, UT CRAIG JONES, Director, Vermont Blueprint for Health, Burlington GARY KAPLAN, Chairman and Chief Executive Officer, Virginia Mason Health System, Seattle, WA ARTHUR A. LEVIN, Director, Center for Medical Consumers, New York, NY EUGENE LITVAK, President and Chief Executive Officer, Institute for Healthcare Optimization, Newton, MA DAVID O. MELTZER, Director, Center for Health and the Social Sciences, University of Chicago, IL MARY D. NAYLOR, Director, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia RITA F. REDBERG, Professor of Medicine, University of California, San Francisco PAUL C. TANG, Vice President and Chief Innovation and Technology Officer, Palo Alto Medical Foundation, and Consulting Associate Professor of Medicine, Stanford University, Palo Alto, CA IOM Staff ROBERT SAUNDERS, Study Director LEIGH STUCKHARDT, Program Associate JULIA SANDERS, Senior Program Assistant BRIAN POWERS, Senior Program Assistant (through July 2012) VALERIE ROHRBACH, Senior Program Assistant CLAUDIA GROSSMAN, Senior Program Officer ISABELLE VON KOHORN, Program Officer BARRET ZIMMERMANN, Program Assistant J. MICHAEL MCGINNIS, Senior Scholar Copyright © National Academy of Sciences. All rights reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America vi BEST CARE AT LOWER COST Consultants RONA BRIERE, Briere Associates, Inc. ALISA DECATUR, Briere Associates, Inc. Copyright © National Academy of Sciences. All rights reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America vii REVIEWERS This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: WYLIE BURKE, Professor and Chair, Department of Bioethics and Humanities, University of Washington, Seattle MICHAEL CHERNEW, Professor of Health Care Policy, Harvard Medical School, Boston, MA JANET CORRIGAN, Former President and Chief Executive Officer, The National Quality Forum, Washington, DC JOHN HALAMKA, Chief Information Officer, CareGroup Health System, Boston, MA GEORGE ISHAM, Medical Director and Chief Health Officer, HealthPartners, Inc., Bloomington, MN STEPHEN KIMMEL, Professor of Medicine, University of Pennsylvania School of Medicine, Philadelphia ALLEN S. LICHTER, Chief Executive Officer, American Society of Clinical Oncology, Alexandria, VA ANGELA BARRON MCBRIDE, Distinguished Professor and University Dean Emerita, Indiana University School of Nursing, Lafayette MARK MCCLELLAN, Director, Engelberg Center for Health Care Reform, The Brookings Institution, Washington, DC LYN PAGET, Director of Policy and Outreach, Informed Medical Decisions Foundation, Boston, MA LEWIS SANDY, Senior Vice President, Clinical Advancement, UnitedHealth Group, Minnetonka, MN EDWARD H. SHORTLIFFE, Scholar in Residence, New York Academy of Medicine, New York STEVEN SPEAR, Senior Lecturer, Engineering Systems Division, Massachusetts Institute of Technology, Cambridge JOHN TOUSSAINT, Chief Executive Officer, ThedaCare Center for Healthcare Value, Appleton, WI YULUN WANG, Chairman and CEO, InTouch Health, Goleta, CA DIANA ZUCKERMAN, President, National Research Center for Women & Families, Washington, DC Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the report’s conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by coordinator ROBERT S. GALVIN, Chief Executive Officer, Equity Healthcare, The Blackstone Group, New York, NY and monitor EMMETT B. KEELER, Professor of Health Copyright © National Academy of Sciences. All rights reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America viii BEST CARE AT LOWER COST Services, Pardee RAND Graduate School, UCLA School of Public Health, Santa Monica, CA. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. Copyright © National Academy of Sciences. All rights reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America ix Foreword Best Care at Lower Cost: The Path to Continuously Learning Health Care in America presents a vision of what is possible if the nation applies the resources and tools at hand by marshaling science, information technology, incentives, and care culture to transform the effectiveness and efficiency of care—to produce high-quality health care that continuously learns to be better. More than a decade since the Institute of Medicine’s (IOM) To Err Is Human: Building a Safer Health System was published, the U.S. health care system continues to fall far short of its potential. While To Err Is Human and other IOM reports, including the Crossing the Quality Chasm series, have helped spark numerous efforts to improve practices, persistent health care underperformance and high costs highlight the considerable challenge of bringing isolated successes to scale. The nation has yet to see the broad improvements in safety, accessibility, quality, or efficiency that the American people need and deserve. Leaders from every sector that bears on health have a part to play in realizing such broad improvements. Recognizing the need for cross-sector collaboration, in 2006 the IOM organized the Roundtable on Value & Science-Driven Health Care. The Roundtable convenes leaders from across the health care system—including representatives of patients and consumers, providers, manufacturers, payers, research, and policy—to help make continuous improvement in performance an intrinsic part of U.S. health care. Under the guidance of its membership, the Roundtable has developed and articulated a vision of this new system—a learning health care system that links personal and population data to researchers and practitioners, dramatically enhancing the knowledge base on effectiveness of interventions and providing real-time guidance for superior care in treating and preventing illness. A health care system that gains from continuous learning is a system that can provide Americans with superior care at lower cost. The IOM Committee on the Learning Health Care System in America was convened to explore and advance this vision of continuously learning health care. The committee’s report describes the key challenges faced by the health care system today—the mounting complexity of modern medicine, the rising cost of care, and the limited return on investment—and outlines how to harness new technologies, innovations, and approaches to overcome these challenges. [...].. .Best Care at Lower Cost: The Path to Continuously Learning Health Care in America x BEST CARE AT LOWER COST Importantly, the report demonstrates how a health care system that delivers the best care at lower cost is not only necessary, but also possible The committee has articulated detailed strategies for incorporating continuous learning and improvement into all facets of health care The... Americans with best care at lower cost Mark D Smith, Chair Committee on the Learning Health Care System in America Copyright © National Academy of Sciences All rights reserved Best Care at Lower Cost: The Path to Continuously Learning Health Care in America Copyright © National Academy of Sciences All rights reserved Best Care at Lower Cost: The Path to Continuously Learning Health Care in America... a learning health care system xv Copyright © National Academy of Sciences All rights reserved Best Care at Lower Cost: The Path to Continuously Learning Health Care in America Copyright © National Academy of Sciences All rights reserved Best Care at Lower Cost: The Path to Continuously Learning Health Care in America Contents ABSTRACT Ab-1 SUMMARY The Imperatives The Vision The Path Actions for Continuous... report no fatalities from 2007 to 2010 (Bureau of Transportation Statistics, 2011) New capabilities in PREPUBLICATION COPY: UNCORRECTED PROOFS Copyright © National Academy of Sciences All rights reserved Best Care at Lower Cost: The Path to Continuously Learning Health Care in America S-10 BEST CARE AT LOWER COST systems engineering, operations management, and production can be adapted to health care settings... the health care system’s growing challenges and to ensure that the system reaches its full potential The nation’s health and economic futures best care at lower cost depend on the ability to steward the evolution of a continuously learning health care system PREPUBLICATION COPY: UNCORRECTED PROOFS Copyright © National Academy of Sciences All rights reserved Best Care at Lower Cost: The Path to Continuously... travel were like health care, each pilot would be free to design his or her own preflight safety check, or not to perform one at all PREPUBLICATION COPY: UNCORRECTED PROOFS S-1 Copyright © National Academy of Sciences All rights reserved Best Care at Lower Cost: The Path to Continuously Learning Health Care in America S-2 BEST CARE AT LOWER COST The point is not that health care can or should function... their health care, Medicare patients now see an average of seven physicians, including five PREPUBLICATION COPY: UNCORRECTED PROOFS Copyright © National Academy of Sciences All rights reserved Best Care at Lower Cost: The Path to Continuously Learning Health Care in America S-6 BEST CARE AT LOWER COST specialists, split among four different practices (Pham et al., 2007) One study found that in a single... References 2-1 2-2 2-15 2-18 3 Imperative: Achieving Greater Value in Health Care Unacceptable Outcomes Unsustainable Costs Consequences of Inaction References 3-1 3-2 3-8 3-12 3-13 xvii Copyright © National Academy of Sciences All rights reserved Best Care at Lower Cost: The Path to Continuously Learning Health Care in America xviii 4 BEST CARE AT LOWER COST Imperative: Capturing Opportunities from... sources—payers, clinicians, patients $75 billion SOURCE: Adapted with permission from IOM, 2010 PREPUBLICATION COPY: UNCORRECTED PROOFS Copyright © National Academy of Sciences All rights reserved Best Care at Lower Cost: The Path to Continuously Learning Health Care in America S-8 BEST CARE AT LOWER COST Although these estimates have unknown overlap, the sum of the individual estimates— $765 billion—suggests... PROOFS Copyright © National Academy of Sciences All rights reserved Best Care at Lower Cost: The Path to Continuously Learning Health Care in America S-4 BEST CARE AT LOWER COST During much of the twentieth century, heart attacks commonly were treated with weeks of bed rest Today, advanced diagnostics allow for customized treatments for patients; interventions such as percutaneous coronary interventions . Copyright © National Academy of Sciences. All rights reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America ix Foreword Best Care at Lower Cost: The Path to. patients and society. Copyright © National Academy of Sciences. All rights reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America xii BEST CARE AT LOWER COST. reserved. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America xv Acknowledgments Best Care at Lower Cost: The Path to Continuously Learning Health Care for