Health_Transformation

Abstract The Institute of Medicine (IOM), a non-profit organization consisting of a diverse panel of experts has published an in-depth study titled: Crossing the Quality Chasm: A New Health System for the 21st Century. The study provides guidelines to help transform the future of quality health care with an evidence-based focus directed by 6 specific health care aims for improvement. Health care should be safe, effective, patient-centered, timely, efficient and equitable (Institute of Medicine, 2001). Research has revealed that our present health care system is in need of change, but is fundamentally unable to transform to the degree described by the Institute of Medicine. In order to accomplish real progress in health care, the whole system will have to change. Recognizing that our current health care delivery system is inefficient in many areas, this paper focuses on the structural elements detailed within the IOM study and will explain what the 6 ‘Aims for Improvement’ are and how they relate to healthcare transformation. Additionally, answers for the following questions will be provided. Who are the stakeholders interested in healthcare transformation' What is the role of health information technology (HIT) and how does it affect performance measures' Why is healthcare transformation so difficult' The Basics of Health Care Transformation: The Structural Elements The issue of health care transformation and patient safety is a very important topic in the discussion of health care system improvement. Crossing the Quality Chasm describes our current health care system structure as outdated, and the space between quality and care - a chasm. The guidelines presented within this study, designed to lead our current system to transformation, builds all structural elements for healthcare transformation around 6 ‘Aims for Improvement’. What are the 6 ‘aims of improvement’ and how do they relate to healthcare transformation' Aims of Improvement The 6 ‘Aims of Improvement’ is a vision created by a group of experts in an attempt to build standardized essential guidelines surrounding factors that will ultimately improve patient care, and achieve better outcomes and measurements while lowering costs. The core of health care needs to be: * Safe – avoid injuries to patients * Effective – provide services based knowledge to all who benefit * Patient-centered – ensure patient values guide all clinical decisions * Timely – reduce harmful delays for those who receive and those who give care * Efficient – avoid waste (equipment, supplies, ideas, energy) * Equitable – care to all that does not vary in quality These six aims address areas in which the current health care system functions at levels that can negatively affect and lower the standard of care. Research reveals that a health care system that can excel in these six areas will provide effective and efficient standard of care and will meet a patient’s needs successfully. Care will be safer, more reliable, more responsive to patients, and more organized than today’s current system (Institute of Medicine, 2001, p. 6). As mentioned previously, the 6 ‘Aims of Improvement’ are an ideology foundation that is the basis of healthcare transformation. As this foundation is put into place, it will become interoperable with the 5 ‘Pillars of Healthcare Transformation’ and will help reinforce and support the Triple Aim Initiative. Triple Aim The Institute for Healthcare Information (IHI) is an independent non-profit organization and leader in health care improvement. The ‘Triple Aim’ is a framework designed by IHI that defines an approach to improve health system performance. The framework requires the simultaneous quest of three aims: “improving the experience of care, improving the health of populations, and reducing per capita costs of health care” (Berwick, Nolan, & Whittington, 2012). The IHI idea of transformation is that by providing better care while lowering costs, there will be an increased value for providers, patients, and consumers. Triple Aim is a cyclical transformation and each value is dependent on the other for a successful transformation. Although the ‘Triple Aim’ framework is slightly different than the 6 ‘Aims of Improvement’, both are structured models that are similar in regards to what must happen in order to have effective health care change. The Triple Aim guidelines and design concepts include: A focus on individuals and families, the redesign of primary care services and structures, population health management, a cost-control platform, and system integration and execution (Berwick, Nolan, & Whittington, 2012). How do the 6 Aims of Improvement relate to the Triple Aim Initiative' Both frameworks address population health, individual involvement, and lowering costs. Table 1 Triple Aim and 6 Aims of Improvement Relation Triple Aim | 6 Aims of Improvement | Individuals/Family Focus | Patient-centered/Equitable | Redesign of Primary Care Services/Structures | Effective/ Timely/Efficient | Population Health Management | Safe/Effective/Patient-centered/Timely/Efficient/Equitable | Cost-control Platform | Efficient | System Integration/Execution | Safe/Effective/Timely/Efficient | Accomplishing aims for either of these frameworks will require complex modifications. According to studies, these modifications will require structural environmental changes that will affect existing processes for health care professionals and organizations, patients, and their families. Five Pillars of Healthcare Transformation The five pillars of healthcare transformation are environmental elements that will require potential process and structural changes to have the capability to accommodate the 6 ‘Aims of Improvement’ effectively. These pillars include: * Health Information Technology (data exchange, electronic medical and health records etc.) * Quality Improvement * Performance Measurement * Consumer Engagement (cost, quality, outcomes) * Payment Innovation The current health care system is not providing consistent high quality of care. This recognition is the motivation for a wide range of initiatives to improve quality through increased use of measurement, public and private reporting of results, and incentives for better performance. Of all potential transformations, none is more pronounced than the shift toward value and care quality. To support the recommended changes in health care, the environment of care must also change. The ‘five pillars of healthcare transformation’ are health care environmental components that must evolve toward quality as relationships between structure, process, and outcomes are developed and implemented, and as the 6 ‘Aims of Improvement’ are integrated into health care transformation. Reform for each element of the pillars of healthcare transformation can only occur by understanding the root causes for the failure of the current process models, and designing processes that will lessen current process negative effects while encouraging processes and behaviors that will allow health care transformation. As stated previously, the current health care environment often impedes the changes needed to achieve quality health care transformation. Major modifications need to occur in the following areas to promote a base-line structure of data and information that will support the 5 ‘Pillars of Healthcare Transformation’. * Infrastructure that supports the distribution and application of new clinical knowledge and technologies * Information technology infrastructure Unfortunately, within a health care setting the definition of quality can be complex and debatable because of the different views of stakeholders. Furthermore, these same stakeholders have a large amount of influence on health care transformation and how health care change can evolve. Due to the nature of the stakeholder network and the design of the delivery system, there are potential difficulties surrounding the successful transformation of the current health care system. Stakeholders What is a stakeholder' “Any individual, group or business with a vested interest (a stake) in the success of an organization…A stakeholder is typically concerned with an organization delivering intended results and meeting its financial objectives” (Investor Glossary, 2013). With this definition in mind, the stakeholders interested in healthcare transformation include: people (patients and consumers), providers (physicians, hospitals, etc.), plans (commercial health plans, Medicare/Medicaid (CMS), VA, state, county, federal governments), and payers (employers, employees, state, county, and federal government government). The definition of health care quality is complex. Because of this complex ideology, health care stakeholders have different views of what quality health care transformation should be. What does each stakeholder want, and how does that affect health care transformation' People and consumers want consideration as well as expertise with clear communication, and the ability to control and keep their costs down. Providers want the capability to access efficient and accurate diagnosis information and results that may help create an outcome with integrity. Plans and payers want cost-effectiveness. The general consensus is that all stakeholders want positive transformation. The most well-known and debatable issue is the conflict between providers and payers. Providers want to deliver the best service using the most current accurate tests and treatments. These treatments may be more expensive than alternatives. They also want to provide preventative care which the insurance company (payer) may not cover. Payers want providers to follow a clear, evidence-based plan, and reach an accurate diagnosis with as few visits and tests as possible. Additionally, guidelines incorporated via the federal, state, and private sectors can negatively impact provider and payer efforts to work together in a positive manner. To positively influence health care transformation, the health care stakeholders must support the vision of the 6 ‘Aims of Improvement’ by using identifiable defined incentives to create high quality, cost-effective health care while utilizing health information technology (HIT). Health Information Technology Health information technology (HIT) plays a critical part in supporting new models of health care that are designed to attain health care’s triple aim: improve health, improve care for patients and families, and reduce the cost of care. It is a well-known fact that although information technology has taken over every other aspect of life, our current healthcare system lags behind in this technology. Health information technology (HIT) is an area of IT that involves the design, development, and use of information systems for the healthcare industry. Healthcare information systems are expected to lower costs, improve efficiency and reduce patient data error, and effectively aid in providing better patient care. There are a number of studies and initiatives underway that prove it is possible to use existing data that is currently being collected as part of patient care delivery, to provide insight into many aspects of patient care and service. Health information technology, when implemented properly contributes to an improved health care delivery system by providing access to medical knowledge-bases and computer-aided decision support systems, aids in the collection and sharing of clinical information, reduces potential errors, and can enhance patient and clinician communication (Institute of Medicine, 2001). Integrating information technology into healthcare allows the healthcare system to explore opportunities for improving the quality of care through the use of clinical performance measures and tools. Health information technology (HIT) consisting of data collection is the key component to providing evidence-based applications and tools, performance measurement, and public transparency. Furthermore, new recommended guidelines are initiating the exchange of standards-based data and definitions across groups in which care and services are delivered (all stakeholders), using current information technology trends designed to implement health care transformation. HIT is a critical piece for health care transformation and performance measurement. Improving the quality of care through clinical performance measurement and data aggregation requires the use of clinical performance measures. Current HIT trends that integrate electronic health records (EHRs) provide more accurate measurement and documentation of diagnoses and care processes and make it easier to capture certain types of information. Performance Measures Performance measures within a healthcare environment quantify the quality of activities and services. These measurements often depict a structure, process, or outcome considered significant to the assessment of the performance and which can be documented. In order for performance measures to have integrity, consensus-based standards must be the starting point for measurement. This is a critical element for measures to have an effective impact in improving health care quality and allow transformation. According to Donabedian’s Framework, there are 3 types of basic measures for evaluation quality: structure, process, and outcome. A complete quality assessment requires the simultaneous use of all three concepts, and an analysis of the relationships between the three. Structures of care are the elements of organization and administration that guide the processes of care (e.g., physical equipment and protocols, leadership, organizational hierarchy, decision-making processes, and administrative decision-making processes). Structures have a direct impact on the process of care and outcomes. Processes are harder to define and require observation, interviews, and research methodologies (e.g., utilization of structural elements, what the organization does, processes surrounding visits and continuity of care). Components of process are standards of care (norm by which quality of care is judged) and practice styles. These are dimensions that directly influence quality. The outcome is not as simple as it may seem. The outcome is a measurable change directly linked to an identified process (e.g., functional status, patient well-being, patient satisfaction, results of work done, measurable change). Structure and processes are much easier to measure and manage due to identifiable variability. Outcome measures are more important due to the results. Research reveals that the first condition of any performance measurement system is to create a reliable framework which performance measures can be developed and reviewed. (Institute of Medicine, 2001). Collection of quality data requires a stable IT foundation. Health information technology provides the needed infrastructure to create a reliable performance measure framework. The method in which data is collected for performance measures has important effects on the integrity of data, timeliness of information, and liability for providers. Incorporating Electronic Medical and Health Records (EMR/EHR) and implementing Health Information Exchange (HIE) are current attempts to collect patient data for interoperability and transition. Integrating HIT into the healthcare environment improves the possibility of quality measurement by presenting a structure for the development of standards to guide defined data collection. The creation of an information infrastructure to support data collection will provide baselines for quality measurement and evidenced-based tools for decision-making, which can be used by patients and members of the healthcare system. Ultimately, this improves patient health, reduces the cost of care, and improves patient outcomes. Studies reveal that our current healthcare system is still in the early stages of health care transformation and that major steps need to be taken to improve the effectiveness of transformation for quality care. Additional advances in HIT are likely to increase this potential. Difficulty of Health Care Transformation In order for health care transformation to be successful, key essentials must be in place. There must be an extensive provider adoption of HIT and standard-based EMR systems, improved connectivity between providers and patients, and a strong unified focus on improving quality and efficient performance (Institute of Medicine, 2001). In lieu of these essentials, the three elements that are contributing to the difficulty of implementing health care transformation and realizing the 6 ‘Aims of Improvement’ are the complexity of the current healthcare system, system economics, and the disorganization of the system (Berwick, Nolan, & Whittington, 2012). By large, our current health care delivery system is decentralized and consists of levels of silo information. Additionally, the traditional model of health care delivery is complicated and consists of complex layers of processes. The challenge is to move from the current decentralized infrastructure model to a unified standardized model that can be utilized by all, while understanding and addressing the normal growth within the healthcare and IT industry simultaneously. Conclusion The structural elements of health care transformation provide a framework that will substantially improve the quality, cost, and accessibility of care that is currently experienced today. For this to happen there must be a commitment from all stakeholders to work toward integrating the 6 ‘Aims of Improvement’ into established frameworks that surround structure, processes, and outcomes. Based on recommendations stated within Crossing the Quality Chasm, the committee proposes 5 Steps for transforming the current health care system. (1) All health care constituencies, including policymakers, purchasers, regulators, health professionals, health care trustees and management, and consumers, commit to a national statement of purpose for the healthcare system as a whole and to a shared agenda of six aims for improvement that can raise the quality of care to unprecedented levels; (2) Clinicians and patients, and the health care organizations that support care delivery, adopt a new set of principles to guide the redesign of care processes; (3) The Department of Health and Human Services identify a set of priority conditions upon which to focus initial efforts, provide resources to stimulate innovation, and initiate the change process; (4) Health care organizations design and implement more effective organizational support processes to make change in the delivery of care possible; (5) Purchasers, regulators, health professions, educational institutions, and the Department of Health and Human Services create an environment that fosters and rewards improvement by creating an infrastructure to support evidence-based practice, facilitating the use of information technology, aligning payment incentives, and preparing the workforce to better serve patients in a world of expanding knowledge and rapid change. (Institute of Medicine, 2001, p. 34) References Berwick, D., Nolan, T., & Whittington, J. (2012, April 17). Institute for Healthcare Improvement. Retrieved from The Triple Aim: http://www.ihi.org/knowledge/Pages/Publications/TripleAimCareHealthandCost.aspx Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington: National Academy Press. Investor Glossary. (2013). Investor Glossary. Retrieved from Investor Glossary: http://www.investorglossary.com/stakeholder.htm