1. Eastman, Peggy

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WASHINGTON, DC-Against the background of an escalating U.S. Presidential campaign, the Institute of Medicine (IOM) released a new report at the National Press Club here calling for specific steps to improve health care and reduce costs. The report, "Best Care at Lower Cost: The Path to Continuously Learning Health Care in America," is the latest in a group of comprehensive IOM reports released over the last 10 years, each focused on problems within the US health care system and how to fix them.


"We're in the midst of the high political season," and both party platforms support the best care at reasonable cost, said IOM President Harvey Fineberg, MD, PhD, in introducing the report. To the IOM committee members present who wrote the report, he said, "You are showing the way that America can achieve a health care system that improves on a continuous basis."


A continuously learning health care system, as described by the committee, is one in which the latest knowledge available is applied to improve the patient care experience, and the patient care experience, in turn, adds to the available body of knowledge. The new report contains examples of continuous learning applications; actions for continuous learning, best care, and lower costs; and a CEO checklist for high-value health care.


Rising Costs, Increasing Complexity

IOM Committee Chair Mark D. Smith, MD, MBA, President and CEO of the California HealthCare Foundation and an attending physician at the Positive Health Program for AIDS Care at San Francisco General Hospital, said the two issues the committee identified as needing the most urgent attention now are rising costs and increasing complexity. As to cost, he said, clinicians must move from being "cost-agnostic" to "cost-aware." Health care costs have increased at a greater rate than the economy as a whole for 31 of the past 40 years, he noted.


As to complexity, with today's knowledge explosion, "health care must be a team sport," Smith emphasized. And because of this knowledge explosion, "our sense is that the system must learn continuously."


The IOM committee found that U.S. health care is often inefficient, wasteful, and plagued with both under-treatment and over-treatment. Specifically, the committee found that some 30 percent of health care spending in 2009-about $750 billion-was wasted on unnecessary services, excessive administrative costs, outright fraud, and other problems.


Committee member Gail H. Cassell, PhD, Visiting Professor in the Department of Global Health and Social Medicine at Harvard Medical School, said that science and research are the key to improving this disheartening statistic, and "are essential to a learning health care system."

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Cassell, a former vice president for scientific affairs at Eli Lilly, added, "We cannot slip backwards," and emphasized that the country must continue to invest generously in science and research.


Praise from ASCO

The American Society of Clinical Oncology praised the report for its vision: "ASCO wholeheartedly supports the IOM's recommendations," ASCO President Sandra M. Swain, MD, Medical Director of the Washington Cancer Institute at Washington Hospital Center in Washington, DC, said in a statement. "We not only share the vision of this new report, but are already working to achieve it in the cancer care arena with CancerLinQ."


CancerLinQ (OT, 8/25/12 issue) is ASCO's new multi-phased rapid learning initiative, which aims to assemble and analyze millions of unconnected medical records from cancer patients in a central knowledge base. CancerLinQ will, in ASCO's words, "harness technological advances to connect oncology practices; measure quality and performance; obtain new insights from the vast pool of 'real-world' data on cancer care; and provide physicians with decision support in real time."


The Society plans to develop a plan for integrating CancerLinQ with its Quality Oncology Practice Initiative (QOPI), and share the CancerLinQ prototype at the inaugural Quality Care Symposium, which will be held November 30 to December 1 in San Diego.


New Technologies

Another member of the report committee, Archives of Internal Medicine Editor Rita Redberg, MD, MSc, Professor of Medicine at the University of California, San Francisco, noted that the United States spends more than 17 percent of its gross domestic product on health care-more than anywhere else in the westernized world. Much of this cost growth is due to new technologies, she said, and there are so many choices available today that it is essential to determine whether a new technology truly confers benefit and causes no harm.


Asked by OT how the U.S. health care system should address new therapies that are extremely expensive and provide at most four to five more months of life (as with new treatments for advanced prostate cancer), she said that incremental steps are needed to determine a therapy's true worth: "Today it may be five months, but in five years it may be increased years," she said. "We have to take small steps. [horizontal ellipsis] it may not be cheap.


"A lot of the challenge is addressing the right groups" to receive the expensive therapies in question. "I think we can get to personalized medicine, but it's going to take a lot of work."


And IOM committee member Craig A. Jones, MD, Director of the Vermont Blueprint for Health in Burlington, added that "this goes to what patients and families really want most." He asked, "What is that four or five months really going to look like?" If patients and their families actually knew what side effects and adverse events might be experienced during that expensive treatment to extend life, they might decline the therapy, he noted.

IOM Committee Chair ... - Click to enlarge in new windowIOM Committee Chair MARK D. SMITH, MD, MBA, said that clinicians must move from being "cost-agnostic" to "cost-aware," and that with today's knowledge explosion, "health care must be a team sport and that the system must learn continuously."

Smith agreed: "At the [California HealthCare] Foundation, we do a fair amount of end-of-life care," he said in remarks after the briefing. Especially when disease is advanced, "it's very clear that patients would choose for themselves a much less aggressive course of therapy than doctors would choose for them.


"I'm actually optimistic in the long run" about the ability of the United States to deliver high-quality care in a continuous learning system. The country has not been willing to let people die for lack of money," he emphasized, citing coverage for life-extending dialysis and AIDS drugs as two examples.


IOM Report Recommendations


1. Digital infrastructure: Improve the capacity to capture clinical, care-delivery process and financial data for better health care system improvement and the generation of new knowledge.


2. Data utility: Streamline and revise research regulations to improve care, promote the capture of clinical data, and promote knowledge.


3. Clinical decision support: Accelerate the integration of the best clinical knowledge into care decisions.


4. Patient-centered care: Involve patients and their families in decisions regarding health care, tailored to their preferences.


5. Community links: Promote community-clinical partnerships and services aimed at managing and improving health at the community level.


6. Care continuity: Improve coordination and communication within and across organizations.


7. Optimized operations: Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.


8. Financial incentives: Structure payment to reward continuous learning and improvement in providing the best care at lower cost.


9. Performance transparency: Increase transparency on health care system performance.


10. Broad leadership: Expand an overall commitment to the goals of a continuously learning health care system.