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Changing the US healthcare system
  1. H BAUCHNER, US Editor

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Ever since the healthcare debacle of the early Clinton years, the voices calling for change in the US healthcare system have been quite muted. However, this past month, the Institute of Medicine, which was established in 1970 by the National Academy of Sciences to advise the federal government on matters related to the health of the public, published a report entitled Crossing the quality chasm: a new health system for the 21st century.1The report describes serious shortcomings in US healthcare, including medical errors of both of co-mission and omission, as well as the failure to practice medicine in adherence with established evidence. These are a result of the growing complexity of science and technology, an increase in the percentage of children and adults with chronic conditions, and a poorly organised healthcare delivery system. Despite the dedicated and high quality people who work within the delivery system, they cannot compensate for its shortcomings. Recognising that the American healthcare system is in need of fundamental change, the group articulates a new vision for it. The report espouses six aims, suggesting that the system should be:

  • Safe: avoids injuries to patients

  • Effective: avoids both overuse and underuse of services

  • Patient centred: patient values should guide all decisions

  • Timely: reduces waiting time

  • Efficient: avoids waste

  • Equitable: provides care that does not vary based upon patient characteristics.

In addition, the authors make 12 recommendations; the following points are those that are relevant to the subset that is relevant to healthcare systems other than the US:

  • A National Quality Report that tracks progress towards each of the aims stated above should be released regularly

  • Healthcare systems should be designed to support continuous healing relationships, the patient as the source of control, shared knowledge and free flow of information, evidence-based decision making, safety as a system property, and cooperation of clinicians

  • No fewer than 15 priority conditions should be identified as the focus of achieving quality improvement initiatives in the next five years

  • There must be a national commitment to building an information infrastructure to support healthcare delivery, consumer health, quality measurement and improvement, public accountability, clinical and health services research, and clinical education.

The report suggests that information technology should play a central role in the redesign of the healthcare system. An increasing number of US physicians have access to the world wide web, and use email for professional communications, although the number of physicians using electronic medical records, communicating with patients by email, and using computerised physician entry remains quite limited. Each of these are examples of how information technology can impact on healthcare. The report is somewhat vague as to who will pay for the initial investment in information technology. Although I believe that most hospitals in the US will move toward and support computerised physician order entry as a way to reduce medical errors, that does not address issues related to electronic medical records or email communication. There will be two hurdles to overcome with respect to these advances. The first relates to issues of privacy and confidentiality with both electronic medical records and email communication. The second relates to financing, we are not a healthcare system that often makes short term investments for possible long term reductions in cost and improvement in quality.

The US spends more money on healthcare than virtually any other nation. Although many patients get absolutely superb medical care, there remain many areas for improvement. Medical errors must be reduced. Evidence must be available to practitioners when they need it. Racial and ethnic disparities in healthcare must be eliminated and finally, our system (and physicians) should listen more carefully to what patients want from healthcare and help them get it. Unfortunately, I am increasingly concerned that we may develop a two tiered healthcare system. Well educated patients with private insurance may increasingly enter systems that can provide the key components of healthcare as articulated in this report, while less educated patients and those with public insurance will enter systems of care with fewer resources and less ability to respond to patient needs.

I applaud the report from the Institute of Medicine. There are only two areas to which I would take exception. Although the report addresses the financing of the healthcare system, emphasising the need to align incentives with reimbursement, it does not address either health insurance for all citizens or for a single payer system. Despite its call for radical change in the system, without significant changes in the number of citizens that are insured and how we finance the system, I am concerned that few dramatic changes will be possible. Firstly, virtually every group involved in healthcare—patients, insurers, hospitals, purchasers, and clinicians—decry the administrative complexity of our system, but fail to articulate that change is unlikely with so many different payers. Hopefully, I will be proved wrong. Secondly, the faith in information technology and quality improvement may not be supported by evidence. Information technology should help to computerise reminders for physicians and patients, but whether it can help with complex medical decisions is uncertain. Although I agree that quality improvement is a critically important endeavour for medicine, I do not believe that it should be its essence.

What does this report mean for healthcare systems in other countries? Although many countries insure a larger percentage of their citizens than the US, problems with efficiency, disparities, medical errors, waiting times, translating evidence into practice, and responsiveness to patients, are not unique to the US. The Institute of Medicine report articulates a vision of healthcare for the 21st century that is relevant to healthcare systems worldwide.