July 2004
Health Care System Crisis: View from the Front Lines
The United States will spend $1.8 trillion-over 15 percent of GDP-on health care this year. Despite that enormous expenditure, doctors remain trapped in an inefficient system that too often impedes the flow of clinical information necessary for sound treatment decisions. Patients have little information about the quality of their care, health insurance costs have skyrocketed, and millions of people do not have health insurance.
At a July 20 AEI conference, Dr. Denis Cortese, president and CEO of the Mayo Clinic, presented his vision for health care reform.
Denis Cortese, M.D.
Mayo Clinic
The health community has fooled itself into believing our health care system is broken, when really we have no system at all. It was simply not designed to operate cohesively. As we move forward, we must consider what the key components of a solid health care system should be.
First, the Institute of Medicine (IOM) proposed standards of care--requiring the health care system to be safe, effective, efficient, timely, patient-centered, and equitable--must be met. We must also have a true professional organization underpinning the system. We must involve system engineers to create and continuously refine the infrastructure that connects patients and health professionals. Information technology (IT) is also tremendously important. Physicians have two obligations--one to care for patients, and the other to handle information. We must facilitate and improve the way they do the latter. The system must be a learning organization in which all practitioners profit from the experiences of their colleagues. From the patient side, it is imperative that the system provide insurance and guarantee access to it for all.
To meet the IOM standards, the health care system must invest in the professionalism of its caregivers, IT, and the system's learning infrastructure. Joining a profession typically entails learning a body of knowledge, holding an apprenticeship, and then practicing. A true professional commits to continuous learning over his entire career. In order to be professionals, physicians must constantly exchange knowledge, contribute to the existing wisdom, and continually refine the way they practice medicine.
Physicians must become open to learning at a distance and by simulation. While we can expect extensive simulation training from pilots, we cannot from physicians. In fact, only three institutions in the United States currently have that capacity. Most importantly, physicians should be knowledgeable of processes of care that encompass more than their own narrow experience with a patient. Medical training is fragmented, requiring little or no collaboration among peers, but this is not the way medicine is practiced.
To facilitate learning from experiences and sharing new knowledge, all physicians should practice medicine under established protocols. They, at the front lines, should evaluate new technologies and methods they use with patients. Every doctor undertakes his own process management research as he finds ways to streamline scheduling or improve interactions with patients. These innovations should be shared among all physicians.
Medicine of the future will rely intensively on proteomics, genomics, and other areas of biotechnology. Advances in these fields will allow physicians to more accurately predict risk, and in turn better prevent disease. Current science has identified 150 types of breast cancer, each treated differently. As we hone our diagnostic technologies, we will be able to deliver more personalized care to patients. This has serious implications for the research and development of new medicines undertaken by the pharmaceutical industry.
System engineers are indispensable to the health care system envisioned by the IOM guidelines. While the Mayo Clinic has invested in system engineering for decades, all of health care needs to recognize this valuable component to the system. Information technology is the key to ongoing patient care. All knowable information about a patient should be instantly available to the patient and physicians. Electronic medical records (EMR) would have the capacity to integrate a patient's past medical history, family history, social history, medications, and allergies. The medication screen would be able to interface with drug references to detect any drug interactions or collective side effects of a patient's drug regimen. It would also store all lab tests, radiological images, genetic, and proteomic information. This complete patient profile would generate a very specific diagnosis and produce the most current recommendations for treatment, linked to all existing studies on them.
All of the pieces of the EMR described above are currently available, but not in a unified resource. As patients, we should expect a complete record like this. Having unified, accessible patient information would also allow physicians and patients to know the experiences of other patients with the same conditions or undergoing the same treatments. This wealth of information about a patient and his prospects could be accessed from anywhere. This technology has the potential to standardize the process of improving care. It does not, however, remove the art of being a physician. Physicians should shape the way they care for their patients. Diagnoses and treatments, on the other hand, should be governed by science.
The role of the government must evolve to support a market-based health care system. The government should not be in the business of providing health insurance. It should focus instead on financing coverage for the needy and aligning its reimbursement with its goals and expectations. The government should also resist extensively regulating insurance markets as they develop with this new system. A market-based insurance product will ensure choice and portability. State mandates discourage both these benefits. The right model to pursue is the Federal Employee Health Benefits Program, where rules for fair competition earn individuals the best deals. A market infrastructure will also support a system that is value-based, flexible, and transparent about risk management.
AEI research assistant Ximena Pinell prepared this summary.
