Healthcare System

CHAPTER 10

Healthcare Institutions

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LEARNING OBJECTIVES

By the end of this chapter, the student will be able to:

•   identify a range of inpatient healthcare facilities that exist in the United States.

•   identify a range of outpatient healthcare facilities that exist in the United States.

•   describe approaches being used to define and measure the quality of health care.

•   describe types of coordination of care and methods available to facilitate coordination of care.

•   identify ways that healthcare systems and Medicare demonstration projects are attempting to improve the quality of care.

•   identify roles that may be played by electronic medical records in improving the delivery of health care.

•   identify components of medical malpractice and disclosure of medical errors.

George did not have health insurance and went to the emergency room whenever he needed care. They always treated him there, but then tried to get him connected to a primary care facility. He was not eligible for care at the Veterans Administration facilities, so they sent him to the local community health center, which they called the “safety net” provider. George did go there and they tried to treat his problems and get him his medicine. When he got sick, however, George went back to the emergency department. Even George agreed that it was not the best way to get care, but he wondered: What is needed to make the system work better?

Laura had breast cancer and it had spread. Her medical records were on file at the hospital, at four doctor’s offices, in two emergency rooms, and at an outpatient imaging facility. No one seemed to know how to put the system together. Whenever her old records were essential, they asked her to go get a copy of them and bring them to her next appointment. That worked for a while, but when she ended up in the emergency room, her records just were not available. There must be a better way, Laura thought to herself. Has the healthcare system not discovered the Internet yet?

Fred ended his walk one day at the emergency room. He seemed confused about how to get home. “It looks like we are dealing with Alzheimer’s,” his doctor told Fred’s wife, Sonya, at their next appointment. Taking care of Fred at home was not easy. Home health aides and occasional weekend relief called “respite care” eased the burden for a while. The new assisted-living facilities looked attractive, but Fred’s family just could not afford one. When Fred fell and broke his hip, he required hospitalization for surgery. The hospital discharge planner arranged for a skilled nursing home for rehabilitation services paid for by Medicare. After a few weeks there, the only alternative was long-term or custodial care in a nursing home paid for by Medicaid. The care at the nursing home was not what the family had expected. The staff did clean Fred up before the announced family visits, but once when the family arrived unannounced, they were shocked to see Fred lying half-naked in his wheelchair. The end came almost two years from the day they moved him to the nursing home. Looking back, the family asked: Can the healthcare system do better at addressing the needs of Alzheimer’s patients?

 

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These are the types of situations faced by many patients as they try to navigate through the institutions that provide health care in the United States. Let us take a look at these different institutions.

WHAT INSTITUTIONS MAKE UP THE HEALTHCARE SYSTEM?

The number and types of healthcare institutions are almost as diverse and complicated as the number and types of healthcare professionals. In recent years, the complexity has grown as a range of facilities have developed to serve new needs and new financial reimbursement approaches. 1 , 2 Nonetheless, it is possible to understand the scope of healthcare institutions by categorizing them as inpatient facilities and outpatient facilities, with inpatient facilities implying that patients remain in the facility for at least 24 hours.

Inpatient facilities include hospitals, skilled nursing and rehabilitation facilities, nursing homes, and institutional hospices. Outpatient facilities include those providing clinical services by one or more clinicians and those providing diagnostic testing or treatment. We will provide an overview of inpatient and outpatient facilities and then ask: Do these facilities together provide a coordinated system of care? Let us begin by looking at inpatient facilities.

WHAT TYPES OF INPATIENT FACILITIES EXIST IN THE UNITED STATES?

We can classify inpatient facilities as: 1) hospitals generally designed for short-term stays by patients, and 2) long-term care facilities. Let us first take a look at hospitals.

The history of hospitals in the United States goes back to the colonial period. However, prior to the middle of the 1800s, hospitals were generally institutions for those without other sources of care, which included the poor, the military, and those with communicable diseases. Hospitals generally provided little more than shelter and food and separated the sick—especially those with communicable diseases—from the healthy. 1

Today, the U.S. hospital is usually a modern high-tech enterprise that lies at the center of the healthcare system educationally, structurally, and psychologically. You can often identify the hospital from far away because it is frequently the largest and most modern facility in town. The psychological hold that the hospital has on U.S. health care is symbolized by the term “house” and the concept of “house staff,” or residents who practically live full time in the hospital during their training. 3 , a

Hospitals share some common features, including:

•   Hospitals are licensed by the state and usually accredited by a national organization, such as The Joint Commission (formally called the Joint Commission on the Accreditation of Healthcare Organizations [JCAHO]).

•   Hospitals have an organized physician staff and provide 24-hour-a-day nursing services.

•   The hospital is governed by a governing board separate from the medical and nursing staff that has overall responsibility for the operation of the hospital consistent with state and federal laws.

The several types of hospitals in the United States differ in their purposes and organizational structures. Hospitals can be categorized as general hospitals and specialty hospitals. General hospitals attempt to serve a wide spectrum of patients and problems, though they may concentrate on serving only children or only those who qualify for services, such as a Veterans Administration (VA) hospital. In the past, specialty hospitals sought to serve the needs of patients who could not be accommodated in general hospitals, such as those with tuberculosis or severe mental illness. Today, these conditions are usually addressed in general hospitals. Today’s specialty hospitals are more a result of the specialization of medical services. Institutions focused on cancer, heart disease, psychiatric illness, ophthalmology, and orthopaedics, for instance, are rapidly developing.

Hospitals are often categorized today by their funding source and financial arrangements. They can be divided into nonprofit and for-profit, or investor-owned, hospitals. Nearly 90% of the approximately 5,000 hospitals in the United States are nonprofits. These include the broad category of private nonprofit hospitals, hospitals run by state or federal government, and hospitals run by institutions, such as universities. b

Approximately half of these 5,000 hospitals are private nonprofit hospitals, many of which have affiliations with religious denominations, but accept patients of all faiths. State and local governments run nearly 20% of hospitals, many of which are described—along with private nonprofit hospitals—as community hospitals. Federal medical institutions include the Veterans Administration hospitals and the military hospital system. For-profit, or investor-owned, hospitals make up over 10% of all hospitals, many of which are owned by several large corporations specializing in providing healthcare services.

Hospitals today are often more than an inpatient facility. The most rapidly growing component of most hospitals is the spectrum of outpatient services they provide. In addition to emergency departments, hospitals usually also provide outpatient surgical and medical services, including diagnostic and treatment services, and may provide facilities for routine office-type visits.

The hospital should no longer be viewed as one building. Hospital networks or systems are increasingly being created, some of which provide a range of services, including skilled nursing and rehabilitative services, as well as long-term care.

We have classified inpatient facilities as including hospitals and long-term care facilities. Today, there are a range of long-term care facilities, some of which are not primarily operated as healthcare facilities. 1 , 2 These facilities may include skilled nursing facilities, nursing homes, assisted living and dementia care, and, at times, hospice care. To fully understand the provision of long-term care, you also need to appreciate the types of services that are increasingly being provided in an individual’s home.

It is important to distinguish between skilled nursing and rehabilitative services in contrast to nursing home or custodial services. Skilled nursing and rehabilitative services, like hospital services, are generally short term and aimed at accomplishing specific objectives, such as recovery from a stroke or injury. Though these services may continue for many months, they are not designed to provide long-term care beyond the point at which improvement can no longer be expected.

Nursing homes, on the other hand, are designed for long-term or custodial care while also providing a limited amount of healthcare services. Individuals in nursing homes usually require care because of their inability to perform the activities of daily living, such as dressing, feeding, and bathing themselves. Nursing homes may provide routine medical care and some acute care, but this type of facility is not primarily designed to improve the medical status of its residents. c

Nursing homes are generally operated according to a specific set of nursing home regulations determined by and enforced by the states. Federal minimal standards are set as part of the requirements to receive payment through the Medicare and Medicaid systems. Most nursing homes, like most hospitals, are run as private nonprofit institutions. However, for-profit, or investor-owned, nursing homes provide approximately 15% of the beds nationally. There are over 16,000 nursing homes in the United States, with over 1.5 million residents. Most, but not all, residents are elderly. Over 80% need help with mobility, nearly 66% are considered incontinent, and nearly 50% require assistance with eating. Alzheimer’s patients are the most rapidly growing population in the nursing home system of care. 1 , 2

Although not strictly inpatient healthcare facilities, assisted-living facilities and home health care increasingly provide long-term care for those who have less severe impairments. Assisted-living facilities are not organized as healthcare facilities, but may provide or coordinate health care as part of their services. New concepts, such as continuing care retirement communities, attempt to provide a range of options, including independent-living, assisted-living, and nursing home facilities.

Most elderly and disabled individuals are not residents in long-term care institutions; rather, they live on their own or with family members. Thus, much attention in recent years has been paid to providing and financing home healthcare services, including home health aides, healthcare delivered at home, and respite care. Respite care provides short-term time away for primary caregivers such as family members.

The hospice movement today can be viewed as part of the long-term care system. It is care provided to those with a life expectancy of six months or fewer as determined by a physician. The goal of hospice care is to provide comfort, emotional support, and palliation—not to increase longevity. In some cases, hospice care may occur in a separate institution, but today, it is more often provided in the patient’s place of residence.

WHAT TYPES OF OUTPATIENT FACILITIES EXIST IN THE UNITED STATES?

The variety of types of outpatient facilities is even more diverse and complicated than that of inpatient facilities. The basic distinction between clinical facilities and diagnostic testing or therapeutic facilities helps define the types of services provided.

Clinical services were traditionally viewed as being provided in “the doctor’s office.” None of these words—“the,” “doctor’s,” “office”—does a good job of describing the current organization of clinical services. “The” implies one. Today, clinical services are rarely organized around one doctor or clinician. Group practice and multispecialty practices have become the rule. “Doctors” (or physicians) are by no means the only health professionals to organize and provide clinical services. Physical therapists, nurse practitioners, audiologists, optometrists, clinical psychologists, and a long list of other health professionals often provide their own office services. Rather than “doctor,” the term provider is increasingly used to encompass this growing array of health professionals. Even the term “office” is no longer appropriate. In addition to the traditional office setting, many clinicians now provide services in shopping centers and work places, and even make house calls.

The average American makes over three visits for clinical services per year. An increasing number of these visits are provided outside of “the doctor’s office” in the traditional sense. These sites now include a growing network of community health centers designed to provide what is called the “safety net” services for those who cannot or do not wish to seek other types of clinical services. Box 10-1 provides an overview of community health centers. 4

A key issue in the organization of health care is the delivery of quality services. Let us take a look at what we mean by “quality” and what mechanisms are being used to ensure the quality of healthcare services.

WHAT DO WE MEAN BY THE “QUALITY OF HEALTHCARE SERVICES?”

The quality of healthcare services may mean different things to different people. Administrators may focus on the structures, such as the availability of operating rooms or laboratory services. Clinicians may focus on the process, such as the technical competence of the practitioners. Patients may focus on different types of processes, like the personal relationships and their personal satisfaction. External reviewers may focus on the outcome—lives saved or disabilities prevented.

Quality can be assessed using what are called structure, process, and outcome measures. Structure focuses on the physical and organizational infrastructure in which care is delivered. Process concentrates on the procedures and formal processes that go into delivering care—for example, systems for ensuring credentialing of health professionals and procedures to ensure timely response to complaints. Outcome measures imply a focus on the result of care, from rates of infection to readmissions with complications.

Defining and measuring quality remains a controversial subject. However, the National Committee for Quality Assurance (NCQA) has developed a widely recognized framework to assist with this challenge. 5 Table 10-1 outlines this framework. d

The complexity of inpatient and outpatient services in the United States has made the delivery of quality healthcare services very challenging. The complexity of the system raises two closely connected questions:

BOX 10-1 Community Health Centers

Initially named neighborhood health centers, community health centers were established in 1965 as part of the Johnson administration’s War on Poverty. The centers were designed based on a community empowerment philosophy that encouraged the flow of funds directly to nonprofit, community-level organizations, often bypassing state governments.

The Health Centers Consolidation Act of 1996 combined community health centers with healthcare services for migrants, the homeless population, and residents of public housing to create the consolidated health centers program under Section 330 of the Public Health Service Act. These centers are often called 330 grantees. To receive a 330 grant, a clinic must meet certain statutory requirements. It must:

•   Be located in a federally designated medically underserved area (MUA) or serve a federally designated medically underserved population (MUP)

•   Have nonprofit, public, or tax exempt status

•   Provide comprehensive primary healthcare services, referrals, and other services needed to facilitate access to care, such as case management, translation, and transportation

•   Have a governing board, the majority of whose members are patients of the health center

•   Provide services to all in the service area regardless of ability to pay and offer a sliding fee schedule that adjusts according to family income

Community health centers have undergone rapid expansion in recent years and now serve approximately 20 million individuals annually at more than 4,000 sites in all 50 states and the District of Columbia. Most patients have low incomes and the majority qualify for Medicaid. According to a review, “health centers have proven to be an effective investment of federal funds, have garnered sustained goodwill and advocacy in the communities they serve, and, as a result, generally have enjoyed broad, bipartisan support.” 4

TABLE 10-1 Characteristics of Healthcare Quality—National Committee for Quality Assurance

Data from NCQA Health Plan Report Care. Available at http://reportcard.ncqa.org/plan/external/Resources.aspx?Header=yes&Tab=Glossary#Accreditation . Accessed August 12, 2013.

•   How can the pieces of the system be coordinated to provide integrated care?

•   How can we improve and ensure the quality of health care?

The coordination and integration of healthcare delivery is often considered key to both the efficiency and the quality of health care. Let us begin by taking a look at how healthcare delivery can be coordinated among institutions.

HOW CAN HEALTH CARE BE COORDINATED AMONG THE MULTIPLE INSTITUTIONS THAT PROVIDE HEALTHCARE SERVICES?

The types of institutions that deliver health care in the United States have continued to proliferate in recent years. Each type differs in its governance, finance, accreditation, and organizational structure. It is not surprising that most patients, policy makers, and even clinicians do not have a good overview of the system. Connecting the institutions to achieve an organized system has become a major challenge.

Healthcare delivery systems aim to connect inpatient and outpatient services, as well as short-term and long-term clinical services, to provide a coordinated system of care. The desire for an integrated healthcare delivery system is not a new idea. For many years, the concept of “the patient’s doctor” was seen as the mechanism to hold together the system. The doctor provided all care or coordinated the care with other clinicians. The doctor “followed” the patient into the inpatient facility and provided the patient’s “follow-up” care after he or she left.

Like the concept of “the doctor’s office,” the concept of “the patient’s doctor” is no longer a reflection of reality. Once again “the” rarely reflects the reality of multiple providers of care. Primary care physicians are now far less likely to follow the patient into the hospital or the nursing home and far less likely to be aware of the patient’s multiple sources of and approaches to care.

Efforts to integrate the system are under way. We will look at two basic approaches that are being used: the development of integrated healthcare delivery systems and the use of integrated electronic medical records. These approaches are likely to be used together and form the basis for a future integrated system of healthcare delivery. In order to understand the uses and potential of these two approaches, we first need to think about the types of coordination of care that we want to see occur and the purposes they serve.

WHAT TYPES OF COORDINATION OF CARE ARE NEEDED AND WHAT PURPOSES DO THEY SERVE?

As we have discussed, the traditional approach to coordination of care revolved around the clinician–patient or doctor–patient relationship. Traditionally, the concepts of continuity of care and coordination of care have been almost synonymous. This approach assumed that the relationship between one doctor and one patient would provide the individualized knowledge, trust, and commitment that would ensure the coordination of care by ensuring the continuity of care. The concepts of primary care that we have discussed were built in large part upon this concept of one-to-one continuity.

Today, there is an increasing emphasis on ensuring coordination rather than one-to-one continuity. Coordination is sought between institutions and settings where care is delivered. The approach that leaves continuity of information and continuity of responsibility for care to individual clinicians alone has often failed to produce the desired results. As we will see, efforts are under way to formally link institutions, services, and information between the various healthcare delivery sites and institutions.

Institutional coordination often relies on financial coordination. If services are covered by insurance in one setting but not another, the system is not likely to function efficiently or effectively. When services are not covered at all, patients may receive excellent care in one setting only to lose the benefits of that care when necessary preparation or follow-up is not paid for and not accomplished in another setting.

Coordination is not just an issue within the healthcare delivery system; it is also an issue that straddles healthcare delivery and public health functions. Communicable disease control and environmental protections, such as controlling antibiotic resistance and lead exposure, cannot be successful without effective and efficient coordination between healthcare and public health professionals and institutions. Table 10-2 outlines these types of coordination, their intended function, and the types of challenges that commonly occur with their implementation.

Let us take a look at the development of healthcare delivery systems as one approach to ensuring coordination of health care.

WHAT TYPES OF HEALTHCARE DELIVERY SYSTEMS ARE BEING DEVELOPED AND HOW CAN THEY HELP ENSURE COORDINATION OF HEALTH CARE?

We will use the term “healthcare delivery system” to imply a linkage of institutions and healthcare professionals that together take on the responsibility of delivering coordinated care. e

TABLE 10-2 Type of Coordination of Care, Intended Functions, and Challenges with Implementation

Type of coordination	Intended function	Challenges with implementation
Clinician–patient relationship	Continuity as a mechanism for ensuring coordination Development of one-to-one relationships built on knowledge and trust over extended periods of time	Multiple clinicians involved in care Team rather than individual concept of primary care Frequent changes in insurance coverage require change in health professionals
Institutional coordination	Coordination of individual’s information between institutions needed to inform individual clinical and administrative decision making	Different structures and governance often lead to lack of coordination between inpatient facilities and between inpatient and outpatient facilities
Financial coordination	Implies that a patient has comprehensive coverage for services provided by the full range of institutions Aims to maximize the efficiency of the care received and minimize the administrative effort required to manage the payment system	Lack of comprehensive insurance coverage often means that essential services cannot be delivered or cannot be delivered at the most efficient or effective institutional site
Coordination between health care and public health	Coordination of services between clinical care and public heath requires communication to ensure follow-up and to protect the health of others	Lack of coordination of services between public health services and clinical care is often based on lack of communications

In a nation such as the United States, in which health care is provided by a range of providers and institutions, holding together one delivery system is not easy. A wide range of efforts are under way to connect the pieces. Let us take a look at some successful examples.

Care coordination challenges have been quite successfully met in the emergency response system. Today, there is a network of institutions, including government agencies and private emergency medical services providers that cooperate with hospital emergency departments to facilitate and expedite the care of the seriously ill and injured. The emergency response system helps to quickly respond to emergencies, provide onsite assistance and information, and identify the healthcare institution that is best prepared to handle the emergency based on location, staffing, and capabilities. This system, while not perfect, demonstrates that coordination of care—at least urgent care—is possible.

Coordination of routine health care has proven to be a more difficult challenge. Healthcare systems are beginning to be developed, often based on common ownership or governance. These integrated systems are designed to provide a wide range of services, from outpatient clinical care, diagnostic testing, and treatment services, to inpatient, home health, skilled nursing, nursing home, and even hospice care.

Two of the longest standing and most developed healthcare systems are the Kaiser Permanente and Veterans Administration systems. 6 , 7 These are discussed in Box 10-2. Many more healthcare systems are being formed by caregivers, such as multispecialty group practices, and by institutions, such as university medical centers. The coming years are likely to produce a number of successful models that will become examples that others will try to replicate.

In addition to the development of comprehensive healthcare delivery systems, experimentation is under way to improve the functioning of existing systems such as Medicare. The Affordable Care Act has a large number of provisions that encourage demonstration projects for Medicare patients. These provisions are designed to improve performance and often focus on incentives for efficiency and coordination of care. Box 10-3 discusses a number of the Medicare programs that are now under way. 8

BOX 10-2 Healthcare Delivery Systems: Kaiser Permanente and the Veterans Administration

The Kaiser Permanente and the Veterans Administration healthcare systems are two of the largest organized healthcare systems in the United States. They have very different histories and philosophies, and they serve quite different populations. Nonetheless, they have both moved in the direction of developing an integrated set of healthcare delivery institutions linked together by an electronic health record and fostering evidence-based interventions. They share a common advantage in that they are financed by single sources, the Kaiser Permanente health plan and the federal government, respectively.

Kaiser helped introduce the concept of the health maintenance organization by offering a comprehensive package of preventive and curative services at a fixed monthly fee. The Kaiser Permanente health system has its roots in World War II, when employers offered health benefits when they were prohibited from raising wages. In the subsequent decades, Kaiser Permanente grew from its California base, enrolling over nine million individuals. It was created as a staff model prepaid health plan, enrolling patients who would receive all of their services directly from clinicians and institutions that were part of the plan. This allowed Kaiser Permanente to develop an integrated approach to healthcare delivery.

Kaiser, the management component, owns or contracts with hospitals, skilled nursing facilities, home healthcare systems, and a range of other institutions that provide care under their management. Permanente, the physician component, aims to provide an integrated set of inpatient and outpatient services. Kaiser Permanente competes actively in the market for healthcare services and often limits the amount and types of care that can be provided. Nonetheless, it has been able to develop an integrated healthcare delivery system, promote evidence-based interventions, and introduce an integrated electronic health record system.

The Veterans Administration healthcare system began as an outgrowth of World War I, though its roots go back to the Revolutionary War. After World War II, the Veterans Administration hospital system rapidly increased in size and developed strong relationships with medical schools and other health professional training schools for education and research. Today, the VA healthcare system is part of the cabinet-level Department of Veterans Affairs and serves over eight million patients each year.

For many years, the VA system was accused of poor quality care and lack of coordination of care because it emphasized inpatient services and patients often went back and forth between the VA and other healthcare delivery sites. In the mid-1990s, the VA health system underwent a major “systems reengineering,” designed to improve quality. The changes included the development of an integrated electronic health record and an emphasis on evidence-based interventions for preventive, acute, and chronic care.

In recent years, the VA health system has been organized into a series of networks, including inpatient and outpatient facilities. Many of the networks aim to provide comprehensive outpatient and inpatient services, including skilled nursing and nursing home services, as well as outpatient and hospital services. Survey data collected a decade after the systems reengineering initiative began suggests that the VA health system provides an increasing quality of integrated care based upon evidence-based interventions.

The VA and Kaiser Permanente systems represent two of the largest healthcare systems in the United States. Both aim to serve a large number of patients and provide coordinated care utilizing evidence-based interventions and integrated healthcare records. The success of these two quite different healthcare systems suggests that an integrated system of care, patient information, and financing is possible and can be widely applied to improve the quality of health care.

HOW CAN ELECTRONIC MEDICAL RECORDS BE USED TO FACILITATE COORDINATION OF CARE AND IMPROVE QUALITY?

There is widespread agreement that an electronic health record system could improve coordination of care, as well as achieve a number of other quality objectives. The Institute of Medicine (IOM) outlined the following potential roles for an electronic health information system. These roles aim in large part to provide the cornerstone for coordination of healthcare delivery.

BOX 10-3 The Affordable Care Act and Medicare

The ACA’s impact on health services focuses primarily on funding experiments or demonstration programs designed to improve the delivery of health services. The ACA and other federal legislation encourage and authorize funding for the federal Centers for Medicare and Medicaid Services (CMS) to implement a series of new programs. Key programs are described by the CMS as follows:

Accountable Care Organizations (ACOs): ACOs will allow providers who voluntarily agree to work together to coordinate care for patients and providers who meet certain quality standards to share in any savings they achieve for the Medicare program. ACOs that elect to become accountable for shared losses have the opportunity to share in greater savings. ACOs will coordinate and integrate Medicare services, with success being gauged by roughly 30 quality measures organized in 4 domains. These domains include patient experience, care coordination and patient safety, preventive health, and at-risk populations. The higher the quality of care providers deliver, the more shared savings their Accountable Care Organization may earn, provided they also lower growth in healthcare expenditures.

Partnership for Patients: This partnership is a test care model to reduce hospital-acquired conditions and improve transitions in care. This public–private partnership supports the efforts of physicians, nurses, and other clinicians to make care safer and better coordinate patients’ transitions from hospitals to other settings.

Bundled Payments for Care Improvement: The Bundled Payments for Care Improvement initiative seeks to improve patient care by fostering improved coordination through payments for multiple related services rather than for single services.

Comprehensive Primary Care Initiative: In addition to regular fee-for-service payments, CMS will pay primary care practices a monthly fee for clinicians to help patients with serious or chronic diseases follow personalized care plans; give patients 24-hour access to care and health information; deliver preventive care; engage patients and their families in their own care; and work together with other doctors, including specialists, to provide better coordinated care.

Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration: This demonstration evaluates the impact of advanced primary care practice on improving care, focusing on prevention, and reducing healthcare costs among Medicare beneficiaries served by FQHCs (in other words, community health centers).

The results of these experiments and demonstration programs will take several years to determine. It is likely that these results will contribute to ongoing reform of the U.S. healthcare delivery system.

•   Health information and data—laboratory and pharmacy data, as well as records of a patient’s history and findings on examination, including past medical records

•   Results management—integration of findings from multiple providers at multiple sites

•   Order entry/management—electronic ordering of tests and prescriptions to maximize accuracy and speed implementation

•   Decision support management—computer reminders and prompts to encourage timely follow-up and adherence to evidence-based guidelines

•   Electronic communication and connectivity—facilitation of communications between providers and between providers and patients

•   Patient support—tools for patient education and patient involvement in decision making

•   Administrative processes—facilitation of scheduling, billing, and other administrative services to increase efficiency and reduce costs

•   Reporting and population health—improvements in the efficiency and completeness of required reporting and the speed and completeness of public health surveillance

The IOM also concluded that electronic record systems have the potential for helping achieve quality and efficiency objectives as outlined in Box 10-4. 9

Efforts to implement a national system of electronic health records are under way. Nearly $20 billion was allocated to this effort as part of the 2009–2010 stimulus plan. Recent efforts to include patients as direct users of their health information may spur more rapid acceptance of the electronic records. The need for security of data and control by patients over who has access and for what purposes is critical to the acceptance and use of an electronic system such as this. Assuming that security issues can be adequately addressed, you should expect to see widespread use of electronic records and an increased role for patients in accessing and managing their own medical records. f

BOX 10-4 Use of Electronic Health Records to Improve Quality and Efficiency of Healthcare Delivery

The IOM report indicates that the electronic health record has the potential to improve the quality and efficiency of patient care in the following ways:

•   Improve patient safety. Safety is the prevention of harm to patients. Each year in the United States, tens of thousands of people die as a result of preventable adverse events due to health care. Electronic records containing information on prescribed drugs and other treatments are expected to improve patient safety.

•   Support the delivery of effective patient care. Effectiveness is providing services based on scientific knowledge to those who could benefit and at the same time refraining from providing services to those not likely to benefit. Only about one-half (55%) of Americans receive recommended medical care that is consistent with evidence-based guidelines. Reminder systems that require clinicians to accept or reject the recommendations of a clinical guideline are expected to increase the use of evidence-based guidelines.

•   Facilitate management of chronic conditions. More than half of those with chronic conditions have three or more different providers and report that they often receive conflicting information from those providers; moreover, many undergo duplicate tests and procedures, but still do not receive recommended care. Physicians also report difficulty in coordinating care for their patients with chronic conditions and believe that this lack of coordination produces poor outcomes. Electronic records can help inform clinicians of other care being given to their patients.

•   Improve efficiency. Efficiency is the avoidance of waste—in particular, waste of equipment, supplies, ideas, and energy. Methods must be found to enhance the efficiency of healthcare professionals and reduce the administrative and labor costs associated with healthcare delivery and financing. Electronic records, if consistently and widely implemented in the healthcare arena, can be expected to reduce costs as they have in many other fields.

While there is widespread agreement that electronic medical records have the potential to improve health care, concerns have also been raised about privacy. In addition, the ease of ordering tests provided by many health information systems has raised concerns that these systems will result in additional ordering of costly and often unnecessary tests.

Electronic health records are only one of the many ways that technology is changing the delivery and quality of healthcare services in the United States.

HOW IS TECHNOLOGY BEING USED TO IMPROVE THE QUALITY OF CARE?

The United States is among the leaders in adoption of new healthcare technologies, especially those that allow for technological approaches to disease diagnosis and treatment. In comparison with most other nations, the United States has more rapidly developed and accepted the use of medical technologies ranging from magnetic resonance imaging (MRI), to invasive cardiac procedures, to surgery for weight loss.

This country has generally relied on market mechanisms to develop, introduce, and disseminate or diffuse technology. This has resulted in extremely rapid innovation in areas with high levels of financial compensation and slower innovation in areas with less financial support. For instance, high-tech procedures ranging from heart surgery to hip replacements have been well compensated and have seen rapid innovation and diffusion. Well-compensated preventive procedures, such as mammography, have likewise seen widespread use. Other technologies, like telemedicine, are likely to have widespread applications only after financial reimbursement is provided.

Longer term innovations in technology have been fueled by the long-term U.S. investment in basic and applied research through the National Institutes of Health (NIH). The budget for the NIH was doubled during the 1990s, but has been relatively flat in recent years when adjusted for inflation. The innovations in care and in technology pioneered by the NIH have often led to new approaches and new health-related industries. In recent years, the NIH has begun to focus on translational research or efforts to bring the benefits of new knowledge and new technologies to individual patients and whole communities.

Increased knowledge of the human genome has laid the groundwork for new diagnostic and therapeutic approaches, as well as a better understanding of the causes of disease. Better understanding of brain function and better technology for measuring changes in the brain are leading to new strategies for dealing with diseases ranging from Alzheimer’s to depression. Advances in technology continue to provide hope and new challenges to improving health care.

We have now looked at how the development of integrated healthcare delivery systems and electronic health records and other technologies are being used to try to improve the quality and efficiency of healthcare delivery. Now, let us take a look at mechanisms that are being developed to monitor and ensure quality of care.

WHAT MECHANISMS ARE BEING USED TO MONITOR AND ENSURE THE QUALITY OF HEALTH CARE IN THE UNITED STATES?

There are a variety of methods, including accreditation of academic institutions and individual credentialing to help ensure that health professionals are well educated and prepared for clinical practice. Increasing requirements for continuing education, recertification, and maintenance of licensure are being used to help ensure continued competence. Integrating financial compensation with quality of care through the use of pay-for-performance approaches is gaining momentum as an additional approach to ensuring quality.

In addition, there is a new emphasis on the use of evidence-based recommendations or clinical guidelines. Today, these recommendations are often available to clinicians in the form of protocols or step-by-step advice on approaches to the diagnosis and treatment of specific conditions. Computer systems increasingly prompt clinicians to take actions or confirm their actions with an aim to implement evidence-based recommendations. The complexity of clinical practice and the limits of current research, however, mean that evidence-based recommendations are available for only a small percentage of the problems that clinicians face on a daily basis.

In addition to these approaches, a series of other mechanisms attempts to address issues of quality. They include:

•   Hospital privileges and approval to perform specific procedures

•   Accreditation of additional healthcare organizations, including clinical practices

•   Malpractice liability, not only for physicians, but increasingly for other health professionals

•   Disclosure of medical errors

Hospital privileges imply that hospitals may set criteria for allowing clinicians to practice in their facility. The criteria may include specialty and/or subspecialty boards. Approval to perform specific procedures implies the need to demonstrate competence either by training or experience or both.

Accreditation of hospitals and long-term care facilities has been a long-standing effort. It is often linked to reimbursement, and is thus essential to the survival of these institutions. Accreditation of clinical practices, especially large group practices, is a growing trend. The NCQA and The Joint Commission are encouraging this process and providing quality criteria that need to be met. While still a voluntary process, these new forms of accreditation are becoming a sign of quality that is useful when recruiting patients and dealing with insurance companies.

The U.S. healthcare delivery system has a unique body of law called medical malpractice. Medical malpractice is hailed by its supporters as the ultimate guarantor of quality. It is attacked by its detractors as leading to defensive medicine, increased costs, and shortages in vulnerable professions, such as obstetrics. Regardless of your view of malpractice, it has come to have a major impact on the relationship between clinicians and patients. Box 10-5 examines the criteria for malpractice so you can understand what it means. 10

Malpractice is an inherently adversarial process. Increasingly, patients, clinicians, and healthcare institutions are looking for alternatives. One recent approach is the disclosure of medical errors.

CAN DISCLOSING MEDICAL ERRORS CONTRIBUTE TO QUALITY OF CARE AND SERVE AS AN ALTERNATIVE TO MALPRACTICE?

In its report To Error Is Human, the IOM documented the extent to which medical errors produce harm to patients—they estimated over 40,000 deaths per year. 11 This makes medical errors a slightly more common cause of death than either breast cancer or motor vehicle accidents. Errors may be due to deficiencies in the diagnostic or therapeutic process on the part of clinician(s). They may also be due to what are called system errors, problems resulting from deficiencies in the system for delivering health care.

BOX 10-5 Medical Malpractice

Medical malpractice is a body of state law; therefore, it differs from state to state. It is part of the civil law, as opposed to criminal law, which means that a case may be decided by a jury based upon what is called the preponderance of the evidence. This implies that malpractice was more likely than not. Despite the differences that exist from state to state, malpractice law builds upon a tradition known as negligence law, which is intended to protect the individual from harm.

The occurrence of harm or a bad outcome resulting from health care is not the same as negligence or malpractice. Errors in judgment and unsuccessful efforts are only considered medical malpractice if the patient can establish all four of the following:

1.   A duty was owed.

2.   A duty was breached.

3.   The breach caused an injury.

4.   Damages occurred.

Let us look at each of these requirements. a

1.   A duty was owed—This implies that a healthcare provider undertook the care or treatment of a patient. This duty may stem from services provided, ranging from a long-term relationship, a single visit, or a telephone call to a contractual relationship based upon an insurance agreement.

2.   A duty was breached—This implies a failure of the healthcare provider to meet a relevant standard of care. The standard of care is defined in terms of the clinician’s specialty. A healthcare provider is generally expected to possess the knowledge and skill and exercise the care and judgment expected of a reasonably competent clinician of the same specialty.

3.   The breach caused an injury—The legal concept of causation is based on what is called proximal cause. In medical malpractice, responsibility for an injury lies with the last negligent act. Proximal cause asks whether the injury or other outcome would have occurred if the negligent act had not occurred. Causation can be divided among different “parties,” including clinicians and institutions.

4.   Damages occurred—Damages can be divided into direct, indirect, and punitive categories. Direct damages include lost earnings, as well as current and future medical expenses. Indirect damages may include pain and emotional distress. Punitive damages may be awarded when conduct is intentionally harmful or grossly negligent. b

Instructions to a jury in a medical malpractice case include efforts to convey the meaning of each of these components of malpractice law. However, juries have a great deal of latitude when interpreting their meaning. For example, the concept of proximal causation used in the law may not conform to the jurors’ understanding of causation. For instance, assume a clinician refused to continue to provide prenatal care after the first 13 weeks. The jurors may decide based upon their own understanding of causation that the clinician’s refusal was the cause of a subsequent birth defect.

Medical malpractice is a complex and changing field. Many factors affect whether or not a malpractice suit is brought. These include the extent of damages, the relationship between the patient and the healthcare provider, and the standards of practice of both medicine and law in the community.

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a Physicians are not the only providers of health care who can be sued under malpractice laws. Other clinicians, such as pharmacists, may be sued, especially those who do not work directly under the authority of physicians. In addition, healthcare facilities as institutions may be sued and are often included as additional defendants in malpractice cases. In this section, we will refer to the defendant in a malpractice suit as a healthcare provider.

b Indirect damages may include what has been called a “loss of consortium,” which includes services provided by a domestic partner, including companionship, homemaking, etc., and future reproductive capabilities of either sex. Gross negligence includes the intentional or wanton omission of care that would be proper to provide, or, alternatively, doing that which would be improper to do. Punitive damages are often justified as a method of deterring such conduct by other providers of care.

Clinicians in the not-too-distant past often withheld key information from patients, including a diagnosis of cancer and the potential harms of recommended treatment. Today, disclosure of these types of information is an expected part of clinical practice. However, until recently, disclosure of medical errors had not been an expected part of clinical practice.

Beginning in 2001, The Joint Commission has required that patients be informed of all outcomes of care, including “unanticipated outcomes.” Recent efforts to develop a system of disclosure have included a far more specific set of expectations, including conveying to the patient:

•   Facts about the event

•   Presence of error or systems failure

•   Expression of regret

•   A formal apology

In addition, institutions are expected to integrate the disclosure process with other aspects of patient safety and risk management activities; provide support for the process, including educating clinicians; and keep track of the use of disclosure at their institutions. Such formal efforts to disclose errors are becoming increasingly common in clinical care. It is still too early to determine the impact of these efforts on quality and their ability to reduce malpractice suits. However, there has already been a growing acceptance of disclosure as a way of addressing medical errors. 12

We have examined the structure of the U.S. healthcare delivery system, including the types of services that are provided in the inpatient and the outpatient settings. We have seen the need for and difficulty in developing a coordinated system to provide continuity of care. We have also seen how the U.S. system is developing models of coordination linking institutions and providers in new ways. The use of technology is a major strategy used by the U.S. healthcare delivery system to hold itself together through electronic medical records and innovative approaches to diagnosis and treatment. The development of the healthcare delivery system is closely tied to the way that health care is financed and services are paid for. Therefore, let us turn our attention directly to the issue of paying for health care.