IOM calls for overhaul of health care system

While medical science and technology have advanced rapidly over the last several decades, the U.S. health care system has foundered, says a new report from the Institute of Medicine (IOM). “Between the care we have and the care we could have lies not just a gap but a wide chasm,” said William Richardson, president of the W.K. Kellogg Foundation and chair of the IOM's Committee on the Quality of Health Care in America, which wrote the report, titled “Crossing the Quality Chasm: A New Health System for the 21st Century.” The report offers an action plan for creating a system in which care is “safe, effective, patient-centered, timely, efficient and equitable.” The plan includes the following recommendations:

• The Department of Health and Human Services should be given the resources and responsibility to establish a program to help make scientific evidence more accessible and useful to physicians and patients. In addition, the Agency for Healthcare Research and Quality should lead the development of evidence-based care processes for the approximately 15 to 25 conditions (most of them chronic) that account for a majority of health care services.

• Through improved use of technology, the health care system should work to eliminate most handwritten clinical data by the end of the decade. “Health care has been relatively untouched by the revolution in information technology that has been transforming nearly every other aspect of society,” said Richardson. “The meticulous collection of personal health information throughout a patient's life can be one of the most important parts of providing proper care. Yet, for most individuals, that health information is dispersed in a collection of paper records that are poorly organized and often illegible, and often cannot be retrieved in a timely fashion.”

• To help create an environment that encourages quality improvement, public and private insurers should re-examine their payment methods. “In some instances, [current payment methods] may actually impede local innovations and efforts to improve quality,” said Richardson.

• The health care workforce should prepare itself for major change. “The people working in the health care systems are its most important resource but will face many challenges in the transition to the 21st century. They may be required to do their work differently and in new types of organizations that may use a different mix of health professionals,” said Richardson.

The new report is a follow-up to the IOM's 1999 report on the quality of health care, which focused on the prevalence of medical errors.

HIPAA privacy rules delayed

The privacy standards of the Health Insurance Portability and Accountability Act (HIPAA), which were to take effect on Feb. 26, have been temporarily postponed. Under the Congressional Review Act of 1996, Congress was supposed to have been given 60 days beginning in December to review the proposed regulations, which seek to protect the privacy of patients' medical records. However, due to an oversight on the part of the Clinton administration, the review did not begin until mid-February, pushing the effective date back to April 14.

At press time Health and Human Services Secretary Tommy G. Thompson had re-opened the public comment period on the rules, which could further delay implementation. The AMA applauded this move. “Many areas of the rule need strengthening. … In many instances health plans are not required to obtain consent to use or disclose patient health records,” said Donald J. Palmisano, MD, AMA Trustee. “Ironically, the rule does substantially increase the administrative burdens for the physicians – the one sector of the health care system already ethically bound to safeguard patient privacy.”

For more information about HIPAA and the pending privacy rules, see “What You Need to Know About HIPAA Now,” FPM, March 2001, p. 43, available online at www.aafp.org/fpm/20010300/43what.html.

PRACTICE PEARLS from here and there

Reducing the risks of change

When implementing a change in your practice, don't be afraid to fail, but do plan accordingly. For example, if you are unsure whether a change will succeed and believe its failure would have major consequences, test the change on a very small scale first. On the other hand, if you believe strongly that a change will succeed and its failure would have only minor consequences, implement the change rapidly on a much larger scale.

– Langley GJ, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide. San Francisco: Jossey-Bass; 1996. In: Continuous Improvement newsletter. Boston: Institute for Healthcare Improvement; 2001;1.

PRACTICE PEARLS from here and there

Why do patients leave?

When patients leave your practice to seek care from other physicians, take the time to ask why and to seek their input on the following issues: quality of medical care, physician responsiveness, staff responsiveness, ease of contacting the office and chances of the patient returning to the practice for care. Tabulate these results monthly to determine whether you should participate with other insurance plans, revamp your office systems or improve your patient communication, among other things.

– Track patients who leave your practice. On Managing newsletter. Plymouth Meeting, Pa: Health Care Publishing; 2001;11(1):4–5.

Managed care loses steam

Over the last two years, as consumer demand for less restrictive health insurance products has increased and hospitals and physicians have learned to “push back” against unfair payment policies, managed care has been losing its power to control costs, says a new report from the Center for Studying Health System Change. This apparent increase in provider clout has caused a “discernible shift” away from capitation, says the report.

Care guidelines for all

Five major Minnesota health plans recently announced that they will begin using a common set of treatment and prevention protocols for 50 common ailments such as low-back pain and diabetes. The evidence-based guidelines were created by physicians working with the Institute for Clinical Systems Improvement. This is the first time all major health plans in a state have collaborated to endorse a standard set of protocols and is considered a major step toward adopting national medical standards.

Change of heart

The quality of physician-patient relationships is declining, at least in Massachusetts, according to a three-year study published in the February 2001 Journal of Family Practice. Although the study showed an increase in physicians' knowledge of their patients, it found significant declines in the three other relationship scales studied: communication, interpersonal treatment and trust. Researchers speculate that the decline could be a result of tremendous organizational change, such as mergers and pressures to increase productivity.

Wide-open spaces

Are your staff members stressed, de-motivated and at risk for musculoskeletal injuries? They may be if they work in open office areas or cubicles, according to a study from Cornell University, reported on in the March 6 Washington Post. The study found that, due to constant low-level noise, employees in such offices made 40 percent fewer attempts to solve a difficult puzzle and were half as likely to take stretch breaks or change positions as those in quieter offices with walls.

Can't get no satisfaction

Physicians employed by group-model HMOs are generally more satisfied with a variety of professional and quality of care issues than those in independent practices, according to a Stanford study published in the Jan. 22 Archives of Internal Medicine. In particular, employed physicians were found to be more satisfied with their time spent on administrative matters and their ability to establish long-term relationships with patients.

Better late than never

Some of the best-known medical Web sites are failing to offer up-to-date information on drugs and diseases, says a study by The Detwiler Group. For example, only one out of six medical Web sites the group monitored had posted a prominent FDA drug warning within two months of its release, and a new Alzheimer's drug took more than six months to be mentioned as “approved” on three out of nine sites.

Be our guest

In an effort to increase patient satisfaction, health plans such as Blue Cross and Blue Shield of Michigan are learning about customer service from the masters: Disney and Ritz-Carlton. According to Larry Lynch, director of business development for the Disney Institute, health care organizations should pay greater attention to detail and should attempt to exceed their customers' expectations, reports the January 2001 Healthplan journal. We just hope hospitals don't start tucking in their bed sheets as tight as the Ritz does.

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