The Institute of Medicine (2001) report Crossing the Quality Chasm: Health Care in the 21st Century was released on March 1, 2001. Following in the wake of To Err Is Human (Institute of Medicine, 1999), the report makes for tempting speculation. This special issue of JACM (25:1) on balance, focuses on the immediate challenges faced by the health services research and ambulatory care practice communities.
In 1984, I wrote an article in the Journal of Health Administration Education entitled "DRGs and Health Administration Education: The Long View" (Greene, 1984). I recall having to argue the point about "the long view." With all the clamor about DRGs and the operational aspects of hospital inpatient services, the main educational point was that forevermore hospital analysts would be forced into a systems frame of reference in order to understand hospital outputs. But even more important was the certainty that managers, policy analysts, consultants, and researchers would force health services providers to specify outputs across the service continuum of health care. Systems thinking would become an essential requirement for those seated around any conference table discussing health care services. If there were indeed specifiable processes with measurable products of clinical and administrative meaningfulness, then product management would eventually get to wherever care was delivered. Crossing the Quality Chasm has as its root the analyses made possible through redesigning the systems of health organizations. We are not likely to turn away from that logical flow of process specification and where it will lead us.
This issue of JACM is an early look at some of the work, both empirical and conceptual, that pertains to the six aims formulated in Crossing the Quality Chasm (Institute of Medicine, 2001, p. 95). The report stipulates that the health care should be safe, effective (i.e., scientific or evidenced based), patient centered, timely, efficient, and equitable. These six aims will undoubtedly influence organizational redesign and guide research, operational processes, and analysis, and hence these aims are taken as the focus of the articles contained herein.
In the first article, Douglas Conrad shows that ambulatory care efficiency is partly a function of the activities of patients, providers, payers, and investors. In the second, Keith Moore and Dean Coddington use a case study approach to look at how effectiveness, patient-centeredness, timeliness, and efficiency are viewed by provider organizations and physicians. Their case descriptions are important for many reasons, not least because many deal with information technology. Crossing the Quality Chasm refers to the inability of health organizations to keep pace with technological change and sees the divide between the potential of technology and its actual use as a "chasm."
Dr. Prince looks at medical groups and at information technology in support of patient-centered care. In my opinion, by looking at medical groups, Dr. Prince is venturing into one of the least understood yet widely utilized models of health care delivery. This is an important area, and Crossing the Quality Chasm calls for more research to understand which patient protocols can push forward the patient-centered perspective. Dr. Suri links information technology with cost-effective care and quality care. In looking at technology growth in the way he does, Dr. Suri is closing the gap between the rate of growth of information technology and of our ability to use it effectively. Dr. Suri looks at the problems of database coordination and the strains on the high level of quality communication necessitated by caring for chronic patients across care and provider systems.
Dr. Johnson and his research colleagues examine the adoption of computer-based information systems by medical groups. They studied 120 medical groups that provide care within a managed care environment, and looking at the dependent measure of adoption, they tested hypotheses related to the profit motive, the size and complexity of the medical groups, and their administrative capacity.
Senator Durenburger provides a brief commentary that works well as an introduction to the article by Dr. Wahls and her colleagues, which explores the likely federal response to the findings presented in To Err Is Human, the earlier IOM report. These findings on patient safety and medical errors shocked the health field and the public and stimulated a flurry of governmental activity. Dr. Wahls and her colleagues provide an instructive account of the federal actions that resulted from the report and predict probable future actions.
In the next article, Robert Keller and colleagues describe the Maine Medical Assessment Foundation's Outcomes Dissemination Project, which was designed to educate physicians on their practice patterns by providing them with information on health care utilization within their area and getting them to discuss these patterns in study groups. As a consequence of learning about the utilization rates of other physicians, high users of a particular treatment often reduced their rates, especially if good evidence of the efficacy of the treatment was lacking.
The following piece, by Ray Carey, represents the beginning of a new feature in the journal. Carey will contribute an article each issue on understanding and applying statistical concepts. This month's article describes some basic statistical concepts and presents a simple tool for assessing the effectiveness of interventions.
Finally, we hear again from Mark Holt, live and direct from the Republic of Texas.
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