Mapping the future of health care

Physician Executive, Jan-Feb, 2005 by Joe Flower

How do we get to the future of health care? What can we actually do? Is there a chart, a map, something with details? Where do we find the steps and stages that get us to the hospital and the clinical environment that is truly "Next"?

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First: What's the goal? The old rule still applies: If you're not sure where you're going, that's where you'll end up.

The goal is two-fold: clinical and financial.

* Clinically, the goal is laid out in four of the five guidelines of the Institute for Healthcare Improvement--eliminate unnecessary deaths, unnecessary pain, helplessness and waiting.

* Financially, the goal is summed up in the fifth guideline--eliminate waste, or, more broadly, lower the cost and increase the productivity of everything your institution does.

These goals are intertwined: Unnecessary deaths, pain, helplessness and waiting are symptoms of broken, inefficient systems. They cost money and increase stress.

We have over a decade of experience being victims of managed cost programs that attempt to get to lower cost by decreasing the quality of care. What has been our experience? Year by year, care costs more, even as it gets worse, with medical mistakes on the rise, and more and more clinicians simply leaving their professions in frustration.

The only real path to cost-efficient health care is through a major increase in quality. That's the goal. That's the challenge. Improve the core processes of health care using IT and automation, using techniques of organizational change, using the best knowledge we have of how to design the physical spaces, the supply chain, the methods and procedures.

Where's the map?

So that's the goal. Where's the map? What are the waypoints? How do we know if we are on track or not?

Here's a good start: Download and read two recent reports from the Robert Woods Johnson Foundation: "Designing the 21st Century Hospital," and "The Role of the Physical Environment in the Hospital of the 21st Century: A Once-in-a-Lifetime Opportunity."

(They are free. To find them, go to http://tinyurl.com/5pygn. Or: Go to www.rwjf.org. Choose "Publications" from the search box's pull-down menu, and type "Century" in the search box itself.)

The first is the result of a conference on the future hospital that RWJF held in June 2004. It's a practical document, not some spacey, cool, gadget-filled "oh wow" future spasm.

In fact, two things that strike me as remarkable spring from the pages of this tight, insightful, well-researched report:

1) The high-tech aspects of these designs are not all that "futuristic." They are, today, off-the-shelf systems that seamlessly integrate CPOE, PAX, EMR.

2) Most of the design features are not so much high-tech as common sense

* More hand-washing stations

* Private rooms.

* "Swing" rooms

* Super-sized ventilation systems with powerful filtering

* Sound-absorbing ceiling tiles and carpeting

* Better lighting

* Natural light

* Easier-to-navigate layouts

* Something "natural" to look at

The second is the scientific foundation of many of the recommendations in the first paper. The authors surveyed over 600 recent studies of evidence-based design that looked at basic questions about the design and set up of hospital spaces to see what works and what doesn't.

Do single rooms save lives? (Actually, they do, in half a dozen ways).

Do more sinks encourage hand-washing? (Some. Placement matters.)

What about HEPA air filtration? (Helps a lot. So does variable pressure ventilation, for some uses.)

Some of the information is counter-intuitive, or runs against recent design trends. (No, patients don't get stressed by seeing too many signs. They get stressed by not seeing enough signs.)

Some is only useful if you are building or re-building. Other ideas can be used in existing structures. The authors present the information in 27 tight pages, followed by 40 pages of references. This is a must-read for anybody who runs a clinical environment.

What about technology?

That gives us design parameters for the physical space and for some of the processes. The next layer is IT and automation. This is the deepest well from which we can draw quality and productivity improvements.

A properly-designed and implemented IT/automation program not only will cut labor costs, it will cut medical mistakes. PeaceHealth, in the Northwest, recently reported that going to a CPOE system dropped potential adverse drug events by 83 percent.

When Brigham and Women's and Mass General adopted an "econsult" program, which allows attending physicians, residents, surgeons and other clinicians to share images and EMRs while discussing the case, they found the process resulted in a change in three percent of the orders and five percent of the diagnoses.

Organizations that have automated their laboratories, pharmacies, pharmaceutical delivery carts, fusion pumps and other critical links in the chain of care often find that mistakes in these areas asymptote toward zero.

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But digitizing health care offers a wide array of opportunities to improve both quality and productivity. The process of getting to digitization itself offers thousands of opportunities, simply because in order to digitize any process you have to take it apart and put it back together. You have to ask questions, you have to make choices. To some extent you have to standardize. The process itself can both allow and force insular physicians to work together more closely.