Balancing the Research Portfolio

Jerome H. Grossman, MDDirector, Health Care Delivery Policy Program

Harvard University JFK School of Government

October 28, 2003

Economic and Societal Changes

• Zuboff (1988) – In the Age of the Smart Machine

• Giddens (1988) – The Third Way: The Renewal of Social Democracy

• Rivlin (2002) – Challenges of Modern Capitalism

Elements of Healthcare Delivery

• Starr (1982) – The Social Transformation of Medicine

• Fuchs (1996) – Individual and Social Responsibility

• Institute of Medicine (2000/01) – To Err is Human, Crossing the Quality Chasm

Solving the Simultaneous Equations

Consumer AggregatorsInsurers/Risk Managers/Plans

Delivery Aggregators

Consumer AggregatorsInsurers/Risk Managers/Plans

Delivery Aggregators

Government RegulationGovernment Regulation

ProductivityProductivity

Delivery SystemDelivery System

Government Consumers Employers

Knowledge Into Practice

Biologic Science• Clinical trial to production• Genome as building block• Systems biology• Reimbursement• Implementation• Diffusion

Engineering Science• Prototype to production

• Productivity as building block• Systems engineering• Bundled payment/disease• Implementation • Diffusion

Engineering Based Delivery System

Patient-Centered System

Patient

Front Line Team

Support Organizations

Environment

Information

Connectivity

Responsibility Innovation

CoordinationStandards

Sequential Information Experiments

Data Analysis Hypothesis Validation

Integration of Multiple Subsystems

PCPPCP

EDED

AdmittingAdmitting

SurgerySurgeryLabLab

TriageTriage

Patient Ed.

Patient Ed.

LibraryLibrary

SpecialistSpecialist

ICUICU

Post-OPPost-OP

NursingNursing

Every Home an ICU

Source: Boston Globe

Evolving Role of Insurers

• Catastrophic care

• Disease management

• Pay for performance

• Tools for consumer education

Care for the Future

Source: Boston Globe

The Genome of Productivity

• Measurement of quality and efficiency

• Patient (biosensors, micro-systems)

• EMR, CPOE (CAD/CAM)

• Organization (scheduling, queuing)

• Environment (regulation, policy, homeland security)

Keeping Patients Connected

Source: Boston Globe

Barriers to Progress

• Medical industrial complex

• Provider as professional/patient as passive

• Lack of oversight

• Fragmented health care system

• Reform proposals not founded on research

• Healthcare delivery vs. medical care

What Hasn’t Happened

Very little progress has been made.

Source: Wall Street Journal

Medical Injuries CostBillions Every Year

Researchers studying health-care quality have concluded that medical injuries caused during hospital stay kill tens of thousands of patients annually, requiring at least 2.4 billion extra hospital days resulting in potential medical charges of $9.3 billion.

The work underscores both the scope of the problem and the relative lack of action in solving it. In 1999, for instance, the Institute of Medicine recommended the creation of a “nationwide mandatory reporting system” for medical errors. That hasn’t happened. Very little progress has been made.

Program Recommendations

• Research on engineering systems design

• Information and connectivity

• Coordination and standards

• Responsibility

• Continuous innovation

Our Vision

“The clinical operating system will improve interactions between doctors and patients, who will not have to be in the same room or even in the same time frame.

Enterprise software will provide a patient’s personal health record with information from the person’s entire clinical history”. (Jeffrey Goldsmith)