Missing Steps on “The Path to Continuously Learning Health Care in America”

By James E. Lewis, PhD 

On September 6, 2012, the Institute of Medicine of the National Academies released Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. As a student and promoter of “learning organizations” and a long-time participant in local and national efforts in pursuit of positive change in managing academic medicine, clinical research, patient care at all levels, and health care organization and finance, I searched the recommendations for recognition of:

  • the fundamental roles that physicians would have to play in moving forward along this path
  • physician resistance to change as a, perhaps even the, major factor to be overcome if, indeed, there is to be progress toward achieving the IOM Committee’s recommendations.

Additionally, I searched in vain for such recognition in the recommendations below.

Categories of the Committee’s Recommendations

Foundational Elements1. The digital infrastructure. Improve the capacity to capture clinical, care delivery process, and financial data for better care system improvement, and the generation of new knowledge.

2. The data utility. Streamline and revise research regulations to improve care, promote the capture of clinical data, and generate knowledge.

Care Improvement Targets3. Clinical decision support. Accelerate integration of the best clinical knowledge into care decisions.

4. Patient-centered care. Involve patients and families in decisions regarding health and health care tailored to fit their preferences.

5. Community links. Promote community-clinical partnerships and services aimed at managing and improving health at the community level.

6. Care continuity. Improve coordination and communication within and across organizations.

7. Optimized operations. Continuously improve health care operations to reduce waste, streamline care delivery, and focus on activities that improve patient health.

Supportive Policy Environment8. Financial incentives. Structure payment to reward continuous learning and improvement in the provision of best care at lowest cost.

9. Performance transparency. Increase transparency on health care system performance.

10. Broad leadership. Expand commitment to the goals of a continuously learning health care system.

There is no question that this is a monumental study and report typifying the work of the members and staff of the IOM. But we cannot ignore or deny the fact that it is physicians who admit patients to hospitals, decide the course of care for inpatients and outpatients (especially the small fraction of patients who incur the largest fraction of the costs of health care), and influence patterns of care at national as well as local levels. If they aren’t committed, not just involved, change in health care delivery occurs spottily and at a glacial pace, if at all. Ask anyone who has tried to introduce and disseminate protocol-guided or evidence-based clinical care in the past fifty years in even the most sophisticated and advanced medical centers, academic or otherwise, and for even the most prosaic or dreaded diseases.

“Systems thinking” is fundamental to learning organizations. A central principle underlying systems thinking is “policy resistance, the tendency of complex systems to resist efforts to change their behavior.” If there aren’t informed, focused efforts to neutralize policy resistance, or turn it into a commitment to policy change, building a learning organization is almost certain to be impossible.

Why is this the case, especially with the highly educated, trained, and committed individuals who populate the health care industry? Medical school admission committees work hard to select those believed to be “the best and the brightest” of the applicants. Does medical school and residency somehow teach the students/trainees to resist change? Or do our clinician faculties, in general, teach their students and residents to practice the way they were taught, the way they practice now, or the way they will need to practice and learn continuously throughout their active years?

Whatever the answers, we are a long way from being able to experience the beneficial results of “continuously learning health care in America.” Additionally, my experience indicates that these questions are not being addressed by medical educators, regulatory gatekeepers, or the medical specialty societies and boards among many other key players and stakeholders. Even “lifelong learning” as espoused by the AAMC over 40 years ago doesn’t seem to have found an effective audience or home.

—James E. Lewis, Ph.D., is an independent consultant to departments and schools of medicine, teaching hospitals, cardiovascular and cancer research and clinical programs, medical professional associations, disease oriented foundations, consulting firms, pharmaceutical companies, components of the National Institutes of Health, the Centers for Communicable Diseases, and the predecessors of the Center for Medicare and Medicaid Services. Previously he served as Deputy Dean for Operations and Vice President for Academic Administration, The Mount Sinai School of Medicine and Medical Center, New York City, where his academic title was Professor of Medicine and Health Policy; and Senior Executive Officer, Department of Medicine, University of Alabama at Birmingham, where his academic titles were Professor of Medicine and Adjunct Professor of Sociology. He can be reached at hrdg@earthlink.net.