New IOM report says doctors are trying but system needs work

An Institute of Medicine call for wholesale change in the health care delivery system meets with mixed reviews.

By Damon Adams, amednews staff. March 19, 2001.

Leaders of several key physician groups voiced support for a new Institute of Medicine report that recommends overhauling the health care delivery system. They called on the federal government to take action.

The nonprofit institute's report, "Crossing the Quality Chasm: A New Health System for the 21st Century," was met with a unified front from physician groups -- a contrast to their response to the 1999 IOM report on medical errors, which caught the physician community off guard and scrambling to respond to allegations that medical errors killed up to 98,000 people per year.

10 criteria for better health care delivery
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In contrast, "Crossing the Quality Chasm" says that physicians, nurses and other health care professionals are doing their best to provide good care but are swimming upstream in an inefficient system that does not reward innovation and communication.

The report, released this month, says key things need to happen if health care quality is to substantially improve. It must become more patient centered, efforts should be focused on treating chronic conditions and technology must play a much more significant role in health care communication and delivery.

Among the physician groups that support the report's call to action are the American Academy of Family Physicians, the American Medical Association, the American College of Physicians--American Society of Internal Medicine and the American College of Surgeons. Even as the groups were beginning to contemplate what action they should take to guide the report's implementation, they said the federal government must play a key role to ensure quality of care.

Physician groups see federal government playing key role in ensuring quality of care.

"Our organizations call on Congress to enact legislation to make it possible for physicians to identify, diagnose, report and correct potential system problems that undermine quality -- with assurances that they will not be penalized for doing the right thing by identifying and reporting such problems," said Walter J. McDonald, MD, the executive vice president and CEO of ACP-ASIM, in a joint statement from the physician groups.

The new report said health care should be safe, effective, patient centered, timely, efficient and equitable. It recommends over the next decade giving patients more control of their own care and allowing them to receive it whenever they need it -- 24 hours a day -- through e-mail communication with doctors if necessary.

Physicians should base decisions on the best scientific knowledge and be more proactive to patient needs, the report said. Greater use of technology would save time and money.

Show the money

The report committee asked Congress to set aside $1 billion over the next three to five years to help fund promising projects and encourage change in the system.

"Health care today harms too frequently, and fails to deliver its potential benefits routinely," said William Richardson, IOM report committee chair and president of the W.K. Kellogg Foundation in Battle Creek, Mich.

"As medical science and technology have advanced at a rapid pace, the health care delivery system has foundered," Richardson said. "Between the care we have and the care we could have lies not just a gap, but a wide chasm."

Although much of the report calls for sweeping changes that would be made by government, hospitals, health insurers and health insurance purchasers, some aspects of the report could more directly affect practicing physicians.

For example, the report says patients should have "unfettered access" to their own medical information and to clinical knowledge. But some doctors said easy access may place patient confidentiality at risk if medical records or e-mails to patients get in the wrong hands.

The report said use of information technology would reduce cumbersome paper records and promote e-mail communication between doctor and patient.

It calls on the government, health care organizations, insurers and others to work together in a nationwide effort to build a technology-based information infrastructure. But the report doesn't address the cost of such technology for individual medical practices.

"It's costly. [Physicians] may not have the capital reserves to move into that level of sophistication," said AMA President Randolph D. Smoak Jr., MD.

The AAFP estimates that less than 10% of its members have computerized medical records. By 2003, the group wants physicians to use the Internet to help care for patients, and has set 2005 as the year when all members' offices should have computerized record systems.

Putting a dollar figure on installing technology is difficult, physician groups say, and varies according to the size of medical practice.

Samuel Fink, MD, has a computer in his Tarzana, Calif., office. But he doesn't see himself getting a computerized system anytime soon. "It's too expensive. I don't have the $50,000 to $100,000 laying around to implement it," said Dr. Fink, an internist.

The IOM report notes that current payment methods provide little reward to physicians who make quality improvements. It advises private and public purchasers to develop payment policies that reward quality.

The slow process of change

But, despite all the recommendations, it is expected that some physicians will stick to the status quo.

"There's going to be a fair amount of opposition. Change is definitely going to be slow. You're going to have to show why they should do it," said Melissa Behringer, MD, a family physician in Huntsville, Ala., who believes change is needed.

B. Dale Magee, MD, a gynecologist in Worcester, Mass., pointed out that federal reports of this nature can have little immediate impact on individual physicians.

"I don't think doctors will do very much just because this report came out," he said. "The average physician is not going to see this report."

But physician group leaders say change won't be far off if the medical community starts to enact at least some of the report's ideas.

"The whole system has to be looked at and revamped so it comes into better alignment with these principles," said Bruce Bagley, MD, chair of the AAFP board. "Something could happen within five years."

ADDITIONAL INFORMATION:

10 criteria for better health care delivery

1. Patients should receive care whenever they need it and in many forms, including over the Internet and by telephone.
2. The system of care should be able to respond to individual patient choices and preferences.
3. Patients should be given the necessary information and the opportunity to exercise the degree of control they choose over decisions that affect them.
4. Patients should have unfettered access to their own medical information and to clinical knowledge.
5. Patients should receive care based on the best available scientific knowledge.
6. Patients should be safe from injuries caused by errors.
7. The health care system should make information available to patients and their families so they can make informed decisions when selecting a health plan, hospital or clinical practice.
8. Rather than reacting to events, the system should anticipate patient needs.
9. The system should not waste resources or patient time.
10. Clinicians and institutions should collaborate and communicate to ensure an exchange of information and coordination of care.