Change, Challenges, and Innovation in Health Care Delivery

Since the 1970s the U.S. health care system has experienced rapid and unprecedented change. The sites where health care is delivered have shifted from acute inpatient hospitals to outpatient settings, such as ambulatory care and surgical centers, clinics, and physicians' offices, and long-term care and rehabilitation facilities. Patterns of disease have changed from acute infectious diseases that require episodic care to chronic conditions that require ongoing care. Even threats to U.S. public health have changed—for example, epidemics of infectious diseases have largely been replaced by epidemics of chronic conditions such as obesity, diabetes, and mental illness. At the end of 2001 the threat of bioterrorism became an urgent concern of health care planners, providers, policy makers, and the American public; in 2006 the nation prepared for the possibility of pandemic influenza; and in 2008 the nation continued to discuss ways to address the nation's growing numbers of people without health care coverage.

There are new health care providers—midlevel practitioners (advance practice nurses, certified nurse midwives, physician assistants, and medical technologists)—and new modes of diagnosis such as genetic testing. Furthermore, the rise of managed care, the explosion of biotechnology, and the availability of information on the Internet have dramatically changed how health care is delivered.

Some health care industry observers suggest the speed at which these changes have occurred has further harmed an already complicated and uncoordinated health care system. There is concern that the present health care system cannot keep pace with scientific and technological advances. Many worry that the health care system is already unable to deliver quality care to all Americans and that it is so disorganized that it will be unable to meet the needs of the growing population of older Americans or to respond to the threat of a pandemic or bioterrorism.

This chapter considers several of the most pressing challenges and opportunities faced by the U.S. health care system. These include:

• Safety: ensuring safety by protecting patients from harm or injury inflicted by the health care system (e.g., preventing medical errors, reducing hospital-acquired infections, and safeguarding consumers from medical fraud). Besides actions to reduce problems caused by the health care system, safety and quality may be ensured by providers' use of clinical practice guidelines (e.g., standardized plans for diagnosis and treatment of disease and the effective application of technology to information and communication systems).
• Information management: information technology (IT), including the Internet, can provide health care providers and consumers with timely access to medical data, patient information, and the clinical expertise of specialists. For example, Gerard F. Anderson et al. discuss in “Health Care Spending and Use of Information Technology in OECD Countries” (Health Affairs, vol. 25, no. 3, May—June 2006) that effective deployment of IT can also reduce health care expenditures. Reliable public sources of consumer and provider health information on the Internet include the National Institutes of Health, the Centers for Disease Control and Prevention (CDC), and MEDLINE. Using this technology effectively is a health system challenge, especially in terms of protecting patient privacy and confidentiality and ensuring that consumers have access to accurate and reliable health information.
• Innovation: widespread use of innovations in health care delivery should be recommended only after objective analysis has demonstrated that the innovation will measurably benefit the safety, effectiveness, efficiency, or timeliness of health service delivery. Innovations should also be considered if they have the potential to reduce waste of equipment, supplies, or personnel time or if they have the capacity to allocate or distribute health care more equitably. Equitable distribution refers to access to care that does not vary in quality based on the characteristics, such as race, gender, ethnicity, or socioeconomic status, of the population served.

SAFETY

Even though the United States is generally viewed as providing quality health care services to its citizens, the Institute of Medicine (IOM) estimates in the landmark report To Err Is Human: Building a Safer Health System (1999, http://www.nap.edu/books/0309068371/html/) that as many as ninety-eight thousand American deaths per year are the result of preventable medical errors. More than seven thousand of these deaths are estimated to be due to preventable medication errors.

In 2008 HealthGrades, Inc., an independent health care qualityresearchorganizationthatgradeshospitalsbasedona range of criteria and provides hospital ratings to health plans and other payers, issued its fifth update to the 1999 IOM report. In Fifth Annual Patient Safety in American Hospitals Study (April 2008, http://www.healthgrades.com/media/dms/pdf/PatientSafetyInAmericanHospitalsStudy2008.pdf), HealthGrades finds that even though participation in patient safety initiatives to reduce the frequency of medical errors has increased, there is still considerable variation in patient safety in U.S. hospitals.

HealthGrades looks at forty-one million Medicare patient records and nearly every one of the nation's five thousand hospitals to assess the mortality and economic impact of medical errors and injuries that occurred during hospital admissions nationwide from 2004 through 2006. The organization finds that about 1.1 million patient safety incidents occurred in nearly 41 million Medicare hospitalizations.

Some of the most significant patient safety findings are:

• If all the nation's hospitals performed as well as the top 15% identified in the study, then a staggering 220,106 patient safety incidents, 37,214 deaths of Medicare patients, and $2 billion in costs could have been avoided during the three-year period.
• One out of every five Medicare patients hospitalized from 2004 through 2006 who experienced a patient-safety incident died. This rate was lower than the previous year when it was one out of four.
• Patient-safety incidents with the highest rates per one thousand hospitalizations were failure to rescue (this indicator identifies patients who die following the development of a complication and assumes that quality hospitals identify these complications promptly and treat them aggressively), decubitus ulcer (bedsores), and postoperative respiratory failure (failure of lung function following surgical procedures), which accounted for 63.4% of all documented patient-safety incidents.
• Compared to the 2004 research results, the rates of ten out of sixteen key patient safety indicators improved from 2004 to 2006.

Strengthening Safety Measures

In response to a request from the U.S. Department of Health and Human Services (HHS), the Committee on Data Standards for Patient Safety of the IOM created a detailed plan to develop standards for the collection, coding, and classification of patient safety information. The 550-page plan, Patient Safety: Achieving a New Standard for Care (2004), called on the HHS to assume the lead in establishing a national health information infrastructure that would provide immediate access to complete patient information and decision support tools, such as clinical practice guidelines, and capture patient safety data for use in designing ever-improving and safer health care delivery systems.

The IOM plan exhorted all health care settings to develop and implement comprehensive patient safety programs and recommended that the federal government launch patient safety research initiatives aimed at increasing knowledge, developing tools, and disseminating results to maximize the effectiveness of patient safety systems. The plan also advised the designation of a standardized format and terminology for identifying and reporting data related to medical errors.

In July 2005 President George W. Bush (1946—) signed into law the Patient Safety and Quality Improvement Act. Angela S. Mattie and Rosalyn Ben-Chitrit surmise in “Patient Safety Legislation: A Look at Health Policy Development” (Policy, Politics, and Nursing Practice, vol. 8, no. 4, November 2007) that the IOM calls for actions to improve patient safety in To Err Is Human are credited with heightening awareness of this issue and prompting Congress to pass legislation.

Who Is Responsible for Patient Safety?

Many federal, state, and private-sector organizations work together to reduce medical errors and improve patient safety. The CDC and the U.S. Food and Drug Administration (FDA) are the leading federal agencies that conduct surveillance and collect information about adverse events resulting from treatment or the use of medical devices, drugs, or other products. In “Estimates of Healthcare-Associated Infections” (May 30, 2007, http://www.cdc.gov/ncidod/dhqp/hai.html), the CDC estimates that every year 1.7 million patients are diagnosed with hospital- and health care—acquired infections and that these infections claim 99,000 lives. The CDC collaborates with state and local health departments, private-sector groups, academic medical centers, and health care providers to develop and implement other programs to reduce errors and adverse outcomes of care.

The Centers for Medicare and Medicaid Services acts to reduce medical errors for Medicare, Medicaid, and State Children's Health Insurance Program beneficiaries through its peer review organizations. Peer review organizations concentrate on preventing delays in diagnosis and treatment that have adverse effects on health.

The U.S. Departments of Defense and of Veterans Affairs (VA), which is responsible for health care services for U.S. military personnel, their families, and veterans, have instituted computerized systems that have reduced medical errors. The VA established the Centers of Inquiry for Patient Safety, and its hospitals also use bar-code technology and computerized medical records to prevent medical errors.

Safe medical care is also a top priority of the states and the private sector. In 2000 some of the nation's largest corporations, including General Motors and General Electric, joined together to address health care safety and efficacy and to help direct their workers to health care providers (hospitals and physicians) with the best performance records. Called the Leapfrog Group (http://www.leapfroggroup.org/), this business coalition was founded by the Business Roundtable, a national association of Fortune 500 chief executive officers, to leverage employer purchasing power that initiates innovation and improves the safety of health care.

The Leapfrog Group publishes hospital quality and safety data to assist consumers in making informed hospital choices. Hospitals provide information to the Leapfrog Group through a voluntary survey that requests information about hospital performance across four quality and safety practices with the potential to reduce preventable medical mistakes and improve health care quality. Leah F. Binder (April 16, 2008, http://www.leapfroggroup.org/news/leapfrog_news/4732651), the chief executive officer of the Leapfrog Group, explained in her testimony before the U.S. House of Representative's Committee on Oversight and Government Reform that the group is composed of major companies and other private and public purchasers of health care benefits for more than thirty-seven million Americans. Its mission is to promote health care safety programs and advocate innovative solutions to existing problems.

IMPROVING TEAMWORK TO PREVENT MEDICAL ERRORS AND IMPROVE PATIENT SAFETY . In November 2007 the U.S. Agency for Healthcare Research and Quality (AHRQ) and the Department of Defense launched TeamSTEPPS (http://teamstepps.ahrq.gov/abouttoolsmaterials.htm), a program that aims to optimize patient outcomes by improving communication and other teamwork skills among health care professionals. TeamSTEPPS applies team training principles developed in military aviation and in private industry to health care delivery. Carolyn Clancy, the director of the AHRQ, asserts in “Physicians and Nurses Together Can Improve Patient Safety” (Medscape Journal of Medicine, vol.10, no. 2, 2008), that “nurses are trained to manage a variety of patient care situations, whereas physicians regard their role as having ultimate responsibility for the patients. In few instances do both nurses and physician train together, a disconnect that can be counterproductive to high-quality healthcare. In the new culture of medicine, teamwork should be the standard, not the ideal. As physicians, we can be leaders in the effort to instill teamwork where we practice and do right by our patients.”

Professional societies are also concerned with patient safety. Over half of all the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) hospital standards pertain to patient safety. Since 2002 hospitals seeking accreditation from the JCAHO have been required to adhere to stringent patient safety standards to prevent medical errors. The JCAHO standards also require hospitals and individual health care providers to inform patients when they have been harmed in the course of treatment. The aim of these standards is to prevent medical errors by identifying actions and systems likely to produce problems before they occur. An example of this type of preventive measure, which is called prospective review, is close scrutiny of hospital pharmacies to be certain that the ordering, preparation, and dispensing of medications is accurate. Similar standards have been developed for JCAHO-accredited nursing homes, outpatient clinics, laboratories, and managed care organizations.

On January 1, 2004, the JCAHO began surveying and evaluating health care organizations using new medication management standards. The new standards revise and consolidate existing standards and place even greater emphasis on medication safety. The revised standards increase the role of pharmacists in managing appropriate and safe medication use and strengthen their authority to implement organization-wide improvements in medication safety.

HOSPITALS DESIGNED FOR SAFETY . Even though HealthGrades finds in Third Annual Patient Safety in American Hospitals Study (April 2006, http://www.healthgrades.com/media/dms/pdf/patientsafetyinamericanhospitalsstudy 2006.pdf) that just 74% of hospitals surveyed had fully implemented a patient safety plan and 9% had no plan at all, some hospitals are taking extraordinary measures to reduce medical errors and enhance safety. As Gautam Naik reports in “Ounce of Prevention to Reduce Errors, Hospitals Prescribe Innovative Designs” (Wall Street Journal, May 8, 2006), novel approaches include hot-lines to enable staff to anonymously report medical errors and architectural innovations such as slip-proof floors, special lighting to aid diagnosis, round rather than sharp interior wall corners, and standardized layout of equipment enabling staff to quickly and easily access needed equipment and supplies. Some hospitals have chosen to abandon the practice of recycling the air in the buildings to reduce the risk of spreading infections. Others have chosen to forgo vinyl coverings on external walls because it attracts infection-causing mold. Naik explains that at least one hospital that instituted facility-wide design and layout changes reports preliminary evidence that the changes it instituted have already reduced rates of infection, falls, and medication errors.

CLINICAL PRACTICE GUIDELINES

Clinical practice guidelines (CPGs) are evidence-based protocols—documents that advise health care providers about how to diagnose and treat specific medical conditions and diseases. CPGs offer physicians, nurses, other health care practitioners, health plans, and institutions objective, detailed, and condition- or disease-specific action plans.

Widespread dissemination and use of CPGs began duringthe 1990sinan efforttoimprove the qualityofhealth care delivery by giving health care professionals access to current scientific information on which to base clinical decisions. The use of guidelines also aimed to enhance quality by standardizing care and treatment throughout a health care delivery system such as a managed care plan or hospital and throughout the nation.

Early attempts to encourage physicians and other health professionals to use practice guidelines was met with resistance, because many physicians rejected CPGs as formulaic “cookbook medicine” and believed they interfered with physician-patient relationships. Over time, however, physicians were educated about the quality problems resulting from variations in medical practice, and opinions about CPGs gradually changed. Physician willingness to use CPGs also increased when they learned that adherence to CPGs offered some protection from medical malpractice and other liability. Nurses and other health professionals more readily adopted CPGs, presumably because their training and practice was oriented more toward following instructions than physicians' practices had been.

The National Guideline Clearinghouse is a database of CPGs produced by the AHRQ in conjunction with the AMA and the American Association of Health Plans. The clearinghouse offers guideline summaries and comparisons of guidelines covering the same disease or condition prepared by different sources and serves as a resource for the exchange of guidelines between practitioners and health care organizations.

CPGs vary depending on their source. All recovery and treatment plans, however, are intended to generate the most favorable health outcomes. Federal agencies such as the U.S. Public Health Service and the CDC, as well as professional societies, managed care plans, hospitals, academic medical centers, and health care consulting firms, have produced their own versions of CPGs.

Practically all guidelines assume that treatment and healing will occur without complications. Because CPGs represent an optimistic approach to treatment, they are not used as the sole resource for development or evaluation of treatment plans for specific patients. CPGs are intended for use in conjunction with evaluation by qualified health professionals able to determine the applicability of a specific CPG to the specific circumstances involved. Modification of the CPGs is often required and advisable to meet specific, organizational objectives of health care providers and payers.

It is unrealistic to expect that all patients will obtain ideal health outcomes as a result of health care providers' use of CPGs. Guidelines may have greater utility as quality indicators. Evaluating health care delivery against CPGs enables providers, payers, and policy makers to identify and evaluate care that deviates from CPGs as part of a concerted program of continuous improvement of health care quality.

INFORMATION AND COMMUNICATION TECHNOLOGY

The explosion of communication and information management technologies has already revolutionized health care delivery and holds great promise for the future. Health care data can be easily and securely collected, shared, stored, and used to promote research and development over great geographic distances and across traditionally isolated industries. Online distance learning programs for health professionals and the widespread availability of reliable consumer health information on the Internet have increased understanding and awareness of the causes and treatment of illness. This section describes several recent applications of technology to the health care system.

Telemedicine

The term telemedicine describes a variety of interactions that occur by way of telephone lines. Telemedicine may be as simple and commonplace as a conversation between a patient and a health professional in the same town or as sophisticated as surgery directed by way of satellite and video technology from one continent to another.

In “Telemedicine Coming of Age” (January 13, 2005, http://tie.telemed.org/articles/article.asp?path=telemed101& article=tmcoming_nb_tie96.xml), Nancy Brown of the Telemedicine Research Center, a nonprofit public research organization, explains that there are two types of technology used in most telemedicine applications. The first type stores digital images taken with a digital camera and sends them from one location to another. The most common application of this kind of telemedicine is teleradiology–sending x-rays, computerized tomography scans, or magnetic resonance imaging scans from one facility to another. The same technology may be used to send slides or images from the pathology laboratory to another physician or laboratory for a second opinion. Another example of the use of digital image transfer is the rural primary care physician who, miles from the nearest dermatologist (physician specialist in skin diseases), can send a photograph of a patient's rash or lesion and receive an immediate, long-distance consultation from the dermatologist.

Another application of telemedicine that uses only the standard telephone line in a patient's home is trans-telephonic pacemaker monitoring. (Cardiac pacemakers are battery-operated implanted devices that maintain normal heart rhythm.) Cardiac technicians at the other end of the telephone are able to check the implanted cardiac pacemaker's functions, including the status of its battery. Transtelephonic pacemaker monitoring is able to identify early signs of possible pacemaker failure and detect potential pacemaker system abnormalities, thereby reducing the number of emergency replacements. It can also send an electrocardiogram rhythm strip to the patient's cardiologist (physician specialist in heart diseases).

The second type of technology described by Brown is two-way interactive television, which uses video-teleconferencing equipment to create a meeting between a patient and primary care physician in one location and a physician specialist elsewhere when a face-to-face consultation is not feasible because of time or distance. Peripheral equipment even enables the consulting physician specialist to perform a virtual physical examination and hear the patient's heart sounds through a stethoscope. The availability of desktop videoconferencing has expanded this form of telemedicine from a novelty found exclusively in urban, university teaching hospitals to a valuable tool for patients and physicians in rural areas who were previously underserved and unable to access specialists readily.

Despite the promise of telemedicine, several obstacles have prevented Americans from realizing all its potential benefits. As of August 2008, many states did not permit physicians who are not licensed in their state to practice telemedicine, and the Centers for Medicare and Medicaid Services reimbursed for interactive teleconference services but would not pay for digital image transfer. Many private insurers have been reluctant to pay for telemedicine, and some physicians fear additional liability (medical malpractice suits or other litigation) arising from tele-medicine. Finally, some of the communities that would benefit most from telemedicine do not have the telecommunications equipment necessary to deliver the bandwidth for telemedicine.

In “Perspectives on Medical Outsourcing and Tele-medicine–Rough Edges in a Flat World?” (New England Journal of Medicine, vol. 358, no. 15, April 10, 2008), Sanjiv N. Singh and Robert M. Wachter observe increasing use of telemedicine, with projected annual growth rates of 15% to 20% and particularly strong growth in the fields of radiology, dermatology, mental health consultation, and home care. Singh and Wachter report that as many as three hundred U.S. hospitals and two-thirds of radiology practices use some form of teleradiology, and that the VA conducts nearly a quarter of a million tele-consultations per year.

Telemedicine appears to improve patient outcomes. For example, Andreas S. Morguet et al. find in “Impact of Telemedical Care and Monitoring on Morbidity in Mild to Moderate Chronic Heart Failure” (Cardiology, vol. 111, no. 2, 2008) that telemedical care and monitoring may reduce the frequency and severity of illness in patients with chronic heart failure (a condition in which the heart is unable to supply the body with enough blood). In “Telemedicine Facilitates CHF Home Health Care for Those with Systolic Dysfunction” (International Journal of Telemedicine and Applications, 2008), Pennie S. Seibert et al. find improved control of congestive heart failure when telemedicine was implemented.

Telemedicine has been used in schools to improve access to care, treat middle ear infections, and increase appropriate referral to specialists. It has also proven beneficial in helping to manage asthma in school-aged children. David A. Bergman et al. hypothesize in “The Use of Telemedicine Access to Schools to Facilitate Expert Assessment of Children with Asthma” (International Journal of Telemedicine and Applications, 2008) that asthma care would be improved through a telemedicine link between an asthma specialist and a school-based asthma program, which involved real-time video and audio conferencing between the patient and school nurse on-site at the school and the asthma specialist at San Francisco General Hospital. The researchers conducted the program in three urban schools to determine the feasibility of asthma-focused telemedicine. They find that the program produced significant improvements in health status outcomes and note that the use of telemedicine ensured that children identified with asthma received comprehensive assessments, action plans, and asthma education. Bergman et al. conclude that telemedicine “allowed for a more efficient use of the asthma subspecialist's time when contrasted with hospital-based asthma clinics.”

Telemedicine has also proven to be a cost-effective alternative to emergency department visits. Kevin McKe-ever reports in “Telemedicine a Cost-Effective Alternative to ER Visits” (HealthDay News, May 9, 2008) on two presentations that were made at the May 2008 Pediatrics Annual Societies meeting in Honolulu, Hawaii. The first presentation was by researchers from the University of Rochester Medical Center, which operates a Rochester-based telemedicine program that provides interactive, Internet-based pediatric health-care service. The researchers asserted that “telemedicine is a cost-effective way to replace more than a quarter of all visits to the pediatric emergency department.” The second presentation noted that telelmedicine has the capacity to provide quality care at a lower cost–saving payers more than $14 per child per year.

Wireless Technology in the Hospital.

In “Ten Lessons from the Top 100” (Hospitals and Health Networks, July 2007), Alden Solovy asserts that the most wired hospitals have better outcomes than other hospitals on key measures including mortality rates, the AHRQ's patient safety measures, and average length of stay. Solovy's assertion is based on the results of the 2007 Hospitals and Health Networks Most Wired Survey and Benchmarking Study, which revealed a strong association between the implementation and adoption of IT and the quality and cost of patient care.

The top hospitals used technology to improve patient flow and to improve workflow by, for example, providing a central location for the nursing task list, so that all of a nurse's activities for an upcoming shift, including physician orders, reminders, and nursing interventions, are in one convenient place. Technology was also employed to measure and analyze process improvements such as “time to care”–the time between order placement and delivery of care. The most wired hospitals used technology to facilitate electronic ordering and bedside medication matching to reduce the number of potential medication errors. They also used “smart alerts”–real-time monitors that use information in the medical record to identify patients with potentially deteriorating conditions. Other uses of wireless technology include disseminating digital images, such as radiological images, to multiple sites, such as clinics and physicians' offices, and automating processes in the operating room.

Industry observers caution that IT is not itself a solution to the many problems plaguing the U.S. health care system. It is one of many tools for achieving process improvements that lead to better outcomes, and it must be used in combination with other tools and techniques to affect care. Solovy notes that the survey results reveal “an association between IT adoption and key quality measures, but association is not causality.”

Online Patient-Physician Consultations

Even though no one is certain about the frequency with which online encounters or exchanges between physicians and patients occur, Harris Interactive reveals in “Few Patients Use or Have Access to Online Services for Communicating with their Doctors, but Most Would Like To” (September 22, 2006, http://www.harrisinteractive.com/news/allnewsbydate.asp?NewsID=1096) that a majority of respondents in a 2006 survey wanted access to a variety of electronic medicine (e-medicine) technologies in communicating with their doctors. For example, 77% wanted e-mail reminders of when a visit with their physician is coming up, 74% expressed the desire for e-mail communication with their physician, 67% wanted to receive diagnostic test results via e-mail, and 57% said they wanted to use a home monitoring device that sends information (blood pressure readings or blood tests) to their physician.

In “Communication between Physicians and Patients in the Era of E-Medicine” (New England Journal of Medicine, vol. 356, no. 24, June 14, 2007), John H. Stone observes that payers in Florida, California, Massachusetts, and New York reimburse physicians for Web consultations. In those states that do not reimburse physicians for Web consultations, such “electronic visits” typically cost between $10 and $25, and patients pay for them out of pocket. Other electronic communications between patients and physicians' offices include appointment scheduling, reminders of follow-up visits, prescription renewal requests, administrative functions (e.g., billing, insurance verification, and changes of address), and questions about test results, all of which are generally provided free of charge. Stone notes that “early studies indicate that e-medicine methods improve the productivity of providers, reduce the number of office visits, and save money.”

One important advantage of electronic encounters (e-encounters) over telephone conversations is the patient's ability to communicate home monitoring results such as blood pressure or blood glucose levels in a format that is easily included as documentation in the patient's permanent (paper or electronic) medical record. Another advantage is that less time devoted to telephone calls improves the efficiency of the physician's office, thereby boosting productivity and potentially reducing practice expenses.

Concerns about e-encounters center on privacy and security of patient information exchanged and physician reimbursement for the time spent in electronic correspondence with patients. Besides legal and privacy issues, some industry observers suggest that guidelines should be developed for e-encounters to ensure that they are clinically appropriate and are not used as substitutes for needed, but more costly, face-to-face office visits.

Peter Stalberg et al. find in “E-mail Access and Improved Communication between Patient and Surgeon” (Archives of Surgery, vol. 143, no. 2, February 2008) that despite medicolegal concerns, providing patients undergoing elective surgery with e-mail access to their surgeons proves to be an effective means of improving patient-physician communication.

Despite promising research findings about the benefits of e-mail correspondence between patients and physicians as well as increasing consumer demand for electronic communication, most physicians are not engaging in online communication with patients. Alicia Chang reports in “It's No LOL: Few US Doctors Answer E-mails from Patients” (Associated Press, April 22, 2008) that a 2007 study found that just 31% of physicians e-mailed their patients. The American Medical Association cautions that e-mail should not be used as a substitute for face-to-face time with patients and advises physicians to talk with patients about the technology's limitations.

Is Applied Technology the Solution to the Nursing Shortage?

In “What Nurses Want” (Government Health IT, March 31, 2008), John Pulley explains that many efforts are being made to address the current nursing shortage in the United States. Instead of trying to recruit more nurses and nursing students, the American Academy of Nurses (AAN) is endeavoring to make better use of nurses, in large measure by using IT to improve their efficiency. With the assistance of the Robert Wood Johnson Foundation, the AAN Workforce Commission examined the work processes and environments of nurses and other health care providers at twenty-five sites throughout the United States.

The commission found that nurses and other health professionals sought IT solutions to assist with coordination and delivery of care, communication, discharge planning, documentation, patient transport, and supplies and equipment. Nurses want completely electronic medical records, which in 2007 were only used by an estimated 10% of the nation's health care providers; computerized order entry systems to eliminate problems arising from illegible handwriting; touch-screen or voice-activated technology for documentation; and automated networks to collect and download patient data. They are especially enthusiastic about hands-free tools and wireless technology. Other needs identified by the commission include nurses' desire for increased use of radio frequency identification technology to track people, supplies, and equipment, and greater use of robotics to deliver supplies. Nurses also endorse the use of smart beds that monitor patient movements and pressure sensors to help reduce the frequency of bedsores.

MORE STAFF, RATHER THAN TECHNOLOGY, IS KEY TO IMPROVING QUALITY OF CARE . Despite rapid advances in technology, many industry observers feel that it is not sufficient to solve the nursing shortage that the Bureau of Labor Statistics projects in the press release “Employment Projections: 2006—16” (December 4, 2007, http://www.bls.gov/news.release/pdf/ecopro.pdf), which will require over one million replacement nurses by 2016. In “Nurse Staffing in Hospitals: Is There a Business Case for Quality?” (Health Affairs, January—February 2006), Jack Needleman et al. report on their study of 799 acute care hospitals in 11 states. They find that U.S. hospitals could prevent an estimated 6,700 patient deaths, 70,416 complications, and 4.1 million hospital days of care by hiring more registered nurses and increasing the hours of nursing care per patient. Needleman et al. project that increased staffing would produce minimal increases in hospital budgets, ranging from 0.4% to 0.8%, when offset by savings realized by reducing rates of medical errors and hospital lengths of stay.

The American Hospital Association (AHA) reports in “America's Hospitals Confront Serious Workforce Challenges” (AHA News, August 21, 2007) that in 2006, 5,000 community hospitals alone were in need of 116,000 registered nurses to fill vacancies. In “Bill Would Ease Nurse Visa Backlog, Bolster Nurse Education” (AHA News, May 12, 2008), the AHA expresses its support for legislation to provide funds to help U.S. nursing schools expand the domestic supply of nurses and establish a three-year pilot program aimed at keeping U.S. nurses in the workforce. The bill, the Emergency Nursing Supply Relief Act (H.R. 5924), would also set aside twenty thousand employment-based visas per year for the next three years for foreign-educated registered nurses and physical therapists.

Promise of Robotics

One technological advance that promises to reduce hospital operating costs and enable hospital workers to spend more time caring for patients is the use of robots. Once relegated to the realm of science fiction, the twenty-first century has seen a resurgence of interest in automated machines such as self-guided robots to perform many routine hospital functions.

Mike Crissey describes in “Courier Robots Get Traction in Hospitals” (Associated Press, July 7, 2004) the “Robo-Cart,” a motorized table that transports linens, medical supplies, x-rays, food, and other materials throughout a hospital. Another automated robot courier, a four-foot-tall cabinet with flashing lights and turn signals called “HelpMate,” speaks in English and Spanish. The robots use wireless radio to call elevators and open automatic doors, and they communicate respectfully, saying “thank you” on entering an elevator and inviting hospital employees to “please examine my contents when making deliveries.” According to Kawanza Newson, in “Robot Now Makes Tracks through Hospital” (Milwaukee Journal Sentinel, March 30, 2008), a robotic cart that looks like a train, warns onlookers to “pardon my caboose” when it backs up, and makes deliveries of oxygen monitors and feeding pumps was one of a hundred such robotic carts in use in U.S. hospitals in 2008.

Some robots are involved in more than simply routine, menial tasks. Barnaby J. Feder explains in “Prepping Robots to Perform Surgery” (New York Times, May 4, 2008) that a growing number of surgeons delegate much of their work to medical robots controlled from computer consoles. The robotic system allows a cardiovascular surgeon to perform heart surgery without touching the patient, or a urologist to ensure precise, tremor-free incisions to prevent damage to delicate nerves during prostate surgery. Seated at a console with a computer and video monitor, the surgeon uses handgrips and foot pedals to manipulate robotic arms that hold scalpels, sutures, and other surgical instruments to perform the operation. These robotic systems have been approved for use by the FDA, and in 2008 they represented a $1 billion segment of the medical device industry.

Robots do not, however, trump humans in all aspects of health care delivery. In “Enhanced Gait-Related Improvements after Therapist- versus Robotic-Assisted Locomotor Training in Subjects with Chronic Stroke. A Randomized Controlled Study” (Stroke, vol. 39, no. 6, 2008), T. George Hornby et al. of the University of Illinois, Chicago, compare the results of physical therapist—assisted training and rehabilitation of stroke patients with training provided by a robotic device. They find that therapist-assisted training produced greater improvement in walking speed and symmetry as well as in overall walking ability than did training provided by a robotic device. At the end of treatment, the increase in gait speed and the ability to stand using one limb was twice as high in the group of patients receiving services from physical therapists than in the group treated by robots.

The Future Is Here for Pioneering Hospitals

In 2008 many hospitals instituted new technology to help reduce errors, improve safety, and assist nurses to perform their responsibilities more easily, accurately, and efficiently. For example, the article “Survey Investigates Role of Pharmacy in Technology Use in Hospitals” (Medical News Today, February 26, 2008) notes that most U.S. hospitals and health systems use multiple complex health ITs to support patient medication use, but only some of them have integrated these systems.

In “Information Technologies and Improved Patient Safety: A Study of 98 Hospitals in Florida” (Journal of Healthcare Management, vol. 52, no. 6, November— December 2007), Nir Menachemi et al. examine the overall adoption of IT by hospitals and patient outcome measures. The researchers looked at a large sample of Florida hospitals, public and private, rural and urban, and used widely accepted patient safety indicators to measure the effect of IT systems on patient outcomes. Menachemi et al. find that patients are more likely to have better health outcomes when they are treated at hospitals using IT.

INNOVATION SUPPORTS QUALITY HEALTH CARE DELIVERY

The health care industry is awash in wave after wave of new technologies, models of service delivery, reimbursement formulae, legislative and regulatory changes, and increasingly specialized personnel ranks. Creating change in hospitals and other health care organizations requires an understanding of diffusion–the process and channels by which new ideas are communicated, spread, and adopted throughout institutions or organizations. Diffusion of technology involves all the stakeholders in the health care system: policy makers and regulatory agencies establish safety and efficacy, government and private payers determine reimbursement, vendors of the technology are compared and one is selected, hospitals and health professionals adopt the technology and are trained in its use, and consumers are informed about the benefits of the new technology.

The decision to adopt new technology involves a five-stage process beginning with knowledge about the innovation. The second stage is persuasion, the period when decision makers form opinions based on experience and knowledge. Decision is the third phase, when commitment is made to a trial or pilot program, and is followed by implementation, the stage during which the new technology is put in place. The process concludes with the confirmation stage, the period during which the decision makers seek reinforcement for their decision to adopt and implement the new technology.

Innovation to Improve Access

In April 2006 Massachusetts made national news when it enacted a compulsory health insurance plan intended to extend health coverage to every state resident by 2009. According to Christopher Rowland, in “Mass. Health Plan Seems Unlikely to Be US Model” (Boston Globe, April 14, 2006), other states have passed legislation aimed at providing universal coverage but none are as ambitious as the Massachusetts plan, which seeks to unite employers and health access advocates to achieve their shared objectives. In 2003 Maine passed a law to make coverage available for all residents by 2009, Hawaii requires all employers to contribute to health care coverage for their workers, and Illinois provides coverage for children up to age eighteen.

Conservative critics of the Massachusetts plan, which requires employers and individuals to purchase health insurance, consider the state mandate an unwelcome government intrusion on individual rights. Liberal skeptics fear that many individuals will suffer when forced to purchase insurance the state deems affordable, but still constitutes an unworkable proportion of their income.

Even though it is not yet known how well the plan will work to improve health care coverage and access or whether it will be a model for other states, which have higher proportions of uninsured residents (Rowland notes that in 2006 Massachusetts had just 10% uninsured, compared to the national average of 18%), many states may look more closely at some of the plan's other provisions, such as its requirement that hospitals fully disclose cost and quality measures to enable health care consumers and payers to choose quality, cost-effective providers of medical care.

Alice Dembner reports in “Subsidized Care Plan's Cost to Double” (Boston Globe, February 3, 2008) that by 2008,169,000 people had enrolled in the Commonwealth Care plan, which provides free or subsidized insurance for low and moderate income residents, at a cost of $618 million for the fiscal year ending June 30, 2008. According to Dembner, state officials estimated that the plan will double in size and expense over the next three years– to 342,000 people at a cost of nearly $1.4 billion annually–which means that the plan will have to scale back its ambitious goals in terms of coverage or pass the associated expenses along to taxpayers. These projections far exceed forecasts developed at the plan's inception. The state has requested assistance from the federal government to finance the plan from 2009 to 2011; however, as of August 2008, there was no assurance that the federal funds would be available.

Communicating Quality

In Crossing the Quality Chasm: A New Health System for the 21st Century (2001, http://www.nap.edu/books/0309072808/html/), the IOM sets forth six goals for improvement and ten rules for redesign of the U.S. health care system. These ten rules are:

1. Care is based on continuous healing relationships
2. Care is customized according to patient needs and values
3. The patient is the source of control
4. Knowledge is shared and information flows freely
5. Decision making is evidence based
6. Safety is a system priority
7. Transparency is necessary
8. Needs are anticipated
9. Waste is continuously decreased
10. Cooperation among clinicians is a priority

Rule number seven, which focuses on transparency, refers to the need for public accountability for the quality of the health care system. Health care consumers should be given information that allows them to make thoughtful, informed choices and decisions about health insurance plans and providers.

The requirement for transparency requires health care providers and plans to disclose information they previously did not share among themselves or with consumers. Furthermore, many health care plans and providers find that to compete successfully for health care consumers, they must demonstrate the ability not only to deliver health care services effectively but also to document and communicate measures of clinical quality and fiscal accountability.

The publication of medical outcomes report cards and disease- and procedure-specific morbidity rates (the degree of disability caused by disease) and mortality rates (the number of deaths caused by disease) has attracted widespread media attention and sparked controversy. Advocates of the public release of clinical outcomes and other performance measures contend that despite some essential limitations, these studies offer consumers, employers, and payers the means for comparing health care providers.

Some skeptics question the clinical credibility of scales such as surgical mortality, which they claim are incomplete indicators of quality. Others cite problems with data collection or speculate that data are readily manipulated by providers to enhance marketing opportunities sufficient to compromise the utility and validity of published reports. Long term, the effects of published comparative evaluation of health care providers on network establishment, contracting, and exclusion from existing health plans are uncertain and in many instances may be punitive (damaging). Hospitals and medical groups may be forced to compete for network inclusion on the basis of standardized performance measures.

The number of Web sites that rate physicians and hospitals continues to grow, with Angie's List and Vitals.com joining more established sites such as HealthGrades.com in 2008. The sites describe physicians' training, experience, certification, and any disciplinary actions taken against them, as well as patient ratings. They also encourage physicians to respond to patient comments. Some industry observers contend that the sites, especially those that use anonymous ratings, have the potential to further erode patient-physician relationships by prompting physicians to behave defensively. In “Online Ratings Irk Doctors” (USA Today, March 31, 2008), Kim Painter quotes Nancy Nielsen, the president-elect of the American Medical Association, as saying that even though “doctors care very much what patients think and welcome scientifically valid patient surveys, anonymous online ratings and rants can ruin reputations and destroy trust.”

Despite legitimate concern about the reliability, validity, and interpretation of data, there is consensus that scrutiny and dissemination of quality data will escalate. As of August 2008, consumer interest focused on individual providers (local hospitals and physicians). When choosing between health plans involving the same group of participating hospitals and physicians, employers requested plan-specific information to guide their decisions.