Crossing the Quality Chasm: A New Health System for the 21st Century
by Committee on Quality of Health Care in America, Institute of Medicine

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Book Reviews of Crossing the Quality Chasm: A New Health System for the 21st Century

Book Review: This book will not get you there
Summary: 4 Stars

The format of the book is to present evidence for quality problems in healthcare in America and make recommendations. The operational definition of quality used in the book is "The degree to which health care services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." There are thirteen recommendations presented initially and are discussed in relevant chapters. The recommendations vary in scope from suggesting that multiple parties need to be committed to quality as a way to decrease the burden of disease to suggestions that specific agencies fund pilot studies to look at how reimbursement can be aligned with quality. Six major parameters are discussed as guiding quality and it is suggested that 15 specific conditions be a focus for improving quality.

There is no difficulty in identifying literature studies that demonstrate quality problems in hospital and clinical populations. A survey of current research is included in Appendix A. A review of the tables in this appendix show the types of quality markers that are typically studied in the literature. The authors make the argument that errors due to quality lapses or deficiencies need to be actively worked on and that the current high error rates are not acceptable. Health care has become a major political issue and the political factions are shaping up to be government and business on one side and physicians and other health care providers on the other. There has been a major revamping of the health care system in the past decade to control costs. That required the active cooperation of the insurance industry and government. There is still medical inflation and limited access with 40 million Americans uninsured. Should we believe that another cooperative effort between industry and government will improve quality any more than it has controlled cost or improved access?

The authors acknowledge weaknesses in their suggestions about changing the face of American medicine, but they minimize the adverse impact of the current funding mechanisms for medical care and the issue of information systems integration and security. A good example can be found in their application of engineering principles to clinical settings - - where teams see patients for four hours of direct contact time and the remaining time is for documentation and returning calls. That plan would not be economically feasible in many settings. The high cost and lack of flexibility of the current reimbursement schemes are not mentioned as a potential reason why these plans won't work.

Information technology is seen as a way to enhance both productivity and safety. The authors suggest that e-mail can lead to productive exchanges between physicians and patients. Many physicians have been doing this for years. Many have also stopped with the advent of security concerns about medical privacy. With larger IT systems the critical issue is backward compatability with older systems. That usually requires custom designs that are extremely expensive. Those problems usually need to be solved before bedside computing and decision support can be developed. Security is acknowledged as a problem that needs to be solved. In spite of a federal initiative in this area, the important precedent to remember is how the financial privacy of Americans was protected. The authors point out that medical privacy requirements need to be more stringent than other industries. At the same time they point out that some opinions suggest that there is a trade off between privacy protections and the need to advance information technology in health care. If they are suggesting that the Internet should be at the heart of this infrastructure and the Internet is not secure, what does that mean?

A practical approach might be to focus on the areas where data is entered into computer systems and make sure that non-human analysis occurs at those levels. For example, all hospitals enter pharmacy orders into computer systems. Many hospitals require that physicians write separate discharge orders. Both of these points are areas where there could be immediate improvements in accuracy. A focused study and solution could be engineered now. The necessary software and hardware requirements could be placed on a central web site and available for download by hospital and clinic IT staff. Existing reviewers could be charged with documenting the baseline level of errors and the degree of improvement.

This book succeeds as a broad survey of what has been done about quality in certain settings. It contains some interesting ideas about what can possibly be accomplished by applying conceptual advances from other fields. It does not discuss the significant drawbacks of evidence based medicine. It lacks a practical plan for transitioning to a new system and in effect creates a new chasm. With a work like this, whether you like the conclusions depends a lot on your interpretation of the evidence and your personal experience. As a practicing physician and a previous quality reviewer I have significant areas of disagreement with what is presented in this book. Areas of controversy are not elaborated upon. I suppose you could say that level of analysis is not required, but recommendations about the future of health care in America should at least meet the criteria of "evidence based" and all the evidence should be discussed.

George Dawson, MD

Summary of Crossing the Quality Chasm: A New Health System for the 21st Century

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