A new health system and its quality agenda.

This article reviews recent work on healthcare quality, highlights findings and recommendations of the Institute of Medicine (IOM) reports on medical errors and quality, and describes response to the reports to date. In it, Detmer, chair of the IOM's Board of Health Care Services and a member of its Committee on Quality of Health Care in America, identifies implications of the reports for healthcare delivery organizations and professionals and outlines ways organizations and professionals can improve the six dimensions of patient quality defined by the IOM. Sustained efforts at the point of care and in policy development are needed to overcome cultural inertia, realign incentives, support innovation, and address technical and human resource issues. Success requires that healthcare executives embrace the goal of transforming the healthcare sector into a true system and provide leadership for their organizations and communities in this most fundamental of challenges for twenty-first century healthcare.

Veterans Affairs residency realignment and National Graduate Medical Education policy.

The supply of physicians in the United States is affected by a variety of complex factors. Given the current abundance, if not oversupply, of physicians and the dramatic changes under way in the US health care delivery system, policy makers have renewed efforts to implement strategies that will lead to an appropriate balance of physicians in the United States. Several organizations have recommended specific strategies for achieving that goal. The Veterans Health Administration has already decided to change the number and distribution of its residency training positions. These changes cannot, however, be viewed in isolation. The Veterans Health Administration plays an important role in the graduate medical education of many physicians in the United States, and the magnitude of the intended changes could have a significant impact on residency opportunities.

The future of the IAIMS in a managed care environment: a call for private action and public investment.

A national public and private "grand challenge" initiative should be undertaken to assure the American public that the telecommunications and computing revolutions improve health care, health education, and biomedical and health services research, and secure accountability for cost, quality, and access. The initiative should focus on meeting the needs of the patient and society at large. It needs to be a national vision, but it also ought to have regional focus. A plan for action would include a health-infrastructure strategy, a service strategy, an education strategy, a research and development strategy, and an international-linkages strategy. Without this type of initiative, health care will lack the basic building blocks it needs to more effectively deal with the transformational forces that have already been unleashed. These forces will strengthen or weaken health care in the next century depending on whether and how the nation--including the leadership in health care and the informatics community--responds to this challenge.

The computer-based record: patient moving from concept toward reality.

In 1991 the Institute of Medicine issued a report on improving patient records which has proven to be a landmark for the many individuals and institutions involved in the development of computer-based patient records (CPRs). The report called Computer-based Patient Records: An Essential Technology for Health Care, recommended that CPRs become the primary form for patient records, and urged widespread implementation of CPRs within a decade. It also provides a framework for reviewing the current status of CPRs. In reviewing progress that has been made toward CPRs since the Institute of Medicine (IOM) report was released, it is useful to look beyond the IOM report's major focus on efforts in the USA and include international activities related to CPR development and implementation. Looking forward, CPR efforts are likely to be expedited through greater collaboration.

Diagnosis related groups (DRGs): efficiency and/or quality producing? Some evidence from surgical patients.

Hospital charges and length of stay for inguinal hernia and acute appendicitis patients were examined in a university hospital to determine the degree of variation with DRGs. Evidence presented here suggests that DRGs may lead to a reduction in medical care costs without a reduction in patient outcomes. Mode/year DRGs to take account of source of admission and maintaining outliers payments may be desirable to avoid patient selectivity and incentives for lowering quality of care of the most severely ill patients.

A decision theoretic methodology for severity index development.

Severity indices are a key element in evaluation of health programs. But the methodologies used in development of such indices are rarely clearly defined. Moreover, there have been no tests of transportability of the index development methodologies that do exist, so there is no guarantee that panels of physicians convened by different facilitators would produce indices with similar performance characteristics. This paper describes a replicable index development strategy, a heart disease severity index developed by using that methodology, and a test of that methodology's transportability.

The economics of surgical signatures.

Identification and analysis of practice patterns for a group of surgeons within the same institution show a significant variation in total hospital charges, length of stay, and ancillary charges for simple uncomplicated hernia repairs and appendectomies. When presented to surgeons, these data can be of immense value in terms of altering practice patterns in order to deliver cost-effective, high-quality health care.

The University of Wisconsin Clinical Practice Plan.

The evolution and structure of the University of Wisconsin Clinical Practice Plan (CPP) is described, along with political and economic factors that have influenced its development. Comparison of clinical faculty numbers, average clinical earnings, average clinical base salaries, and average research funding per clinical faculty member in 1958, 1968, and 1978 (all in 1978 dollars) reveals a trend of rapid initial growth followed by a marked slowing of growth. This suggests that the CPP is reaching a stage of continued slow growth. Further analysis of the data also suggests the effect on the CPP of changes in federal and state government funding of medical research, medical education, and health care for indigents. The effects of these fluctuations in federal and state government funding of these three areas on CPP income and expenses have made long-range planning and budgeting for the CPP difficult.

Regional differences in surgical care based upon uniform physician and hospital discharge abstract data.

Population based surgical rates for various common surgical procedures were analyzed on a regional basis by examining select uniform hospital discharge abstract data from Wisconsin hospitals. The surgical asbracts of nearly 64,000 procedures were compared to the supply of physicians and showed a significant variation in the rates of common procedures even within rather large planning districts. In general, the volume of surgery correlated with the supply of surgeons. Exceptions were noted; for example, primary appendectomy, tonsillectomy and adenoidectomy (T & A), and inguinal herniorrhaphy did not correlate with the supply of surgeons, but did correlate with the supply of general practitioners. Further, T & A had a strong negative correlation to the supply of ear, nose and throat specialists. Information of this type has significance both for Professional Standard Review Organizations (PSROs) and Health Planning Agencies (HPAs). Further work will be necessary to define optimal surgical rates.