Barriers to change in engineering the system of health care delivery.

Significant reform of the health care system sufficient to achieve universal coverage, a value-driven system and administrative simplification faces enormous barriers at the level of our societal ecosystem - barriers as large as any that can be faced in public policy. These barriers exist within the health system itself as a complex adaptive system, and are structured by our economic, legal, cultural and political systems. Because there are so many barriers, significant reform is a relatively rare occurrence. Yet it does happen and there are some important examples of major health care reforms. There are a number of lessons to be learned from the successful enactment of the Medicare and Medicaid programs that appear relevant to current and future reform efforts. First, a necessary condition for achieving significant reform is the existence of large and sufficiently enduring social forces sufficient to disrupt legislative and policy stasis and drive the necessary political solutions. Second, public sentiment and electoral "mandates" might be necessary to significant reform, but they are not sufficient. Third, assuming the theoretical capacity to manage the constellation of systemic, economic, legal, cultural and legislative barriers, there remains a political "tipping point" that must be crossed and translated into a Congressional super-majority in order to enact significant nationwide reform.

Service supply chains for population health: Overcoming fragmentation of service delivery ecosystems.

INTRODUCTION: Population health involves integration of health, education, and social services to keep a defined population healthy, to address health challenges holistically, and to assist with the realities of being mortal. The fragmentation of the US population health delivery system is addressed. The impacts of this fragmentation on the treatment of substance abuse in the United States are considered. Innovations needed to overcome this fragmentation are proposed. APPROACH: Treatment capacity issues, including scheduling practices, are discussed. Costs of treatment and lack of treatment are considered. Models of integrated care delivery are reviewed. Potential innovations from systems science, behavioral economics, and social networks are considered. The implications of these innovations are discussed in terms of information technology (IT) systems and governance. CONCLUSIONS: Enormous savings are possible with more integrated treatment. Based on a range of empirical findings, it is argued that investments of these resources in integrated delivery of care have the potential to dramatically improve health outcomes, thereby significantly reducing the costs of population health.

Viewpoint: developing integrated clinical programs: it's what academic health centers should do better than anyone. So why don't they?

Few would dispute that health care should be provided in seamless, well-integrated clinical care environments that bring together the various disciplines needed to provide patient-centered care, to educate trainees, and to conduct research into a particular disease or episode of care. Yet there are relatively few examples of successful or sustained clinical integration, either in the community setting or in academic health centers (AHCs). The authors draw on their experience with several AHCs and other health care settings to address why AHCs have not made better progress in developing integrated centers of clinical care. They characterize two fundamental types of integration that have evolved within the AHC setting: lateral and vertical. Lateral integration tends to occur among similarly situated specialties. It is easier to accomplish and far more common than is vertical integration, which brings together most, if not all, of the professionals and staff necessary to treat or manage many medical conditions and health problems. The vast majority of examples of clinical integration, whether lateral or vertical, fail to integrate essential administrative and financial functions, which has significant consequences for the ability of either laterally or vertically integrated centers to provide seamless, patient-centered care. The authors identify the emergence of several new examples of vertical clinical integration that also integrate administrative and financial functions as models for AHCs to follow and derive lessons and recommendations concerning how AHCs and others can address the cultural, financial, and governance issues that continue to limit the development of vertically integrated, patient-centered care.

Realizing the vision of leadership development in an academic health center: the Woodruff Leadership Academy.

In 2001, senior administrators in Emory University's Woodruff Health Sciences Center (WHSC) designated leadership as the central element of a new strategic plan, believing that an academic health center (AHC) requires excellence in leadership at all organizational levels to carry out the tripartite mission of teaching, research, and patient care. Leadership development in academic medicine presents unique challenges, however, including a wide range of professional roles and diverse operational centers that may be obstacles to unifying a leadership team in the pursuit of a central mission. Many administrators within academic medicine, although highly competent in their areas of expertise, possess limited leadership skills. In 2003, the WHSC created the Woodruff Leadership Academy (WLA) with the goal of developing a cadre of leaders throughout the WHSC with leadership skills relevant to an AHC and, specifically, to the WHSC. The graduates, called Woodruff Fellows, would work with senior leadership to create a shared vision of excellence and to pursue the goal of advancing all WHSC programs into the top rank of AHCs. After the first three years of the WLA, an informal assessment and a formal survey of the 70 fellows who had completed the program indicated that program graduates had embraced enhanced roles and responsibilities, undertaken new cross-disciplinary collaborative relationships, and acquired a renewed enthusiasm and respect for the shared vision of the WHSC.

Learning in the health care enterprise.

INTRODUCTION: The overall enterprise of health care delivery is considered. The 4 levels of the enterprise include clinical practices, processes that provide capabilities and information, structure that includes the business entities involved, and ecosystem that includes Centers for Medicare and Medicaid Services and Congress, as well as societal values and norms. It is argued that the enterprise of health care delivery needs to be transformed to enable high-quality, affordable care for everyone. DISCUSSION: The constructs of enterprise transformation and organizational learning are reviewed. The distinction of single-loop versus double-loop learning is discussed and illustrated for all levels of the health care delivery enterprise. Three health care examples are used to elaborate this distinction-cancer, population health, and health IT. Four strategies are outlined that the health care delivery enterprise can use to more effectively learn at all levels of the enterprise. CONCLUSIONS: This overall line of reasoning suggests several important research issues. The health care delivery enterprise involves much more than treating disease and paying for it. We need to improve our methods and tools for addressing the overall enterprise. Research is also needed on better means for portraying consequences of decisions to the full range of stakeholders in the enterprise. In general, the overall goal should be a healthy, educated, and productive population that is competitive in the global marketplace. We need to better understand the available levers for achieving this goal and how to best portray the intricacies of the overall enterprise to motivate those who can pull these levers to do so.

Reforming graduate medical education.

Because of the traditional subordination of education to service, graduate medical education (GME) in the United States has never realized its full educational potential. This article suggests 4 strategies for reasserting the primacy of education in GME: limit the number of patients house officers manage at one time, relieve the resident staff of noneducational chores, improve educational content, and ease emotional stresses. Achieving these goals will require regulatory reform, adequate funding, and institutional competency in the use of educational resources. Modern medicine grows ever more complex. The need to address the deficiencies of GME is urgent.

Integrating comparative effectiveness research programs into predictive health: a unique role for academic health centers.

The growing burden of chronic disease, an aging population, and rising health care costs threaten the sustainability of our current model for health care delivery. At the same time, innovations in predictive health offer a pathway to reduce disease burden by preventing and mitigating the development of disease. Academic health centers are uniquely positioned to evaluate the comparative effectiveness of predictive and personalized health interventions, given institutional core competencies in innovative knowledge development. The authors describe Emory University's commitment to integrating comparative effectiveness research (CER) into predictive health programs through the creation and concurrent evaluation of its Center for Health Discovery and Well Being (hereafter, "the Center"). Established in 2008, the Center is a clinical laboratory for testing the validity and utility of a health-focused rather than disease-focused care setting. The Center provides preventive health services based on the current evidence base, evaluates the effectiveness of its care delivery model, involves trainees in both the delivery and evaluation of its services, and collects structured physical, social, and emotional health data on all participants over time. Concurrent evaluation allows the prospective exploration of the complex interactions among health determinants as well as the comparative effectiveness of novel biomarkers in predicting health. Central to the Center is a cohort study of randomly selected university employees. The authors describe how the Center has fostered a foundation for CER through the structured recruitment of study cohorts, standardized interventions, and scheduled data collection strategies that support pilot studies by faculty and trainees.

Restoring balance to industry-academia relationships in an era of institutional financial conflicts of interest: promoting research while maintaining trust.

Economic partnerships between industry and academia accelerate medical innovation and enhance patient access to medical advances, but such partnerships have sometimes eroded public trust in the research enterprise. There is particular risk for conflict of interest when economic partnerships extend beyond a university's corporate interests to involve institutional decision makers. Institutions and institutional decision makers should fully disclose industry-related financial interests and relationships. Without legitimate justification for such interests, individuals should divest themselves from these interests or recuse themselves from responsibility for research oversight. Management of institutional partnerships also might entail the physical separation of certain facilities, the placement of restrictions on information shared between investment and research staffs, and provision of oversight by independent review panels made up of persons who have expertise in intellectual property, finance, and research, but who are not financially or otherwise dependent on the institution. Through these means, it is possible to restore balance to industry-academia relationships, thereby promoting progress while maintaining public trust in research.