1. Balancing the Research Portfolio Jerome H. Grossman, MD Director, Health Care Delivery Policy Program Harvard University JFK School of Government October 28, 2003

2. Economic and Societal Changes Zuboff (1988) – In the Age of the Smart Machine Giddens (1988) – The Third Way: The Renewal of Social Democracy Rivlin (2002) – Challenges of Modern Capitalism

3. Elements of Healthcare Delivery Starr (1982) – The Social Transformation of Medicine Fuchs (1996) – Individual and Social Responsibility Institute of Medicine (2000/01) – To Err is Human, Crossing the Quality Chasm

4. Solving the Simultaneous Equations Consumer Aggregators Insurers/Risk Managers/Plans Delivery Aggregators Consumer Aggregators Insurers/Risk Managers/Plans Delivery Aggregators Government Regulation Productivity Delivery System GovernmentConsumersEmployers

5. Knowledge Into Practice Biologic Science Clinical trial to production Genome as building block Systems biology Reimbursement Implementation Diffusion Engineering Science Prototype to production Productivity as building block Systems engineering Bundled payment/disease Implementation Diffusion

6. Engineering Based Delivery System Patient-Centered System Patient Front Line Team Support Organizations Environment Information Connectivity Responsibility Innovation Coordination Standards

7. Sequential Information Experiments DataAnalysisHypothesisValidation

8. Integration of Multiple Subsystems PCP ED Admitting Surgery Lab Triage Patient Ed. Patient Ed. Library Specialist ICU Post-OP Nursing

9. Every Home an ICU Source: Boston Globe

10. Evolving Role of Insurers Catastrophic care Disease management Pay for performance Tools for consumer education

11. Care for the Future Source: Boston Globe

12. The Genome of Productivity Measurement of quality and efficiency Patient (biosensors, micro-systems) EMR, CPOE (CAD/CAM) Organization (scheduling, queuing) Environment (regulation, policy, homeland security)

13. Keeping Patients Connected Source: Boston Globe

14. Barriers to Progress Medical industrial complex Provider as professional/patient as passive Lack of oversight Fragmented health care system Reform proposals not founded on research Healthcare delivery vs. medical care

15. What Hasn’t Happened Very little progress has been made. Source: Wall Street Journal Medical Injuries Cost Billions Every Year Researchers studying health- care quality have concluded that medical injuries caused during hospital stay kill tens of thousands of patients annually, requiring at least 2.4 billion extra hospital days resulting in potential medical charges of $9.3 billion. The work underscores both the scope of the problem and the relative lack of action in solving it. In 1999, for instance, the Institute of Medicine recommended the creation of a “nationwide mandatory reporting system” for medical errors. That hasn’t happened. Very little progress has been made.

16. Program Recommendations Research on engineering systems design Information and connectivity Coordination and standards Responsibility Continuous innovation

17. Our Vision “The clinical operating system will improve interactions between doctors and patients, who will not have to be in the same room or even in the same time frame. Enterprise software will provide a patient’s personal health record with information from the person’s entire clinical history”. (Jeffrey Goldsmith)