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Healthcare decisions can change as circumstances change

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Research into the causes of infectious diseases and the development of vaccines and pharmaceuticals quelled once-devastating illnesses such as polio and smallpox.

The first successful organ transplant occurred in , and now, thousands of transplants each year—more than 28, in —are prolonging the lives of recipients UNOS, Over the past decade alone, better understanding of the mechanisms that cause disease has improved the ability to prevent, diagnose, and treat common afflictions such as diabetes and heart disease.

The innovation underlying such progress continues to advance and accelerate change, while many new technologies and medical interventions provide new options for care and treatment.

Between and , for example, the number of medical device patents per year doubled AdvaMed, , and the biotechnology patents tripled over roughly the same time BIO, Increasingly, discoveries in the biological sciences are being applied toward the development of medicines and treatments targeted to refined subsets of patients to better address genetic or life circumstances. Recent advances in research, however, are not producing commensurate improvements in the quality of the health care received.

In a survey about perceptions of health care, 60 percent of Americans said they did not believe that the United States had the best healthcare system in the world, and 41 percent said they knew of a time when they or a family member had received the wrong care Research! America, These perceptions are borne out by recent reports and analyses and were highlighted in several IOM Annual Meeting presentations summarized in this publication.

For example, despite spending more on health care than other industrialized nations, the United States lags significantly in basic measures of quality such as overall life expectancy at birth and infant mortality Anderson, ; Mathers et al.

Additional reports characterize a healthcare system that is highly fragmented and prone to errors IOM, , Unnecessary spending, duplication of efforts, and widespread disparities in spending and health outcomes across geographic areas are also common features of health care IOM, b. Underlying many of these shortfalls is a system struggling to contend with the changing nature of health care—from shifting patient demographics and disease burden to the increased complexity of therapy and treatment options and factors to consider as part of clinical decision making.

Systems of care, historically devoted to the prevention and treatment of infectious diseases and discrete episodes of acute care, are now increasingly occupied with the management of chronic health conditions such as heart disease, diabetes, and asthma. In fact, half of those reporting a chronic illness suffer from more than one Wu and Green, Chronic illnesses make up the leading cause of illness, disability, and death in the United States, and also account for 78 percent of U.

In contrast to acute care, chronic care processes often require sustained coordination across multiple specialists and facilities, a characteristic that is currently testing the limits of an often-fragmented healthcare system. Key system components are also under increased pressure.

However, clinical encounters often require providers to manage a significant number of variables and factors for any one medical decision IOM, a. The number of journal articles, technology assessments, and practice guidelines that any provider must read to stay current is now well beyond human capacity and the rapid evolution of care practices and availability of many therapeutic alternatives compound this already overwhelming body of information available to guide clinical decision making.

Despite the quantity of information available, there are also substantial shortfalls with respect to the quality of information available to guide decision making. Evidence is often not available or not presented in a form useful to practitioners at the point of care delivery. Often, when evidence is available, it has little relevance to the questions and patients faced by healthcare professionals in clinical practice.

Also, as emphasized in several presentations, very little evidence exists on the comparative effectiveness of one course of treatment versus another. While 5 percent of the overall healthcare expenditure is devoted to research, the majority of that is spent on basic research or product development Research! It is estimated that, currently, less than 0. To orient our existing expertise and emerging resources towards improved development and application of evidence in health care, a broad view of the changing nature of health care and implications for capacity and necessary cultural change is needed.

The challenges to creating an evidence-driven healthcare system are great, but so, too, is the potential reward: affordable health care, based on evidence of what works that improves health outcomes for individual patients. Leadership is needed from the healthcare professions to reach consensus on the problems and solutions and to facilitate the necessary change. Since its establishment in by the National Academy of Sciences, the IOM has been committed to advancing the quality of health care in the United States and has undertaken many important studies on the topic.

Perhaps the most widely known are a series of reports by the Committee on the Quality of Health Care in America. The first of these reports, To Err Is Human, estimated that as many as 98, patients die in any given year from medical errors that occur in hospitals and established ensuring patient safety a critical first step in improving quality of health care.

A year later, a follow-on report, Crossing the Quality Chasm , focused on the delivery system as a whole and issued a call to action to improve system performance in the six dimensions of quality—to ensure safe, effective, patient-centered, timely, efficient, and equitable care. Expanding the evidence base to support quality medical care for each patient poses an ongoing challenge to healthcare improvement, and to contend with this issue, in , the IOM convened the Roundtable on Evidence-Based Medicine.

Over the last 2 years, the Roundtable has explored, through its series of meetings and workshops on the learning health-care system, the key opportunities and challenges to establishing evidence as the linchpin of the healthcare enterprise. Collectively, the Roundtable seeks the development of a healthcare system that is designed to generate and apply the best evidence for the collaborative healthcare choices of each patient and provider; to drive the process of discovery as a natural outgrowth of patient care; and to ensure innovation, quality, safety, and value in health care.

Roundtable activities focus on accelerating the development of a learning healthcare system; expanding the capacity to generate evidence on medical care that is the most effective and produces the greatest value; and improving public understanding of the nature, importance, and dynamic character of medical evidence.

The IOM convenes annual meetings dedicated to the examination of topical and critical issues in health care and health policy.

The meeting was structured to provide an overview of some of the key issues and challenges as well as to present some of the primary opportunities for progress that have emerged from the work of the Roundtable. The chapters in this publication provide important perspectives on the changing nature of health care: from the forces driving the need for better medical evidence and the many new challenges confronting patients and providers to opportunities to transform the speed and reliability of new medical evidence and enable an evidence-based healthcare system.

To provide context for these discussions, comments were provided by the meeting co-chairs Mark B. McClellan and Elizabeth G. Nabel and by session moderators Denis A. Cortese, Michael M. Johns, John W. Rowe, and John K. A summary of these perspectives follows.

Two core challenges are facing health care and health policy in the 21st century. Healthcare costs are rising and not sustainable, and a tremendous, largely untapped potential exists for much better health through better, more targeted treatments. In principle, better evidence will result in higher confidence about what works for every patient in the healthcare system.

This is a precondition to achieving what health care should be about in the 21st century—care that is based on solid evidence about what will work in particular patients.

With the advent of electronic medical records EMRs , clinical data registries, and other new forms of electronic data, care is becoming rich with information that can reveal patterns of disease mechanisms and markers of risks and benefits.

These data also hold promise for instilling a greater confidence in health care than currently exists for a system that offers widely varying medical practices, with possible consequences for outcomes and definite consequences for costs. In addition, even treatments effective for some may not be beneficial for others and may carry significant risks. With the cost of health care rising along with its benefits, creating an evidence-based system will be critical to achieving the promise of personalized medicine in which treatments are more effectively targeted to those that benefit, an achievement well worth its cost.

Although there has been progress toward this goal, attaining such a system remains a distant prospect. Better disease models and evidence relevant to the treatment of individual patients is lacking, despite publications and news stories that seem to suggest otherwise. Also, much of the current data are not from traditional randomized controlled trials RCTs , creating a dilemma about the relevance of EBM in clinical practice.

Some practitioners believe that if evidence is developed using traditional RCTs, it may not be reflective of the complexities of populations and the delivery settings in real-world practice. For example, even if different practice methods appear to have a similar effect in an overall population, this may not be the case for different subgroups or different types of patients within that population.

The key elements that should inform strategies for change are contained within these pages. As Michael E. Porter notes in Chapter 7 , while simple steps such as price controls or restrictions on access to control costs might seem useful on the surface, they have failed in the past. Instead, a new vision is needed, marked by effective evidence and targeted treatments that account for the diverse characteristics—findings, histories, validated biomarkers, and preferences—of the various patient groups in this country.

With the complement of secure EMRs, access to these patient and population characteristics will bring relevant evidence to healthcare decision making. This will, in turn, lead to better results and higher value.

Clearly, there will be challenges along the way to gather the evidence necessary for the backbone of this type of healthcare system: data must be consistent; low-cost alternatives to RCTs must be agreed upon; electronic systems should be integrated; and sophisticated longitudinal databases, such as provider-led clinical registries, should be supported.

In addition to studying the discrete interventions of particular drugs or particular modalities in treatments, the performance of healthcare systems themselves should be addressed. The variations in care discussed by Elliott S. Fisher in Chapter 2 must be aligned. Also, costs will increase and value will be compromised if patients receive care from a number of different providers who do not collaborate effectively. To study these delivery system issues in real-world practices, traditional approaches such as RCTs will not be effective.

Policy challenges must also be addressed. As George C. Halvorson acknowledges in Chapter 6 , small shifts in the system will not create fundamental change. Value and outcomes cannot be achieved by micromanaging practices, but rather by providing support for better care at a lower cost. Rewarding better quality and lower costs will give healthcare professionals the opportunity to deliver quality care and still make ends meet. This includes changing reimbursements to focus on higher value.

Making these changes will provide an opportunity for patients to become more involved, and not simply through cost sharing. Many opportunities exist for people with chronic diseases to improve their own health, since most care is actually self-care. In our traditional insurance system, these individuals do not always have the opportunity to make choices that can save money.

However, recent reforms have begun to allow chronically ill patients in this country to control the services they receive. For example, the tiered benefits in Medicare allow beneficiaries to save money by switching to generic drugs—one of the main reasons that Part D in Medicare is less expensive than projected.

There are a number of programs being implemented around this concept of shared savings, in which healthcare professionals working together reap savings when they document better outcomes at a lower cost. However those savings are accomplished—through system redesign, information technology IT , or remote monitoring systems—they are a step toward a bundled reimbursement approach that focuses on the effective outcomes in our healthcare system while promoting better care for everyone in it.

Clearly, the technical and policy challenges of fulfilling the vision of EBM are great. In spite of these challenges, the promise of EBM has put it at the forefront of policy making.

The Food and Drug Administration is working to implement major new reforms, including plans for a public-private partnership to support a post-marketing surveillance system to gather data on drug risks and benefits. Also, Congress is considering proposals for a major initiative to support the generation of comparative effectiveness information about healthcare interventions.

In addition to work by the federal government, the practice of EBM will require numerous public- and private-sector strategies and collaborations. Needed are new approaches to the evaluation and adoption of medical best practices, new methods for drawing appropriate conclusions from vastly expanded data resources, and new approaches for using evidence to improve care and reduce health costs. The process will not be easy, but unlike previous times, there are now widespread calls from healthcare leaders for the reforms needed to develop a system that delivers efficient and effective care.

The IOM has the opportunity to catalyze that change. Healthcare reform will be one of the top domestic issues of the political agenda in the next presidential election, making our focus on EBM and the changing nature of health care very timely.

The roles and responsibilities of all healthcare stakeholders are undergoing transformative change and—whether we approach reform as providers, payers, researchers, health product developers, or consumers—there is much to learn from all who are involved in these collaborative discussions about how to contend with the rapid changes in the healthcare system.

Healthcare providers, whether involved in delivering or reimbursing care, face a unique set of challenges as care is increasingly informed by and organized around rapidly evolving evidence. Developing better approaches to reimbursement and other mechanisms that support the delivery of quality care are at the forefront for all providers, and many pilot projects are already under way. A key consideration, as illustrated throughout this report, is the strong influence of local cultures on practice patterns.

They can prevent the infiltration of evidence-based decision making, but they can also lead to great innovation to support the application and development of evidence.

The papers by William W. Stead and George C. Halvorson in Chapters 4 and 6 discuss lessons learned from their efforts to harness electronic health record EHR systems for improved application of evidence in practice and improved capacity for research and discovery, respectively. However, these local solutions may need restructuring to succeed at a national level. There has been considerable advocacy for sharing best practices nationwide, but it may be necessary to set goals and work backwards to align the systems.

For consumers, access to care is a priority but an additional, emerging challenge will be to ensure that incentives for research and care are properly aligned to support care focused on individual patient needs, circumstances, and preferences. The very nature of patient-physician relationships is also undergoing a rapid change as healthcare data are increasingly captured and made available in various forms through IT.

Patients will be presented with more health information from a variety of sources and, increasingly, they will be pivotal in making decisions about their own health care. As we are reminded by Peter M. Neupert in Chapter 5 , most of health care is self-care and much of the care delivered throughout this country is family-based.

Family health managers and the availability of secure personal health records will be critical to informing and providing increasingly individualized patient care. EBM will also impact researchers.

Methodologies to generate evidence are evolving and need to be continually defined and adapted. EHRs will provide the opportunity to quickly gather large amounts of data from real-world practice and produce evidence in real time, but how these data can be used appropriately and effectively will be a major challenge for researchers and practitioners. Clearly, developing evidence that draws from and informs real-world care practices is a science, and improved methods for modeling and analyzing work processes and decision management are needed.

This may require restructuring of the way we fund research. Federal agencies, such as the National Institutes of Health, the Food and Drug Administration, the Centers for Medicare and Medicaid Services, the Agency for Healthcare Research and Quality, the Department of Defense, the Veterans Health Administration, the Centers for Disease Control and Prevention, and others, will be essential components of this dialogue and can demonstrate leadership by partnering across agencies, as well as with others in the private sector.

There is no doubt that the work to transform our healthcare system will be challenging. Many healthcare leaders have been working on improving the system for decades; but we all need to get on with finding a solution now.

In the United States the cost of health insurance is rising faster than wages at a rate that is not sustainable, but the quality of care—measured in outcomes, safety, and service—is much lower than it should be. Especially in comparison to other countries, the value of medical care in the United States is low but even among individual states of the United States the variability in the value of health care delivered is dramatic.

Only 10 percent of the states provide high-value care on average, and the value of care in the United States on a whole is well below what should be expected. Given the current approach to health care, however, these shortfalls are not surprising. Across the healthcare system, competition and rewards are not based on value, and there are scant incentives for patients to seek—or for professionals to provide—high-quality, cost-effective health care. It can be determined as a process of planning, organizing, leading, forecasting, coordinating, and controlling all available resources of a unit in a way that helps to achieve the existing goals Buchbinder and Shanks, It means that the application of the basic assumptions of management is vital for the elimination of ineffective or inappropriate patterns and their replacement with new ones Buchbinder and Shanks, For the healthcare sector, the theory becomes more specified as it is focused on the means of organizing human and material resources within the healthcare setting to provide clients with the appropriate care and guarantee their recovery Burns, Bradley, and Weiner, The given purpose can be achieved by initiating a change process aimed at the continuous improvement of all components, which is vital for the healthcare sector.

Healthcare management includes a set of functions that emerge because of the need to ensure the appropriate delivery of care to patients and their recovery. For any unit within the given sector, it is critical to be ready to operate and treat clients, which might demand additional effort or use of specific resources. That is why the major functions of management in this setting include planning, organizing, leading, and coordinating Buchbinder and Shanks, The correct scheduling is a key to high effectiveness as it preconditions the determination of the number of supplies, beds, workers, and equipment required to remain prepared and provide clients with the desired treatment.

Organizing is another aspect of management that is needed to align the work of the whole unit and avoid critical flaws caused by the poor understanding of the current patterns or rules Dunn, Leading means managing the staff in practical ways for them to be able to perform their functions with the best possible outcomes. Finally, coordinating presupposes the establishment of a beneficial framework for collaboration between workers and units to guarantee the continuity of care and the ability to meet the needs of all patients Dunn, The existence of these basic functions contributes to the effective management of health units and their improved performance.

Radical change programs can be considered a method that is used to introduce significant reconsideration of the work of a health unit and attain better outcomes. Managing change means handling the complexity of all processes peculiar to the healthcare sector, which also means that it is a complex, dynamic, and challenging aspect of the practice Ginter, Duncan, and Swayne, Any effective change includes unfreezing old behaviors, creating new ones, and re-freezing them to establish a new framework Dunn, For radical change projects characterized by the significant scope of planned interventions and alterations, the complexity increases as there are some major challenges and issues that should be considered at external and internal levels to achieve the desired goal and accept new patterns.

The central challenges peculiar to radical change programs are mainly associated with their scope and the need to consider all elements of a healthcare unit to create an effective paradigm. Moreover, predicable change presupposes time for preparation and planning; however, in healthcare changes occur rapidly, and in the majority of cases, they cannot be predicted Ginter, Duncan, and Swayne, It introduces another challenge as there is a need for emergent actions under complex circumstances.

It might trigger the appearance of resistance to change, decreased motivation, and reduced performance. That is why the main challenges that are usually linked to radical change are related to human resources, leadership, and the effectiveness of managerial decisions.

Resistance to change is one of the most common issues that are associated with this process. It appears when specialists consider a planned alteration as a threat to them and their status Spath, It is characterized by reduced performance, motivation, and actions that might undermine the change process. For this reason, the establishment of a clear vision about plans, directions, and the whole process is a key element for a successful radical transformation.

Health workers should be able to understand the benefits that will be achieved due to the proposed actions and engage in the process to attain outlined goals and cultivate a new environment.

Motivation is another issue that is linked to any transformation process. Since any change is confusing for workers, it is associated with a high level of uncertainty about the future position, the ability to meet new requirements, and other factors that would affect them in the end McLaughlin, For this reason, the decrease in motivation levels is a common problem for the radical change process in the healthcare setting.

One of the possible ways to manage this challenge is to provide security guarantees to all individuals affected by the change and explain to them the need for this alteration and the benefits that might be associated with it Spath, The correct understanding of future demands and required skills can eliminate confusion and uncertainty, which is vital for the preservation of high motivation levels.

Moreover, as far as there is a positive correlation between motivation and performance, monitoring of this aspect is critical for improved outcomes. For this reason, costs often become one of the serious challenges that are associated with the transformation process.

The establishment of the correct price of the planned change is one of the complex issues as it might change during the next period because of emergencies or other unplanned accidents Nowicki, Additionally, both internal and external stakeholders, along with the regulating agencies, might be unsatisfied with the proposed budget Nowicki, Under these conditions, the most effective way to resolve this problem is the establishment of a certain cost of change that is negotiated with all actors involved in the process Nowicki, It will help to reduce financial risks and increase the transparency of the process.

The problem of costs mentioned above can be linked to the need for additional training that often comes with radical change projects. In numerous cases, the attempt to unfreeze old patterns and create new ones is followed by the need for additional education for clinicians to be able to work under new conditions and perform their basic functions providing care by new demands McLaughlin, The creation of an appropriate schedule for training and explanation of its necessity are the main ways to overcome challenges that might be triggered by this component.

Under these conditions, specialists can benefit from the radical change as they will acquire new skills and experiences needed to attain better outcomes and build a successful career. The successful transformation also presupposes the use of effective monitoring practices to be able to respond to any emergencies or unsatisfactory results and introduce demanded response.

However, regarding radical change incentives, the major challenge comes from the scope of the project and the need to control a significant number of aspects peculiar to the functioning of a particular health unit. Under these conditions, the probability of mistakes or biased data increases significantly.

It means that there is a need for practical monitoring practices that will help to avoid such problems. One of the possible solutions is the distribution of tasks presupposing the appointment of specialists responsible for the collection and provision of data about the change process. It will help to avoid the use of irrelevant data and problems with planning during the final stages of the transformation.

Leadership plays the central role in any change process as it might have a positive effect on works and inspire them to move forward, or, on the contrary, precondition the failure of the incentive. For this reason, it presupposes organizational, motivational, and other activities that help to improve collaboration between all members of the staff.

During the transformation projects, leaders also become responsible for decision-making and consideration of possible options to achieve the best possible outcomes. Selection of the appropriate leadership style and ways to cooperate with employees significantly affects the results of the transformation. The Decision-making process is one of the central elements of radical change.

Several approaches are used by managers and leaders to make decisions within the healthcare setting. One of the possible ways to avoid mistakes is the use of relevant data about the current state of the facility, problems that affect it, and the competencies of clinicians Dye, The given information can be collected during the evaluation procedure that should precede the initiation of the radical transformation incentive Dye, In general, an effective decision-making process considers several stages, which include problem definition, identification of limits, consideration of alternatives to choose the best one, implementation of the decision, and monitoring phase to evaluate outcomes Weberg et al.

The given approach to decision-making guarantees the absence of critical flaws; however, there is still a comparatively high risk of failure if the data is biased, or there is a structured approach to planning. It means that leaders responsible for decision-making face a serious challenge associated with radical change. They have to accept and implement a solution that will promote the positive transformation of a unit to introduce new patterns vital for the continuous improvement and achievement of new levels of excellence.

Provision of additional knowledge regarding decision-making and planning will also help to prepare active participants of any change process as they will be able not only to follow the existing course but take part in its discussion and introduction of some changes vital for positive outcomes.

Planning radical change in a health organization, it is also critical to consider the response of internal and external stakeholders as they play a vital role in its functioning. The first group consists of specialists who operate within a selected unit, or, in the majority of cases, the hospital staff Karuppan, Dunlap, and Waldrum, They will be the first affected by the transformation as their work will be realigned by new recommendations and regulations Karuppan, Dunlap, and Waldrum, For this reason, their support is vital for the final success of the planned intervention and its ability to bring positive change.

Internal stakeholders possess the ability to facilitate or limit change by their actions and behaviors. External stakeholders are defined as groups who are impacted by the functioning of the unit but do not work in it. These are suppliers, interest groups, patients, and competitors.

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Healthcare decisions can change as circumstances change They work together. We've updated all our guidance to highlight the importance of balancing professional judgment and expertise with the needs and wishes of people receiving care. Doctors can use several artificial or mechanical ways to try to do this. Sign up for e-alerts about healthy aging. Chapman CB.
Cvs health product lines Supporting your shared decision making through our guidance and tools We're working to help put it at the centre of the way care and treatment is given. Third, a good effect never be a result of the wrong action. For example, if a physician promises the patient they will always be there to care for them, yet leaves the organization and joins another healthcare facility, the patient may feel the physician betrayed their loyalty. Note that this approach does not protect the patient against the situation where read more is no longer available because he cannot meet the standard. Medical Treatment in an Emergency The right to medical care in an emergency is derived from the principles of beneficence and justice, and its concept dates to the Hippocratic Writings.
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Why is it so hard to change health care?

Healthcare decisions can change as circumstances change because one’s moral character can change as circumstances change. This referred to as situational ethics and Refers to a . Jan 15,  · If your household size increases due to marriage, birth, adoption, foster care, or court order, you can choose to add the new dependent to your current plan or add them to . Changes in circumstances can cause product delivery cases to be reassessed, which can result in one of the following outcomes: A complete or partial change in the product deliveries .