Viewpoint: A Revolution in Health Care

By Risa Lavizzo-Mourey, M.D., M.B.A., President and CEO, The Robert Wood Johnson Foundation

When people talk about what is needed to improve the quality of health care in America, the conversations are often accompanied by heavy sighs. The sighs come after the inevitable listing of barriers to system-wide quality improvement. Those barriers include racial, ethnic, and gender disparities that persist regardless of patients' economic or insurance status; providers who are frustrated and disaffected with a system that is as difficult for them as it is for their patients; a scarcity of nurses so severe it threatens patient safety in many institutions; an information infrastructure that, despite all our high technology, is weak, worn, and wanting; an aging population that lacks long-term care insurance and prescription drug coverage; a financing system that allows more than 41 million people to go without health insurance coverage; costs that are rising so relentlessly that health care's share of our gross domestic product will be nearly 18 percent by 2012; and an education system that reinforces process and procedure with more vigor than it promotes quality of care and positive patient outcomes.

Sigh.

To be sure, these are not insignificant barriers. But focusing only on the barriers means we are looking backwards instead of looking forward.

In its landmark report, Crossing the Quality Chasm, the Institute of Medicine provided us with three principles to help us look forward. First, health care should be centered on the patient. That means giving patients control of their own care, in a system that respects individuality, values, ethnicity, and, yes, even social justice. Second, health care should be based on knowledge. The decisions about our treatment must be based on the best - and the most up-to-the-minute - scientific and clinical evidence. Amazingly, this is something we aren't doing well today. Third, health care should be systems-minded. It means dissolving the old system's hardened silos and cutting across traditional turf boundaries, disciplines, roles, and institutions. Paramount value must be attached to cooperation and coordination.

At the Robert Wood Johnson Foundation, we're learning through some of our programs, including Improving Chronic Illness Care, headed by Dr. Ed Wagner, and Pursuing Perfection, headed by Dr. Don Berwick, what those principles look like in practice.

Today, patient care is based on office visits and hospital stays. Tomorrow, it will be determined by what kind of care patients need, when they need it, and how they need it - whether it's in the office or on the phone, through video conferencing or over the Internet.

Today, the autonomy of the professionals rules patient care. Tomorrow, it will be patient needs, patient values, and patient choices that rule. Healthcare professionals will ensure patients have all the information necessary to make the right choices.

Today, too often medical and healthcare information is impossible to access. Tomorrow, there will be no more frustrating hunting expeditions. Knowledge will be a power "tool" that is shared freely. Patients will finally know as much about their health care as the system knows, and as much as they need to know to make their own, informed healthcare decisions for themselves and their families.

Today, the ancient Hippocratic admonition to "do no harm" is left up to the individual practitioner who often feels powerless to protect a patient and vulnerable to unjust criticism. Tomorrow, the safety of each patient will be the responsibility of the entire system. That's as basic a patient right as there can be. It will be the job of each component of the system, in tandem with the others, to ensure that patients will be safe from injury.

Today, cost reduction is the mantra. Cut, cut, cut - jobs, services, care. Tomorrow, it will be the tremendous waste of time and material that is cut, cut, cut.

Today's system reacts - too often only after an avoidable crisis. Tomorrow's system will anticipate what we need before we need it. We'll be proactive, tracking what works and what does not work, and heading off crises before they occur.

The changes needed to achieve tomorrow's system are so basic and so sweeping, they're nothing less than a revolution - a revolution we at the Robert Wood Johnson Foundation would like to see in your lifetime. And while some may find revolutions to be scary, the goal of this revolution is actual liberation of our system in the service of improved health and health care for all Americans.

Everyone has a role to play in this revolution - hospitals and health systems, health professionals of every kind, public and private payers, and, educators.

Educators have a special role to play, as they touch providers at every step along the continuum of their professional lives. Eleanor Roosevelt once wrote in "My Day," her daily newspaper column, that while a single leader may chart the way, many leaders and many people must do the building. We must all be the builders of tomorrow's health care system.