In This Issue
Engineering and the Health Care Delivery System
March 1, 2008 Volume 38 Issue 1
Volume 38, Number 1, Spring 2008. There are abundant reasons for the problems in health care delivery. Engineers may not be able to solve all of them, but the benefits of working toward solutions can be tremendous, and the challenges they present are enormously intellectually stimulating.

Engineering and the Health Care Delivery System (editorial)

Wednesday, December 3, 2008

Author: W. Dale Compton, Proctor P. Reid

Editor’s Note

The suggestion that engineers join in the struggle to improve the health care system almost always elicits surprise, even though engineers have been actively involved in bioengineering and biomaterials engineering for years. In addition, publications on using operations-research techniques to model hospital operating rooms and schedule personnel and materials in various medical facilities date back more than three decades. Today, however, the participation of engineers is more important than ever before.

Health care delivery today is in turmoil. Despite rapid advances in medical procedures and the understanding of diseases and their treatment, the efficiency, safety, and cost-effectiveness of the delivery of health care have not kept pace. Improvements in the delivery of services in other industries have simply not been transferred to health care.

The question is why not. Here are a few of the most obvious reasons. For one thing, the third-party reimbursement system is not conducive to a competitive environment in which customers (i.e., patients) can seek out the most cost-effective treatment or provider. Second, health care delivery is still a “cottage industry.” Third, very little has been invested in information technology. Fourth, the quality of care delivery and benefits are difficult to quantify. Finally, the annual cost of health care is increasing by double digits. The five papers in this issue, which are based on presentations at the Symposium on Health Care as an Adaptive Enterprise: An Engineering Challenge, at the 2007 NAE Annual Meeting, address several of these issues.

Changing the Health Care Environment
Industries, particularly large, entrenched industries, often find it difficult to change, even when they recognize that change is in their best interest. Therefore, a key driver of change is crisis, a situation that forces an industry either to change or, to put it bluntly, go under. Unlike other industries, however, health care cannot simply go under, so it must change. Like other industries, health care must become more efficient, more responsive to patients’ (i.e., customers) needs, more flexible, safer, and of higher quality. Industries around the world aspire to achieve the same characteristics.

Health Care as a Cottage Industry
In a so-called cottage industry, many components of the overall system operate as independent agencies. To an engineer, this indicates that the overall system was not designed as a system and does not operate as a system, that no single entity is in charge of the overall system, and that no cost objectives, standards of efficiency, or safety goals have been established for the overall system. In addition, there is little, if any, feedback in terms of measuring overall operating goals.

As systems engineers know, you cannot optimize a large, complex system by optimizing its individual parts, because this does not take into account interactions among the parts. Nevertheless, in the short run, improvements in some components can be made and should be encouraged. For example, systems engineering principles were critical to improving clinical operations—and quality of care—at the Mayo Clinic. Another example is described by Paul Levy, the director of Beth Israel Deaconess Medical Center, who details how process-improvement techniques that have been used in other industries can be applied to some aspects of health care in an academic medical center.

Moving the overall system toward optimization will require many more improvements like these, as well as sharing the lessons learned among providers, empowering patients and encouraging them to take more responsibility for their health care decisions, ensuring that markets for health care services are more transparent and open to new business models, and finding better methods of reimbursement.

Jerry Grossman, director of the Harvard/Kennedy School Health Care Delivery Program, argues in his article that disruptive events, including revolutionary advances in technology and business models, can be effective forces of change in the way an industry performs. Disruptive innovations in the health care sector, he says, are already driving changes in some parts of the system.

Optimizing a Complex, Adaptive System
Bill Rouse, executive director of the Tennenbaum Institute at Georgia Institute of Technology, focuses in his paper on the complex, diffuse nature of health care delivery, which can only be described by a broader definition of “system.” Because of the nature of the system in which health care operates, he says, some of the corrective directions engineers usually pursue will not work. A complex adaptive system such as health care, he argues, is not amenable to the controls and feedback forces we generally ascribe to a system.

Even though system tools that have been used successfully in many other industries will not suffice to solve all of the operational problems of the health care system, they are the best tools we have to improve the quality and efficiency of care until more powerful tools for optimizing this adaptive system can be developed. For one thing, even if the performance of some parts of the system is optimized, changing the very complex overall system will require strong, effective incentives and other tools for system governance rather than system control. Chris Meyer, chief executive officer of Monitor Networks Inc., describes an approach to change based on natural systems. He argues that the very complex adaptive health care system requires “adaptive management.”

Investing in Information Technologies
Although many attempts have been made to increase the use of information technologies (IT) in health care, overall investment in IT is the lowest of any major industry. Thus many places still use paper records, and only a small number of clinicians use physician order entry systems or electronic medical records that are controlled by the patient. In addition, computerized systems are often incompatible, either in hardware or software, making communication difficult, sometimes even impossible.

Steps being taken to overcome these problems include efforts to create a national health information infrastructure and a number of actions, being explored by Congress, to develop a nationwide system of electronic records. Several private-sector consortia, including health care provider organizations, insurers, and technology vendors, are implementing large-scale clinical data exchanges/repositories and personalized health record systems. But there are many barriers to achieving these goals, including the exorbitant cost of these systems, especially for the 80 percent of physicians who work in groups of 10 or fewer.

IT, however, involves much more than computers. For example, wireless communications combined with microelectronic sensors that can remotely sense physiologic parameters may make it possible to monitor and treat patients at home, thus making it possible for chronically ill patients to visit caregivers less often. These advanced IT devices and systems may also improve the quality of treatment of patients in hospitals. It has been said that these systems may someday make every hospital room an intensive care unit.

Educating a New Class of Professionals
Unfortunately, most health care professionals do not even know what questions to ask systems engineers nor what to do with the answers, and vice versa. Most engineers only have contact with the health care system as patients, and few of them understand the constraints under which health care providers operate. In short, these two groups of professionals often talk to each other but seldom understand each other.

Jerry Grossman and the authors of this introduction experienced this firsthand as members of the NAE/Institute of Medicine study committee that published the 2005 report, Building a Better Delivery System. The committee comprised an equal number of engineers and health care professionals. Even though no significant disagreements arose and all of the committee members were outstanding professionals, we had great difficulty finding a common language, and thus, great difficulty writing a report that could, and would, be read by both groups.

Based on our own experience, we recognized that we must educate a new class of professionals, which will require a new class of multidisciplinary research and educational centers that bring together engineers and health care professionals in an environment devoted to improving health care. One goal of both medical and engineering education must be that the members of these professions learn from each other, undertake joint research on common problems to develop new or modified tools, and demonstrate these tools to other professionals.

The committee members agreed that both professions need to understand the limitations and opportunities of the other. Although it will be difficult to add interdisciplinary material to present curricula, we dare not continue to ignore the crisis in our health care system.

Only in the area of biomedical engineering have engineers, scientists, and medical practitioners developed a truly common language. Some of the breathtaking advances in the integration of engineering and biological systems to create new therapies for the treatment of diseases are described in the paper by Mark Saltzman, professor of chemical and biomedical engineering at Yale University.

Conclusion
There are abundant reasons for the problems in health care delivery. There are also abundant opportunities for working toward solving these problems. Engineers may not be able to solve all of them, but the benefits of working toward solutions can be tremendous, and the challenges they present are enormously intellectually stimulating. Someday, the engineering profession may look back with pride on its contributions to solving this significant social problem.

About the Author:W. Dale Compton is NAE Home Secretary and Proctor P. Reid is Director of the NAE Program Office.