Four New Frames for Health Care

For the past half century, the US has assembled a remarkable set of cultures, institutions, and practices to organize, deliver and finance health care. Each year, tens of thousands of the best and brightest of each generation accept the demanding challenge to enter one of the pathways to become the next generation of leaders within these amazing arrangements for health. In large American cities, the aggregation of these health centers takes up multiple city blocks, and they are often the largest employer, and a place where world class research, patient care and education come together in the service of society. There is no less pride in small town America, where the local hospital, staffed with graduates from the big city health center, is often the tallest building on the horizon; and parents take pride that their sons and daughters have found a good job in the helping business. These citadels of health, large and small, have come to represent many of the good things of life: helping others, growing and applying knowledge, having a career, being responsible. The truth is that in the walls of these shining cities on the hill miracles do happen and lives are saved. In gratitude and hope we have left behind larger and larger financial gifts as recompense at their doors.

But as valuable as these towers have been and as accomplished as the individuals who work their professional practices within their walls are, it is now time to bring some redirection to their mission and their work. This work must be accomplished by the professional leaders that occupy the top positions within this world, but because of how health professionals work, it is a responsibility that will need to be taken up by every practitioner and become a part of the education of every health professional student. There are many skills that leaders must master to bring about change and these will perforce be a part of what every health professional will need to know to provide the most effective care for patients and families. But before the skills can be transacted, there are four frameworks of seeing and understanding that all professionals must master before movement toward better health and health care can be accomplished.

The first framework is integration itself. Over the past five decades, much of health success has been afforded by growing the towers of the professions and institutions higher and higher with correspondingly thicker walls. If one needs the diagnosis and treatment that these specialized towers offer, then it is delivered with effectiveness, if not efficiency. This dimension of our health care is famous the world over. But we have reached the limits of what this approach to care can provide for the needs of the general public. As the population ages and chronic disease becomes more prevalent we need other less intensive ways of both preventing and managing disease and disability in the community. The vertical towers we have built with all of their specialized knowledge must begin the work of integrating their value across a horizontal continuum. This will not be easy work. It will require new partnerships, collaborations and structures. It will require valuing the other parts and professions in new ways. And it will require a balancing of our specialized perspective with a different orientation. Why do we so exclusively search for the answers to health and disease through the reductionist search for a more specialized answer? As technology and science have allowed, we have moved from the organ to the tissue, to the cellular, sub-cellular and molecular. There is much to learn in these quests, but there is much to gain by moving back up to the individual, family and social organization. Newly integrating systems will make tremendous gains as they move care and health to a better balance between reductionist and more holistic approaches. The integration frame of mind will struggle against the institutional frame, but ultimately it will produce a value which is widely desired by the consumer.

A second frame for leaders to recover and use as they create new systems of care is the team. Teams have always been a vital part of the way health care has been organized and delivered in the US, but we need to reconsider them in the context of the change the broad shift of care from acute to chronic demands and with the new information and communication technologies which change fundamentally the way in which we organize, access, share and use the knowledge necessary to produce health and health care. A generation ago "team" meant a large group of professionals sitting around a table case managing an individual using their physical proximity as a mechanism for sharing the specialty perspectives that were relevant. Today such an encounter could only be cost effective in the most expensive of cases. Rather, patients need a great variety of services as they manage a disease burden that is increasingly chronic and complex. These patients need a greater variety of services from a much richer set of professional and even paraprofessional providers. These providers have much more effective tools to access, integrate and apply the relevant knowledge for the patient. Because of this technology, the patients themselves are increasingly an active and vital part of the team. This new tech team frame will have to contend with the old hegemony of the single profession, but the richness and affordability of what it offers will ultimately win the day in a reformed approach to care.

As the tech team model implies, the consumer perspective also offers a new way to frame the way we think about health care. There has been of course much rhetoric about consumer driven or responsive health care, and the nation is rushing to build patient centered health homes. But are our efforts in the past or even now really tied to what the consumer wants and needs, and is it organized and delivered in a manner that is easily accessible and genuinely affordable? Or, do our new models for organizing care still have the bias of professional domination determining what the consumer should want, how they should want it and how much it should cost. Those innovations that have assumed nothing from the past and simply assembled care delivery options that were accessible, effective and affordable should be the sparks that inspire innovation and change. Perhaps the best evidence of this development is the rich growth of the non-traditional, consumer driven, alternative provider offered services that are found in every self-help group, healing clinic or retail store provider. Too often these efforts are denigrated as unprofessional, too commercial or not truly understanding of patient needs. The consumer frame will of necessity struggle with the dominant professional frame paradigm, which will always accuse the upstart innovation of failing to meet the comprehensive needs of the patient. But anyone who really understands the argument will know that such failures are endemic to the dominant professionally framed system as well. And it is the upstart consumer frame which may not fear, but welcome the active presence of consumer preference.

The final new frame is evidence. This framework revolution has been going on for a couple of decades. Driven primarily by the outside purchasers who wanted demonstrated value from health care, it has now been incorporated into the ethos of most professions, institutions and approaches to training. It has had a measurable impact and is in itself a good example of how changing the framework from subjective professional and institutional judgment on quality to more objective and comparable assessments against processes -- which could demonstrate evidence of efficacy -- could change the ways institutions go about their business. But for all of the progress two obstacles remain. First is the rearguard resistance to embracing such approaches over the idiosyncratic efforts of the past. But these will eventually give way. The more insidious problem is the focus of the evidence based improvement efforts. If our focus is not on the full scope of the problem, we may improve the functioning of a suboptimal system and fail in our efforts to improve matters. Making the transfer process from the emergency room to the intensive care unit move with more efficiency and better transfer of knowledge does improve things. But if that closes out our ability to ask whether or not the admission to the ER in the first place was a mistake which could have been avoided with better care in the community, then we have lost the larger battle -- if not war. The evidence frame will not have to struggle too much with the highly individualistic frame from the recent past; its challenge will be to ensure that we frame the right problem before we use the tools of improvement and evidence.

Leaders make things coherent for their followers. These frames are the elements of the visions that will need to be crafted at every hospital, clinic, practice, school and health care organization which hopes to make the right response to the new challenges from the market and the policy realm.