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Chaos and Organization in Health Care

Chaos and Organization in Health Care

Thomas H. Lee
James J. Mongan
Copyright Date: 2009
Published by: MIT Press
Pages: 296
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  • Book Info
    Chaos and Organization in Health Care
    Book Description:

    One of the most daunting challenges facing the new U.S. administration is health care reform. The size of the system, the number of stakeholders, and ever-rising costs make the problem seem almost intractable. But in Chaos and Organization in Health Care, two leading physicians offer an optimistic prognosis. In their frontline work as providers, Thomas Lee and James Mongan see the inefficiency, the missed opportunities, and the occasional harm that can result from the current system. The root cause of these problems, they argue, is chaos in the delivery of care. If the problem is chaos, the solution is organization, and in this timely and outspoken book, they offer a plan.In many ways, this chaos is caused by something good: the dramatic progress in medical science--the explosion of medical knowledge and the exponential increase in treatment options. Imposed on a fragmented system of small practices and individual patients with multiple providers, progress results in chaos. Lee and Mongan argue that attacking this chaos is even more important than whether health care is managed by government or controlled by market forces. Some providers are already tightly organized, adapting management principles from business and offering care that is by many measures safer, better, and less costly. Lee and Mongan propose multiple strategies that can be adopted nationwide, including electronic medical records and information systems for sharing knowledge; team-based care, with doctors and other providers working together; and disease management programs to coordinate care for the sickest patients.

    eISBN: 978-0-262-25903-3
    Subjects: Health Sciences

Table of Contents

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  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. Introduction
    (pp. ix-xvi)

    As daunting as the challenges for U.S. health care may be, there is reason for optimism that a delivery system that is much more efficient, reliable, and safe is within our reach. Our optimism is derived not from theory but from our day-to-day work, which ranges from health policy leadership roles to the management of an academic integrated delivery system to hands-on patient care. From this work, we have a frontline view of the good that modern medicine can produce, but also the inefficiency, missed opportunities, confusion, and occasional harm. We see the consequences of a lack of health insurance...

  4. I The Problem Is Chaos

    • 1 Chaos
      (pp. 3-18)

      Her friends and doctors still describe her as “formidable,” and at age eighty, SC finds that amusing. When she was younger and still teaching William Shakespeare to college students, she knew she was a force—a passionate, sometimes intimidating teacher who knew how to make her points. She used those same skills after she retired as a community activist—the sort of well-informed, overwhelmingly articulate citizen who just by walking into a public hearing, can cause local politicians’ hearts to sink.

      Today, she remains imposing. SC leans toward her listeners as she speaks, and they tend to lean ever so...

    • 2 Progress
      (pp. 19-36)

      Health care has its share of “bad guys” who warrant criticism—including businesses reaping exorbitant profits, criminals who commit fraud, and physicians who practice sloppy medicine, to name a few. And our challenges would be simpler if the driving force behind U.S. health care’s problems was the greed or incompetence of these people. We could round the culprits up and put them out of business.

      Unfortunately, we cannot lock up the dominant force behind rising health care costs, and even if we could, we would not want to. That force is progress itself—technological innovations like new drugs that make...

    • 3 Fragmentation
      (pp. 37-52)

      The conventional wisdom is that the U.S. health care system is broken, but that assessment is misleading. After all, can a system that has never truly existed be called broken? All of the components of fabulous health care exist in abundance in the United States, yet with a few exceptions, they have never been organized to work together. These health care providers are small and not-so-small businesses performing their specific roles—virtually all of which are altruistic and honorable. But these providers have not yet been asked, encouraged, cajoled, or forced to work together around the common goal of meeting...

  5. II The Solution Is Organization

    • 4 What Does Organization in Health Care Look Like?
      (pp. 55-70)

      Most Americans know what disorganized health care is like. Amid a swirl of activity in our hospitals and physician offices, patients wait—for appointments, test results, and clear information that sometimes never comes. Physicians cannot reach each other, and thus do not give patients consistent or coherent answers to questions. Tests are duplicated by accident or forgotten altogether. Abnormal test results are overlooked. Costs are high, and quality is disappointing.

      Patients and providers who have known nothing but disorganized care have been accepting of this chaos, but medical progress is intensifying the cost and quality problems that result. Providersand...

    • 5 What Kinds of Systems Improve Health Care?
      (pp. 71-96)

      Physicians, patients, and nurses sit in different spots in the health care system, but they all face one common impossible task. They are constantly bombarded by information, most of it mundane and reassuring. But some of those data are potentially ominous, and the consequences of missing warning signs or abnormal test results can be tragic.

      The flood of information is overwhelming. Abnormal mammograms are occasionally overlooked. Medications are given even though patients have allergies to the drugs. Tests are repeated because the results from earlier examinations cannot be located. Patients leave the hospital or physicians’ offices confused about what medications...

    • 6 Tightly Structured Health Care Delivery Organizations
      (pp. 97-118)

      Organized health care is not an abstract concept, a fantasy, or an unattainable ideal. In fact, millions of Americans already benefit from health care organizations that use information systems and teams of clinicians to provide safe, reliable, and efficient care. Many of the patients who use these organizations are unaware of the advantages that their systems offer—until those patients leave, and rediscover what health care is like when physicians do not share the same medical records, when letters and lab tests get lost on a regular basis, and when there are no processes that address their needs in between...

    • 7 Organizing the Mainstream of U.S. Medicine
      (pp. 119-142)

      The organizations profiled in the previous chapter are tightly structured provider groups, which own their own hospitals, employ their own physicians, and often have their own insurance companies. This management structure is sometimes called the clinic model, meaning that all caregivers work for the same clinic, regardless of whether the individuals may be focused on inpatient or outpatient care. When all the components of the provider organization sit under one management team, responding to crises and market imperatives is at least possible—even if collaboration in the improvement of care can be difficult even in these circumstances.

      Perhaps advantages derived...

    • 8 What Can Payers, Employers, and Patients Do?
      (pp. 143-160)

      Although physicians and other health care providers may be best trained and best positioned to bring order to the chaos of modern medicine, most of them are not sufficiently organized to take on this task with optimal effectiveness. Even providers in tightly structured organizations such as those described in chapter 6 frequently fall short of their goals. When providers cannot make care safe, efficient, and reliable, how can the gaps in performance get filled?

      In this chapter, we examine the contributions that can be made by payers, employers, and patients themselves. These contributions are aimed in many cases at improving...

  6. III How Do We Get There?

    • 9 Evolution or Revolution?
      (pp. 163-174)

      Change is needed in health care—and change is under way. Physicians and hospitals are implementing systems that make care safer, like EMRs and CPOE systems. With increasing frequency, physicians and nonphysicians are working in teams that coordinate the care of the most complex patients and those with chronic diseases. And retiring physicians are being replaced by a new generation of doctors who are computer savvy and receptive to the notion that being part of an organized team just might be beneficial for their patients.

      These changes are being driven by demographic shifts, technological advances, and the demands of an...

    • 10 Provider Change
      (pp. 175-194)

      As is probably evident from what we have written thus far, we believe in groupness. We think that the economic challenges and quality issues in health care cannot be addressed effectively unless physicians and other providers are organized into groups that have enough size and effectiveness to adopt tools that improve care. Those tools should help clinicians keep track of data, and make decisions that are safe, efficient, and beneficial for their patients. And these tools should reinforce groupness by helping clinicians work within teams that include patients themselves.

      Patients are the real focus of health care, of course, and...

    • 11 Payment Change
      (pp. 195-210)

      We have argued throughout this book that health care can improve as providers adopt systems that bring organization to care, and we believe that this evolution is under way. But this improvement will come too slowly if the only drivers are the desire of individual providers to give excellent care, and the gradual replacement of older physicians by younger clinicians who are more computer savvy and team oriented. Improvement can and should be accelerated by environmental forces, and in this chapter, we will examine the potential role of changes in the financing of health care.

      Some of our fellow physicians...

    • 12 Market Change
      (pp. 211-228)

      Any decent vision of a better health care system has the patient at the center. This book began with the description of the chaotic experience of one of our own patients, SC, an elderly woman with lymphoma and multiple other conditions, and more than ten doctors who do their best on her behalf, but sometimes give her conflicting messages and advice, or fail to answer her questions. Her care is actually more coordinated than that received by most patients, because most of her physicians are within a single organization and use the same EMR. But her physicians and she would...

    • 13 Accelerating Evolution
      (pp. 229-248)

      The central argument of this book is that the organization of providers is an essential step in the development of a better health care system. Organization enables providers to bring order to the chaos generated by technological progress. Organized providers can use EMRs, patient registries, disease management programs, and other systems described in this book to make health care more efficient, reliable, and safe.

      Perhaps because we are optimists, we believe that the adoption of such systems and the resulting improvement in health care is already under way. But because we are realists, we know that the pace of improvement...

  7. References
    (pp. 249-262)
  8. Further Readings
    (pp. 263-266)
  9. Index
    (pp. 267-278)