How do we best engineer a “system” composed of the people, place and products elements that we introduced last time that can deliver improved value-based care?  A key step in engineering any large scale system is the development of a functional architecture that identifies system functional components and their interactions[1]. It defines how the functions will operate together to perform the system mission. Generally, more than one architecture can satisfy the requirements, and good systems engineers use abstract concepts such as internal “cohesion”  of a component and inter-component “coupling” to compare alternative architectural approaches, typically seeking system functional architectures that are composed of highly cohesive/loosely coupled components[2].

Today’s healthcare system could be viewed as a siloed “provider-centric” functional architecture, designed around medical disciplines (primary care, specialized medicine) and/or types of services (in-patient, out-patient, skilled nursing, etc.).  When viewed through the lens of providers, such an architecture could be viewed as “highly cohesive” and “loosely coupled” across components.  But when viewed through the lens of a patient seeking improved value based care, where interactions/teamwork between siloed providers is key to improved outcomes, the existing care delivery architecture is, at best weakly cohesive (e.g. patients may seek a second opinion from a specialist), and highly coupled (e.g. frequent high value interactions/coordination across multidiscipline providers on care team critical to outcomes).

We must move away from a system organized around what physicians and institutions “do” and towards a patient-centered functional architecture organized around what patients “need”.

The systems engineering principles of “top-down” functional decomposition/allocation of high level system-level requirements (e.g. efficient delivery of measurable patient-centered improved outcomes) and “bottom-up” synthesis of existing siloed components (numerous organizational units, ranging from hospitals to physicians’ practices to units providing single services) can be used towards definition of a patient-centered high quality functional health care system architecture[3].

The overarching goal of improved (holistic) value for patients combined with the complexity and inter-relationships of care associated with patients with complex medical conditions (e.g. diabetics with eye disorders, kidney, heart, foot conditions) drives the functional architecture to patient-centered components that cut across existing specialty-care silos and can deal with the entire set of care needed for a specific complex medical conditions such as diabetes or cancer that generally require team-based care.  The high level functional components are selected to ensure high levels of care coordination for high value outcomes for common, complex conditions while supporting lower level interactions across components (e.g. across diabetes and cancer providers). Porter and Lee[4] call these highly cohesive, loosely coupled healthcare delivery architecture functional components “integrated practice units (IPUs)”.  Highlight desirable characteristics of IPUs include:

1) An IPU is organized/focused around a medical condition or a set of closely related conditions (or around defined patient segments for primary care). This feature constrains the informatics domain enabling effective use of domain-specific ontologies/terminologies, rules-based guidelines/protocols, machine learning for detection of effective patterns of care in data repositories of patients that share a common condition or closely related conditions, and effective measurements of value/outcomes.

2) Care is delivered by a dedicated, multidisciplinary team of clinicians who devote a significant portion of their time to the medical condition.  In addition to the benefits of volume-based team learning, highly coordinated care in enabled through repetitive practice patterns that reduce unwanted variation in care and optimize value-based outcomes.

3) Providers see themselves as part of a common, cohesive organizational unit. The providers on the team meet formally and informally on a regular basis to discuss patients, processes, and results. A physician team captain or a clinical care manager (or both) oversees each patient’s care process.  Joint accountability is accepted for outcomes and costs. The team measures outcomes, costs, and processes for each patient using a common measurement platform.

4) The team takes responsibility for the full cycle of care for the condition, encompassing outpatient, inpatient, and rehabilitative care, and supporting services (such as nutrition, social work, and behavioral health). Patient education, engagement, shared decision-making and follow-up are integrated into care.  The unit has a single administrative and scheduling structure. To a large extent, care is co-located in dedicated facilities.

In my next blog post, I will discuss additional benefits of IPUs and how information technology can be used as a force multiplier to achieve greater efficiencies and improved outcomes.





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