CHAPTER 11

Health Systems Science

Stephanie R. Starr, MD, FAAP

Introduction

Rapid Evolution of US Health Care and Persistence of Significant Gaps in Health

For decades, primary care pediatricians have focused on the individual needs of infants, children, adolescents, young adults, and their families, and have made every effort to provide the highest quality care to their patients. The components of primary care and the patient-centered medical home are ideally combined to optimize the care of children using a holistic approach (see Chapter 1). The role of the primary care pediatrician is changing from managing acute illness to preventing illness to diagnosing and treating new morbidities, such as mental health disorders, neurodevelopmental disabilities, chronic disease, and other disorders that often stem from socioeconomic determinants of health, including poverty, family dysfunction, abuse, and other adverse childhood experiences. Although advocacy (see Chapter 10), culturally competent care (see Chapters 8 and 57), and global child health (see Chapter 9) have long been emphasized in caring for pediatric patients, these new morbidities and other changes in the lives of patients and their families require an explicit focus on new topics. Social determinants of health are estimated to contribute more toward health outcomes than health behaviors, care via the health care system, or genetics. Advances in shared decision making and conversations with patients and families on choosing tests and treatments that are high value to patients, families, clinicians, and the system require new clinical skills not traditionally taught in caring for individual patients.

As children, their families, and their health issues have changed, so have pediatric practices and the broader US health care system. In 2007, the Institute for Healthcare Improvement proposed Triple Aim as the ultimate goal of health care, that is, optimal health of the population and best experience of care at the lowest cost. Health care stakeholders (ie, patients, families, payors, insurers, health professionals, health care systems, society) more commonly frame this as value, that is, the quality of care (ie, care that is safe, timely, effective, efficient, equitable, and patient-centered) divided by the cost of care over time. Health care spending does not correlate to health outcomes, and health care costs are the largest contributor to personal US bankruptcies. Substantial gaps in health care access, equity, affordability, safety, effectiveness, and efficiency persist despite significant advances in biomedical science. Primary care pediatricians and other health professionals are advancing child health via health care improvement (ie, quality improvement [QI], patient safety [see Chapter 21]) initiatives locally, regionally, and nationally. Doing so requires the ability to see levels of the health care system beyond the individual patient alone and to espouse the professional responsibility to care for the system in addition to caring for individual patients. In current practice, some health professionals have added a fourth aim: wellness of the health professionals and others on the care team.

Many interactions and systems issues that affect health care and health underlie every physician-patient interaction (Figure 11.1). This complex health care system is rapidly changing, including but not limited to payment models and insurance reform, new care delivery models, population health strategies, and emerging technology. Medicine and health care have become a team sport, with less focus on the physician-patient interaction alone and increased incorporation of interprofessional health teams into the patient-centered medical home model. Although pediatric health issues have changed significantly and the health care system is constantly evolving, little has changed in the training of the primary care pediatric workforce. The American Academy of Pediatrics (AAP) “Agenda for Children 2017-2018” includes topics not traditionally learned in medical school or residency, including access, finance, and social determinants of health. Practicing pediatric health professionals enter the profession with a steadfast commitment to improving the health of children, and many identify additional learning that would help them practice in this rapidly evolving health care system.

Medical Education and the Needs of Society

Medical education has an obligation to improve quality of life, reduce the burden of disease, and help advance the Triple Aim to fulfill its contract with society. Despite gaps in health care quality and rising costs of care, little has changed in physician education since Abraham Flexner proposed reform in 1910. Accreditation and certification bodies have added requirements in some areas, such as the Accreditation Council for Graduate Medical Education Systems-Based Practice and Practice-Based Learning and Improvement competencies in residency and fellowship, but many changes are incremental and gaps persist. Because medical costs are the most common reason for personal bankruptcy filings in the United States and because of the desire to first do no financial harm, some health professionals have advocated for high-value care as the seventh competency required for graduate medical education.

Traditional physician training in basic and clinical science alone does not meet the current health needs. Many practicing health professionals identify additional learning that would help them practice in the rapidly evolving system and achieve the Triple Aim. To help medical education evolve to match the pace of change in practice, and in recognition that rigorous basic and clinical science training is insufficient to meet the Triple Aim, many medical educators are advocating for training physicians in a “third” science: health systems science (HSS; Figure 11.2).

Figure 11.1. The “iceberg” of health care concepts affecting health.

Reprinted with permission of the American Medical Association from Health Systems Science, first edition. ©Copyright American Medical Association 2017. All rights reserved.

Figure 11.2. The 3-pillar model of medical education.

Health Systems Science in Medical Education

Health Systems Science Education: Definition, Framework, and Relevance to Primary Care Pediatricians

In 2017, experts from 11 medical schools published a curricular framework for HSS education to help address health and health care gaps. The curricular framework was proposed based on existing or planned systems-related curricula at their schools (Figure 11.3). Health systems science in medical education is defined as the principles, methods, and practice of improving quality, outcomes, and costs of health care delivery for patients and populations with systems of medical care. Stated another way, HSS can also be defined as the concepts and skills needed by health professionals to ensure that the basic and clinical sciences and the good intentions of health professionals have maximal effect on the Triple Aim.

The core content domains within HSS were described as health care structures and processes; health care policy, economics, and management; clinical informatics and health information technology; population and public health; value-based care, and health system improvement. Content areas (ie, cross-cutting domains) traditionally included in many schools but re-envisioned within HSS included scholarship; leadership and change agency; professionalism and ethics; teamwork and interprofessional education; and evidence-based medicine and practice. Systems thinking was described as the linking domain for the HSS framework.

Some schools use terms similar to HSS, such as “science of health care delivery,” “health care delivery science,” and “foundations of health care delivery” (Figure 11.4). Many medical schools in the United States and elsewhere are incorporating HSS-related curricula, with variation in scope and depth. The nomenclature related to this third science and the evidence for best methods to teach and assess it will continue to evolve. The old mantra “we are training students to care for tomorrow’s patients” is no longer the ideal; schools are demonstrating that medical students can improve the care of today’s patients as they learn about HSS.

Figure 11.3. Core, cross-cutting, and linking domains for a health systems science (HSS) curricular framework. Core curricular domains are content areas that align directly with HSS. The cross-cutting domains are content areas that traditionally may have been included in undergraduate medical education curricula but that have a new context in the HSS. The 1 linking domain—systems thinking—unifies or links the core curricular or cross-cutting domains to other core curricular or cross-cutting domains (ie, internal linking, depicted in this figure) and to other areas of the curriculum, such as the basic and clinical sciences (ie, external linking, not depicted in this figure).

Reprinted with permission from Gonzalo JD, Dekhtyar M, Starr SR, et al. Health systems science curricula in undergraduate medical education: identifying and defining a potential curricular framework. Acad Med. 2017;92(1):123–131.

Figure 11.4. Health care curricular framework.

Reprinted with permission from Starr SR, Reed DA, Essary A, et al. Science of health care delivery as a first step to advance undergraduate medical education: a multi-institutional collaboration. Healthc (Amst). 2017;5(3):98–104.

Pediatricians in training and those in practice likely have significant variation in their understanding and practice of HSS-related concepts and skills based on their undergraduate medical education, graduate medical education, and/or their practice experiences. Although health professionals may have experience and expertise in some HSS-related areas, which for pediatricians includes a focus on advocacy and culturally competent care, they may not be able to easily explain relationships across HSS topics to team members and/or the students and residents they teach. Without a broad definition of the third science concepts that affect health and health care, pediatricians may miss opportunities to recognize and close gaps in care for children and their families. Pediatricians committed to caring for children can have great impact when they see their professional duty is both to doing their work (caring for individual patients) as they improve their work (caring for the health care system and for populations of patients). Envisioning HSS as a third science with a conceptual framework can foster systematic thinking and help pediatricians recognize the actions they can take (or “levers” they can pull) to meaningfully improve child and family health.

Systems Thinking: Components and Levels

Systems thinking is at the core of HSS. Pediatricians may recognize gaps in care that occur during office interactions with patients (eg, inability to identify a dentist who accepts the family’s government health insurance) more easily than they can anticipate or see other gaps through the lens of the patients’ and families’ view as they experience care across a system. It can be difficult to really know what patients and families experience from the moment they call to try and schedule an office visit, to parking, to checking in to the front desk, to being led to a room by a nurse or other care team member, to being seen by the pediatrician, to going to the laboratory (on site or at a distance) for a blood test, to accessing test results and interpretation from the pediatrician.

Health professionals should ideally understand 3 essential concepts related to health care systems: systems thinking; the structures, processes, and outcomes comprising the building blocks of health care delivery; and effect on the patient of every level of the health care system.

Systems Thinking

The Waters Foundation has summarized 14 habits of systems thinkers that encourage health professionals to be flexible in their thinking, identify new insights, and appreciate other perspectives, including recognition that a system’s structure generates its behavior. Stated another way, every process is perfectly designed to get the results it gets, so to get a different outcome, the structure and/ or process must be changed as well. Systems thinkers can apply tools (many of which are used in QI training) to augment these 14 habits.

The Building Blocks of Health Care Delivery: Structures, Processes, and Outcomes

Avedis Donabedian, MD, MPH, considered by many to be the grandfather of US health care quality, explained the importance of improving health care quality by using structural, process, and outcomes measures. These measures provide a granular way of showing that health improvement efforts are “moving the needle” and having a positive effect (see Chapter 21). Examples of structure, process, and outcomes measures are given in Table 11.1.

Effect on Patients: Recognizing the Levels of the Health Care System

The effect—both positive and negative—on patients occurs at every level of the health care system, and clinicians must be able to recognize the levels of the health care system on behalf of patients and clinical team members. Patient- and family- centered pediatricians and their care teams consider the experience of care, disease, and treatment burden from the perspective of the patient and family. Pediatricians who think with a systems perspective are more likely to identify additional opportunities to improve care not only for their individual patients, but also for groups of similar patients. They can make or influence changes (ie, pull levers) not only at the patient-clinician level, but also at the microsystem, mesosystem, and macrosystem levels (Figure 11.5).

The microsystem is most familiar to pediatricians; it is the front-line clinical team that, in addition to physicians, may include nurses, nurse practitioners, clinical assistants, secretaries, and receptionists. Nurses on the team may have several specialized roles based on their scope of licensure, including clinic nurse, triage nurse, and care manager (eg, for complex patients). Ideally, every team member has a role that enables that person to work at the peak of that individual’s experience and licensure, and all perspectives are leveraged to recognize gaps in care and contribute to closing gaps (eg, via QI initiatives).

Abbreviation: ED, emergency department.

^a Most important to patients and families.

Figure 11.5. Levels of the health care system. Self care is care provided by patients and their families. Note that patients and/or families can obtain resources for their health directly from the community (outer circle). The microsystem is the front-line interprofessional clinical team with whom patients and/or families interface. In pediatric primary care, physicians, nurse practitioners, nurses, and secretaries are part of the primary care team/practice. The mesosystem comprises connected microsystems that patients and/or families traverse in their experience of care (eg, primary care team, inpatient care team, radiology team, pharmacy team, outpatient specialty care team, emergency department team). The macrosystem comprises mesosystems that patients and/or families traverse in their experience of care (eg, community health center, referral specialty health center, public health).

Reprinted with permission from Nelson EC, Batalden PB, Godfrey MM. Quality by Design: A Clinical Microsystems Approach. San Francisco, CA: Jossey-Bass; 2007.

Mesosystems are collections of microsystems that a patient may move across during an episode of care. For example, a large multispecialty group practice at 1 clinic may have multiple pediatric, family medicine, and internal medicine teams (ie, microsystems) as well as other microsystems (eg, laboratory, radiology, and pharmacy teams). During a visit for possible pneumonia, a patient may move across 3 microsystems (ie, pediatric, radiology, and pharmacy teams) before leaving the clinic. Opportunities to improve the care of other patients like that one may occur at the microsystem level (eg, improving wait times) or may require a coordinated effort across 2 microsystems. Quality improvement and advocacy are levers that can be pulled to make or influence change at this level.

Similarly, macrosystems are collections of mesosystems across which a patient may move during an episode of care. An ill child seen in a primary care mesosystem who is transported to the emergency department mesosystem (with, for example, emergency medicine microsystem, laboratory microsystem, radiology microsystem) and is later admitted to the hospital (with similar mesosystem members) encounters an entire macrosystem. The quality of care this child receives is dependent in part on the strengths or weaknesses not only of each team, but on how the teams communicate during handoffs and how everyone is able to envision the patient’s journey from the start of his or her experience (ie, in the primary care office) to the end (ie, hospitalization and eventually, discharge home). To reiterate, both QI and advocacy can occur at the macrosystem level.

Applying Health Systems Science to the Components of Pediatrics

Primary Care

The components of primary care as described by Charney and Alpert in 1974 include first contact, longitudinal care, family orientation, and integration of comprehensive care (see Chapter 1). For all pediatricians working in the current US health care system, these components remain critical and relevant, but the pediatrician with a systems view will recognize the need for additional components and will understand that it is necessary to evaluate each component at multiple levels of the system to maximize the health of all children. Examples of each component at multiple levels of the health care system are described in Table 11.2. These examples are opportunities for pediatricians and colleagues in their clinical (ie, microsystem) teams to see opportunities to promote high-value care and improve child health and, in doing so, advance the Triple Aim.

Pre–First Contact

The process or steps that patients and families encounter before having their first contact (ie, office visit) was not conceptualized when medicine and care delivery outside of public health was purely transactional, an interaction between the patient and the physician (or in the inpatient setting, a patient and a hospital team). Variation in access to care based on health insurance, geography, transportation, and other barriers now affect how a patient interacts with primary pediatric teams in primary care medical homes. Pediatricians and pediatric medical homes seeking to improve child health care and health must conceptualize their role in ensuring the patients in their care have access to care when they need it and to preventive care to maintain their health.

For example, in 2015 the National Academies of Sciences, Engineering, and Medicine (NASEM) published a white paper titled Improving Diagnosis in Health Care. The authors proposed a systems view of diagnostic errors, with the recognition that accurate and timely diagnosis cannot be made without access to the care team (Figure 11.6). Pediatricians must envision the health care system from the patients’ and families’ point of view and recognize opportunities to improve the likelihood that children who need the first contact are able to benefit from the team’s care.

First Contact

A first contact in a pediatric medical home may be a visit for an acute or chronic health issue or for a well visit. Using a systems view, the pediatrician should consider how excellence in this first contact would be defined by patients and their families. In addition to the patient-physician relationship and cultural effectiveness (see Chapters 8 and 57), patients and families might prioritize a focus on needs, desires, and goals unique to the child and/or family. Pediatricians might also include screening for poverty and for financial harm from medical treatment. Currently, this first contact may be with another care team member via a nurse triage telephone call or via an online patient portal message.

Longitudinal Care

Longitudinal care requires providing optimal care over time to individual patients and to populations of patients, ideally within the medical home model. The Joint Principles of the Patient-Centered Medical Home (PCMH) were co-published in 2007 by the AAP, American Academy of Family Physicians, American College of Physicians, and the American Osteopathic Association. An emphasis on the Triple Aim and the change in payment models (from fee-for-service to payment for value) have helped fuel this population health approach. Care is no longer limited to face-to-face physician visits and phone triage with nurses; it includes nonvisit care via electronic patient portals between in-person visits to address simple new concerns, determine if a visit is necessary, provide test results, and follow up with patients and families on chronic health issues.

The AAP aptly describes the population health mindset as a change by health professionals from passivity to proactivity. Rather than waiting for patients to come to providers and care teams, the care teams reach out to patients and families. Not all patients in a given practice have the same level of need; thus, different systems approaches are necessary. Relatively healthy patients benefit from preventive interventions (eg, immunizations) and screenings (eg, review of growth at well visits, lead and developmental screenings). Children with a single chronic disease (eg, persistent asthma) may benefit from practice-level processes to improve their health outcomes by targeting identification of emergency department visits, monitoring oral steroid use, and regularly updating asthma action plans. For children with medical complexity, care management may be necessary to help families and the PCMH team optimize the value of care rendered (eg, assigning a primary nurse who knows the child well and who can triage concerns as they arise).

The National Resource Center for Patient/Family-Centered Medical Home (formerly the National Center for Medical Home Implementation), a collaboration between the AAP and the Maternal and Child Health Bureau of the Health Resources and Services Administration of the US Department of Health and Human Services, summarized a number of promising practices and their PCMH innovations, including family orientation and integration of comprehensive care.

Family Orientation

Children and their caregivers will not achieve optimal health or have an optimal experience of care unless pediatricians and their care teams are deliberate in their commitment to systematic culturally competent and effective care, both for individual patients and groups of patients. Care team members must have knowledge of the social determinants of health and their effect on health (see Chapter 141). This is particularly important when establishing a strong relationship with children and their caregivers at the first visit.

Abbreviations: IEP, Individualized Education Program; PHQ-9M, 9-item Patient Health Questionnaire Modified for Teens; QI, quality improvement.

^a Institute for Healthcare Improvement. What matters? IHI.org website. www.ihi.org/Topics/WhatMatters/Pages/default.aspx. Accessed August 19, 2019.

^b Modified from Smith CD; Alliance for Academic Internal Medicine–American College of Physicians High Value, Cost-Conscious Care Curriculum Development Committee. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine–American College of Physicians Curriculum. Ann Intern Med. 2012;157(4):284–286.

^c Hoffmann TC, Montori VM, Del Mar C. The connection between evidence-based medicine and shared decision making. JAMA. 2014;312(13):1295–1296.

Integration of Comprehensive Care

Integration of comprehensive care requires pediatricians and their PCMH team members to integrate the care of patients within the PCMH and across other parts of each patient’s health ecosystem to ensure that data are shared appropriately and handoffs occur effectively. This includes the interaction between primary and secondary (or specialty) care (see Chapter 1). Several new care delivery innovations include electronic specialty consults as well as integrated behavioral health and other specialty care models integrated within the PCMH. It also includes integration as part of ongoing care (eg, in conjunction with community partners, such as public health, schools, child care centers, home health and nursing agencies, and pharmacies).

To Err is Human, published in 1999 by the Institute of Medicine (now the Health and Medicine division of the National Academies), catalyzed the US patient safety movement. A critical component of safe care is the expert and deliberate process for communicating with teams and across teams at times of transition. This includes transitions across care settings during an episode of care (eg, emergency department to hospital, hospital to PCMH, PCMH to specialty care). The Agency for Healthcare Research and Quality Team STEPPS program provides a model for training in interprofessional teams to improve patient safety. The I-PASS program is a framework studied in pediatric residencies to increase patient safety during provider handoffs. Common handoffs in integrated, comprehensive care include dismissal of patients with complex medical issues from an acute care hospital setting to the PCMH.

Figure 11.6. The diagnostic process.

Reprinted with permission from National Academies of Sciences, Engineering, and Medicine. Improving Diagnosis in Health Care. Washington, DC: The National Academies Press; 2015. https://doi.org/10.17226/21794.

Pediatric Primary Care Examples of Health Systems Science Principles

Advocacy

Advocacy has long been a professional expectation of pediatricians on behalf of children, a segment of society without a legal voice. Advocacy occurs at the individual patient-pediatrician level (eg, working with schools to evaluate students who may qualify for special education services) or at a higher level (eg, the state legislature for effective booster seat laws). Carol Berkowitz, MD, has described advocacy for individual patients as advocacy with a “little a,” and for groups of patients as advocacy with a “big A.”

Systems thinking can help reveal opportunities to advance child health in the realm of advocacy. For example, pediatricians can use the AAP Oral Health Toolkit to advance oral health initiatives for children at multiple levels of the system, including the community. Alternatively, if during a face-to-face clinic visit a pediatrician notes findings that are suspicious for child abuse and maltreatment, the pediatrician is legally bound to advocate for the child by reporting to Child Protective Services. Pediatricians can work with their clinical (ie, microsystem) team to develop new strategies for making children more comfortable during visits when suspected abuse is the chief concern. They can work with community partners to ensure child-friendly handoffs to those conducting forensic interviews and to educate child caregivers on reporting requirements and parents on abuse prevention strategies (ie, macrosystem). Conceptualizing the system in this manner may also help pediatricians consider the stakeholders who can align with their efforts and/or inform their efforts to help ensure success.

Population Health

As mentioned previously, 1 intervention to improve pediatric health is care coordination of children with complex health needs. In 2014, the AAP published recommendations for care coordination of children with medical complexity, including features of care coordination excellence, such as use of health information technology and health outcomes tracking over time. This recommendation was reaffirmed in 2018. As with many population health strategies, the perspective focuses on the health of all patients empaneled to the PCMH, not just those who come in for face-to-face visits.

Recent years have seen several successful population health models within primary care settings, including collaborative care models for adolescent depression and other integrated behavioral health strategies. Primary care pediatricians have collaborated with pediatric subspecialists and nurse care managers using patient registries to proactively care for their population of children and adolescents with persistent asthma. Registries can also be helpful to proactively manage children with medical complexity and children with other chronic conditions, such as attention-deficit/hyperactivity disorder.

Social Determinants of Health

As previously noted, social determinants of health (see Chapter 141) are estimated to have a more significant effect on health than health behaviors, health care, or genetics. Pediatricians must elicit information about social determinants of health to be successful in caring for individual patients. At the microsystem level and above within the health system, pediatricians and their care teams can use population health approaches to identify subpopulations of patients in their practice (eg, refugee families) and conduct a needs assessment to tailor the practice to meet the needs of these patients.

Beyond the health system, many opportunities exist for pediatricians and other child health advocates to influence change to minimize the negative effect of social determinants of health. The Centers for Disease Control and Prevention developed the “Health Impact in 5 Years” initiative, which highlights nonclinical, community- wide strategies (Figure 11.7). These evidence-based strategies report positive health impacts within 5 years, and cost effectiveness and/or cost savings over the lifetime of the population.

High-Value Care

The role and limitations of laboratory tests and other diagnostic studies in making an accurate diagnosis for patients and families has long been taught as part of the basic and clinical sciences. With a systems approach, the NASEM model for improving diagnoses emphasizes diagnoses as a series of hypothesis testing (see Figure 11.6). For example, the diagnosis of acute otitis media is made based on history and physical examination alone. A patient presenting with a limited diet and fatigue may require only 1 laboratory test (ie, complete blood count) to confirm iron deficiency anemia. Many diagnoses are made over time, however.

In 2012, the Alliance for Academic Internal Medicine and the American College of Physicians published a 5-step model for teaching high-value care to residents (Figure 11.8). These evidence-based strategies report positive health impacts within 5 years of implementation and are cost effective and/or cost saving over the lifetime of the population. They can help pediatricians see the relationships across the key HSS-related knowledge and concepts of evidence-based medicine, shared decision making, and health care improvement.

Steps 1 and 3 of the model are part of critical appraisal of the literature and evidence-based medicine. Step 2 provides an opportunity for pediatricians to stop medications or reconsider unnecessary testing if it does not provide value to the patient. Step 4, which is part of shared decision making, requires pediatricians to apply what they have learned from the evidence to the patient in front of them. More broadly, this is the stage at which shared decision making, whether formal or informal, is necessary to ensure that the patient (as age allows) and family are given adequate information to make a decision that reflects their context (eg, other aspects of their lives they are balancing as a family, the work of being a patient), their preferences, and their values. Step 5 is health care improvement at the microsystem level or above, that is, QI or safety efforts to increase value for multiple patients.

Figure 11.7. Public health impact pyramid. The pyramid depicts the potential impact of different types of public health interventions from greatest potential impact at the base (because they reach entire populations of people and require less individual effort) to least potential impact (because they target specific populations and require more individual effort).

Reprinted from Centers for Disease Control and Prevention, Office of the Associate Director for Policy and Strategy. Health Impact in 5 Years. CDC.gov website. www.cdc.gov/policy/hst/hi5/index.html.

Figure 11.8. Framework for teaching high-value care, showing some of the relationships to other health systems science–related concepts.

Abbreviations: EBM, evidence-based medicine; SDM, shared decision-making.

Adapted with permission from Smith CD; Alliance for Academic Internal Medicine–American College of Physicians High Value, Cost-Conscious Care Curriculum Development Committee. Teaching high-value, cost-conscious care to residents: the Alliance for Academic Internal Medicine–American College of Physicians Curriculum. Ann Intern Med. 2012;157(4):284–286.

Physicians may need help determining which tests to order using a high-value approach that reflects the individual considerations for each patient while also reflecting what is known to be effective care. Choosing Wisely collaborated with the AAP to identify 10 tests or treatments that pediatricians should question (Box 11.1).

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