Health systems science addresses the complex interactions in healthcare delivery. At its core, health systems science describes the intricate details required to provide high-quality care to individual patients by assisting them in navigating the multifaceted and often complicated US healthcare delivery system. With advances in technology, informatics, and communication, the modern physician is required to have a strong working knowledge of health systems science to provide effective, low-cost, high-quality care to patients. Medical educators are poised to introduce health systems science concepts alongside the basic science and clinical science courses already being taught in medical school. Because of the common overlap of women’s healthcare subject matter with health systems science topics, such as interprofessional collaboration, ethics, advocacy, and quality improvement, women’s health medical educators are at the forefront of incorporating health systems science into the current medical school educational model. Here, the authors have described the concept of health systems science and discussed both why and how it should be integrated into the undergraduate medical education curriculum. Medical educators must develop physicians of the future who can not only provide excellent patient care but also actively participate in the advancement and improvement of the healthcare delivery system.
The changing American healthcare landscape
In generations past, a well-trained and successful physician was considered a person that could memorize, recall, and properly apply all the encyclopedic medical facts learned during medical school and residency. This type of physician could accomplish all of the goals required for healthcare delivery through personal 1-on-1 interaction with the patient. The rest of the healthcare system existed in the context of this relationship.
Advancements, including the expansion of the Internet, the transition to the electronic medical record, and the embrace of the Institute for Health Care Improvement’s Triple Aim ([1] improving the patient experience of care, [2] improving the health of populations, and [3] reducing the per capita cost of healthcare) obliges the modern physician to consider the effect of their care within the broader healthcare system. As patients physically travel and their personal information virtually interacts with healthcare systems across state and international lines, their health data can now easily be accessible at all times and from any location. Similarly, with aggregate data collection and benchmarking, patient care outcomes are already being used to assess the quality of care by the individual clinician.
At the same time, US healthcare expenditure has grown from 5% of the gross domestic product in 1960 to 18% in 2017. This fact, coupled with several markers of poor overall health in America relative to similarly developed nations, has driven an increased focus on the quality and cost of healthcare in recent times. After the passage of the Affordable Care Act in 2010, healthcare insurance coverage expanded to include 20 million additional Americans, and there was an increased focus on individual hospital and physician quality of care metrics for their patients. Merit-Based Incentive Payment System and Bundled Payment programs are examples of recent federally mandated requirements of future physicians to use real-time cost and quality outcomes data to analyze how physicians deliver care to their patients.
The onus: medical education
Practicing clinicians will identify that a challenging aspect of their day-to-day practice of medicine is helping patients navigate the healthcare system. Although administrative office staff often assist with surgical procedure authorization, negotiating insurance coverage for medications, and identifying reliable community resources for patients’ psychosocial and emotional needs, physicians play an important role in initiating these healthcare system processes and supporting their staff.
The skills and talents required of the modern physician to navigate the healthcare system are currently only taught on the periphery of the medical school curriculum. Most physicians in training begin to learn the process and procedures required to care for patients during their residency. Unfortunately, residents often find themselves with a patient in acute need of coordinated care only to realize that they have a superficial understanding of how to assist the patient through navigating the healthcare system. For the first time in their medical training, residents begin to interact with social workers and care coordinators to learn the concept of discharge planning.
Undergraduate medical educators are well positioned to introduce the systems aspect of healthcare delivery to medical students early in their education. Alongside learning the foundational basic science concept of glucose metabolism, and the clinical application of the diagnosis and treatment of gestational diabetes mellitus, using the case of a postpartum patient newly diagnosed with type II diabetes mellitus struggling to find ongoing care after her pregnancy insurance ceases allows students to understand the real-life relevance of learning these basic science and clinical concepts. Debriefing the effect of the healthcare system on this patient’s case emphasizes to medical students the importance of understanding care coordination and patient advocacy in addition to learning about metabolism and diabetes mellitus management to optimize long-term health outcomes for individual patients.
What is health systems science?
Gonzalo et al described that health systems science (HSS) addresses the complex interactions among all aspects of healthcare delivery. As demonstrated in the Figure , the authors deconstructed the concept of HSS into core domains, cross-cutting domains, and linking domains of systems thinking.
The 6 core domains are as follows: healthcare structures and processes; healthcare policy, economics, and management; clinical informatics and health information technology; population health; value-based care; and health systems improvement.
The 5 cross-cutting domains span the core domains through methods to approach, deliver, and adapt the core domains within the application of healthcare. The cross-cutting domains are as follows: leadership and change agency, teamwork and interprofessional education (IPE), evidence-based medicine (EBM) and practice, professionalism and ethics, and scholarship.
Systems thinking refers to the purposeful thought process of continuously considering the interaction among all core and cross-cutting domains at every point in the delivery of care within a health system.
Women’s healthcare and health systems science
Engagement from all levels of the undergraduate medical education curriculum design and implementation team is required for the successful incorporation of HSS topics threaded throughout the curriculum from the preclinical years, through the clerkships, and on into the transition to the residency period. Curricular deans have the authority to work with their curriculum designers to realize the effect of weaving case examples of HSS concepts throughout the curriculum. Course directors find increased student engagement by incorporating HSS topics into their teaching as students begin to identify their current and future roles in interacting within the healthcare system. Faculty and resident educators understand the utility of using real-world case prompts of HSS materials as a starting point for discussing medical knowledge and patient care topics.
Women’s health medical educators are poised to be leaders in the implementation of comprehensive HSS curricula. The clinical practice of obstetrics and gynecology requires the regular engagement of all aspects of the healthcare system. Women’s healthcare rights and topics are regularly discussed in the media, debated by politicians, and make up a large portion of the healthcare system. It is not uncommon for an individual women’s health physician to interact closely with other specialty providers in a collaborative manner, including pharmacists, nurse-midwives, social workers, and case managers. Coverage of medications, hospital admissions, and procedures often require the obstetrician and gynecologist to navigate the health insurance policy and coverage system for their patients’ best interests. Women’s health physicians often find that they are required to be their patients’ advocates when it comes to fair and equitable access to healthcare. Although this is not always in front of state or federal legislators, obstetricians and gynecologists commonly are placed in the role of patient advocate.
Therefore, it is not surprising to see that women’s health subject matter lends itself to be an ideal opportunity to develop HSS curricula alongside the basic science and clinical science curricula being taught in our medical schools. In the current published literature, no single institution has created a successful formalized longitudinal HSS curriculum. However, there are examples of individual components of HSS that have been developed into curricula that have been met with success. The following are examples of how HSS curricula from the published literature could be adapted by curricular deans, course directors, and faculty to fit the women’s health subject matter being taught in our medical schools.
Preterm labor
The medical understanding of the causes, screening, treatment, and prevention of preterm labor and birth is limited at best. This is evidenced by the relatively stable and unchanged rate of preterm birth in the United States, consistently around 10% to 11% since the early 1990s. Preterm birth is the leading cause of neonatal morbidity and mortality in the United States. In 2007, the Institute of Medicine reported the societal costs of preterm birth at an estimated $26 billion annually. Finally, the infant mortality rate is widely used as a measure of population health and the quality of healthcare in the United States relative to other nations.
A basic science curriculum focusing on the topic of preterm birth will undoubtedly cover myometrial estrogen and progesterone receptors, microbiology of the vagina and cervix, and composition of fetal fibronectin. Although on clinical rotations, clerkship students will be exposed to preterm labor screening through cervical length measurements, use of tocolytics to delay preterm birth in the setting of preterm labor, and cerclage placement for women with a history of cervical insufficiency. For the modern physician in clinical practice, the challenge of caring for a 21-year-old G2P0101 woman with a history of preterm delivery at 26 weeks of gestation will be navigating the conflicting literature on best practices for preventing recurrent preterm birth and coordinating her care with the various aspects of the healthcare system, such as insurance coverage, pharmacists, nursing, home health aides, and transportation.
As shown in Table 1 , the 6 core domains of HSS play an important role in fully managing preterm labor as a competent healthcare provider. Applying examples of evidence-based curricula from other subject matter, the topic of preterm labor can be addressed through the incorporation of the HSS cross-cutting domains of IPE and EBM
| Variable | Healthcare structure and processes | Healthcare policy, economics, and management | Clinical informatics and health information technology | Population health | Value-based care | Health system improvement |
|---|---|---|---|---|---|---|
| Preterm labor | > Preterm labor screening tools and programs > Clinical access to and support for the administration of progesterone >Transition of care between inpatient and outpatient and high-risk and general obstetrics | > Reimbursement for preterm labor screening and diagnostic testing > Insurance coverage of progesterone > Economic cost of preterm birth | > Exchange of health information and treatment sharing between inpatient and outpatient and high-risk and general obstetrics > Integration of preterm labor risk calculators | > Effect of racial, socioeconomic and environmental factors on occurrence and prevention of preterm labor > Community resources available for prevention and support > Access to contraception | > Balancing the cost of screening and treating patients at high risk of preterm labor with the cost of preterm birth > Appropriate withholding of interventions where data are lacking, that is, multiple gestations, cerclage patients, and bedrest | > Measurement and reduction of variation among women being offered preterm labor risk assessment and screening > Reduction of variation of uptake of progesterone for women at risk |
| Pregnancy termination | > Process for accessing abortion services in various settings: hospitals, ambulatory surgery centers, clinics, and non-for-profit organizations | > Federal or state coverage of abortion services > Economic cost of unintended pregnancy and abortion | > Exchange of health information and treatment between abortion provider, primary gynecologist and primary care physician > Patient privacy and health data security | > Effect of racial, socioeconomic and environmental factors on abortion access and outcomes > Community resources available for support > Access to contraception | > Ensuring safe patient outcomes after abortion > Reporting and analyzing patient safety events after abortion | > Measurement and reduction of variation among women being offered family planning services—abortion, contraception, adoption, birth spacing, etc. |
| Cervical cancer screening | > Process for accessing Papanicolaou test screening > Process for accessing HPV vaccines > Follow-up and management of dysplasia > Follow-up and management of cervical cancer | > Patient and provider incentives for Papanicolaou test screening and HPV vaccination > Economic cost of cervical dysplasia and cancer treatment | > Exchange of health information and treatment between gynecologist and primary care physician > Integration of laboratory, histopathology, and clinical documentation | > Effect of racial, socioeconomic and environmental factors on occurrence and prevention of cervical cancer > Community resources available for prevention and support > Access to Papanicolaou testing and HPV vaccines | > Adherence to cervical cancer screening and management guidelines > Adherence to HPV vaccination guidelines > Reporting and analyzing cervical cancer cases as serious safety events | > Measurement and reduction of variation among women being offered Papanicolaou testing and HPV vaccination > Improvement in women returning for follow-up and treatment of cervical dysplasia |
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