Kenneth Shine on How to Make the Shift to Value, and Whether Healthcare is Safer

A Q&A with the distinguished physician, who oversaw publication of the seminal "To Err is Human" report and who has prescriptions to help transform American medicine.

Even in a field sparkling with stars, Kenneth I. Shine stands out.

Shine began his career in Boston, earning his MD degree from Harvard Medical School in 1961 and training at Massachusetts General Hospital, where the cardiologist and physiologist became chief resident in medicine. Shine left the Bay State in 1969, joining the faculty at University of California, Los Angeles School of Medicine, where he was named dean in 1986. After a stint chief of the American Heart Association, Shine served as president of the Institute of Medicine from 1992 to 2002. In 1999, the nonprofit group published the earthshaking exposé on patient deaths linked to medical errors, "To Err Is Human: Building a Safer Health System." From 2003 to 2013, when he announced his (active) retirement, Shine served in several roles at the University of Texas System, including responsibility for six UT Health campuses and a budget of nearly $9 billion as executive vice chancellor for health affairs.

I talked with Shine recently about the ongoing transformation of healthcare financing and processes, and whether healthcare delivery is any safer since the publication of "To Err is Human."

HealthLeaders Media: The shift to healthcare industry business models that emphasize value involves costly investments and complicated administrative processes. Are there sufficient financial resources to support this transformation?

Kenneth Shine: There are adequate resources. We are talking about 18% of the [U.S.] gross domestic product. That is substantially more than other Organisation of Economic Co-operation and Development countries that provide as good or better care in many areas. I don't believe the resources are the issue. The issues have to do with the organization of the system, the misalignment of financial incentives with the outcomes that we want, and the fact that our prices are the highest in the world. A couple of years ago, the average cost for a hospitalization in this country was about $16,000. That's cost—not charges. At that time in France, it was $4,700 and the length of stay was longer. The fact is that we pay far more for what we get, and we don't get the highest quality.

From my perspective, the issue is: Do we have the will to make the kind of changes that are required? This is an exciting time. Even in the absence of Obamacare, the cost of healthcare had risen to such an extent that there was an increased willingness of people to take on that cost. How do you take on that cost? You change the delivery system, you change the reimbursement system, and you make organizational changes. The resources are there … and physicians can make a good living, particularly if they are incented to keep people healthy and get paid for it.

HealthLeaders: Describe the ideal integrated health system of the emerging value-based era.

Shine: First, it does have to be value-based, where value relates the outcomes of care to the costs of care. And the health system has to be judged on the basis of whether it is providing value. Secondly, it has to be able to provide outcomes while maintaining the highest level of quality. The movement toward outcomes can only take place under circumstances in which you know how to measure quality and quality is very much a part of what the outcomes are to be measured. Thirdly, it has to be organized in such a way that it promotes health as opposed to solely treating disease. That's quite closely connected to the notion that the system has to be organized increasingly so that it is responsible for a population of patients, which is not only managed to minimize the costs of care but also organized in such a way that it promotes health.

Finally, the economic incentives, the value we pay for, have to clearly be aligned with the desirable outcomes, which include a healthy population. The incentives also need to have a process that finds the least expensive way to provide quality and takes into consideration the entire state of the individual patient's health. Such a health system has to be patient-centered: It has to be focused around the patient and the patient's needs in terms of where and how the patient gets information, gets advice, and gets treatment. And it has to be focused around the patient and the family in terms of the full spectrum of components that produce health. Only a fraction of those components are medications and procedures. Many of those components have to do with lifestyle and environment, and a truly successful health system would take those kinds of factors into consideration.

HealthLeaders: One of the areas you are working on now is supporting efforts to ease the sharing of healthcare data, such as your recent addition to the advisory board at Austin, TX-based vitaTrackr. Why do you think data sharing is one of the keys to improving healthcare?

Shine: We have a fragmented system—a fragmented industry, with a large number of large cottages. In many ways, it is a cottage industry that uses high technology but lacks organization as a real system. One of the ingredients of a real system would be a method for all of the elements of that system to effectively communicate with each other. The system I'm talking about involves physicians, it involves hospitals, it involves pharmacists, it involves everywhere where healthcare is provided. But it also, if it was a real system, would include social services, nutrition counseling, and a whole variety of elements that are critical to improve health. Having an information utility that can connect all of the different elements of the system so they can communicate with each other is essential. The patient is a key member of that system. I have talked for a long time about the concept that 21st-century care is team care, and the patient has to be a member of that team. That means we need a way to communicate between the patient and the rest of the system.

HealthLeaders: It has been 15 years since the Institute of Medicine's publication of "To Err Is Human." Is the healthcare industry safer today?

Shine: The definition of patient safety and the number of deaths from patient safety have expanded dramatically over what "To Err Is Human" described. What "To Err Is Human" focused on was the failure to carry out an action on behalf of the patient in a safe manner. It focused on medication errors, wrong-side surgery—a variety of those kinds of considerations. At that time, there was an estimate that there were between anywhere from 48,000 to 98,000 deaths. Since that time, the definition of patient safety has expanded dramatically. I am not sure the original [review] committee would have considered ventilator-associated infections as necessarily a medical error. It would have been an important complication, but it has become part of a much expanded definition of what errors are.

Many of the areas where "To Err Is Human" looked have improved substantially, and the overall system is substantially safer than it was 15 years ago. But there still is an enormous amount to do, and as the definition of deadly medical error has expanded, there are more and more things that we recognize that we have to do.