effectively, but are too bogged down in bureaucracy to make the necessary policy changes.

While telehealth is largely about extending the impact of the healthcare system into people’s homes, when we talk about redefining the boundaries of the hospital it is also important to consider how healthcare institutions can have a bigger impact in communities, perhaps even by bringing these communities into the hospital. While it may be common sense to many of us, a 2009 paper in the Archives of Internal Medicine showed a 38 percent lower incidence of Type 2 Diabetes among people who lived in neighborhoods with better resources for food and exercise [ 9].

Determining exactly what should be done as a result of this data is certainly a ripe opportunity for design thinking, and some would reasonably argue that access to healthy food and exercise is a civic good that is best handled at the municipal level. That said, if we truly want to orient our healthcare infrastructure in such a way as to result in better health at a lower cost, perhaps there is an opportunity for healthcare institutions to have a hand in providing these essentials to a community. It’s clearly outside their core expertise now, but as these institutions move in the direction of encouraging healthy behavior, is it really too much of a stretch to imagine that hospitals could have a hand in providing exercise facilities and farmers markets full of fresh veggies (one of the biggest drivers of diabetes reduction on the food side of the above-mentioned study)?

Changing Care Delivery

Even if we are successfully and proactively engaging people to live more healthily and we are better able to use telemedicine to avoid expensive trips to the hospital, a significant portion of medical care will still be delivered in hospitals and doctor’s offices. One of the most significant recent changes in healthcare is a move to standardize treatment upon what has been scientifically shown to produce the best outcomes. It turns out that this incredibly reasonable (and surprisingly new) approach does in fact tend to improve patient outcomes while reducing cost of care.

For example, at Intermountain Healthcare, a Salt Lake City– based system of hospitals and clinics, clinicians adopted practices to more tightly control the glucose level of patients in intensive care units (ICUs), which “led to a statistically significant reduction in the rates of mortality in this patient group.” And by standardizing care for patients on ventilators, they ended up reducing the average time each patient was on a ventilator by more than a day. These adjustments reduced the rate of ventilator-associated pneumonia by 10 percent over two years, shortened the overall length of stay in the ICU, and reduced costs by more than $3,000 per ICU patient [ 10]. (In the name of full disclosure, I’ve should say I’ve worked with IHC for the past couple years.)

As obvious as it might sound,
on a practical level, actually prac-
ticing evidence-based medicine
is harder than it might appear.
The rate of new findings in
medical science continues to
increase, and for all but the sub-
sub-specialists it is nearly impos-
sible for a physician to read and
retain all the research relevant
to the patients that they see. For
evidence-based medicine to be
a reality, it requires that medi-
cal decisions be made in light of
appropriate patient data, which
is viewed in the context of up-
to-date medical research (it also
requires that substantial data
be captured about the treatment
and progress of each patient to
feed back into research). Further,
while all this data is absolutely
critical to the endeavor, informa-
tion systems must also be smart
and help make people smart.

[ 10] Baker, G. R. et
al. High Performing
Healthcare Systems:
Delivering qual-
ity by design. Toronto:
Longwoods Publishing,
2008. For more on
ICH, see Leonhardt, D.
“Making Health Care
Better.” New York Times,
3 November 2009;
http://www.nytimes.
com/2009/11/08/
Magazine/08Health
care-t.html/
November + December 2010