Culture change matters more than technological change, US healthcare expert tells integrated care summit

BMJ 2012; 344 doi: (Published 03 May 2012) Cite this as: BMJ 2012;344:e3178
  1. David Payne
  1. 1BMJ

Integrating health and social care more closely should be seen as a sociological rather than technological challenge, says the US doctor who deployed electronic health records for hospital and clinics serving US veterans.

When Kenneth Kizer took over as head of the Department for Veterans Affairs in 1994, the staff was demoralised by the federal bureaucracy’s risk averse and punitive culture. Patients faced long waiting times, and the service was highly hospital-centric. First established in 1946 to provide treatment for veterans with combat related injuries, Veterans Affairs is now the largest provider of healthcare services in the United States, with outposts in Guam, Samoa, and the Philippines. It aims to deliver on a pledge by Abraham Lincoln “to care for him who shall have borne the battle, and for his widow, and his orphan—by serving and honoring the men and women who are America’s veterans.”

When Kizer left Veteran Affairs in 1999 BusinessWeek said the department provided “the best medical care in the US,” and a cover feature in Fortune magazine described “How the VA healed itself.”

A 2003 paper in the New England Journal of Medicine that was based on observational data found that the department outscored Medicare’s fee for service programme for the quality of preventive, acute, and chronic care (New England Journal of Medicine 2003:348:2218-27, doi:10.1056/NEJMsa021899).

The changes led by Kizer over five years included the closure of 29 000 acute beds and the opening of 300 community clinics staffed by general internists.

Inpatient admissions fell by more than 350 000 a year, and the introduction of a limited national formulary led to price negotiations with drug companies.

But it was the integration of the service’s electronic health records programme across 172 hospitals in less than three years—and the elimination of almost 3000 forms—that often gets cited as Kizer’s most important achievement before he left to establish the US National Quality Forum.

Speaking to an international summit on integrated care hosted by the King’s Fund health think tank in London this week, Kizer said, “The achievement is more sociological than technological.”

He told his audience, many of whom are charged with delivering integrated care as part of the Health and Social Care Act for England: “So much of healthcare teaching is based on the physiological.

“We forget how systems operate, about the science of team working and collaboration, quality and information management.”

Speaking afterwards, he said, “Part of why I think it [the technology] got somewhat disproportionate attention is because it’s easy to understand. It’s tangible. You can get your hands around it. It’s not squishy like culture change.

“And it also feeds into our infatuation with technology [in general] and particularly our American infatuation with technology.

“So yes, it was important. But if you actually look at the data about how quality was improving, dramatic improvements occurred before we even launched the implementation.

“The technology enables a different way of care to be done. It supports a new culture. It supports some new processes. But it’s just a dumb computer.”


Cite this as: BMJ 2012;344:e3178


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