Managing Knowledge for Better Value Healthcare

Summary

I believe in cultural reform more so than structural reform.

Every country faces major healthcare problems due to population aging and rising consumer demand. Attempts to control expenditure or to improve the quality of care are essential. But knowledge management is of equal importance.

A clinician must bring together values, evidence, and condition to make a decision. I believe that we should have computers do the remembering (of data), while the clinician should relate the evidence and condition to the patient. Evidence must be combined with other types of knowledge: there is knowledge from research, from experience, and from the analysis of routine data.

Effective and efficient knowledge management can contribute to the solution of the universal problems of healthcare: unknowing variations in policy and practice; waste; medical errors; failure to get new knowledge into practice; over-enthusiastic adoption of new technology; poor quality clinical practice; and poor patient experience and patient dissatisfaction.

While managing clinicians and patients is difficult, we can manage knowledge. To improve knowledge management, what is needed is a high level decision that knowledge management is important. Effective knowledge management requires the following: high quality document management (for example, the National Electronic Library for Health); organizational development to ensure that knowledge management systems and culture pervade every organization; and professional development to ensure that all decision-makers can find, appraise, and use knowledge.

Knowledge is wealth. And it must be managed as carefully as money or people. The key decision-maker for the 21st century will be the resourceful patient.To sum up, structural reform is important, but it is not likely to add value to the healthcare industry. Patients and doctors drive the healthcare industry-it is a knowledge business. Systems are needed to manage knowledge.

Questions and Answers

Q: What is the difference between cultural reform and structural reform?

Reform comes from structural, cultural, and systems change. In the UK, we have had ten structural reorganizations with little change. There is no "correct" structure (meaning where people or equipment are placed in an organization). The culture of professions changes very slowly. Change is out of step with public sympathy. The patient needs more power, more say. Changing the structure does not add value. We are saying that the three most important words for a doctor will be "I don't know." Doctors cannot be certain that they are up-to-date. Because of the nature of the patient-doctor relationship, the healthcare system is more of a web than a clear hierarchy. So we need to look at new methods of learning and new relationships.

Q: Isn't the British healthcare system quite advanced?

We are only spending 7% of our GDP on healthcare. We are under investing. I would like to see the country spending a percentage point more. Nevertheless, the tight fiscal policy has created a good environment for evidence-based medicine (EBM). Tight money means you have to be more creative.

Q: Eventually Japanese doctors must accept knowledge management.

More people are looking at the Internet before and after consultations. Doctors were hostile to the idea of patients bringing information with them to consultations, so we must retrain doctors to accept patient-led healthcare.

Q: How does the British profession create its clinical pathway?

It is important to think of local application: local phone numbers and local involvement encourage use. It is also useful to start by referring to the libraries of other people's experience.

Q: Which are you now promoting-EBM or knowledge management (KM)? Knowledge or evidence? What is the relationship of the two?

It is partly a marketing issue. But EBM is a style of medical practice that is facilitated by KM. So KM is the means and EMB is the objective. So keep aiming for EBM.

Q: Do you have evidence of EBM's effect on incomes or customer satisfaction?

In the UK, payment is not based on activity; it is based on salary. We have discovered that patients in every country have different styles of decision-making. Either the patient wants the doctor to decide, they want to decide themselves, or it is a shared decision-making process. A patient's style is not always immediately apparent. Yet a significant minority and sometimes a majority of patients want more information and responsibility.

Q: What is the incentive for doctors to share their know-how?

We try to encourage doctors by offering status and small monetary incentives to those who share their know-how, sit on boards, and consult. We also try to network hospitals so that they will see neighboring hospitals as partners, not competitors. We want to emphasize networks, not organizations; teams, not individuals.

Q: Prime Minister Koizumi is trying to increase patients' burden. But doctors are resisting simply because they will loose customers. Can this sort of conflict of interest be mediated? Is free competition appropriate for the healthcare industry?

Mr. Koizumi is doing cultural reform, so I think that the newspapers say "structural reform" may be a mistranslation. We must think of the patient's perspective. We should not mix up the associations' interests with what is best for the patient. Professions are always about 20 years behind public sentiment.

*This transcript was compiled by RIETI Editorial staff.