Blog | Tuesday, February 21, 2017

A new textbook on health systems science

Many aspects of academic medicine, from the structure of the medical school curriculum to the organization of departments in schools of medicine, are neatly segregated into two buckets: basic science and clinical science. In the jargon of medical schools and education, basic science refers to the basic biomedical sciences that have traditionally been taught in the first two years of medical school, such as anatomy, physiology, biochemistry, and pharmacology. While plenty of clinical material has migrated into the first two years of medical school over the years, such as learning to interact professionally with patients and perform a physical examination, the main focus of the first half of medical school has historically been on basic science, culminating in the U.S. Medical Education Licensure Examination (USMLE) Step 1 exam.

Once students finish their basic science years, they move on to the clinical sciences, where they begin rotations, also called clerkships or clinical experiences. They usually first rotate through the core medical specialties, i.e., internal medicine, surgery, pediatrics, obstetrics/gynecology, and psychiatry. This is then followed by rotations in other specialties and subspecialties, ultimately leading to graduation and the start of their residency training.

This division of medical education goes beyond just the medical school curriculum. The organizational structure in most medical schools is to group academic departments into basic science and clinical departments. These two types of departments usually have different funding models. Basic science departments are usually funded by base budgets for teaching and grants for research, with an expectation that just about all faculty have research grant funding. Clinical departments have base budgets and research programs as well, but they perform another activity, which is clinical care that provides practice opportunities (and revenues) for faculty and learning experiences for students, residents, and fellows. In many clinical departments in medical schools, research activity is modest and may be partially subsidized by the margins from clinical revenues.

The focus on these two groups of sciences takes the perspective of the physician taking care of a single patient, i.e., applying the best biomedical science through the lens of a specific clinical specialty. However, despite its primacy, there is more to the practice of medicine than taking care of single patients. Physicians and other clinicians work in a healthcare system that has other concerns, such as continually increasing costs, worries about patient safety, and questions about the quality of care delivered. As such, 21st century clinicians must be competent in more than the diagnosis and treatment of disease in individual patients. This has led to emergence of the notion of a “third science” of medicine, which focuses on how to optimally provide healthcare for patients and populations. While some describe this as “healthcare delivery science” (my preference) or “implementation science,” the emerging name, as given to a textbook in this area, is now “health systems science.”

The textbook is published by the American Medical Association (AMA), which has been supporting innovation in medical education through its Accelerating Change in Education (ACE) consortium, funded by grants to medical schools [1]. OHSU was one of the original grantees in this program to establish “medical schools of the future.” I have been pleased that one outcome of this program has been the expansion of instruction in clinical informatics for medical students, which I consider to be an essential competency for 21st century physicians [2].

The titles of the chapters of the new textbook describe the important topics covered by health systems science:
1. Health Systems Science in Medical Education
2. What Is Health Systems Science? Building an Integrated Vision
3. The Health Care Delivery System
4. Value in Health Care
5. Patient Safety
6. Quality Improvement
7. Principles of Teamwork and Team Science
8. Leadership in Health Care
9. Clinical Informatics
10. Population Health
11. Socio-Ecologic Determinants of Health
12. Health Care Policy and Economics
13. Application of Foundational Skills to Health Systems Science
14. The Use of Assessment to Support Learning and Improvement in Health Systems Science
15. The Future of Health Systems Science

I am delighted myself to be the lead author of one of the chapters, not surprisingly the one on clinical informatics [3]. I hope this chapter will introduce many new generations of medical and other health professions students to the informatics field and its role in healthcare delivery. Of course, informatics plays many roles beyond healthcare delivery, such as informing the care of individual patients and facilitating all types of research, but the effective use of data and informatics is a key aspect of health systems science.

I hope that this new textbook will lead the way in emphasizing the importance of health systems science in the work of physicians and other healthcare professionals. Clinicians have long known that diagnosing and treating disease, while the centerpiece of medical practice, cannot be carried out in a vacuum outside the realm of the patient's and larger health system's context. The care delivered to those individual patients will be better if the clinician has the perspective of that larger system.

1. Skochelak, SE, Hawkins, RE, et al., Eds. (2017). Health Systems Science. New York, NY, Elsevier.
2. Hersh, WR, Gorman, PN, et al. (2014). Beyond information retrieval and EHR use: competencies in clinical informatics for medical education. Advances in Medical Education and Practice. 5: 205-212.
3. Hersh, W and Ehrenfeld, J (2017). Clinical Informatics. in Health Systems Science. S. Skochelak, R. Hawkins, L. Lawson et al. New York, NY, Elsevier: 105-116.

This post by William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, appeared on his blog Informatics Professor, where he posts his thoughts on various topics related to biomedical and health informatics.