- •Health systems science (HSS) is the study of how health care is delivered, including how health professionals collaborate and how the health care system can improve patient care and health care delivery.
- •A foundational understanding of the HSS framework can aid pediatric professionals of all backgrounds to identify and close existing and emerging pediatric health and health care gaps.
- •The pediatric medical home is a prime setting to close health care delivery gaps through longitudinal care, with strategies including care coordination, advocacy, and incorporation of telehealth.
- •Pediatric health professionals must have an understanding of pediatric-relevant health economics and health policy, as well as the structural and social determinants of health, to meaningfully improve the health of children, especially in the setting of the COVID-19 (coronavirus disease 2019) pandemic.
Health professions education requires a new approach
Gaps in United States health and the health care system
- Schneider E.C.
- Sarnack D.O.
- Squires D.
- et al.
University of Wisconsin Public Health Institute.
Existing and emerging pediatric health problems
- Children with Special Health Care Needs: National Survey of Children’s Health Data Brief
- Children with Special Health Care Needs: National Survey of Children’s Health Data Brief
- Tomaskovic-Devey D.
- Giordano M.
Third science is needed to close current and future gaps in child health
Health systems science as the third science
Definition and framework
- Yong P.L.
- Olsen L.
- McGinnis J.M.
- Perlo J.
- Balik B.
- Swensen S.
- et al.
|You are a pediatric hospitalist. You are discharging a 3-y-old patient with history of liver transplant home today following hospitalization for dehydration secondary to viral gastroenteritis. The patient has occasionally used ondansetron for management of nausea in the hospital. You have electronically prescribed a short course of ondansetron to the hospital pharmacy and have discussed the home use, risks, and benefits of this medication with the family. The child and family return home. The following night, you receive a call that the child had an episode of emesis following the immunosuppressive medication. They mention they were never able to pick up the ondansetron because it was not ready at the pharmacy when they left the hospital. As a systems thinker, you adapt to the situation at hand and critically think about the underlying system that created this gap in patient care to help prevent similar gaps in the future.|
Which systems thinking habits might you apply in this situation? What actions might you take that would show systems thinking?
|Changes perspectives to increase understanding|
|Considers short-term, long-term, and unintended consequences of actions|
|Considers an issue fully and resists the urge to come to a quick conclusion|
|Uses understanding of system structure to identify possible leverage actions|
Health care structures and processes
Pediatric medical home
- Medical Home
Application in clinical practice
- •You enroll him in your clinic’s integrated behavioral health care management program for adolescents with depression. A team member will call him each week, and monthly follow-up virtual visits will be established with you or a colleague.
- •You encourage him to contact his high school counselor as a resource to optimize his success in school, focusing on classes, and completing homework in a timely manner. You print information from the school’s Web site to help him secure an appointment.
- •You share with the family the contact information for an adolescent peer support group led virtually by a certified nurse at the county public health department.
- •You provide details on local community organization programs that provide an encouraging learning environment for students engaged in virtual learning, and whose parents are working outside the home during business hours.
Population, public, and social determinants of health
Social determinants of health as part of structural competency
- 1.Recognizing the structures that shape clinical interactions
- 2.Developing an extraclinical language of structure
- 3.Rearticulating cultural formulations in structural terms
- 4.Observing and imagining structural interventions
- 5.Developing structural humility
Clinical informatics and health technology: telehealth
- Fiks A.G.
- Jenssen B.P.
- Ray K.N.
Health care policy and economics
- 1.Health policy
- 2.Health care financing
- 3.The impact of policy on insurance and reimbursement
- 4.Incentives for clinicians and health systems within different payment models
Office of the associate director for policy and strategy.
Health policy and health insurance that enable health
Payment system reform for children
Change agency, management, and advocacy
|You care for a 10-y-old girl with moderate persistent asthma that is poorly controlled. You know her family well and call them because she has missed 2 recent follow-up appointments. Her father answers and says he recently became unemployed. He no longer has employer-sponsored insurance and was nervous to bring his daughter to the scheduled visit because of visit costs. You talk with her father about her poorly controlled asthma, looking for opportunities to help their family identify and address additional barriers to care. Her father shares barriers including transportation, cost of visits and medications, time, lack of insurance, and access to an inhaler with spacer device at school.|
Using a systems thinking approach, you consider the number of ways you can apply HSS concepts and skills to improve asthma care and outcomes for this girl and other children in your practice
|Potential Actions||HSS Domains|
|Collaborate with social worker to connect with the family to start discussing enrollment in Medicaid|
|Enroll your patient in your asthma care coordination, enabling nurses reach out on a scheduled basis to assess her asthma control, challenges with adherence to her asthma treatment plan, and access to her written, individualized asthma action plan at both home and school|
|Share community resources for receiving timely and equitable health care and resources for transportation to appointments|
|Review your office scheduling procedures to ensure appointments are being offered at times that facilitate access for families with a variety of schedules|
|Consider developing a quality improvement project designed to increase the percentage of patients with asthma in your practice with optimal asthma control and access to asthma action plans|
|Consider opportunities to work with local health leaders (schools, public health) to improve health outcomes for children with asthma|
Clinics care points (evidence-based pearls and pitfalls for point of care)
- •All pediatric health teams should ensure all members understand and commit to their 2 essential roles in advancing the health of children: direct clinical care and their work to improve the system.
- •All clinical teams caring for children should commit to and engage in ongoing work to ensure equitable care for all children rooted in cultural humility and culturally sensitive care.
- •Pediatricians, other pediatric health professionals, and their interprofessional teams should screen for social determinants of health and ACEs during hospitalizations and outpatient visits.
- •Clinicians providing acute, emergency, and specialty care for children should confirm the medical home for every child, helping to establish a connection for those without one.
- •All pediatric medical homes should work to ensure high-quality, accessible telehealth for their pediatric patients and families.
- •All pediatric health professionals can identify opportunities to improve the health of children in their population and/or community. Opportunities include population medicine efforts (eg, care management for children with chronic diseases), quality improvement initiatives, policy or other local/regional advocacy, and partnerships with schools and public health departments.
- •Pediatric health professionals should understand how health care payment models affect the financial impact on families for the common tests and treatments they order as part of their approach to discussing effectiveness, cost, and families’ preferences and values.
- •Pediatric health teams should consider incorporating HSS principles such as systems thinking to closing clinical gaps and addressing practice challenges.
- The triple aim: care, health, and cost.Health Aff (Millwood). 2008; 27: 759-769
- From triple to quadruple aim: care of the patient requires care of the provider.Ann Fam Med. 2014; 12: 573-576
- For the Commonwealth Fund. Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care.(Available at:)Accessed November 22, 2020)
- University of Wisconsin Public Health Institute.(Available at:)https://www.countyhealthrankings.org/explore-health-rankings/measures-data-sources/county-health-rankings-model(Accessed November 21, 2020)
- Life expectancy: could where you live influence how long you live? Robert Wood Johnson Foundation.(Available at:)Accessed November 21, 2020)
- Health Resources and Services Administration Maternal and Child Health.(Available at:)Accessed November 22, 2020)
- The Impact of Gun Violence on Children and Teens. Everytown Research & Policy.(Available at:)Accessed November 21, 2020)
- Leading Causes of Death and Injury - PDFs|Injury Center|CDC.(Available at:)Accessed November 26, 2020)
- Adverse Childhood Experiences. Violence Prevention. Centers for Disease Control and Prevention.(Available at:)Accessed November 21, 2020)
- Climate Change and Public Health - Climate Effects on Health | CDC.(Available at:)Accessed November 26, 2020)
- Children’s Environmental Health Module.(Available at:)Accessed November 26, 2020)
- Disproportionate impact of the COVID-19 pandemic on immigrant communities in the United States.PLoS Negl Trop Dis. 2020; 14: e0008484
- Millions Of Children Have Lost Their Health Insurance—What’s Our Plan? | Health Affairs Blog.(Available at:)Accessed November 21, 2020)
- Emergency Food Provision for Children and Families during the COVID-19 Pandemic: Examples from Five U.S. Cities.Applied Economic Perspectives and Policy. 2021; 43: 169-184
- The COVID-19 pandemic: normal accidents and cascading system failures (inequality, poverty, and mobility).American Sociological Association, 2020 (Available at:)https://www.asanet.org/news-events/footnotes/may-jun-2020/research-policy/covid-19-pandemic-normal-accidents-and-cascading-system-failures-inequality-poverty-and-mobility(Accessed November 21, 2020)
- COVID-19 and the documented failure of the American illness profit system — We have to stop treating our doctors, nurses, healthcare workers, and ourselves this way.Explore (NY). 2020; 16: 210-213
- Physician Burnout, Interrupted.N Engl J Med. 2020; 382: 2485-2487
- Children’s doctors in the world of adults. The Hospitalist.(Available at:)https://www.the-hospitalist.org/hospitalist/article/226687/pediatrics/childrens-doctors-world-adults(Accessed November 21, 2020)Date: 2020
- When grief and crises intersect: perspectives of a black physician in the time of two pandemics.J Hosp Med. 2020; 15: 566-567https://doi.org/10.12788/jhm.3481
- Calls for reform of medical education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010.Acad Med. 2010; 85: 220-227
- A decade of reports calling for change in medical education: what do they say?.Acad Med. 2010; 85: S26-S33
- Gaps in residency training should be addressed to better prepare doctors for a twenty-first-century delivery system.Health Aff (Millwood). 2011; 30: 2142-2148
- Medical education: part of the problem and part of the solution.JAMA Intern Med. 2013; 173: 1639-1643
- Preparing medical students for the continual improvement of health and health care: Abraham Flexner and the new "public interest".Acad Med. 2010; 85: S56-S65
- Educating for the 21st-century health care system: an interdependent framework of basic, clinical, and systems sciences.Acad Med. 2017; 92: 35-39
- Health systems science.2nd edition. Elsevier, Philadelpia2020
- Value in health care: accounting for cost, quality, safety, outcomes, and innovation. Institute of Medicine: roundtable on value & science-driven health care: charter and vision statement.National Academies Press, Washington, DC2010 (Available at:)Accessed November 21, 2020)
- Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. The National Academies of Sciences, Engineering, Medicine. National Academies Press, Washington, DC2013 (Available at:)Accessed November 22, 2020)
- Educating physicians prepared to improve care and safety is no accident: it requires a systematic approach.Qual Saf Health Care. 2002; 11: 168-173
- Curricular transformation in health systems science: the need for global change.Acad Med. 2018; 93: 1431-1433
- Moving beyond nostalgia and motives: towards a complexity science view of medical professionalism.Perspect Biol Med. 2008; 51: 599-615
- Lead was poisoning the water in Flint, Michigan: Dr. Mona Hanna-Attisha put her reputation on the line to prove it. USA Today.(Available at:)https://www.usatoday.com/in-depth/life/women-of-the-century/2020/08/11/19th-amendment-flint-water-crisis-elevated-dr-mona-hanna-attisha/5535823002/(Accessed November 21, 2020)Date: 2020
- National Academies of Sciences, Engineering, and Medicine. Taking action against clinician burnout: a systems approach to professional well-being. The National Academies of Sciences, Engineering, Medicine. National Academies Press,
Washington, DC2019 (Available at:)https://www.nap.edu/catalog/25521/taking-action-against-clinician-burnout-a-systems-approach-to-professional(Accessed November 22, 2020)
- IHI framework for improving joy in work. IHI white paper.Institute for Healthcare Improvement, Cambridge (MA)2017 (Available at:)Accessed November 21, 2020)
- What Is Systems Thinking? Waters Center for Systems Thinking.(Available at:)https://waterscenterst.org/systems-thinking-tools-and-strategies/what-is-systems-thinking/(Accessed November 21, 2020)Date: 2020
- The quality of care: how can it be assessed?.JAMA. 1988; 260: 1743-1748
- American Academy of Pediatrics.(Available at:)Accessed November 21, 2020)
- What is population health? Milken Institute School of Public Health. The George Washington University, 2015 (Available at:)Accessed November 22, 2020)
- Health Outreach Partners and the Structural Competency Working Group.(Available at:)Accessed November 22, 2020)
- Structural competency: theorizing a new medical engagement with stigma and inequality.Soc Sci Med. 2014; 103: 126-133
- The impact of racism on child and adolescent health.Pediatrics. 2019; 144: e20191765
Hassan I, Bui T. Developing social medicine cases using a structural competency framework. Workshop presented at AMA ChangeMedEd Conference; September 18, 2019; Chicago, IL.
- The promise of precision population health: reducing health disparities through a community partnership framework.Adv Pediatr. 2019; 66: 1-13
- The use of telehealth to address access and physician workforce shortages.Pediatrics. 2015; 136: 202-209
- Telehealth and telemedicine: a research anthology of law and policy resources. Health professionals gateway. Centers for Disease Control and Prevention, 2019 (Available at:)Accessed November 22, 2020)
- Pediatrician attitudes toward and experiences with telehealth use: results from a national survey.Acad Pediatr. 2020; 20: 628-635
- Pediatric telehealth: approaches by specialty and implications for general pediatric care.Adv Pediatr. 2019; 66: 55-85
- A defining moment for pediatric primary care telehealth.JAMA Pediatr. 2020; https://doi.org/10.1001/jamapediatrics.2020.1881
- Office of the associate director for policy and strategy.Centers for Disease Control and Prevention, 2015 (Available at:)Accessed November 22, 2020)
- Public Charge Rule and Its Impact on Child Health: A Call to Action.Pediatrics. 2020; 146https://doi.org/10.1542/peds.2020-001495
- Public Charge Rule and Its Impact on Child Health: A Call to Action.Pediatrics. 2020; 146
- Joint Statement of America’s Frontline Physicians Opposing Public Charge Final Rule.(Available at:)https://www.psychiatry.org/newsroom/news-releases/joint-statement-of-america-s-frontline-physicians-opposing-public-charge-final-rule(Accessed November 21, 2020)Date: 2019
- Health Care Payment and Delivery System Reform for Children as a Tool to Improve the Health of Vulnerable Communities. Families USA and Futures Without Violence.(Available at:)https://familiesusa.org/wp-content/uploads/2020/07/CHI_Kids-System-Transformation_FINAL.pdf(Accessed November 22, 2020)Date: 2020
- Child Advocacy in the Twenty-first Century.Adv Pediatr. 2015; 62: 91-103
- COVID-19 Response: Advocacy Report. American Academy of Pediatrics.(Available at:)Accessed November 22, 2020)