We began a discussion in an earlier blog of the roles of responsibility, accountability and authority in the health system.  At this point, however, before proceeding further, it would be well to pause and define “health system” as we will use the term in these blogs..  This is particularly apropos now when ‘health system reform” is the major topic of concern in Washington and elsewhere in the country, In those discussions the word “system” seems to relate primarily to the provision of health services.  Occasionally “prevention” is included, but in those cases it seems to be considered as one of the services offered by health professionals, eg., immunization.

Our view is broader than that.  For us “health system” is a macrosystem including both “upstream” health promotion and disease prevention as well as “downstream” screening, diagnosis, treatment, disease management and palliative care, ie., the provision of health services. The latter, the provision of health services, is the subject of most of today’s sometimes heated discussions, especially in Congress. However, we believe it is essential to identify and deal as effectively with the factors contributing to disease development as we do with disease diagnosis and treatment if we are going to reduce the burden of disease in this country.  That is the rationale for our more inclusive definition of “health system”. 

In reality, as Berwick has pointed out, our “system of health care” is a macrosystem composed of a variable number of often independent “small units of care delivery” or microsystems.  These include individual, or groups of, physicians and their professional associates, other health professionals, and a variety of ambulatory care sites.  Beyond that, the macrosystem includes hospitals and organizations providing a range of supporting services.  Still others deal with payment for services, and additional ones are concerned with policy, accreditation, etc.  And each of these elements in the macrosystem   has some degrees of autonomy.  Therefore as things now stand, it is only by taking an extremely tolerant view that we can call what is being discussed in Washington a “health system”.   

However, if there were effective means of information transfer existing among these various units, making possible coordinated, comprehensive and continuity care of patients and their families, and if there was an agreed upon understanding among the service units about the provision of a coherent set of services focused on effectively meeting a recognized patient health problem or problems, then we could justifiably refer to a “health system”.  The Kaiser Permanente organization is just such a system, as are the Mayo Clinic, the Geisinger Clinic, and the Veterans Administration Health System. 

We will have more “system talk” on subsequent occasions, with this clarification about terminology we can return to further discussion of responsibility, accountability and authority in upcoming blogs.