Anna Lembke, Assistant Professor of Psychiatry and Behavioral Sciences at the Stanford University Medical Center, visited SCPKU for two weeks as a faculty fellow in July 2014.  Below are the highlights of a conversation Professor Lembke had with SCPKU in which she shares more details about her research and how SCPKU helped to advance her work in China.

Q: Describe your research and its connection to China

My research focuses on improving the lives of those with addictive disorders. I am especially interested in the intersection between health care systems and culture, and how this intersection impacts addiction treatment. I became interested in studying drug use disorders in China for a number of reasons. First, I spent a year after college living in China (1989-1990) teaching English as part of the Yale China Program. I have followed events in China with keen interest ever since. Second, the total number of drug users in China may be as high as 7 million, with China predicted to have the most heroin users of any country in the world within 5 years. I was curious to find out how China is addressing its burgeoning drug problem, and didn’t just want the “party line.” I wanted to learn about how people addicted to drugs in China are seeking and getting help.

Q: What got you interested in the study of addiction?

When I first began practicing psychiatry, I was not interested in treating addiction. But over time, I came to realize that if I didn’t treat my patients’ drug and alcohol problems, their other mental health issues were unlikely to improve. I also realized that in targeting and treating addiction, I could help patients transform their lives for the better, as well as the lives of those who love them.

Q: Why did you decide to apply for an SCPKU Faculty Fellowship?

SCPKU gave me the financial and logistical support to pursue a research project in China, an opportunity that would not have been possible without their help.

Q: How valuable was SCPKU's team in supporting your fellowship at SCPKU?

The team here at Stanford was helpful with drafting the initial proposal, creating the budget, which was especially challenging, due to my lack of familiarity with what things cost in China, and making contact with the SCPKU staff in Beijing. The team in Beijing was helpful in setting up temporary housing and meals in Beijing, as well as providing maps, information on how to take the subway, and logistical support getting back to the airport.

Q: What were your fellowship objectives and were they met? 

My fellowship objective was to interview treatment-seeking heroin users in China to learn more about the state of addiction treatment in China. My research assistant, Dr. Niushen Zhang, and I planned to publish our findings in a peer-reviewed journal.

We learned that individuals in China addicted to drugs experience intense social stigma. They are reluctant to utilize government-sponsored treatment, because of fear of loss of anonymity and the ensuing social and economic consequences that follow when they are publicly identified as “addicts,” not to mention the potential loss of their personal freedom. (Addicted persons in China are sent against their will to forced detention centers, or “rehabilitation through labor camps.”) As a result, drug addicted persons in China are deeply mistrusting of government-sponsored treatment, and willing to sacrifice large sums of their own money for anonymous, confidential treatment.

Dr. Niushen Zhang and I recently published our findings in Addiction Science and Clinical Practice, 2015, “A qualitative study of treatment-seeking heroin users in contemporary China.” (To access the article online go to http://www.ascpjournal.org/content/10/1/23)

Q: Describe some highlights of your stay in China/SCPKU. 

The highlight for me was hearing the life stories of heroin-addicted patients at New Hospital in Beijing, and attending an Alcoholics Anonymous meeting, conducted entirely in Chinese. The AA members we met told us their participation in this grass-roots 12-step movement literally saved their lives. I also met many wonderful doctors and nurses working with addicted patients in China. Finally, Dr. Zhang and I became good friends. We had hardly known each other before venturing off to do research in China.

Q: List at least THREE words or thoughts that come to mind which best describe your experience at SCPKU. 

Compassion, endurance, overcoming adversity
 

Q: Any future plans in China? 

I’m thinking about taking a group of Stanford residents and/or medical students to China for a total immersion 3-week course to learn about addiction in China.  But not right away.

Stanford students belong to the first generation that could witness the end of extreme global poverty — in what would be one of humankind's greatest achievements — the head of the World Bank said during a recent talk on campus.

But their generation, he said, is also likely to experience the first global pandemic since the 1918 influenza that killed more than 50 million people.

Jim Yong Kim, president of the World Bank, said innovations in health, education and finance are behind the World Bank's twin goals of ending extreme poverty and boosting shared prosperity for the bottom 40 percent of the global population.

Speaking at the inaugural conference of the Stanford Global Development and Poverty Initiative on Oct. 29, Kim lauded faculty and students for their multidisciplinary approach in tackling poverty and improving public health. He is an infectious disease physician who oversaw World Health Organization initiatives on HIV/AIDS.

"Seeking transformative solutions to challenges of development and poverty that are necessarily cross-disciplinary is exactly what a great university should be doing," Kim said in his speech at Stanford.

The World Bank announced last month that the number of people living on less than $1.90 a day is expected to drop to 9.6 percent of the global population by the end of the year. That is down from 36 percent in 1990.

The bank has pledged to cut that rate to 3 percent by 2030.

"We expect the extreme poverty rate to drop below 10 percent for the first time in human history," he said. "This is the best news in the world today. And this is the first generation in human history that has been able to see that potential outcome." 

Promoting prosperity

One of the co-founders of Partners in Health, Kim was the keynote speaker at the daylong conference, "Shared Prosperity and Health," which drew together Stanford faculty and researchers, plus government and NGO officials from around the world.

Stanford's global development and poverty effort is a university-wide initiative of the Stanford Institute for Innovation in Developing Economies, known as Stanford Seed, and the Freeman Spogli Institute for International Studies. The conference was held at Stanford's Graduate School of Business, which was a partner in the event.

Kim's talk was optimistic about the newly adopted U.N. Sustainable Development Goals, with an ambitious agenda to end poverty and hunger, ensure healthy lives, empower women and girls and attain quality education for all children by 2030.

While those goals seem lofty, Kim pointed to the accomplishment of bringing down extreme poverty to 10 percent, a figure many had once said was impossible.

Ninety-one percent of children in developing countries now attend primary school, up from 83 percent in 2000, he said. And the number of people on antiretroviral drugs for treatment of HIV in sub-Saharan Africa has increased eightfold in the last decade.

"But we're humbled by the challenges ahead," Kim said. "Rising global temperatures will have devastating impacts on poor countries and poor people – and, as we saw with Ebola, major pandemics are likely to disproportionately affect the poor."

Pandemic threats

Kim said that most virologists and infectious disease experts are certain a pandemic will sweep the world in the next 30 years. He said that would lead to more than 30 million deaths and anywhere from 5 to 10 percent of lost GDP.

He blasted the global community for taking eight months to respond to the Ebola crisis in West Africa, noting that Guinea, Sierra Leone and Liberia had among the fastest growing economies in Africa before the outbreak killed more than 11,000 people – most of whom were poor.

In an effort to speed up financial aid the next time such an outbreak occurs, the World Bank is developing the Pandemic Emergency Facility, which would disburse funding immediately to national governments and responding agencies.

Rajiv Shah, the administrator for the U.S. Agency for International Development from 2010-2015, spoke earlier at the conference about his work leading the U.S. efforts to contain Ebola.

"Three small countries with total population of maybe 30 million people had such weak health systems with so little domestic investment – in one country $6 per capita health investment per year – that when Ebola became a crisis there was no first-line of defense," he said.

By October 2014, the U.S. was pouring hundreds of millions of dollars into containment efforts, including the establishment of a 2,500-personnel military deployment to hit Ebola on the ground. Shah said President Obama "stayed extraordinarily true to the science" of containment at the source.

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Stunted children 

Moving beyond containment of epidemics, Kim said the most important investment developing countries could make in their people starts when a woman becomes pregnant. Using a combination of health, nutrition and education will have lifelong benefits for each child, as well as for the country in which each prospers.

The World Bank estimates that 26 percent of all children under age 5 in developing countries are stunted, which means they are malnourished and under-stimulated, risking a loss of cognitive abilities that lasts a lifetime. The number climbs to 36 percent in sub-Saharan Africa, giving those children limited prospects in life."This is a disgrace, a global scandal and, in my view, akin to a medical emergency," Kim said. "Children who are stunted by age 5 will not have an equal opportunity in life. If your brain won't let you learn and adapt in a fast-changing world, you won't prosper and, neither will society. All of us lose."

From 2001 to 2013, the World Bank invested $3.3 billion in early childhood development programs in poor countries. Kim said innovative policymaking and financial tools allowed the bank to help Peru cut its rate of child stunting in half to 14 percent in just eight years.

"Progress is possible – and it can happen quickly. But we must do even more,"he said.

Kim said the world set a target in 2012 to reduce stunting in children by 40 percent. But that would still leave 100 million children malnourished and undereducated. The bank and world leaders should pledge to end stunting for all children by 2030, he said.

"With partners like the Global Development and Poverty Initiative and the entire Stanford community, I'm full of hope that we can indeed be the first generation in human history to end extreme poverty and create a more just and prosperous world for everyone on the planet."

Read more here about another innovation to improve health in the developing world.

India celebrates the 10th anniversary of its Emergency Management and Research Institute (EMRI), the world's largest ambulance service that is saving the lives of the poorest Indian residents free of charge. Stanford Medicine experts, who trained responders in emergency medical procedures, joined EMRI to celebrate the program's success. Read More

Medical researchers must work together across disciplines to provide better health care to those who need it most, according to panelists at Stanford Medicine’s Annual Population Health Sciences Colloquium.

The symposium, hosted by the Stanford Center for Population Health Sciences, brought together working groups from across the Stanford campus to showcase the latest findings in population health research.

“Population health science at Stanford is likely to make the most important contributions when we cross traditional intellectual expertise disciplines,” said Paul H. Wise, a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research (CHP/PCOR).

Many of the scholars at the daylong conference on Tuesday stressed that an interdisciplinary approach to health care is crucial to understanding and aiding underserved populations.

“To deal with life-course questions we need to create-life course observational windows,” said Mark Cullen, chief of the Division of General Medical Disciplines and director of the Stanford Center for Population Health Sciences.

Instead of trying to create an all-encompassing care plan for the human population as a whole, panelists demonstrated that studying the needs of particular groups, or smaller populations, can better serve individuals within populations that may not receive the best care.

Douglas K. Owens, director of CHP/PCOR, said the U.S.  Preventive Services Task Force, of which he is a member, has “often faced a real paucity of data trying to develop prediction guidelines for both the very young and the old.”

The Task Force, a panel of experts that makes recommendations for medical prevention services, is generally able to make guidelines for large populations like adults, but suggestions for specialized groups like children and the elderly are more challenging. Though Stanford researchers like Wise are working to improve care for particular sectors like children, more study is needed.

Several speakers at the conference said the underserved population of poor children could benefit from research targeted toward their population group.

“We don’t really understand the biology of the life-course, why things taking place in gestation and early life actually affect healthy aging and adult onset disease,” said Wise, adding, “We have a very poor understanding of how to translate this understanding into effective interventions for communities in need.”

Panelists agreed that big data can help them understand smaller, poorly served populations, such as young children in impoverished communities. By collecting large amounts of data from the general population, researchers will increase the amount of data available for more specific groups. This allows researchers to study these populations more closely and help create better outcomes.

Abby King, a professor of health research and policy and of medicine, and Jason Wang, director of the Center for Policy, Outcomes and Prevention (CPOP) and a CHP/PCOR core faculty member, believe life-course digital applications can provide individualized care while collecting data on a large-scale.

According to King, a life-course app, or a device to track health and provide care throughout one’s life, would grow with the user and help them through important developmental stages.

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Health-care techniques using mobile devices, known as mHealth, could be particularly useful in underserved populations. King notes that even low-income populations have cell phones, so using phones as health-care tools could help decrease the gap between higher- and lower-income populations.

“I think for us one of the major challenges of the century is to really close that health-disparities gap and mHealth can help.”

However, each app must be tailored to the user.

“There’s no reason to believe that an African-American 16-year-old is going to be motivated the same way as a 45-year-old white man,” said Wang. “You need to involve patients in the design of the app.” When the app fits the specific patient’s needs, they are more likely to use it regularly, and knowing the needs of their population helps determine their preferences.

As the world continues to become more connected, the panelists said that reaching across disciplines and incorporating technology may hold the key to effective health care in the 21^st century.

As more physicians move from solo and small practices, a dozen common medical procedures are becoming more expensive in areas where physicians are clustered into large medical practices, according to a new study.

The October study in Health Affairs assessed the relationships between physician competition and prices paid by private organizations in 2010 for 15 common, high-cost procedures to determine whether high concentrations of physician practices and accompanying increased market power were associated with higher prices for services.

They found that prices were indeed 8 to 26 percent higher in the thousands of counties analyzed, with the highest average physician concentration compared to counties with the lowest. This was for 12 of the 15 procedures they examined, including colonoscopy with lesion removal, vasectomy, laparoscopic appendectomy and knee replacement surgery.

“Our findings are consistent with the hypothesis that greater market power allows physicians to bargain for higher prices from insurers,” wrote Dan Austin, a graduate of the Stanford University School of Medicine and a resident physician at the University of California, San Francisco, and Laurence C. Baker, chair of Health Research and Policy at Stanford and a core faculty member at CHP/PCOR.

“We concluded that physician competition is frequently associated with prices,” they said. “Policies that would influence physician practice organization should take this into consideration.”

The authors studied 15 high-cost, high-volume procedures that generated 7,000 total bills in 2010 and had a mean price of at least $500. They identified nine surgical and medical specialties: dermatology, cardiology, radiation oncology, gastroenterology, otolaryngology, urology, ophthalmology, orthopedics, and general surgery.

Average prices for the procedures studied varied. Total knee replacement surgery and insertion of intracoronary stent were the two most expensive, at  $2,301 and $1,282, respectively. Vasectomy and colonoscopy were the least expensive, at  $576 and $586.

The authors found there was also considerable variation across counties within each specialty. The mean price in the 90th-percentile county was 1.8 to 2.7 times higher than in the 10th-percentile county. The 75th-percentile county was commonly $200 to $300 more expensive than the 25th-percentile county, and in some cases more.

This study adds to the growing body of research that demonstrates wide variation in medical prices for the same procedure or test based on a number of factors, including where a procedure is performed and who performs it.

“We know from some good examples that larger, well-run practices can provide high- quality care," Baker said in an interview. “And many of our current policies are built around the notion that we should encourage the formation of larger organizations in the hope of improving the quality of care and fostering improvements in value."

But, adds Baker: “It is also important that we factor in these kinds of effects on prices and the downstream impacts this can have on our health-care costs.”

Matt Sheehan
China Correspondent, The WorldPost
October 12th, 2015

Simply giving nearsighted children glasses can dramatically boost their school performance. Convincing teachers and parents is harder.

This article is the second in a What’s Working series that looks at innovative policy solutions pioneered by the Rural Education Action Program. REAP brings together researchers from Stanford University and China to devise new ways to improve rural education and alleviate poverty. You can read the first article in the series here.  

QIN'AN COUNTY, China -- Wei Wentai can barely be heard over the crescendo of cackles coming from the hallway. Fourth graders everywhere cane be boisterousness, but today the presence of two foreigners, an exotic breed in the rugged hills of western China, has driven these kids into a frenzy.

You could try to reason with the children: tell them they need to quiet down because Dr. Wei is here to train their teachers in how to perform vision tests. Those tests will give some kids free glasses so they can see the blackboard, dramatically improving their grades and chances of graduating high school.

But yeah, that’d be about as effective here in rural Gansu, in China's northwest, as it would be in Alabama, and it takes the lunch bell to drag the mob away from the classroom window. 

With relative peace restored, Wei continues to tutor the 12 village schoolteachers in the basics of eyesight and education. Having grown up nearby, he knows what superstitions to dispel (“No, glasses do not make your eyes worse”) and what points to drive home (“Yes, glasses dramatically improve grades for nearsighted students”). Despite receiving his medical training in Shanghai, Wei returned home after graduating and always speaks in the local dialect when training the teachers to perform this basic eye exam and write referrals.

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It’s a simple presentation tailored to this county, but one predicated on years of trust building and scientific trials by researchers on both sides of the Pacific Ocean.

Driving the project, called Seeing is Learning, are researchers from Stanford University’s Rural Education Action Plan (REAP) and Shaanxi Normal University’s Center for Experimental Economics in Education (CEEE). These groups operate in an emerging field of development economics that prizes rigorous experimentation over theory. Concrete interventions, randomized controlled trials and impact analysis are what drive their research and policy recommendations. Randomized controlled trials compare a randomly assigned group of participants receiving a particular treatment being studied with one not receiving the treatments. These trials are often called the gold standard of scientific research. 

REAP and CEEE have spent almost five years accruing the political capital and research results that they hope will overcome one of the biggest obstacles standing between rural Chinese kids and a high school diploma: most of them can’t even see the writing on the blackboard. 

Like many of their peers around East Asia, rural Chinese children suffer high rates of myopia. Around 57 percent are nearsighted by middle school, according to one REAP study. Unlike schoolchildren in Singapore or in China’s cities, most kids growing up in the Chinese countryside are ignorant of and isolated from vision care. 

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In hundreds of visits to rural Chinese classrooms, REAP program director Matt Boswell has rarely seen a bespectacled face. A patchy and inadequate rural medical system, the high cost of glasses and cultural preferences for eye exercises over glasses (what one researcher calls “voodoo health”) mean that most children growing up in townships and villages never take a vision test. 

“There is no eye care at the township level in China,” said Boswell. “Period.”

That void has a huge impact on education. In a study published in the British Medical Journal, REAP and Chinese researchers showed that giving myopic kids free glasses improved their math test scores by about as much as reducing class sizes. Those improvements came despite the fact that only 41 percent of students who were prescribed glasses actually wore them regularly. According to Boswell, when results were limited to the students who actually wore the glasses they were given, the impact proved enormous: it roughly halved the achievement gap between these rural students and their urban peers in just nine months.

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Improvements of that size represent some of the juiciest low-hanging fruit in Chinese education. Sixty percent of children in the countryside will drop out before high school, many due to failed grades and entrance exams. These tens of millions of dropouts threaten to throw a wrench in the Chinese government's plan to transition to a service- and innovation-based economy.

But when dealing with China’s bureaucracies, having a simple solution to a vexing problem isn’t enough to start harvesting that low-hanging fruit. The real art and science of the project came in aligning bureaucratic interests to get it off the ground.

“Every issue has its own little ecosystem,” Boswell said. 

For Seeing is Learning, that ecosystem involved education officials committed to the eye exercise regime, schools that closely guard access to their students, families who are deeply suspicious of the effect of eyeglasses and hospitals that saw no reason to screen rural kids.

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To break the impasse, the researchers had to first get local education bureaucrats on board. Randomized controlled trials proved the effectiveness of glasses and debunked the myth of eye exercises. They caught the eye of a powerful official in the nearby city of Tianshui, whose backing opened the doors to local schools. With REAP’s pledge to subsidize glasses, the hospitals suddenly saw large new markets materialize.

As a kicker, one trial found that when teachers were offered an iPad if their students were wearing glasses during random inspections, usage rates jumped from 9 to 80 percent.

“Hospitals love it because they get in the schools. Principals love it because of the impact on scores,” said Boswell. “We love it because the kids are learning.”

Turning that newfound excitement into a working program required the creation of two “Model Vision Counties” in which nurses and doctors like Wei Wentai receive accelerated optometry training.  In order to expand that reach from the county seat down to the village,  REAP ran another trial to see if teachers could conduct accurate eye exams after just a half-day training (answer: yes). So the newly trained doctors now rotate through the village schools, training teachers who then refer students to the hospital vision centers for proper prescriptions.

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Now the researchers are looking to scale up the program to six counties and at the same time turn the vision centers into sustainable social enterprises. Using their privileged access to schools, the vision centers can sell glasses to urban children with the resources to pay. Those profits then subsidize the first pair of glasses for rural kids, and repay REAP's initial loan, which REAP can then reinvest in creating further Model Vision Counties.

It’s a new model for REAP and one that prompts many new research questions. Can the vision centers earn enough revenue to both subsidize glasses and keep the hospitals happy? Will teachers enforce wearing eyeglasses if given a simple mandate rather than an iPad? Will the impact of the first pair of glasses convince rural parents to purchase the second pair?

Those questions will be investigated and answered when the project scales up. But as this van winds its way back down from the village to the county hospital, Wei Wentai reflects on the work they’ve done.

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A child takes an eye exam administered by REAP and CEEE.

Health economics expert Laurence C. Baker has been appointed chair of the Department of Health Research and Policy (HRP) in the Stanford School of Medicine. He said he intends to encourage students and faculty within the department to expand the use of emerging data and analytic tools in their health-care research and policy recommendations.

Baker, a professor of health research and policy and a core faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research, succeeds Philip W. Lavori, who becomes vice chair of the newly established Department of Biomedical Data Science.

“Laurence is a natural and excellent choice for the HRP chair position,” said Stanford Dean of Medicine Lloyd Minor. “Well-respected, trusted, and admired by his peers, Laurence has been chief of Health Services Research within HRP since 2001, during which time the division has grown in strength and reputation.”

Minor called Baker one of the top health economic experts in the world with a strong policy focus, saying he would “bring the unique perspective, energy, and thoughtful guidance needed during this time of change for the department.”

The Health Research and Policy department houses the divisions of Health Services Research and Epidemiology, and provides the analytical foundation for research conducted at the Stanford School of Medicine, offering expertise, research and training on collecting and interpreting the scientific evidence essential to improving human health.

“It’s an exciting time for health policy and the Division of Health Services Research,” Baker said. “The country is facing important challenges in our health-care system, and countries around the globe are looking for insights and new ideas that can improve health care. So  there are real opportunities for Stanford to be a leader and make a difference.”

Baker, who is also a research associate at the National Bureau of Economic Research, said that in his new role he intends to strengthen the epidemiology and the health services research groups at HRP. He will build on Lavori’s efforts to recruit diverse junior and senior faculty, train and retain graduate students and post-MD physician scientists, and make significant contributions to the Stanford Cancer Institute and Population Health Sciences.

“I’ve learned a lot from Phil and have really appreciated his steady and thoughtful leadership of HRP, as well as his insightful approaches to seeking excellence at a time of great change,"  Baker said. “We already have a strong history of making important contributions, and I think we are in an excellent position to make the most of new opportunities — like bigger and better emerging data and analytic tools and new settings for research — to do outstanding work.”

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Baker said that the department successes have also included growing its faculty, establishing  new PhD programs and working on interdisciplinary research projects at the School of Medicine and in collaborations with CHP/PCOR.

“I want to continue looking for opportunities to grow and strengthen the research and education that we offer, in the hope that we can strengthen the overall contribution to national and international health policy that Stanford can make,” he said.

Baker’s research examines the impact of financial incentives, regulations and organizational structures in health care. He also looks at the impact of managed care and related insurance arrangements on health care costs, the pricing of physician services, prices for health insurance and the availability and utilization of medical technologies.

Baker completed his doctoral degree in Economics at Princeton in 1994, and joined the faculty at Stanford in HRP soon after. His research focuses on the way that changes in health-care delivery systems influence the cost and quality of care, with a particular interest in the growth of large, multi-specialty, and hospital-affiliated medical practices.

In addition to his position in HRP, Baker is a professor of economics (by courtesy) at Stanford, a fellow of the Center for Health Policy, and a senior fellow of the Stanford Institute for Economic Policy Research.

He also leads the School of Medicine’s Scholarly Concentration and Medical Scholars programs. Baker has received multiple honors and awards, including the ASHE medal from the American Society of Health Economists, and has helped lead key professional groups, serving on the boards of directors of the International Health Economics Association, AcademyHealth, and the American Society of Health Economists.

“There is growing recognition of the need for well-crafted health policies that can help us deliver quality care and real value,” Baker said. “More and more people are on the lookout for ways to improve population health in the United States and around the world, so I think we’re going to see more interest in the kind of work we do.”

Most Americans will get at least one faulty diagnosis in their lifetime, sometimes with devastating consequences and “urgent change is warranted to address this challenge,” a panel of medical experts said Tuesday.

In a landmark report by the Institute of Medicine, the medical arm of the National Academies of Sciences, Engineering and Medicine, the experts said that despite dramatic improvements in patient safety over the last 15 years, diagnostic errors have been the critical blind spot of health-care providers.

Exact figures on diagnostic errors are hard to come by, as reporting is not required. Some medical experts have estimated that more than 12 million adults are misdiagnosed every year.

“Despite the pervasiveness of diagnostic error and the risk for patient harm, they have been largely unappreciated within the quality-safety movement in healthcare — and this cannot and must not continue,” said Dr. Victor Dzau, president of the Institute of Medicine, an independent organization of the country’s leading medical and health policy researchers.

“Diagnostic errors are a significant contributor to patient harm and have received too little attention until now,” he said at a public briefing in Washington, D.C., about the report, “Improving Diagnosis in Health Care.”

To address the challenge, the IOM convened the committee comprised of medical and health policy researchers to improve diagnosis in medicine. The Committee on Diagnostic Error in Health Care members include experts from Stanford, Harvard, Drexel, Tufts, the Memorial-Sloan Kettering Cancer Center, Kaiser Permanente and more than a dozen other universities and national medical organizations.

“We defined diagnostic error from a patient's perspective, and brought together the research so far that clearly shows the opportunity and grave need to improve the current situation,” said Kathryn M. McDonald executive director of Stanford’s Center for Health Policy/Center for Primary Care and Outcomes Research, and a member of the IOM committee.

“The report is packed with reasons and directions for action from all, in ways that support what patients deserve from the health-care system: freedom from worry about inattention to diagnostic errors,” McDonald said. “That's been the status quo for too long.”

The committee issued a set of goals to reduce diagnostic errors and improve medical outcomes. They recommend that the health-care community:

1. Facilitate more effective teamwork in the diagnostic process among health-care professionals, patients and their families.

2. Enhance health-care professional education and training in the diagnostic process.

3. Ensure that health information technologies support patients and health-care professionals in the diagnostic process.

4. Develop and deploy approaches to identify, learn from and reduce diagnostic errors and near misses in clinical practice.

5. Establish a work system and culture that supports the diagnostic process and improvements in diagnostic performances.

6. Develop a reporting environment and medical liability system that facilitates improved diagnosis through learning from diagnostic errors and near misses.

7. Design a payment and care delivery environment that supports the diagnostic process.

8. And provide dedicated funding for research on the diagnostic process and diagnostic errors.

The experts emphasized that medical education must include more of an emphasis on the diagnostic process. And new technologies, such as electronic health records, should be built on better collaboration among the IT vendors, users and the Office of the National Coordinator for Health Information Technology.

The new study was an extension of two benchmark reports by the institute released 15 years ago, which revealed the startling statistic that 100,000 Americans die in hospitals every year due to medical errors.

“These landmark reports from IOM reverberated throughout the healthcare community and were the impetus for system-wide improvement in patient safety and quality,” Dzau said.

The Department of Health and Human Services reported in December that there was a decline from 2010 to 2013 in hospital-acquired infections, which translated to 1.3 million patients and $12 billion in health spending avoided.

“You can see we have come a long way,” Dzau said. But, he added: “The critical element that has been absent from patient safety and quality is diagnostic error.”

In a video released at the public briefing, two patients talk about their own misdiagnosis and that of a loved one, and how those errors forever changed their lives. They were told they were overreacting and not to question their doctor. One said she was embarrassed at having wasted the valuable time of the hospital doctors and nurses.

“The video has two patients for whom things went poorly and one who had a first-class diagnostic experience because of excellent teamwork,” McDonald said. “And this is one of the key messages of the report. We need less of the old model of diagnosis from one expert to more of a teamwork approach to the diagnostic process.”

Dr. John Ball, chair of the committee and executive vice president emeritus of the American College of Physicians, said clinicians must work toward a culture where patients are central to the solution.

“Patients and families are first; diagnostics are second and those who support it, third,” said Ball. “This is an issue that matters to patients, and we’re shining a light on it.”

Ball said getting the right diagnosis is critical because it impacts every other health care decision that follows, as well as the quality of life for the patient.

The committee members were asked during the briefing why they were not recommending that misdiagnosis reporting be mandatory, something that likely will lead to controversy.

“The committee believes that given the lack of agreement on what constitutes a diagnostic error, given the complexity of hard data and the lack of valid measurement approaches, the time was not right to call for mandatory reporting,” Ball said. “Instead it was appropriate at this time to leverage the intrinsic motivation of health-care professionals to improve the diagnostic performance and to treat diagnostic error in the same way we treat other quality improvement efforts by health-care organizations.”

The three women who are the first doctoral candidates in the School of Medicine’s new PhD in Health Policy program have one guiding belief:  economics, decision science and data are now key to improving health care.

Stanford Health Policy, through the Department of Health Research and Policy at the School of Medicine, launched the PhD program to educate the next generation of scholarly leaders in the field of health policy.

And the first crop of candidates is taking their backgrounds in science and economics to pursue health policy careers based on medical information technology, data and analytics.

“We live in an era where information in health care is more rapidly and readily available than ever before,” said Catherine Lei, who will focus on the industrial organization of health care, the effects of insurance costs and the impact of regulation on health insurance markets.

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“Whether it be the digitization of medical records, the aggregation of pharmaceutical companies’ research into electronic databases, or the increased transparency of the health-care sector as a whole — stakeholders from every corner of the industry recognize that this is a critical turning point in health care,” said Lei.

Kyu Eun Lee, who worked as a research assistant at the Harvard Center for Health Decision Science before joining Stanford, intends to develop mathematical models for health interventions in Asia and other parts of the developing world.

“I am seeking advanced training in quantitative methodology and the application of those skills to support decision-making in a global health context,” said Lee, who graduated from Pohang University of Science and Technology in South Korea and then got her master’s of science at the University of Minnesota.

“I am particularly interested in model-based, cost-effectiveness analysis of cancer interventions in South or Southeast Asia, where the risks of communicable and noncommunicable diseases compete under limited resources,” she said.

The new program offers coursework in two tracks: Health Economics, including the economic behavior of individuals, providers, insurers and governments and how their actions affect health and medical care; and Decision Sciences, which uses quantitative techniques to assess the effectiveness and value of medical treatments.

“The new PhD program really developed because of our aim to offer premier educational programs that will train the next generation of health policy leaders,” said Laurence Baker, professor of Health Research and Policy and chief of Health Services Research in the department of Health Research and Policy.

“One of the real strengths of the program is its context at Stanford, with a rich set of opportunities for health policy students to interact with the clinicians and scientists from around the school of medicine and the university,” said Baker, who is also an affiliated faculty member at the Center for Health Policy/Center for Primary Care and Outcomes Research (CHP/PCOR).

Yiqun Chen, who will focus on the supply and demand of health care both in the United States and China, said her double major in economics and medicine at Peking University made her aware of the integral role that economics plays in providing an analytic framework for studying the meaty issues in health care today.Chen, who went on to get her master’s in economics at Duke University, has published several papers and intends to investigate whether Medicaid payment increases to nursing homes result in cost offsets.

“The utilization of hospital services is high among nursing home residents; yet a large proportion of stays are documented to be avoidable through provision of better quality of nursing home care,” Chen said.

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She will also research the recent consolidation of health insurers and of health care providers and how that is impacting the consumer.

“As a result of such consolidation, not only is there a potential loss of consumer choice, but it gives the pricing power to insurers and health-care service suppliers,” Chen said. And those who argue health-care and insurance consolidation results in greater efficiencies have yet to document these gains or losses — something she intends to do.

Faculty belonging to the health policy centers will advise the PhD candidates. The students will take courses in health economics, health insurance and government program operations, health financing, international health policy and economic development, as well as the cost-effectiveness analysis of new medical technologies.

“The PhD program enables us to train clinicians and non-clinicians in state-of-the-art methods of health policy analysis,” said Douglas K. Owens, director of CHP/PCOR within the Freeman Spogli Institute of International Studies.

Coursework in the new program will also cover relevant statistical and methodological approaches to public health concerns such as obesity and chronic disease.

"Our PhD students will learn from faculty across the University who bring perspectives from economics, medicine, law, decision science, business and other disciplines," said Michelle Mello, a professor of law and professor of health research and policy at the School of Medicine. "They will become truly cross-disciplinary thinkers and problem solvers."

Learn more here.