Practices for Comprehensive Health IT Systems

Following are practices for developing comprehensive health IT systems.

Something I realized early on is that such systems should be flexible enough to continually adapt to new healthcare knowledge and concepts; data models; value sets; data format, terminology and transport standards; use cases; workflows; and diverse user needs.

It should be able to accommodate the needs of PCPs and all clinical specialties, approaches and user roles, as well as patients, with highly useful and useable tools.

It should be able to work in centralized, distributed, point-to-point, and tightly- and loosely-coupled networks using client-server and standalone (desktop) tools.

It should be able to leverage cloud-based storage and computing (all flavors), as well as the local resources of untethered devices that may connect to the internet occasionally.

It should be able to work with third-party tools that provide additional relevant capabilities.

And if it provides decision support, it should focus on enabling knowledge-feedback loops among diverse groups of collaborators who build, share and refine models aimed at continually increasing the value of care patients receive through systematic process and outcomes research that cross organizational and geopolitical boundaries. These models should include ones that focus on the whole person (biomedical and psychosocial), social determinants of health (SDH), precision medicine, clinical workflows, population health, finances, and prevention (wellness care) as well as treatment and self-maintenance of chronic conditions.

Wellness: A Proposed Definition

There has been much written about the importance of promoting "wellness" in value-based care. Yet there is no definitive definition of the concept. In this post I offer a conceptual framework for discussion in which I attempt to delineate many of the key factors discussed in the literature, along with my observations as a clinical psychologist. 

Proposed definition: Wellness is a measure of a person’s overall state of health, which is greatest when a person has and uses a set of abilities, desires, behaviors, and resources to avoid, manage, and cope with physiological, psychological (mental and emotional), and mind-body health problems to the extent possible.

The Following delineates some of the concepts in this proposed wellness definition.

1.      Health problems include (but not limited to):

1.1.   At-risk, acute, subacute, chronic, catastrophic, and end-of-life conditions.

1.2.   Illness, injury, dysfunction, disability, disfigurement, and debilitating distress with associated causes (e.g., contagion, trauma, genetics, etc.) and signs and symptoms (physical, emotional, behavioral, and cognitive).

1.3.   Mind-body (biopsychosocial) health problems in which psychological distress adversely affects a person’s physical health and vice versa.

2.      Requisite abilities, resources, and desires include:

2.1.   Abilities:

2.1.1.      Psychological capabilities that enable people to cope effectively with their health problems in a way that reduces the likelihood of denial, ignorance, self-deception, debilitating depression, irrational despair/discouragement and fear, hostility, blame, shame, and self-destructive behavior. These capabilities include focused awareness, rational and adaptive beliefs/thoughts/cognitions, open-mindedness, adequate drive/motivation/will and impulse control, self-determination, reasonable self-confidence, self-understanding, self-acceptance, sound/logical reasoning, reliable knowledge, and intelligence.

2.1.2.      Behavioral capabilities characterized by proactive, competent, and responsible actions that include adherence to evidence-based care plans/guidelines and making recommended lifestyle changes.

2.2.    Social, economic, and environmental resources (e.g., having access to quality healthcare, good health literacy, money, time, a healthy/safe living environment, social/family support, education and access to useful information, access to foods that support healthy eating patterns.

2.3.    Desire to live and develop one’s potential for a fulfilling life characterized love, learning, accomplishment, and other positive activities, experiences, and feelings.

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 5

In my last post [click here for the first of the series], I discussed the personalities, coping strategies, and health-related needs of the third type of individual, the "Inactives." I now conclude this series by examining the fourth and most resistant group: the "Ignorers/Deniers."

Simply put, Ignorers/Deniers just don't focus on their health. This is for a variety of reasons, which I'll be discussing. First, these people "close their eyes and ears" to information about healthy living. They refuse to acknowledge or accept they have health problems or risk factors, or they refuse to do anything about it. These maladaptive behaviors are a consequence of a mindset they adopt, which includes thoughts such as:

• "I do not accept there's a problem with my health" – despite convincing evidence.
• "I fine the way I am … It doesn't matter what others say" – even though their health is deteriorating, relationships are crumbling, and overall quality of life is suffering.
• "I'm different … I'm special … I'm not like those other people … Nothing's going to happen to me!" – a false sense of security and invincibility.
• "I don't trust doctors" – an attitude based on gross overgeneralization.
• "Getting help is a sign of weakness ... A strong person handles one's own problems" – an irrational belief driven by pride and based on a distorted measure of self-worth.

Ignorers/Deniers, therefore, differ from the other personality types in essential ways; for example:

• The three other types of individuals think about their health, and when confronted with a health problem, many question whether they can make good decisions and help improve things, which may make them anxious due to self-doubt. Nevertheless, despite their anxiety and doubt, they are willing to learn and act wisely. Many Ignorers/Deniers, on the other hand, are so terrified by the notion they may have (or get) a severe illness that they avoid thinking about their physical and emotional health—preferring, instead, to pretend everything is all right. As a result, Ignorers/Deniers may refuse to accept the reality of their situation, even when confronted with the threat that they will probably die from their health problems; to them, the thought of being or being ill is too great to consider. Although this self-deception may keep their fear in check for a while, their inaction and ignorance make them vulnerable to worsening health and personal problems.
• If Ignorers/Deniers did think about their health, many would feel hopeless and helpless, believing they cannot deal with serious illnesses or personal problems. And those who portray an air of invincibility are likely covering up great self-doubt and fear, or they may be delusional.
• While other types of individuals may have valid concerns about finding a competent healthcare practitioner, some Ignorers/Deniers are so distrustful of the healthcare profession that they won't even consider seeing a doctor, even if they are in pain or distress, often until it's too late.
• While health problems may cause other types of people to become sad or even depressed, for a time, they can get themselves motivated and begin to take constructive action because they want to live and be happy. Ignorers/Deniers, on the other hand, may be so lonely and depressed that they believe they have nothing for which to live. For them, living longer in chronic emotional pain isn't motivating. And when confronted with the knowledge that their health risks can kill them, many Ignorers/Deniers deny the facts because the idea of dying is also too emotionally painful for them to acknowledge; the threat of death, therefore, isn't a motivator. In fact, the odds are great that such a person will fail to make substantial lifestyle changes, even if facing probable death. This prevents them from having the drive and focus needed for constructive action.
• While other individuals are willing to get help when needed, Ignorers/Deniers may have been so influenced by their cultures that they believe seeking assistance for personal problems is a sign of weakness.
• Unlike the other personality types, Ignorers/Deniers may have physical addictions or powerful psychological compulsions that prevent them from focusing on healthy living until they reach "rock bottom," which, unfortunately, may be too late.

What this means is that Ignorers/Deniers rely on some of the same "avoidance" coping strategies as the Wannabes and Inactives; that is, they may:

• Try to feel better by doing enjoyable or interesting things rather than gaining knowledge and developing a plan of action
• Act as if nothing has happened or trying not to think about their problems
• Resign themselves that nothing can be done to improve the situation, even though they lack adequate understanding and fail to exert sufficient effort.

As I discussed in my previous posts, these coping strategies are maladaptive in the long term since the inertia (inaction) they promote allows their health risks to emerging as serious problems and their existing health problems to worsen.

Because these thoughts, feelings, and reactions are so deeply ingrained in their personalities, getting through to Ignorers/Deniers is very difficult. However, all is not lost! Consider the following:

• There are compelling discoveries in cognitive science, linguistics, and neuroscience about how "reframing" serious health-related issues can help motivate resistant people to change. For example, instead of trying to break through the denial of Ignorers/Deniers through threats they will die, it may be much more helpful to reframe the issue in a way that focuses them on a vision of "joyful living" rather than a "fear of dying," since joy is a more powerful motivator than fear [reference]. This kind of reframing changes the mental structures that shape one's view of the world; it typically requires months of psychological counseling to break through the thoughts and feelings that block Ignorers/Deniers' awareness and motivation to change.
• When cultural influences create a "machismo" attitude, in which Ignorers/Deniers perceive getting help as a sign of personal weakness or failure, cognitive-behavioral counseling can combat that belief. In addition, innovative self-help software that guides the person toward healthier behavior and thinking can be helpful. One focus would be reframing the situation from (a) getting help revealing weakness to (b) receiving help when needed and using it to improve one's life is a sign of wisdom and personal strength, whereas refusing help is childish and self-destructive.
• Dealing with a person's lack of trust may require the intervention of a wellness coach who takes the time to establish a close, positive relationship with the Ignorer/Denier and has the knowledge and experience to gain the person's confidence.
• As for Ignorers/Deniers with addictions or compulsions, lengthy counseling (and possible medications) may be needed before they acknowledge their problems and have the will to confront them.

Regarding wellness programs, the Ignorers/Deniers are the least likely to participate. Engaging them is critical, such as offering meaningful incentives to take a self-assessment and speak with a wellness coach. The initial goal of such wellness counseling should focus on understanding and helping reframe their beliefs and perceptions. This will enable them to be more open to gaining awareness about their health situation. Innovative technologies that help focus and entice people to break through their negative mindsets and resistance would be helpful. Once Ignorers/Deniers stop deceiving themselves, have a stronger desire to live and enjoy life, gain trust, are more aware and open to receiving help, and are no longer controlled by their addictions/compulsions, they can be treated as Inactives or Wannabes as appropriate.

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 4

In my last post, I discussed the personalities, coping strategies, and need of the "Wannabes." This time I examine the "Inactives."

Inactives think about their health on occasion but do not believe they should or can do anything to improve their health and wellbeing. This is because they tend to have thoughts such as:

• "I doubt I'll be able to do what's required to improve my health, so why even bother."
• "I don't deserve to be sick…it's not my fault…so why should I have to be the one to do anything about it"—or—"I do deserve to be sick…Illness is my punishment…I'm just getting what I deserve."

Inactives doubt that they can deal effectively with their health risks and problems, which causes them great stress. Some also believe they don't deserve what happened to them, making them resentful and angry. This stress and resentful anger not only distract them from focusing on constructive health improvement activities; it is also likely to worsen their physical health since illnesses such as coronary heart disease and cancer may be exacerbated by a negative psychological state (for examples of how this mind-body connection affects one's health, see: this link, this link, and this link). Other Inactives may have different views, such as believing they deserve to be sick and there's no hope because they are doomed.

The result is that the Inactives, like the Wannabes, lack the self-confidence and motivation to improve their health and wellbeing. But what makes Inactives less likely to change their unhealthy lifestyles is that:

• Their self-doubt is stronger because it comes from the belief that they are not able (rather than may not be able) to (a) make the correct decision about treatment for an existing problem or (b) make the attitude and behavior changes required for better health and wellbeing.
• Their inertia (inaction) may be exacerbated by (a) fear that they will be shamed if they try to improve their health and failure causes them to resist taking constructive action, (b) the belief that there is no good way to solve their health problems or prevent their health risks from becoming problems, and (c) despair related to the belief they deserve to be ill.
• Their stress and resentful anger likely worsen their health through distraction and the adverse effect of negative emotions on physiology.

Furthermore, they will likely look for reasons for not adhering to the wellness care plan, such as:

• Money problems that prevent them from carrying out their wellness plan of care (e.g., buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc.)
• Family and other demands consume their time and thus make lifestyle change difficult.
• Physical handicaps or cognitive impairments.

The result is that Inactives fail to deal with their health risk and problems promptly and effectively while simultaneously worsening their health and wellbeing through inertia and emotional distress.

The way Inactives attempt to cope with their pessimism, fear, anger, resentment, and despair is similar to the negative avoidance strategies the Wannabes use. That is, they may

• Try to feel better by doing enjoyable or interesting things rather than focusing on the problem.
• Act as if nothing has happened or try not to think about their problems.
• Express negative emotions by yelling or crying, taking it out on others, or avoiding certain people rather than doing something constructive.
• Hope a miracle will make things better or that one's wishes or prayers will be answered, rather than gaining knowledge and developing a plan of action.
• Resign themselves that nothing can be done to improve the situation, even though they lack adequate understanding and fail to exert sufficient effort.

While these coping strategies may alleviate their emotional distress temporarily, they are maladaptive in the long term since their inaction allows their health risks to emerging as serious problems and their existing health problems to worsen.

Nevertheless, since Inactives think about their health & wellbeing on occasion, it is possible for them to become more focused and motivated with the help of wellness coaches/counselors and helpful health information technologies. They may be willing, for example, to take health risk assessments that evaluate their health status, especially if they have concerns about their physical or emotional health. They may also be willing to gain greater knowledge about their problems, risks, and constructive strategies for dealing with them, although they will likely have to be convinced (through counseling and maybe incentives) to use these tools and professionals. And they may be willing to get help to:

• Use the knowledge they gain to make a treatment decision for dealing with an acute physical or mental health problem.
• Implement a wellness care plan designed to self-manage a chronic condition.
• Make positive lifestyle changes to avoid a risk factor from becoming a health problem.

All this means they will need wellness counseling, which should focus on the following:

• Overcoming their inertia, changing their self-defeating cognitive and emotional blocks (including self-doubt, fear, anger, and shame)
• Replacing their negative avoidance-based coping strategies with the positive approaches of the Activists.

This counseling should include powerful forms of persuasion in which well-care professionals--using next-generation health information technologies, which I will describe in a future post--help increase their willingness to take responsible action that improves their health and wellbeing. This is likely to involve significant effort focused on changing beliefs/thoughts. I have previously posted about the relationship between beliefs and physical health, starting at this link.

In my next post, I examine the fourth most challenging personality type: the "Ignorers/Deniers."

The Whole-Person Integrated-Care (WPIC) Wellness Solution: Part 3

In my last post, I explained why "Activists" — the first of four types of people affected by influential psychological characteristics — tend to be healthiest and why they are most likely to take advantage of wellness programs. In addition, I discussed how they have the kind of personality traits that enable them to cope with health-related issues through positive action and rational acceptance. In this post, I discuss a second group of individuals with different personalities and coping strategies: the "Wannabes."

Wannabes talk about improving their health & well-being and are willing to learn about healthy living, but they never seem to act on it or do so half-heartedly. This is because they tend to have thoughts such as:

• "I may be able to do what's required to improve my health, but I'd rather not deal with it right now."
• "I'm not sure what to do."
• "I'm just not ready."

As a result, Wannabes tend to be aware--or are willing to be aware--of their physical and mental health problems & risks, but they lack the self-confidence and motivation they need when it comes to doing something about it. Their self-doubt and lack of drive may come from the belief that they may not make correct decisions about preventing or treating their problems. This uncertainty, in turn, may cause them to avoid making decisions and changing their attitudes & behaviors for fear of failure; i.e., they don't want to be ashamed or embarrassed if they try but fail. Or if they believe there's no acceptable way to solve their health problems or prevent their health risks from becoming problems, they will likely take no action.

Wannabes, in other words, tend to cope with their doubts and fears through avoidance. What they do, for example, is:

• Try to feel better by doing enjoyable or interesting things rather than focusing on the problem.
• Act as if nothing has happened or try not to think about their problems.
• Express negative emotions by yelling or crying, taking it out on others, or avoiding certain people rather than doing something constructive.
• Hope a miracle will make things better or that one's wishes or prayers will be answered, rather than gaining knowledge and developing a plan of action.
• Resign themselves that nothing can be done to improve the situation, even though they lack adequate understanding and fail to exert adequate effort.

While some of these coping strategies may temporarily alleviate their emotional distress, they are maladaptive in the long term since they foster procrastination, which allows their health risks to become severe and worsen their existing health problems. Nevertheless, there are several positive and negative aspects of the Wannabe personality.

On the positive side, since Wannabes think and talk about improving their health & well-being, they will likely want to participate (to some degree) in health promotion programs that:

• Evaluate their health status, especially if they have concerns about their physical and/or emotional states.
• Help them learn about their problems or risk factors, including understanding the pros & cons of different treatment and prevention options.

On the negative side, Wannabes are likely to procrastinate when it comes to:

• Using their knowledge to make decisions about dealing with (treating) acute physical or mental health problems
• Acting on wellness plans designed to self-manage chronic conditions and avoid complications
• Making positive lifestyle changes to prevent risk factors from becoming health problems.

If they have money problems—which prevent them from carrying out their wellness plan of care (e.g., buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc.)—they may use it as an excuse for not making a firm decision or adhering to the wellness care plan.

If they have family and other demands that consume their time and thus make lifestyle change difficult, they will likely use it as an excuse for non-action. And if they have physical handicaps or cognitive impairments, they will likely use these limitations as excuses for inaction.

All this means they will need wellness counseling focused on modifying their self-defeating cognitive and emotional blocks (including self-doubt, fear, and shame) and changing their avoidance-based coping strategies. The goal is to help them become more like Activists. Only then will they be willing to take responsible action that improves their health and well-being.

In my next post, I'll examine the third personality type: the "Inactive."

Workplace Wellness Programs: Motivating Employees to Live Healthy

A recent Wall Street Journal article--Wellness Programs May Face Legal Tests: Plans That Penalize Unhealthy Workers Could Get Tighter Rules--discusses the US Department of Labor’s decision to curtail the ability of employers to motivate workers to kick unhealthy habits by making health insurance more expensive for unhealthy workers than for their colleagues.

Workplace wellness programs--which focus on illness prevention and chronic disease management through self-maintenance--are one key ingredient for healthcare cost control. Healthier employees tend to be happier, more motivated and more focused, which benefit their employers through reduced healthcare-related expenditures, improved productivity, lowered absenteeism and fewer on-the-job accidents. While “sticks and carrots” can help convince some employees to adhere to their wellness plan and lead healthier lifestyles, it will be ineffective or even harmful for some due to powerful psychological, physiological and situational factors. These strong internal and external influences will affect the wellness market by giving credence to the legal issues in article and by stressing the judicious use of incentives and disincentives.

Even most presidential candidates agree that wellness programs are essential for controlling healthcare costs. Employer-based wellness programs have been shown to have substantial return on investment through increased productivity and reduced absenteeism, by promoting employee health & safety and organizational effectiveness, and by reducing expenses through lowered sick-care utilization. For example:

• The Leapfrog Group reported that many of the largest U.S. employers, with 54% of them now offering some version of health coaching to employees.
• The US Dept. of Health and Human Services reported that: (a) a Johnson and Johnson’s wellness program yielded an estimated savings of at least $1.9 million through decreased medical costs, reduced sick leave, and increased productivity; (b) city employees insured by the City of Mesa, Arizona revealed a significantly greater decrease in health care costs of employees who participated in a mobile worksite health promotion program, as opposed to employees not participating. Health care costs decreased 16%, resulting in a $3.6 savings for every dollar spent on health promotion services; and (c) the return on investment enjoyed by five large companies, as a result of their health promotion and disease prevention activities, ranged from $2.05 to $6.15 per employee.
• The Small Business Wellness Initiative found that businesses that invest $1 in workplace wellness can often reap $3 to $5 in savings through lowered healthcare costs, decreased absenteeism and decreased workers’ compensation claims.
• The Texas Coalition for Worksite Wellness reported that the average cost of adding prevention and wellness services to a private health insurance program is typically $50 to $85 per person. Yet, every dollar invested in worksite health promotion yields $3.50 to nearly $6 in savings through reduced absenteeism, increased productivity and decreased health care costs.
• And a wellness program at IBM returned $3 in healthcare savings for every $1 spent on wellness.

Despite these convincing numbers, workplace wellness programs ought to be cautious in their use of rewards and punishments for motivating employees to lead healthier lifestyles. There is good reason for the Department of Labor’s recently issued regulatory guidelines rejecting the use of incentives and disincentives that make health insurance more expensive for unhealthy workers than for their colleagues. I’ve identified the following three reasons why such tactics are unrealistic and won’t work for many employees.

1. Addiction (and compulsion). As mentioned in the article, smoking (as well as drug and alcohol) addiction is due to the influence of a powerful complex of biological and psychological factors. For many people, counseling (and medications) is required, and numerous relapses are common. Instead of simply punishing smoking, those addicted ought to be rewarded initially for participating in counseling to deal with the physical and psychological causes of their addictions. For employees whose health would improve if the curtailed their use of alcoholic beverages and recreational drugs, the same strategy should be offered, assuming they are not breaking company policies.

Similarly, certain compulsions, such as the drive to persistently overeat, are driven by powerful physiological, mental and emotional influences. As with addictions, weight loss typically requires counseling, family/peer support, and even medications or other medical procedures (e.g., gastric bypass or band). Our culture makes matters worse by promoting unhealthy diets through commercials and fast-food companies selling high-carb and high-fat foods and beverages. If we’re serious about reducing obesity, our society also should focus on changing these maladaptive cultural influences.

2. Hopelessness/Helplessness, Depression, and Denial. Some people lack the optimism and confidence to change their unhealthy lifestyles. Feelings and perceptions of hopelessness and helplessness are part of their personalities, which have been created by their personal experiences, attitudes and emotions. People who don’t believe they can succeed are not motivated to change, of course. Likewise, lonely or depressed people aren’t going to change their lifestyles in order to extend their lives because the prospect of living longer in chronic emotional pain isn’t very motivating. And when confronted with the knowledge that their health risks can kill them, many people tend to deny it because the idea is just too emotionally painful to acknowledge. So, threat of death isn’t a powerful motivator for many. In fact, the odds are nine to one that a person will fail to make substantial lifestyle changes, even if facing probable death!

Compelling discoveries in the fields of cognitive science, linguistics and neuroscience, however, are helping us understand how “reframing” the issue is essential. For example, people are more motivated to change if they can have a vision of “joy of living” rather than a “fear of dying,” since joy is a more powerful motivator than fear. This kind of reframing changes the mental structures that shape one’s view of the world, and it typically requires psychological counseling (individual and/or group). It may take months of counseling to the break through the thoughts and feelings that block one’s motivation to change. [Reference]

Sticks and carrots alone will not motivate these people to change; and some sticks may even lead to denial. Instead, they must first believe they can succeed in making the necessary changes in their lives and they must have a mental framework in which the prospect of a longer life brings them joy. Their initial incentives, therefore, ought to be focused on getting them involved in the counseling they need.

3. Time and Money (Resource) Constraints. Many employees have work, family and other demands that consume their time and make lifestyle change difficult. What they need is help with time management and developing wellness plans that take their busy schedules into account. Some have serious money problems, which prevent them from buying more healthy foods, a gym membership, prescribed medications, diagnostic tests, etc. s Sticks and carrots will be useless until these time and financial issues are resolved.

In conclusion, using incentives and disincentives fails to motivate many employees to live healthier lives. Wellness programs, therefore, ought to focus on providing the risk assessment, feedback and counseling necessary to deal with the emotional, attitudinal and resource blocks that prevent employees from making positive changes. Rewarding these people for participating in such counseling make sense, but punishing them for failing to improve their health is foolish and worthy of criticism by the Labor Dept. Not until these employees have attained a more positive psychological/emotional state will they be motivated to change. Only then does is make sense to reward them for achieving biologic benchmarks (e.g., weight, cholesterol levels, blood pressure, etc.) and behavioral goals (e.g., diet, exercise, non-smoking, reduced alcohol consumption, medication compliance, etc.).

In my next post, I discuss how a "whole-person integrated care" model addresses the particular needs of people with different personalities and levels of motivation.

How to determine the best healthcare reform plan

There’s great debate about which candidate is presenting the best healthcare reform plan. A key issue is whether insurance companies (the private sector) or our government would do a better job managing universal healthcare. Both have been criticized for serious problems of inefficiency, bureaucracy and waste (as well as questionable practices and fraud).

 

It seems to me that the only way to determine who presents the best strategy is to compare the different plans head-to-head. The comparisons must consider costs to the public and patients in terms of taxes, premiums, deductible, co-pays, and coverage for people in different locales, who are in different economic and age groups, and who have different types of health problems and risk factors. This is a very complex issue, which cannot be understood with generalities and sound-bites. So, access to a detailed comparison grid that enables in-depth analysis is critical.

 

But even such an analysis, I contend, would fail to deal with the most important factor: The need for radical reduction of inefficiency, waste and fraud; errors and omissions; over-testing, under-testing, over-treatment, under-treatment; inappropriate care, problems with safety, quality and accessibility; inadequate wellness/preventive services; poor coordination of care; etc.

 

In other words, I assert that if all patients received cost-effective (high value) sick-care and well-care services—delivered safely, efficiently and competently—people would stay healthy longer, recover more quickly from illness, utilize fewer expensive services, medications and medical devices, and have a better quality of life. In addition, the system should give competitive advantage and financial reward to healthcare providers who get the best results for the best price. The resulting quality improvements and cost savings would be astronomical.

 

I would vote for plans—be they single-payer/government-controlled or private-sector insurer based—that return the greatest savings to the consumer through lower out-of-pocket expense (including taxes and shared responsibility payments), while providing the broadest coverage and supporting policies/plans/procedures that promote continuous improvements in quality and efficiency.