Numerous public policy, payment, and legal issues also must be resolved. Many applications in the public health arena (e.g., videoconferencing during emergency situations, collection of information from local and state public health departments, incident reporting and disease surveillance) are within technical reach at relatively low cost, but are not widely used because of a lack of targeted public-sector funding and organizational barriers (e.g., shortage of adequately trained personnel). Fee-for-service payment, the most common method of payment for physicians, does not compensate clinicians for time spent on e-mail communication. State-based professional licensing requirements and restrictions on practice have stymied widespread use of other applications, such as remote medical consultations. Online access to and transfer of clinical information has also been slow to evolve, in part because of concerns about privacy and confidentiality. Chapter 7 reviews in greater detail the use of information technology to improve the quality of health care and some of the barriers to its more widespread adoption.


Throughout the course of its work, the committee has been cognizant of the fact that the health care system has been in a rapid state of flux for more than 10 years and that this situation is likely to continue. Over the last decade, the primary impetus for change has been a desire to slow the rate of inflation of health care costs. During the coming decades, cost pressures will remain, but the health care system will also be shaped dramatically by broader forces transforming society in general, most notably the growth of the Internet and changing population needs for chronic care.

There is little doubt that the health care enterprise has been slow to change. Research documenting safety and quality concerns has been mounting for over a decade. Successful quality improvement initiatives are very slow to spread, and rarely adopted on a widespread basis. For these reasons, the committee believes that a more intense and far-reaching effort will be needed. Substantial improvement in quality over the coming decade can be achieved only by engaging the support of patients, clinicians, governing boards and managers of health care organizations, private and public purchasers, state and federal policy makers, regulators, researchers, and others. Change is needed at all levels, including the clinician and patient relationship; the structure, management, and operation of health care organizations; the purchasing and financing of health care; the regulatory and liability environment; and others.

This report offers general principles, not a detailed blueprint, for the building of a new system. In part, the committee cannot foresee all the new organizations, forces, technologies, needs, and relationships that will develop even in the early years of the 21st century. More than that, however, the committee has come to

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