whatever facts may be relevant to a patient’s decision making. This new rule is expected to supplement trust in the good training and intentions of health care professionals with trust based on good information and well-designed systems of care.

Although changes in the tort system may be desirable, improving the health care system cannot wait for such change to occur. Some organizations have successfully implemented programs of increased transparency despite the liability risk (Peterkin, 1990). Indeed, some evidence shows that open disclosure of errors may decrease the likelihood of malpractice loss (Kraman and Hamm, 1999; Pietro et al., 2000; Witman et al., 1990; Wu, 1999).

In the future health care system envisioned by the committee, transparency is the route to accountability—the identification of who is responsible both financially and clinically for the actions of health care organizations and individuals. The committee believes trust will improve in a health care system that poses few barriers to the flow of information, including aggregate (non-personally identifiable) research data and information about the quality of care. A health care system that operates under a rule of transparency will be more patient-centered and safer because patients will be able to recognize outdated and wrong information and to share in information that affects their care, such as the results of laboratory tests, medications being taken, and the correct doses.

Rule 8: Anticipation of Needs

Under the current approach, health care resources are marshaled when they are needed. The system works largely in a reactive mode, awaiting complications and underinvesting in prevention. The new system would not wait for trouble. It would use patient registries to track patients and draw them into care. It would use predictive models to anticipate demand and allocate its resources according to those predictions, thereby smoothing workflow. The corresponding 21st-century rule would state: Organize health care to predict and anticipate needs based on knowledge of patients, local conditions, and a thorough knowledge of the natural history of illness. A system that adopted this new rule would be more patient-centered and more effective. It would make and use better predictions about the flow of need and demand, allowing for anticipation of the needs of both individuals and the patient population at risk. Box 3–4 illustrates the new rule and the current approach.

Scenarios similar to the current approach described in Box 3–4 are common today. Crises for older persons occur because anticipatory management of multiple problems is rare. When care hinges on scheduled office visits or emergency room visits, anticipatory management that can prevent acute hospitalization is difficult. Under the new rule, anticipation could include more and better linkages among care teams, linkages among health systems and community resources, and more frequent communication with patients through telephone consultations and



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