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THE RICHARD AND HINDA ROSENTHAL LECTURES 2002 Fostering Rapid Advances in Health Care INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engi- neering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for ap- propriate balance. Support for this project was provided by the Richard and Hinda Rosenthal Foun- dation. Copies of this report are available from the Office of Reports and Communication, Institute of Medicine, 500 5th St. N.W., Washington, DC 20001. For more informa- tion about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2003 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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"I(nowing is not enough; we invest apply. Willing is not enough; we invest do." Goethe ...... ........ . . ................. ........... ...... ... :: .:: ...... .... .... .. ..... : ::::: .- INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Shaping the Future for Health

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THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal govern- ment on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal gov- ernment. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in pro- viding services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www. nationa l-academies.org

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Foreword In 1988, an exciting and important new program was launched at the Institute of Medicine. Through the generosity of the Richard and Hinda Rosenthal Foundation, a lecture series was established to bring to greater attention some of the critical health policy issues facing our nation today. Each year a subject of particular relevance is addressed through three lec- tures presented by experts in the field. The lectures are published at a later date for national dissemination. The Rosenthal lectures have attracted an enthusiastic following among health policy researchers and decision makers, both in Washing- ton, D.C., and across the country. Our speakers are the leading experts on the subjects under discussion and our audience includes many of the ma- jor policymakers charged with making the U.S. health care system more effective and humane. The lectures and associated remarks have engen- dered lively and productive dialogue. The Rosenthal lecture included in this volume captures a panel discussion on the IOM report Fostering Rapid Advances in Health Care, which did an excellent job of identifying potential demonstrations that might lead to broader health reform. There is much to learn from the informed and real-world perspectives provided by the contributors to this book. I would like to give special thanks to Gail Warden for moderating the November 2002 lecture. In addition, I would like to express my apprecia- tion to Bronwyn Schrecker, Shari Erickson, lennifer Bitticks, Leah Covington, lennifer Often, and Hattie Wilfert for ably handling the many details associated with the lecture programs and the publication. No in- troduction to this volume would be complete, however, without a special v

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~1 ; FORE~RD expression of gratitude to the late Richard Rosenthal and to Linda Rosenthal for making As valued and important education effort pos- s~le and Those keen interest in Me themes under discussion further en- riches this valuable ION activity. Harvey V. F1n~erg' ~.D.' Fh.D. Fresident Institute of Medicine

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Contents boduchon Overview Call a. #~" ~1 ' ~ nromc ware ^~~ a. Foper Primary Care surfer Carom, ~ Informat10n Necrology End H. Swords Uninsured L1~111ty ^~~ ad. Sad . a- . . Discussion B10sketches . . ~11 1 4 6 9 12 15 18 21 30

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