blurred vision, could be identified and treated more quickly given assurance that proper follow-up services were available and utilized.

When assessing the quality of the health care delivery system treating David, outcomes and costs should be considered. In a hospital, for example, measurements of the ability of David to perform daily activities and function both physically and mentally at normal levels would be important outcomes. Combined with the costs associated with treating these patients, this information would permit an overall assessment of the longitudinal efficiency of the hospital systems.

Individual-patient-level, population-based, and systems-level measurement. While assessing care at the individual patient level, David’s doctors could measure the comprehensiveness of his care through the use of composites. Composite measures of his diabetes testing for a predetermined bundle of routine disease-specific measures, such as checking for hemoglobin levels, blood pressure management, and eye and foot exams, would provide a complete picture of the evidence-based care David should be receiving. They would also allow David to become a more informed patient, aware of what types of treatment he should, at a minimum, be receiving. As an active participant in his care, David could also collaborate with his physician to ensure that he received all recommended treatment protocols.

When measuring care based on a given population, David’s care measures could be aggregated with those of others, such as members of his local community, socioeconomic group, and state. These measures of personal health can be evaluated in combination with data reflecting the public and population health systems to better assess the overall health care system. This information would depict how well those in his population were living with their chronic illnesses, as well as provide tangible data for comparison with other populations.

Shared accountability. David’s multiple caregivers should take responsibility for ensuring that his care is well coordinated and responsive to his individual needs. This would require his clinicians to embrace a more holistic approach to care, as opposed to practicing in a way that targets a single specialty. For example, David’s cardiovascular specialist would also want to ensure that preventive testing, such as foot and eye exams, was performed. If these tests were not performed, she could take corrective action and contact David’s other providers. This does not ensure that David’s health care will be more coordinated; however, it is important that all the players involved with providing David’s care have the opportunity to affect his health without having to worry about being held liable for the actions of others. Finally, just as David is an example of how well an individual patient’s physicians interact, care provided to larger patient populations reflects the interactions among the various systems these populations encounter.

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