that in many sectors of the service and manufacturing economies a few high-performance organizations seem to be the leaders, and their competitors essentially compete for second place. These pioneers deliver value with less effort and cost, even though they have similar—or identical—tools, customers, suppliers, labor, and regulations. Spear said that these organizational leaders continue to push the envelope through differences in systems management and that the lessons from their success might offer perspectives on value, efficiency, quality, and other areas that are important to producing a learning, team-oriented, patient-centric culture within health care. Based on his close observations of Toyota, Southwest Airlines, Alcoa, and other industry leaders, Spear reported that, in contrast to organizations that address systems anomalies with workarounds, industry leaders carefully analyze adverse events and use them as sentinels for investigation into causes. Spear hypothesized that by adopting similar techniques, healthcare systems may be able to deliver better care to more people at less cost and with less effort—on the order of twice as good for twice as many people at half the cost.

Examining the value of knowledge management, access, and use, Donald E. Detmer, president and chief executive officer (CEO) of the American Medical Informatics Association (AMIA) and professor of medical education at the University of Virginia, argued that improved management of information applied to clinical decision support (CDS) will require structured policies and complementary agendas for informatics education and research. Detmer discussed the CDS Roadmap for National Action developed by the AMIA, which is based on the principles of (1) best knowledge available when needed, (2) high adoption and effective use, and (3) continuous improvement of CDS methods and knowledge. Detmer also discussed the Morningside Initiative, which seeks to share information broadly for CDS. Detmer highlighted the AMIA–Association of Academic Health Centers’ (AAHC’s) current collaboration to develop enhanced informatics curriculums for health professional and continuing education students. He also discussed current developments in CDS policy and infrastructure and identified areas for further investigation and efforts. Looking to the future, he emphasized the importance of determining the appropriate mechanism for integrating personal health records with electronic health records (EHRs).

Stephen J. Swensen, director of quality for the Mayo Clinic and professor of radiology at the Mayo Clinic College of Medicine, said the healthcare industry must address specific elements of technology management in order to drive systems change. He described work in technology management at the Mayo Clinic to develop networks that embody optimal reliability, permit nimble and effective diffusion of best practices, have built-in safety nets, and support optimal organizational learning and communication. Swensen



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