with no compromise in medical outcomes or patient satisfaction;5 if so, resources might be freed to implement additional coverage for the uninsured and/or additional best practices that are not reflected in today’s health care practices.

For the most part, these persistent problems do not reflect incompetence on the part of health care workers.6 Instead, they are a consequence of the inherent intellectual complexity of health care taken as a whole and a medical care environment that provides insufficient help for clinicians to avoid mistakes or to inform their decision making and practice. Administrative and organizational fragmentation, together with complex, distributed, and unclear authority and responsibility, further complicates the health care environment.

Many of the relevant factors can be classified into three distinct areas: the tasks and workflow of health care, the institution and economics of health care, and the nature of health care IT as it is currently implemented. (In this report, observations from site visits are cross-referenced where appropriate with the notation CxOy. Cx refers to the Category x (1-6) of observation made in Table C.1 (Appendix C), and Oy refers by number (1-25) to a particular observation as listed in Table C.1.


  • Health care decisions that require reasoning in the face of uncertainty. Sources of uncertainty include biological variability,7 uncertainty about the medications that a patient is actually taking because of missing medical records at the point of care,8 uncertainty about the effectiveness of past and future treatments for the particular patient [C1O1], simple randomness arising from inherently stochastic processes, and imperfect models or understanding of causality.

  • Complex and non-transparent workflow [C2O6] that is characterized by many interruptions [C2O7], inadequately defined roles and responsibilities, poorly kept and managed schedules, and little documentation of


Elliott S. Fisher et al., “The Implications of Regional Variations in Medicare Spending. Part 2: Health Outcomes and Satisfaction with Care,” Annals of Internal Medicine 138(4):288-298, February 18, 2003.


U.S. Department of Health and Human Services Factsheet: “Improving Patient Safety and Preventing Medical Errors,” HHS Factsheet, March 25, 2002.


Ute Schwarz et al., “Genetic Determinants of Response to Warfarin During Initial Anticoagulation,” New England Journal of Medicine 358(10):999-1008, March 6, 2008.


As much as 30 percent of the information an internist needs is often not accessible during a patient’s visit because of missing clinical information and missing laboratory reports. See D.G. Covell, G.C. Uman, and P.R. Manning, “Information Needs in Office Practice: Are They Being Met?,” Annals of Internal Medicine 103(4):596-599, 1995.

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