steps, expectations, and outcomes.9 Poor information flow is particularly apparent at the interfaces of health care (e.g., when a patient transitions from inpatient to outpatient, when nurses change shifts) [C2O5].

  • Increasing complexity of the care provided to patients in a time-pressured environment.10 The aging patient population has a growing number of chronic disease conditions that must be managed.11 According to Yarnall et al.,12 managing in accordance with the preventive guidelines relevant to “average” adult patients would require an average of approximately 40 minutes per patient per year. A typical patient sees his primary care physician only 4 times a year for a 15-minute appointment (for a total of 60 minutes of interaction), which would leave only 20 minutes per year (60 minutes − 40 minutes) for everything other than matters related to the guidelines for preventive care (by 2030, about half of all Americans will have at least one chronic disease).13


  • A large number of payers for health care, each with their own rules for coverage. For example, a large medical center may have to handle the complexity associated with managing thousands of different health insurance plans.14 A typical family physician or internist in the United States wastes


See, for example, S. Panzarasa et al., “Improving Compliance to Guidelines Through Workflow Technology: Implementation and Results in a Stroke Unit,” Studies in Health Technology and Informatics 129(Pt. 2):834-839, 2007.


Center for Studying Health System Change. Physician Survey, available at


Brian Raymond and Cynthia Dold, Clinical Information Systems: Achieving the Vision, Kaiser Permanente Institute for Health Policy, Oakland, Calif., February 2002, available at


Kimberly S.H. Yarnall, Kathryn I. Pollak, Truls Østbye, Katrina M. Krause, and J. Lloyd Michener, “Primary Care: Is There Enough Time for Prevention?,” American Journal of Public Health 93(4):635-641, April 2003, available at


Shin-Yi Wu and Anthony Green, Projection of Chronic Illness Prevalence and Cost Inflation, RAND Corporation, October 2000.


Respondents to an informal poll of the ACMI discussion list in June 2008 indicated that their home organizations (medical centers) often had to cope with many dozens of health care payers (usually insurers), each of which had hundreds of different plans with different rules for coverage. (ACMI, the American College of Medical Informatics, consists of elected fellows from the United States and abroad who have made significant and sustained contributions to the field of medical informatics.) The range reported was from a low of 578 plans to a high in excess of 20,000.

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