It is widely recognized that today’s health care fails to deliver the most effective care and suffers substantially as a result of medical errors. In addition, many medical interventions undertaken today are in fact not necessary. These persistent problems do not reflect incompetence on the part of health care professionals—rather, they are a consequence of the inherent intellectual complexity of health care taken as a whole and a medical care environment that has not been adequately structured to help clinicians avoid mistakes or to systematically improve 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 largely 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.

  • The tasks and workflow of health care. Health care decisions often require reasoning under high degrees of uncertainty about a patient’s medical state and the effectiveness of past and future treatments for the particular patient. In addition, medical workflows are often complex and non-transparent and are characterized by many interruptions, inadequately defined roles and responsibilities, poorly kept and managed schedules, and little documentation of steps, expectations, and outcomes. Complex care is increasingly provided to patients in a time- and resource-pressured environment because of the need to contain costs.

  • The institution and economics of health care. The large number of health care payers and coverage plans, each with its own rules for coverage, complicates administration. In addition, incentives for payment are often distorted or perverse, leading (for example) to more generous compensation for medical procedures than for communication with patients or for diagnosis or preventive care. Patients and providers must also navigate a confusing landscape of tertiary care centers, community hospitals, clinics, primary and specialist doctors and other providers, payers, health plans, and information sources.

  • Current implementations of health care IT. Many health care organizations do spend considerable money on IT, but the IT is often implemented in systems in a monolithic fashion that makes even small changes hard to introduce. Furthermore, IT applications appear designed largely to automate tasks or business processes. They are often designed in ways that simply mimic existing paper-based forms and provide little support for the cognitive tasks of clinicians or the workflow of the people who must actually use the system. Moreover, these applications do not take advan-

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