a few quality improvement initiatives at a time. Given the quality chasm facing many health care organizations, such a slow rate of change is unacceptable.

In contrast, iterative local improvement at the small group or even individual practitioner level has the major advantage of being faster and cheaper to accomplish because of its small scale. This allows for improvement efforts to be conducted in parallel, increasing the chances of finding successful approaches, while unsuccessful approaches can be rapidly and inexpensively discarded. Local successes also tend to build support for additional improvement efforts. Government should promote exploration of methods and models for small-scale improvement efforts as well as efforts to integrate these small-scale improvements on a larger scale. A balance with many small-scale efforts providing the evidence base for a smaller number of large-scale efforts seems appropriate.

IT is a fundamental enabler for both large-scale and small-scale improvement efforts. But for the most part, the health care IT available in today’s market is not well suited to support small-scale optimization, which requires applications that are rapidly customizable in the field by end users. Federally inspired or supported initiatives that incentivize health care organizations to undertake iterative small-scale optimization, and subsequent translation of successes to a larger scale, are likely to help stimulate the creation of a new market for these applications—for example, such incentives might take the form of payment premiums for demonstrations of major improvement of a result (process or clinical) for a unit of the organization.

A last point is that work at the health care–IT nexus is interdisciplinary. A lack of familiarity with the domain-specific problems in the health care domain has often impeded the efforts of well-meaning computer scientists. Formal and elegant computer science, as understood by most computer science researchers, is often a poor match with the complex cultural and organizational environment of health care and biomedicine—topics about which a well-trained computer science graduate is generally ignorant. Academic medical centers often fail to take advantage of relevant expertise—especially in health/biomedical informatics—that is available to them. Such organizations are often inclined to turn to internal expertise—the in-house health care IT professionals—rather than to the relevant health/biomedical informatics and computer science faculty on campus. Progress at this nexus will require contributions of health care experts, computer science experts, experts from the health/biomedical informatics community, and health care IT experts working together to understand the problems related to improving health care and how IT might be applied to address those problems.

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