Focusing on workflow efficiency, Kim R. Pittenger of Virginia Mason Medical Center and Sandeep Green Vaswani of the Institute for Healthcare Optimization describe different approaches to maximize the current resources in the health system. Describing the Virginia Mason Medical Center (VMMC) production system, Pittenger emphasizes the importance of flow production, mistake proofing, and standardizing work, suggesting that nationwide use of this type of strategy (extrapolated from results seen at VMMC) could yield clinical and patient safety savings of $44 billion and operational savings of over $7 billion. Vaswani describes the related process of managing variability in hospital operations and management in order to improve patient safety and quality of care. While describing successful case studies and outlining the assumptions made to extrapolate nationally, he suggests that the annual savings opportunity from application of variability methodology at the national level is in the range of $35 to $112 billion.

Meanwhile, Timothy G. Ferris of Massachusetts General Hospital (MGH) discusses care coordination, specifically describing how one demonstration project has already yielded promising results. By focusing on those patients with the highest illness burden, a similar national effort could potentially save up to $1 billion for the Medicare program annually. He cautions that several of MGH’s characteristics—integration of hospital and physician services, existing electronic medical records system, extensive primary care service network—may limit generalizability of their success. However, he concludes that the apparent success of the MGH Care Management Program suggests that prospective payment for the enhanced management of high-risk patients holds some promise for reducing costs.

Building on the idea of integration, coordination across providers, and information technology as central elements of care coordination, Ashish Jha of Harvard University describes interoperability of health information technology as a method of facilitating health information exchange (HIE). He reviews the literature suggesting that widespread health information exchange can not only streamline the over 30 billion healthcare transactions occurring each year within the delivery system, but it can simultaneously decrease annual healthcare spending by nearly $80 billion annually. Jha cites the formation of a national strategy and standardized infrastructure protocols as keys to driving the success of HIE.

Turning to regulatory interventions, Roger Feldman of the University of Minnesota moves the discussion to the broader context of market competition and antitrust regulations. While he frames antitrust policy as an important tool for ensuring that markets provide goods and services at the lowest price to consumers, he elaborates on the reasons why it has not been as effective in the healthcare arena and provides specific suggestions to increase its impact. Frank A. Sloan of Duke University provides an overview of a strategy to control increases in capital healthcare expenditures: service capacity restrictions. After reviewing the history of certificate-of-

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