Value & Science-Driven Health Care has termed a learning health system. Central to such a system is the notion that advances in biological research, clinical medicine, and information technology provide powerful tools for health improvement if applied within a system that promotes the mutually dependent aims of science, value, and patient-centered care (IOM, 2007, 2010b, 2010c, 2011a, 2011b).
Currently, health care in the United States falls substantially short of what should be possible given the nation’s substantial healthcare investment. At $2.5 trillion, $7,500 a person, and 17 percent of gross domestic product in 2009, that investment totaled twice the expenditure levels of other industrial countries, yet the United States consistently rates poorly (currently 37th) on overall health system performance and on key component measures such as infant mortality (39th) and life expectancy (36th) (IOM, 2010a; Murray and Frenk, 2010). Although the overall quality of care in the United States compared with other developed nations varies by condition—for example, the United States is a leader in cancer care but lags behind other nations in asthma and hip fracture mortality—perhaps the most compelling illustration of system shortfalls is found in the wide variation in the quality of care from state to state and practice to practice. It is not unusual to see several-fold differences in care intensity and costs, with no effect on outcomes (Docteur and Berenson, 2009; Fisher et al., 2003; OECD, 2009). This geographic variation in quality of care has been shown to extend to cities in the same state and hospitals in the same city.
The systematic barriers to effective and efficient healthcare decisions have contributed to the development of a system that, by some estimates, delivers recommended care less than half of the time and often lacks definitive research evidence to guide clinical practice (IOM, 2008, 2009). Across the United States, however, many organizations deliver high-value care, and collectively, these organizations illustrate the many missed opportunities for healthcare improvement, such as system fragmentation, a lack of infrastructure and healthcare culture to support learning and continuous improvement, and incentives that reward care volume over value.
Perhaps the greatest missed opportunity for creating a health system that delivers the right care to the right patient at the right time is the failure to fully engage patients and the public as active partners in advancing the delivery of care that works best for the circumstances and ensuring that the care delivered is of value. Despite the potential to achieve this engagement, evidence suggests that such efforts are limited at both the health systems level, where provider preferences and supply often shape the care delivered, as well as at the level of individual healthcare decisions (Berwick, 2009; Sepucha and Barry, 2009; Zikmund-Fisher et al., 2010).
In part, this shortfall is a communication problem with respect to public awareness as well as encouragement and support by the healthcare