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Summary Health care in America presents a fundamental paradox. The past 50 years have seen an explosion in biomedical knowledge, dramatic innova- tion in therapies and surgical procedures, and management of conditions that previously were fatal, with ever more exciting clinical capabilities on the horizon. Yet, American health care is falling short on basic dimensions of quality, outcomes, costs, and equity. Available knowledge is too rarely applied to improve the care experience, and information generated by the care experience is too rarely gathered to improve the knowledge available. The traditional systems for transmitting new knowledge—the ways clini- cians are educated, deployed, rewarded, and updated—can no longer keep pace with scientific advances. If unaddressed, the current shortfalls in the performance of the nation’s health care system will deepen on both qual- ity and cost dimensions, challenging the well-being of Americans now and potentially far into the future. Consider the impact on American services if other industries routinely operated in the same manner as many aspects of health care: • If banking were like health care, automated teller machine (ATM) transactions would take not seconds but perhaps days or longer as a result of unavailable or misplaced records. • If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination. 5

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6 BEST CARE AT LOWER COST • If shopping were like health care, product prices would not be posted, and the price charged would vary widely within the same store, depending on the source of payment. • If automobile manufacturing were like health care, warranties for cars that require manufacturers to pay for defects would not ex- ist. As a result, few factories would seek to monitor and improve production line performance and product quality. • If airline travel were like health care, each pilot would be free to design his or her own preflight safety check, or not to perform one at all. The point is not that health care can or should function in precisely the same way as all other sectors of people’s lives—each is very different from the others, and every industry has room for improvement. Yet, if some of the transferable best practices from banking, construction, retailing, auto- mobile manufacturing, flight safety, public utilities, and personal services were adopted as standard best practices in health care, the nation could see patient care in which • r  ecords would be immediately updated and available for use by patients; • care delivered would be proven reliable at the core and tailored at the margins; • patient and family needs and preferences would be a central part of the decision process; • all team members would be fully informed in real time about each other’s activities; • prices and total costs would be fully transparent to all participants; • payment incentives were structured to reward outcomes and value, not volume; • errors would be promptly identified and corrected; and • results would be routinely captured and used for continuous improvement. Unfortunately, these are not features that would describe much of health care in America today. Health care can lag behind many other sectors with respect to its ability to meet patients’ specific needs, to offer choice, to adapt, to become more affordable, to improve—in short, to learn. Ameri- cans should be served by a health care system that consistently delivers reli- able performance and constantly improves, systematically and seamlessly, with each care experience and transition. In the face of these realities, the Institute of Medicine (IOM) convened the Committee on the Learning Health Care System in America to explore

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SUMMARY 7 the most fundamental challenges to health care today and to propose ac- tions that can be taken to achieve a health care system characterized by continuous learning and improvement. This study builds on earlier IOM studies on various aspects of the health care system, from To Err Is Human: Building a Safer Health System (1999), on patient safety; to Crossing the Quality Chasm: A New Health System for the 21st Century (2001a), on health care quality; to Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (2003), on health care disparities. The study process was also facilitated and informed by the published summaries of workshops conducted under the auspices of the IOM Roundtable on Value & Science-Driven Health Care. Over the past 6 years, 11 workshop sum- maries have been produced, exploring various aspects of the challenges and opportunities in health care today, with a particular focus on the founda- tional elements of a learning health system. Meeting the challenges discussed at those workshops has taken on great urgency as a result of two overarching imperatives: • to manage the health care system’s ever-increasing complexity, and • to curb ever-escalating costs. The convergence of these imperatives makes the status quo untenable. At the same time, however, opportunities exist to address these problems— opportunities that did not exist even a decade ago: • vast computational power that is affordable and widely available; • connectivity that allows information to be accessed in real time virtually anywhere; • human and organizational capabilities that improve the reliability and efficiency of care processes; and • the recognition that effective care must be delivered by collabora- tions between teams of clinicians and patients, each playing a vital role in the care process. The committee undertook its work to consider how these opportuni- ties for best care at lower cost can be leveraged to meet the challenges outlined above. The committee, whose work was supported by the Blue Shield of California Foundation, the Charina Endowment Fund, and the Robert Wood Johnson Foundation, was charged with (1) identifying how the effectiveness and efficiency of the current health care system can be transformed through tools and incentives for continuous assessment and improvement and (2) developing recommendations for actions that can be taken to that end. This report explores the imperatives for change, describes the emerging tools that make transformation possible, sets forth a vision

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8 BEST CARE AT LOWER COST for a continuously learning health care system, and delineates a path for achieving this vision. Detailed findings are presented throughout the report, together with the conclusions and recommendations they support, which are also highlighted in this summary. The title of the report underscores that care that is based on the best available evidence, takes appropriate account of individual preferences, and is delivered reliably and efficiently—best care—is possible today. When such care is routinely implemented, moreover, it is generally less expensive than the less effective, less efficient care that is now too commonly provided. Moreover, the transition to best care envisioned in this report is urgently needed given the budgetary, economic, and health pressures facing the na- tion’s health care system. THE IMPERATIVES Decades of rapid innovation and technological improvement have cre- ated an extraordinarily complex health care system. Clinicians and health care staff work tirelessly to care for their patients in an increasingly com- plex, inefficient, and stressful environment. Certain breakthrough innova- tions have benefited millions of patients, but the aggregate impact of the flood of new interventions has introduced challenges for both clinicians and patients in treating and managing health conditions. In addition to the chal- lenge of complexity, and in part because of it, health care often falls short of its potential in the quality of care delivered and the patient outcomes achieved. These shortfalls are occurring even as costs are rising to unsus- tainable levels. Additionally, new opportunities emerging from technology, industry, and policy can be leveraged to help mold the system into one characterized by continuous learning and improvement. In this context, the committee identified three imperatives for achieving a continuously learning health care system that provides the best care at lower cost: (1) managing rapidly increasing complexity; (2) achieving greater value in health care; and (3) capturing opportunities from technology, industry, and policy. Managing Rapidly Increasing Complexity The complexity of health care has increased in multiple dimensions—in the ever-increasing treatment, diagnostic, and care management options available; in the rapidly rising levels of biomedical and clinical evidence; and in administrative complexities, from complicated workflows to frag- mented financing. The complexity due to ever-increasing treatment options can be illustrated by the evolution of care for two common conditions— heart disease and cancer. During much of the twentieth century, heart attacks commonly were treated with weeks of bed rest. Today, advanced diagnostics allow for customized treatments for patients; interventions

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SUMMARY 9 such as percutaneous coronary interventions and coronary artery bypass grafts can reopen blocked vessels and restore blood flow to the heart; and pharmaceutical therapies, such as thrombolytics and beta-blockers, improve survival and reduce the chances of subsequent heart attacks (Certo, 1985; Nabel and Braunwald, 2012). Similarly, five decades ago, breast cancer was detected from a physical exam, and mastectomy was the recommended treatment. Today, multiple imaging technologies exist for the detection and diagnosis of the disease, and once diagnosed, the cancer can be further clas- sified and treated according to genetic characteristics and hormone receptor status (Harrison, 1962; IOM, 2001b; Kasper and Harrison, 2005). As a result of improved scientific understanding, new treatments and interventions, and new diagnostic technologies, the U.S. health care system now is characterized by more to do, more to know, and more to manage than at any time in history. As one quantification of this increase, the vol- ume of the biomedical and clinical knowledge base has rapidly expanded, with research publications having risen from more than 200,000 per year in 1970 to more than 750,000 in 2010 (see Figure S-1). The result is a 800,000 Medical Journal Articles 600,000 400,000 200,000 0 1970 1980 1990 2000 2010 Year FIGURE S-1  Number of journal articles published on health care topics per year from 1970 to 2010. Publications have increased steadily over 40 years, with the rate of increase becoming more pronounced Figure approximately in 2000. starting S-1 and 2-5 SOURCE: Data obtained from online searches at PubMed: http://www.ncbi.nlm. nih.gov/pubmed/.

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10 BEST CARE AT LOWER COST paradox: advances in science and technology have improved the ability of the health care system to treat diseases, yet the sheer volume of new dis- coveries stresses the capabilities of the system to effectively generate and manage knowledge and apply it to regular care. These advances have oc- curred at the same time as, and sometimes have contributed to, challenges in health care quality and value. Conclusion: Diagnostic and treatment options are expanding and changing at an accelerating rate, placing new stresses on clinicians and patients, as well as potentially impacting the effectiveness and efficiency of care delivery. Beyond the increasing stores of biomedical and clinical knowledge, changes in disease prevalence and patient demographics have altered the landscape for care delivery. The prevalence of chronic conditions, for ex- ample, has increased over time. In 2000, 125 million people suffered from such conditions; by 2020, that number is projected to grow to an estimated 157 million (Anderson, 2010). The role of chronic diseases has changed as the demographics of the population have shifted. In general, the population has gotten older; in the past decade, the portion of the population over age 65 has increased at 1.5 times the rate of the rest of the population (Howden and Meyer, 2011). Almost half of those over 65 receive treatment for at least one chronic disease, and more than 20 percent receive treatment for mul- tiple chronic diseases (Schneider et al., 2009); fully 75 million people in the United States have multiple chronic conditions (Parekh and Barton, 2010). Managing these multiple conditions requires a holistic approach, be- cause the use of various clinical practice guidelines developed for single diseases may have adverse effects (Boyd et al., 2005a; Parekh and Barton, 2010; Tinetti et al., 2004). For example, existing clinical practice guidelines would suggest that a hypothetical 79-year-old woman with osteo­ orosis, p osteoarthritis, type 2 diabetes, hypertension, and chronic obstructive pul- monary disease should take as many as 19 doses of medication per day. Such guidelines might also make conflicting recommendations for the woman’s­ care. If she had peripheral neuropathy, guidelines for osteoporosis would recommend that she perform weight-bearing exercise, while guidelines for diabetes would recommend that she avoid such exercise (Boyd et al., 2005a). These situations create uncertainty for clinicians and patients as to the best course of action to pursue as they attempt to manage the treatments for multiple conditions. Conclusion: Chronic diseases and comorbid conditions are increas- ing, exacerbating the clinical, logistical, decision-making, and eco- nomic challenges faced by patients and clinicians.

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SUMMARY 11 Care delivery also has become increasingly demanding. It would take an estimated 21 hours per day for individual primary care physicians to provide all of the care recommended to meet their patients’ acute, preven- tive, and chronic disease management needs (Yarnall et al., 2009). Clini- cians in intensive care units, who care for the sickest patients in a hospital, must manage in the range of 180 activities per patient per day—from replacing intravenous fluids, to administering drugs, to monitoring pa- tients’ vital signs (Donchin et al., 2003). In addition, rising administrative burdens and inefficient workflows mean that hospital nurses spend only about 30 percent of their time in direct patient care (Hendrich et al., 2008; Hendrickson et al., 1990; Tucker and Spear, 2006). These pressures are not limited to clinicians; patients often find the health care system uncoor- dinated, opaque, and stressful to navigate. One study found that for 1 of every 14 tests, either the patient was not informed of a clinically significant abnormal test result, or the clinician failed to record reporting the result to the patient (Casalino et al., 2009). With specialization, moreover, clinicians must coordinate with multiple other providers; for their health care, Medicare patients now see an aver- age of seven physicians, including five specialists, split among four differ- ent practices (Pham et al., 2007). One study found that in a single year, a typical primary care physician coordinated with an average of 229 other physicians in 117 different practices just for Medicare patients (Pham et al., 2009). The involvement of multiple providers tends to blur accountability. One survey found that 75 percent of hospital patients were unable to iden- tify the clinician in charge of their care (Arora et al., 2009). Conclusion: Care delivery has become increasingly fragmented, leading to coordination and communication challenges for patients and clinicians. Achieving Greater Value in Health Care In addition to, and sometimes as a result of, the challenge of complex- ity, health care quality and outcomes often fall short of their potential. A decade after the IOM (1999) estimated that 44,000 to 98,000 patients died each year from preventable medical errors, recent studies have reported that as many as one-third of hospitalized patients may experience harm or an adverse event, often from preventable errors (Classen et al., 2011; Landrigan et al., 2010; Levinson, 2010). While infections and complica- tions once were viewed as routine consequences of medical care, it is now recognized that strategies and evidence-based interventions exist that can significantly reduce the incidence and severity of such events.

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12 BEST CARE AT LOWER COST Similarly, medical care often is guided insufficiently by evidence, with Americans receiving only about half of the preventive, acute, and chronic care recommended by current research and evidence-based guidelines (McGlynn et al., 2003). Sometimes this occurs because available evidence is not applied to clinical care, while in other cases evidence is not available. As a result of all of these factors, the nature and quality of health care vary considerably among states, with serious health and economic con- sequences. If all states could provide care of the quality delivered by the highest-performing state, an estimated 75,000 fewer deaths would have occurred across the country in 2005 (McCarthy et al., 2009; Schoenbaum et al., 2011). Conclusion: Health care safety, quality, and outcomes for Ameri- cans fall substantially short of their potential and vary significantly for different populations of Americans. These deficiencies in care quality have occurred even as expenses have risen significantly. Health care costs1 have increased at a greater rate than the economy as a whole for 31 of the past 40 years, and now constitute 18 percent of the nation’s gross domestic product (CMS, 2012; Keehan et al., 2011). The growth in health care costs has contributed to stagnation in real income for American families. Although income has increased by 30 percent over the past decade, these gains have effectively been eliminated by a 76 percent increase in health care costs (Auerbach and Kellermann, 2011). These high costs have strained families’ budgets and put health insurance coverage out of reach for many, contributing to the 50 million Americans without coverage (DeNavas-Walt et al., 2011). In addition to unsustainable cost growth, there is evidence that a sub- stantial proportion of health care expenditures is wasted, leading to little improvement in health or in the quality of care. Estimates vary on waste and excess health care costs, but they are large. The IOM workshop summary The Healthcare Imperative: Lowering Costs and Improving Outcomes con- tains estimates of excess costs in six domains: unnecessary services, services inefficiently delivered, prices that are too high, excess administrative costs, missed prevention opportunities, and medical fraud (IOM, 2010). These estimates, presented by workshop speakers with respect to their areas of expertise and based on assumptions from limited observations, suggest the 1  n this report, price refers to the amount charged for a given health care service or product. I It is important to note that there are frequently multiple prices for the same service or product, depending on the patient’s insurance status and payer, as well as other factors. Cost is the total sum of money spent at a given level (episodes, patients, organizations, state, national), or price multiplied by the volume of services or products used.

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SUMMARY 13 substantial contribution of each domain to excessive health care costs (see Table S-1). Although these estimates have unknown overlap, the sum of the indi- vidual estimates—$765 billion—suggests the significant scale of waste in the system. Two other independent and differing analytic approaches— considering regional variation in costs and comparing costs across coun- tries—produce similar estimates, with total excess costs approaching $750 billion in 2009 (Farrell et al., 2008; IOM, 2010; Wennberg et al., 2002). TABLE S-1  Estimated Sources of Excess Costs in Health Care (2009) Estimate of Category Sources Excess Costs Unnecessary Services • Overuse—beyond evidence- $210 billion established levels • Discretionary use beyond benchmarks • Unnecessary choice of higher-cost services Inefficiently Delivered • Mistakes—errors, preventable $130 billion Services complications • Care fragmentation • Unnecessary use of higher-cost providers • Operational inefficiencies at care delivery sites Excess Administrative • Insurance paperwork costs beyond $190 billion Costs benchmarks • Insurers’ administrative inefficiencies • Inefficiencies due to care documentation requirements Prices That Are Too High • Service prices beyond competitive $105 billion benchmarks • Product prices beyond competitive benchmarks Missed Prevention • Primary prevention $55 billion Opportunities • Secondary prevention • Tertiary prevention Fraud • All sources—payers, clinicians, $75 billion patients SOURCE: Adapted with permission from IOM, 2010.

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14 BEST CARE AT LOWER COST While there are methodological issues with each method for estimating excess costs, the consistently large figures produced by each signal the po- tential for reducing health care costs while improving quality and health outcomes. At this level, unnecessary health care costs and waste exceed the 2009 budget for the Department of Defense by more than $100 billion (OMB, 2010). Health care waste also amounts to more than 1.5 times the nation’s total infrastructure investment in 2004, including roads, railroads, aviation, drinking water, telecommunications, and other structures.2 To put these es- timates in the context of health care expenditures, the estimated redirected funds could provide health insurance coverage for more than 150 million workers (including both employer and employee contributions), which exceeds the 2009 civilian labor force.3 And the total projected amounts could pay the salaries of all of the nation’s first response personnel, includ- ing firefighters, police officers, and emergency medical technicians, for more than 12 years.4 Conclusion: The growth rate of health care expenditures is unsus- tainable, with waste that diverts major resources from necessary care and other priorities at every level—individual, family, com- munity, state, and national. In sum, as illustrated in Figure S-2, each stage in the processes that shape the health care received—knowledge development, translation into medical evidence, application of evidence-based care—has prominent short- comings and inefficiencies that contribute to a large reservoir of missed opportunities, waste, and harm. The threats to the health and economic security of Americans are clear, present, and compelling. 2  The Department of Defense budget was calculated from the fiscal year 2009 outlays listed in the Fiscal Year 2011 U.S. Government Budget (OMB, 2010); the comparison of health care waste with the national infrastructure investment was drawn from a Congressional Budget Office analysis, with inflation adjusted according to the Consumer Price Index (CPI) (Congres- sional Budget Office, 2008). 3  The average premiums for a single worker were calculated using the Kaiser Family Founda- tion’s 2009 Employer Health Benefits survey, with the size of the civilian labor force drawn from Bureau of Labor Statistics estimates for 2009 (Kaiser Family Foundation and Health Research & Educational Trust, 2009; U.S. Bureau of Labor Statistics, 2012). 4  he comparison with expenditures on first responders was calculated from the annual T salary data for firefighters, police officers, and emergency medical technicians provided in the 2009 National Compensation Survey, while the total number of individuals in those occupa- tions was drawn from the 2009 Occupational Employment Statistics (U.S. Bureau of Labor Statistics, 2010a,b).

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SUMMARY 15 Communities Patients Clinicians Science Evidence Care Patient Experience Insights Evidence Experience poorly poorly poorly managed used captured Missed Opportunities, Waste, and Harm FIGURE S-2  Schematic of the health care system today. Capturing Opportunities from Technology, Industry, and Policy Care As noted earlier, new opportunities exist to address the challenges Inc re outlined above. Just as the information revolution has transformed many en ltu other fields, growing stores of data and computational abilities hold the tiv Cu same promise for improving clinical research, clinical practice, and clinical es decision making. In the past three decades, for example, computer process- ing speed has grown by 60 percent per Cliniciansaverage, while the capacity Patients year on to share information over telecommunications networks has risen by an average of 30 percent per year (Hilbert and López, 2011). These advances in computing and connectivity Communities have the potential to improve health care by expanding the reach of knowledge, increasing access to clinical information when and where needed, and assisting patients and providers in managing Science Evidence chronic diseases. Studies also have found that using such electronic systems can improve safety—one study reported a 41 percent reduction in potential adverse drug events following the implementation of a computerized pa- tient management system (computerized physician order entry, or CPOE), while another estimated that overall medication error rates dropped by 81 Leadership percent (Bates et al., 1998, 1999; Potts et al., 2004). Projections are for 90 percent of office-based physicians to have access to fully operational electronic health records by 2019, up from 34 percent in 2011 (Congres- sional Budget Office, 2009; Hsiao et al., 2011). Because these capacities are relatively early in their development in the health care arena, there is sub- stantial room for progress as they are implemented in the field. However,

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34 BEST CARE AT LOWER COST Strategies for progress toward this goal: • Health care delivery organizations should utilize systems engineer- ing tools and process improvement methods to eliminate inefficien- cies, remove unnecessary burdens on clinicians and staff, enhance patient experience, and improve patient health outcomes. • The Centers for Medicare & Medicaid Services, the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, quality improvement organizations, and process improvement leaders should develop a learning consortium aimed at accelerating training, technical assistance, and the collection and validation of lessons learned about ways to transform the ef- fectiveness and efficiency of care through continuous improvement programs and initiatives. Supportive Policy Environment Recommendation 8: Financial Incentives  tructure payment to reward continuous learning and improvement in S the provision of best care at lower cost. Payers should structure pay- ment models, contracting policies, and benefit designs to reward care that is effective and efficient and continuously learns and improves. Strategies for progress toward this goal: • Public and private payers should reward continuous learning and improvement through outcome- and value-oriented payment models, contracting policies, and benefit designs. Payment models should adequately incentivize and support high-quality team-based care focused on the needs and goals of patients and families. • Health care delivery organizations should reward continuous learning and improvement through the use of internal practice incentives. • Health economists, health service researchers, professional spe- cialty societies, and measure development organizations should partner with public and private payers to develop and evaluate metrics, payment models, contracting policies, and benefit designs that reward high-value care that improves health outcomes.

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SUMMARY 35 Recommendation 9: Performance Transparency  ncrease transparency on health care system performance. Health care I delivery organizations, clinicians, and payers should increase the avail- ability of information on the quality, prices and cost, and outcomes of care to help inform care decisions and guide improvement efforts. Strategies for progress toward this goal: • Health care delivery organizations should collect and expand the availability of information on the safety, quality, prices and cost, and health outcomes of care. • Professional specialty societies should encourage transparency on the quality, value, and outcomes of the care provided by their members. • Public and private payers should promote transparency in quality, value, and outcomes to aid plan members in their care decision making. • Consumer and patient organizations should disseminate this infor- mation to facilitate discussion, informed decision making, and care improvement. Recommendation 10: Broad Leadership  xpand commitment to the goals of a continuously learning health care E system. Continuous learning and improvement should be a core and constant priority for all participants in health care—patients, families, clinicians, care leaders, and those involved in supporting their work. Strategies for progress toward this goal: • Health care delivery organizations should develop organizational cultures that support and encourage continuous improvement, the use of best practices, transparency, open communication, staff em- powerment, coordination, teamwork, and mutual respect and align rewards accordingly. • Leaders of these organizations should define, disseminate, support, and commit to a vision of continuous improvement; focus atten- tion, training, and resources on continuous learning; and build an operational model that incentivizes continuous improvement and ensures its sustainability. • Governing boards of health care delivery organizations should sup- port and actively participate in fostering a culture of continuous

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36 BEST CARE AT LOWER COST improvement, request continuous feedback on the progress being made toward the adoption of such a culture, and align leadership incentive structures accordingly. • Clinical professional specialty societies, health professional edu- cation programs, health professions specialty boards, licensing boards, and accreditation organizations should incorporate basic concepts and specialized applications of continuous learning and improvement into health professions education; continuing educa- tion; and licensing, certification, and accreditation requirements. Given the interconnected nature of the problems to be solved, it will be important to take the actions identified above in concert. To elevate the quantity of evidence available to inform clinical decisions, for example, it is necessary to increase the supply of evidence by expanding the clinical re- search base; make the evidence easily accessible by embedding it in clinical technological tools, such as clinical decision support; encourage use of the evidence through appropriate payment, contracting, and regulatory poli- cies and cultural factors; and assess progress toward the goal using reliable metrics and appropriate transparency. The absence of any one of these fac- tors will substantially limit overall improvement. To guide success, progress on the recommendations in this report should be monitored continuously. ACHIEVING THE VISION Implementing the actions detailed above and achieving the vision of continuous learning and improvement will depend on the exercise of broad leadership by the complex network of decentralized and loosely associated individuals and organizations that make up the health care system. Given the complexity of the system and the interconnectedness of its different actors and sectors, no one actor or sector alone can bring about the scope and scale of transformative change necessary to develop a system that con- tinuously learns and improves. Each stakeholder brings different strengths, skills, needs, and expertise to the task of improving the system, faces unique challenges, and is accountable for different aspects of the system’s success. There is a distinct need for collaboration between and among stakeholders to produce effective and sustainable change. As the end users of all health care services, patients are central to the success of any improvement initiative. Any large-scale change will require the participation of patients as partners, with the system building trust on every dimension. Patients can promote learning and improvement by engag- ing in their own care; setting high expectations for their care in terms of quality, value, and the use of scientific evidence and selecting clinicians, or- ganizations, and plans that meet those expectations; sharing decision making

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SUMMARY 37 with their clinicians; and, with the help of their caregivers, directly applying evidence to their self-care and self-management on an ongoing basis. Partnering with patients are the health care professionals who deliver care. Physicians, nurses, pharmacists, and other health professionals rep- resent the front lines of health care delivery and the primary interface for patients and consumers. Expanding the supply of clinical information, pro- moting the use of evidence, and better involving patients in their care are all contingent upon the engagement and teaming of health professionals. By convening their constituent professionals and providing a forum for action, professional societies have important roles in achieving the vision of a learning health care system. Through guidelines, performance measures, quality improvement initiatives, and data infrastructures for assessing per- formance with respect to specific procedures or conditions, these societies can take a leadership role in improving quality, safety, and efficiency. Health care delivery organizations, because of their size and care ca- pacities, have several levers by which they can steward progress toward a continuously improving system, such as using new practice methods, setting standards, and sharing resources and information with other care delivery organizations. Furthermore, through investments in health information technology, these organizations can build their capacity to perform near- real-time research, speeding the generation of practical evidence and its translation to the bedside. Those who finance care also have opportunities to leverage their unique position to improve the quality and efficiency of care. As organizations that interact directly with patients, public and private payers can support patients as they seek to maintain healthy behaviors and access quality health care services, while their payment and contracting policies have a strong influence on how clinicians practice. Similarly, employers can sup- port efforts to improve quality and value by using their purchasing power to drive improvement efforts through contracts with providers and insurers, the design of benefit plans, and the provision of incentives and information for employees. Digital technology developers, health product innovators, and regula- tors are additional stakeholders that need to be engaged in achieving the vision of a learning health care system. Digital technology developers create the products and infrastructure necessary to meet the growing demand for capturing, storing, retrieving, and sharing information in virtually every aspect of health care. Continuous improvement in diagnostic and treat- ment options is contingent on a safe and innovative product development enterprise. Health product innovators, by conducting clinical research and devising new treatments and interventions, can develop novel products for diagnosis and treatment. Essential partners in this arena are regulators, including the Food and Drug Administration, who can work to develop

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38 BEST CARE AT LOWER COST streamlined methods for ensuring that safe, effective products are brought to market without delay. A learning health care system depends on evidence to promote im- provements in care delivery processes and patient care and overall system improvement. Consequently, health researchers are critical partners in gen- erating knowledge on the effectiveness and value of interventions and care protocols. A commitment to practical and efficient research methods across the spectrum of the research enterprise—the design and operation of clini- cal trials, the development of clinical registries and clinical databases, the creation of standards and metrics, modeling and simulation studies, studies of health services and care delivery processes, and the aggregation of study results into systematic reviews and clinical guidelines—is foundational for a learning system. Through their programmatic and funding activities, private philanthropies, as well as agencies and organizations such as the Agency for Healthcare Research and Quality, the National Institutes of Health, and the Patient-Centered Outcomes Research Institute have a central role to play in the stewardship and strategic direction of these activities. Missed opportunities for better health care have real human and eco- nomic impacts. If the care in every state was at the quality delivered by the highest performing state, there would have been an estimated 75,000 fewer deaths across the country in 2005 (McCarthy et al., 2009; Schoenbaum et al., 2011). Current waste diverts resources from productive use—an estimated $750 billion lost (IOM, 2010). It is only through shared commitments, in alignment with a supportive policy environment, that the opportunities o ­ ffered by science and information technology can be captured to address the health care system’s growing challenges and to ensure that it reaches its full potential to provide the best care for each patient. The nation’s health and economic futures—best care at lower cost—depend on the ability to steward the evolution of a continuously learning health care system. REFERENCES Anderson, G. F. 2010. Chronic care: Making the case for ongoing care. Princeton, NJ: Robert Wood Johnson Foundation. Antman, E. M., J. Lau, B. Kupelnick, F. Mosteller, and T. C. Chalmers. 1992. A comparison of results of meta-analyses of randomized control trials and recommendations of clinical experts. Treatments for myocardial infarction. Journal of the American Medical Associa- tion 268(2):240-248. Arora, V., S. Gangireddy, A. Mehrotra, R. Ginde, M. Tormey, and D. Meltzer. 2009. Abil- ity of hospitalized patients to identify their in-hospital physicians. Archives of Internal Medicine 169(2):199-201. Auerbach, D. I., and A. L. Kellermann. 2011. A decade of health care cost growth has wiped out real income gains for an average US family. Health Affairs 30(9):1630-1636.

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