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important factor in choosing a primary care physician, the response is neither cost nor location; by far the factor that people cite most often is having a doctor who will take the time to explain things. I translate that into not just a desire for information that I, the patient, can get impersonally from books and other sources; it is also a desire to be treated by someone who relates to me as a whole person, who takes the time to understand my situation, as well as the social and medical-psychological aspects of care.

As important as health care outcomes are, I think these patient preferences argue for a focus on the processes of care as well. We know from other studies that trust in the process, the hope that the process will be successful, and the sense that one is being cared for—these intangibles—are often central to the likely success of medical intervention.

A corollary point is also pertinent. Just as the "whole" person is central to the idea of quality, a quality assurance mechanism must measure how the whole system relates to that person. Fragmentary quality assessment and quality assurance, in other words, are a problem. We need to look at quality across inpatient, outpatient, long-term, and home health care settings. A major source of a patient's frustration with the caregiving system today is the lack of coordination, the absence of a guide to help him or her through the health care maze. If we are serious about quality, we have to talk not only about reimbursement, but also about a coordinated system of care that allows us to look at quality as the patient experiences the various components of the delivery system. We must create a system that allows us to judge the entire spectrum of inputs, rather than just the input from a particular provider in a particular setting. Ultimately, I think, that leads to a call for some fairly major changes in the way our health care system is structured and financed.

In this connection, I should note that an effective, well-coordinated quality assurance program will itself require adequate initial investment and ongoing financial support. The benefit-cost payoff, however, in terms of overall health system savings promises to be substantial.


Given the evolving nature of the doctor-patient relationship, the IOM is to be strongly commended for explicitly recognizing the centrality of patient interests and desires in its definition of quality. AARP believes that two major categories of information needs are pertinent to the achievement of greater patient autonomy and involvement in decisionmaking: treatment information, and individual provider and practitioner performance information.

With regard to the first category, treatment information, the section of the IOM report on capacity building is particularly welcome. The report's

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