adequate emotional support for the pain, loneliness, and grief that may accompany the illness (Branch, 2000).

The new rule asserts that the product of health care is not visits or “encounters” but healing relationships that allow patients to obtain the trustworthy information and support they need. A focus on the healing relationship emphasizes that this transfer of trustworthy information is the core product of health care, not something tacked onto a health care visit. In the 21st-century health care system, interaction should be understood in a fundamentally different way. Interaction is not the price of care; it is care (Berwick, 1999). A patient with a question represents an opportunity, not a burden. Time spent in building patients’ skills in self-care is not a way of shifting care; it is care. And access to information is not desirable because it allows care to be completed more quickly or supports compliance; it is care.

The new rule calls for continuous access (24 hours a day, 7 days a week, 365 days a year. Three points are critical to understanding how this could be achieved by the 21st-century health care system. First, as suggested above, “access” does not necessarily mean face-to-face contact with a health care professional. Second, such access would not be a matter of extending the current system; rather, it would involve fundamental redesign, attention to human factors, and respect for the limits of human beings. Third, with information technology, continuous access is possible in health care just as it has become increasingly possible in so many other venues of American society through new forms of electronic communication.

A continuous flow of interactions can span evenings, nights, and weekends if information systems make scheduling, access to medical records, e-mail, and the like available directly to patients. Such interactions would also be more individualized, patient-centered, and timely than much of today’s care. Much can be learned in this regard from the financial services industry. Just as banking customers have been freed from using teller lines that were open only from 9:00 a.m. to 3:00 p.m. on weekdays, information technology can liberate patient care from the confines of the face-to-face visit. The knowledge and technology now exist to provide many alternatives to visits, including self-care that is strongly supported and unequivocally encouraged (Hart, 1995; Lorig et al., 1993, 1999; Von Korff et al., 1997; Wagner et al., 1996); group visits for patients with like needs, with or without professionals being involved (Beck et al., 1997; Kane and Sands, 1998); use of the Internet for access to scientific information and well-managed discussion groups; and e-mail communication between patients and clinicians (Jadad, 1999; Plsek, 1999; Simon et al., 2000).

We emphasize that this rule cannot be accommodated by the current system working three shifts, nor does it mean that ambulatory settings would never close. Hospitals today rely on back-up double shifts for nursing staff and very long hours for resident physicians, an approach that ignores a large body of work on the effects of fatigue on human performance (Galinsky et al., 1993; Pilcher and