working together to provide a working information and knowledge infrastructure for 21st century health care.

Lastly, there are many unsolved problems related to health care IT, including supporting appropriate access while respecting the confidentiality of medical records, managing the cognitive load on care providers that results from the availability of large volumes of information, and managing the information in a medical record over the multidecade lifetime of individuals in the context of rapidly changing scientific and medical knowledge.

Three distinct groups have a meaningful role in addressing these areas. Federal and state government and the health care community must speak to acquisition policy. The health care community must insist that vendors supply health care IT systems that provide meaningful cognitive support. And the research community, including researchers in computer science and health/biomedical informatics, must play a lead intellectual role in advancing the current state of the art in health care IT systems.


Federal and state governments play important roles as supporters of research, payers for health care, and stimulators for education. The committee believes that government organizations—especially the federal government—should explicitly embrace measurable health care quality improvement as the driving rationale for its health care IT adoption efforts, and should shun programs that focus on promoting the adoption of specific clinical applications. While this principle should not be taken to discourage incentives to invest in infrastructure (networks, workstations, administrative transaction processing systems, platforms for data mining, data repositories, and so on) that provides a foundation on which other specific clinical applications can be built, a top-down focus on specific clinical applications is likely to result in a premature “freezing” of inefficient workflows and processes and to impede iterative change. In focusing on the goal to be achieved, namely better and/or less expensive health care, clinicians and other providers will be eager to use new health care IT-enabled clinical applications if, where, and when such applications can be shown to enable them to do their jobs more effectively.

Health care quality improvement efforts scale from practice groups and individual practitioners to large health care organizations to the health care system as a whole. Traditionally, quality improvement efforts tend to occur at the level of larger practice groups and health care organizations, and are slowed by the requirement to develop consensus among the universe of relevant clinicians. Indeed, these efforts require such volume of collective effort that most organizations cannot sustain more than

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