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INTRODUCTION

Ms Avery Jones shuffles through the magazines in the waiting room, looking for one she has not yet read. She recently lamented to her grandson that these days she seems to spend more time sitting in medical offices than doing anything else. She is an 82-year-old woman who has lived most of her life as a committed elementary school teacher. She is now retired, widowed, and carries a long list of medical diagnoses, including congestive heart failure (CHF), atrial fibrillation, chronic obstructive pulmonary disease (COPD), osteoporosis, arthritis, and chronic kidney disease. She regularly sees her primary care provider (PCP), her cardiologist, her pulmonologist, and a nephrologist. She is prescribed a total of 12 medications, some of which are taken twice per day. She has to pay a few hundred dollars out-of-pocket each month for her medications, which places a significant strain on her fixed retirement budget. Unbeknownst to her, some of her brand-name prescriptions have effective, cheaper generic alternatives readily available, which would save her more than a hundred dollars each month.

Today she is scheduled to get an echocardiogram that was ordered by her pulmonologist to assess her chronically worsening shortness of breath. As they place the ultrasound probe on her chest to start the echocardiogram, she realizes that this is the exact same test that she had undergone a few weeks ago, when it was ordered by her cardiologist to “check on her CHF.” It occurs to her now that she was never told the results of that test. Her multiple physicians use different electronic medical record systems (in fact, her pulmonologist still uses paper charts), and they never seem to know what tests the other has ordered. One time she asked her nephrologist why she needed to have blood work done when she had just had blood drawn a few days prior by her PCP, and she was told that it was “better to just have it done here again so that it is in our system.”

At her last cardiology appointment her cardiologist told her that she may need a pacemaker with an automatic implantable cardioverter-defibrillator (AICD). He warned that without it she could possibly “die from a sudden heart arrhythmia.” This worried her a great deal; however, when she mentioned this to her PCP he just shrugged and told her that she didn’t need this done because her “QRS is not yet wide.” She does not know what this means but her doctor seemed to be in a rush and so she didn’t ask him to clarify. She trusts both her PCP and her cardiologist dearly and is not sure what she is supposed to do.

Healthcare in the United States is fraught with complexity, fragmentation, inefficiency, unexplained variation, and waste. In order to navigate this complexity in ways that make care more affordable, safe, and convenient, patients and their caregivers will need to understand how to deliver ...

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