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INTRODUCTION

Coordination of care, for which personnel are constantly striving but know they are not often attaining, is something of a mirage except for the most standardized of trajectories. Its attainment is something of a miracle when it does occur.1

We could easily become discouraged. Despite having some of the best clinicians and health policy analysts in the world, the U.S. healthcare industry is failing to deliver cost-effective quality care. The McKinsey Global Institute found recently that "even after adjusting for its higher per capita income levels, the United States spends some $477 billion more on healthcare than its peer countries" per year.2 Meanwhile we suffer from an epidemic of medical errors that threatens our well-being—even our lives—with medical errors that cause 44,000 to 98,000 deaths annually, at a cost of $17 billion to $29 billion.3 To add insult to injury, a growing number of our fellow citizens live with the fear that they will not have access to care when illness strikes.4

Some of these problems, such as the prevalence of medical errors and the costs associated with them, can be addressed in part through improved clinical training and expanded information systems. Other problems, such as lack of access and the associated costs, are likely to be addressed under our new political leadership as we finally garner the will to ensure universal access to healthcare. But many of our cost and quality problems are more fundamental and cannot be resolved by these means alone.

Indeed, the source of our cost and quality problems goes deeper into the very work processes through which healthcare is delivered. Healthcare is complex, with high levels of specialization that are driven—perhaps inevitably—by the complexity of the human body, the human mind, and the social world in which we live. The complexity and fragmentation of healthcare make coordination exceedingly difficult.5 Patients are often required to sort their way through the system, receiving diagnoses and treatments from a fragmented, loosely connected set of providers. Patients with diabetes typically see 8 distinct physicians belonging to five distinct medical practices, and patients with coronary artery disease typically see 10 distinct physicians belonging to six distinct medical practices.6 Even within the hospital setting, where resources presumably are brought together within a single organization to improve the coordination of their deployment, the responsibility for coordination often falls to the patient and his or her family members.

Coordination problems appear to have gotten worse rather than better over the years. The Institute of Medicine identified coordination as one of the most critical problems plaguing the U.S. healthcare system: "In the current system, care is taken to protect professional prerogatives and separate roles. The current system shows too little cooperation and teamwork. Instead, each discipline and type of organization tends to defend its authority at the expense of the total system's function."7 A recent study by the ...

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