Introduction: the drivers of change.

IMAGINE A HEALTH CARE system that is truly patient centered. Sick patients would not wait days for an appointment with their primary care physician and then hours in the front office. Referrals to a specialist would be scheduled promptly, at a convenient location, and at a convenient time. In this system, providers would respect patients' wishes and understand cultural differences in healthcare practices. Care protocols would be designed in collaboration with the patient and, when desired, the patient's family. Providers would readily share information about the patient's condition and discuss treatment alternatives, and full disclosure would be made about the costs involved. In this system, both clinical care and healthcare management would be evidenced-based, so that the most appropriate care would be provided in the most efficient, effective, and safe manner. Patient outcomes, and not cost or organizational structure, would be the guiding force behind care design. Errors would be documented and studied so that processes could be improved, and any harm caused to the patient would be readily disclosed. In this system, physicians, nurses, healthcare executives, and a host of other healthcare practitioners would work together in teams because they all believe it is in the best interest of the patient. Their efforts to improve the health of the patient would rely on highly sophisticated and integrated information systems that have been designed to ensure confidentiality. This is the type of healthcare system envisioned by the Institute of Medicine's (10M) Committee on Quality of Health Care in America (10M 1999; 10M 2001). At its core is the patient, but it relies on finely tuned care processes or systems and integrated information technology to deliver patient care. Achieving this vision will require fundamental changes in the healthcare system operating today, changes that were thoroughly explored in a recent issue of Frontiers (Detmer 2001). But a new healthcare system also means important changes for healthcare professionals who will need to learn new skills and new values, and educational and training programs will need to respond appropriately. Making these changes in the training, culture, and behavior of healthcare professionals will not be easy. Some direction can be found in the series of ten rules for twenty-first century healthcare that were enumerated in the 10M's Quality Chasm (10M 2001) report. These rules were formulated as a guide to achieving patient-centered care, and they have obvious implications for health professionals. NEW RULES FOR HEALTH PROFESSIONALS 1. Care should be based on continuous healing relationships. Patients need care on a 24-hour-a-day, 7-day-a-week basis, but the current system is largely limited to workday office visits. To provide this continuous care, new modes of communication will be necessary, and the Internet provides great potential. While face-to-face visits will continue to be important, much follow-up care can be accomplished in other ways. Electronic and other modes of communication could make care more continuous and enable clinicians to have more office visit time to devote to each in-person encounter. 2. Care should be customized based on patient needs and values. Variability in treatment will be based only on individual patient needs and values. Clinicians will use information technology to determine the various courses of action for a given condition, discuss these treatments and the associated probabilities of success, and then select the course of action that fits best with the patient's wishes and needs. Clinicians will learn to harvest the information infrastructure for treatment alternatives rather than attempt to memorize an unwieldy amount of information. They will also need strong communication skills, including the art of listening to the patient. 3. The patient will be the source of control. …