1. Berwick, Donald MPP, MD

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In the landmark report, Crossing the Quality Chasm, the Institute of Medicine summarized a disturbing terrain of defects in American healthcare quality, as well as an ambitious and promising agenda for redesign. The majority of both the defects and the redesign ideas swirl around one recurring theme: that our system of care, built in fragments and designed for reaction, is frustratingly unable to meet the needs of people that extend over time and place. The most vulnerable victims are the chronically ill, whose journey through the years touches healthcare in many places at many times. But, they are not the only victims. Even well adults know how erosive an uncoordinated system can be of both their time and their safety. Systems without plans and memories cannot serve healthcare well.


The chasm will not be closed without restructured care. The title of this supplement correctly names the key design criteria: "Patient-centered" and "Collaborative." Patient-centered care will be customized, "24/7," proactive, inclusive of loved ones (when wanted by the patient), transparent, and guaranteed. It will use many ways, not just visits, to extend help; will build patients' skills in self-management; will employ and improve supports for authentic shared decision making; and will track patients' status through time to learn about the effects of and problems with care and treatment plans. Collaborative care will create and support teams where they should exist, help develop shared skills and affection among team members, keep information flowing freely to wherever it can be of use, and-absolutely-include patients in everything they wish to be included in.


I suppose we can make progress toward patient-centered, collaborative care without technology, but why would we try? The potential of modern communication, knowledge management, and expert decision-support technologies is immense, and hardly harnessed at all yet in healthcare as a system. We have a very long leg in biotechnology but a very short one in system technology, and therefore we let our patients and each other down far, far too often. The result-care that is neither patient-centered nor collaborative-is at the heart of the "quality chasm."


In this issue of the journal, the reader will find many bright lights to follow. The arena of technological innovation to improve patient-centeredness and coordination is rapidly getting populated with visionaries and early adopters. Now, this good work can and should head for the mainstream.


Donald Berwick, MPP, MD


President and CEO, Institute for Healthcare Improvement, Cambridge, Mass