1. Donnelly, Gloria F. PhD, RN, FAAN, Editor-in-Chief

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The recent Senate hearings on health information technology highlighted the wicked nature of the problem of transforming the US healthcare system. The United States has always claimed to have the best healthcare in the world, yet our general health outcomes like maternal and infant mortality are competing with third world countries; medical errors kill between 44,000 and 98,000 individuals per year; the bureaucracy of access and reimbursement for care is daunting; the number of individuals and families without healthcare coverage is in excess of 45 million and rising; and best practices in healthcare are on average 17 years behind in reaching mainstream practice.

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In 1972, Horst Rittel, an urban planner and designer, used the phrase "wicked problem" to describe the issues he experienced in his own work.1 Wicked problems are complex and ill structured. You cannot get a handle on them until you try a solution that changes the nature of the problem and may take you in a different direction with a whole new set of issues and problems emerging. Wicked problems usually reach a semblance of resolution when time, energy, and money run out given that they never have a definitive solution, one that is right or wrong. Novelty and uniqueness characterize wicked problems; that is, improving the healthcare systems in the United States, Canada, or Africa would look very different. Finally, there may be many potential solutions to wicked problems that could be creatively applied. In the end, however, testing and good judgment will determine which path to take in achieving improvement.


The physicians and politicians testifying before the Senate Subcommittee on Technology were passionate in their belief that care would improve and clinicians would be less stressed if they practiced in a data-driven manner and if they had quick access to the data they needed both about the patient and best practices to make good clinical decisions. An emergency medicine physician testified to how much better emergency care would be if people wore their health records on a bar-coded bracelet or device that was always with them. Another physician spoke of the need to password protect patients' health records to guarantee patients' privacy given that not everyone needs to see the entire health record of every patient. Newt Gingrich, former Speaker of the House, formed the Center for Health Transformation in 2003. He also testified to the importance of the US healthcare system integrating technologies that will permit the consumer to shop for quality care and stretch the healthcare dollar.2


In the meantime, consumers of healthcare are going their own way spending billions of dollars out of pocket on alternative and complementary therapies such as nutritional supplements, chiropractic, and culturally based interventions. Nurses are reaching out to the medically underserved offering primary care and other services on the frontlines of healthcare. Holistic nursing interventions have always originated from the perspective of the person, community, or family. Perhaps that is the best place to start when tackling the wickedness of transforming healthcare in this century.


Gloria F. Donnelly, PhD, RN, FAAN, Editor-in-Chief




1. Rittel H. On the Planning Crisis: Systems Analysis of the "First and Second Generations." Reprint No. 107. Berkeley: The Institute of Urban and Regional Development, University of California; 1972. [Context Link]


2. Gingrich N, Frogue J. 21st Century healthcare consumerism. Available at: Accessed June 24, 2006. [Context Link]