The tragic life of Dr. Ignaz Semmelweis offers an example of the challenges faced in building a truly learning health care system. The Hungarian physician observed that simply washing hands could drastically reduce high rates of maternal death during childbirth. But since he could not prove a connection between hand washing and the spread of infection, he was ridiculed and ignored. Hounded out of his profession, he died in a mental hospital. More than 165 years later, half of clinicians still do not regularly wash their hands before seeing patients.

The challenges today are in some ways that straightforward, and in many other ways significantly more complex. Narrow-minded rejection of scientific evidence is rarely encountered today in medicine, yet the American health care system imposes significant institutional, economic, and pedagogic barriers to learning and adapting.

For more than a decade, reports of the Institute of Medicine (IOM) have focused attention on a persistent set of problems within the American health care system that urgently need to be addressed, including poor quality; lax safety; high cost; questionable value; and the maldistribution of care based on income, race, and ethnicity. Each report has called for substantive transformation of the nation's health care system. Many have pointed out a disturbing paradox: the coexistence of overtreatment and undertreatment. The committee that authored this report found a similar situation: learning and adoption that are maddeningly slow—as with hand washing—coexisting with overly rapid adoption of some new techniques, devices, and drugs, with harmful results.

Exemplary efforts under way across the nation are working on these problems. Indeed, some members of this committee come from organizations that are pacesetters in continuous learning. But the pace of change is too slow, and adoption is too spotty; the system is not evolving quickly enough. The system needs to learn more rapidly, digest what does and does not work, and spread that knowledge in ways that can be broadly adapted and adopted. This report offers a roadmap for accomplishing this vision to benefit patients and society.

The committee identified two reasons for the above problems that grow more urgent every year. One is the increasingly unmanageable complexity of the science of health care. During the past half-century, there has been an explosion of biomedical and clinical knowledge, with even more dazzling clinical capabilities just over the horizon. However, the systems by which health care providers are trained, deployed, paid, and updated cannot usefully digest this deluge of information. Second is the ever-escalating cost of care, which is widely acknowledged to be wasteful and unsustainable. Unless ways are found to provide more efficient, lower-cost health care, more and more Americans will lose coverage of and access to care.

The committee also believes that opportunities exist for attacking these problems—opportunities that did not exist even a decade ago.

• Vast computational power (with associated sophistication of information technology) has become affordable and widely available. This capability makes it possible to harvest useful information from actual patient care (as opposed to one-time studies), something that previously was impossible.
• Connectivity allows that power to be accessed in real time virtually anywhere by professionals and patients, permitting unprecedented diffusion of information cheaply, quickly, and on demand.
• Progress in human and organizational capabilities and management science can improve the reliability and efficiency of care, permitting more scientific deployment of human and technical resources to match the complexity of systems and institutions.
• Increasing empowerment of patients unleashes the potential for their participation, in concert with clinicians, in the prevention and treatment of disease—tasks that increasingly depend on personal behavior change.

The committee recognizes that individual physicians, nurses, technicians, pharmacists, and others involved in patient care work diligently to provide high-quality, compassionate care to their patients. The problem is not that they are not working hard enough; it is that the system does not adequately support them in their work. The system lags in adjusting to new discoveries, disseminating data in real time, organizing and coordinating the enormous volume of research and recommendations, and providing incentives for choosing the smartest route to health, not just the newest, shiniest—and often most expensive—tool. These broader issues prevent clinicians from providing the best care to their patients and limit their ability to continuously learn and improve.

In completing its work, the committee solicited the views of more than 200 individuals, representing clinicians, patients, health care delivery leaders, clinical researchers, professional societies, life science industries, information technology developers, and government agencies. The information gleaned from these individuals enabled the committee to better understand the challenges to learning and improvement, as well as to learn from the experiences of those who have successfully incorporated learning and improvement into their regular work. In addition, the IOM staff provided excellent research, analysis, and writing support for this project and assisted the committee in its deliberative process.

Given the imperatives and opportunities outlined above, this is the right time for the vision proposed in this report to be realized. Developing a continuously learning health care system is critical for the future of health care, as well as for the future physical and financial health of the nation. There is no simple path forward; rather, actions need to be taken by every stakeholder if this vision is to become a reality. Such concerted action will enable the nation's health care system to evolve to one that continuously learns and improves, finally providing Americans with the best care at lower cost.

Mark D. Smith, Chair

Committee on the Learning Health Care System in America