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Chaos and Organization in Health Care

Thomas H. Lee, M.D. and James J. Mongan, M.D.

Publication Year: 2009

Two leading physicians’ prescription for solving our health care problems: organizing the fragmented system that delivers care.

Published by: The MIT Press


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p. 1-1

Title Page, Copyright

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pp. 2-7


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pp. vii-9

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pp. ix-xv

As daunting as the challenges for U.S. health care may be, there is reason for optimism that a delivery system that is much more efficient, reliable, and safe is within our reach. Our optimism is derived not from theory but from our day-to-day work, which ranges from health policy leadership roles to the management...

I. The Problem Is Chaos

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pp. 1-19

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1. Chaos

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pp. 3-18

Her friends and doctors still describe her as “formidable,” and at age eighty, SC finds that amusing. When she was younger and still teaching William Shakespeare to college students, she knew she was a force—a passionate, sometimes intimidating teacher who knew how to make her points. She used those same...

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2. Progress

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pp. 19-36

Health care has its share of “bad guys” who warrant criticism—including businesses reaping exorbitant profits, criminals who commit fraud, and physicians who practice sloppy medicine, to name a few. And our challenges would be simpler if the driving force behind U.S. health care’s problems was the greed...

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3. Fragmentation

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pp. 37-51

The conventional wisdom is that the U.S. health care system is broken, but that assessment is misleading. After all, can a system that has never truly existed be called broken? All of the components of fabulous health care exist in abundance in the United States, yet with a few exceptions, they have never been organized...

II. The Solution Is Organization

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pp. 53-71

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4. What Does Organization in Health Care Look Like?

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pp. 55-69

Most Americans know what disorganized health care is like. Amid a swirl of activity in our hospitals and physician offices, patients wait— for appointments, test results, and clear information that sometimes never comes. Physicians cannot reach each other, and thus do not give patients consistent or coherent...

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5. What Kinds of Systems Improve Health Care?

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pp. 71-95

Physicians, patients, and nurses sit in different spots in the health care system, but they all face one common impossible task. They are constantly bombarded by information, most of it mundane and reassuring. But some of those data are potentially ominous, and the consequences of missing warning...

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6. Tightly Structured Health Care Delivery Organizations

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pp. 97-118

Organized health care is not an abstract concept, a fantasy, or an unattainable ideal. In fact, millions of Americans already benefit from health care organizations that use information systems and teams of clinicians to provide safe, reliable, and efficient care. Many of the patients who use these organizations...

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7. Organizing the Mainstream of U.S. Medicine

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pp. 119-142

The organizations profiled in the previous chapter are tightly structured provider groups, which own their own hospitals, employ their own physicians, and often have their own insurance companies. This management structure is sometimes called the clinic model, meaning that all caregivers...

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8. What Can Payers, Employers, and Patients Do?

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pp. 143-160

Although physicians and other health care providers may be best trained and best positioned to bring order to the chaos of modern medicine, most of them are not sufficiently organized to take on this task with optimal effectiveness. Even providers in tightly structured organizations such as those described in chapter 6 frequently fall...

III. How Do We Get There?

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pp. 161-179

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9. Evolution or Revolution?

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pp. 163-174

Change is needed in health care—and change is under way. Physicians and hospitals are implementing systems that make care safer, like EMRs and CPOE systems. With increasing frequency, physicians and nonphysicians are working in teams that coordinate the care of the most complex patients and those...

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10. Provider Change

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pp. 175-194

As is probably evident from what we have written thus far, we believe in groupness. We think that the economic challenges and quality issues in health care cannot be addressed effectively unless physicians and other providers are organized into groups that have enough size and effectiveness to adopt tools...

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11. Payment Change

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pp. 195-210

We have argued throughout this book that health care can improve as providers adopt systems that bring organization to care, and we believe that this evolution is under way. But this improvement will come too slowly if the only drivers are the desire of individual providers to give excellent care, and the gradual...

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12. Market Change

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pp. 211-228

Any decent vision of a better health care system has the patient at the center. This book began with the description of the chaotic experience of one of our own patients, SC, an elderly woman with lymphoma and multiple other conditions, and more than ten doctors who do their best on her behalf, but sometimes...

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13. Accelerating Evolution

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pp. 229-248

The central argument of this book is that the organization of providers is an essential step in the development of a better health care system. Organization enables providers to bring order to the chaos generated by technological progress. Organized providers can use EMRs, patient registries, disease management...


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pp. 249-261

Further Readings

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pp. 263-266


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pp. 267-278

E-ISBN-13: 9780262259033
E-ISBN-10: 0262259036
Print-ISBN-13: 9780262013536
Print-ISBN-10: 0262013533

Page Count: 296
Illustrations: 19 figures
Publication Year: 2009