To achieve the diverse health care goals of the United States, health care value must increase. The capacity to create value through innovation is facilitated by an integrated delivery system focused on creating value, measuring innovation returns, and receiving market rewards. This paper describes the Geisinger Health System's innovation strategy for care model redesign. Geisinger's clinical leadership, dedicated innovation team, electronic health information systems, and financial incentive alignment each contribute to its innovation record. Although Geisinger's characteristics raise serious questions about broad applicability to nonintegrated health care organizations, its experience can provide useful insights for health system reform. [Health Affairs 27, no. 5 (2008): 1235-1245 10.1377/hlthaff.27.5.1235 F o r d e c a d e s , o b s e rv e r s o f t h e U.S. health care system have watched a struggle against seemingly intractable problems: incomplete and unequal access to care; perverse payment incentives that fail to reward good outcomes; fragmented, uncoordinated, and highly variable care that results in safety risks and waste; a disconnect between quality and price; rising costs; consumer dissatisfaction; and the absence of productivity and efficiency gains common in other industries. These problems have resulted in a loss of value within the health system and have generated various reform proposals, with most focusing on providing greater access to or controlling the costs of care. Although laudable, this focus ignores the fundamental problem: health care value (defined here as outcomes relative to input costs) simply must increase to achieve these diverse goals.Enhancing value requires both explicit delivery system reform strategies and the associated organizational capacity to execute change. Sustainable health care value is created only when care process steps are eliminated, automated, appropri-

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Diverse stakeholders--clinicians, researchers, business leaders, policy makers, and the public--have good reason to believe that the effective use of electronic health care records (EHRs) is essential to meaningful advances in health care quality and patient safety. However, several reports have documented the potential of EHRs to contribute to health care system flaws and patient harm. As organizations (including small hospitals and physician practices) with limited resources for care-process transformation, human-factors engineering, software safety, and project management begin to use EHRs, the chance of EHR-associated harm may increase. The authors propose a coordinated set of steps to advance the practice and theory of safe EHR design, implementation, and continuous improvement. These include setting EHR implementation in the context of health care process improvement, building safety into the specification and design of EHRs, safety testing and reporting, and rapid communication of EHR-related safety flaws and incidents.

The Patient Protection and Affordable Care Act of 2010 provides for a number of major payment and delivery system initiatives. These potential changes need to be tested, scaled, and adapted with an urgency not evident in previous demonstration projects of the Centers for Medicare and Medicaid Services. We discuss lessons learned from our iterative tests of care reengineering at Geisinger--specifically, through our advanced medical home model, ProvenHealth Navigator, and the way we continuously modified the model to improve quality and value. We hypothesize that the most important ingredient in our model has been the embedding of nurse case managers into our community practices and the real-time feedback of data on the use of health services by the most complex patients.

Most clinical decisions involve bridging the inferential gap: Clinicians are required to "fill in" where they lack knowledge or where no knowledge yet exists. In this context we consider how the inferential gap is a product, in part, of how knowledge is created, the limits to gaining access to such knowledge, and the variable ways in which knowledge is translated into decisions. We consider how electronic health records (EHRs) will help narrow this gap by accelerating the creation of evidence relevant to everyday practice needs and facilitating real-time use of knowledge in practice.