The long wait for medical excellence.

In October 1997 the book Demanding Medical Excellence: Doctors and Accountability in the Information Age provided a pathbreaking examination of the quality of American health care. It documented rampant medical error and the absence of evidence-based practice, highlighted the potential of electronic health records (EHRs), endorsed what is now known as value purchasing, and showed how patients could exert more control over their care. Although the book suggested that transformational change was imminent, sixteen years later little has changed in some areas (medical error), while in others (evidence-based medicine and population health) change is only now gaining momentum. The exception is technology, where incentives boosted EHR use and the Internet has made a vast array of information available to patients. Paradigm shifts are traumatic, and only recently has intense financial pressure made greater clinical accountability seem less painful than retaining the tradition of untrammeled autonomy. In hearing rooms and hospital hallways, the policy conversation is changing. This shift, though an unavoidable source of anxiety, nonetheless promises a genuine renewal of American medicine.