What can the UK and US health systems learn from each other
1 Ovations, PO Box 1459, Minneapolis MN 55440, USA,2 UnitedHealth Europe, London SW1P 1SB
The NHS and US insurance based health systems seem worlds apart. Despite the differences, each has much to learn from examples of good practice in the other
Introduction
Learning within clinical medicine often spreads rapidly across the globe. Once an innovation—for example, thrombolysis for patients with heart attacks—is accepted, it is likely to be picked up rapidly in most countries. This is because cardiologists travel to world meetings, know each other well, read the same international journals, and are encouraged to innovate by global pharmaceutical companies. In stark contrast, innovations in how care is organised and delivered have rarely spread. We examine why countries have not been good at learning from each other and some of the areas where learning between the United Kingdom and United States could be beneficial.
, 百拇医药
Barriers to learning
One obvious barrier is that healthcare systems are culturally, politically, economically, and socially bound in a way that cardiological interventions are not. This has led some people to believe that international learning is impossible. Another barrier is mutual ignorance. Health systems have become so complex that few people have a deep understanding of more than one system. Who in Britain, for example, could explain with complete confidence the workings of the NHS in England, Scotland, Wales, and Northern Ireland This inhibits learning not only internationally but also within one nation state.
, 百拇医药
A more disturbing block to learning is a feeling that to learn from others is a sign of weakness—even failure. We saw some of this perhaps in the hostile reaction to the BMJ paper that suggested that Kaiser Permante might get significantly better outputs than the NHS for roughly similar inputs.1 There were legitimate reasons for criticising the study,2 3 but a much healthier reaction to the paper would have been to look more deeply at Kaiser and try to learn from the opportunity.4 It is a demonstration of strength rather than weakness to be open to learning from others.
, http://www.100md.com
Most learning, says Peter Senge, inventor of the learning organisation, comes from doing, not simply from reading, observing, or listening; think of learning to tie shoelaces.5 This presents another barrier to learning across health systems. Reading an article on what happens in other countries or visiting for a few days will not be enough—although it may provide a spark, and we concur with W B Yeats that "education is not the filling of a pail but the lighting of a fire." True learning, says Senge, comes from doing things together and occurs when teacher and learner are in a new place. "By learning you will teach; by teaching you will learn," says the Latin proverb. "All teach, all learn" is the modern version and implies not a fleeting visit but a joint project. The NHS has examples of the Modernisation Agency working with the Institute for Health Care Improvement in Boston on many projects and of 10 primary care trusts working with the United-Health Group to try to improve the care of frail elderly people. The results are not copies but something new.
, 百拇医药
Opportunities to learn
We thought it important for this article to have a prelude on learning, but we want now to identify opportunities for transatlantic learning. Although we can outline opportunities, true innovation will come from joint projects. The box lists some of the examples of learning we considered, but we have space here to consider only four—two in each direction. We've deliberately avoided some of the more obvious learning points—like the new general practitioner contract, the National Institute for Clinical Excellence, the care of patients with long term conditions, and the integration of primary and secondary care in a model like that of Kaiser—which have been well covered elsewhere.1 5-8
, 百拇医药
Opportunities for the United Kingdom
The Institute of Medicine
Britain would undoubtedly benefit from having an organisation like the Institute of Medicine. Indeed, some prominent figures in British health—particularly Sir George Godber, arguably England's most distinguished chief medical officer—have been arguing this for decades. The Institute of Medicine, which was chartered as part of the National Academy of Sciences in 1970, has huge influence in American health care. Its report on medical error, for example, pushed that long neglected issue to the top of the agenda and had reverberations around the world.9 10 In the past year it has produced reports on childhood obesity, health literacy, and the uninsured.
, http://www.100md.com
The institute's influence comes from a combination of factors that are not found together in one institution in the United Kingdom:
It can call on the best and the brightest—It has over 1500 members, all of them distinguished, but anybody can be invited to join a committee producing a report. And people will respond because of the prestige and influence of the organisation
Members are not all from health care—At least one quarter of members must be selected from outside the health professions, from fields such as the natural, social, and behavioural sciences as well as law, administration, engineering, and the humanities. This diverse membership improves the quality of the thinking and the credibility of the reports
, http://www.100md.com
The institute is independent of both government and professional factions
It has adequate resources to produce high quality reports—Too many British organisations (for example, the Academy of Medical Sciences) lack the resources to do the quality of work that the Institute of Medicine can achieve
The institute has well designed processes of peer review and for avoiding conflicts of interest. Those who work on reports are not compensated for their work.
, http://www.100md.com
Opportunities for transatlantic learning in health care
What the US might learn from the UK
The effectiveness and efficiency of ensuring health care without regard to ability to pay
Paying general practitioners for quality and outcomes
National Institute for Clinical Excellence—particularly its use of cost utility data to help decide which innovations should be introduced into the NHS, how it incorporates public values into its decisions, and how it is beginning to regulate surgical procedures
, http://www.100md.com
National Patient Safety Agency—one of few examples of a national programme to make health care safer
What the UK might learn from the US
Institute of Medicine—how medicine can speak with one highly respected and well informed voice
Building a network of high performance, low cost centres for complex healthcare procedures
Getting maximum value for money through knowing much more about the costs and benefits of different procedures
, 百拇医药
Management of patients with long term conditions
The full list of examples considered is on bmj.com
All of these ingredients are important, and if Britain had a similar body there might be much less suspicion of science. The quality of public debate on health issues could also be much improved.
High performance, low cost centres for complex procedures
Britain tends to have fewer centres doing many of these activities, but combining the production of high quality data on outcomes and costs with the building of networks could produce better outcomes at lower cost—especially if such networks were European rather than simply British.
, http://www.100md.com
Opportunities for the United States
Modernising professional learning
Continuing medical education (CME) in the United States is a multibillion dollar business funded largely by pharmaceutical companies. Much of it comprises traditional forms of education, with "experts" (often funded and even invited by the pharmaceutical companies) giving lectures to non-experts. The result is little learning and no change in practice,11 but physicians need to accumulate "CME points" in order to remain in their specialty practice.
, 百拇医药
The United Kingdom also has its share of this expensive but largely ineffective enterprise, but it is increasingly recognising that it's possible to do much better. Every doctor in the United Kingdom is now required to have a personal development plan, and this must be built from a "diagnosis" of learning needs. Doctors measure their competencies against those needed for their specialties. The General Medical Council has defined the competencies needed by all doctors,12 and various specialist groups, including for example, the Royal College of General Practitioners, have defined the extra competencies needed for their specialties.13 Professional bodies in the United States have not defined what is a good doctor, but without such a definition it is impossible to know whether professional examinations are measuring what they should be measuring.
, 百拇医药
Many other tools can be used to identify the learning needs of doctors, including some that are derived from interactions with patients. Once they have identified their needs, doctors in Britain are required to show how they respond to those needs, recognising that there are many different ways to learn and that individual doctors will have different learning styles. A record of their needs and the responses is kept in a personal development plan, which must be presented during the annual appraisal that is now required for all doctors in Britain.
, 百拇医药
Increasingly, doctors are also encouraged to learn with other professional groups. Multidisciplinary learning has long been praised but hasn't happened much. Now it is beginning to happen. We lack the evidence that this new form of learning will improve patient care, but there are sound educational reasons for thinking that it will be much superior to a diet of lectures from experts.
Using information technology to improve patient care and experience
, http://www.100md.com
The Institute of Medicine, which we praised above, advised that moving from a paper to an electronic based system would be the single step that would most improve patient safety.9 At the moment, patient records are often not available when patients are admitted for emergency care and are regularly lost in routine care. Furthermore, they are held in multiple places and are disorganised. For patients with long term or complex conditions, it can be impossible to find essential information in the bulging and often disintegrating files.
, 百拇医药
In addition, health care has heavily underinvested in information technology compared with other enterprises (fig 3). Those who pay for health care have understandably put investment in staff and treatments before investment in technology, but in the long term this is a mistake. Health is a knowledge based enterprise, and yet the knowledge has been disorganised and often inaccessible.
In 2002, a major report on the needs of the NHS over the next 20 years concluded that "without a major advance in the effective use of information and communications technology, the health service will find it increasingly difficult to deliver the efficient high quality service, which the public will demand."14 A massive programme—the National Programme for Information Technology—is now under way in England.15 It is costing more than ￡6bn ($11.3bn, 8.7bn), will take 10 years, and aims to link all parts of the NHS so that records will be accessible everywhere and to provide a platform for the employment of increasingly sophisticated information tools.
, 百拇医药
Unsurprisingly, the programme faces major hurdles, but the first stage of procuring and installing the technology is well under way; the government seems to have used its buying power effectively. The next stage of encouraging people to change the way they work will be both more difficult and more important in terms of delivering value from the investment.
Some parts of the US health system use information technology very effectively, particularly the Veterans Health Administration, but the biggest benefits depend on having information systems that work right across a health system, providing information on patients no matter where they may travel or which doctors or institutions they might use. Groups in the United States have recognised that an improved information technology system may be the "big hope" for improving the quality of health care and slowing the relentless rise in costs. But within the fractured US health system it's hard, perhaps impossible, to find organisations willing to make the huge investment that is needed to "wire the whole system." If the UK programme can show that substantial improvements can flow from such a major investment, pressure to find a way to do something similar in the United States will grow.
, 百拇医药
Summary box
Learning across health systems comes mostly from joint projects
The United Kingdom would benefit from having an organisation like the US Institute of Medicine
Europe should consider building a network of high performance, low cost centres to do complex procedures
The United States is wasting large sums on old fashioned continuing medical education, whereas Britain is modernising professional learning
, 百拇医药
The US would benefit from system-wide information technology such as that being introduced in England
Conclusions
Learning from other healthcare systems is not straightforward, but all systems face the same fundamental problems of quality, safety, access, usability, availability, and affordability—and all perform suboptimally. We see increasing examples of interaction and learning among systems. Such learning will benefit patients.
, 百拇医药
This is the first article in a series in which we asked experts in UK and US healthcare systems to identify opportunities for learning between the two countries
A list of learning opportunities is on bmj.com
Contributors and sources: LQ was a Rhodes scholar in Oxford and is now the chief executive of Ovations, which provides services for seniors in the United States. She also worked with Hillary Clinton on the reform of US health care. Formerly a member of the BMJ editorial board, she has worked closely with staff in the Department of Health and the NHS to establish programmes in England. RS was editor of the BMJ and chief executive of the BMJ Publishing Group for 13 years. Before becoming the editor he spent a year at the Graduate School of Business at Stanford in California. LQ and RS produced a list of possible options for transatlantic learning, partly through the experience and reading and partly through asking others on both sides of the Atlantic. RS produced the first draft, which LQ then corrected. Both have read and approved the final version. RS is the guarantor.
, 百拇医药
Competing interests: Both authors are employees of the UnitedHealth Group, which operates predominantly in America but is hoping to develop its business internationally.
References
Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente [commentaries by Dixon J, Berwick DM, and Enthoven AC]. BMJ 2002;324: 135-43.
Correspondence. Getting more for their dollar: Kaiser v the NHS. BMJ 2002;324: 1332-5.
, 百拇医药
Talbot-Smith A, Gnani S, Pollock AM, Gray DP. Questioning the claims from Kaiser. Br J Gen Pract 2004;54: 415-21.
Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data. BMJ 2003;327:1257-60 (full version on bmj.com).
Senge P. The fifth discipline: art and practice of the learning organisation. New York: Random House, 1993.
, 百拇医药
Roland M. Linking physicians' pay to the quality of care—a major experiment in the United Kingdom. N Engl J Med 2004;351: 1448-54.
Rawlins MD. NICE work—providing guidance to the British National Health Service. N Engl J Med 2004;351: 1383-5.
Murphy E. Case management and community matrons for long term conditions. BMJ 2004;329: 1251-2.
Committee on the Quality of Healthcare in America. To err is human: building a safer health system. Washington, DC: Institute of Medicine, 1999.
, 百拇医药
Committee on Quality of Healthcare in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: Institute of Medicine, 2001.
Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA 1992;268: 1111-7.
General Medical Council. Good medical practice. London: GMC, 1998.
Royal College of General Practitioners. Good medical practice for general practitioners. London: RCGP, 2002.
Wanless D. Securing our future health: taking a long term view. London: HM Treasury, 2002. www.hm-treasury.gov.uk/Consultations_and_Legislation/wanless/consult_wanless_final.cfm (accessed 14 Feb 2005).
Humber M. National programme for information technology. BMJ 2004;328: 1145-6., 百拇医药(Lois Quam, Richard Smith)
The NHS and US insurance based health systems seem worlds apart. Despite the differences, each has much to learn from examples of good practice in the other
Introduction
Learning within clinical medicine often spreads rapidly across the globe. Once an innovation—for example, thrombolysis for patients with heart attacks—is accepted, it is likely to be picked up rapidly in most countries. This is because cardiologists travel to world meetings, know each other well, read the same international journals, and are encouraged to innovate by global pharmaceutical companies. In stark contrast, innovations in how care is organised and delivered have rarely spread. We examine why countries have not been good at learning from each other and some of the areas where learning between the United Kingdom and United States could be beneficial.
, 百拇医药
Barriers to learning
One obvious barrier is that healthcare systems are culturally, politically, economically, and socially bound in a way that cardiological interventions are not. This has led some people to believe that international learning is impossible. Another barrier is mutual ignorance. Health systems have become so complex that few people have a deep understanding of more than one system. Who in Britain, for example, could explain with complete confidence the workings of the NHS in England, Scotland, Wales, and Northern Ireland This inhibits learning not only internationally but also within one nation state.
, 百拇医药
A more disturbing block to learning is a feeling that to learn from others is a sign of weakness—even failure. We saw some of this perhaps in the hostile reaction to the BMJ paper that suggested that Kaiser Permante might get significantly better outputs than the NHS for roughly similar inputs.1 There were legitimate reasons for criticising the study,2 3 but a much healthier reaction to the paper would have been to look more deeply at Kaiser and try to learn from the opportunity.4 It is a demonstration of strength rather than weakness to be open to learning from others.
, http://www.100md.com
Most learning, says Peter Senge, inventor of the learning organisation, comes from doing, not simply from reading, observing, or listening; think of learning to tie shoelaces.5 This presents another barrier to learning across health systems. Reading an article on what happens in other countries or visiting for a few days will not be enough—although it may provide a spark, and we concur with W B Yeats that "education is not the filling of a pail but the lighting of a fire." True learning, says Senge, comes from doing things together and occurs when teacher and learner are in a new place. "By learning you will teach; by teaching you will learn," says the Latin proverb. "All teach, all learn" is the modern version and implies not a fleeting visit but a joint project. The NHS has examples of the Modernisation Agency working with the Institute for Health Care Improvement in Boston on many projects and of 10 primary care trusts working with the United-Health Group to try to improve the care of frail elderly people. The results are not copies but something new.
, 百拇医药
Opportunities to learn
We thought it important for this article to have a prelude on learning, but we want now to identify opportunities for transatlantic learning. Although we can outline opportunities, true innovation will come from joint projects. The box lists some of the examples of learning we considered, but we have space here to consider only four—two in each direction. We've deliberately avoided some of the more obvious learning points—like the new general practitioner contract, the National Institute for Clinical Excellence, the care of patients with long term conditions, and the integration of primary and secondary care in a model like that of Kaiser—which have been well covered elsewhere.1 5-8
, 百拇医药
Opportunities for the United Kingdom
The Institute of Medicine
Britain would undoubtedly benefit from having an organisation like the Institute of Medicine. Indeed, some prominent figures in British health—particularly Sir George Godber, arguably England's most distinguished chief medical officer—have been arguing this for decades. The Institute of Medicine, which was chartered as part of the National Academy of Sciences in 1970, has huge influence in American health care. Its report on medical error, for example, pushed that long neglected issue to the top of the agenda and had reverberations around the world.9 10 In the past year it has produced reports on childhood obesity, health literacy, and the uninsured.
, http://www.100md.com
The institute's influence comes from a combination of factors that are not found together in one institution in the United Kingdom:
It can call on the best and the brightest—It has over 1500 members, all of them distinguished, but anybody can be invited to join a committee producing a report. And people will respond because of the prestige and influence of the organisation
Members are not all from health care—At least one quarter of members must be selected from outside the health professions, from fields such as the natural, social, and behavioural sciences as well as law, administration, engineering, and the humanities. This diverse membership improves the quality of the thinking and the credibility of the reports
, http://www.100md.com
The institute is independent of both government and professional factions
It has adequate resources to produce high quality reports—Too many British organisations (for example, the Academy of Medical Sciences) lack the resources to do the quality of work that the Institute of Medicine can achieve
The institute has well designed processes of peer review and for avoiding conflicts of interest. Those who work on reports are not compensated for their work.
, http://www.100md.com
Opportunities for transatlantic learning in health care
What the US might learn from the UK
The effectiveness and efficiency of ensuring health care without regard to ability to pay
Paying general practitioners for quality and outcomes
National Institute for Clinical Excellence—particularly its use of cost utility data to help decide which innovations should be introduced into the NHS, how it incorporates public values into its decisions, and how it is beginning to regulate surgical procedures
, http://www.100md.com
National Patient Safety Agency—one of few examples of a national programme to make health care safer
What the UK might learn from the US
Institute of Medicine—how medicine can speak with one highly respected and well informed voice
Building a network of high performance, low cost centres for complex healthcare procedures
Getting maximum value for money through knowing much more about the costs and benefits of different procedures
, 百拇医药
Management of patients with long term conditions
The full list of examples considered is on bmj.com
All of these ingredients are important, and if Britain had a similar body there might be much less suspicion of science. The quality of public debate on health issues could also be much improved.
High performance, low cost centres for complex procedures
Britain tends to have fewer centres doing many of these activities, but combining the production of high quality data on outcomes and costs with the building of networks could produce better outcomes at lower cost—especially if such networks were European rather than simply British.
, http://www.100md.com
Opportunities for the United States
Modernising professional learning
Continuing medical education (CME) in the United States is a multibillion dollar business funded largely by pharmaceutical companies. Much of it comprises traditional forms of education, with "experts" (often funded and even invited by the pharmaceutical companies) giving lectures to non-experts. The result is little learning and no change in practice,11 but physicians need to accumulate "CME points" in order to remain in their specialty practice.
, 百拇医药
The United Kingdom also has its share of this expensive but largely ineffective enterprise, but it is increasingly recognising that it's possible to do much better. Every doctor in the United Kingdom is now required to have a personal development plan, and this must be built from a "diagnosis" of learning needs. Doctors measure their competencies against those needed for their specialties. The General Medical Council has defined the competencies needed by all doctors,12 and various specialist groups, including for example, the Royal College of General Practitioners, have defined the extra competencies needed for their specialties.13 Professional bodies in the United States have not defined what is a good doctor, but without such a definition it is impossible to know whether professional examinations are measuring what they should be measuring.
, 百拇医药
Many other tools can be used to identify the learning needs of doctors, including some that are derived from interactions with patients. Once they have identified their needs, doctors in Britain are required to show how they respond to those needs, recognising that there are many different ways to learn and that individual doctors will have different learning styles. A record of their needs and the responses is kept in a personal development plan, which must be presented during the annual appraisal that is now required for all doctors in Britain.
, 百拇医药
Increasingly, doctors are also encouraged to learn with other professional groups. Multidisciplinary learning has long been praised but hasn't happened much. Now it is beginning to happen. We lack the evidence that this new form of learning will improve patient care, but there are sound educational reasons for thinking that it will be much superior to a diet of lectures from experts.
Using information technology to improve patient care and experience
, http://www.100md.com
The Institute of Medicine, which we praised above, advised that moving from a paper to an electronic based system would be the single step that would most improve patient safety.9 At the moment, patient records are often not available when patients are admitted for emergency care and are regularly lost in routine care. Furthermore, they are held in multiple places and are disorganised. For patients with long term or complex conditions, it can be impossible to find essential information in the bulging and often disintegrating files.
, 百拇医药
In addition, health care has heavily underinvested in information technology compared with other enterprises (fig 3). Those who pay for health care have understandably put investment in staff and treatments before investment in technology, but in the long term this is a mistake. Health is a knowledge based enterprise, and yet the knowledge has been disorganised and often inaccessible.
In 2002, a major report on the needs of the NHS over the next 20 years concluded that "without a major advance in the effective use of information and communications technology, the health service will find it increasingly difficult to deliver the efficient high quality service, which the public will demand."14 A massive programme—the National Programme for Information Technology—is now under way in England.15 It is costing more than ￡6bn ($11.3bn, 8.7bn), will take 10 years, and aims to link all parts of the NHS so that records will be accessible everywhere and to provide a platform for the employment of increasingly sophisticated information tools.
, 百拇医药
Unsurprisingly, the programme faces major hurdles, but the first stage of procuring and installing the technology is well under way; the government seems to have used its buying power effectively. The next stage of encouraging people to change the way they work will be both more difficult and more important in terms of delivering value from the investment.
Some parts of the US health system use information technology very effectively, particularly the Veterans Health Administration, but the biggest benefits depend on having information systems that work right across a health system, providing information on patients no matter where they may travel or which doctors or institutions they might use. Groups in the United States have recognised that an improved information technology system may be the "big hope" for improving the quality of health care and slowing the relentless rise in costs. But within the fractured US health system it's hard, perhaps impossible, to find organisations willing to make the huge investment that is needed to "wire the whole system." If the UK programme can show that substantial improvements can flow from such a major investment, pressure to find a way to do something similar in the United States will grow.
, 百拇医药
Summary box
Learning across health systems comes mostly from joint projects
The United Kingdom would benefit from having an organisation like the US Institute of Medicine
Europe should consider building a network of high performance, low cost centres to do complex procedures
The United States is wasting large sums on old fashioned continuing medical education, whereas Britain is modernising professional learning
, 百拇医药
The US would benefit from system-wide information technology such as that being introduced in England
Conclusions
Learning from other healthcare systems is not straightforward, but all systems face the same fundamental problems of quality, safety, access, usability, availability, and affordability—and all perform suboptimally. We see increasing examples of interaction and learning among systems. Such learning will benefit patients.
, 百拇医药
This is the first article in a series in which we asked experts in UK and US healthcare systems to identify opportunities for learning between the two countries
A list of learning opportunities is on bmj.com
Contributors and sources: LQ was a Rhodes scholar in Oxford and is now the chief executive of Ovations, which provides services for seniors in the United States. She also worked with Hillary Clinton on the reform of US health care. Formerly a member of the BMJ editorial board, she has worked closely with staff in the Department of Health and the NHS to establish programmes in England. RS was editor of the BMJ and chief executive of the BMJ Publishing Group for 13 years. Before becoming the editor he spent a year at the Graduate School of Business at Stanford in California. LQ and RS produced a list of possible options for transatlantic learning, partly through the experience and reading and partly through asking others on both sides of the Atlantic. RS produced the first draft, which LQ then corrected. Both have read and approved the final version. RS is the guarantor.
, 百拇医药
Competing interests: Both authors are employees of the UnitedHealth Group, which operates predominantly in America but is hoping to develop its business internationally.
References
Feachem RGA, Sekhri NK, White KL. Getting more for their dollar: a comparison of the NHS with California's Kaiser Permanente [commentaries by Dixon J, Berwick DM, and Enthoven AC]. BMJ 2002;324: 135-43.
Correspondence. Getting more for their dollar: Kaiser v the NHS. BMJ 2002;324: 1332-5.
, 百拇医药
Talbot-Smith A, Gnani S, Pollock AM, Gray DP. Questioning the claims from Kaiser. Br J Gen Pract 2004;54: 415-21.
Ham C, York N, Sutch S, Shaw R. Hospital bed utilisation in the NHS, Kaiser Permanente, and the US Medicare programme: analysis of routine data. BMJ 2003;327:1257-60 (full version on bmj.com).
Senge P. The fifth discipline: art and practice of the learning organisation. New York: Random House, 1993.
, 百拇医药
Roland M. Linking physicians' pay to the quality of care—a major experiment in the United Kingdom. N Engl J Med 2004;351: 1448-54.
Rawlins MD. NICE work—providing guidance to the British National Health Service. N Engl J Med 2004;351: 1383-5.
Murphy E. Case management and community matrons for long term conditions. BMJ 2004;329: 1251-2.
Committee on the Quality of Healthcare in America. To err is human: building a safer health system. Washington, DC: Institute of Medicine, 1999.
, 百拇医药
Committee on Quality of Healthcare in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: Institute of Medicine, 2001.
Davis DA, Thomson MA, Oxman AD, Haynes RB. Evidence for the effectiveness of CME. A review of 50 randomized controlled trials. JAMA 1992;268: 1111-7.
General Medical Council. Good medical practice. London: GMC, 1998.
Royal College of General Practitioners. Good medical practice for general practitioners. London: RCGP, 2002.
Wanless D. Securing our future health: taking a long term view. London: HM Treasury, 2002. www.hm-treasury.gov.uk/Consultations_and_Legislation/wanless/consult_wanless_final.cfm (accessed 14 Feb 2005).
Humber M. National programme for information technology. BMJ 2004;328: 1145-6., 百拇医药(Lois Quam, Richard Smith)