The ongoing decline in under-5 mortality ranks among the most significant public and population health successes of the past 30 years. Deaths of children under the age of 5 years have fallen from nearly 13 million per year in 1990 to less than 6 million per year in 2015, even as the world's under-5 population grew by nearly 100 million children. However, the amount of variability underlying this broad global progress is substantial. On a regional level, east Asia and the Pacific have surpassed the Millennium Development Goal target of a two-thirds reduction in under-5 mortality rate between 1990 and 2015, whereas sub-Saharan Africa has had only a 24% decline over the same period. Large differences in progress are also evident within sub-Saharan Africa, where mortality rates have declined by more than 70% from 1990 to 2015 in some countries and increased in others; in 2015, the mortality rate in some countries was more than three times that in others.

What explains this remarkable variation in progress against under-5 mortality? Answering this question requires understanding of where the main sources of variation in mortality lie. One view that is implicit in the way that mortality rates are tracked and targeted is that national policies and conditions drive first-order changes in under-5 mortality. This country-level focus is justified by research that emphasises the role of institutional factors in explaining variation in mortality—factors such as universal health coverage, women's education, and the effectiveness of national health systems. It is argued that these factors, which vary measurably at the country level, fundamentally shape the ability of individuals and communities to affect more proximate causes of child death such as malaria and diarrhoeal disease.

An alternate view has focused on exploring the importance of subnational variation in the distribution of disease. In the USA, studies on the geographical distribution of health care and mortality have been influential for targeting of resources and policy design. Similar studies in developing regions have shown the substantial variability in the distribution and changes of important health outcomes such HIV, malaria, and schistosomiasis—information that can then be used to improve the targeting of interventions. Nevertheless, the relative contribution of within-country and between-country differences in explaining under-5 mortality remains unknown. Improved understanding of the relative contribution of national and sub-national factors could provide insight into the drivers of mortality levels and declines in mortality, as well as improve the targeting of interventions to the areas where they are most needed.

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform:

1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment.
2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions.
3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions.
4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange.
5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make deidentified information from this database on clinical interventions, patient outcomes, and costs available to researchers.
6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans.
7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage.
8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.

High-quality medical care requires implementing evidence-based best practices, with continued monitoring to improve performance. Implementation science is beginning to identify approaches to developing, implementing, and evaluating quality improvement strategies across health care systems that lead to good outcomes for patients. Health information technology has much to contribute to quality improvement for hypertension, particularly as part of multidimensional strategies for improved care. Clinical reminders closely aligned with organizational commitment to quality improvement may be one component of a successful strategy for improving blood pressure control. The ATHENA-Hypertension (Assessment and Treatment of Hypertension: Evidence-based Automation) system is an example of more complex clinical decision support. It is feasible to implement and deploy innovative health information technologies for clinical decision support with features such as clinical data visualizations and evidence to support specific recommendations. Further study is needed to determine the optimal contexts for such systems and their impact on patient outcomes.

Objective:

To describe an academic medical center's experience with housestaff involvement in the implementation of a new clinical information system, with particular emphasis on resident contributions in tailoring the technology to meet the workflow needs of the center.

Methods:

A resident advisory group was formed to tailor the new system. Housestaff developed user interface screens to streamline presentation of patient data. Order sets were developed, offering an opportunity for education in standardized care and "best practice." A rounds report displays aggregated patient specific data for use in prerounding and rapid assessment of patient information. A sign-out tool was designed to facilitate transfer of information during change of shift.

Results:

Residents contributed in tailoring the technology to meet the workflow needs of our academic medical center setting.

Conclusion:

The design and implementation of a new clinical information system can be used to introduce concepts important in practice-based learning and systems-based practice.