accelerating quality improvement in health care · 2015-04-26 · strategies to speed the diffusion...

Strategies to Speed the Diffusion of Evidence-Based Innovations

P R O C E E D I N G S F R O M A C O N F E R E N C E

Accelerating Quality Improvement in Health Care

Executive Summary 1

Introduction 3

Devices and Drugs: Obstacles to Timely Product Uptake 7

Stents: A Case of Rapid Diffusion 9

Prescription Drugs 10

Innovation in the Hospital and at the Bedside 11

Surgery 11

Hospital Design 12

Care at the End of Life 12

Innovation in Public Health, Prevention, and Disease Management 15

Public Health 15

Prevention and Screening Services 17

Disease Management 18

The Imperative of Information Technology and E-Health 19

Adopting IT at a Teaching Hospital 20

Getting Doctors to Buy Into IT 23

Better Quality Through Informed Consumer Choice 24

Appendix A: Conference Faculty with Contact Information 25

Table of Contents

Synopses of Commissioned PapersThe Tipping Point and Health Care Innovations: Advancingthe Adoption of Beneficial Technologies 4

Medical Technology, Innovation, and the Nature of Medical Progress 16

Complexity and the Adoption of Innovation in Health Care 22

© 2003 National Institute for Health Care Management Foundation

NoteThe following literature review and three papers were commissioned for thisconference. They are available at www.nihcm.org and www.ncqhc.org. Synopses ofthe three papers appear in the text of this report.• Technology and Quality: Considerations for Adoption and Diffusion � A Literature

Review (Prepared by the Health Technology Center), 20 pages• The Tipping Point and Health Care Innovations: Advancing the Adoption of Beneficial

Technologies � By Molly Joel Coye, MD, MPH, Wade Aubry, MD, and Will Yu (TheHealth Technology Center), 18 pages

• Complexity and the Adoption of Innovation in Health Care � By Paul Plsek, PhD(DirectedCreativity.com and The Institute for Healthcare Improvement), 18 pages

• Medical Technology, Innovation, and the Nature of Medical Progress � By DanielCallahan, PhD (The Hastings Center), 18 pages

CreditsThe National Institute for Health Care Management (NIHCM) Research and EducationalFoundation and the National Committee for Quality Health Care (NCQHC) co-sponsoredand convened the conference on which this publication is based. The conference was heldJanuary 27-28, 2003 in Washington, D.C.

Funding for the conference was also provided by:

The Agency for Healthcare Research and Quality

The Centers for Disease Control and Prevention

The Robert Wood Johnson Foundation

The Anthem Foundation

eHealth Initiative

The NIHCM Foundation is a non-profit, non-partisan organization whose mission is topromote improvement in health care access, quality, efficiency and management. The NIHCMFoundation is in Washington, D.C.

NCQHC is a non-profit membership organization comprised of senior health care leaderssharing a common interest in quality as a foundation of healthcare delivery. NCQHC is inWashington, D.C.

This report was written by Larry Stepnick, president of The Severyn Group, a health careresearch and consulting firm, and Steven Findlay, MPH, of the NIHCM Foundation.


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Executive Summary It is a vexing problem. The US healthcare system runs on an engine of entrepreneurialinnovation fueled by technology. And yet, manyinnovations, technological advances, and provennew treatments are too slowly adopted bydoctors, hospitals, health administrators, andhealth care facilities. At the same time, otherinnovations and new treatments get diffused tooquickly, despite insufficient scientific evidence oftheir clinical utility. This dichotomy is at the heartof the growing movement to improve the qualityof care by correcting the underuse of many proventreatments and innovations even as wediscourage the overuse or inappropriate use ofothers.This report summarizes the proceedings of aconference convened to explore: (a) why the slowdiffusion of many health care and medicalinnovations persists and (b) how to accelerate theadoption of clinical technologies and healthservice innovations that have been shown toimprove the quality and/or cost effectiveness ofhealth care. The conference brought togetherspeakers and participants from health plans,employers, hospitals, medical and providergroups, government, and academia. Speakersaddressed the adoption of innovation in a diversearray of topics, from medical devices and surgeryto public health, end-of-life care, hospital design,disease management, and information technology.Speakers broadly concurred that the �diffusioncurve� continues to be much longer in health carethan in other sectors of the economy � preventingmillions of people each year from getting optimalcare and impeding progress in enhancing thequality of care and better health outcomesgenerally. In some cases, speakers said, it can take10 or more years for an innovation or newtreatment to penetrate into full acceptance andwidespread use.With new treatments, the primary reasons for thislag are: (a) the nature of medical practice itself,with its emphasis on the autonomy of individualphysicians practicing either alone or in smallgroups; (b) an inherent skepticism about the�new� versus the �tried and true,� even when thetried and true may lack scientific support or be

outmoded; (c) the slow pace at which anindividual doctor�s practice patterns change whenthey are shaped largely by local peer-grouppractice patterns; (d) reluctance to be an �earlyadopter� of treatments (particularly newprocedures and surgical techniques) that maycarry new risks; (e) lack of clarity about theevidence base for many treatments; (f) a sub-optimal system for the quick transfer of importantnew technical and scientific knowledge toclinicians (i.e., difficulty separating the wheatfrom the chaff); and (g) the sometimes ploddingprocess that government, regulatory agencies,and private insurers apply to coverage andreimbursement decisions.With respect to new technology, barriers toquicker diffusion center on cost, anticipatedreturn on investment, regulatory approval,Medicare and Medicaid reimbursement, andprivate insurance coverage. But these barriersmay not always be the dominant forces slowingdiffusion. Speakers cited (and this reportpresents) more than a few innovations andeffective care practices that are low-cost and havegained relatively speedy approval and coverage,but which still have been underused for years(e.g., diabetic eye exams, influenza andpneumococcal vaccinations among the elderly).Health service innovations (e.g., informationtechnology, patient safety measures, hospitaldesign, physician work flow, and clinical teammanagement) that aim to improve the patient�sexperience and the quality of care are an essentialingredient in high-quality care, but they also faceboth technical and financial barriers to adoptionwithin hospitals and physicians� offices. The rapidpace of change in medicine and shear volume ofnew tools being developed adds to the problem,as clinicians and providers struggle to keep upand make smart investments.Speakers and participants agreed that there is nomagic bullet that will accelerate the adoption ofevidence-based innovations. Neither is there aneasy way to wean providers off unproventreatments as fast as is desirable. They discussedand proposed a broad array of fresh ideas and anumber of unifying themes emerged.

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Among the most important:! Payers and purchasers (private sector and

government) must begin to �pay forperformance� to improve quality. Doing sowill speed providers towards use of clinicalguidelines, recommended treatmentprotocols, and evidence-based practice. Inaddition, the federal government and insurersshould consider boosting reimbursement fortechnologies that, over time, demonstratesubstantially improved outcomes.

! A much larger investment should be made(by both government and the private sector)in gauging the usefulness and cost-effectiveness of new technologies andinnovations, including head-to-headcomparisons of existing treatments.

! The federal regulatory process for approvingand deciding on reimbursement policy fornew treatments and technologies needs to beimproved. The process itself should be asinnovative, creative, and adaptive as theinnovations being evaluated. The agenciescharged with these tasks�the Food and DrugAdministration (FDA) and the Centers forMedicare and Medicaid Services (CMS)�needto more closely coordinate their activities.

! A high priority should be put on creating anddiffusing physician decision-supporttechnology that can help clinicians makeevidence-based diagnostic and treatmentdecisions. Such technology includes laptopcomputers and personal digital assistants(PDAs) with specialized software and highspeed wireless internet access.

! Innovations in two areas hold especially largepotential to constrain the rising cost of healthcare even as they improve the quality of care.These two areas are care at the end of life anddisease management programs for thechronically ill. Roughly 15% of the populationaccounts for 75% of total health care costs inthe U.S. � and almost everyone in that 15%has one or more chronic conditions or isnearing the end of life. New �mental models�are needed to replace current misconceptionsabout how and why people die, and the carethey really need at the end of life. Despiteexcellent emerging models of chronic illnesscare, and mounting evidence that disease

management benefits patients and savesmoney, diffusion has been woefully slow.

! More federal funds should be committed tofoster the uptake of information technology(IT) and electronic medical records, especiallyas applied to facilities and providers that treatunder-served populations. IT is also aneffective tool for accelerating the diffusion ofother innovations in health care.

! Physician and public health groups can andmust do more to push clinicians andadministrators to adopt evidence-basedinnovations faster. They should also helpinform their constituencies about whichinnovations are the most useful.

! Preventive care continues to be underutilized.Enhanced coverage should be based onevidence and the recommendations of theUnited States Preventive Services Task Force(housed at the Agency for HealthcareResearch and Quality) and from the Guide toCommunity Preventive Services developed bythe Centers for Disease Control andPrevention. Employers, government, healthplans, and providers should collaborate at thelocal level to increase public awareness of theimportance of preventive health services andscreening tests to personal health. Rewardsfor healthy lifestyle changes should also beconsidered.

! More substantial efforts must be made to helpconsumers become better informed about thegaps in health care quality, and about how touse information, data, and other resources tochoose providers and make health caredecisions wisely. Messages should emphasizethat disparities in quality can affect theoutcome of care.

! Tenacious consumer and public interestgroups play a vital role in pushing socialchange to protect and promote public health(e.g., publicizing the health effects of tobaccoand lead, promoting automobile safety,discouraging drunk driving). Clinicians andthe health care community should listen tothem sooner. The latest movement: childhoodand adult overweight and obesity. The goal ofsubstantially altering American eating habitsand physical activity levels should be broadlyembraced and advocated by all stakeholders.


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Introduction The two day conference on which this reportis based brought together 200 health leaders andstakeholders in an effort to better understandhow to accelerate the adoption and diffusion ofclinical technologies and health serviceinnovations that have been shown to improve thequality and/or cost effectiveness of health care.Nancy Chockley, MBA, president of the NIHCMFoundation, and Catherine McDermott, presidentand CEO of NCQHC, emphasized the power andmomentum of the idea of evidence-basedmedicine � and the role it is playing in drivinghealth care quality improvement in the U.S. today.Each stressed the challenges inherent inidentifying what does and does not work inhealth care, both clinically and in the delivery ofcare. Ms. Chockley said the conference�s maingoal was to advance understanding of why somehealth care practices take hold and others do not,and how adoption of the best, proven practicescan be significantly enhanced. A secondary goalwas to stimulate collaboration across healthsectors to achieve more rapid health systemimprovement. Ms. McDermott noted that healthcare quality improvement has finally emerged asa potent political issue, offering the promise ofnew resources and commitment.In introductory remarks, Samuel Nussbaum,MD, executive vice president and chief medicalofficer of Anthem, Inc., whomoderated the first day�ssessions, said it is now wellunderstood that many proveninnovations and clinicalbreakthroughs diffuse tooslowly. He cited researchshowing that it can take 10years or longer for even themost definitive clinical trialresults to filter down topracticing physicians.

At the same time, other innovations, technologies,and treatments get adopted too fast, despiteinsufficient evidence of their clinical utility. Thisdichotomy is at the heart of the twin issuesplaguing quality of care � the underuse of manyproven treatments and innovations and theoveruse of other treatments and innovations forwhich there is sketchy or insufficient scientificsupport.E. Andrew Balas, MD, PhD, dean of the Schoolof Public Health and professor of health policy atSaint Louis University, cited eye exams amongdiabetics as one notable example of persistentunderuse. Definitive studies showing the benefitof periodic exams to prevent impaired vision andblindness in diabetics were first published in theearly 1980s. Yet the latest published research (in2000) indicates that only 48% of diabetics got aneye exam in the previous year. A second exampleis pneumococcal vaccine. Definitive studiespublished in the late 1970s showed the vaccine�sbenefit, particularly among older Americans athigh risk of bacterial pneumonia. The Centers forDisease Control and Prevention (CDC) has longrecommended that everyone age 65 and over beimmunized, since pneumonia causes 64,000hospitalizations and 7,300 deaths per year. YetCDC data show that only 53% of people age 65and over were immunized in 2000. (See Figure 1.)

Figure 1: Landmark Clinical Trialsand Their Current Rate of Use

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Commissioned Paper SynopsisThe Tipping Point and Health Care Innovations:

Advancing the Adoption of Beneficial TechnologiesBy Molly Coye, MD, MPH, Wade Aubry, MD, and Will Yu, The Health Technology Center

In a world burgeoning with new health careknowledge and technology, do we really need astrategy to speed the rate at which innovationsdiffuse?

The answer is yes, especially with respect toinnovations targeted at improving the quality ofcare. Mounting research indicates that the benefitof health care service and delivery innovation �even incremental innovation � outweighs the addedcost. And much of the recent onslaught oftechnological improvements in medicine (drugs,devices, new imaging tools) are of indisputablevalue, too.

The plain fact is that the �natural� rate of diffusiontoday of many proven new health technologies andtreatments is not optimal. In fact, it proceeds inmany cases at a snail�s pace. Take cochlearimplants. They first reached the market in 1978,and have been improved over the years. But aconfluence of factors, including poor Medicare andprivate insurer reimbursement, has slowed theirdiffusion.

Our major challenge today is to better understandthe drivers and barriers of diffusion. As we gleanthem, we must push on the drivers and reduce oreliminate the barriers, when appropriate. One clearbarrier is that we have no systematic way ofidentifying breakthrough innovations early in theirdevelopment so we can give them the push theyneed. Important innovations are often left tolanguish, sometimes for years, because there is noor slow recognition of their value. We need earliergauges of what is improving care.

Resistance to change is also a factor. We need toidentify as early as possible so-called �disruptive�technologies (those that face resistance becausethey replace outmoded technologies or ways ofdoing things) and then develop a strategy forpromoting their wider acceptance. This happens inother areas of the economy quite rapidly (e.g.consumer electronics), but not in health care.Here are just a few disruptive technologies thatdid not diffuse rapidly enough:

! Arthroscopic and endoscopic surgery(replacing open surgery)

! Angioplasty (replacing bypass surgery)

! High-quality home care (replacing more costlyinpatient care)

! Outpatient clinics (supplanting inpatient care).

! Ultrasound (replacing some MRIs and CTscans)

! Remote monitoring (replacing the need forpatients to go to a doctor�s office and allowingfor inter-hospital consultation)

! Disease management of diabetics and heartattack patients

! Computer- and internet-based information anddata in support of diagnosis, medical decision-making, and ordering (replacing slow access towritten documents and paper-based systems)

The landmark Institute of Medicine report, Crossingthe Quality Chasm, identified two barriers inparticular that are today impeding health qualityimprovement: suboptimal investment in IT and areimbursement system that fails to providecoverage for innovative technologies in a timelymanner. Many barriers to IT persist, includingsecurity concerns and technical issues surroundingcomputer coding standards and interoperability.Just as important are the �systems� issues: (a)getting the human beings who run the system toembrace IT and alternative reimbursementsystems, and (b) integrating such changes intoexisting complex systems and organizations (e.g.,a hospital or large insurer).

We must also develop regulatory and paymentsystems that promote competition aimed at theearly (but judicious) use of new tools. One pathhere is to learn from organizations that adapt andchange rapidly. Some delivery systems, healthplans, and employers clearly act as �earlyadopters� and �risk takers.� Studies indicate thatthey do so primarily for competitive reasons in themarketplace.

It is absolutely critical to the health qualitymovement in the U.S. today that we speed thediffusion of those technologies that offer superiorclinical results and performance.


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In a keynote address based on her commissionedpaper for the conference (see page 4 for asynopsis), Molly Coye, MD, MPH, CEO of TheHealth Technology Center, said all newtechnologies and innovations have naturaldiffusion �drivers� and �barriers.� Regulatoryapproval (e.g., by the FDA) and insurancecoverage are well-recognized drivers of diffusion,as are marketing and advertising. Notablebarriers include liability issues, cost, capitalinvestment, worker retraining, complexity of thetechnology, and facility requirements. Thesedrivers and barriers, in addition to social,economic, and clinical circumstances, conspire,often in unpredictable ways, to yield the rapiduptake of some innovations and the slowdiffusion of others.Dr. Coye told attendees that the adoption ofinnovations in health care is complicated by theoverwhelming pace of change and shear volumeof new tools being developed in medicine. It isnot humanly possible for clinicians to keep upwith all the new beneficial tools, tests, devices,drugs, techniques, and technologies, let alonedistinguish them from those that warrant morecaution.This phenomena presents one of the most seriousbarriers not only to the practice of evidence-based medicine, but also to the implementation ofsystems changes that improve the delivery ofcare. It is a behavioral problem that affects otherindustries as well. Humans are naturally reluctantto adopt new things untilother �early adopters�have done so and proventheir worth. (See Figure 2.)But Dr. Coye argues thatthis process is inadequatein medicine since it deniespotentially life-saving careto millions of people, oftenfor years.Carolyn Clancy, MD,director of the Agency forHealthcare Research andQuality (AHRQ), notedthat the reluctance toadopt new innovations isan age-old problem inmedicine. In 1601, an

Figure 2: The Diffusion Curve

English sea captain named James Lancasterdiscovered that lemon juice supplements were acure for scurvy in sailors. But it took the Britishnavy 194 years to implement the practice ofroutinely stocking ships with citrus fruits andsupplements. A century later, researchers provedconclusively that the simple practice of handwashing by nurses and doctors when movingfrom one patient to the next dramatically slowedthe spread of infections in hospitals. But thepractice did not become routine in hospitals until30 years later, and doctors and nurses makingrounds today still sometimes forget this simpleprocedure. Yet another example is thestethoscope. Originally developed in 1816, it wasmet with skepticism and mistrust, and thereforelanguished as a valuable innovation until the1860s.Dr. Clancy believes the challenges today arefundamentally no different than they were in the17th and 18th century, but that we have far fewerexcuses for failing to:! Discern the best medical treatments through

careful, well-designed research.! Transmit new, fast-evolving knowledge to

physicians and other clinicians in a timelymanner.

! Get practicing doctors to change theirbehavior as new knowledge warrants it.

! Translate the discoveries of basic research intopractice and action.

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The failure to get innovations and clinicalbreakthroughs into the mainstream of care meansthat the vast majority of patients in the U.S. todayreceive average care, with only alucky few receiving the best, top-quality care.Dr. Nussbaum cited the high profileissue of medical errors as perhapsthe most recent and egregiousexample of diffusion failure. Manytechnologies and processes nowexist that could help identify andprevent medical errors. Yet only aminority of hospitals have alteredthese processes and invested insystems that can prevent errors. Forexample, only about 5% of hospitalstoday have a fully integrated CPOE(computerized physician orderentry) system despite evidence thatthey reduce medication errors by60%. And still today, years after

Transforming the Health Care SystemIn a keynote address, Newt Gingrich, former House Speaker and Republican Representative from Georgia,presented material from a new book, Saving Lives and Saving Money, he has co-authored with Dana Paveyand Ann Woodbury of The American Enterprise Institute. Much of the book presents case studies of healthtechnology and quality improvement initiatives now underway around the country that Mr. Gingrich thinksshould be more widely diffused. Among those:

!!!!! Electronic ICU monitoring by intensivists:At Sentara Health System in Norfolk, Virginia,Visicu, an electronic monitoring system, allowsintensivists to closely track the vital signs ofintensive care unit (ICU) patients. It hasreduced hospital mortality among ICU patientsby 25%, average hospital length of stay by17%, and overall costs by $2,150 per patient.Projections suggest that Visicu�s e-ICU couldsave 54,000 lives and $8 billion a year if putto use in every ICU in the nation. Only ahandful of hospitals have the system now.

!!!!! An electronic medical record (EMR) system:The Mayo Clinic in Jacksonville, Florida, beganin 1993 to shift to an EMR for all patient care,and completed the transition by 1996.Virtually all clinical orders and transactions,including test orders and results, doctor�spatient notes, surgery orders, and drugprescribing, are now done electronically. Thesystem has reduced medical errors, sharply

cut the time it takes to access a full patientrecord, improved the flow of clinicalinformation, and enhanced clinical consultationby allowing simultaneous access to patientmedical records. The cost of implementationwas a hefty $21 million, but the ROI isconsiderable, with savings of $3 to $7 milliona year, a figure that will grow as the system isimproved. Fewer than 10% of U.S. hospitalsand doctor offices have shifted to EMRsystems thus far.

!!!!! Computer system to authorize inpatienttests: In December 1999, VanderbiltUniversity Medical Center in Nashville,Tennessee, modified an existing computerordering system to require doctors toauthorize every test (such as blood tests andx-rays) that had previously been performedroutinely and automatically. The idea was, byrequiring a simple �click� by the physician, toallow the computer to screen for the necessity

enormous attention was paid to the problem,hospital error rates remain higher than those forairline baggage handling. (See Figure 3.)

Figure 3: Healthcare Quality Defects Occur atAlarming Rates


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In a provocative keynote address, NewtGingrich, CEO of The Gingrich Group andformer Speaker of the U.S. House ofRepresentatives, called for a �transformation ofthe health care system� through rapidacceleration of quality improvement and thespread of best practices. (See box below.)The conference was organized in large partaround specific categories of medical products,clinical tests and treatments, and health careservices. Speakers explored the pace of innovationadoption in their fields, using examples and casestudies where possible, and discussed ways toaccelerate the adoption of innovation.

Devices and Drugs: Obstaclesto Timely Product UptakeSusan Bartlett Foote, JD, MA, associate professorand head of the Division of Health ServicesResearch and Policy at the University ofMinnesota School of Public Health, told conferees

that politics as well as science plays a major rolein the speed of technological diffusion in healthcare. Federal regulatory bodies can make orbreak a technology, and they are not at all outsidethe political process.Less well known and understood is that thepolicy goals and values applied to drug anddevice approval and reimbursement are often influx and change over time. For example, over thepast 15 years the FDA has waxed and waned withrespect to the speed of drug approval. Until the1990s, the agency was cautious on approvals andoversight. More recently, the trend has been toaccommodate industry demands for acceleratingthe approval process. CMS is charged withmaking coverage and reimbursementdeterminations. Ms. Foote noted that there havebeen periods when CMS paid less attention tothat role. Recently, it has been perceived to bemore restrictive in terms of coverage andpayment for new technologies. This is driven inlarge part by budgeting constraints and health

of a test. It was conceived after internalanalysis suggested that many routine testswere clinically unnecessary. The new systemclearly worked, as the medical center hasdocumented a sharp decline in use of thesetests. The number of CHEM7 bloodtests, for example, declined 40%without any harm to patients,yielding savings of $300,000 a year.The number of portable x-ray testsdeclined 30%, saving $1 million ayear. Mr. Gingrich and his co-authorscalculate that if this system wereused in hospitals nationwide, thesavings would range between $10and $20 billion a year.

!!!!! Disease management: Pfizer andFlorida�s Agency for Health CareAdministration teamed up in 2001 tolaunch a unique statewide Medicaiddisease management program. Theprogram is targeted initially atbeneficiaries with heart failure, highblood pressure, diabetes, andasthma. Approximately 55 caremanagers situated at 10 hospitalscoordinate the care, tapping into the

resources of doctors and clinics throughoutthe state. Patients also enjoy 24-hour nursingsupport. So far the program has reducedinpatient admissions by 17% and emergencydepartment visits by 7%.

Moving from a 20th to a 21st CenturyHealth Care System

20th Century 21st CenturyProvider-centered ------------------------- Patient-centered

Price driven --------------------------------- Value driven

Knowledge fragmented ------------------ Knowledge organized

Care decisions widely varying -------- Evidence-based care

Slow diffusion of innovation ------------ Rapid diffusion

Paper-based -------------------------------- Electronically-based

Episodic care ------------------------------ Continuous care

Fragmented care -------------------------- Coordinated care

Limited choice ----------------------------- More choice

Little quality measurement ------------ Ubiquitous measurement

Management by process --------------- Management for outcomes

Adversarial government regulation -- Collaborative regulation

Persistent escalating cost ------------- Overall cost decline

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The Federal Government�s Role in Accelerating Health Care Innovation

timely manner (e.g., immunizations, betablockers for post-MI patients) without adoctor�s order.

Also as a regulator, the government couldenact rules to make proprietary IT systemsless of a �black box,� thereby promotingstandardization and interoperability. Suchregulations might encourage greaterinvestment in IT by providers. Finally, as thetaxing power, the federal government mightinvestigate creative ways to reward (with taxcredits, for example) health care providersfor adopting evidence-based innovations.

Sean R. Tunis, MD, MSc, chief medicalofficer and director of the Office of ClinicalStandards and Quality at CMS, agreed thatthe government must become more activelyinvolved and more innovative in fosteringquality improvement in health care. To thatend, he outlined CMS�s multi-prongedapproach that includes:

!!!!! Clarifying payment and coverage policies.

!!!!! Boosting reimbursement for technologiesthat demonstrate substantially improvedoutcomes.

!!!!! Coordinating CMS and FDA activities. Bysharing information and linking FDAactivities to internal CMS policydevelopment, CMS can develop coveragedecisions in parallel with FDA approvalprocesses, thus speeding diffusion.

!!!!! Issuing explicit guidance on CMScoverage standards.

!!!!! Improving the efficiency of clinicalresearch by providing early designconsultation and prioritizing andsupporting clinical research that iscritical to the Medicare program.

CMS is also seeking to stimulate qualityimprovement by disseminating performancemeasurement and quality data directly toconsumers. The agency now has nursinghome and home care data available on itsweb site, with hospital measures to comesoon. The agency expects this initiative togalvanize providers into a wide variety ofquality improvement activities.

Carolyn M. Clancy, MD, director AHRQ, toldparticipants that one of her agency�s coremissions was to create new avenues of�knowledge transfer� in health care. But shecautioned that one reason for the slowdiffusion of many new innovations is theissue of �who owns� the knowledge transferand translation function. Though the federalgovernment is positioned to gather andorganize vast amounts of medical knowledgeand data on new technologies, there is noconsensus that it should be the primary or amajor conduit of this data to health careproviders. In fact, there is strong sentimentin some quarters against the governmentplaying a central role in influencing thepractice of medicine. She said communitieswant the right to adopt new technologiesdifferently. In addition, she said that one-size-fits-all solutions can and often dobackfire.

Dr. Clancy said AHRQ�s research at themoment suggests that the best opportunityto improve health care quality in the shortterm lies in enhanced diffusion of informationtechnology � particularly as it applies toreducing medical errors. The Department ofHealth and Human Services (DHHS) andAHRQ are currently focusing enormousresources and attention on this issue.

Richard Dixon, MD, FACP, director of theDivision of Prevention Research and AnalyticMethods at CDC, told conferees that there isa need for more �outside-the-box� thinkingabout the government�s role. As a purchaser,the federal government can and should moreexplicitly promote evidence-based care. Forexample, the Medicare program couldreward nursing homes or hospitals(financially and otherwise) that do a betterjob administering influenza andpneumococcal vaccinations to high-riskseniors, Dr. Dixon said. And as a regulator,CMS could require organizations to meetcertain standards of care as a condition ofparticipation in the Medicare program. Itcould, for example, require hospitals topermit so-called standing orders, which allownon-physicians to administer certain known-to-be-effective services in a routine and


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care cost trends, but it can also be a function ofagency leadership and politics.The Bush administration, Ms. Foote noted, hasbeen challenged by the advent of new high-costdevices and drugs that are in high demand. Thepolicy thrust is to question the relative value ofthese new products over existing technologiesand treatments. For example, CMS in late 2002ruled that a new anemia drug (Aranesp) was�functionally equivalent� to an older drug andthus not eligible for higher Medicarereimbursement. At the same time, CMS hasstepped in to advance some technologies whenthe data show clear evidence of their value. (Seethe drug-eluting stents example that follows.)A recent General Accounting Office (GAO) report(released in April 2003) questioned some CMScoverage procedures. The report, DividedAuthority for Policies on Coverage of Procedures andDevices Results in Inequities, concludes thatinefficiencies and inequities exist because localcarriers and intermediaries are empowered underMedicare rules to make localized coveragedeterminations, which results in varied coverageacross geographic regions. The report alsocriticized the agency for failing to consult withoutside experts when making coveragedeterminations. The GAO recommended thatcoverage policy be centralized, but the medicaldevice industry has challenged that conclusion. Inlate 2003, CMS announced changes in itstechnology review process. The agency willstrive to make coverage determinations in 270days, put a coverage-tracking system online, andrespond to special appeals more quickly.The GAO report illustrates the difficulty inbalancing interests in the design of governmentdecision-making processes. Ms. Foote also arguedthat the regulatory process itself is not asinnovative as it should be. New methods can andshould be applied to the evaluation oftechnologies and the approval process to assurethat it is more science-based and can take cost-benefit issues into account when appropriate.There should also be explicit political and policydebate about the role federal agencies play ininfluencing the speed with which certaintechnologies are adopted. The process is too oftencontrolled by special interests (such as theindustries affected) and not debated openly in a

way that the public can understand. If the publicwants access to new technologies faster, theyshould be fully aware of the scientific evidence onvalue and the potential tradeoffs between costsand access to these technologies.Complicating matters is that medical technologiesoften do not fit well into the bureaucraticstructures set up to oversee them. More and moredevices, for example, are �combination� products;they combine elements of being a drug, device,and a new procedure. (See the stents example thatfollows.) Such products stem frommultidisciplinary research that brings togetherinformation technologies with the biological,material, and pharmaceutical sciences. The FDAand CMS have only recently begun to makeadjustments to evaluate such products, and morework is needed before they will be up to speed.

Stents: A Case of Rapid DiffusionStents to treat coronary artery disease were oneof the most highly anticipated medicaltechnologies to come along in years. They alsorepresent a unique example of an innovation thathas diffused relatively rapidly and optimally (forboth expected and unexpected reasons), causing aparadigm shift in the treatment of heart disease.Paul R. Marshall, director of health economics atCordis Corporation (the Johnson & Johnson-owned company that makes one brand of stents),presented the company�s perspective. Firstcommercialized in 1994, stents are wire meshdevices inserted in coronary arteries inconjunction with angioplasty to widen occludedarteries. Studies show they reduce restenosis(renarrowing of the arteries after angioplasty) by30% to 50%. And they virtually eliminate abruptclosures that lead to emergency bypass surgery.Stents have diffused rapidly, with roughly onemillion being implanted in patients in 2002. Mr.Marshall said the main reason for this rapiddiffusion was a decision in October 1997 byfederal authorities to increase reimbursement foruse of stents in the Medicare population.Drug-eluting stents represent an improvementthat will likely will push stents into the categoryof being a �disruptive technology� � one thatthreatens to supplant existing treatments, namelybypass surgery. Drug-eluting stents reduce bythree-quarters the 15%-20% rate of restenosis in

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patients receiving regular stents. (See Figure 4.)That could save up to $1 billion per year by 2005,a powerful stimulant for the technology�sdiffusion. The FDA approved Cordis� drug-eluting stent in April 2003. Competitors areexpected on the market soon.

Mr. Marshall expects use of drug-eluting stents totake off in the marketplace despite its higher cost.Publicity is one reason, but regulators haveplayed a key role as well. In an unusual step, CMSsignaled very early (months before the FDAapproved the device) that it would cover thetechnology and the agency set a reimbursementamount. It also issued a unique ICD-9 code, twonew diagnosis-related groups (DRGs), and a newambulatory patient code (APC). CMS will payhospitals about $2,000 more if a drug-eluting stentis used versus a bare stent (around $14,500 versus$12,500, for example, for treatment of patientswho have a heart attack).But Mr. Marshall acknowledged that manyhospitals are concerned about the stents� impacton their overall finances. Hospitals are expectedto see their revenues from profitable bypasssurgery plummet as a result of drug-elutingstents. For some hospitals, the decline in bypassrevenue could be 30% to 50% over the next fewyears, according to some estimates. Whether thisinhibits diffusion of the stent in any way remainsto be seen.

Prescription DrugsA number of prescription drugs have fairedalmost as well as drug-eluting stents in recentyears, with rapid uptakes being driven byaggressive marketing and by physicians andconsumers who are eager for new treatments.David H. Kreling, PhD, professor and chair ofpharmacy administration at the School ofPharmacy, University of Wisconsin-Madison, saiddirect-to-consumer (DTC) marketing has boostedthe sales of many new drugs, particularly thosethat treat symptoms that are easily identifiable byconsumers themselves. This relatively new formof marketing is an innovation in itself that ischanging the dynamics in the prescription drugmarketplace.The question is whether DTC ads are leading toinappropriate prescriptions by creating pressureon doctors to prescribe drugs their patientsrequest. That, in turn, raises an importantquestion about the speed with which new drugsare adopted. Most drugs in the past have beenadopted by physicians at a measured pace, asthey and their patients became more comfortablewith them. But drug company emphasis in recentyears on creating blockbuster drugs to boostrevenues has spurred significant investments inmarketing designed to elicit early adoption bydoctors and consumers.Dr. Kreling suggested the following strategies toensure that new drugs diffuse at an appropriatespeed � i.e., that truly innovative drugs diffuserapidly while those that offer little or noadvantage compared to existing agents diffusemore slowly.! Greater use of clinical guidelines and

prescribing protocols.! Economic and cost-benefit evaluations of

pharmaceuticals.! Head-to-head trials comparing new drugs to

existing agents.! Directives or prohibitions related to certain

kinds of promotion.! More and better education of physicians and

patients, both of whom often lack definitivedata to guide their pharmacy decisions.

Figure 4: Relative Reduction inRevascularization Rate

(9-Month Follow-up)

Source: Paul Marshall, Cordis


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Innovation in the Hospitaland at the BedsideSeveral speakers discussed the pace of diffusionof innovations within the hospital and at thepatient�s bedside.

SurgeryIn contrast to drugs and devices, surgicalprocedures and innovations are not technicallyapproved by government. (Procedures thatinvolve using new devices, tools, or substancesare an exception, requiring FDA approval.)However, as with drugs and devices, governmentreimbursement under Medicare and Medicaid iscritical to the diffusion of many new surgicalprocedures. In addition, their adoption is drivenby research and professional assessment (e.g.,guidelines developed by medical associations).But in all too many cases surgical procedures gainpopularity in the absence of definitive evidencethat they work, according to Charles Wilson,MD, MSHA, DSc, a professor emeritus ofneurosurgery at the University of California SanFrancisco, senior fellow at the Institute for theFuture, and advisor to The Health TechnologyCenter. In some cases, surgical procedures lackingan evidence base are used for years before theyare proven to be useless � or worse, harmful topatients. Dr. Wilson cited several examples ofhow surgical procedures have diffused, some tooquickly (and inappropriately), some too slowly,and some appropriately.!!!!! Chymopapain for lumbar disc herniation: In

1964, a surgeon named Lyman Smith firsttried injecting chymopapain (an enzyme) intolumbar discs, building on animal research thatsuggested this approach was effective intreating disc herniation. By 1974, theprocedure was very popular, with anestimated 17,000 patients being treatedannually. The simplicity of the procedure (it iseasy to learn and do) and aggressivemarketing combined to drive rapid diffusion,in spite of skepticism from a handful ofsurgeons (which was dismissed as �sourgrapes� since surgeons lost income because ofthe rapid adoption of the procedure). But 15years later, in 1989, a landmark studyinvolving 75,000 patients showed that the

procedure offered no clinical benefit. Thisstudy, along with highly publicized (thoughrare) cases of fatal complications and paralysisas a result of the procedure, prompted theFDA to withdraw its approval ofchymopapain in 1999.

!!!!! Cerebral artery bypass: This procedure wasdeveloped to increase cerebral blood flow inpatients who suffered a transient ischemicattack (TIA, which signals a 50% chance of amajor stroke within a year) or who have hada non-disabling first stroke. First performedin 1967, the procedure diffused widely in the1970s. In 1985, a randomized internationaltrial published in the New England Journal ofMedicine found that it was ineffective inpreventing strokes, prompting Medicare towithdraw reimbursement the following year.

!!!!! Endovascular obliteration of intracranialaneurysms: This technique was first used in1974, using a detachable balloon. In spite ofpositive studies that were initially reported in1982, the procedure was still only used infewer than 5% of eligible patients, primarilybecause of a dearth of surgeons willing tolearn how to perform it. Following animprovement to the procedure in 1982(making use of platinum coils), use increasedsomewhat, but diffusion still proceededslowly. In 1991, the introduction of a bettercoil (using electrolytic detachment) began toalter this pattern, and by 1998 endovascularsurgery was used in 10% of rupturedaneurysms. Diffusion spread even morerapidly after 1998, and by 2002 endovascularsurgery was used to treat 35% of eligiblepatients. The key drivers of this diffusionwere growth in the number of neurovascularstroke units in hospitals, outcomes data thatprovided comparisons of various treatmentapproaches, technologic advances in imageguidance and the versatility of coils, andreaching a critical mass of neurovascularsurgeons who were familiar with thetechnique.

!!!!! Gamma knife surgery (GKS) for acoustictumors: The concept for this minimallyinvasive procedure was first introduced in1951, although it was not applied to acoustictumors until the early 1970s. The first gamma

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knife appeared in the U.S. in 1987. By 2002,about 28% of surgeries for acoustic tumorsutilized the GKS technique. By 2007, it isprojected that GKS will have a 45% marketshare. The rapid diffusion of GKS has beendriven by a few simple facts: it works, it issafe, it is simple to learn and do, and it isnow reimbursed.

Hospital DesignWhen planning for the building of a brand newhospital began in the mid-1990s, the leaders ofNorthwestern Memorial Hospital in Chicago sawan opportunity to create a truly unique 21st

century institution integrating innovative designwith new technologies and tools. By manyaccounts, the hospital (which opened in 1999) hassucceeded, creating a model for others aroundthe world.Jean Przybylek, MS, RN, vice president ofhospital operations at Northwestern, toldattendees the planning process itself representedan innovation that, in her view, should diffuserapidly in the industry. It included the following:! Developing an overall vision to guide the

process. Northwestern started from a simplepremise: the patient�s perspective andexperience comes first and drives the design.This meant more than designing for optimumclinical care flow, but also taking into accountpatient comfort, ease of access to facilities,and ease of movement for patients and theirfamilies.

! Creating a physical and working environmentthat would attract and retain the bestmedical, nursing, and administrative staff.

! Using a flexible process in which workgroupteams routinely provided input and feedbackat each stage of the design process.

! Taking infection control and other patientsafety issues into account in the design andconstruction.

! Designing to allow both integration oftoday�s latest technology as well astechnological upgrades over time.

The end result is a unique facility that uses lightand space to create a non-clinical ambiance, artand design to enhance the patient experience,and numerous, cozy family visiting and waiting

areas to promote socialization. Other innovationsinclude patient rooms wired for fiber opticcommunications and patient-focusedentertainment, and a state-of-the-art infectioncontrol system that makes use of a new air flowtechnique. Since 1999, hundreds of hospitalexecutives from around the world have touredthe new facility.

Care at the End of LifeSubstantial improvement and innovation in end-of-life care have already occurred throughout thesystem. But Joanne Lynn, MD, MA, MS,director of the Washington Home Center forPalliative Care Studies and a researcher at RANDHealth, believes that end-of-life care in the U.S. isstill far from adequate. She discussed thediffusion of three components of end-of-life care:hospice, pain management, and complex caremanagement.Before the mid-1980s, a small percentage ofdying people in the U.S. had access to hospicecare. Today, it is available almost everywhere,due in large part to the fact that Medicare coverssix months of hospice care for those who qualify(i.e., if a physician and the hospice medicaldirector determine that they have a prognosis ofdeath within six months). Hospice is also coveredby most private insurers, although often withrestrictions. Hospice care has also diffusedbecause it is a relatively easy business toestablish.But even though hospice care is availablevirtually everywhere in the country, only onequarter of all dying people get any kind of hospiceservice today. Why? Dr. Lynn cited three corereasons:! Lack of knowledge about hospice services.

Consumers do not understand hospice care.And it is not widely marketed.

! Low patient demand. Many Americans stillprefer to manage their own death or rely onfamily members. They may be in denial orthink that entering a hospice facility istantamount to giving up. Many also opt outof hospice because to qualify they have toforego treatments that might prolong theirlives, which of course is a difficult andemotional choice for many people, theirfamilies, and their doctors.


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! Low reimbursement, which produces ashortage of providers in some areas.

Dr. Lynn said increasing reimbursement wouldspur growth in hospice care, but that enhancededucation of the public and physicians abouthospice is also essential.Like hospice care, end-of-life pain managementhas improved in recent years. Opioid use in dyingpatients, for example, has risen tenfold since 1995,driven largely by the development of new andbetter drugs. Notably, the Joint Commission onthe Accreditation of Healthcare Organizationsnow requires that hospitals have discernable painmanagement programs. Research has alsoconvinced doctors that more aggressive painmanagement is safe. And more clinicians havereceived training (and some even have begun tospecialize) in palliative care management.Still, obstacles continue to stand in the way ofmore rapid adoption of aggressive painmanagement in the dying, Dr. Lynn said. Forexample, recent studies indicate that half ofnursing home patients suffer from serious painproblems that are not adequately addressed.Doctors continue to fear that patients inlegitimate need will become addicted topainkillers, even though the evidence suggeststhat they will not. Payment for counseling andmultidisciplinary care continues to lag, as doesfull integration of pain specialists into team care.Perceived legal barriers also stand in the way. Areport released in April 2003 found widespreadunder-prescribing of painkillers nationwidebecause doctors overestimate their risk of legalliability if patients misuse the drugs. The report,published in the Journal of Law, Medicine and Ethics,estimates that on any given day 75 millionAmericans are in pain unnecessarily, including 15million people who have chronic conditions.Complex or multi-condition care management isanother cornerstone of end-of-life care today.Most people who die of old age have multipleconditions, and their death may be precipitatedor accelerated by several of these. Programs thatare organized to deal with this can not only easepain and suffering but save money. The Hospiceof Winston Salem (North Carolina), for example,built a care management program for the dyingthat uses care teams and advance care planning. Italso trains patients in self-management. Nurses

are dispatched to a dying patient�s home withinan hour of an �exacerbating� event. The programsharply reduced the need for emergency care.Yet outside of certain parts of the VeteransAdministration health system or a handful ofgroup-model HMOs, this model is seldom usedfor the frail elderly who need it, Dr. Lynn said.Factors inhibiting the spread include thefollowing:! Medicare does not provide coverage for

complex care management, in part because ithas not been definitively shown to savemoney.

! Needed services, such as home evaluation andtreatment, 24-hour on-call nursing, andcertain types of drugs, are not available orcovered by Medicare.

! There is a reluctance to develop care plans forpatients who are dying.

! The organization of the delivery system doesnot support continuity of care.

New �mental models� are needed to replacecurrent misconceptions about how and whypeople die, and the care they need. (See Figure 5 )These models should recognize that death oftencomes slowly and is the result of multipleconditions and causes. Dying patients need helpin living this last phase of life as fully as possible,including a customized care plan that involves thefamily and that conforms to the patient�s wishes.To make this type of care more commonplace, Dr.Lynn recommended a realignment of paymentincentives to recognize the value of this type ofcare and demonstration projects to document thevalue of the approach.

Figure 5. How Americans Die:Century of Change

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The Next Wave of Biomedical and Health Technology InnovationPresentation by William Dwyer, MBA, divisional vice president of strategic marketing for the AbbottHealthSystem Division of Abbott Laboratories. Response and comments by Wade Aubry, M.D., senior advisor tothe Health Technology Center; Jerry Parrott, vice president of public policy and corporate communications atHuman Genome Sciences, Inc.; and Paul Citron, MSEE, vice president of technology policy and academicrelations at Medtronic.

Mr. Dwyer reminded participants that close to 500gene therapy treatments have been testedworldwide, with only one positive clinical trial todate. And that was halted due to patientcomplications. Despite this slow beginning, Mr.Dwyer said he believes that genomics andproteonomics will one day provide treatments noteven dreamed about today.

Among the most promising technologies on thehorizon:

! Gene therapies that promote new blood vesselgrowth, with the potential to bypass existingvessels that have life-threatening blockages.

! Diagnostic gene �chips� that can provide aDNA profile of a person, revealing theirpredisposed risk of certain diseases.

! Disposable imaging capsules that can beswallowed, providing detailed images non-invasively.

! Techniques that let the cells from bone marrowtissue be �morphed� into tissues such as skin,bone, and cartilage, allowing the creation ofnew skin and tissue grafts.

! Nanometers�small �machines� built fromsingle DNA molecules that will travel throughthe body to target pathogens.

Mr. Dwyer predicted that cloning will continue toadvance at a rapid pace, even if there is amoratorium in the U.S. The field has already movedfrom the cloning of the first animal from an adultcell in 1996�a task declared impossible in1985�to the cloning of 50 mice from a singleadult mouse in 1998. Mr. Dwyer said he believesthat human cloning will be achieved in the nearfuture.

And though it may take a bit longer than peoplethought a few years ago, the Human GenomeProject and the research it has spawned will yieldnovel drugs and therapies. Techniques will bedeveloped that allow drugs to be tailored toindividuals, for example. And drugs and vaccineswill be developed with increased speed and atlower costs as well. Mr. Dwyer also foresees a

revolution in drug delivery. Aerosol devices, forexample, will allow inhalation of vaccines,hormones, and other drugs.

These developments have the potential tosignificantly lower costs, Mr. Dwyer said. Forexample, roughly 100,000 ulcer surgeries wereperformed in 1977. But once researchersdiscovered the bacteria that causes ulcers, drugswere developed that have replaced this surgery ata fraction of the cost � $1,000 for drug treatmentcompared to roughly $28,000 for surgery.

The three discussants agreed that despitesounding like science fiction, many of the futuretechnologies Mr. Dywer discussed were within therealm of the possible, if not probable. But whethersociety is ready for the ethical and financial impactis another issue. Dr. Aubry said that employers andhealth insurers may be increasingly reluctant tocover some new technologies if health costscontinue to rise. Just as some insurers do notcover lifestyle drugs such as Viagra, it is not clearthat they will be willing to cover human�replacement parts� and drugs aimed at enhancingnormal function. Mr. Parrott concurred with Mr.Dwyer that within the next 20 years drugs will beproduced that can be targeted at subgroups ofpeople or even individuals. And within 40 years, itwill be possible to �reset� a person�s genetic clock,Mr. Parrott predicted.

Mr. Citron cautioned that a variety of forces standin the way of the �next wave� of biotechnologyinnovation. These include regulatory uncertaintiesfor breakthrough and combination technologies,legislative limits on stem cell research, delays inreimbursement, and a highly constrained venturecapital environment for start-up companies. Mr.Citron called for an examination of the governmentapproval and reimbursement policies that governpotentially life-saving technologies. But Dr. Aubrycautioned against moving too quickly. He said thatdemand for innovations often precedes evidence ofeffectiveness (as occurred with autologous bonemarrow transplants for breast cancer, for example).Some unproven technologies diffuse too rapidly,putting patients at risk of harm.


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Innovation in Public Health,Prevention, and DiseaseManagement

Public HealthStephen Isaacs, JD, president of Health PolicyAssociates in San Francisco, highlighted publichealth success stories of the 20th century, and thelessons they hold for the public health challengesof the 21st century. Among the best known successstories were the eradication of polio and thecontrol of measles, diphtheria, and whoopingcough � each of which was accomplished throughthe unusually rapid diffusion of massimmunizations. Less well known successesinclude the control of tuberculosis and declines inthe following: traffic deaths due to drunkdriving, neurological damage from lead, toothdecay, heart disease, stroke, unwanted pregnancy,and smoking. These public health successes offertwo critical lessons:! Tenacious consumer and public interest groups

often play a leading role in pushing socialchange to protect and promote public health.

! Once the evidence is clear, decisivegovernment action to enact laws andregulations to protect public health is essentialand successful.

For example, research in the 1930s and 1940sconclusively showed that fluoride indrinking water reduced toothdecay. A small number ofadvocates and several dentalsocieties spread the news andadvocated that fluoride beput in water supplies. Stateand local laws quicklyestablished the practice,despite bizarre (but popular)claims that such action was a�communist plot.�Similarly, mounting researchin the 1950s showed thedangers of lead to childhooddevelopment. As a result,groups such as the NaturalResources Defense Council,Consumer�s Union, and the

Environmental Defense Fund pushed for lead-free gasoline. The Clean Air Act of 1970 mandatedthe transition to lead-free gasoline, despite aseries of lawsuits from industry that threatenedto slow down the transition.The same pattern played out in auto safety, drunkdriving, and tobacco control. Ralph Nader andothers led the fight for seatbelts and airbags andfor greater attention by the auto industry tosafety. The net result was the development andwidespread use of innovations that car makersinitially thought would be too expensive todeploy. Congress in 1966 passed the NationalTraffic and Motor Vehicle Safety Act. Statespassed laws as well, including those that requireseat belt use.Mothers Against Drunk Driving (MADD) andStudents Against Drunk Driving (SADD) led thefight in the 1980s to curb drunk driving. Severalof the leaders of these organizations weremotivated by personal loss to launch theinitiatives. The movement led most states to passmuch tougher DUI (driving under the influence)and DWI (driving while intoxicated) laws. Inaddition, the federal government has tied theavailability of highway funds to states� successrates in reducing deaths from drunk driving andto their willingness to raise drinking ages. Peoplehave changed their behavior as well; use ofdesignated drivers is now commonplace, forexample. (See Figure 6.)

Figure 6. Decline in Traffic Deaths

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The campaign to reduce smoking tooklonger to reach fruition. Research in the1950s led early advocates to spotlight thelink between tobacco products and cancerand to call for action. In a twist,government, in the person of SurgeonGeneral Luther Terry, took up the cause. Alandmark Surgeon General�s report in the1960s led to widespread calls for publichealth measures. Follow-up reports byfuture Surgeons General strengthened thecase, especially the fact that tobacco isaddictive. In 1965, the governmentmandated the boxed health warning oncigarette packs. The FDA also got involvedin the late 1980s when Commissioner DavidKessler sought FDA regulatory power overtobacco products. That effort failed, butCongress and most states eventually passed lawsallowing restrictions on smoking and bans oncigarette advertising. High profile lawsuits,including the states� landmark case seeking torecoup Medicaid costs related to smoking, also

Figure 7: Decline in Smoking in the U.S.

Commissioned Paper SynopsisMedical Technology, Innovation, and the Nature of Medical Progress

By Daniel Callahan, Ph.D., Director, International Programs, The Hastings Center

Between 40% and 50% of the persistent rise inhealth care costs in the U.S. is attributable to newmedical technologies and the intensified use ofolder ones. This presents a difficult problem. As aculture, we are hooked on medical technology, andcan not imagine living without it much less beingsick without it. On the other hand, there is growingrecognition that the inexorable rise in costs andthe liberal use of new technologies could somedaysoon make health care all but unaffordable, forcingunpleasant tradeoffs.

We have reached a point where a basic clash ofvalues is occurring. It is a clash between the valueof equitable access to affordable health care for allcitizens on the one hand, and that of constanthigh-tech medical �progress� on the other. Wehave been living with a model of health careprogress that in fact admits little if any limits tothe development and use of technology. Thatmodel has led, and will continue to lead, to a pathof endlessly rising costs and increasinglyinequitable care. I believe that model and pathmust now be abandoned.

In its place we need a new model and frameworkfor defining medical progress. We must start byrecognizing that there are three ways of conceivingof medical progress � (a) as a scientific enterprise,(b) a clinical enterprise, and (c) a populationenterprise. Our culture for 100 years has put mostof its energy and resources into the scientific andclinical enterprise of medicine. That has producedmany wondrous breakthroughs.

But we have badly ignored the population frame ofreference. The most egregious example of this isour lopsided focus on acute care at the expense ofpreventive care and chronic care management.Indeed, much of our technology today yields only anegligible impact on the overall health status of thepopulation. And lately we have shifted to anoveremphasis on the clinical enterprise � building avast (mostly profit-oriented) health care andfinancing infrastructure that has large incentives todeliver the most costly care. Almost everyoneagrees that this system wastes enormousresources.

Source: CDC, �Current Smoking Among Adults � United States 2000�

led to widespread changes. (See Figure 7 for dataon declines in smoking rates.)Mr. Isaacs said emerging public health problemsare tracking past experience. In particular, early


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advocates, including several prominent healthcare groups and philanthropies, are calling foraction to reduce a rapid increase in the prevalenceof obese and overweight individuals in the U.S.Media attention to the issue is also growing.People are talking for the first time aboutlegislation that would strengthen warning labelson foods, and perhaps even limit the fat contentof certain foods. Mr. Isaacs predicted a knock-down, drag-out fight on these issues over thenext decade if the proportion of the populationthat is overweight keeps rising, as expected.

Prevention and Screening ServicesDavid Atkins, MD, MPH, chief medical officerfor the Center for Practice and TechnologyAssessment at AHRQ, told conferees thataccelerating the use of clinical preventive healthservices is one of the most powerful paths toimproved population health status in the U.S. Butwhile use of some services and screening tests hasrisen significantly in recent years, use of othershas foundered. And even in those areas where

improvements have occurred, usage rates remainwell below best-practice levels. (See Figures 8 and9 on page 18.)This should come as no surprise, since theobstacles to greater use abound. Inadequateknowledge about which services are mosteffective results in a lack of demand forpreventive care services on the part of bothphysicians and consumers. Inadequate insurancereimbursement also inhibits access. Coverage hasimproved in recent years but still falls short forsome recommend services. Over 80% ofemployers, for example, provided coverage in2001 for physical/wellness exams, gynecologicalexams, and childhood immunizations. But farfewer covered chlamydia screening, smokingcessation programs, cholesterol tests, nutrition/diet counseling, and weight loss programs. Also,employer and health plan coverage of preventiveservices does not always follow therecommendations of the United States PreventiveServices Task Force (USPSTF), a government-sponsored panel of experts affiliated with AHRQ.

We need now to shift back to the scientificenterprise, and a re-orientation to population-based health care. We need to put moreresources into basic research, new cures andtreatments, and diffusing existing evidence andknowledge more effectively. At the same time, weneed a fresh embrace of the goal of maximizing theoverall health of the population.

Of course it is not easy to discern which newtechnologies and innovations truly advance thehealth of the population and which are of littlevalue. Good measures and barometers must bedeveloped. The chief question we face is this: Isthe diffusion of a technology that is very expensivebut increases life expectancy by, for example, oneyear (and perhaps mostly for people over age 75)something we want to diffuse rapidly?

Take the ventricular assist device, for example. Itcosts $160,000 and increases life expectancy (forpatients whose hearts have failed but are notcandidates for a transplant) by roughly 400 days,about 250 days longer than if these same patientstook the medicines available today. The estimatedcost for treating all clinically eligible patients in theU.S. in 2001 was $16 billion. Is it worth it? Thereis no easy answer.

Clearly, some technologies will be of obvious andclear benefit (at low cost). Consensus for rapiddiffusion of them will come quickly. Others willrequire longer evaluation but may be of such lowcost that they do not pose problems. It�s a thirdset of technologies that poses the most problem �technologies that are very costly and whoseclinical usefulness is not yet proven. We canexpect more technologies to fall into this categoryin the years ahead. This should compel us todevelop a rigorous set of cost-benefit analysesthat must be applied to them. My modestproposal is this: require manufacturers of costlynew medical technologies (as judged by somecriteria) to conduct cost- benefit analyses of them.This data would be evaluated by a new governmentagency that includes impartial outside experts asscientific evaluators.

My aim is not to undermine the engine of medicalinnovation. Rather, it is to provoke a rationaldebate about how we should allocate increasinglyscarce medical resources, and then to move to asystem that rationally uses these resources to themaximal benefit of the population as a whole. Ibelieve this is the responsible course of action totake.

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For example, task force recommendations includescreening for colorectal cancer but not forprostate cancer, yet more employers cover thelatter.The task force has been systematically evaluatingthe scientific evidence for many clinicalpreventive services in recent years. In addition,

the CDC sponsors the Guide to CommunityPreventive Services (often referred to simply asthe Community Guide), which provides publichealth decision makers with recommendationson population-based interventions. But Dr.Atkins believes it is an uphill battle to makefront-line providers aware of the evidence and

the ongoing evaluations. All too oftenthey will be swayed by stories in themedia rather than by the medicalliterature.Dr. Atkins recommended that the useof evidence-based preventiveservices be enhanced by:! Collaboration at the local level

between payers, health plans, andproviders to increase awareness ofpreventive health services andscreening tests.

! Providing patients and employeeswith personalized remindernotices from their physicians,delivered in the mail, by e-mail, orby phone.

! Enhancing coverage based onevidence and the USPSTF andCDC recommendations.

! Creating financial incentives foraccessing preventive services, suchas reduced copayments and/ordeductibles, wellness accounts,and rewards for lifestyle changes.

! Enacting state laws mandating theprovision of preventive services.

Disease ManagementDavid Plocher, MD, vice presidentin Cap Gemini Ernst & Young�sHealth Consulting Practice, saiddisease management programs are aninnovation that should have diffusedrelatively rapidly. The conceptbehind such programs is simple andgenerally accepted by administrators,doctors, and patients. And there haslong been evidence that they benefitpatients. Yet the adoption and use ofdisease management has been neitherrapid nor smooth.

Figure 8: Increasing Delivery ofClinical Preventive Services

Figure 9: Room for Improvement

National Rates vs. Best Performing Plans

Percent of Eligible Population Receiving Service

Percent of Eligible Population Receiving Service


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Many obstacles are to blame, Dr. Plocher toldconferees. Chief among these is physicianresistance. Put simply, doctors resent being toldhow to treat their patients and having carecoordinated by external organizations. Theywidely believe that they already have systems inplace to coordinate care for high-risk and high-cost patients. They do not want to cede control,due in part to professional integrity, but alsobecause of financial incentives. Doctors resentbeing asked to spend uncompensated time as apart of disease management teams.A second potent reason for the less-than-optimaladoption of disease management is the perception�and in some cases the reality�that the costs tooperate the programs exceed short-term savings.This has been largely because predictive models toidentify the high-risk patients who would mostbenefit from the programs did not work asexpected. Many people with chronic and/or high-cost diseases who could have benefited nevergained access or were never identified. At thesame time, call centers to coordinate patient care,staffed by registered nurses, proved moreexpensive than anticipated. In addition, somehealth plans did not like the idea of outsourcingdisease management functions to specialtyvendors. Many early contracts were terminated asdisagreements arose.Health plans and disease management vendorsare taking steps and making improvements intheir systems that are designed to overcome theseobstacles. Among these:! Involving physicians in the planning and

design of disease management programs, andlimiting physician communications to brief,unobtrusive prompts at the point of care.

! Creating financial incentives for physicians toengage in disease management, includingperformance-based bonuses.

! Sponsoring provider contact with enrollees/patients, instead of direct plan-to-enrolleecommunications.

! Improving predictive modeling so that moreat-risk individuals are identified and enrolledin disease management programs.

! Reducing costs at call centers through morereliance on technology (e.g., auto-dialing, e-mail communications, and remote monitoringand transmission of vital signs).

The Imperative of InformationTechnology and E-HealthNo arena of health care innovation is stirringmore excitement than information technology(IT). Yet even IT�s most vocal advocates cautionthat hype has surrounded the topic for years. Atrail of failed initiatives and business ventures aretestimony to overstated promises. Still, severalspeakers told conferees that IT�s time may havefinally come.In his keynote address, Mr. Gingrich said that therapid deployment of IT is now the glue that willmake so many other innovations in health carepossible. He called on government and theprivate sector to make a massive investment, and hescolded the health care industry for its failure toembrace IT technologies that are increasingproductivity in other sectors of the economy.Dr. Balas agreed that IT is an effective strategyfor accelerating diffusion of other innovations inhealth care. But so far, he said, widespreadadoption of simple IT tools�such as computers inhospitals and physician offices that offer only afew rudimentary software programs and accessto the Internet�have in no way had the impactthat full use of IT tools could have. For example,computer-based reminder systems (for flu shots,pap smears, mammograms, and the like) led toonly a 2% increase in the use of these servicesbetween 1992 and 1997, according to one recentstudy. That is likely higher now, heacknowledged, but still suboptimal. Dr. Balascontrasted this experience with the diffusion ofgenetically-altered cotton in cotton farming from1996 to 2001, which enjoyed an average rate ofdiffusion of roughly 5% a year in severaldeveloped and developing countries where it hasbeen approved.To spread faster, IT must become an integral partof the practice of medicine, not just back officeprocedures. For example, IT vendors andcompanies must begin to offer easy-to-usedecision-support and diagnostic pathway systemsthat can help clinicians make testing andtreatment choices based on evidence. The key todoing this is improved knowledge management.Just as travelers have moved from conventionalapproaches to trip planning (reading books,checking maps) to computerized, integrated ones

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(using the Internet to generate customizedrouting), health care professionals must embracenew ways of using and acting on knowledge.Randy Spratt, senior vice president of businessprocesses and diagnostic systems for McKessonInformation Solutions, said that new systemsunder development now (at McKesson and othercompanies) are a vast improvement over earlierefforts. Mr. Spratt called on academic medicine todevelop the content for these systems, includingguidelines that have adequate detail (e.g.,diagnoses, orders, citations, clinicaldocumentation, and reimbursementdocumentation). He also urged groupsdeveloping guidelines and vendors to adopt the

emerging �HL-7� standards, which will makedissemination easier.

Adopting IT at a Teaching HospitalJohn P. Glaser, PhD, vice president and chiefinformation officer at Partners HealthCare Systemin Boston, told conferees about that healthsystem�s adoption of IT. Formed in 1994, Partnersis a 10-hospital system that includes Brigham &Women�s Hospital (BWH) and MassachusettsGeneral Hospital (MGH).Partners� hospitals were early adopters of CPOEsystems, with BWH implementing a system in1991, which spread to MGH in 1997 after themerger. The remaining hospitals in the system

Financial Incentives to Promote the Diffusion of InnovationsWhat�s in it for me? It�s a question that resonatesacross the health quality improvement landscape.Hospitals and physicians are in the business ofproviding patient care, easing human suffering, andrepairing bodies. But they are also in the businessof earning a living and making a payroll.Conference speakers universally concurred thatinnovations that improve the quality of care will notand can not be optimally diffused in the absenceof financial incentives.

Many speakers recommended that payers beginto subsidize and reward quality improvement � bypaying providers more when they demonstratebetter performance and by footing the bill for someproven technologies and innovations that improvequality of care but may not necessarily accrue tothe bottom line right away.

Dr. Sean Tunis told conferees that CMS fullyembraces the idea of paying for quality and willsoon give it a try. The agency announced in July2003 a demonstration project that will give $7million in bonuses in 2004 to hospitals that scorewell on 35 quality measures. It remains to beseen how quickly CMS can move in implementing afull-blown pay-for-quality program, given some ofthe methodological issues and barriers involved.But the pilot program should help to identify andovercome some of these barriers, he said.

Dr. John Glaser said it is vital to accuratelymeasure the return on investment (ROI) of qualityimprovement demonstration projects. There iswidespread concern among providers, he said,

that new IT systems and other new technologiesdo not offer a timely ROI. In addition, investmentin systems to improve the flow of care compete forresources with technologies (such as imagingmachines) that generate revenues for hospitalsand doctors.

Dr Sam Nussbaum said health plans are intenselyinterested in �paying for performance,� and manyhave launched demonstration projects to test theconcept. One Anthem initiative, for example, paysbonuses to primary care physicians in NewHampshire who are top performers. The bonusesrepresent more than 10% of total Anthempayments to the doctors, and they have resultedin significant improvements in the provision ofpreventive services. (See chart next page.) Asecond Anthem initiative has 50 Virginia hospitalsunder contracts that link up to half their annualreimbursements from Anthem to meetingperformance goals. A third initiative involves 33obstetricians/gynecologists in Columbus, Ohio,who can earn up to a 5% bonus by scoring 90%or better on a set of measures, includingimproving postpartum care, conducting regularmammograms and pap smears, meeting nationalstandards for hysterectomies, and using moregeneric drugs. The program has boosted quality.For example, 100% of new mothers had apostpartum visit two years after the program waslaunched, up from 73.3% in 1999.

In another targeted experiment, HealthPartners, alarge managed care organization in Minnesota,created bonus pools of $7,000 to $44,000 for 20


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must integrate CPOE by 2005. While there havebeen objections and technical issues to deal with,Dr. Glaser said the implementation process hasprogressed relatively smoothly and withreasonable speed. At present, 26,000 orders eachday are entered into the system, 80% to 85% ofwhich are written by physicians. It has alreadyyielded a 55% decline in serious medicationerrors.Implementation of an EMR has proven to be morecomplicated. Early efforts were launched in 1979at MGH, but foundered. Ten years later BWHtried again, but that effort flagged too. After themerger that formed Partners HealthCare, thesystem committed itself to implement an EMR in1996. By 1999, serious objections to the system

medical groups depending on how well theyperformed in identifying and counseling smokers toquit. Counseling rates jumped from 32% in 1996to 53% in 1999. Blue Cross of California, EmpireBlue Cross Blue Shield in New York, Aetna, Cigna,PacifiCare Health Systems, and a large employercoalition (The Leapfrog Group, which includes GE,Ford, Proctor and Gamble, and VerizonCommunications) have also launched pay-for-performance pilots in the last two years.

Mr. Newt Gingrich told attendees that financialincentives must go beyond rewarding the best-performing organizations. He called for direct

subsidies to speed the diffusion of an initialset of specific innovations that are likely tohave a major impact on the health caredelivery system and quality of care in thefuture. These include:

! Electronic medical records (EMRs). Hecalled for the creation of financialincentives for every hospital and physicianoffice to use EMRs, preferably one that isnationally standardized. Implementation ofEMRs that provide access to expertsystems for diagnosis and drug orderingcould save up to $80 billion annually, Mr.Gingrich predicted. Such systems couldalso be vital in helping the nation�sproviders respond to a terrorist attack.

! Computerized physician order entry(CPOE). Very few hospitals have CPOEsystems, and in those that do physiciansuse these systems only 25% of the time.Payers, including government, need toreward facilities that adopt and use CPOEby offering them a higher level ofreimbursement.

! Telemedicine and e-mail consultations.Both have the potential to improve careand should be rewarded.

Speakers cautioned, however, that rewards for highperformers and quality improvement must bebased on sound criteria and measurement. Effortsmust also be undertaken to avoid inducing qualityimprovement in some areas while letting otherclinical areas founder.

Quality Performance:Incentives for Primary Care Physicians

resulted in a �near-death experience,� but by 2002EMR was back on track as a system-wide priority,with $30 million allocated to the project annually.Today the EMR system has reached reasonablescale, with 1,800 physicians and over 4,000 otherclinicians and nurses using it at 58 practice sites.Partners has set a goal of 5,000 physicians usingthe system in the next few years.What made both these IT initiatives happen, Dr.Glaser said, was leadership from administrators andmedical staff who were willing to stay the coursebecause they firmly believed in the need forCPOE and EMRs and in their ability to ultimatelyproduce a sizable ROI. An organized process ofadoption and technical integration was alsoessential.

Source: Sam Nussbaum, MD, Anthem, Inc.

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Commissioned Paper SynopsisComplexity and the Adoption of Innovation in Health Care

By Paul Plsek, Ph.D., President, DirectedCreativity

Health care organizations are complex systems.As such they behave in certain ways, somepredictable, some not. One key to understandingthe diffusion of innovations in health care is tounderstand the way complex systems behaveand adapt to change.

There are essentially three inter-relatedprocesses associated with innovation in healthcare systems: (a) generation or acceptance ofnew ideas or products; (b) implementation ofthose ideas, processes, or products into theroutine work of the organization; and (c)widespread adoption across the organization.

Opportunities exist at each of these levels toaccelerate innovation and improve the quality ofcare. First, enhancing the generation of newideas, especially around service delivery in healthcare, can perhaps best be achieved by a culturalchange in organizations. Many organizations,including hospitals, health plans, large clinics,and nursing homes, suffer from process inertiaand from fragmented systems. Most are notamenable to new ideas, and some are actuallyhostile to them. These organizations need tocreate cultures of innovation.

Many would be well advised to take pages fromthe books of other industries. For example, 3MCorporation holds its senior managersaccountable for generating one-third of theirrevenues from products that did not exist threeyears prior. An analogous goal in health carewould hold managers accountable forimprovements in care delivery and outcomes intheir areas of responsibility based on changesthat have taken place over specified periods oftime.

Accelerating the implementation of a new ideaposes another set of challenges. The mostimportant of these is overcoming resistance tochange. For example, a hospital administrator canmandate implementation of a CPOE system. Butas has occurred at several hospitals nationwide,individual physicians may refuse to use it.Coercive strategies are of limited value in suchcircumstances. A better tactic is to involve thephysicians in the process, so that they takeownership of the idea, the need for the change,and the implementation process itself. The lessonhere is that the uptake of an innovation is almostalways faster when those �on the ground�implementing the change have an investment in itand stand to gain from it � financially,professionally, and emotionally.

Diffusing an innovation throughout an organizationalso requires overcoming inertia and energizing the�natural� social network systems that exist. Forexample, every organization has individuals whomthe rest of the staff look to for leadership. Studieshave shown that focusing on getting these leadersto change their behavior fosters more rapidbehavior change among the rest of the staff.Pharmaceutical companies have long used thisapproach, but it can be effective in changing healthsystem behavior as well.

Creating a context and receptivity for change isalso critical. All too often health careorganizations that want to alter processes toimprove quality fail to lay a foundation that willallow the idea to take off. Organizations thatrequire all decisions to be run up the formalhierarchy, or that allow a few powerful individualsto block changes that they do not personally favor,should not be surprised when innovations do notspread naturally.

To spur broad national hospital investment in IT,Dr. Glaser called for federal funds to partiallysubsidize its adoption, especially in smallhospitals. He also strongly supports the federalgovernment�s efforts (now in early stages) toestablish a national health care informationinfrastructure. Both Dr. Clancy and Dr. Tunisagreed with that goal and said DHHS was

committed to it. Dr. Clancy noted that theimmediate task is to establish health careinformation interoperability standards as thebasis for electronic health data transfer in allactivities and projects and among all federalagencies and departments. DHHS SecretaryTommy Thompson announced such an initiative inMarch 2003. The Consolidated Health Informatics


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Initiative involves 20 federal agencies that willwork with roughly 100 medical, technical, policy,management, and subject matter experts to makethis goal a reality in the next few years.

Getting Doctors to Buy Into ITKatherine Kim, MBA, MPH, partner in theHealth Technology Group LLC and president ofCask Solutions, Inc., presented the results of astudy (supported by the California HealthcareFoundation) examining technology adoption inCalifornia community clinics, medical groups, andindependent practice associations (IPAs). Thestudy of 40 organizations found limited use of ITthrough 2001. Administrative functions such aselectronic claims submission, e-mail, andeligibility verification were the most commonuses of IT. There were few IT links to otherproviders, such as hospitals. But virtually all thegroups said that building EMR and diseasemanagement systems were high priorities for thenext several years.However, whether the funds will be available tobuild such systems is in question. Most of the 40organizations claimed to lack the resources tomake major IT investments. In addition, many ofthe organizations that had built clinical IT systemsin the past few years reportedsome negative experiences.Physicians balked and someadministrators were not yetconvinced they were yet getting areturn on their investment.For example, one California IPAcomposed of 2,500 physicians builtan automated, web-based systemto facilitate communications withmanaged care plans and amongmember physicians. But afterspending millions of dollars todevelop and implement theprogram over three years, themanagement team dispersed, thevendor changed priorities, and thesystem is being dismantled. Thegroup now realizes that it wasnaive to believe that such amassive change would be possible.

Ms. Kim countered that negative experience witha successful one. A Catholic hospital and anetwork of 14 city and county clinics in Austin,Texas were having a tough time scheduling visitsin a timely manner. Patients spent hours on holdtrying to reach the clinics by telephone and wereexperiencing six-month waiting times forappointments. No-show rates were around 50%for some services.To address this situation, the providers set out toautomate manual processes, better matchresources to demand, and improve customersatisfaction by developing a web-based referraland scheduling system with automatedscheduling rules and real-time alignment ofsupply and demand for services. Phased in slowlyover several years (beginning with six clinics andthe hospital), the system quickly eliminated callcenter bottlenecks and allowed the clinics toschedule referrals before patients left. The systemreduced call volume by 20%, virtually eliminatedcomplaints, and paid for itself within the firstyear.Ms. Kim contrasted the California and Austinexperiences. As shown in Figure 10, many driversof adoption were present in Austin that were notin California.

Figure 10: Comparing the Case Studies

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Better Quality ThroughInformed Consumer ChoiceQuality ratings of health plans, hospitals, andother providers are increasingly available toconsumers. If used broadly, this informationrepresents an innovation that could lead to moreinformed choices by consumers and improvedquality, speakers agreed. Recent surveys indicatethat consumers are increasingly willing to usequality ratings in making decisions, althoughrelatively few have access to or use suchinformation today. One survey conducted in 2000found that 38% of consumers would choose asurgeon with higher ratings rather than one theyhad seen before, up from 20% four years earlier.Only 50% would continue to go to a lower-ratedsurgeon, down from 76% in 1996. The samesurvey found that consumers were especiallyinterested in information on medical errors (69%wanted error rate information when choosing ahospital); volumes of specific surgeries (66%);post-surgery death rates (57%); the number ofpatients who do not receive evidence-basedtreatments (51%); and how other patients ratequality (50%).But David Lansky, PhD, president of theFoundation for Accountability (FACCT), toldconferees that the movement to provide qualityinformation to consumers is in early stages, andthat many initial efforts have been of limitedvalue. Because participation is usually voluntary,there has been limited uptake by those beingmeasured. For example, HEDIS (Health PlanEmployer Data and Information Set) and CAHPS(Consumer Assessment of Health Plans Survey)data are widely available for HMOs, but not forother types of managed care plans. In addition:! Many �quality report cards� are not

consumer-friendly.! To encourage participation among health

plans and providers, most efforts havedeliberately been designed not todiscriminate too harshly among those beingmeasured.

! There have been few efforts to �tease out� thefactors that are most important to consumersand patients, or to show clear differences inperformance.

! Most efforts to communicate information onquality to consumers have been weak.

In short, the consumer information movementthus far has been characterized by passiveapproaches that provide data but hesitate toprovide information that actually assistsconsumers in making decisions. That approach isshortsighted, according to Dr. Lansky, sinceconsumer involvement is a vital component of thebroader effort to improve the quality of healthcare in the U.S.Dr. Lansky recommended the following steps tofoster wider use of quality measurement andcommunication to consumers:! An aggressive public information campaign to

raise awareness of quality issues in healthcare. Messages should emphasize thatdisparities in quality can affect the personalhealth of individuals.

! Bold steps to reveal gaps in safety andperformance.

! Identification of�and rewards for�excellentplans and providers.

! Development of tools to assist consumers inasking probing questions.

! Highly personalized quality signals that speakto an individual�s stage of life and his or herfamily�s health.

FACCT has developed a web-based tool(compareyourcare.org.) to inform consumersabout quality issues and help them make choices.It collects data about the quality of care at thephysician, medical group, and health plan levelsto support consumer choice. Other web sites arealso emerging and evolving, includinghealthgrades.org, Subimo, and Healthscope.Subimo, in particular, is diffusing rapidly throughhealth plan web sites, which contract for itscontent.Charles B. Inlander, president of the People�sMedical Society, agreed with Dr. Lansky that thevoluntary nature of most current performanceand quality measurement in health care limits itsscope and utility to consumers. He called ongovernment to require that quality data bereported by hospitals and physicians.


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Mr. Inlander said health care was the �last bastionof non-consumerism� and that organizedmedicine has until recently put up roadblock afterroadblock to obtaining data and usefulinformation on physician performance. He calledfor better provider-consumer communication bymaking greater use of modern technology and byproviding reimbursement to physicians forplaying a vital consulting role with their patients.Kevin Piper, MA, CHE, former director of theNational Health Care Purchasing Institute, echoed

the importance of �actionable information� forconsumers and health care purchasers. He notedthat for every $10 spent on research, only $1 isspent trying to get the information disseminatedinto the health system, with the vast majority ofthis $1 being spent on publishing. Little effort ismade to synthesize, translate, and disseminateresearch findings so that they are useful to healthcare decisionmakers. He called for a concertedeffort to change the way information is compiledand disseminated.

David Atkins, M.D., M.P.H.Chief Medical OfficerCenter for Practice and Technology AssessmentAgency for Healthcare Research and [email protected]

Wade M. Aubry, M.D.Senior AdvisorThe Health Technology [email protected]

Andy Balas, M.D., Ph.D.Dean, School of Public HealthSt. Louis [email protected]

Elise Berliner, Ph.D.Senior Service FellowCenter for Practice and Technology AssessmentAgency for Healthcare Research and [email protected]

Daniel Callahan, Ph.D.Director of International ProgramsThe Hastings [email protected]

Nancy Chockley, M.B.A.PresidentNational Institute for Health Care ManagementResearch and Educational [email protected]

Paul Citron, M.S.E.E.Vice President, Technology Policy and AcademicRelationsMedtronic, [email protected]

Carolyn Clancy, M.D.DirectorAgency for Healthcare Research and [email protected]

Appendix A: Conference Faculty with Contact Information

(in alphabetical order)

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Molly Joel Coye, M.D., M.P.H.President and CEOThe Health Technology [email protected]

Susan DentzerCorrespondentThe Newshour with Jim [email protected]

Richard Dixon, M.D., F.A.C.P.Director, Division of Prevention Research andAnalytic MethodsCenters for Disease Control and [email protected]

William M. Dwyer, M.B.A.Divisional Vice President, Strategic MarketingAbbott HealthSystem Division, [email protected]

Susan Foote, J.D.Associate Professor and Division HeadDivision of Health Services Research and PolicySchool of Public Health, University [email protected]

Newt GingrichCEOThe Gingrich [email protected] (Amy Pearman)

John Glaser, Ph.D.Vice President & Chief Information OfficerPartners HealthCare [email protected]

Charles InlanderPresidentThe People�s Medical [email protected]

Steven Isaacs, J.D.PresidentHealth Policy Associates/Center for Health andSocial [email protected]

Katherine Kim, M.B.A., M.P.H.PartnerHealth Technology Group, LLC510-836-8985, ext. [email protected]

Lisa Koonin, M.N., M.P.H.Director, Office of Health Care PartnershipsDivision of Prevention and Research andAnalytic Methods,Centers for Disease Control and [email protected]

Dave Kreling, Ph.D.Hammel/Sanders Chair in PharmacyAdministrationSonderegger Research CenterUniversity of Wisconsin School of [email protected]

David Lansky, Ph.D.PresidentFoundation for [email protected]

Joanne Lynn, M.D.DirectorThe Washington Home Center for PalliativeCare [email protected]


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Janet E. MarchibrodaCEOThe eHealth [email protected]

Paul R. MarshallDirector, Health EconomicsCordis [email protected]

Catherine McDermottPresident and CEONational Committee for Quality Health [email protected]

Samuel Nussbaum, M.D.Executive Vice President, Chief Medical OfficerAnthem, [email protected]

Jerry ParrottVice President, Public PolicyHuman Genome Sciences, [email protected]

Kevin Piper, M.A.PresidentHealth Results [email protected]

Paul Plsek, Ph.D.PresidentDirectedCreativity770-587-2492paulplsek@directedcreativity.com

David W. Plocher, M.D.Vice PresidentCap Gemini/Ernst & [email protected]

Jean Przybylek, M.S., R.N.Vice President, Hospital OperationsNorthwestern Memorial Hospital312-926-4174 (Sheila Brown)[email protected]

John Smith, M.D., J.D.Assistant Professor of RadiologyHarvard Medical School & Director ofRegulatory AffairsCenter for Integration of Medicine andInnovative [email protected]

Randy SprattSenior Vice PresidentMcKesson Information [email protected]

Sean Tunis, M.D., M.Sc.Director, Coverage and Analysis Group &Acting Deputy Director, Office of ClinicalStandards and QualityCenters for Medicare & Medicaid ServicesDepartment of Health and Human [email protected]

Charles Wilson, M.D., M.S.H.A., D.Sc.Professor Emeritus of NeurosurgeryUniversity of California, San FranciscoSenior AdvisorHealth Technology [email protected]

1225 19th Street, NW

Suite 710

Washington, DC 20036

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W E B www.nihcm.org

1701 K Street, NW

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T E L 202.331.7535

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W E B www.ncqhc.org

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