Maybe it’s because I have the subject of innovation on the brain these days, but I couldn’t help thinking about it as I read Atul Gawande’s article The Checklist in the December 10 issue of the New Yorker. Because Gawande is a practicing surgeon, as well as an amazingly gifted writer, he has always been fascinated with human fallibility and the ways we can (try to) guard against it. That’s been the subject of many of his New Yorker articles, as well as his books Complications: A Surgeon’s Notes on an Imperfect Science,
That’s reason enough to read the article right there. But what really struck me was the broader issue that Gawande sums up toward the end with a quotation from medical checklist champion Peter Pronovost:
“The fundamental problem with the quality of American medicine is that
we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.” We have a thirty-billion-dollar-a-year National Institutes of Health, he [Pronovost] pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.
As Gawande pointed out this past spring in a number of guest columns for the New York Times, this inattention to health-care delivery is one of the core reasons that our health-care system is in such a mess right now.
But that’s also what got me to thinking about innovation policy: Pronovost’s critique resonates strongly with a lot of the discussions I’ve been hearing about this subject lately. Over the past six decades, the United States has made massive public and private investments in basic scientific research—the analog of understanding disease biology—and even more massive investments in the effort to turn basic discoveries into products: the analog of finding effective therapies. But policy-makers haven’t taken the “delivery” aspects of innovation nearly as seriously. And that kind of inattention could hurt us. As Chris Hill points out in his new article on “The Post-Scientific Society,” those aspects are becoming more and more important:
Just as the post-industrial society continues to require the products of agriculture and manufacturing for its effective functioning, so too will the post-scientific society continue to require the results of advanced scientific and engineering research. Nevertheless, …[t]here are growing indications that new innovation-based wealth in the United States is arising from something other than organized research in science and engineering. Companies based on radical innovations, exemplified by network firms such as Google, YouTube, eBay, and Yahoo, create billions in new wealth with only modest contributions from industrial research as it has traditionally been understood. Huge and successful firms like Wal-Mart, FedEx, Dell, Amazon.com, and Cisco have grown to be among the largest in the world, not as much by mastering the intricacies of physics, chemistry, or molecular biology as by structuring human work and organizational practices in radical new ways.
There is a lot that could be said to follow up on that thought. But rather than pontificate all by myself, I’d like to hear other opinions. Comments, anyone?
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4 Comments
This would be an interesting question to pose to the authors of the Academies reports — they’ve done several. From personal experience (not much of a source, I know), I’ve been very pleased with how my new doctor tracks my visits over an electronic system. She followed a checklist while doing my initial exam and then was able to link my medical records from that single point from that day forward — even my cardiologist was able to access these records when I had later visits with him and my bloodwork labels are regularly printed from that source as well. Simple system, but incredibly valuable.
Diffusion of innovation has always been the laissez faire portion of the process. It is assumed that if the innovation is good enough, the market will work its magic (build a better mousetrap …). Every once and awhile some one realizes that in a specific area, diffusion needs help. That was the rationale for the Agricultural Extension Service (to diffuse new agricultural science) and the Manufacturing Extension Partnership. But the idea of a more systematic process for diffusing innovation generally is seen as an anathema — “picking winners and losers.” Maybe we need to change our mindset.
In October 2006, the National Institutes of Health launched a major initiative designed to promote and accelerate the translation of basic biomedical research into clinical studies, and ultimately, into clinical practice. Called the Clinical and Translational Science Awards (CTSA) program, this initiative will provide funding for up to 60 academic health centers across the US by the year 2012. The CTSA program is one of the cornerstones of the NIH’s Roadmap for Medical Research effort. It is based on a clear recognition that the pace of translation of findings from basic research within the US has slowed over the past several decades for a number of reasons,and that revitalizing this system will require a massive “re-engineering of the clinical research enterprise”. To date, 24 institutions have received funding through this program.
The CTSA program addresses this re-engineering effort in two fundamental ways. First, it seeks to remove some of the structural obstacles that might impede clinical and translational research by supporting the development of research infrastructure (e.g., biomedical informatics, etc.) and the streamlining of internal processes (such as the Institutional Review Board process.) Second, it funds the development of new training programs to train the next generation of clinical and translational researchers, and supports the development of institutional career paths and incentives to attract these young investigators to clinical and translational research and retain them over time.
If you want more information about this, there is a good website on the program which you can find at http://www.ctsaweb.org.
An emailed comment from Jeffrey Murrah, http://www.RestoreTheFamily.com :
My experience is that government policy interferes with innovation in health care. Innovation is not rewarded, but rather penalized. There are efforts to standardize procedures, but these are often driven by utilization of financial resources and legal risks, rather than innovation. Besides government regulation and policy, there is the problem of insurance. Many insurance companies only pay for specific procedures based on variables they determine rather than being driven by patient care. The insurance companies go so far as to limit the medications available to the patient. They limit their consideration to the specific formularies that the company approves.
Innovation involves risks. Anytime procedures are performed that are outside of the defined “standards of care”, they are frowned upon at a minimum. In hospitals, there is usually additional paperwork and scrutiny when someone deviates from the accepted procedure, which tends to stifle innovation. Innovation is also stifled by lawsuits which make anyone who attempts innovative procedures or techniques look negligent. They often define negligence as deviating from the accepted procedure. Since most people in health care do not want to be sued, they stay within the “accepted” procedures and policies.
The systems set up for health care have put restraints on innovation. There is some innovation, but even that is limited to following the established procedures for trials, studies, etc. If government and insurance companies took off the restraints, health care could operate more like a science rather than kitchen that only prepares approved dishes prepared in approved methods.