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Contributor Richard L. Reece, M.D., has asked healthcare leaders to rank the innovations that are transforming U.S. healthcare. He shares the results and outlines the directions he's observed as a result.

I recently gave 100 healthcare leaders from hospital, physician, supply chain and policy sectors a list of 35 major innovations and asked them to rank the top 10 that are transforming U.S. healthcare.

The poll revealed five major directions:

1. Information technology tools for consumers to better manage and pay for care are on everybody’s docket.
2. Consumer-driven healthcare has staying power.
3. Chronic care management will be huge.
4. Public-private partnerships to manage care for Medicare and Medicaid recipients will be a preoccupation.
5. Customized ambulatory care centers and chains to deliver high quality, cost effective patient services locally, regionally and nationally will flourish.

Consensus on the top 10 specific innovations

The belief in healthcare IT was particularly strong. I offer as evidence this consensus among 100 health leaders on the 10 most important innovations transforming healthcare:

1. Pay-for-performance programs
2. Introduction of electronic health records into medical practices
3. Add-ons to EHRs--instant medical histories, coding devices, prescription-enabling modules, or Web sites that permit registration, virtual visits, prescription refills and open-access scheduling
4. Software facilitating office dispensing and prescription writing
5. Software enabling self-care, self-service and self-empowerment of consumers
6. New practice business models (concierge, cash and retail)
7. High tech/high touch remote patient monitoring with patient interactive capacity
8. Personal health records with and without EHRs
9. Disease management programs
10. The transparency movement as part of the consumer-driven care movement

LEADERSHIP AGREEMENTS

This list shows what surveyed leaders agree upon:

• Major innovations will depend on information technologies to rationalize and target resources.
• Data-driven quality care (pay for performance) will become a central reality. Given the impersonal and non-judgmental nature of data, this would seem to be a sensible way to segregate “good” doctors and “good” hospitals from those that do not perform so well. But given the small sample sizes of practices, local and regional differences, and what constitutes “art” and “science” and “hard” versus “soft” evidence, doctors in the field are not entirely convinced that data differentiates quality.
• The most fruitful sites of innovation will reside in physicians’ offices, retail outlets and patients’ homes.
• Healthcare will be more technology-aided and decentralized.
• A deep faith exists in IT’s capacity to transform the system by leveraging transparency. This is related to technology’s power to influence consumer preferences, track prices, aggregate quality data across the healthcare spectrum and allocate resources.
• The combined effect of EHRs in medical offices and personal health records will transform patient-doctor relationships. Patients may be ahead of doctors in this regard. However, doctors see the handwriting--or perhaps I should say, the “digitizing”--on the wall as EHRs take root with surprising speed.
• Consumer-driven care will be a strong cost-leveling and quality-raising force.
• Technology-aided disease management programs will dominate government and private management styles.
• New business models--some doctor-driven and some nurse-directed--will be required to deal with change.

POTENTIAL ROADBLOCKS

Major hurdles like perceived threats to the status quo, federal and state regulations, inadequate funding, human behavioral idiosyncrasies and resistance to change may impede the implementation of these innovations. In May, Regina Herzlinger, a leading advocate for consumer-driven change, outlined and specified innovation-blockers in a Harvard Business Review article entitled, “Why Innovation in Health Care is So Hard.”

Pfizer has had some experience with innovation barriers. In 1995, the world’s largest pharmaceutical corporation made a decision to create Pfizer Health Solutions, a wholly owned subsidiary with the goals of promoting health, preventing and managing disease, and coordinating care. The company also sought to increase access to care for patients suffering from chronic disease while reducing costs.

These goals are worthwhile; Medicaid disease management, after all, looms as a huge potential tool for cutting costs and improving outcomes. But like all innovations, success depends on ease of implementation, cooperation, trust and outcome measurements. One can measure cost reductions, as Pfizer did, by saving $41 million in medical costs through reduced emergency room use and hospitalizations and by positively impacting disease management. But outcome measurements were blocked by vagaries of human behavior of the Medicaid population. After winning a contract to care for a portion of Florida’s Medicaid population through innovative community and statewide programs and technologies to promote health, prevent disease and monitor chronic care, Pfizer realized they had a lot to learn about Medicaid recipients who may:

Move frequently

Switch jobs

Be away from home often

Lack telephone access

Avoid answering phone calls

Be reluctant to change unhealthy behavior

Distrust anyone asking about their health status

Such unanticipated factors made outcome measurement difficult and generated political controversy about exactly what had been accomplished.

The lesson here is that humans are not robots. They do not necessarily march to the beat of management or measurement drummers. Healthcare innovations are important, but the human equation must be factored in.

MEDICAL INNOVATIONS

In a 2001 article in Health Affairs entitled, “Physicians’ Views of the Relative Importance of Thirty Medical Innovations,” Victor R. Fuchs, Ph.D., and Harold Sox, Jr., M.D., reveal a strong consensus among 225 general internists on the relative importance of 10 major medical innovations. General internists were given a list of 30 innovations. They were asked to select five to seven that they felt would have the most adverse effect on their patients if the innovations did not exist, as well as the five to seven that would have the least adverse effect.

The result was a top-10 ranking of the most beneficial “medical” innovations (of the 30 innovations) based on the physicians’ ratings:

1. MRI and CT
2. ACE inhibitors to treat high blood pressure
3. Balloo angioplasty to open blocked blood vessels of the heart
4. Statins to improve lipid metabolism and reduce risk for coronary heart disease and other vascular diseases
5. Mammography
6. Coronary artery bypass graft
7. Proton pump inhibitors and H2 blockers to treat gastro-esophageal reflux disease
8. Selective serotonin reuptake inhibitors and new non-SSRI anti-depressants
9. Cataract extraction and lens implant
10. Hip and knee replacement

These are, of course, technology-based medical innovations, rather than social or organizational innovations. Most of these innovations (except for MRI and CT) originated in the United States. Over the last 30 years, the U.S. has produced more medical Nobel Prize winners than all other nations combined, and drug companies headquartered here have created eight of the 10 top-selling drugs.

The downsides to these technological innovations are high costs and, in some instances, unregulated entrepreneurialism on the part of manufacturers and physician-users of these innovations. American patients are often willing accomplices to overuse--they, like their doctors, often see medical technologies as a “quick fix” for their ailments.

1. Some historical perspective
2. In thinking through innovations on the broader social scene, it is instructive to go back to John Naisbitt’s 1982 list of 10 “megatrends” to see how current healthcare innovations apply:
3. Industrial Society to Information Society--This prediction was dead-on.
4. Forced Technology to High Tech/High Touch—This is being felt as society moves to technology-aided home care, to consumers as partners in care and to alternative, complementary and integrative medicine.
5. 
   National Economy to World Economy--This has been limited in health care, as some Americans seek less expensive care abroad and as Europeans and others seek access to American technologies under their health systems.
6. Short Term to Long Term--I do not yet see a big move toward long-term solutions, although predictive decision-making is a step in that direction.
7. Centralization to Decentralization—This is moving ahead at warp speed.
8. Institutional to Self-Help--Just look at health food sales and the growing alternative medicine movement.
9. Representative Democracy to Partipatory Democracy--Healthcare consumers are not yet “partners in care,” but they are getting there.
10. Hierarchies to Networking—Though hard to document, this is very real.
11. North to South--The South, Southwest and West will dominate national healthcare politics and may be more open to innovations.
12. Either/Or to Multiple Option--This may be one reason people are skeptical about Universal Coverage.

In sum, healthcare leaders agree the future will be a technologically-aided, consumer-demanding, self-helping, market-based, data-sorted, centralized-to-decentralized system with multiple options offered by new practice models.

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Richard L. Reece, M.D., is a pathologist, writer, editor, speaker and consultant in Old Saybrook, Conn. His latest book, Innovation-Driven Care: Key “Under the Radar” Innovations Transforming U.S. Health Care, will be published later this year. He may be reached at rreece1500@aol.com.

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