Innovations in Health Care Delivery

Abstract

The pace of innovation has become a gauge for the health of national economies, individual businesses, and educational systems. It is a crucial gauge, too, for the health of the health care industry. Health care innovation has centuries of tradition, as far back as Galen, Vesalius, and the champions of the scientific method. It is now a vast field. In 2015, health care innovation comprises entire subindustries developing new drugs, diagnostic tests, therapeutic devices, prosthetics, information technologies, and more. In2012, total estimatedUSmedical andhealth researchexpenditures were about $130 billion, or just over 4.4% of total UShealth care expenditures.1 The vastmajority of this investment is in biomedical and technological research and underlying basic sciences. From the viewpoint of health care delivery, however, aggravating shortfalls persist in health care innovation. First is the translational shortfall. Biomedical andbiotechnical innovationscan improvehealthonly if theyactually reach patients and communities, only if their value is accurately assessed, and only if choices about which innovations are used forwhomandwhenreflect thoseassessments.Thisproperand prudent translation of innovations into practice is famously slowanddeficient.2Recenteffortshavebeenmountedtospeed up the process, such as the Bench-to-Bedside initiative of the National Institutes of Health,3 but how much they are helping, and at what cost, is not yet known. Second is a shortfall in focus. The bulk of innovations in health care have added cost, often with little proven benefit, to an industry reeling from outside and inside cost pressures. Whereas innovations in other industries have often steadily reduced costs to consumers while improving functionality (eg, laptop computers, cellphones, and web-based access to information), health care shifts more and more costs to consumers,4 takes an ever-increasing share of public and private budgets, and even flirts with rationing as allegedly inevitable. Under these circumstances, it could be expected, and hoped for, that a vast and authentic shift of innovation energies would occur toward changes that reduce costs while improving the outcomes and experiences of patients, families, and communities. No such shift is evident yet at anything near the scale needed. Third is a shortfall in thedemocratizationof capacity. The millennial ethos and new information capabilities have combined through innovations to produce previously undreamed-ofcapacities forpeople tomeet theirownneeds,with less intermediation of layers of supply. People use ATMs insteadof bank tellers andqueues,make travel reservations online instead of through travel agents, shop online instead of in stores, and use tax return software instead of accountants. Health care, in contrast, has clung more tightly to centralized, institutionallybased,physically local, professionally controlled procedures and habits. For each of these shortfalls and others, examples are developing rapidly to fill thevoid, especially in local settings that are for one reason or another friendly to experimentation in health caredelivery.But it isnot likebiotechnology,which,despite high levels of competition and corporate protection of intellectual property, has thriving systemsand institutions for theexchangeof ideasandgrowingknowledge. “Innovation incubators”arepoppingup inmanycities,withsponsorship from venture capitalists, corporations, andphilanthropistswhoare confident that such communities of endeavorwill yield valuable new products and maybe nurture the next Bill Gates or Steve Jobs. Heath care deliveryneeds its “innovation incubators” every bit as much as biotechnology does. Fortunately, that idea seems tobegaining traction.Forexample, theCenter forMedicare and Medicaid Innovation, funded under the Affordable Care Act at $10 billion over 10 years, is up and running and is projected to receive another $10 billion in 2019.5 The charge of the center is explicitly to foster the testing of new models of care andpayment. TheAgency forHealthcareResearch and Quality curates a web-based Innovations Exchange with descriptions of more than 2000 delivery innovations and tools for improvement.6 The Robert Wood Johnson Foundation’s strong new focus on community health is energizing dozens of new projects. JAMA would like to contribute to this important discussion. Innovationand improvements inhealth caredelivery require reliable access tomainstream journals to encourage innovators, subject their work to the refining effects of public discourse, and speed spread and adoption. In pursuit of those goals, JAMA is planning a yearlong series of articles on innovations inhealthcaredelivery tobepublishedthroughout2016. Because innovations, by their nature, are supposed to be surprising and unexpected, a closed list of topics of interest would be self-defeating. To prompt thinking, however, the following topics are suggestions like the ones authors might address: • Self-care, allowing patients and families to do for themselves what is usually reserved to health care professionals • New roles for caregivers, including entirely new jobdescriptions • Teamwork Opinion