Fall 2004 Edition

September 29, 2004

“Be ready when opportunity comes...Luck is the time when preparation and opportunity meet."
-- Roy D. Chapin, Jr. (CEO, American Motors, 1967-1977).

The electronic health record and patient-provider portal are platforms that offer unique opportunities for transforming healthcare use and delivery. The prospects for increasing productivity while simultaneously improving quality and access, and not simply choosing one at the expense of another, are enormous. The challenges, however, are daunting.

We live in a remarkable era. Knowledge about how to effectively deliver healthcare is generated at an accelerated pace and masterfully codified. Yet, mounting knowledge rarely translates into solutions that matter, underscoring barriers in how we frame or how we design and test solutions. The stark gap between what we know and what we do signals the need for a paradigm shift – a shift that may not have been possible without recent advances in health information technology. It’s that translation thing! Or, is it?

Sensible discoveries of how to best deliver healthcare abound, paralleling advances seen in other service and information businesses in past decades. Notions of patient-centered care (e.g., informed decision making, shared decision making, motivating self-management), continuous care (e.g., chronic care models), quality care (e.g., automated drug-drug interaction checks, real-time clinical decision support), and productive care (e.g., engaging patient participation, self-scheduling, encounter preparation, automated monitoring) are increasingly formalized and supported by evidence. The real opportunity in revolutionizing care, however, may not be with any one (or even all) of these emerging strategies. Rather, the real opportunity may be in how we formalize principles for designing meaningful solutions.

Research on how best to deliver care, like most of healthcare itself, is highly fragmented. Sometimes discoveries have local influence. Sometimes knowledge diffusion strategies are used to try and export and scale a solution nationwide – a process akin to the pony express. Solutions tend to be idiosyncratic and incomplete, with no cost-effective means of exporting or scaling them for external consumers. By choice, healthcare’s paradigm isolates “research” of a solution from development, human engineering challenges, and implementation. Is it any wonder that research and development have rarely met? The research and development paradigm that we currently have in healthcare would sink any other enterprise. In this era of advances in health information technology, have we set the bar too low? Is the door now finally open that will allow us to make a fundamental shift in what we expect of research?

Expectations motivate discovery. We should question how our research model itself is organized, funded and structured, and whether it is optimal in serving our needs. We should expect inventions to simultaneously improve quality, reduce cost, and increase access. In the past, solutions that have addressed only one or two of these key goals rarely last or even see the light of day. We should address issues of exportability, scalability and sustainability as standard fixtures of any solution. Does it make sense to test a solution that meets a patient’s needs without also addressing those of the provider and payer? What standards should we adopt for the design of healthcare solutions? We now have an opportunity to make choices that may matter as we stand at the edge of a new frontier.

For years, we have implicitly adopted a solution paradigm that may or may not be generally applicable. Remarkably, however, this paradigm has never really been explicitly defined. This is why the opportunity is so enormous, but daunting. Acting on the opportunity means “thinking outside the box,” articulating how research should contribute to healthcare solutions and restructuring how healthcare research is organized. It also means redefining what is expected of researchers.

Inventiveness will always decline or rise to expectations. History is replete with examples. To move forward we will need to “break the mold,” set high expectations, and motivate performance to these expectations. Opportunity beckons. Preparing to take advantage is the first task. The rest is follow-through.

Buzz Stewart, Ph.D., MPH
Director
Center for Health Research & Rural Advocacy
Geisinger Health System
Danville, PA

and

Nirav R. Shah, MD, MPH
Assistant Professor
NYU School of Medicine & Geisinger Health
New York, NY

The views expressed in this article are those of the author and do not imply endorsement by The Robert Wood Johnson Foundation or the Health e-Technologies Initiative.