Innovation has become one of those buzz words that connotes different things to different people – newness, discovery, or perhaps an advance in technology. But no matter how it's defined, constant innovation has undoubtedly brought the science of medicine to dizzying new heights, and we are all beneficiaries of an ever-improving healthcare system.
Unfortunately, many of these improvements have also been blamed for exacerbating the systemic problem of rising costs. The result is a longstanding contradiction in our attitudes toward healthcare--new technologies are both embraced as a lifeline to better medical care and vilified as a determined path to self-collapse.
Making sense of this paradox requires that we first understand that innovation is not just about new breakthrough technologies, but more importantly about how those technologies are used. The technologies themselves can be quite simple, but the accompanying changes they create in the workforce are responsible for transformative changes throughout entire industries.
Below are a few historical and forthcoming examples of these "disruptive" innovations that illustrate how the cost-quality paradox in healthcare can be resolved by enabling the delivery of quality care that is also more accessible and cost-effective.
The balloon catheter created an entirely new field of vascular interventionalists by making it possible to treat diseases that were previously amenable only to risky and expensive surgery. What started as a low-tech device eventually became much more sophisticated with subsequent add-on technologies, particularly stents and drug-elution, and catheterization has proven to be the preferred mode of treatment for increasingly complex vascular diseases.
More importantly, the new interventionalists did not come from the same highly-skilled—though expensive—pool of surgeons, but rather they came from a less-costly and more numerous set of providers known as cardiologists. This was vital to making this new treatment both affordable and widely available.
Edwards Lifesciences Corporation's transcatheter heart valve is a more recent attempt to redefine the landscape of the healthcare workforce, potentially adding to the growing legion of interventional radiologists, cardiac electrophysiologists, virtual colonoscopists, and other fields enabled by disruptive technologies. And these changes don't always require a new crowd of cross-trained specialists. The advent of portable ultrasound systems meant that obstetricians, cardiologists, emergency medicine physicians, and others didn't always have to refer patients out to a radiologist.
More recently, Ethicon Endo-Surgery is aiming to introduce a computerized sedation system that will allow minimal sedation during GI endoscopy without the supervision of an anesthesiologist. By reducing the number of specialists or referrals involved, these innovations promise cost savings, as well as added convenience for patients.
On the other hand, the money saved by replacing one or several doctors with another type of doctor seems marginal when compared to that saved by technologies which help obviate physician intervention altogether. Some of these devices fall under the "set-it-and-forget-it" variety, such as implantable cardiac defibrillators and insulin pumps. These require surgical intervention for implantation, but subsequent monitoring is minimally taxing compared to the alternative. Similar devices such as Medtronic's implants for treating seizures and chronic neuropathic pain all hold promise to greatly reduce the need for constant medical intervention.
Even more noteworthy, however, are technologies that empower non-physicians and patients to do for themselves things that they used to rely on professionals to do for them. Nurse practitioners, armed with point-of-care diagnostics and evidence-based treatment algorithms, have proven to be more than capable of providing basic medical care in retail clinics conveniently located in pharmacies, grocery stores, and retail outlets. As their arsenal of diagnostic tools expands, so will their patient pools.
The safety hurdle is much higher for developing care routines which patients can manage themselves, but the potential for impact is enormous. NxStage's home hemodialysis machine, Invisalign's invisible braces, and Hill-Rom's chest wall oscillation vest (used to clear bronchial secretions) all rely on patients or their family members to use the devices on their own.
Direct-to-consumer genetic assays from 23andMe and Navigenics are newer additions to a market that already includes more widely-used diagnostics like home international normalized ratio (INR) and early pregnancy testing. There are a number of well-intentioned skeptics whenever patient-directed care is discussed, but lest we forget, we already rely on millions of diabetics to manage their own insulin regimens using home glucose meters.
Further, empowering patients doesn't simply involve sophisticated devices and diagnostics. HealthPartners in Minneapolis allows patients to schedule their own clinic appointments online, Kaiser Permanente e-mails test results to their patients at the same time as their doctors, and a growing number of systems, including Palo Alto Medical Foundation, provide their patients with online access to their medical records. This democratization of access to information is vital to getting patients more involved with their care and will serve as the gateway to future products, such as personally-controlled, fully portable electronic health records.
Few of these innovations involve breakthrough technologies. More often, they are old inventions repurposed and simplified in such a way that they open up access to a broader set of users. It is this reinvention of the workforce surrounding the technology that has immense impact on lowering costs and adding convenience, and this is where innovation in healthcare really gets interesting.
There are a host of physician assistants, nurse practitioners, clinical pharmacists, and other allied health personnel just waiting to take on more lucrative responsibilities, not to mention a burgeoning group of patient "participants" wanting to manage more of their own healthcare. They seemingly fight an uphill battle against physicians who express fears for patient safety (or perhaps for their own livelihoods), but in the long run, it is the physicians who face the tougher fight.
Disruptive innovations like retail clinics, direct-to-consumer diagnostics, and patient-controlled electronic health records may seem like radical threats to the system, but they merely represent a continuation of changes in the healthcare workforce that have always shifted toward accessibility and affordability.