diffusion fnl guts spot 5/15/02 12:08 PM Page 1 Diffusion of Innovation in Health Care Prepared for: CALIFORNIA HEALTHCARE FOUNDATION Prepared by: Institute for the Future Authors: Mary Cain and Robert Mittman May 2002 diffusion fnl guts spot 5/15/02 12:08 PM Page 2 Acknowledgments Institute for the Future (IFTF) is a nonprofit research and consulting firm founded in 1968 and dedicated to under- standing technological, environmental, and societal changes and their long-range consequences. We help public and private organizations think systematically about the future by evalu- ating long-term trends and their implications, identifying potential markets, and analyzing policy options. Our clients include Fortune 500 companies, public and private foundations, multinational corporations, and government offices and agencies. For more information about IFTF, visit our Web site at www.iftf.org. IFTF wishes to acknowledge Jody Ranck for contributions to this report as well as Susannah Kirsch, Jane Sarasohn-Kahn, and Charles Wilson, M.D. for peer review. The California HealthCare Foundation (CHCF) is an inde- pendent philanthropy committed to improving California’s health care delivery and financing systems. Our goal is to ensure that all Californians have access to affordable, quality health care. CHCF’s work focuses on informing health policy decisions, advancing efficient business practices, improving the quality and efficiency of care delivery, and promoting informed health care and coverage decisions. The iHealth Reports series focuses on emerging technology trends and applications and related policy and regulatory developments. Additional copies of this report and other publications in the iHealth Report series can be obtained by calling the California HealthCare Foundation’s publications line at 1-888-430-CHCF (2423) or visiting us online at www.chcf.org. ISBN 1-929008-97-X Copyright © 2002 California HealthCare Foundation diffusion fnl guts spot 5/15/02 12:08 PM Page 3 Contents 4 I. What Is Diffusion? 7 II. The Ten Critical Dynamics of Innovation Diffusion Relative Advantage Trialability Observability Communications Channels Homophilous Groups Pace of Innovation/Reinvention Norms, Roles, and Social Networks Opinion Leaders Compatibility Infrastructure 26 III. Epilogue 28 Endnotes diffusion fnl guts spot 5/15/02 12:08 PM Page 4 I. What Is Diffusion? “Ideas and products and HEALTH CARE IS CONSTANTLY EVOLVING. Wave messages and behaviors spread after wave of new technologies, insurance models, information systems, regulatory changes, and institutional arrangements just like viruses do.” buffet the system and the people in it. But people and institu- — Malcolm Gladwell, tions, for the most part, do not like change. It is painful, The Tipping Point difficult, and uncertain. Entire organizations in health care are devoted either to pro- moting innovations—selling the latest drug, imaging system, medical device, software package, or Internet site—or to preventing innovations from disrupting the status quo by counter-detailing, keeping drug reps away from doctors, requiring certificates of need, or disallowing reimbursement. Trying to change the pace at which new ideas about health care spread through the system is a priority of health care professionals; such changes easily have major impacts on cost, quality, and patient satisfaction. “Diffusion is the process by which an innovation is communi- cated through certain channels over time among the members of a social system.” So says Everett Rogers, who masterfully represents a vast literature that spans 50 years in his classic Diffusion of Innovations, now in its fourth edition. This report draws from that literature to describe how the dynamics of innovation diffusion play out in health care. 4 | CALIFORNIA HEALTHCARE FOUNDATION diffusion fnl guts spot 5/15/02 12:08 PM Page 5 About the Report 7. Norms, roles, and social networks. Innova- This report presents the basics of innovation tions are shaped by the rules, formal diffusion: the stages of adoption, including hierarchies, and informal mechanisms of the typical “S” curve, and the types of individuals communication operative in the social who adopt the innovation at different stages. systems in which they diffuse. The ten critical dynamics of innovation diffusion 8. Opinion leaders. Individuals whose opinions are explored: are respected (or even just listened to) by others 1. Relative advantage. The more potential the in a population affect the pace of diffusion. value or benefit anticipated from adoption of 9. Compatibility. The ability of an innovation the innovation relative to current practice, the to coexist with technologies and social pat- more rapidly it will diffuse. terns already in place improves the prospects 2. Trialability. The ability to try out an innova- for adoption/diffusion. tion without total commitment and with 10. Infrastructure. The adoption of many inno- minimal investment improves the prospects vations depends on the presence of some for adoption and diffusion. form of infrastructure or of other technolo- 3. Observability. The extent to which potential gies that cluster with the innovation. adopters can witness the adoption of an The dynamics that govern the adoption (or lack innovation by others improves its prospects of adoption) of new medical and information for diffusion. technologies in the health care industry are com- 4. Communications channels. The paths plex. This report is intended to help those frus- through which opinion leaders and others trated with the pace of adoption to understand communicate about an innovation affect how diffusion works and how to affect the pace the pace and pattern of diffusion. and style of diffusion in their own organizations. 5. Homophilous groups. Innovations spread faster among homophilous groups (those with similar characteristics) than among hetero- philous groups (those that differ in important ways). 6. Pace of innovation/reinvention. Some innovations are relatively stable and do not evolve much while they diffuse. Others evolve much more rapidly and are altered by users along the way. Diffusion of Innovation in Health Care | 5 diffusion fnl guts spot 5/15/02 12:08 PM Page 6 Defining Innovation Diffusion Stakeholders In Health Care An outgrowth of sociology, diffusion research Medical and information technology adoption first looked at how agricultural innovations spread decisions differ when made by individuals or from farmer to farmer. The first researchers in organizations. Beyond that distinction, the this discipline sought to explain why one farmer number of stakeholders potentially affected by would know about and adopt use of a certain any technology adoption decision varies greatly. pesticide while his neighbor didn’t. The master of Once a clinician decides to use a new device this research is Everett Rogers, of the University or piece of technology, the clinician must often of New Mexico, who has studied the dynamics consider not only the impact on the patient of the diffusion of innovations for most of his and on the practice but also what it means for 45-year career. His classic text, The Diffusion of reimbursement, health care policy, and the Innovations, summarizes and interprets decades organization in which the clinician works. A short of diffusion research, identifying basic patterns, list of stakeholders involved in a technology categories of adopters, and factors that influence adoption decision are: the decision to adopt. I The policy makers and regulators who Two definitions create a lens through which evaluate the safety and efficacy of to view technology diffusion in health care. the technology; Diffusion is the process by which an innovation is I The payer, such as Medicare or other communicated through certain channels over insurer, who decides whether payment will time among members of a social system. be made for use of the technology; (Rogers, 5) An innovation is an idea, practice, or object that is perceived as new by an individual I The provider organization (in the form of or some other unit of adoption. (Rogers,11) physicians and hospitals) that must decide Though often described as bureaucratic and whether to provide the technology and then incrementally changing, health care is also a very also get the proper training and education dynamic and innovative field. Around the globe, to use it appropriately; research scientists, private industries, academics, I The patient who must know enough and governmental and nongovernmental about the technology to give consent for agencies work to create new ways to provide its use; and better care, find cures, and improve health. I The vendor company that researches, develops, and sells the technology. Change Agents The vendor representative often plays an impor- tant role in innovation diffusion as the change agent. A change agent is an individual who influ- ences clients’ innovation-decisions in a direction deemed desirable by a change agency (Rogers, 27). For example, there are almost 60,000 phar- maceutical sales representatives who are perfect examples of change agents. Their job is to influence physician decisions in favor of using their drug over another by providing the physician educational materials, free samples, junkets, etc., in an effort to win them over. 6 | CALIFORNIA HEALTHCARE FOUNDATION diffusion fnl guts spot 5/15/02 12:08 PM Page 7 II. The Ten Critical Dynamics of Innovation Diffusion 1. Relative Advantage The decision to adopt a technology is influenced by (1) the