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Philip J Schneider
Clinical Professor and Director
College of Pharmacy
Ohio State University
More is spent per capita on healthcare in the USA than in any other country. According to WHO statistics, 13% of the gross national product was spent on healthcare in the USA in 2001.(1) Despite this, life expectancy ranks 24th among countries compared in a WHO study,(2) and the USA ranks even lower for overall health system performance.(3) Yet, when asked, Americans consider their healthcare system to be “the finest in the world”.(4) This illustrates two often conflicting concerns that exist within the US healthcare
system – the need to control costs and the need to improve the effectiveness and quality of care. Indeed, in a penetrating self-assessment by the Institute of Medicine, it was noted that: “The American healthcare system is in need of fundamental change.”(5)
Change is not easy. This is particularly true when new technologies are so expensive. Hospital pharmacists are often faced with, or even held responsible for, the challenge of evaluating the balance of gains in efficiency and safety with the attendant costs. While this may be perceived by some as a problem, forward-thinking pharmacists will see this as an opportunity. Pharmacists are uniquely qualified to bridge the gap between the financial and clinical goals of the hospital and healthcare system, as they can interact well with both administrators and clinicians. Knowledge of pharmacoeconomics is an important contribution to this dialogue, and pharmacists can also benefit by learning about the “diffusion of innovations”. In an important work with the same title, Everett M Rogers defines this diffusion as “the process by which innovation is communicated through certain channels over time among the members of the social system”.(6)
Because of the expense, health systems are often reluctant to make use of medical breakthroughs. Part of the problem with the “diffusion” of these innovations is the lack of an effective communication process for reconciling the benefits compared with the costs. Problems often occur when the individuals who interact have different beliefs, education and social status. Rogers suggests introducing empathy to create effective communications among these “heterophilous” persons, and face-to-face exchanges between individuals (“interpersonal channels”) to facilitate diffusion of innovations. The adoption of change is never immediate or complete – it follows an “S”-shaped curve over time, starting with a few innovators accepting an innovation, followed by more “early adopters”, then by the majority of “late adopters”, and lastly by a few “laggards”. The goal is to involve innovators and early adopters in the discussion of innovations, and not waste too much time trying to get late adopters or laggards to change.
Finally, it is important to understand the social system in which change is both resisted and occurs. In the USA, each of the healthcare disciplines has a great degree of independence. There is also a hierarchy among professional groups and differences in education, training and social status. Rogers identifies the importance of identifying the opinion leader within the organisation as the change agent. This opinion leader will often be a physician, because of their status within the US healthcare system; however, the clinical pharmacy movement within the USA has made it possible for some pharmacists to assume an opinion leadership role for drug therapy.
As we struggle for ways to both improve the quality of healthcare in the USA and try to manage the costs, it will be important for healthcare systems to get better at understanding when and how innovation can benefit patients. Pharmacists in the USA are becoming an important resource in this process.