ECMO is a relatively new technology, so it is not surprising that few, if any, policies currently influence its use at existing centers or its spread to other facilities. Even technologies with longer histories have few formal policies governing their use. Decisions about who will perform medical and surgical procedures and where they will be performed are often under the control of hospitals and other health care facilities, as well as being strongly influenced by the organizations that pay for such procedures.  Professional organizations, accrediting bodies, the Federal Food and Drug Administration, and state regulatory agencies also establish policies. 
    To make ECMO available to those infants who would benefit from it, and in the most cost effective manner, the development of three types of policies is recommended:

• Those that would promote effective and efficient use of existing ECMO centers and avoid inefficient and expensive proliferation.
• Those that would monitor the quanity and quality of ECMO treatment.
• Those that would encourage long-term studies.

To promote effective and efficient use of existing ECMO centers and avoid inefficient and expensive proliferation, the following should be implemented:

• Planning at the state and regional levels. This should include obtaining epidemiologic information that can be used to forecast the need for ECMO in various geographic areas.
• Development of guidelines for ECMO centers. Such guidelines should include staffing needs, minimum number of cases per year, acceptance criteria, data to be collected and submitted to the registry, quality criteria, and other aspects of care. (For the present, such guidelines should be limited to the use of ECMO with neonates.) Expansion of the technology for the treatment of pediatric or adult patients would necessitate the development of additional guidelines. Several organizations should be involved in the development of additional guidelines. The Extracorporeal Life Support Organization (ELSO) has already developed guidelines and the Committee on the Fetus and Newborn of the AMerican Academy of Pediatrics (AAP) has issued "Recommendations on ECMO" (Pediatrics 85:618-619, 1990.) These groups should be encouraged to remain active in guideline development.  The Agency for Health Care Policy and Research (AHCPR) now has a mandate to develop practice guidelines; although its work to date has been primarily in relation to practices supported by Medicare, it should be expanding to tother fields in the near future. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) should be asked to become involved in accreditation of ECMO centers (see next bulleted section).
• Development of an accreditation procedure. ECMO centers should be accredited, or licensed, or designated. Models for such accreditation are those currently used by the 10 American College of Surgeons (ACS) for Cancer and Trauma Centers.  The JCAHOmight be asked to form and ad hoc ECMO Accreditation Task Force, which shouldinclude representatives from groups such as ELSO, AAP and ACS. Other groups that might be involved in the process are federal and state rate-setting agencies and state maternal and child health agencies because of their concern for children with special health care needs.
• Encouragement of the developement of hospital "strategic alliances." Hospitals can work together to promote efficient utilization of existing centers through regional cooperation. Alliances have the potential to stabilize referrals, secure economy of scale, and promote continuing education of staff. This model of collaboration already exists in the Community Clinical Oncology Program.
• Development of funding policies that encourage use of existing ECMO centers and discourage inappropriate proliferation. Medicaid and other third-party payers should provide reimbursement for ECMO treatment outside of the state in which the infant resides and for transportation to and from ECMO regional centers.

   To monitor the quality and quantity of ECMO treatment, the following recommendations concerning data and case registration are made:

• Continuation and improvement of the existing ELSO case registry-The case registry should be used as a management and research tool in order to determine efficacy and effectiveness. It should be able to indicate quality problems such as institutions that treat too few infants or have high failure rates. It should be used to help defelop long-term outcome studies.

• Formation of an advisory board—This board should develop a list of data elements and undertake other relevant tasks, such as the development of procedures and incentives for establishing and maintaining data quality.

• Development of a permanent funding base— Funding of the registry should be the ultimate responsibility of participating ECMO centers.

• The Federal Government and foundations have assisted with initial efforts and should continue in the short term.

• Participation in the registry should be required for accreditation.

• The registry should be used to monitor the relevance of guidelines.

 

Diffusion of Medical Technology:
The Case of ECMO

Ann Lennarson Greer, Ph.D.
University of Wisconsin—Milwaukee

Abstract

This overview distills accepted diffusion theory and the author’s ongoing research to outline factors and dynamics which come into play around high-cost, high-risk, highly-complex technologies like Extracorporeal Membrane Oxygenation (ECMO). Three themes are developed. The first is the need to understand adoption of new technology as a social process wherein a consensus for change develops among local medical colleagues who communicate directly with one another in a situation of common circumstances, pressures, and experience. The second concerns the fact of medical technologies such as ECMO diffusing into practice even as they continue to change and develop. With such dynamic technologies, the state-of-the-art is as much a consequence of practice as of science. The third theme concerns the fact that hospital technology adoptions engage multiple interests, decision-makers, and criteria for adoption. The assessments of doctors are combined with those of businessmen and organizational planners in a dynamic local process which drives adoption and use. There is a brief discussion of the difficulties of using guidelines to affect this process.

The Diffusion of Dynamic Technology

The diffusion of an innovation is a highly social process. The spread of even a simple technology, a new drug for example, is characterized by many interpersonal contacts and differentiated social roles—change agents, idea champions, early and late adopters, and opinion leaders.¹’² Except for quacks and cranks and geniuses recognizable only after the fact, innovation is adopted not by isolated individuals alone with their journals but by networks of people who adopt more or less as a body, following a change in the local consensus about what one should do and be seen doing. Initial awareness of an innovation may come through reading but one-on-one activities—observation, trial, and social reinforcement—are usually necessary to adoption. The spread of a technical innovation is not so different from the spread of a new dance step. Most want to be neither first nor last, perform badly, or look like a fool.

    The desire for consensus is most understandable. Research findings and their application are rarely clear-cut. In our studies, doctors have shown themselves to be skeptical of their professional literature. (It could easily lead you to foolishness.) They cite the over-optimism of scientists and developers in interpreting early findings, the frequent inconsistency of published results, and the coming and going of touted procedures. In addition to confusion over results actually achieved at research sites, local physicians have many uncertainties regarding their personal ability and the ability of their colleagues to achieve benefits in their practices. They fault the medical literature for omitting details of application and report skepticism regarding the application of findings to their own patients and institutions. Personal contacts made at professional meetings or instructional seminars permit resolution of some difficulties but uncertainties ordinarily slow adoption until time and local opinion support (or may even seem to demand) behavioral change.³’⁴’⁵

    In shaping the local consensus, opinion leaders are key actors. Found in all groups, opinion leaders are respected by their local colleagues both for their competence and for their commitment to the welfare of the group. Colleagues trust that they will know what a new thing is about, what it means to the group, and that they will not steer associates wrong. Their acceptance of an innovation portends adoption by other members of their social network.

    Assessing new technology in its relation to local circumstances may be difficult. Allen contrasts the acceptance of scientific findings with the introduction of new technology. Scientists share a universal language and common criteria for judgement. Technology is local, defined by local goals, problems, people, facilities, equipment, systems, and values.⁶ Appraising the implications of a new technology may then presuppose its prior local demonstration. When this is the case, successful introduction requires a local innovator, a technical person who is able to adapt the technology to the specific situation. This innovator’s activities may, in turn, affect the technology’s ongoing development, creating a dynamic interaction between concept and practice.

    The difficulties of application compound when the technology is itself a complex mix of human as well as technical components. The potential for interpersonal problems can lead to another role which is associated with successful implementations. This is the advocate, or idea champion. Internal to the adopting group or organization, this champion becomes committed to an innovation’s acceptance. The idea champion keeps the idea alive through the innumerable organizational, financial, and political hazards which beset any undertaking that has the potential to absorb scarce resources or alter personal relationships. Both the technical innovator and the idea champion must be in a position to devote time to the tasks of reconciling technology and local circumstance.

    Rogers has used the term "re-invention," to indicate the degree to which an innovation is changed by adopters in the process of adopton and implementation.² Not only may the tool be changed, the technology may be used by different personnel, combined with other technologies in new ways, or used for purposes other than those originally intended. In this process of trial and modification, ambiguities are removed and possibilities are revealed or restricted. In the case of dynamic technologies, what diffuses is not so much a prepackaged product as a concept that is specified as it is applied.

    ECMO does not appear to be an exception. ECMO offers a high tech, high cost, labor and equipment-intensive rescue for newborns suffering from intractable respiratory failure. External cardiopulmonary support is provided to the infant by a modified heart-lung machine so that the damaged lung may rest. It is a technically high-risk procedure which ordinarily includes ligation of the right carotid artery and jugular vein through which the support system has been connected. Claims of remarkable results by developers have generated controversy in the literature over 1) the design of evaluations which have, for the most part, lacked a true control group⁷ and 2) the baseline predictions of mortality against which the survival of ECMO babies is so startling. Some writers have suggested that the high mortality associated with pre-ECMO management of candidate babies may have been iatrogenic.^8,9

    The technology itself is changing rapidly. Even as the University of Michigan developers of ECMO are proposing a new means of cannulation to avoid permanent ligation of the carotid artery, other surgeons in other locations are reconstructing the artery.^{10, 11} Independent teams are varying other components also, such as the time during which infants are maintained on ECMO.¹¹ Conditions for expanding the indications for ECMO are being discussed as are possible new uses. Donn reports optimism that new technical developments will open the procedure to premature infants and prove useful in preserving transplant organs or as "a temporizing device for cardiac surgery."¹⁰ He reports that the development of expertise in ECMO centers has made possible the application of technologies other than that which organized the teams. Some ECMO programs are able to treat up to one-half the babies referred for ECMO with conventional methods.¹⁰ ECMO team members are drawn from several specialties and tasks are performed by members of more than one specialty with the key supervisor, for example, being sometimes a pediatric intensivist, sometimes a neonatologist, and sometimes a pediatric cardiac surgeon. This might suggest an early division of opinion as to whether childrens’ hospitals or neonatal intensive care units (NICUs) attached to large obstetric units are to be preferred locations for ECMO technology. Finally, experience with a wide variety of technologies from ultrasound to lasers shows how quickly new technologies jump the boundaries of their originating specialties when medical tinkerers see them in action.

    With dynamic medical technologies, the experience of early (and not so early) adopters may be considered part of a technology’s development. These technologies develop as they diffuse with adopters’ activities complementing or diverging from the work of the initial developers, whose work may also be ongoing. This process of adaptation may seem to develop or to betray the original innovation. It leads to inconsistencies in results and in the published literature and to variations in local practice. Different versions in different hands provide different localities with differing experiences which may lead to inappropriate curtailment of use in one community and to excessive optimism in another. While highly significant in affecting local assessment, diverse experiences may or not make it to the published literature and may or may not be considered to contribute. Patients will have been selected differently, procedures will have been performed differently, outcome measures will be inconsistent, and few will have adequate controls.

Multiple Vantage Points for Adoption Decisions

If it is difficult to develop useful guidelines for medical doctors considering adoption or use of dynamic medical technologies, it is much more difficult to guide adoption when a variety of non-medical concerns and pressures come into play as they do in the operation of contemporary hospitals.¹²’¹³ While it is tempting to focus on medical criteria, other decision criteria may constrain or impel adoption and use. Indeed, our data indicates that medical doctors are less involved in hospital decisions than a decade ago and medical criteria are less influential.¹⁴

    Three types of assessments affect the adoption of hospital-based technologies such as ECMO. These are summarized in Table 1. Medical criteria are applied by doctors, both those who will apply ECMO and those who will refer patients for it. But these decision-makers confront two types of organizational decision-makers who draw their decision criteria from the fiscal/ managerial and strategic planning domains.

Medical Assessments Affecting Adoption by Physician Users

In many studies certain attributes of innovations have been observed to affect physician adoption of a new technology. Among those commonly identified are: relative advantage over previous methods, risk, compatibility with adopters’ values, understandability, and complexity of use.^2,3 Each of these attributes is actually a subjective judgement made by a potential adopter who perceives risk and complexity in relation to personal skill and experience, advantage in relation to failure or success with alternative methods, and complexity in relation to professional backup and organizational capabilities. Given the many questions that are likely to be unanswered in the literature and the difficulty of integrating change into one’s practice, the most common result is to "wait and see"—where the findings of the literature will settle, what models will become available, how one’s local colleague’s will respond, where and when the local consensus will gel.

    ECMO belongs to a small category of desperation technologies that may attract unusually positive assessment since they offer hope where there was no hope. Relative advantage is calculated against death; calculations of risk may also seem niggling. The absence of scientific data on long-term outcomes leaves physicians without the ability to include in their assessment important aspects of risk, benefit, and compatibility with values. In the absence of comprehensive outcome data, application is likely to emphasize (1) short-term goals, (2) theoretical plausibility of benefit, and (3) one’s level of satisfaction with alternative treatments.

    Despite the compelling thrust toward diffusion provided by desperation technologies, adoption remains problematic. Most physicians are very concerned about their ability to perform morally and proficiently within professional guidelines. Application of a technology may involve pain, expense, and anguish for patient and family. Two attributes of innovations that are commonly associated with adoption are firsthand observability of benefits and potential for hands-on trial. Opportunities for observation and training may be initially limited to those offered by developers. Accordingly, they may vary, although many innovators are also energetic educators who open their units to interested colleagues to observe and learn. Well into the diffusion of surgical procedures, it appears that existing sites of activity are the most important dispensers of education and trial.

    The personal experience acquired at such sites is often a motivator to further action but it may also highlight dangers, such as a high complication rate in the learning stage, or difficulties, such as those encountered in mounting a new program. Manufacturers have long been attuned to the need to hand carry reassuring information to potential but skeptical users of their products, and to reduce those barriers over which they have some control, such as providing staff training, technical backup, or a period of equipment trial.

Medical Assessments Affecting Decisions of Referring Physicians

Physicians who refer patients to specialized facilities also grapple with assessment of benefit and risk but from a somewhat different perspective. These physicians are less likely to be abreast of specific findings concerning the procedure and do not expect to make a final determination on appropriate application. They are likely to become aware of new modalities such as ECMO through a personal contact with a person who is familiar with the technique. Physicians affiliated with the hospital offering a new treatment are likely to produce the first referrals. Referrals from neighboring institutions are likely to be next. Most often these will be stimulated by contacts that referring physicians have with the local innovators or from contacts that these physicians have with other physicians who are aware of the option—rotating residents, circuit-riding colleagues who practice at multiple hospitals, or newly affiliated physicians. This process of information diffusion may be speeded by continuing education or marketing activities of the sponsors or the sponsoring hospital, local professional associations, manufacturers, or medical schools.

    Referring physicians will weigh problems of patient transfer against possible benefit. Referral for a life-saving technique is likely to be appealing, although enthusiasm for referral is often tempered by the physician’s general dislike of transporting patients to another institution. They dislike the hazards and inconvenience associated with referral and may perceive the potential to lose a patient to physicians at the referral center. The more referrals from a specific hospital to a referral center expand, the more physicians at the former seem willing to consider local development of the program. This possibility seems reduced to the extent that ECMO is a self-limiting procedure offered at specialized children’s hospitals, although it is possible to imagine that neonatologists at a non-ECMO center might fear loss of referrals to a NICU having the ECMO backup. As a technology such as ECMO is refined, indications are expanded and additional uses are contemplated (e.g., ECMO as a backup for surgery vexed by respiratory failure), the arguments for additional programs may grow.

Fiscal and Managerial
Considerations Affecting Adoption

Current payment strategies that fix the amount that will be paid for procedures, either annual patient care or specific diagnoses, were intended to make adoption of expensive but seldom-used technologies unattractive because they are unprofitable. The acceleration of the hospital "arms race" that has accompanied implementation of competitive policies suggest that they do not work in the way intended.¹⁵

    In response to the new payment policies, the ranks of financial, marketing, and quality control workers in hospitals have swollen. These specialists provide expert analyses of the fiscal and managerial aspects of the organization that affect the bottom line, including technology. These staffs work with such aspects of the organization as management of volume, billing, patient mix, contracts for services, and position in the capital market. They suggest means to maximize and regularize income and control expenditures in ways that accommodate the fixed payments that hospitals have agreed to accept. Toward this end, they combine cost-control and marketing strategies, trying both to hold down costs and increase patient revenues. Such financial calculations are supposed to favor economies of scale and the avoidance of activities where insufficient volume produces high "per unit" costs. However, for each strategy of curtailment there appear to be alternatives, such as increasing volume and providing as many services as possible internally. It has been suggested that administrators of hospitals containing ECMO units may encourage an expansion of indications for its use in the interest of achieving financial solvency for the unit.¹⁰ Similarly, in my area, HMO’s have reportedly questioned the need to refer babies out of a prepaid neonatal center to an ECMO center where additional costs must be paid.

    In advising the development of new programs such as ECMO, fiscal and managerial staff are asked to calculate the period required for "payback," given start-up costs, payments, and projected volume. However, an unfavorable calculation is more likely to restrain low visibility expenditures—routine equipment purchases, staffing, or research—than those with high visibility or potential visibility. Even under rate review, hospitals’ cost-reducing strategies in the area of technology were directed primarily to second pieces of equipment and replacement of equipment, not to new introductions.¹⁶ Under market competition, there is increased pressure to direct funds to areas that enhance the hospital’s visibility, market share, or potential to tap new markets.

Strategic Planning Considerations Affecting Assessment

In recent years, the importance of strategic plans to hospital management has steadily increased.¹⁷ The competitive pressures of policies introduced since 1984 have accented the importance of targeting development to achieve desired position in the marketplace. "Markets" may be diagnoses that are favorably reimbursed under DRG’s, or populations that are well-insured, and one market may be perceived as connected to another. Financial and managerial calculations are advisory to strategic planning, which focuses heavily on the image that the hospital wishes to convey. How costly will it be to convey the desired image of a hospital as better or at least as good as competitors? What is the cost of increasing market share, capturing new markets, or securing future options? Money may have to be saved somewhere in the hospital, but it will not be in areas targeted as strategically important, given concern with image, payment, demographics, or interrelationships with other services. In these cases, the issue is not the balance sheet, but survival viewed strategically.

    Strategic planning may dictate the development of ECMO programs, irrespective of potential financial losses. In my area, cardiac surgery offers a prior example. Hospitals have continued to introduce new programs in spite of a dense supply. Administrators argue that heart surgery is a necessary backup to angioplasty and therefore to cardiology, and because "ambulances will bypass a hospital that does not have heart surgery." They closely watch outward referrals with dismay, often envisioning a domino effect. For similar reasons, it has been difficult to sustain the regionalization that once characterized neonatal intensive care. Obstetrical care is dispersed among hospitals which, if it can be avoided, do not want to refer mothers to regional centers from which they may not return. As one neonatologist told us:

    "I mean the perinatologist [at a regional center] has to work hard to tell the [referred] mother ‘I’ve taken care of you during this high risk delivery. Now you go back to your regular obstetrician in the suburbs. Okay?’ The hospital in the suburbs has to work hard to have itself identified as being still the place that is going to provide medical care for that family and not have the mother say, ‘God, when I have been really sick and I had that real bad baby and I went into the hospital in the middle of the city at the medical center, I had such great care. God, if anybody in my family ever gets sick again, we’re going right back there."

    Hospital administrators routinely cite outward referrals in their arguments for the adoption of a new technology or service. ECMO seems susceptible to such pressures, especially since the existence of superior neonatal intensive care is often advertised as a reason that prospective mothers should choose a hospital’s obstetrical unit. Obstetrical care, in turn, is viewed as the entry point for families to life-long hospital care and an important element in the full-service package sought by HMO’s.

    When are medical, fiscal/managerial or strategic criteria important? How do the decision-makers who employ them exert their influence? What concordance among decision-makers is necessary for a chosen policy to be realized? To inform answers to these questions, the next section will be devoted to developing a brief prototype of adoption dynamics. This simplified representation contains characteristic elements that we have encountered repeatedly across diverse technologies.

Prototype Adoption

Although information on a new technology may be appearing and being noted by local physician communities, active local consideration awaits the emergence of a local medical innovator. This first adopter affiliates with a developing technology, perhaps early enough to be a major contributor, or somewhat later in its evolution. This local innovator is linked from past training or experience to national or regional pioneers of the technique, or now becomes so linked. When the demands of the technology require large expense or organizational adjustment, the innovator is successful to the extent that an idea champion is engaged. This is frequently a hospital administrator who seizes upon the idea of securing a new market or positioning the hospital for future gains. The hospital board is persuaded of the importance of the new development. The program is organized. The innovator addresses technical problems and trains colleagues and staff, while the administrator addresses problems of finance, recruitment, turf, and securing a referral base for the procedure

    The existence of the program alters the local environment. Potential new adopters and referrals surface as the new activity (1) generates visible applicable clinical evidence; (2) opens opportunities for training of both residents and existing specialists; (3) attracts attention of media and patients, thus generating publicity and patient inquiries; (4) focuses attention on merits of the development (wise or unwise, wisely located or misplaced); (5) spotlights the behavior and referrals of physicians in relevant specialties (Do they perform? Refer locally? Refer to more distant sites?); and (6) provides ammunition to equipment or other salesmen who will manipulate the appearance of consensus and rapid diffusion in the hopes of expanding utilization. All of this speeds the need of pertinent specialists to develop a professional opinion, potentially speeding the development of a consensus for change.

    The larger community of physicians is affected by (1) a surge of information following local adoption (brochures, lectures, demonstrations, referral solicitations) from the provider hospital, manufacturers, newspaper reports, continuing medical education, and gossip; (2) circulating individuals who are aware of the new activity; and (3) patient inquiries stemming from newspaper stories or contacts with early patients or their families. This turbulence in the local arena demands a response and raise a suspicion on the part of physicians and hospitals that patient choices of physician and hospital may be affected by this.

    Hospital administrators are aroused as the lead hospital markets the new technology to potential patients as a mark of superiority and to HMO’s as a reason to become a member health care provider. Administrators of rival hospitals perceive the new technology as a threat to their own high technology image, to viability of their own competing units, and possibly thus to the whole of the hospital. They begin to monitor outward referrals, inquiries from patients and HMO’s, outward transfer of prospectively budgeted funds, image benefit to other institutions, and the overall effect of the development on competitive relationships with rival hospitals. They consider their own position in terms of advantages to be gained from offering the technology and the chances of capturing existing or future market share. If the development is viewed as a serious threat or serious opportunity, hospital executives may encourage physicians interested in performing the procedure or begin recruitment of physicians with needed skills and interest.

The Role of Guidelines

Information circulates as this drama plays, but seems not to be master of the forces at work. My own studies of the diffusion of innovation began in 1975, when open heart surgery could be observed in its still early stages in my city of Milwaukee. In one of the first half dozen interviews of what now approaches 800, a local heart surgeon, Dr. Derwood Lepley, pressed into my hands the 1972 report of the Committee on Coronary Artery Surgery of the Intersocietal Commission for Heart Disease Resources. The Intersocietal Commission had as its sponsors virtually every professional society and government institute bearing any relation to heart, surgery, or hospitals. The report was entitled "Optimal Resources for Coronary Artery Surgery."

    The committee had been chaired by Dr. Lepley. The report specified the qualifications and numbers of personnel that the procedure required, the necessary equipment, relationship to diagnostic facilities, and the minimum volume of procedures. Committee members felt so strongly about the need for teams performing the surgery to commit themselves to research that they devoted almost one-third of the 14-page report to criteria for assessing the results of surgery, including three pages devoted to diagrams directing autopsy. Already in 1975, Dr. Lepley was grieving over the disregard of the guidelines. He and other early developers interviewed by us in longitudinal personal interviews were to lament the role of money and other forces in driving a different diffusion pattern than that advised by the committee and to decry their successors’ lack of interest in research.

    I recalled those early days when I read the statement of the Committee on Fetus and Newborns of the American Academy of Pediatrics and pondered the fate of that document and the deliberations of the NIH workshop reported in this publication. Where do such guidelines fit into diffusion? Apparently statements are noted by recipients but not acted upon ^18,19,20,21 In the following paragraphs I briefly consider the potential for guidelines to influence the categories of decision-makers that I have identified in this paper.

Medical Decision-makers: Adopters

Medical innovators, including early adopters, are likely to reject guidelines that are inconsistent with their own assessments of a technology. They embrace as goals the improvement of equipment, technique, knowledge, and results. They are aware of the changes that they and others have introduced and tend to dismiss contrary results, including controlled trials, as inapplicable because dated. Negative results from other teams are often attributed to incompetent performance of the technique. Innovators frequently disavow irresponsible diffusion of a new technology but contribute to it through their own demonstration and training, which provides the pool of professionals available to launch new initiatives.

Medical Decision-makers: Referrers

Education directed to individual physicians does not have a robust effect unless reinforced by local peers whose agreement may be quickened by pressures from patients, local media, manufacturers’ representatives, and health care administrators. Potential referring physicians may be advised to evaluate ECMO facilities for desired characteristics but by the time they are considering a potential referral, they will probably have it associated in their minds with particular places and individuals known to them for this or other reasons. Since referring doctors do not decide appropriate application, additional information provided to them (if it has an effect) will likely stimulate referrals to ECMO teams for evaluation.

Fiscal and Managerial Decision-makers

In a situation of multiple payers, the opportunity to use payment to enforce guidelines seems limited. Fiscal incentives have proven effective enablers of expansion but poor vehicles of restraint. Competition among insurers has all but guaranteed coverage of high profile services atleast for certain groups. Competition among hospitals all but guarantees the pervasive development of these services at the expense of other services if need be. Payment decisions not in accord with local professional and public opinion present themselves not as the basis for a hospital’s strategic plan but as obstacles to be surmounted in the interest of implementing it.

Strategic-Institutional Decision-makers

It is not clear at this time what potential ECMO has to be perceived by the public as a life-saving technique that should be offered by all excellent hospitals. Should it develop this image, it could be the sort of technology which is very hard to contain. Lack of sufficient volume for multiple programs is not necessarily a deterrent and may merely feed competitive rivalry to attract physicians with strong reputations or referral networks or to absorb losses as a cost of doing business. A hospital’s strategic plan rests, finally, on the best guesses of administrators and boards of directors about future hospital care—the services which successful hospitals will offer and the ways they will be provided, including the standards which will be demanded by doctors and the public. Unless strategic decision-makers associate practice guidelines with operating or symbolic values as significant as the hospital’s technology profile, they will be accorded minimal weight.

Conclusion

With dynamic technologies, those evolving as they diffuse, overall patterns of adoption and use of technology reflect a myriad of local decisions. These, in turn, reflect a variety of local considerations, both medical and non-medical. For many reasons guidelines which are externally developed may appear inapplicable and thus fail to achieve their desired results. Local social processes have shown themselves time and again to support their own versions of moral behavior, including sabotage of externally-imposed directives. In the United States, it is now unfashionable to ask physicians to shape the conduct of medical practice, except at the individual level. Nor have physicians come forth. The current system provides no consistent forum for local discussion of medical standards or priorities and no place for local physicians to participate meaningfully in the allocation of resources. Just as the adoption and use of innovation hinge on the action of local professionals, so may the restraint of innovation. Lest vitality and compassion be lost in the pursuit of rational medical behavior, local physicians need mechanisms for response which are as dynamic as the innovations.

Acknowledgments

This research is supported by the Agency for Health Care Policy and Research (Grant #RO1 HS 06065-01) which also supported the collection of baseline data (#1 RO1 HS 03238-01A1).

References