Health Policy$ense

The Exnovation Conundrum

How do we get people and organizations to change, especially when what they are currently doing adds little value, is very costly, is perhaps outmoded, and may, at worst, be dangerous? This is the question Benjamin Roman and David Asch raise in their new Annals of Internal Medicine piece on "Faded Promises". As difficult as it is to get new treatments in medicine adopted, they argue, it is more difficult to get physicians to stop old treatments they have come to believe in, even when there is compelling evidence that those treatments don’t work particularly well.

John Kimberly
John Kimberly, PhD, is both a Professor of Health Care Management at the University of Pennsylvania's Wharton School, and Professor of Sociology at Penn's School of Arts and Sciences. He is also a Senior Fellow at the Leonard Davis Institute of Health Economics (LDI).

What Roman and Asch describe is a perfect example of what I call the exnovation conundrum, and although it may be evident in medicine, this phenomenon is universal. While we tend to focus on what is new and sexy, and while we praise the innovators, the truth is that for new programs, technologies, and products to be embraced, old ones often need to be discarded. The conundrum is that they are often not discarded. Roman and Asch put their finger on part of the problem – it’s tough to get doctors to change and, as they say, we should perhaps “look to the psychology behind those perceptions” for solutions. I would add that it’s tough to get people in general, not just doctors, to change. Habits and routines become ingrained, often subconsciously, and we come to rely on them, they become instinctual, and are locked in.

The challenge, though, is about more than getting people to change. It’s about getting the settings in which they work, study, play, and even pray, to change. The settings intentionally or unintentionally reward and reinforce habits and routines, and asking individuals to change without changing the settings is swimming upstream, to say the least.

Innovators and laggards
Let’s take a step back and look at the problem more carefully. Some time ago, I noticed that most scholars writing on the subject of innovation and diffusion had fallen into the trap of worshiping at innovation’s altar. Although it was never explicitly stated, the underlying assumption in the research and writing of the time (and not much has changed since) was that innovation is good, and more innovation is better. The framework developed by that great synthesizer of research on innovation, Everett Rogers, and cited by Roman and Asch, has that assumption built in. The world of potential adopters, as all of Gaul, can be divided into three parts: the innovators (the small number of pioneers who are way ahead of everyone else and who adopt first); the early adopters (the next wave of adopters, somewhat slower to adopt, but who, nonetheless are to be congratulated for their courage and vision); and the laggards (those poor timid souls who either wait until they see that it’s safe for them to adopt or, worse still, who never adopt at all). The social desirability of being an “innovator” was striking, as was the social undesirability of labelled a “laggard”. That was like being at the bottom of your class! The pro-innovation bias in the literature was both obvious and disturbing.

But what does this have to do with exnovation? What I discovered was that this pro-innovation bias led researchers to focus almost exclusively on the characteristics of individuals and organizational settings that were associated with high rates of adoption. In their rush to determine these characteristics, they overlooked a fundamental truth: adoption of something new doesn’t happen in a void, it happens in the context of an ongoing set of activities, priorities, and resource commitments. When something new gets adopted, it has to be fit into that context. If innovation has to do with getting something new successfully introduced, exnovation has to do with the other end of the process. It has to do with what Roman and Asch call "deadoption".

The Exnovation conundrum
And here is the exnovation conundrum. Often as not, when something new is introduced, that which it is designed to replace is not, in fact, replaced. In a rational world, this replacement would happen automatically, as the benefits of the new would be seen and embraced by all, and the old would be moved out as the new was moved in. But guess what...?

Let me suggest we start developing an inventory of exnovation conundra. Maybe we can learn how to work productively on the problem that Roman and Asch have identified: how to get workers on the front lines of medicine to deadopt practices that are of demonstrably low value. Maybe by expanding the number of different contexts in which exnovation conundra have been experienced we can develop a more general approach to what I believe to be a pervasive challenge. So I invite you, through the comments section below, to submit your ideas for programs, policies, or technology that pose an exnovation conundrum.

In a subsequent post, I will share the fruits of your contributions, and together we will push the envelope. This should be fun!