Diffusion of Innovation
in Health Care
Prepared by Institute for the Future
May 2002
diffusion final cover 5/10/02 2:19 PM Page i

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
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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
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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
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4 | CALIFORNIA HEALTHCARE FOUNDATION
HEALTH CARE IS CONSTANTLY EVOLVING. Wave
after wave of new technologies, insurance models, information
systems, regulatory changes, and institutional arrangements
buffet the system and the people in it. But people and institu-
tions, for the most part, do not like change. It is painful,
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.
“Ideas and products and
messages and behaviors spread
just like viruses do.”
— Malcolm Gladwell,
The Tipping Point
I. What Is Diffusion?
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About the Report
This report presents the basics of innovation
diffusion: the stages of adoption, including
the typical “S” curve, and the types of individuals
who adopt the innovation at different stages.
The ten critical dynamics of innovation diffusion
are explored:
1. Relative advantage. The more potential the
value or benefit anticipated from adoption of
the innovation relative to current practice, the
more rapidly it will diffuse.
2. Trialability. The ability to try out an innova-
tion without total commitment and with
minimal investment improves the prospects
for adoption and diffusion.
3. Observability. The extent to which potential
adopters can witness the adoption of an
innovation by others improves its prospects
for diffusion.
4. Communications channels. The paths
through which opinion leaders and others
communicate about an innovation affect
the pace and pattern of diffusion.
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.
7. Norms, roles, and social networks. Innova-
tions are shaped by the rules, formal
hierarchies, and informal mechanisms of
communication operative in the social
systems in which they diffuse.
8. Opinion leaders. Individuals whose opinions
are respected (or even just listened to) by others
in a population affect the pace of diffusion.
9. Compatibility. The ability of an innovation
to coexist with technologies and social pat-
terns already in place improves the prospects
for adoption/diffusion.
10. Infrastructure. The adoption of many inno-
vations depends on the presence of some
form of infrastructure or of other technolo-
gies that cluster with the innovation.
The dynamics that govern the adoption (or lack
of adoption) of new medical and information
technologies in the health care industry are com-
plex. This report is intended to help those frus-
trated with the pace of adoption to understand
how diffusion works and how to affect the pace
and style of diffusion in their own organizations.
Diffusion of Innovation in Health Care | 5
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Defining Innovation Diffusion
An outgrowth of sociology, diffusion research
first looked at how agricultural innovations spread
from farmer to farmer. The first researchers in
this discipline sought to explain why one farmer
would know about and adopt use of a certain
pesticide while his neighbor didn’t. The master of
this research is Everett Rogers, of the University
of New Mexico, who has studied the dynamics
of the diffusion of innovations for most of his
45-year career. His classic text, The Diffusion of
Innovations, summarizes and interprets decades
of diffusion research, identifying basic patterns,
categories of adopters, and factors that influence
the decision to adopt.
Two definitions create a lens through which
to view technology diffusion in health care.
Diffusion is the process by which an innovation is
communicated through certain channels over
time among members of a social system.
(Rogers, 5) An innovation is an idea, practice, or
object that is perceived as new by an individual
or some other unit of adoption. (Rogers,11)
Though often described as bureaucratic and
incrementally changing, health care is also a very
dynamic and innovative field. Around the globe,
research scientists, private industries, academics,
and governmental and nongovernmental
agencies work to create new ways to provide
better care, find cures, and improve health.
Stakeholders In Health Care
Medical and information technology adoption
decisions differ when made by individuals or
organizations. Beyond that distinction, the
number of stakeholders potentially affected by
any technology adoption decision varies greatly.
Once a clinician decides to use a new device
or piece of technology, the clinician must often
consider not only the impact on the patient
and on the practice but also what it means for
reimbursement, health care policy, and the
organization in which the clinician works. A short
list of stakeholders involved in a technology
adoption decision are:
 The policy makers and regulators who
evaluate the safety and efficacy of
the technology;
 The payer, such as Medicare or other
insurer, who decides whether payment will
be made for use of the technology;
 The provider organization (in the form of
physicians and hospitals) that must decide
whether to provide the technology and then
also get the proper training and education
to use it appropriately;
 The patient who must know enough
about the technology to give consent for
its use; and
 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.
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Diffusion of Innovation in Health Care | 7
1. Relative Advantage
The decision to adopt a technology is influenced by (1) the
ability of a potential adopter to judge whether the benefits of
using the innovation will outweigh the risks of using it, and
(2) whether the innovation improves upon the existing tech-
nology. The more benefit people anticipate from adopting the
innovation relative to what they now do, the more rapidly
it will diffuse. According to Rogers, “the degree of relative
advantage can be expressed as economic profitability, social
prestige, or other benefits.”
Examples of relative advantage as a driver of diffusion
 Some technological advances result in huge improvements
in how health care is provided. In 1895, Roentgen discov-
ered x-rays during his study of light phenomena, and within
six months the first diagnostic radiograph was performed.
X-rays gave physicians the ability to look inside the body
without cutting it open. Though by the end of 1896 the
negative effects of exposure to radiation were starting to be
documented, the value of being able to see the structure and
function of internal organs outweighed the disadvantages of
radiation. X-ray technology diffused rapidly and is still the
imaging modality that generates the greatest revenue today.
A more modern example is minimally invasive surgery,
whereby surgeons use specialized instruments, including a
video camera, to enter the body via small incisions and
move through the tissue to the affected area without
having to expose the entire body cavity. Cholecystectomy,
the surgical removal of the gallbladder, has been radically
changed by minimally invasive surgery techniques. The
amount of trauma to the patient, surgical complications,
and time in the hospital with laparascopic cholecystectomy
is much lower than with a conventional cholecystectomy.
II. The Ten Critical Dynamics of
Innovation Diffusion
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 In many metropolitan markets, having the
latest technology is necessary for health systems
to be competitive. Having a high-tech repu-
tation increases prestige and is important
for attracting the most innovative physicians,
as well as for attracting patients. For some
patients getting the best and most up-to-date
care means judging health systems by the cur-
rency of the facility and staff. Such patients
might choose the hospital with magnetic
resonance imaging facilities (MRI) over one
with no MRI facilities.
 Relative advantage promotes a technology
when the innovation is easier to use than the
previous method, often reducing duplicative
and inefficient practice. In the 1980s, computer-
based practice management systems were
introduced into physician practices to stream-
line and standardize the business end. These
systems automated and consolidated several
accounting functions previously calculated by
hand. Relative benefits increased as regulation
and health insurance policies increased infor-
mation demands on office staff.
Relative advantage is not always clearly expressed
when a technology diffuses.
 Relative advantage does not apply when the
benefits of a technology are controversial or
are not explicit. For example, the National
Institutes of Health and the American
Cancer Society have released conflicting
recommendations about the appropriate age
for mammography screening. Lack of con-
sensus has confused the public and health
insurers and hindered the diffusion of mam-
mography for middle-aged women.
 The risk of using a technology can be so great
that its advantage does not seem worth it.
For some women with a family history of
breast cancer, genetic tests can detect specific
genes that significantly increase the risk of
contracting the disease. With no cure for
breast cancer, for some patients prophylactic
mastectomy is the preventive measure. Many
women choose not to take the genetic test
because the perceived benefit of knowing is
lower than the stress caused by knowing, not
to mention the perceived risk of discrimina-
tion by health insurers.
Lessons for Technology Diffusion
 Understand the end user of the technology,
the person who is measuring the relative
advantage of the new technology, vis á vis
other decision-making and decision-influenc-
ing entities. Though MRIs are very valuable
diagnostic tools for many specialty physicians,
the technologist using the MRI, the chief
financial officer who decides how to fund the
purchase of the MRI, and the chair of ortho-
pedic surgery, for example, will all weigh in on
the purchasing decision.
 Recognize the impact of significant behavior
change and be able to illustrate how a new
technology will offer significantly greater bene-
fit if it is expected to be adopted.
 Consider the business case for the adoption
of a new technology. A calculation of the
return on investment (ROI) helps potential
adopters recognize the tangible benefit of
using the technology. For intangible benefits,
success stories and testimonies from others
who have adopted the technology are a stan-
dard part of most marketing packages.
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2. Trialability
Trialability is the ability to try out an innovation
without total commitment and with minimal
investment. In classic diffusion research, the
easier it is to try out an innovation without hav-
ing to commit fully to it, to discard an existing
way of operating, or to invest heavily in tech-
nology or training, the better the prospects for
adoption and diffusion. Trying out an innovation
or new technology allows potential adopters
to reduce their uncertainty about the risks and
benefits. Even when the weight of evidence
argues for or against the benefits of adopting a
technology, personal experience (one way or the
other) can overcome the evidence.
Examples
The free samples that pharmaceutical companies
distribute to physician offices are the classic
example of using trialability to promote adoption.
Prescription drug manufacturers benefit from the
trialability of their products in two ways—first,
as a new drug is introduced, free samples make
physicians aware of the product. Second, once
the drug is well accepted, free samples help
physicians introduce patients to a new drug.
Beyond drug samples, there are many health care
technologies that lend themselves to sampling
of some sort:
 At professional association conferences and
trade shows for medical and information tech-
nology professionals, technology vendors give
demonstrations that walk individuals through
the mechanics of the innovation and a hands-
on trial using it on a dummy or model.
 New clinical (and even administrative) infor-
mation systems can be tried out with little
commitment through Web sites and applica-
tion services providers (ASPs) that do not
require fully installing or converting to the
new system.
 Simple, stand-alone medical devices that do
not require extensive training or need to
interact with a complex system, such as new
syringes, airway devices, or surgical staples
or adhesive strips to hold together skin edges,
are, like pharmaceuticals, easy to sample.
 Even when a technology fits into a more
extensive or complex system, some compo-
nents of it may be trialable, such as new
reagents in an automated lab system or new
contrast media for imaging systems.
 New medical procedures or disease manage-
ment strategies may be trialable if they do not
require a great deal of coordination of care.
A single practitioner or office can try them out
more readily than a complex health system.
These last examples point to types of innovations
that are not easy to try; other approaches to pro-
moting diffusion will be more successful.
 Innovations that require a large amount of
training before they can be successfully
deployed are not very trialable. New combina-
tions of medical devices and surgical tech-
niques, such as keyhole surgery on a beating
heart or arthroscopic repair of cartilage in knee
and shoulder joints, do not lend themselves
to easy trials.
 Innovations that require hands-on experience
to notice the difference may not be very
trialable. A new grip on a hand-held device
or improved flexibility in a laparoscopic tool
may be something a potential user must
experience first-hand.
 Technologies that require a large capital
expenditure, such as complex radiological
instruments, integrated information systems,
or telemedicine for remote surgery, are not
readily trialable, though it is possible to bring
practitioners to demonstration sites.
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 Innovations that fit into complex legacy
systems—human, organizational, technologi-
cal, or informational—are difficult to sample
because they require adaptation and have
repercussions throughout the system. The slow
diffusion of electronic medical records (EMRs),
for instance, has come in part because,
although it is easy to demonstrate the functions
and benefits of an EMR, it is very difficult to
get a practitioner to try it out in a clinical
setting because it must fit in with so many
other systems. Similarly, consumer-oriented
quality measures interact throughout the
health system, making them difficult to try.
Lessons for Technology Diffusion
 Look for opportunities to carve out some
part of a system that is more trialable, even
if an innovation does not obviously lend itself
to trials. Divide the overall process into com-
ponent pieces, some of which can be attacked.
 When designing a complex new technology
or system, think about which components
of it could be tried out without committing
to the full innovation. Make sure that the
benefits are tangible and even more powerful
when deployed in the context of the complete
system.
3. Observability
Observability is seeing how an innovation works
by watching someone else use it and then acknowl-
edging that the technology is safe and/or bene-
ficial. The extent to which potential adopters can
witness the adoption of an innovation by others
can determine its prospects for diffusion. The
more obvious the evidence of improved experi-
ence, increased functionality, and better outcomes,
the more likely it will be adopted by new users.
Examples
A non-medical example of observability is info-
mercials. An infomercial is a program that is an
advertisement for a product. During an infomer-
cial, an actor shows how much better, faster, and
more efficient a new technology is by demon-
strating its use in comparison to the traditional
method. The audience is only asked to believe
what it sees and is offered to try it, often with a
money-back guarantee. Health care technologies
are often demonstrated in a similar way:
 During internship and residency programs,
physicians are taught by example. When
a surgeon is learning a new procedure or how
to use a new device, he or she usually watches
a more experienced person using the device,
often by watching the operation and then
repeating the procedure.
 Manufacturers of very complex and expensive
medical devices advertise their innovations
much more discriminately than with infomer-
cials. Many new medical technology demon-
strations are conducted by the vendor of the
device or therapy in the office of the targeted
clinician or at seminars, often with extra finan-
cial or other forms of incentive thrown in to
encourage adoption of the technology.
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Some innovations are not easy to observe and
therefore may diffuse more slowly. It is hard
to observe an individual’s experience with infor-
mation technology and even harder when the
observer does not know what to look for.
 Innovations that cannot be demonstrated
easily with immediately visible results are not
very observable. Some innovations improve
the long-term health outcomes but show no
instant change in results. Examples are devices
or drugs to lower the risk of primary or recur-
rent events, such as cholesterol-reducing drugs
to prevent atherosclerosis.
 If a new technology creates observable results
that require additional expertise to interpret
them and make them understandable, that
technology may be slower to diffuse. The more
complex the results, the less obvious they
become. Examples are novel devices that are
likely to benefit a small, but important, sub-
population within a disease category, such as
an implanted cardiac defibrillator.
Lessons for Technology Diffusion
 Make the invisible visible with viral mar-
keting. One marketing challenge is making
non-observable adoption more visible, which is
what pharmaceutical companies have done by
plastering their logos on free items for physi-
cians. It is also the key idea behind viral mar-
keting. By adopting a free Hotmail email serv-
ice and allowing Hotmail to put its footer on
an individual’s outgoing email, the individual
says “I’m a hotmail user and proud of it.” The
use of the Hotmail product makes an act that
typically is not observable—the choice of
email service—more observable.
The Basics of the S-Curve
The S-curve is by now a quite intuitive model
of how technologies and other innovations
spread through a population. It is based in a
tradition of agricultural research that looked at,
for example, the uptake of a hybrid corn variety
among farmers in an Iowa county or the
spread of irrigation technology in California’s
Central Valley.
In essence, the S-curve model shows that any
innovation is first adopted by a few people
(or organizations). As more use it, others see
it in use and, if the innovation is better than
what went before, others begin to use it.
Once the diffusion reaches a level of critical
mass, it proceeds rapidly. At some point, the
innovation reaches a part of the population
that is less likely to adopt it, and diffusion
slows to a point of saturation. Figure 1 traces
this S-curve.
Figure 1. The Diffusion S-Curve
Source: Institute for the Future
Diffusion of Innovation in Health Care | 11
Late majority
Laggards
Early majority
Early adopters
Innovators
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The Basics of the S-Curve, Continued
The S-curve implies a hierarchy of adopters, and
Rogers divides this population into five cate-
gories, based on when different groups are likely
to adopt the technology along its S-curve path.
Table 1 summarizes these groups. The shares of
the population in each group are an arbitrary
Table 1. Hierarchy of Technology Adopters
division that indicates the rough scale of that
group in the total adopter population. (Note that
the population base in this analysis is people
who adopt. There also are non-adopters, who
are not included.)
12 | CALIFORNIA HEALTHCARE FOUNDATION
Category Characteristics Percent of Adopters
Innovators  Venturesome 2.5
 Cosmopolite
 Geographically dispersed contacts
 High tolerance of uncertainty and failure
Early adopters  Well-respected opinion leadership 13.5
 Well integrated in social system
 Judicious and successful use of innovation
Early majority  Deliberate 34.0
 Highly interconnected within a peer system
 Just ahead of the average
Late majority  Skeptical 34.0
 Responsive to economic necessity
 Responsive to social norms
 Limited economic resources
 Low tolerance for uncertainty
Laggards  Traditional 16.0
 Localite
 Relatively isolated
 Precarious economic situation
 Suspicious
Source: Everett Rogers, Diffusion of Innovations. New York: The Free Press, 1995.
In general, early adopters have more years of
education, higher social status, greater empathy,
greater ability to deal with abstractions, greater
ability to cope with uncertainty, more social and
professional contact, more cosmopolite contact,
more change agent contact, more exposure
to mass media, and a greater degree of opinion
leadership than later adopters (Rogers, 276).
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4. Communications Channels
Diffusion of innovations is a social process that
depends on new ideas being communicated from
an individual who knows about the innovation
to an individual who does not. Health care
professionals and consumers are bombarded by
information from many sources, each trying to
persuade them to try a product, a procedure,
or a point of view. Many specialized communica-
tions channels have evolved.
Examples
When the locus of power in health care was clear
and concentrated in the hands of physicians, the
communications channels were simple to discern
and exploit: fund research that was reported in
medical journals; buy advertising in those same
journals; send detail people to the offices to
promote products; show up at meetings of pro-
fessional societies; and wine and dine the opinion
leaders who have influence in each local com-
munity of physicians. As power has dispersed to
managed care organizations, group practices,
and consumers, the communications channels
have become more complex and interact with
each other in unexpected ways.
 The Internet is the single most important
new communication channel to develop in the
past century. It has sped up and democratized
the dissemination of medical information.
The medical literature, traditionally the
province of only trained professionals or the
most diligent and educated consumer, has
become open to all.
 Increasingly, consumers are taking responsibility
for their own health care (some voluntarily,
some pushed by cutbacks in insurance cover-
age). They are thirsty for medical knowledge.
Many channels have evolved to influence their
decisions, including increased coverage of
health technology in the popular press, a host
of Web sites on health care, and a rash of
direct-to-consumer (DTC) advertising of new
pharmaceuticals.
 As consumers become better informed about
their medical conditions, they themselves have
become a communications channel to physi-
cians about medical innovations. This shift in
communication pattern can be upsetting to
physicians, some of whom report that con-
sumers come armed with the latest research or
influenced by the latest DTC ad, demanding
medically inappropriate treatments.
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 A weakness of traditional, peer-reviewed jour-
nals is the time lag between a new finding
and when it reaches health care professionals.
New channels are opening up to speed that
process. Online e-journals now provide early
release and discussion of findings. This new
communications channel may raise questions
about the integrity of information that may
not have undergone the rigors of traditional
peer-review.
 Personal contact remains a powerful commu-
nication channel. Even as consumers and
managed care organizations have gained
power, pharmaceutical companies have tripled
their sales forces. Detailing still works.
 Groups that want to carry a message have
learned to piggyback their messages on exist-
ing communications channels. Managed care
organizations (MCOs) have, for example,
negotiated with drug companies to have their
representatives carry MCO-determined mes-
sages (in addition to their samples and market-
ing materials) to the MCO’s physicians.
Not all communications channels are equally
effective and some have either not been adopted
widely or are quite ineffective.
 Email, a staple of communications in many
business areas, has been very slow to penetrate
the doctor-patient relationship. Estimates of
how many doctors use email to communicate
with their patients range from 10 percent to
30 percent. Despite its popularity with con-
sumers, a range of legal, ethical, and financial
issues prevent physicians from adopting email
widely. Like the telephone, which was slow
to diffuse into medical practice initially, but
eventually became a universal communications
channel, email likely will reach large penetra-
tion in the future.
 Accrual rates of adult cancer patients into
clinical trials remain very low, on the order of
2 to 5 percent, compared with childhood can-
cer patients, some 70 percent of whom reach
clinical trials. Diffusion of the best cancer
treatments, often represented by the practices
in clinical trials, depends on patients becoming
informed about their direct and indirect
benefits. But many cancer doctors, for whom
clinical trials are sometimes unrewarding
and burdensome, often neglect to tell patients
about the option to participate in trials or
indicate that treatment will be determined by
“drawing a card.” A key communication link
is broken, slowing diffusion.
 Scientific innovation depends on the free flow
of information. The academic tradition of
rapid publication of interesting results has
begun to give way to more protective behavior,
in which results are not published or are
published incompletely until final intellectual
property rights are resolved. Breaking or slow-
ing this critical communication link risks
impeding scientific progress.
Lessons for Technology Diffusion
 To inform people about an innovation, select
mass media and “cosmopolite” sources.
To persuade people to adopt the innovation,
closer links and interpersonal channels are
more effective.
 To communicate more complex messages,
select interpersonal communications
channels. Describing surgical techniques or
complex medical devices works best one-on-
one with a trusted source.
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 In order to select the right communication
channels, select the right target audience. For
example, promoting administrative IT systems
to physicians has limited effectiveness. Practice
administrators or CIOs are the primary target,
and they have their own, often separate, com-
munications channels.
 Identify individuals who are “Connectors.”
Malcolm Gladwell, in his book The Tipping
Point, identifies a type of individual who has
many acquaintances (not necessarily with
strong ties to them) and propagates informa-
tion freely through an established network.
People, ideas, and innovations that get the
attention of Connectors have a much better
chance of diffusing. They are a key communi-
cation channel.
5. Homophilous Groups
The degree of similarity among group members
across which an innovation diffuses will affect the
ease and speed with which the diffusion
takes place. Innovations spread faster among
homophilous groups (those with similar charac-
teristics) than among heterophilous groups
(those that differ in important ways).
In general, communication is more effective
when the source and receiver share common
meanings, beliefs, and mutual understandings.
Communication among like individuals will
be more effective because individuals feel
more comfortable interacting with others like
themselves. However, differences in training,
social status, beliefs, and language can lead to
mistaken meanings, thereby causing messages to
be distorted or to go unheeded.
Physicians are a relatively homophilous group.
The medical profession is a guild with rituals,
hierarchy, and rules of professional etiquette that
go well beyond their common schooling. Physi-
cians all take the Hippocratic oath, a promise
to do no harm. They are trained with a relatively
standard curriculum that is focused on clinical
skills in diagnosis and treatment. As a group,
they enjoy the same high status in society.
Examples
 Most clinicians join professional associations
during their careers. Associations count on the
homophily of their members in communicat-
ing with them and offering services such as
conferences, continuing medical education,
and special certification. Associations can
encompass a broad range of a profession, such
as the American Medical Association for doc-
tors or the American Nursing Association for
nurses, or it can encompass a much smaller,
more specialized community, such as the
American Society of Clinical Oncologists.
 Most associations also publish a scientific
journal that tracks the latest advances in
clinical and laboratory research. Beyond the
most widely-read general medical journals
such as the Journal of the American Medical
Association or the New England Journal of
Medicine, researchers try to publish in specialty
journals with specialist physician readers. The
researchers and readers are both considering
the homophily of the specialty as a way to
filter out less pertinent information.
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Though physicians are very similar, sometimes
homophily is simply not there.
 Executive leadership at health systems is a mix
of physicians and administrators. Though the
primary incentive to adopt new technology is
to improve patient care, the heterophilous
nature of the roles in health system leadership
and their expertise also influences their deci-
sions. Physicians who leave clinical practice to
become full-time administrators are likely to
think as an administrator and be so considered
by the practicing physician community.
 An example of physician heterophily that has
thwarted health care quality advocates is
practice variation. Though physicians all over
the U.S. are trained using a similar curricu-
lum, practice behavior varies quite drastically
depending on the practice standards in the
geographic area. Quality advocates attempt to
overcome discrepancies in local clinical culture
by disseminating clinical practice guidelines
and protocols, using the appeal of adherence
to generally accepted practices.
Lessons for Technology Diffusion
 To use homophily as a technology promoter,
understand the degree of homophily in the
target group. Though some groups may share
training and biases and appear homophilous,
when introduced to something that they are
not familiar with as a group, such as informa-
tion technology, their homophily as clinicians
may be overcome by their heterophily as IT
consumers.
 Look for other homophilous groups beyond
physicians. Examples of other groups that
may share similar needs with each other are
practice administrators, health system strategic
planners, nurses, specialty nurses, interest
groups, and patient advocacy groups such as
AIDS or breast cancer. Communication
within these groups may speed up diffusion
of information.
 Put the right person in front of your target
audience. People are more likely to be per-
suaded by like individuals. Doctors respect
other doctors because they share training,
have the same commitment to heal, and feel
the shared pain of increases in managed
care administrative burdens, etc. It is valuable
to speak to potential adopters from their own
perspective and show that you understand
their daily challenges.
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6. Pace of Innovation/Reinvention
Some innovations are relatively stable and do
not evolve as they diffuse. Others evolve more
rapidly and are altered by users along the way.
The degree of reinvention of any innovation
affects both its pace and style of diffusion. Some
innovations lend themselves readily to being
appropriated and altered by their users, and can
diffuse rapidly even as they change, becoming
almost unrecognizable as they reach new popula-
tions. Others are much less mutable—either they
are used as intended or are not used at all.
Examples
Innovations that are general, not specialized, very
complex, and that are process-oriented often get
reinvented to a larger extent than innovations
that are not.
 Physicians are trained to be autonomous,
scientific thinkers. As such, many medical
technologies get reinvented and reinterpreted
in the hands of practicing doctors. Off-label
uses of prescription drugs are increasingly
common, and compendia are published that
list off-label uses, as well as those that are
approved. Consumers also will find new
applications for existing drugs, as evidenced
by the recent publicity about women using
Viagra. Surgeons are ever eager to add a per-
sonal signature on a new surgical procedure,
e.g., off-pump cardiac surgery.
 Other medical technologies, such as lasers,
often are reinvented. Sometimes this results in
extending the range of conditions for which the
device can be used. An example is radiosurgery.
Initially applied to only two neurosurgical
conditions, it is being used today in a range of
applications within and outside of the nervous
system, such as epilepsy and abdominal cancer.
 Reinvention is often a necessary step for
diffusing a flexible technology into a complex
social environment. Most hospitals will insist
that their administrative procedures are
unique, and that a standardized information
system would not fit the local culture. In
fact, 70 to 90 percent of the transactions and
procedures typically are very similar to those
of other hospitals, and only a small degree
of customization is required. But the act
of customizing—of reinventing—increases
acceptance of the technology. A similar
phenomenon takes place with practice guide-
lines. Local providers must put their stamp
on standard frameworks to feel that they are
locally adapted.
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Stages in the Innovation—Decision Process
The decision to adopt an innovation takes time.
There is inherent uncertainty to a new untested
alternative. There are actions and choices that
one must make in order to evaluate the new idea
and decide whether or not to put it into practice.
Rogers maps this Innovation—Decision Process
into five steps.
The Innovation—Decision Process is the process
through which an individual (or other decision-
making unit) passes from first knowledge of an
innovation, to forming an attitude toward the
innovation, to a decision to adopt or reject,
to implementation of the new idea, to confirma-
tion of this decision.
18 | CALIFORNIA HEALTHCARE FOUNDATION
Knowledge
Knowledge occurs when the decision-maker is exposed to an innovation’s existence and
gains some understanding of how it functions. Acquiring knowledge occurs throughout the
innovation—decision process.
Persuasion
Persuasion occurs when the decision-maker forms a favorable or unfavorable attitude toward
the innovation. Persuasion is when the decision-maker becomes psychologically involved and
starts to feel something about the innovation. Early information received or past experience
with a similar technology affects the attitude towards the innovation.
Decision
Decision occurs when the decision-maker engages in activities, such as partial trial of the
innovation, that lead to a choice to adopt or reject the innovation.
Implementation
Implementation occurs when the decision-maker puts an innovation into use and overt
behavior change happens. The new user seeks information about how to obtain the innova-
tion, thinks about what problems might be encountered, and seeks support in putting the
innovation in place.
Confirmation
Confirmation occurs when the decision-maker seeks reinforcement of an innovation—decision
already made, or reverses a previous decision to adopt or reject the innovation if exposed
to conflicting messages about the innovation. At this point, the decision-maker seeks to avoid
a state of dissonance or to reduce it if it occurs.
Source: Institute for the Future; adopted from Everett Rogers, Diffusion of Innovations. New York: The Free Press, 1995.
diffusion fnl guts spot 5/15/02 12:08 PM Page 18

Reinvention may be a signal that there is some-
thing wrong with the technology as initially
released. The fact that it must be adapted and
reinvented may indicate flaws in the original
design.
 Pharmaceutical manufacturers must track
their products post-approval to be certain that
there are no severe adverse side effects not
observed in pre-approval drug trials that only
are manifested once the product is in wide use.
In some cases, such effects result in redesign
or reapplication of the drug, for instance limit-
ing its use to specified populations or requiring
a diagnostic test to monitor side effects. An
example is the routine ordering of a liver func-
tion panel for patients shortly after a statin is
first prescribed.
 Many IT systems are reinvented after installa-
tion, particularly when the design team did
not initially involve the right individuals in the
process. This reinvention may reflect poor
design and installation, but often is the result
of insufficient after-sale training and support.
Training and support cost money and time,
and so are often overlooked. Change-manage-
ment experts attest that training is a critical
success factor to successful diffusion of new
IT systems.
Lessons for Technology Diffusion
Dissatisfaction is the mother of reinvention
and reinvention is a source of extremely useful
feedback from users. Several devices can be
used to exploit that knowledge.
 Put in place active listening posts. Many IT
companies have mastered the art of creating,
nurturing, and listening constructively to user
groups as a source of early warning about
problems in a system as well as users’ priorities
for new features.
 Monitor medical technologies very carefully
for instances of potentially dangerous
misuses. Early detection can trigger product
changes or education campaigns that avert
significant liability down the road.
 Look for the “work-arounds” that users
employ to make a technology work. Work-
arounds are extremely common with infor-
mation systems users who often do the first
thing that works for them, never learning
often easier ways to operate.
 Don’t be offended by reinvention. It is not
a sign that the innovation was inadequate
or that users did not really understand the
designer’s intent. It is typically a sign that the
innovation is being put to even greater use
than was intended.
7. Norms, Roles, and Social Networks
The norms, roles, and social networks of medi-
cine are very important to the diffusion of new
technology. According to classic diffusion theory,
the configuration of the social networks through
which innovations diffuse help govern the pace
and extent of diffusion. Studies in the mid-1960s
of physicians’ prescribing patterns of tetracycline,
for example, showed that doctors with more
extensive social networks—those on hospital
staffs or who attended hospital staff meetings,
those who practiced in groups, those who con-
sulted with other physicians about their cases,
and those who were cited as being close friends
of other doctors—adopted the drug much more
rapidly than doctors who were relatively more
socially isolated.1
Norms of behavior and expectations about roles
are strongly ingrained in health care professionals
and affect how new ideas and technologies dif-
fuse into practice. These norms and expectations
can be used to target the appropriate social net-
works to help diffuse a given innovation.
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Examples
 Norms that are instilled into physicians in
medical school are very difficult to change.
Some of the geographical variation in surgery
rates such as hysterectomy and mastectomy,
for example, derive from differences in how
the procedures were taught at different teach-
ing hospitals around the country. A single pro-
fessor’s ideas about when surgery is appropriate
can bring about great variations in cost and
quality of care. However, doctors in training
may learn more than one way to manage
a particular problem and what they practice is
often determined by local practices because
“that’s the way we do it.”
 Medical and other professional societies are
a key node in health care’s diffusion networks.
An endorsement by a professional society or
inclusion of a drug or procedure into a
society’s practice guidelines can speed diffusion
and lock a practice in (or out).
 Practice guidelines (PGs) themselves are a
good example of the need to choose the right
social network and a group with appropriate
norms to maximize the pace of diffusion.
Early practice guidelines were derided by
many mainstream physicians as “cookbook
medicine” that threatened to erode physician
autonomy in the service of the financial
incentives of managed care. As more providers
recognized the problems of practice variation
and as more professional societies produced
their own PGs, physicians were more willing to
get on board, as long as their own autonomy
was not threatened. They found a compromise
in many specialties by turning to a group—
nurses—whose social norm is compliance with
routines and orders set by someone else, for
which they had a delivery role. Once nurses
had responsibility for the implementation of
PGs, diffusion was more rapid.
The power of social networks and norms of
behavior in medicine also has acted to retard
innovation and to reward poor practice patterns.
 Although many steps have been taken over
the past decade to improve medical quality
and to remove dangerous physicians from
practice, a sort of medical omertà—a code of
silence protecting members of the guild—still
exists. That social norm, professional courtesy,
and loyalty to the social network can slow
the diffusion of better practices.
 Despite progress in the professionalization of
many parts of health care delivery systems,
the conventional medical hierarchy in which
physicians reign supreme still persists in many
settings. This affects the diffusion of many
technologies. Investments in the latest imaging
system (which may be a revenue center) prevail
over administrative information technology
(which may be viewed as a cost center).
Lessons for Technology Diffusion
An acute awareness of the social settings into
which a new technology or other innovation dif-
fuses is essential for affecting its pace. In the case
of PGs, the first managed care organization to
stop targeting doctors and to start targeting
nurses made an insightful breakthrough. Some
ideas on social networks:
 Pay explicit attention to the physical and
virtual networks of the groups you wish to
reach. In the past, social networks and geo-
graphic proximity were closely linked. Most of
a clinician’s contacts lived or worked close by.
With the advent of the Internet and with the
sustained mobility in American society, net-
works are more far-flung. Look for long links,
members of a network who are geographically
distant; and weak links, people who are only
acquaintances, not close friends. Both are
likely to have a social network that diverges
from the tighter network and are often a
source of innovation.
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 Be aware of opportunities to leverage exist-
ing or create new social networks. People
with AIDS, cancer, and many other diseases
have gravitated to support groups and online
communities. Often these communities have
been a rapid channel to diffuse information
about new medical technologies and for
mobilization of activists. Many pharmaceutical
companies have put in place online communi-
ty spaces for people with a disease their drugs
target. One drug company that produces
cancer drugs helped the American Society for
Clinical Oncology to create a new network of
state oncology societies. These societies served
as a dissemination channel for ASCO’s infor-
mation into community practice.
8. Opinion Leaders
Opinion leaders are key actors in the diffusion
of innovations. Change agents who want to
promote a new idea or technology must pay
attention to those individuals whose words and
behaviors influence that of their peers. In general,
opinion leaders have greater exposure to new
ideas through the media, by being more cosmo-
polite than others, by having more exposure to
change agents, having higher income and educa-
tion, and by having wider social networks than
most people.
Opinion leaders have been a key vector of diffu-
sion for many medical and information technol-
ogies, and a large amount of effort is dedicated to
identifying, informing, and convincing them to
become early adopters.
Examples
 Drug and device companies have perfected
the art of identifying the opinion leaders in a
given community or specialty and of courting
them through their sales forces. They also
have access to detailed databases showing
prescribing patterns in different communities.
Although the norms of how to influence
physician leaders have shifted (free trips to
Hawaii are out; unrestricted educational grants
are in), their importance has not diminished.
 Celebrity endorsements of drugs, nutritional
supplements, or health care facilities are
another form of opinion leadership geared
toward consumers.
 Patterns of opinion leadership vary depending
on the content. Few physicians are opinion
leaders on the business of running a practice,
medical matters, and on information systems,
for example. In the mid-1990s a number of
pharmaceutical manufacturers and health
insurers thought that, because they understood
the patterns of physician opinion leadership
in their respective fields, they could act as
a channel to sell information technologies or
disease management methodologies. They
quickly found that their sales networks did not
translate very effectively.
 For a number of reasons, the diffusion of
information systems in health care has been
much more fragmented than for medical tech-
nologies. Thousands of different practice
management software packages exist, few of
them with any appreciable market share.
The failure to get widespread agreement on
which IT system to use, especially in small
practices, is due in part to the relative scarcity
of physician opinion leaders for guidance
about information systems. This is less of a
problem for hospital information systems and
in larger practices, where IT professionals
(with their own patterns of opinion leader-
ship) make those decisions.
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Lessons for Technology Diffusion
Apart from the obvious lesson to identify and
court opinion leaders, there are several other les-
sons from the literature on diffusion.
 Do not mistake early adopters for opinion
leaders. Although opinion leaders typically do
adopt many innovations before the main-
stream does, they cannot afford to get too far
ahead of the pack. Opinion leaders serve to
reduce the uncertainty of others in their social
system about adopting new technology or
behaviors. This also means that, although
opinion leaders should be courted, they should
not be co-opted. If they adopt innovations
that fail too often, they risk losing leadership.
 Work hard to identify the relevant opinion
leaders. With the advent of the Internet, opin-
ion leadership has, to some extent, become
democratized. It is more difficult than before
to tell the qualifications of an opinion-holder,
because anyone can put together a slick Web
page. More than ever, it is essential to be part
of, and to map explicitly, the social networks
of authentic opinion leaders in health care.
 Be on the lookout for Mavens. Malcolm
Gladwell, in The Tipping Point, (Little, Brown
and Company, 2000), identifies The Maven as
a type of opinion leader who is very important
to the diffusion of new ideas. Mavens are indi-
viduals who study markets and technologies to
gather information on the latest, and the most
effective technologies, sharing that information
with their peers. Mavens have a reputation for
being knowledgeable and are often deferred to
by those in their social network. The Maven is
a special type of opinion leader—one who has
exposure to a wider range of fields and infor-
mation than most other opinion leaders.
9. Compatibility
The familiarity of an innovation, its compatibility
with the existing environment and behavior, is
strongly linked to its diffusion. The more an
innovation can integrate and coexist with tech-
nologies and social patterns already in place, the
greater its prospects for adoption and diffusion.
If the innovation is consistent with a potential
adopter’s past experiences, existing values and
needs, the decision to adopt is facilitated.
Precedent behavior or an installed base of tech-
nology increases compatibility and improves
the likelihood of diffusion. The more compatible
an innovation is, the less change in behavior it
requires.2 A new imaging modality will diffuse
because an installed base of imaging technology
is there, and a new or improved drug therapy will
diffuse along the same path of its predecessors.
Exogenous influencing factors, such as financial
reimbursement for using the technology, can
influence the pace of diffusion. Medical technol-
ogy diffusion often “follows the money” in that
the lack of a clear reimbursement method for a
new technology is a significant barrier even if the
technology offers a perceived competitive advan-
tage to the physician or hospital.
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Examples
 Plug and play technologies, those that mesh
with current standards and do not require
learning new behavior, are the easiest to
diffuse. IV solution bags, tubes, and valves
with standard sizes and interchangeability are
plug and play technologies.
Another example of plug and play technology
in medicine is the introduction of Palm Pilots
and other handheld devices with prescribing
capabilities for physicians. Assuming that
the clinician using the device already knows
how to use it, the introduction of a palm-
based prescription program requires no more
effort to learn than the new software and
reduces error and duplication.
 Most new medical technology improves upon
an earlier version of the technology. Ground-
breaking, revolutionary technologies that are
the first to do something fundamentally
differently, such as x-ray technology, are likely
to be incompatible with current practice.
Such technologies are often the first in what
then becomes a new class of technologies
and all technologies that follow it build upon
the experience with the previous generation
of technology.
Since the discovery of the x-ray, new imaging
technologies have diffused by building on a
potential adopter’s experience of the previous
generation. New users of CT scans had
expectations of results that were based on
their experience with x-ray, and new users of
MRI had expectations built on their experi-
ence with CT scans.
 The federal government wanted to promote
the use of telemedicine in rural areas in the
U.S. to address geographic shortages of clini-
cians and specialty services. In 1997, Congress
increased the amount Medicare reimbursed for
telemedicine services, bringing about a growth
in telemedicine programs.3 By creating a fund-
ing stream for telemedicine, the government
encouraged the use of the technology and sped
its diffusion among providers and vendors.
The concept of incompatibility helps illustrate
why some classes of technology diffuse more
readily than others.
 The use of information technology has been
correlated with education and income, that is,
the more education and income one has, the
more likely they are to use personal computers
and the Internet.4 As individuals who have
high levels of education and income, physi-
cians are assumed to have an affinity for infor-
mation technology. In fact surveys show that
physicians do use information technology, with
70 percent using the Internet and 75 percent
using a personal computer.5 But only a quarter
of physicians use email to communicate with
patients and only 22 percent use electronic
medical records.6 As a rule, physicians do not
use computers in their daily workflow.
 An innovation can be incompatible when an
organization or government controls and
rations the technology budget. In restricted
budgeting environments, such as with Canada
and the United Kingdom, a new technology
will diffuse only after cost-benefit analysis
shows significant improvement over existing
technology and then only minimally, rationing
the amount of technology available. Such
governments do not spend as much as the U.S.
on new medical technology; physicians are
less likely to refer patients for high-end tech-
nological procedures and patients who do get
referred must wait longer for the procedure
than in the U.S.
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Lessons for Technology Diffusion
 Understand current behaviors and values.
Look for currently existing behaviors that are
similar to the behavior being introduced.
Look for and understand both formal and
informal hierarchies and power relationships
(e.g., nurses are trained to take orders from
physicians but have the dominant role in daily
patient care).
 Innovations that reduce hassles are more
likely to be successful. Features that go
beyond the primary function of the technolo-
gy and make it easier and more pleasant to
use will increase its compatibility.
 Mimic things from other parts of life. Soft-
ware developers have created computer
interfaces with icons that represent functions
analogous to those in our daily lives (e.g., the
word processing software icon for cut is
scissors and for paste is a jar of paste, etc.).
10. Infrastructure
The adoption of many innovations depends on
the presence of existing infrastructure that can
support it. Fax machines are an example of
infrastructure’s role in technology diffusion; their
rapid adoption depended on telephone lines,
an infrastructure already in place.
Some technologies diffuse in clusters and are
interdependent on one another to succeed. The
use of email depends, for example, on a cluster
that includes personal computers, email software,
modems, voice and data communications
networks, servers, and common communication
standards.
Examples
 After CT scans were introduced into hospital
radiology departments, they required computers
for image display and digital image storage.
Though computers had been used in radiology
departments for administrative functions, such
as scheduling, display and storage functions
required different features and created demand
for a different type of machine. When MRI
technology came along, it depended on that
same display infrastructure.
 Advances in genomic technology promise
personalized medicine and gene therapy some-
time after the year 2010. Between now and
then, the platform technologies for applying
genetic and genomic knowledge to drug design
and development, such as target validation,
must mature. Only then will the majority of
newly approved biopharmaceuticals originate
from drug discovery based on targets generated
from genomic-based research.
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A lack of infrastructure or the wrong kind of
infrastructure can retard technology diffusion.
 To the dismay of health IT promoters, the
legacy infrastructure of paper patient files is
still in place. IT continues to be stored in sep-
arate, non-integrated databases, used primarily
by non-clinical staff and, other than digital
imaging and telemedicine, it is used mostly
for administrative and billing functions. The
pervasiveness of paper-based infrastructure has
made it difficult for IT to diffuse beyond
administrative and clinical functions.
 Regulatory timelines and procedures can be
significant barriers to diffusion. Pharmaceutical
and medical device manufacturers build the
time needed for regulatory approval into their
development, and are affected adversely by the
time taken up by requests for additional infor-
mation. The longer it takes for a blockbuster
patent-protected drug to make it to market,
the more money a drug company loses in mar-
ket exclusivity. At the opposite end of this
spectrum, the FDA instituted a controversial
fast-track approval process to overcome this
barrier in special circumstances.
Lessons for Technology Diffusion
 Look for opportunities to plug and play. To
do this, it is important to understand how
technologies are connected to each other, what
are the relevant standards and potential contexts,
and how the technologies fit into the daily
workflow of clinicians. Entrepreneurs creating
innovative new IV devices and tubes under-
stand every use of them, who uses them, how
they are stored and what remains challenging
about the current state of the technology.
 Understand current and future regulatory
constraints and competing patent protections.
 Look for leapfrogging technology. In some
cases, it is possible to overcome infrastructure
barriers by jumping to a different level of
technology. An example of this is the diffusion
of cell phones in parts of Asia where there
are no telephone lines.
Diffusion of Innovation in Health Care | 25
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26 | CALIFORNIA HEALTHCARE FOUNDATION
THERE WILL CONTINUE TO BE MANY BENEFICIAL
health care technologies that should diffuse, but will not.
And there will be others—me-too products that offer no real
innovation, health information systems that complicate rather
than simplify life, expensive new therapies that do not extend
life or improve quality—that diffuse despite their shortcomings.
This tour through the basics of innovation diffusion should
help make clear why getting new ideas and technologies put to
good use continues to be both frustrating and rewarding for
innovators and users alike.
“Getting a new idea adopted,
even when it has obvious
advantages, is often very
difficult.”
— Everett Rogers,
Diffusion of Innovations
III. Epilogue
diffusion fnl guts spot 5/15/02 12:08 PM Page 26

Quick Tips for Technology Diffusion
Relative advantage
 Understand the end user of the
technology
 Recognize the impact of significant
behavior change
 Consider the business case for the
adoption of a new technology
Trialability
 Look for opportunities to carve out some
part of a system that is more trialable
 When designing a complex new tech-
nology or system, consider which
components could be tried out without
committing to the full innovation
Observability
 Make the invisible visible with viral
marketing
Communications channels
 To inform people about an innovation,
select mass media and “cosmopolite”
sources. To persuade people to adopt the
innovation, closer links and interpersonal
channels are more effective
 To communicate more complex
messages, select interpersonal com-
munications channels
 In order to select the right com-
munication channels, select the right
target audience
 Identify people who are “Connectors”
Homophilous groups
 To use homophily as a technology
promoter, understand the degree of
homophily in the target group
 Look for other homophilous groups
beyond physicians
 Put the right individual in front of your
target audience
Pace of innovation/reinvention
 Put in place active listening posts
 Monitor medical technologies very
carefully for instances of potentially
dangerous misuses
 Look for the “work-arounds” that users
employ to make a technology work
 Do not be offended by reinvention
Norms, roles, and social networks
 Pay explicit attention to the physical
and virtual networks of the groups you
wish to reach
 Be aware of opportunities to leverage
existing or to create new social networks
Opinion leaders
 Do not mistake early adopters for
opinion leaders
 Work hard to identify the relevant
opinion leaders
 Be on the lookout for “Mavens”
Compatibility
 Understand current behaviors and
values
 Innovations that reduce hassles are
more likely to be successful
 Mimic things from other parts of life
Infrastructure
 Look for opportunities to plug and play
 Understand current and future
regulatory constraints and competing
patent protections
 Look for leapfrogging technology
Diffusion of Innovation in Health Care | 27
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Endnotes
1. Rogers, Everett M. Diffusion of Innovations.
Fourth Edition, The Free Press,
New York, 1995
2. Ibid.
3. American Telemedicine Association.
“Telemedicine Reimbursement Approved by
Congress; Agreement Hailed as Victory for
Advocates of Telemedicine.” 1997.
www.atmeda.org, and PRNewswire
www.prnewswire.com/cgi-bin/stories.
pl?ACCT=104&STORY=/www/story/
7-31-97/289253&EDATE=
4. National Telecommunications and Informa-
tion Administartion, U.S. Department
of Commerce. A Nation Online: How
Americans are Expanding Their Use of the
Internet, 2002. www.ntia.doc.gov
5. Mills, Robert, J. “AMA Survey Finds Upsurge
in Physician Usage and Regard for Internet”
American Medical Association, May 2001.
www.ama-assn.org/ama/pub/article/1616-
4692.html
6. Landro, Laura “Unhealthy Communication:
When it Comes to E-Mail, the Doctor
is Not In” Wall Street Journal, 2/11/02
http://online.wsj.com/article/0,,SB101303370
0555906000.djm,00.html
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