Providing Value to New Health Technology: The Early Contribution of Entrepreneurs, Investors, and Regulatory Agencies.

BACKGROUND: New technologies constitute an important cost-driver in healthcare, but the dynamics that lead to their emergence remains poorly understood from a health policy standpoint. The goal of this paper is to clarify how entrepreneurs, investors, and regulatory agencies influence the value of emerging health technologies. METHODS: Our 5-year qualitative research program examined the processes through which new health technologies were envisioned, financed, developed and commercialized by entrepreneurial clinical teams operating in Quebec's (Canada) publicly funded healthcare system. RESULTS: Entrepreneurs have a direct influence over a new technology's value proposition, but investors actively transform this value. Investors support a technology that can find a market, no matter its intrinsic value for clinical practice or healthcare systems. Regulatory agencies reinforce the "double" value of a new technology-as a health intervention and as an economic commodity-and provide economic worth to the venture that is bringing the technology to market. CONCLUSION: Policy-oriented initiatives such as early health technology assessment (HTA) and coverage with evidence may provide technology developers with useful input regarding the decisions they make at an early stage. But to foster technologies that bring more value to healthcare systems, policy-makers must actively support the consideration of health policy issues in innovation policy.

How do values shape technology design? An exploration of what makes the pursuit of health and wealth legitimate in academic spin-offs.

By actively supporting cooperation between academia, clinical settings and industry, several policy initiatives assume that the two policy agendas of health and wealth can be reconciled through the development of health technology. Our goal in this article is to shed light on the way the concurrent pursuit of health and wealth operates in practice by examining the valuation schemes, actions and decisions that shaped technology development in three Canadian spin-offs. Drawing on the sociology of judgement, our analytical framework conceives of technology development as a purposive collective action that unfolds in a normatively heterogeneous context (one pervaded with both corporate and public service mission values and norms). Our qualitative empirical analyses explore four valuation schemes and their corresponding regimes of engagement that characterise why and how technology developers commit themselves to addressing certain clinical, interactional, organisational and economic concerns throughout the development process. Our discussion suggests that the ability to reconcile health and wealth goals is to be found in the moral repertoires that provide meaning to, and render coherent technology developers' participation in corporate activities driven by economic growth.

How to summarize a 6,000-word paper in a six-minute video clip.

As part of our research team's knowledge transfer and exchange (KTE) efforts, we created a six-minute video clip that summarizes, in plain language, a scientific paper that describes why and how three teams of academic entrepreneurs developed new health technologies. Recognizing that video-based KTE strategies can be a valuable tool for health services and policy researchers, this paper explains the constraints and sources of inspiration that shaped our video production process. Aiming to provide practical guidance, we describe the steps and tools that we used to identify, refine and package the key content of the scientific paper into an original video format.

A six-minute video-clip to ponder the values fostered by health technology.

As part of our research team's knowledge transfer and exchange (KTE) initiatives, we developed a six-minute video-clip to enable productive deliberations among technology developers, clinicians and patient representatives. This video-clip summarises in plain language the valuable goals and features that are embedded in health technology and raises questions regarding the direction that should be taken by health care innovations. The use of such video-clips creates unique opportunities for face-to-face deliberations by enabling participants to interact and debate policy issues that are pivotal to the sustainability of health care systems. In our experience, we found that audiovisual-elicitation-based KTE initiatives can fill an important communication gap among key stakeholders: pondering, from a health care system perspective, why and how certain kinds of medical technologies bring a more valuable response to health care needs when compared to others.

The integration of citizens into a science/policy network in genetics: governance arrangements and asymmetry in expertise.

OBJECTIVE While there are increasing calls for public input into health research and policy, the actual obtaining of such input faces many challenges in practice. This article examines how a Canadian science/policy network in the field of genetics integrated citizens into its structure and then managed their participation. METHODS Our ethnographic case study covers a 5-year period (2003-08) and combines four data sources: observations of the network's meetings and informal activities, debriefing sessions with the network's leaders, semi-structured interviews with network members (n = 20) and document analysis. RESULTS When setting up the network, the leaders wanted to include a range of perspectives (research, clinical and policy) to increase the relevance of their research production and knowledge-transfer activities. After 2 years of operation, the network's members agreed to also include citizens who were not knowledgeable in genetics and policy issues. As neither the structure nor the dynamics of the network were modified, the citizens very soon started to feel uncomfortable with their role. They doubted the relevance of their contribution, pointing to an asymmetry in knowledge between them and the expert members. There were significant tensions in the network's governance and the citizens' concerns during the process were not fully addressed. CONCLUSION The integration of citizens into transdisciplinary networks requires recognizing and addressing the asymmetry of expertise that underpins such a collaborative endeavour. It also requires understanding that citizens may feel uncomfortable adopting the pre-defined role ascribed to them, may need a space of their own or may even withdraw if they feel being used.

Fostering deliberations about health innovation: what do we want to know from publics?

As more complex and uncertain forms of health innovation keep emerging, scholars are increasingly voicing arguments in favour of public involvement in health innovation policy. The current conceptualization of this involvement is, however, somewhat problematic as it tends to assume that scientific facts form a "hard," indisputable core around which "soft," relative values can be attached. This paper, by giving precedence to epistemological issues, explores what there is to know from public involvement. We argue that knowledge and normative assumptions are co-constitutive of each other and pivotal to the ways in which both experts and non-experts reason about health innovations. Because knowledge and normative assumptions are different but interrelated ways of reasoning, public involvement initiatives need to emphasise deliberative processes that maximise mutual learning within and across various groups of both experts and non-experts (who, we argue, all belong to the "publics"). Hence, we believe that what researchers might wish to know from publics is how their reasoning is anchored in normative assumptions (what makes a given innovation desirable?) and in knowledge about the plausibility of their effects (are they likely to be realised?). Accordingly, one sensible goal of greater public involvement in health innovation policy would be to refine normative assumptions and make their articulation with scientific observations explicit and openly contestable. The paper concludes that we must differentiate between normative assumptions and knowledge, rather than set up a dichotomy between them or confound them.

Designing a better place for patients: professional struggles surrounding satellite and mobile dialysis units.

The professional claims and struggles involved in the design of non-traditional health care places are rarely problematized in applied health research, perhaps because they tend to fade away once the new design is implemented. This paper offers insights into such professional tensions and their impact on health care delivery by examining the design of two dialysis service delivery models in Quebec, Canada. The satellite units were hosted in two small hospitals and staffed by recently trained nurses. The mobile unit was a bus fitted to accommodate five dialysis stations. It was staffed by experienced nurses and travelled back and forth between a university teaching hospital and two sites. In both projects, nephrologists supervised from a distance via a videoconferencing system. In this paper, we draw mainly from interviews with managers (mostly nurses) and physicians (n=18), and from on-site observations. Nephrologists, medical internists, and managers all supported the goal of providing "closer-to-patient" services. However, they held varying opinions on how to best materialize this goal. By comparing two models involving different clinical and spatial logics, we underscore the ways in which the design of non-traditional health care places opens up space for the re-negotiation of clinical norms. Instead of relatively straightforward conflicts between professions, we observed subtle but inexorable tensions within and beyond professional groups, who sought to measure up to "ideal standards" while acknowledging the contingencies of health care places.

Focus group research and "the patient's view".

A clear emphasis on the patient's view is discernible in the health services research literature of the past decades. Such a switch to patients' perspectives has been greatly facilitated by a wider acceptance and use of qualitative methods. In particular, focus groups are often used to uncover the range and depth of experiences of health services users and chronically ill individuals. Although this method contributes to a better understanding of patients' perspectives and practices, a number of analytical considerations have been overlooked. The aim of this paper is to consider how to conceptualise and analyse interactions in focus group research. We argue that focus groups are social spaces in which participants co-construct the "patient's view" by sharing, contesting and acquiring knowledge. Focus groups conducted with home care patients in Quebec, Canada (on antibiotic intravenous therapy, parenteral nutrition, peritoneal dialysis and oxygen therapy) are used to illustrate three interactive processes at work in focus groups: (1) establishing oneself as experienced and knowledgeable; (2) establishing oneself as in search of information and advice; and (3) validating or challenging one another's knowledge claims. We develop an analytical template focused on the subtle dynamics underpinning the various and at times competing claims of patients. This template acknowledges the processes through which participants attribute authority to the claims of others, including the focus group moderator. We find that focus group research does not derive epistemological authority simply from the identity of its participants. Rather, an emerging consensus about what constitutes the patient's view is the result of context-dependent social interactions that need to be scrutinised.