In addressing the question of what would really drive fundamental change in the overall system, Rouse suggested a lesson from the university system, where students are “free electrons” and catalyze enthusiasm for new areas of study, attracting faculty to focus on those areas. In the health care system, the catalyst is unclear, but very well could be patients as consumers of care.

Building off Rouse’s points, Wallace discussed consumers as the way to identify change and as the source of leadership for change. For example, the ability for patients to access large parts of their medical charts and to securely e-mail their physicians directly was not an innovation stimulated by providers, but by patients. The success of this was largely due to the innovation being aligned with patient interests. As an example, Kaiser used directed consumer advertising to notify consumers of the availability of a new patient–physician secure messaging service. Another example of how consumers have stimulated change is the Internet itself. Beginning about a decade ago, patients began bringing in piles of research from the Internet about their conditions, changing the physician role from being an oracle to someone who helped patients understand what the information means to them. The opportunities for transparency and access to information to change the system are great. Whether patients will learn how to use this information for their own benefit remains to be seen.

Part of leveraging patients to change the system requires understanding patient preferences and the tradeoffs patients make. For example, the rise of retail-based clinics could be interpreted as patients’ willingness to give up the idea of continuity of care with a single physician because they would rather have care be more tailored to their schedules (e.g., open late and in more convenient locations).

Patients can be used as implementers to facilitate spread for those ideas truly in patients’ interests. This capacity needs to be leveraged where appropriate, Wallace said, such as disease management. On the other side of the continuum, provider systems must also become more self-aware and act on opportunities outside of consumers’ view. Different solutions will be necessary for various parts of the health care system, but the ability to both engage and leverage the consumer has been underused. The design of the health care system, research designs, and program designs all must recognize the need to put the patient at the center of health care and allow patients to become participants in and drivers of change.

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