Maximizing the impact of CER will require the effective delivery of evidence to numerous audiences. For the most part, the five phases of CER translation are not actively managed or supported in a coherent way. Instead, evidence is published, then a variety of stakeholders take actions that serve their interests and motives. The dynamic interplay among these stakeholders can be unpredictable and sometimes haphazard, producing suboptimal implementation of new clinical practices and potentially contributing to poor quality and high costs of care. While larger payers and integrated systems have developed the infrastructure necessary for translation (including committees to appraise and interpret CER evidence, guideline-development processes, and strategies to develop and implement performance measures), they do so at a cost that is prohibitive to most health plans and providers. It is unlikely (and probably undesirable) that any group in the United States will manage the CER translation process centrally. However, a CER-enabling infrastructure could remove some of the perverse incentives of the current approach and reduce the number of missed opportunities to implement new and effective clinical practices.
What is a CER-enabling infrastructure? We envision it as a set of policymaking bodies, policies, and funded activities that achieve three aims: (1) enabling generation of CER that is highly relevant to decisionmakers, (2) enabling more-effective translation of CER results into practice, and (3) enabling more-effective evaluation of the impact of translation activities. This infrastructure is already a work in progress embodied in PCORI and federal agencies that play a role in CER. It exists in a wide array of federal and state agencies, regulators, professional societies, academic institutions, and healthcare-delivery organizations, but it is not sufficiently organized to optimize the implementation of new clinical practices. Similarly, the enabling infrastructure for evaluation of the impact of CER translation activities exists in federal agencies, academic institutions, and research organizations, but it has failed to produce robust, generalizable evidence on best practices to facilitate translation of CER into practice.
The policy options outlined below are not intended to create a command-and-control infrastructure. Changes in the translation process, such as reengineering financial incentives, must be carried out by a diverse set of stakeholders in both the public and private sectors, and these changes must address a remarkable diversity of payment arrangements. These are policy options that could bring greater coherence and transparency to the process of CER translation, achieve greater balance of the influence of participating stakeholders, and enhance the voice of the public and patients whose health outcomes depend on effective, safe, and affordable care. Enacting some or all of these policy options could be expected to modify the financial and other incentives that shape clinical decisionmaking over time, so that decisions could be increasingly based on evidence.