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Director's Letter

As a medical resident, I heard Barry Marshall, the Australian physician and Nobel Laureate, describe the difficulty of publishing his revolutionary thesis that H. pylori caused peptic ulcer disease. All of us dream of coming up with a research finding that truly overturns conventional wisdom, but the reality is that getting truly innovative research funded or published is usually a hard slog. Why is that, and how might we change it? The first reason is that the peer review process can be inherently conservative. Although innovation and impact are explicit review criteria for VA proposals, the reality is that peer reviewers are trained to look for all the reasons a research idea might fail, rather than the potential payoff should the idea succeed. Facing the reality that only one in five proposals get funded, reviewers may focus on the many liabilities presented by innovative studies: the use of unfamiliar methods or concepts, lack of a well-worn road to success, and/or limited preliminary data. The second is that there aren't good metrics for innovation—the definition is still largely in the eye of the beholder. Because we haven't encouraged true innovation, too many researchers are used to claiming that testing a well-established intervention in a slightly different population is innovative. The final barrier is that many funders are conditioned to fear failure. We think more like traditional bankers, giving out safe loans to familiar businesses, when we need to be more like venture capitalists, providing seed money to the most exciting ideas and doubling down on those that succeed.

This issue of FORUM includes a variety of interesting perspectives on innovation in a learning healthcare system. What is clear is that innovation doesn't only occur in research, it can be facilitated or impeded by features of the organization, and that it is critical to being a learning healthcare system. Learning systems monitor and implement best practices based on what we already know, but they also need to test out new ideas and scale those that work. Dr. Naomi Tomoyasu, Deputy Director of HSR&D, also describes the outlines of a new innovation initiative that HSR&D is launching this fall. The aim of this initiative is to encourage investigators to bring forward exciting and untested ideas by simplifying the initial application process—and to create a system to increase our investment in those innovations that seem to be succeeding. While we tried to build on the experiences of other funders in this space, we like to think this initiative is, itself, innovative. We aren't afraid of failure because the payoff for success is so big.

David Atkins, MD, MPH, Director, HSR&D