摘要：The linkages between decisions about health research and policy and actual health outcomes may be extraordinarily difficult to specify. We performed a pilot application of a “road mapping” and technology assessment technique to perinatal health to illustrate how this technique can clarify the relations between available options and improved health outcomes. We used a combination of data-mining techniques and qualitative analyses to set up the underlying structure of a societal health outcomes road map. Societal health outcomes road mapping may be a useful tool for enhancing the ability of the public health community, policymakers, and other stakeholders, such as research administrators, to understand health research and policy options. THE HEALTH SYSTEM OF THE United States is problematical: high levels of spending on health care parallel increasing rates of several diseases or conditions of concern, including some cancers, heart diseases in certain population subgroups, and new HIV infections. The most respected research enterprise in the world feeds into a broken public health infrastructure. An estimated 40 million Americans have essentially no health insurance. These quandaries have been dissected at length in both popular and academic venues, resulting in broad and deep agreement that the problems are real but little consensus on what to do about them. One problem is that it is very difficult to understand the relations among the multitude of institutions, actors, and policies that may influence health outcomes. As a consequence, preferences for particular options (e.g., more money for research on breast cancer genetics vs wider availability of breast cancer screening, subsidizing participation in community-supported agriculture programs vs nutrition education programs) are advanced independently of the broader, more complex context from which health outcomes emerge. 1 In other sectors of society, where the need to achieve specified outcomes is critical but system complexity is great, decision-support tools have been developed and implemented successfully. One of the most effective of these tools, technology “road maps,” can clarify and enhance the connections between inputs, such as research funding, commitment of personnel, education, or laws, and outcomes, 2 such as policy changes and program implementation. This approach, founded in engineering theory, has been shown to be particularly successful for agencies and firms focused on security or on technologies that are expensive to develop or that are potentially dangerous, ranging from consumer goods (most notably, computers 3 ) to space exploration technologies. 4 For example, Semiconductor Manufacturing Technology (now International SEMATECH), a public/private consortium established in 1986 to improve the design (mostly speed) of semiconductors, developed “foresight maps” 3 using an iterative process of surveying customer needs and determining what was available and which actors could carry out appropriate research to achieve a desired innovation. 3 Early versions required only a few printed pages; the current version needs to be stored on a CD-ROM. Other public/private enterprises have employed this approach as well, 5 – 7 and private companies, including Motorola, have used the technique successfully. 8 Although phrases such as “road map” and “foresight map” as used here might be unrecognizable to cartographers, these expressions are established terminology in technology research and policy communities. The inclusion of a timeline or time horizon on a map, which would be nonsensical if applied to a road atlas, is also a standard feature of technology road mapping. Technology “road maps” are perhaps then best understood as graphical overviews of potential solutions over time to specific concerns, no matter how narrowly or broadly defined. These foresight maps or “road maps” frequently extend over long time horizons—10 years or more—but they are constantly revised on the basis of new knowledge. In all cases, what these road maps show are outcomes (what is desired) and an array of interconnected inputs (what is needed). Thus, they do not provide long-term predictions but offer interactive, iterative, and evolving guidelines that maximize, rather than limit, the number of possible research approaches. 2 , 8 , 9 The final selection of a specific research path is left in the hands of decisionmakers such as consortium or firm executives. The principles behind technology “road mapping” are theoretically applicable to any problem for which decisionmakers seek to clarify the inputs necessary for achieving desired outcomes. To enable a more open and knowledgeable policy debate about the roles of various players in the health system, we have initiated the development of a modified foresight mapping technique incorporating well-understood aspects of technology assessment and coupled with a graphical guide. By including the input of both experts and the public in formulating definitions of what “health” is and which societal-level health outcomes are desired, such a road map can begin to reveal—and ultimately help shape—an overall system in all of its complexity and diversity, 10 , 11 including basic research, applied research, prevention techniques, cultural and social conditions, and economics. Importantly, the process also explicitly includes minority and individual views. Access to such a detailed road map, and the information underlying it, could help legislators, research administrators, and federal agency heads, among many others, view outcome-oriented options and trade-offs that can shape the workings of the health system. As the road map grows, stakeholders and their representatives will also be able to critique and contribute to it. The overall approach is somewhat related to some of the technology assessment exercises widely in use 12 , 13 ; in particular, the Royal Netherlands Academy of Arts and Sciences has proposed a mechanism to measure the effects of applied health research on society as a whole. 14 We are not proposing a road mapping approach as a solitary determinant of health policy. Rather, we wish to lay out a number of possible paths, research driven or not, for achieving desired societal health outcomes as a contribution to the development of the health research and health policy components of an overall health system. As stated earlier, the final selection of a specific path will be in the hands of decisionmakers, in this case legislators, research administrators, and so on. Furthermore, a health research and policy road map could be used, for example, as a teaching aid or a research tool. We were inspired by former Motorola CEO Robert Galvin’s description of the characteristics of road maps: [Road maps provide] an extended look at the future of a chosen field of inquiry composed from the collective knowledge and imagination of the brightest drivers of change in that field, [including] statements of theories and trends, the formulation of models, identification of linkages among and within sciences, identification of discontinuities and knowledge voids, and interpretation of investigations and experiments. [Road maps are a means to] communicate visions. 15 (p803)
