From the Editor
Nov 2017

Co-Creation in Health Systems Design

Sonya Makhni, MD, MBA
AMA J Ethics. 2017;19(11):1070-1072. doi: 10.1001/journalofethics.2017.19.11.fred1-1711.


The concept of co-creation has been central to a variety of service industries for several decades. A tool to fuel innovation and customer satisfaction, co-creation acknowledges that the success of any given enterprise depends not only on the expertise, assets, and core competencies of the service provider but also on the knowledge and perspectives of the target customer as well. Co-creation extends beyond consultation with or participation of consumers. It is about integrating customers into the processes of product and service ideation and execution so that their unique perspectives and cooperation may ultimately drive value for both the producer and the customer [1, 2].

Nike® is a prime example of a company that successfully incorporates co-creation into its business model. The athletic footwear company creates online communities that serve as a vehicle for management to be apprised of the latest reactions and feedback to its products. In turn, Nike offers its customers a forum to express their experiences as well as educational resources from Nike “experts.” Customers find value in the platform products and the services that connect them to users and experts, which builds trust and “stickiness,” and Nike derives value from real-time feedback on products that enables more optimal redesigns [3]. Co-creation becomes a win-win for all involved, and it is thus not surprising why several industries—technology, education, retail, law enforcement, and financial services, to name a few—employ co-creation in their core practices [1].

Health care has been slow to adopt co-creation. Historically, patients have been considered passive recipients of services provided to them by those in the health care industry. The ecosystem of health care evolved relatively independently of their voices, which is contrary to the customer-provider interaction in many other industries outside of health care. However, amidst rising health care costs, growing pressures for improved quality and safety metrics, and increasing demand for more personalized care, the field of medicine would benefit by shifting away from the provider-centric model of care toward one that is more responsive to the needs of the other key stakeholder in the formula—the “consumer,” otherwise known as the patient [4].

A growing body of health care literature suggests that such a collaborative approach to medicine can ultimately result in improved efficiencies and outcomes, increased patient satisfaction and trust, and greater capacity for medical research [5]. A variety of models for incorporating the patient perspective have been proposed as well. Models that engage patients as partners from the onset of service development, or those that leverage patient communities as support groups, provide frameworks that can enable the health care industry to better utilize patient perspectives. Meanwhile, patients ultimately benefit from more relevant and optimally designed services that are better tailored to their specific needs [6].

Ethical tensions can arise, however, when health care organizations try to incorporate practices of co-creation within the traditional system of health care delivery and with limited resources. Such tensions concern equitable allocation and distribution of resources, accountability of various stakeholders, and establishment of health care priorities in a complicated health care ecosystem. This issue of the AMA Journal of Ethics will elaborate upon some of these tensions, but it will also examine the challenges and benefits of the co-creation process and how co-creation can be used in medicine.

Three case commentaries highlight common ethical questions that arise in implementing co-creation in practice. Matthew Kucmanic and Amy R. Sheon show how injustices that occur when patient and clinician focus groups disagree about a redesign plan can be rectified by ensuring that decision making is transparent, justifiable, and subject to review. Aveena Kochar and Alia Chisty examine how the four quality improvement principles can be used to facilitate group discussions regarding process and quality improvement within co-creative teams. And Priya Nambisan discusses managing the risk of misinformation in online patient forums as well as strategies that can help such forums achieve their full potential.

Two articles examine how co-creation intersects with medical education. Alan Cribb, John Owens, and Guddi Singh highlight that a truly collaborative health care system based on principles of co-creation depends on successfully integrating such ideals into the medical curriculumand the process of curriculum development. In a separate article, Singh, Owens, and Cribb discuss the importance of local context and transforming professional roles and power dynamics in overcoming challenges to co-creation.

Four articles examine the benefits and challenges of co-creation. Puja Turakhia and Brandon Combs call for co-creation as the next crucial stepfor health organizations pursuing improved outcomes, research, and safety. The remaining articles critically examine the conditions and consequences of co-creation. Sigal Israilov and Hyung J. Cho examine the barriers to co-creation posed by physician autonomy, patients’ limited knowledge and expertise, and conflicts of interest. Satish Nambisan and Priya Nambisan explore policies and strategies necessary for promoting equitable distribution of the risks and benefits of technology within health care. And Brian Van Winkle, Neil Carpenter, and Mauro Moscucci explore the digital injustice to underserved populations for whom technological innovations can be ineffective.

Finally, the podcast examines the roles that design plays in co-creation. John Meyer discusses how design thinking can contribute to health care systems, beginning with its focus on the patient; Bon Ku explains how design can be incorporated into medical education; and Laura Webb shares a patient perspective about how good design can improve patients’ experience with health care applications.

It is crucial that health care transitions from the traditional, paternalistic model of care to a more cooperative, transparent model that involves patient participation on multiple levels. If we are able to better navigate the challenges outlined above, we can hope to see improved levels of patient satisfaction and overall quality of care.


  1. Galvagno M, Dalli D. Theory of value co-creation: a systematic literature review. Manag Serv Qual. 2014;24(6):643-683.
  2. Palumbo R. Contextualizing co-production of health care: a systematic literature review. Int J Public Sector Manage. 2016;29(1):72-90.
  3. Wright A. Nike: facilitating customer experience to co-create value. Marketing Discussions. March 14, 2016. Accessed August 7, 2017.

  4. Janamian T, Crossland L, Wells L. On the road to value co-creation in health care: the role of consumers in defining the destination, planning the journey and sharing the drive. Med J Aust. 2016;204(suppl 7):S12-S14.

  5. Hardyman W, Daunt KL, Kitchener M. Value co-creation through patient engagement in health care: a micro-level approach and research agenda. Public Manage Rev. 2015;17(1):90-107.
  6. Bartl M. Patients as partners—co-creation in health care. December 2009. Accessed August 7, 2017.


AMA J Ethics. 2017;19(11):1070-1072.




I would like to thank all contributors to this issue of the AMA Journal of Ethics and especially my mentor, Hyung J. Cho, MD, for all of his invaluable support.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.