Pioneering Ideas

‘Exergames’ Can Improve Cognitive Function in Older Adults

We all hear about the benefits of physical activity beyond weight management. According to the Centers for Disease Control, exercise helps to improve your ability to do daily activities, mental health and mood. This is especially important later in life to improve cognitive function protecting against the onset of dementia. However, as the CDC estimates, only 14 percent of adults aged 65 to 74 years and 7 percent of those over 75 years exercise regularly.

Health Games Research grantee Dr. Cay Anderson-Hanley and her fellow researchers from the Healthy Aging and Neuropsychology Lab at Union College, New York set, out to find new interventions motivating older adults to exercise and promote good brain health.  They tested the impact of virtual reality-enhanced exercise, or exergames, that combine pedaling a stationary bike with an interactive video game compared to traditional exercise. Researchers evaluated participants’ executive cognitive function such as their ability to multi-task, problem-solve, and working memory and attention.

What they found was that adults ages 58 to 99 who participated in ‘cybercycling’ two to three times a week for three months had significantly better executive functioning than those using a traditional stationary bike.  This is the first study to quantitatively evaluate the benefits of exergames. 

You can also check more about the research featured in The Atlantic’s “Study of the Day,” CNN’s The Chart Blog, MedpageToday.com and The Los Angeles Times Booster Shot Blog.

To learn more, see the article in the February issue of the American Journal of Preventive Medicine, or check out Pioneer’s national program Health Games Research to see what they are doing to explore ways to advance the research, design, and effectiveness of digital games and game technologies that promote health.

Shorter Antibiotic Regimens Might Counter Antibiotic Resistance

Antibiotics on the shelf today are increasingly losing their potency against resistant microbes or “superbugs” like the potentially lethal methicillin-resistant Staphylococcus aureus, or MRSA.

Extending the Cure researchers published an analysis this week that questions the conventional wisdom regarding antibiotic dosing practices and suggests rethinking the guidelines to minimize the growing public health crisis posed by antibiotic resistance. Ramanan Laxminarayan, director of Extending the Cure, and his colleagues, used mathematical models to study antibiotic treatment guidelines, the regimens physicians follow for the standard dose and duration of antibiotic treatment for common infections.

While antibiotic dosing regimens have typically been designed to cure bacterial infections, rarely have these guidelines taken antibiotic resistance into account.  All antibiotic use contributes to the development of antibiotic resistance, and the new research suggests dosing guidelines could be optimized to both treat infections and limit the spread of resistant microbes. The analysis, published January 11 in the online scientific journal PLoS ONE, indicates that in many cases, a shorter regimen of antibiotic treatment could work just as well as a longer course yet still reduce the risk of resistance.

Dosing strategies for antibiotics are not set in stone.  For example, many physicians have switched from the traditional 10-day course of antibiotics and now effectively prescribe a three-day regimen to treat otitis media, or middle ear infections. In some cases, the authors argue, shorter dosing regimens like this one could limit the selection pressure for resistant bacteria and thus reduce the threat of resistance.

Extending the Cure, a project of the Center for Disease Dynamics, Economics & Policy sponsored by the Robert Wood Johnson Foundation’s Pioneer Portfolio, is working to change how we think about antibiotics, a resource that can be depleted with overuse. This study suggests that shorter treatment regimens, in some cases, may help us preserve the power of the antibiotics we still have left.

Let us know what you think:  Are there any risks to shortening current treatment regimens? Are there any other benefits? Leave a comment here or tweet at @ExtendgTheCure and @PioneerRWJF #SaveAbx to tell us what you think.

Inviting Patients to Read Their Doctors' Notes

Will patients be more likely to seek a second or third opinion? New York Times

Will reading your doctor's notes lead to better health? USA Today

Can Patients Handle the Truth? TIME

These questions and others were posed following the release of OpenNotes’ findings about patient and doctor attitudes toward opening doctors’ medical notes to patients. The survey of nearly 38,000 patients and 173 primary care physicians revealed patients were enthusiastic about the prospect of reading their doctors’ notes while doctors were cautious.

Patients who signed up for the project, such as Linda Johnson, 63, a Harborview patient,  told The Seattle Times she found the notes helpful in recalling what she and her doctors had talked about and how she was supposed to follow up. "I have found, as I get older, I need more visits to the doctor, and there are more things we need to talk about…I find having them written down helps a lot." Patient Candice Wolk, a 39-year-old mother of twins, told the New York Times that reading her notes after a pregnancy check-up reminded her to follow-up with a dermatologist to have a dark spot on her back checked. 

Doctors enrolled in the project also shared their thoughts. David Ives, MD, an internist at Beth Israel Deaconess, told American Medical News he thinks OpenNotes is a rousing success, saying “The patients loved it, and it had absolutely no impact on me really at all. It was amazing how little impact it had.”

Bloggers chimed in too, including patient advocate Trisha Torrey who called on her readers to “continue to encourage your doctor to share your records –  to provide easy access to you” and Ted Eytan, who wrote that “here’s something in health care that most patients want to receive, but not all doctors want to provide.”

The media stories and blog posts such as those on The Health Care Blog, TIME’s Healthland Blog, NPR’s Shots Blog, and Vitals on MSNBC.com sparked conversations and debate and were shared widely through social networks.  You can join the conversation by commenting on these stories or tweeting @myopennotes or @pioneerrwjf.

Looking ahead, one thing is clear: the final results of OpenNotes, due later this year, are eagerly awaited and have the potential to spur real change in the way doctors share information with patients about their health and health care.

OpenNotes is funded by the Robert Wood Johnson Foundation’s Pioneer Portfolio. The survey results were published December 19, 2011, in the Annals of Internal Medicine.

Project HealthDesign Provides Input on Health IT Policies

BY PATRICIA FLATLEY BRENNAN, PHD, RN, Project Health Design National Program Director

Since health reform passed almost two years ago, we’ve seen the health care system begin to change quite a bit. The push for better uses of health IT has brought about many proposed rules and programs, and federal agencies have requested public input on many of these proposals.

Because Project HealthDesign has always included multi-disciplinary teams of researchers, clinicians, and patients who are helping to lay the foundation for a patient-centered health IT system, we’ve seized these opportunities to share our unique insights by commenting on several proposed policies. In the process, we’ve been able to share our thoughts about promising practices for collecting patient-generated data and incorporating it into the clinical care process.

In 2011, Project HealthDesign provided feedback on seven proposed policies. These ranged from applauding the HHS Proposed Rule on Patient Access to Lab Reports, which would allow patients to become more engaged with their health data, to calling for better distinctions between mobile apps and mobile medical apps under the FDA Mobile Medical Application Guidance. Working together to help refine these types of policy proposals is even more critical now as we enter a new era of widespread adoption and use of health IT.

Read Project HealthDesign’s policy comments, watch “How Clinicians Can Help Guide Federal Conversations About Health IT,” or visit the Project HealthDesign website to learn more.

You can also check out Dr. Roger Luckmann's post on KevinMD.com about how Project HealthDesign is helping people with chronic diseases manage pain.

OpenNotes: Mind the Gap

Last week, I contributed to The Health Care Blog about OpenNotes, a Pioneer grantee that is enabling patients to view the notes their doctors write after a medical visit. I wrote that it is a simple idea – but also a dangerous one.

OpenNotes recently completed a pre-survey published in the Annals of Internal Medicine that asked doctors and patients about their expectations of how the idea would play out in real life. What they found is fascinating. Doctors and patients are clearly divided. On a wide range of possible benefits, doctors are more skeptical than patients. But what really jumps out are the responses to questions of whether patients would find the notes more confusing than useful, and whether the notes would make them worry more. The gap is dramatic. In each case, most doctors said “yes” while less than one in six patients agreed.

Why this disconnect between doctors and their patients? Why the gap between what doctors believe their patients can handle, and what patients feel they are ready to see?

The post has generated a nice discussion on the blog, and in the comment responses you’ll find that the results of the survey are reflected in the dialogue. I recently added my own two cents to the conversation, and I’d love to see you post your thoughts, as well.

The survey results have also been covered by USA Today, MSNBC.com, and TIME’s Healthland Blog.

Pioneer Grantees Named to HealthLeaders Media’s 20 People Who Make Health Care Better

HealthLeaders Media identified 20 individuals to tell their stories of how they are changing health care for the better in its annual HealthLeaders 20 issue. Two grantees of the Pioneer Portfolio are included in this prestigious honor.

Clayton Christensen is often referred to as the father of disruptive innovation, the concept that new technologies have the potential to turn an industry upside down—but they may be difficult for established organizations to adopt. In 2011, Christensen and his team at Innosight Institute published a Pioneer-funded case study series on disruptive innovations within integrated health systems. In the summary report, researchers investigated how the seven integrated health systems think, act and innovate differently.

Nicholas A. Christakis is a well-established name in the science of human connectivity and social networks. In 2011, Christakis’ innovative Pioneer-funded research looked into how humans interact and coordinate in response to the behavior of one’s social partners in an article published in Science and in this profile.

We’re proud to call these innovating movers and shakers part of the Pioneer family. They, like all of us, are working to make a difference in health care. We encourage you to congratulate Christensen and Christakis (through his book Connected) on Twitter.

Gaining Perspectives on mHealth

In my recent blog post summarizing December’s mHealth Summit, I began by saying that the mHealth organizers must have been pleased with the conference, given its growth in attendance and engagement.

We were equally pleased with RWJF and Pioneer’s presence at the meeting – in fact, I’d say the meeting was a resounding success from our perspective.

Pioneer grantees Ben Sawyer and Debra Lieberman were both on panels featuring their work in health games and mobile technology. Deborah Estrin and Ida Sim announced the launch of Open mHealth, which is supported with funding from RWJF’s Pioneer Portfolio. And a session focused on this summer's mHealth Evidence meeting that was conceived of and co-sponsored by Pioneer.

Our Public Health Portfolio was also there looking for interesting perspectives on how mHealth could be deployed by public health departments to address a variety of health issues.

And finally, I was lucky enough to moderate a special session on a topic of keen interest to me and the portfolio.

“What I Really Need from mHealth: Five Perspectives on Value” featured a great cast of panelists including Robert Jarrin, senior director of Government Affairs for Qualcomm; Carol McCall, chief strategy officer at GNS Healthcare; Anmol Madan, founder of Ginger.io and visiting researcher at MIT Media Lab; and Richard Katz, director of cardiology at George Washington University Hospital.

Our session was structured around an imaginary mobile health application. The panelists discussed the value  of the application and how to demonstrate that value from the point of view of the individual, provider, various payers, regulators and researchers. This generated a fascinating conversation in which participants spoke from both a professional and personal perspective. Toward the end, we opened the discussion up to the attendees, which led to an informative and engaging discussion that will hopefully extend far beyond the session. The various perspectives are not completely aligned but yield something quite important when they do come together.

But wait, as they say on TV, there’s more! In addition to our panelists, we brought together about a dozen thought leaders, including representatives from organizations like NIH, Google, GNS Healthcare and the National Science Foundation, for a series of lively discussions about the future of mHealth and how to build value for all the players in the ecosystem. There was no lack of good ideas or strongly held opinions, and more questions were raised than answers offered. However, at the end of the night, we could all see light at the end of the tunnel. And that light came from a greater understanding of the value others saw in mHealth. From this newly fashioned broader vision, I’m hopeful we all left with a better sense of the way forward and with new ideas on how we could each play a role. 

I look forward to sharing more of what we learned and what this might mean for our investments in mHealth moving forward – and hearing your thoughts as well.

Why OpenNotes Will Open Minds

BY THOMAS FEELEY, MD, Vice President of Medical Operations, University of Texas MD Anderson Cancer Center, Houston, Tex.

Patients should know what’s going on with their health and health care. OpenNotes, which enables patients to see their doctors’ notes, is a simple idea that can help improve the patient experience and empower patients to become true partners in their care.

But OpenNotes has found that most doctors are wary of this intervention. Its survey of patients’ and doctors’ attitudes toward sharing electronic medical notes revealed doctors are worried about increased demands on their time and frightening or confusing patients.

These fears are overreactions. At the University of Texas MD Anderson Cancer Center we have been giving patients access to their electronic medical records—including their doctors’ notes—since May 2009. While initially doctors complained that they had to explain more to their patients about what was written in their records, the doctors soon came to realize the benefit of having patients who are more informed about their care plan and lab results.

Today, 84 percent of our patients have obtained access to their electronic medical records, including their doctor visit notes, via a secure Web-portal. Patients have actually become avid readers of their medical notes. 

This has been a particularly important intervention at a cancer center like ours. Our patients are treated on an outpatient basis and in one visit often travel from the lab to the doctor’s office and then to get chemo. Having their medical information as they move from location to location makes a huge difference to our doctors. And it has made a huge difference to our patients and their caregivers. Cancer is a family event. It’s rare that a patient is not accompanied by a family member when they come to our clinic.  We know they are sharing their records and doctors’ notes with their family and we think it helps them and their family members get a better understanding of what’s going on with them.  

Our experience at MD Anderson helps build the case for why this kind of transparency is a good step for patients and doctors. But what we don’t have yet is the scientific evidence and rigorous research to show that opening medical notes does not significantly impact doctors’ time and work flow, or make patients more confused or anxious. 

That’s why the OpenNotes demonstration results will be so important to mapping out the future.  Because it has been tested for 12 months in three very different sites around the country with very different sets of patients, it can provide important answers to questions and help guide future efforts to make sure this model works effectively.

Rather than spending so much time fretting about the implications of sharing information, we should be looking to projects like OpenNotes to show us how we can make it work for both patients and physicians to improve care and improve lives.

@Choo: Can Twitter Track The Flu?

Now that flu season is upon us, more and more Americans will be tweeting about aches and pains and other symptoms that could signal the onset of the flu.

Pioneer grantee Philip Polgreen and his colleagues at the University of Iowa in Iowa City suggests that social media tools such as Twitter and Foursquare could one day be used to track flu activity—and give public health officials a heads up if activity takes a turn for the worse.

Polgreen and his colleagues published a study last May in the scientific journal PLoS One that tracked millions of tweets during the 2009 swine flu pandemic. They discovered that many Americans used Twitter to express concerns about the flu or talk about early symptoms such as a fever. The researchers collected tweets that used the words “flu,” “fever,” and  other related terms and analyzed them—finding that Twitter data could be used to estimate the incidence of the flu in real time.

Currently, the system the CDC uses to track reported cases of influenza has a time lag of several weeks, giving the flu a chance to spread. Polgreen and his colleagues believe that Twitter might help speed up that process by alerting public health officials about an increase in flu symptoms in real time. The early warning might provide officials the time they need to curtail the spread of the flu or to urge more people to line up for flu shots.

And what about getting a head start on information about where the flu is spreading? The Iowa team recently analyzed data from FourSquare, a social media application that permits users to “check in” and record their current location in exchange for incentives, like coupons.

The information could also be used, the team says, to track the location of individuals infected with the flu or some other contagious disease—and then send alerts to public health officials trying to contain an emerging disease threat.

The team presented the early findings from the study at the International Society for Disease Surveillance meeting held in Atlanta on December 7-8.

Polgreen also says that the Twitter stream might be used to look for public misinformation about the flu—like the mistaken belief that antibiotics can combat it. Twitter reveals all kinds of fears, concerns and behaviors and might give public health officials insight into the myths they should address in public education campaigns.

Such real-time information could also inform the CDC about overuse of antibiotics. On November 14, the CDC launched an annual campaign to curtail the unnecessary use of antibiotics given the estimate that about 50 percent of all antibiotic use is unnecessary. Furthermore, research by Polgreen and colleagues published last July in Infection Control and Hospital Epidemiology suggests that antibiotic use goes way up during flu season.

Antibiotics, however, do nothing to combat the flu or other viral infections. Think about that—or better yet tweet about it—the next time you get an ache or pain that signals the flu.

Let us know what you think: When you feel sick this flu season, will you tweet about your experience?

You can also vote for "The Use of Twitter to Track Levels of Disease Activity and Public Concern in the U.S. During the Influenza A H1N1 Pandemic," published in PLoS ONE in May, as one of RWJF's Most Influential Research Articles of 2011.

Reflections from mHealth Summit 2011

I'm sure that the organizers of this year's mHealth Summit were more than pleased. There were more than 3,600 people in attendance, up 1,200 from last year. The exhibit floor was larger and more complex, rivaling some trade shows. There were tracks for business, research, policy and technology along with a slew of special sessions and keynotes from Secretary of Health & Human Services Kathleen Sebelius and Surgeon General Regina Benjamin, among others. Some presentations soared with whiz-bang demos and promises of how technology will change the world; others bemoaned the complexity of interoperability, the "silo-ization" and the lack of demonstrated value.

While there is no question that mHealth is on the rise, some, including myself, are wondering if we’re heading toward a bubble of inflated expectations. As with all bubbles—dot com, housing etc.—the question isn’t whether there is significant underlying value (there is), but instead “how do we invest in the value that can be realized without buying into overinflated hype?” In the context of the ‘90s’ dot-com bubble, “How do we place our bets on Google and not on pets.com?”

The answer isn’t going to be found in the next jazzy consumer-oriented gadget, but by connecting great ideas that will help us lead happier, healthier lives over the long haul – connecting business, research, technology, and policy interests to find shared value.

I came away from the 2011 mHealth Summit optimistic in the overall potential of mHealth, but a little skeptical about the direction it seems to be heading in. Introducing multiple new and evolving health innovations is inherently complex, as is the perversity of our current health infrastructure. Yet one can’t help but notice that there are some very smart people working on developing the promise mHealth can offer to address some of our most pressing health challenges.

A central question will be how willing those from the “m” will be to ensure that the “health” is improved? And how open will the folks from “health” be in fulfilling the promise of “m” technology?

This will require us all to see value from others’ perspectives in this growing ecosystem. I’ll explore this more in my next blog post, so stay tuned.

In the meantime, take a moment to peruse RWJF’s coverage of the Summit on NewPublic Health.org, which tapped into some of the conversations, new collaborations and innovations in mobile health that might feasibly be applied to public health, and started a conversation about the potential for mobile technologies to help the public health field connect with hard-to-reach populations and bridge disparities.  Read what they learned in interviews with Susannah Fox of the Pew Internet and American Life Project about advances in mHealth, with Yvonne Hunt of the National Cancer Institute about the potential for mHealth in public health, and with Robert Kaplan, director of the Office of Behavioral and Social Sciences at the National Institutes of Health about the rigorous research still needed to support the field. We’d love to know what you think, so don’t forget to comment on each post or below to share your insights.

The False Dichotomy of Nature Versus Nurture

We all attribute certain traits to nurture and others to nature. “I’m stubborn. I get that from my dad’s side. My ambition and leadership skills? I learned those.” But Pioneer grantee Nicholas A. Christakis says more of the traits we typically attribute to culture have evolutionary roots, including who we choose as friends and whether or not we practice healthy behaviors.

In this week’s TIME magazine, Christakis argues that a new synthesis of biological and social science – biosocial science –can unearth solutions to some of the world’s most vexing public health problems. He writes that we can use our understanding of biology and behavior to address problems like how to get medications or tools to remote villages, control the behavior of dangerous crowds, or predict an epidemic before it happens. Christakis, a Pioneer grantee and a professor of sociology and medicine at Harvard, contributed this essay as one in a series by TIME’s most influential people in the world.

You can also learn about Christakis’ innovative research into how humans interact and coordinate in response to the behavior of one’s social partners in a recent Pioneer-funded article published in Science and in this profile.

Read the TIME essay, review Christakis’ work on patterns of human coordination and defection, tweet your thoughts about the nature versus nurture argument, or comment below. We’d love to hear what you think.

Vote for the Most Influential Articles of the Year

It’s time for RWJF’s annual research poll! David C. Colby, vice president of Research and Evaluation, announced the 20 nominees for RWJF’s Most Influential Research Articles of 2011. We are honored that three Pioneer grantees made the list:

• Positive Health – Heart Health When Life is Satisfying: Evidence from the Whitehall II Cohort Study, published in May’s  European Heart Journal, found that satisfaction in four life domains—job, family life, sex life and self—were independently associated with a 12 percent reduced risk of total coronary heart disease. The research supports Positive Health, a new field of inquiry into whether there are assets that help people achieve and maintain good health and recover more quickly when they are sick. Vote for Article 12 or learn more about this project.
• Flu Prediction Market – The Use of Twitter to Track Levels of Disease Activity and Public Concern in the U.S. During the Influenza A H1N1 Pandemic, published in May’s PLoS ONE, followed researchers who used Twitter to effectively track public concerns about H1N1 and follow real-time disease activity. Tweets related to hygiene coincided with public health messages about the outbreak, and there was a distinct association between twitter data and the actual progression of H1N1. Vote for Article 11 and learn more about this project.
• Project ECHO – Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers, published in June’s New England Journal of Medicine, demonstrated that primary care providers can be trained via video communications technology to manage complex chronic conditions formerly outside their expertise, thus expanding their ability to bring better care to more people in their own communities. By putting the best available medical knowledge into the hands of everyday clinical practitioners, Project ECHO exponentially expands the capacity of the health care workforce to provide high-quality care in local communities. Vote for Article 17 or learn more about this project.

Vote for your top 5 Most Influential Research articles of 2011 now and use #Final_5 on Twitter, Facebook, and LinkedIn to follow the conversation and let others know which articles you think should make the top five for 2011. Voting ends on midnight of December 23 so act fast! This year’s winners will be announced in the next issue of Evidence Matters to be released in early 2012.

Pioneer Grantees Named to Forbes’ Top 30 Social Entrepreneurs List

BY BRIAN QUINN, team director of RWJF’s Pioneer Portfolio

Forbes is known for its lists – America’s richest people, most expensive zip codes, most promising companies and more. This year, for the first time in its 94-year history, Forbes released a new list – the top 30 social entrepreneurs. We’re proud to announce that Pioneer grantees made the list – twice!

Jay Coen Gilbert, Bart Houlahan and Andrew Kassoy made the list for B Lab, a nonprofit that certifies businesses as “B Corporations”—companies that adopt a legal structure requiring them to create value for a broad set of stakeholders—employees, communities and the environment–not just their shareholders.  Their hope is that certified “B Corps” will flourish by attracting consumers who are looking to support businesses that align with their values and helping investors to drive capital to higher-impact investments with greater social responsibility, as well as financial returns.  To be certified, companies must adopt the legal structure and pass an annual B Impact Assessment. Under their Pioneer-funded grant, B Lab will develop the first set of criteria to assess a corporation’s performance in areas of employee and community health and safety to be included in the annual assessment.

Sara Horowitz is listed for founding Freelancers Union, which provides affordable health insurance to freelancers, consultants and temps who don’t have access to employer coverage. Her grant from Pioneer enables the Freelancer's Union to expand its group purchasing health-benefits program from New York into New Jersey and Georgia.  A previous grant established the for-profit Freelancers Insurance Company to design a health plan model for freelancers in New York state that combines catastrophic insurance coverage with coverage for prevention and wellness services.

RWJF’s Vulnerable Populations Portfolio is also excited to see two grantees on the list. Jill Vialet made the list for founding Playworks, which improves the health and well-being of children by increasing opportunities for physical activity and safe, meaningful play. Playworks sends trained, full-time coaches to low-income, urban schools, where they transform recess and play into a positive experience that helps kids and teachers get the most out of every learning opportunity throughout the school day. Rebecca Onie is included for co-founding Health Leads, which mobilizes undergraduate volunteers to help patients fill “prescriptions” shared during provider visits for basic resources needed to be healthy, like food, heating assistance, child care or housing. Health Leads is one of many promising models addressing social needs through the health care system.

As team director of the Pioneer Portfolio, I’m thrilled to see our grantees singled out as innovative entrepreneurs. These innovators represent the kind of leadership and ingenuity that can help us tackle the tough health and health care problems we face in the U.S. Check out the story and don’t forget to congratulate Jill Vialet (@jillvialet), Rebecca Onie (@rebeccaonie), Sara (@Sara_Horowitz) and the B Lab crew (@BCorporation) on Twitter using the #Impact30 hashtag.

Innovations in Integrated Health

Posted by RWJF Blog Team
BY DR. JASON HWANG, Executive Director of Healthcare, Innosight Institute

Jason Hwang, MD, MBA is an internal medicine physician and executive director of healthcare at Innosight Institute, a nonprofit social innovation think tank he co-founded with Harvard Business School professor Clayton Christensen, the world’s foremost authority on disruptive innovation. Through a grant from the Pioneer Portfolio, Dr. Hwang has worked to apply the principles of disruptive innovation to the health care delivery system. Disruptive innovations occur when new business or delivery models displace overly complex and costly, expertise-intensive models. Highlighting work from the Pioneer-funded studies, Dr. Hwang recently described the need for innovation in health care in a post on CNBC.com and was featured in a Human Ingenuity series on Forbes.com.

Why have select integrated health systems outpaced their peers across nearly all quality and cost measures? More than one year ago, Innosight Institute–a nonprofit think tank co-founded by innovation expert Professor Clayton Christensen of Harvard Business School –set out to answer this question by identifying the critical factors and decisions that led to successful, integrated health systems.

Our findings are documented in the paper "Disruptive Innovation in Integrated Care Delivery Systems," which is the culmination of research on seven different organizations representing a wide spectrum of health systems around the country. Major observations and findings include: 

• Successful innovations that may be incorporated into today’s ongoing integration efforts, including mergers, accountable care organizations, and virtual assemblages being formed to participate in bundled payment programs and pay-for-performance contracts;
• The importance of expanding the scopes of practice of various clinical staff, including nurse practitioners and physician assistants, to ensure access to quality care through disruptive delivery models;
• Best practices in the use of electronic health records and health IT that should be implemented across all health systems as stimulus funds promote their widespread adoption.

Identifying these success factors is a crucial step forward in paving the way for similar organizations to be cultivated elsewhere and ensuring that one day every American will have access to high quality, affordable care.

Innosight Institute is also pleased to release its latest case study in conjunction with this project, which documents the experience of Sentara Healthcare in Virginia as it prepares for significant changes in how health care will be delivered and priced in the future. Pilots focusing on chronic disease management, bundled payments for procedures, and a patient-centered medical home are underway, yet Sentara is also acutely aware of the challenges these new delivery models pose to its successful, hospital-led health care system.

Not content with simply reacting to change, Sentara also created a test bed for wellness initiatives by targeting employee health with a program that includes a $500-per-employee rebate and has resulted in a return on investment of $6 for every $1 invested in the program. Meanwhile, the organization’s health plan, Optima Health, has sought to grow its consumer-directed, high-deductible health plans by first developing information and pricing tools for patients.

I invite you to read about Sentara and our other case study subjects: HealthPartners, Lancaster General Health, Presbyterian Healthcare Services, Group Health Cooperative, Grand Valley Health Plan, and Baystate Health (forthcoming).

Finally, I offer my special thanks to Robert Wood Johnson Foundation’s Pioneer Portfolio, whose financial support made this work possible.

What Do We Really Need from mHealth?

The December 5-7 mHealth Summit is approaching and I’m pleased and excited to be moderating the special session: What I Really Need from mHealth: Five Perspectives on Value.

Pioneer has been involved with multiple aspects of mHealth since very early on and has seen interest grow into what sometimes seems to me to be an “irrational exuberance,” to borrow a phrase from Alan Greenspan. I’m concerned that we’re on the way to another bubble that’s in danger of bursting with unfortunate consequences. The fact is we often don’t know what “works,” and even what “working” means. And that’s why it’s so important that we discuss the different ways value needs to be demonstrated in mHealth.

This mHealth Summit panel will talk about value from the perspectives of the individual, the provider, the payer, the regulator and the researcher. These can be different, but from time to time they converge. Rather than having a number of separate presentations, experts will engage in discussion around a hypothetic but realistic scenario of a mobile health device and what’s needed to provide enough “value” for each to adopt, approve, purchase, share, fund and embrace this as a tool for better health. It is sure to be a lively and informative discussion.

I hope that you’ll be able to join us either in person in Washington, D.C. or electronically to help us shape the dialogue.

Follow the conference discussion through #mHS11, leave a comment below, or follow me on Twitter to join in the conversation.

Discovery Channel Documentary Highlights Project ECHO

For some years now, health care innovators have been using emerging health information technologies to transform everyday clinical care. But Pioneer grantee Project ECHO applies these technologies in an entirely new and revolutionary way:  to spread medical knowledge throughout the health care workforce, and, in the process, form collaborative practices, build new professional skill sets and exponentially expand the capacity of the entire health care system.

Project leader Sanjeev Arora, MD, of the University of New Mexico Health Sciences Center, developed the ECHO model to break down medical “knowledge monopolies” so that doctors, nurses and other clinicians can deliver better care to more people who need it, right in their communities. Project ECHO uses video communications technology to create real-time virtual networks for sharing the best medical practices and knowledge between specialists at a university medical center and local primary care teams. 

A new Discovery Channel documentary, Health I.T.: Advancing Care, Empowering Patients, features ECHO amongst a handful of innovative efforts using technology to transform patient care. The segment tells the story of a primary care physician living in rural New Mexico who uses technology in a new way to address her patient’s condition. View the program online or watch it on the Discovery Channel this Saturday, November 26, at 8:00 a.m. ET.

For more information on Project ECHO:

• Read a research evaluation published in the New England Journal of Medicine
• View our Facebook infographic

Converging Ideas at the 2011 mHealth Summit

Sometimes things just come together. We funded the first mHealth Summit because it was interesting and pioneering, and it seemed to have a connection to a few of our Project HealthDesign grants. Then came our involvement with and support of Quantified Self, Open mHealth, the Stanford Mobile Health 2011 conference and the mHealth Evidence meeting. Other programs, like our national program Health Games Research, Games for Health Conference and the Reality Mining meeting that we funded at MIT in 2009, also have strong mHealth associations.

This is more than just coincidence--rather, mHealth focuses on many of the qualities that make Pioneer “pioneering.” mHealth has the potential to radically change the way health and health care is delivered, it is inherently oriented to the individual, and it is an area not yet burdened with the organizational and bureaucratic complexities of traditional health care. mHealth is a place where something radical can happen.

It is therefore particularly gratifying to see that Pioneer will be well-represented at the 2011 mHealth Summit on December 5-7 in Washington, D.C., with grantees featured in sessions on Open mHealth, The Evolution of Gaming and its Effect on Prevention and Wellness, and Wireless Patient Monitoring in Care Facilities: The Future of Wearable mHealth Applications, Devices, and Sensors, and with a  Pioneer-sponsored session, What I Really Need from mHealth: Five Perspectives on Value. This session builds on a discussion that began in August at a Pioneer co-sponsored workshop on mHealth Evidence.

I hope that you’ll be able to join us at the conference, tweet me at @alshar using #mHS11,  and help frame what I’m sure will be a very important discussion.

Why We Have to Start Cutting Back on Antibiotic Use

Up to one million antibiotics are prescribed unnecessarily every year, often for colds and other viral infections that they can’t even cure.  This overuse is a serious public health threat because it significantly reduces antibiotics’ effectiveness to combat all sorts of infections, including life-threatening ones caused by microbes like MRSA and E. coli.

As part of a national effort to reduce improper use of antibiotics, the Centers for Disease Control and Prevention (CDC) and its partners are promoting Get Smart About Antibiotics Week, a campaign to educate consumers and health care providers about appropriate antibiotic use in hospitals and throughout the community.

Pioneer grantee Extending the Cure (ETC), a partner in CDC’s campaign, also released new data this week on antibiotic use trends.  These findings are the focus of a guest blog post on CDC’s Safe Healthcare blog, where Ramanan Laxminarayan, ETC director, describes a pattern of high antibiotic consumption in the Southeastern United States, particularly in West Virginia and Kentucky.  USA Today ran a story about the new research on Wednesday.

Laxminarayan also authored an op-ed in the McClatchy Tribune, calling on public health officials to put in place strategies that address these worrisome trends, such as broader flu vaccination. The new research comes to us from ResistanceMap, an online mapping tool developed by ETC that illustrates the growing problem of antibiotic resistance. This new map provides a look at antibiotic use across the U.S. 

Also this week, ETC released a paper describing a new “Drug Resistance Index” that allows policymakers and hospitals to track changes in antibiotic effectiveness over time using a single measure.  The index, similar in concept to the consumer price index, appeared in Monday’s edition of the British Medical Journal Open.

Extending the Cure is working to change how we as a society think about antibiotics, encouraging us to think about these drugs as a shared resource—just like water, trees or oil reserves—that we rely on and should preserve so they maintain their effectiveness. 

Let us know what you think:  Do we, as a society, use antibiotics too often?  What strategies should we use to ensure a future with plenty of powerful antibiotics?  Leave a comment here or tweet @PioneerRWJF #SaveAbx and @CDDEP to tell us what you think.

Introducing Innovations for Health: Solutions that Cross Borders

At RWJF, we’re focused on solving the most intractable health and health care challenges in the United States, but we recognize that innovations come from all over the world and that many effective health solutions are emerging with the potential for immediate adaptation, replication and impact. That’s largely because, despite their differences, many countries throughout the world face a surprisingly similar set of health care challenges.

In today’s interconnected world, we have an important opportunity to learn from each other – especially when a new idea has the potential to make a difference in a big way. For example, the New York Times recently released a special section, “Small Fixes,” which focused on low-cost health care innovations to improve global health. The small fixes ranged from simple, self-adjusting eyeglasses for those who don’t have access to optometrists to the sophisticated, Gates-funded “postage stamp” paper to detect liver disease nearly instantaneously—the samples don’t have to be sent to a laboratory to be processed.

The innovation that most caught my interest in this article was one in Mozambique that organized patient groups to take turns picking up their medications, thereby forming strong social bonds, reducing stigma and increasing adherence to antiretroviral drugs. The organized patient groups also reduced the burden on health care workers while increasing patient engagement and self-management of care. Some consider this “small fix” a potential game changer for HIV care.

What’s striking about many of these solutions is that they highlight the universality of health problems faced throughout the world, such as lack of preventive care, provider shortages and rising health care costs. And, while most of the solutions are geared towards solving health problems outside of the United States, with some imagination, I believe many of these fixes could easily improve people’s lives in our country.

It’s this desire to accelerate change by tapping into unconventional thinking around the globe that led the Pioneer team to partner to launch the Innovations for Health: Solutions that Cross Borders competition with Ashoka Changemakers. We’re looking to find solutions to these universal health care issues, and are most interested in those that have potential to:

• Increase capacity and training for health care workers and providers;
• Scale low-cost interventions to increase access to medical, preventive, or dental care;
• Reduce barriers to health information and services;
• Provide high-quality care in non-traditional settings; and
• Engage patients directly in their care, particularly those managing chronic illnesses.

We’re thrilled to seek these global health care solutions and hope you’ll check out the competition, learn more about the three $10,000 prizes, and share the link with your network of pioneering thinkers. And why not submit an entry yourself, nominate an organization to compete, or comment on the submissions? We can’t wait to see what ideas you might have.

OpenNotes Hints at Great News to Come

Pioneer grantees Tom Delbanco and Jan Walker, the creative and scientific minds behind OpenNotes, this week published an opinion piece in Modern Healthcare championing the need for patients to easily and securely access their doctor’s notes online and discussing early results from their project. The piece says, “We are learning that patients are overwhelmingly interested in gaining rapid access to their notes and that many doctors appreciate the potential for open records to improve care.” Check out “e-Patient” Dave deBronkart’s take on the Modern Healthcare story.  He calls the early results, “A hint of great news to come, for lovers of participatory medicine.” We couldn’t agree more, and can’t wait for an update coming later this year and final results due out later in 2012.  Stay tuned!

The Potential to Solve Perplexing Health Problems

In October, RWJF’s Pioneer portfolio laid down a challenge. Recognizing that good health behaviors often require behavior change, but that making those changes is usually easier said than done, we asked the pioneering world of behavioral economics to come up with solutions—innovative ideas to help people make the “right” decisions for their health.

The results were unbelievable. We’re excited to announce that Robert Wood Johnson Foundation’s Pioneer portfolio received more than 330 responses—a plethora of ideas drawing on behavioral economics to address tough health problems—in reply to our recent call for proposals.

We received applications from a variety of institutions, including universities, business schools, schools of public health, medical schools, clinics, non-profits, and research organizations. Our hope was to discover new interventions and insights that have potential to transform health and health care. In particular, we stated an interest in experiments that test innovative solutions to the challenges of obesity and consumer engagement. More than 50 percent of the applications we received focus on problems involving obesity. Nearly one-third involve consumer engagement. We are eager to dig into these as well as the investigator-initiated topics and invite those with the most pioneering ideas to submit a full proposal later this month.

RWJF’s Pioneer portfolio supports unconventional approaches to difficult problems—visionary solutions that have the potential to change the way we think about health and health care. We are the only RWJF team that accepts unsolicited proposals; however, when we target an area that we think deserves more attention, we are often humbled and excited by the caliber of the results.  I extend my warmest thanks to those scientists, economists, physicians and big thinkers who submitted your pioneering ideas as an answer to this call and to all those in our network who helped spread the word.

The Tip of the Iceberg for Science: Massive Biobank Starts Yielding Results

What do you get when you take 100,000 genotyped biological specimens and link them to longitudinal medical, environmental, behavioral and demographic data? You get Kaiser Permanente’s Research Program on Genes, Environment and Health (RPGEH), a Pioneer-supported effort that has developed the most robust and comprehensive research resource of its kind in the world.

At an unprecedented pace, researchers from the RPGEH biobank at Kaiser Permanente, in collaboration with colleagues at the University of California, San Francisco Institute for Human Genetics, have collected 170,000 samples and genotyped over 100,000 of them in just over a year. While currently the largest biobank in the United States, the ultimate goal is even more impressive: to collect data from a half million members of the Kaiser Permanente health plan linked to their electronic health records and population surveys – creating the largest, most comprehensive biobank on the planet.

Early research findings generated from the RPGEH data were presented this month at the joint annual meeting of the American Society of Human Genetics and the International Conference on Human Genetics in Montreal and are featured in the November issue of Nature Medicine. From an investigation of prostate cancer among African American men to a multi-ethnic study on bipolar disorder to a pharmacogenetic study of response to metformin, a drug used to treat type-2 diabetes, the RPGEH biobank is already starting to deliver.

But this is just the beginning - experts say that the possibilities for studying genetic and environmental influences over time thanks to this project are endless, with enormous potential for accelerating both the pace and breadth of medical research. The implications not only for the science community, but also for public health leaders and patients, are immeasurable. Stay tuned.

Exploring What We Don’t Know at TEDMED 2011



Pioneer is proud to once again sponsor TEDMED, which brings together innovative thinkers and leaders across the fields of medicine, science, business and technology. Traditionally, when people attend TEDMED, they come looking for ideas and inspiration. This year from October 25-28, the Pioneer team will be looking at things from a different perspective: What don't we know about some of the greatest challenges facing health and health care.

TEDMED has identified a tentative set of Twenty Great Challenges of Health and Medicine—deeply rooted problems with multiple, interconnected causes and ripple effects—which they plan to include as part of their 2012 conference. We’ve offered to help TEDMED examine these issues and we believe a good first step is to take a step back and ask: What don’t we know about these problems? What relationships aren’t we seeing?

To do this, we’ll be engaging all 600 conference attendees to get their thoughts on “what don’t we know” about these 20 challenges. Looking closely at what we don't know will help create a big-picture understanding of these challenges—a crucial step to developing truly effective solutions.

We invite you to join us in this exploration. Take a look at TEDMED’s Twenty Great Challenges of Health and Medicine. Then, answer the question, "What don’t we know?" about any of these challenges by tweeting #TEDMEDchallenges, posting a comment below, or e-mailing us at pioneerblog@rwjf.org.

Afterwards, we’ll be compiling what we heard at the conference and what you’ve told us to help TEDMED shape their new Great Challenges Program. Your input is valuable and will directly inform what is done at the TEDMED 2012 conference. We’ll share what we’ve learned in future posts.

How can you share your ideas?

• Tweet #TEDMEDchallenges to tell us what don’t we know about TEDMED’s Twenty Great Challenges of Health and Medicine. Tweet about any or all of the issues. 
• Post a comment below. 
• Follow @pioneerrwjf and #TEDMEDchallenges to see what others are saying.

Be sure to check back throughout the week and next for updates from our guests and team members.

Early Insights from Project HealthDesign

As more patients begin using technology to manage their health, the Pioneer Portfolio's National program Project HealthDesign is helping meet the demand by designing tools that can be used by real people to improve their health and engagement with their health care providers. In the true pioneering spirit, Project HealthDesign research teams are working with real patients to create new technologies that help people living with chronic illnesses and improve their health and coordination of care. Patients are tracking observations of daily living (ODLs) about their sleep patterns, pain levels and moods. They use the resulting ODL data to better communicate with health care providers as they look to see what the trends in their ODLs might suggest, like whether they need to take a certain action to improve their health or whether past actions have made a difference. The incredible experiences these teams are having with real patients and clinicians have uncovered some preliminary lessons.

The teams have learned that new clinical workflows are needed in order to incorporate ODLs into clinical practice. Nurses, health coaches and other caregivers have emerged as the key points of contact for ODL data incorporation. And because each patient is different, personal health applications need to be customizable.

A key outcome of the teams’ work will be to determine how ODLs can be integrated into clinical care and individuals’ daily health decision-making processes. To learn more insights and lessons from Project HealthDesign, view the Early Findings and Challenges report for a quick overview or read the draft Technical Architectures and Implementations report for more detailed findings.

Warm Weather Brings Risk of Resistant Hospital Infections

Two new articles from Extending the Cure, a Pioneer-supported project that examines solutions to the growing problem of antibiotic resistance, advance our understanding of the growth and spread of certain lethal hospital infections and pose policies to address the long-term challenge of antibacterial resistance.

The first article, which appeared Sept. 26 in the online journal PLoS One, describes a new study that found certain potentially lethal hospital infections are more prevalent in warmer weather. In the study researchers examined 211,697 infections reported by 132 hospitals across the nation from 1999 to 2006. The warmer the temperature, the more hospitals reported certain hard-to-treat infections. The problem was particularly severe in the summer: For example, the researchers identified a 52 percent summer spike in bloodstream infections caused by Acinetobacter baumannii, a highly resistant “superbug.”

Hospitals should be on alert during warm weather in any season in order to identify and stop the spread of these resistant infections, the authors say.

In the second article Ramanan Laxminarayan, the director of Extending the Cure at the Center for Disease Dynamics, Economics & Policy, and John H. Powers, associate clinical professor of medicine at George Washington University School of Medicine, argues that we need incentives to crank out newer, more powerful antibiotics and at the same time, preserve the efficacy of antibiotics we have left.

Writing in October issue of the journal Nature, they say that we must start treating antibiotics as a valuable resource, one that can be depleted with overuse and nurtured with public private partnerships(PPPs).  “In our view, government intervention through PPPs that are focused on the development of antibacterials with desirable properties, in combination with incentives to encourage the conservation of antibacterials and the achievement of resistance targets, is the best way to tackle the increasingly serious public health threat of antibacterial resistance.”

Leave a comment to tell us what you think public policy should focus on in the research, development and preservation of antibiotics.

Decisions, Decisions…Behavioral Economics and Behavioral Change

To improve people’s health, we ask them to change their behavior. Quit Smoking. Eat right. Lose Weight. Take a walk. Get your blood pressure checked. See a doctor. But, as many have noted, making a commitment to do the “right” thing is often easier than following through on that commitment.  In fact, many of the nation’s health epidemics are linked to people doing the “wrong” thing despite their best intentions.  Assuming that people want to feel good and live healthy, productive lives, how can we explain actions that unequivocally threaten that outcome?  As a classically trained economist, I am sorry to say: Classical economics can’t give us an answer to that question.  Wearing the hat of program officer with the Robert Wood Johnson Foundation’s Pioneer Portfolio, I’m charged with searching, often in unexpected places, for pioneering ideas that have the potential to accelerate change and radically improve our health and the health care we receive. This quest has led the Pioneer Portfolio to the doorstep of behavioral economics.

Unlike classical economics, which assumes people act rationally and make choices in their best interest, behavioral economics does not assume that people behave in ways that maximize their income or long term happiness and wellbeing.   Rather, behavioral economist study how various factors such as environment and psychology lead people to sub-optimal outcomes. Pioneer is seeking ideas from this field because we understand that, in addition to the social determinants of health that we cannot individually control, we are constantly making conscious and unconscious decisions that relate directly and indirectly to our health. We choose whether or not to take our medication. We select the foods we eat. We decide whether to take the stairs or go to the gym.  

When we interact with the health care system, our health care providers make decisions that impact our understanding of our health condition and our treatment protocol. Doctors decide whether to use positive reinforcement or fear tactics to motivate a patient, encourage her to stop smoking, or ask her to get a test. Nurses choose whether to speak up during rounds and how to impart knowledge to a patient when he is discharged from the hospital.  Insurers seek to influence our decisions with financial incentives related to choice of physician, care facility and frequency of interaction with the health system. The frequency of these decisions is important because when we – or our providers – make poor decisions, our chances for a long, healthy life are hurt.

The emerging field of behavioral economics is working to discover how people make decisions that can affect their health behaviors and health care, and how we can learn to guide people toward decisions that are in their best interest, even if they are hard, inconvenient or easy to forget. With this knowledge, policymakers and others can design environments, campaigns, messages and tools that make it easier for people to choose what is best for themselves, their families and their communities.

That’s why the Robert Wood Johnson Foundation’s Pioneer Portfolio has issued a call for proposals to identify promising experiments that apply the principles and methods of behavioral economics and choice theory to perplexing health and health care problems. By tapping into the behavioral economics community, we hope to uncover pioneering interventions and policies that will transform the way patients and providers make decisions that affect health for ourselves and our communities.

It is our hope that behavioral economists can help us learn how people think about their health and the decisions they make. Some research we fund will fail, but that’s okay–there will be critical lessons learned from these experiments. The successes and the failures will help to educate our work to transform health and health care for the better.

We’re seeking innovative ideas that apply the field’s principles and theories to perplexing health problems. We are particularly interested in supporting either experiments or secondary data analyses that test innovative solutions to the challenges of obesity and consumer engagement, but any problem can be addressed.

Do you have an idea of how behavioral economics can help change health and health care? Can you think of a health problem that can be transformed by learning more about how patients and providers make decisions about the care they give and receive? If you don’t plan to submit a proposal, leave a comment– I’d love to hear your pioneering ideas.

Register here for an informational web conference on October 19 at 11:00 a.m. Eastern. The Robert Wood Johnson Foundation will discuss and answer programmatic questions about Pioneer's new funding initiative, Applying Behavioral Economics to Perplexing Problems.

Advancing the field of mHealth with mEvidence

In August, Pioneer's Al Shar shared his takeaways from the 2011 mHealth Evidence Workshop that we sponsored along with NIH, NSF and the McKesson Foundation. In that post, Al mentioned that the participants were eagerly putting together a statement of direction and would soon publish the key outcomes of the meeting.

We are pleased to report that the group has since shared those thoughts, which we have included below. Additionally, we encourage you to watch the archived webcast of the event.

Let us know how you think the mHealth ecosystem can be strengthened to deliver transformational improvements in the research and practice of health and well-being.

National and global scientists, policymakers, health professionals, technologists, and representatives from regulatory and funding agencies gathered for the invited mHealth Evidence Workshop at the National Institutes of Health August 2011 to discuss and identify more effective methods to generate evidence of efficacy and effectiveness for the unique emerging science of mobile health (mHealth).  mHealth draws from medical and clinical research, behavioral theory, user interface design, sensing technology, computer science and statistical inference to improve health outcomes. The meeting was sponsored by the Pioneer Portfolio of the Robert Wood Johnson Foundation, the McKesson Foundation, the Office of Behavioral and Social Sciences and National Heart, Lung and Blood Institute at the National Institutes of Health, and the National Science Foundation. The overall conclusion of workshop participants was that mHealth has great potential to support health and well-being worldwide, and, therefore, there is a need to enhance its scientific foundation. mHealth tools and interventions must be backed up by rigorous scientific development, evaluation, and evidence generation to enhance meaningful innovation and best practices, and to validate tools and methods for health professionals, consumers, payers, governments, and industry.

Meeting participants also concluded that the science of mHealth must use and further develop systematic research methods adapted to the technology, clinical or program intervention, in addition to analytic methods to process the vast amounts of streaming, tagged, complex and layered data that becomes available using mHealth technologies. 

This spectrum of methods will need to include not only randomized clinical trials, potentially optimized to leverage mHealth advancements, but also alternative study designs and methodologies that  ensure that research studies are able to provide timely information within a rapidly evolving field.  Evaluation methods that incorporate principles of existing study methodologies, including randomization, step-wedge design, n-of-1 trials, and Practice-Based-Evidence (PBE) methodology were discussed, in addition to methods that borrow from engineering, including Multiphase Optimization Strategy (MOST) and Sequential, Multiple Assignment  Randomized Trials (SMART).  Ethical issues related to collection, storage and use of real-time masses of identifiable personal data were also acknowledged as topics requiring updated guidance.

As a follow up to the workshop, participants are identifying and developing the methods needed to best generate mHealth evidence. They are forming working groups to engage the mHealth community in developing a research agenda centered on design methodology, analytic methods, and mHealth technologies. These efforts will support a rigorous and innovative mHealth ecosystem with promise to deliver transformational improvements in the research and practice of health and well-being.

Extending the Cure Launches Interactive Map Featuring Latest Regional and Global Trends in Antibiotic Resistance

The latest iteration of ResistanceMap, an interactive web-based tool that tracks drug resistance in North America and Europe, was launched recently by Extending the Cure, a Pioneer-supported research project that explores policy solutions to the growing threat of antibiotic resistance. (ETC director Ramanan Laxminarayan sums up the initiative’s approach wonderfully in a recent article in The Atlantic .)

 The United States lags behind many Western European nations in controlling the spread of certain drug-resistant microbes or “superbugs,” according to ResistanceMap. The online tool was recently updated to allow users to make side-by-side comparisons of resistance data.

 The maps show that despite significant gains in limiting the spread of hospital acquired Methicillin-resistant Staphylococcus aureus (MRSA), the United States still has one of the highest MRSA rates in the Northern Hemisphere—putting it far behind other developed European countries. Nearly 52 percent of reported Staph samples in the United States are resistant to treatment with methicillin, penicillin and closely related antibiotics, compared to just 1 percent in Sweden.

 Policymakers, researchers and healthcare workers can use maps like these to identify regions in the country or the world that might need greater coordination and tighter infection control. The information in the maps will also be useful in finding models of best practice that could be used to curtail the spread of an emerging superbug, an increasingly urgent need in a world where resistant bacteria can easily and quickly travel from one part of the globe to another.

Several high-profile media outlets covered the launch, including: The Wall Street Journal, The Washington Post and Scientific American.

Check out the map and let us know what you think – what are some trends that jump out at you and how can we re-imagine the way we deal with the issue of antibiotic resistance?

Simple Measure Could Help Address Public Health Threat

Antibiotic prescriptions tend to spike during flu season, even though influenza is caused by a virus and cannot be treated with antibiotics, according to a new study from Extending the Cure, a Pioneer-supported project that examines policy solutions to the growing problem of antibiotic resistance. In the study, authors Phil Polgreen and Ramanan Laxminarayan offer a simple solution to the problem: Get your flu shot this year.

Laxminarayan describes the study findings and calls on health care administrators to get their hospital workers immunized in a Modern Healthcare op-ed, co-authored with U.S. Congressman Michael C. Burgess, and is joined by experts from the Centers for Disease Control and Prevention (CDC) in urging consumers to get their flu shot in another guest commentary in the Health Care blog.

Let us know what you think – can something as simple as getting a flu shot help curtail the misuse of antibiotics? Are there other counterintuitive solutions to this problem we haven’t thought of yet?  

 

Time to Bring Designers to the Table: Thought's From Mayo's Transform Symposium

I'm just back from an exciting Mayo's Transform  Symposium. Before saying anything about the conference, I need to mention that being a pedestrian in Rochester, MN may present a significant health danger. I'll have to remember that cars don't stop on the East Coast just because someone is ready to cross a street.

We brought some guests to the meeting both to excite and engage them in helping move our support of Project ECHO forward. I'll let others write about that aspect of the meeting.

Regarding the meeting. I didn't realize that the theme was one about design innovation more than health or healthcare. At first this was off-putting: I wanted to learn about innovation that was going to help change health, not health packaging. I was wrong. I thought that figuring out how to solve a problem was the hard part. Implementing the solution would more or less follow. That's naive. Understanding the way people and the environment react to how solutions are packaged and presented is critical in their acceptance and ultimate success.

This is a good thing and bringing skilled designers to the table is important. We know that understanding where and how a person lives is important in determining what interventions will work but it's equally important to frame them in ways that are consonant with what they think and feel. Seeing the effect of a pediatric MRI designed to look like a pirate ship ride on a child's acceptance of the study or even just a simple reframing of an intervention in a context that resonates makes a world of difference.

It's sad that a collaboration between design and medical professional, with active consumer engagement, is not more common. Designing a solution to the wrong intervention and poorly implementing the right one are wasteful at best. But when things come together well, it can be a beautiful thing.

 

Blue Button: Driving a Patient-Centered Revolution in Health Care

Editor's note: This post originally appeared 9/13/2011 at the Huffington Post.

A lot can happen in a year.

Last October, I wrote about a promising new offering for people looking to take control of their own health and health care decisions. Known as "blue button," this simple (but rather revolutionary) technology offers individuals the ability to download their own health information with just the click of a mouse. They can then use and share this information however they may choose -- with doctors, care providers, or even third-party applications designed to help them track and make sense of their own personal data.

Born out of a collaborative working group convened by the Markle Foundation, the blue button was beta-tested and then implemented by the Department of Veterans Affairs, the Department of Defense, and the Centers for Medicare & Medicaid Services (CMS). The immediate demand from their patients and beneficiaries was inspiring.

Recognizing the disruptive potential of the blue button idea, we at the Robert Wood Johnson Foundation took an interest in it at an early stage of its growth. One of our aims is to help individuals understand, identify and receive high quality care. As such, exploring and supporting the development of technologies that enable people to make informed decisions is one way we hope to realize our vision of placing patients at the center of their care. Health data download capabilities modeled after the blue button approach can really move the ball forward in that regard. People can review their health records or claims information, educate themselves about conditions, procedures, medications, or test results found in their records, and share their information with family, friends and their health care providers. They can also point out errors they find and make sure that they are corrected.

I concluded my last post on the blue button idea by observing that the federal government had taken a strong step forward to give people access to their own health information, and that it was time for more in the private sector to do the same.

Not even a year later, I'm thrilled to look back and see that progress is being made -- in terms of both demand and implementation. Well over 400,000 veterans, members of the military, and Medicare beneficiaries have downloaded their data using the Department of Veterans Affairs', the Department of Defense's, and CMS' Blue Button, showing just how desired this functionality is by individuals. Equally inspiring is how much the private sector has taken up the challenge to make the health data they hold available to their patients and beneficiaries. Aetna, United Health Care, Walgreens and PatientsLikeMe are just a few of the major care providers, insurers and patient groups that have either implemented or committed to offering their consumers a blue button download capability.

Broader use of the blue button approach also offers opportunity to mobile app and software developers working in the burgeoning consumer e-health field. As the blue button download capability becomes more widespread, we expect to see more and more apps designed to take the data individuals can download and turn it into useful information and valuable tools used to manage one's health like reminders to get preventive services or refill a prescription, or a list of the lowest price outlets to order medications. To encourage these innovations, several organizations (including RWJF) have sponsored "developer challenges," and we expect more to be announced.

It's clear that we're in the middle of a health care quality revolution. But to improve outcomes on a broad scale, we need to empower individuals to become active participants in their care. Download capabilities like blue button can help do that, which is why we at RWJF are continuing to encourage their spread. Today, I am excited to announce the launch of bluebuttondata.org, a web site that is a one-stop-shop for anyone (individuals, providers, insurers, health care organizations, patient groups, mobile app/software developers) who is interested in finding out how they can join the revolution.

I encourage you to help us harness the early momentum blue button has made and turn it into a full-fledged movement. Spread the word. Or better yet, visit the site and commit to transforming health care as we know it. 

 

New Case Studies in Innosight Institute’s Disruptive Innovations in Health Series

 Over the past several months the Innosight Institute, a think tank that applies Clayton Christensen’s theories of disruptive innovation to the social sector, has been exploring the critical factors necessary for facilitating disruptive innovation in health care in integrated delivery systems to achieve increased quality, reduced cost, and access improvements. The work, which is funded by the Pioneer Portfolio, has already produced five case studies, including recent additions that look at processes at Grand Valley Health Plan, Group Health Cooperative, and Presbyterian Healthcare Services.

To learn how Grand Valley provides a high level of access at a low cost of care, how Group Health is employing a successful Medical Home program and how scarcity became “the mother of invention” at Presbyterian Healthcare Services please check out the full case studies here.

 

Building Bridges in the City by the Bay - The 2011 Health 2.0 Conference

By Stephen J. Downs

We have a few questions for you.

Every day there are people who are finding new ways and developing new technologies to observe or collect information about themselves that has the power to improve health.

For example, Pioneer’s Project HealthDesign researchers are exploring practical ways for people to collect their own ODLs (observations of daily living) and integrate them into the clinical setting – empowering individuals to be at the center of their own care.

The pioneers at Open mHealth are equally committed to involving individuals in their own health and health care as they create an open learning ecosystem and share innovative technologies to improve everyone’s health.

In another cutting-edge movement, self-trackers who seek “self knowledge through numbers” are gaining insights into their own health and health-related behaviors everyday. The number of tools, apps and devices to help them are increasing exponentially, and it seems as if we’ve only scratched the surface of what people are starting to do by collecting and sharing their health-related data.

Today’s reality is that individuals have the opportunity to have the power of their own health information literally in the palms of their hands. We can point to when our blood pressure was high during the day, how our diet impacted our energy levels or sleep, what movements or behaviors caused a flare-up in back pain.

But how many will choose to track this information? Can self-tracking become mainstream in the next two years? What about five, 10 or 20 years? And if it does, then what do we do?

How do we make sure that information is put to its best use, both for us personally and the population as a whole? As patients, what do we want our doctors to do with our self-generated data? What do our doctors want us to track, and how? How do they integrate it into our diagnoses and treatment plans?

These are some of the questions we’ll be asking this coming week, September 25-28, at the 2011 Health 2.0 Conference in San Francisco. We’re excited to be a sponsor of this event and we’ve brought a diverse group of grantees and friends with us.

We’ve been involved in the broader Health 2.0 space for some time now. Through our investments in programs like Project HealthDesign, Open mHealth and support of groups like Quantified Self, we’ve been trying to bridge the worlds of technologies and health, and the experiences of patients and clinicians.

Over the course of the conference and beyond, we’ll be asking guests to help us tackle several questions that we think are critical if this movement is to reach its full potential—and we’d like your ideas too.

So tell us what you think. Help us answer these questions. Please add your comments below. You can also message us privately at pioneerblog@rwjf.org.

1. What do you think are the most important challenges to be addressed in order to get more people collecting their own health data and information?
2. What do you think are the most important hurdles to be overcome for patients to bring this information to their doctors and for it to inform clinical care? 
3. Of all the things that one can track, what is the one piece of patient-generated data that has the most potential value to both personal health and clinical care?

As we look for opportunities to advance the thoughtful exploration of these practices, your responses will guide us. We value your input and look forward to hearing what you have to say.

 

What does mEvidence need to look like?

There is something magical that happens when talking about mHealth. People start believing all of the wonderful things that a phone, together with the right gadget, can do: remind me to take my medicine, monitor my vitals, inform my doctor when something goes wrong, just plain automatically keep me healthy. The last few years have seen a huge growth in cell phone companies, technology companies, governments, application and device developers rushing to deliver product in this space. Just look at the over 500% increase in attendance between the 2009 and 2010 mHealth Summit (with the 2011 meeting promising to be even larger.) Along with the hype and the hope, people are beginning to ask for evidence and to question the value of growing a collection of isolated gadgets and apps.

I’d say that mHealth is somewhere around the asterisk on the “hype cycle” model developed by Gartner.

With that as context, RWJF’s Pioneer Portfolio, together with NIH, NSF, HHS and McKesson Foundation, organized a one day event to begin the process of advancing the Science of mHealth. What does mEvidence need to look like? What are the right methods to accelerate the evaluation of the efficacy of mHealth technologies?   First steps to address this have largely been focusing on attempts to demonstrate value by using a traditional randomized controlled trial, which is often ill suited to testing the interventions that mHealth enables. (It’s interesting to note that on August 14, Paul Meier died. I’d be interested in knowing what he’d be thinking.) When we first started to plan this meeting, I wondered how interested the field would be. After all, this is the drier, academic side of mobile health. I was surprised! We had 106 responses to our call for whitepapers of which we were able to choose 23. The demand for attendance was such that NIH had to arrange for a webcast.  Perhaps looking at transforming the way conduct research [in light of new technologies] is not so dry after all. While the attendees were predominantly US-based, academic, international and corporate interests were represented. The outcome was even more surprising. The group agreed that this was a good and important direction, that we needed to have a collaborative, ongoing and forward looking agenda and that the Science of mHealth was critical to achieving a high enough plateau of productivity. The group will soon issue a statement of direction and commitment, publish the key outcomes of the meeting and develop a longer-term agenda. We are also developing an online community so that we can keep the discussion going. In a couple of weeks the webinar will be available for people who missed it and we will work to keep the groundswell moving.

I’d be remiss not to include the fact that closely aligned is the ideas and ideals of Open mHealth and the work of Pioneer grantees Ida Sim and Deborah Estrin. Not only were they and a number of people in the open mHealth area participants, they organized a second day to help formulate how they were going to develop and move forward.

This is important and people are paying attention. One way that you can help is to respond to the request from the NIH Director’s Common Fund, which is designed to fund transformative research that is of interest to the health community. The Common Fund officials are looking for the community (that is you!) to weigh in on new ideas for funding. Go here to add your comments.

 

Another reason to get your flu shot - It can help reduce antibiotic resistance

Pioneer grantee Ramanan Laxminarayan, director of Extending the Cure, recently shared his perspective on The Health Care Blog about a new study published in the July issue of Infection Control and Hospital Epidemology. The study shows that antibiotic prescriptions tend to spike during the flu season, even though influenza is caused by a virus and cannot be treated with antibiotics.

According to Extending the Cure, between 500,000 to one million antibiotic prescriptions are filled each year during the flu season for patients who have the flu and no bacterial illness. This overuse is one of the many causes of the recent spike in antibiotic resistant bacteria.

Laxminarayan proposes a simple solution to this problem – get your flu vaccine this year. If you do not contract the flu, then there is no possible way your care provider will needlessly prescribe you antibiotics to treat it.

 What are some other  ways to curtail the epidemic of drug-resistant bacteria, both during this year’s flu season and beyond? We’re interested in hearing your thoughts – leave a comment here or on THCB.

 

 

mHealth Evidence Workshop and Webinar, August 16

On August 16 the Pioneer Portfolio, along with the National Institutes of Health, McKesson Foundation and the National Science Foundation will present the mHealth Evidence Workshop in Bethesda, Maryland. This workshop, which will be shared via a free webinar, brings together individuals with diverse expertise in data analysis and experimental design to identify methods that can accelerate the evaluation of the efficacy and safety of mHealth technologies. We at Pioneer, along with many others, believe mHealth has the potential to simultaneously reduce the cost of health care and improve our health. The tremendous interest we’ve received in the event is also a great sign that we’ll have a productive day exploring the potential around design and infrastructure innovations, reality mining and plotting a direction to build upon current innovations.

We plan to use this to generate a research agenda to further guide development of the space. To register for the free webinar please visit Eventbrite. Also, be sure to check back here for a recap of the discussion and next steps. 

 

Interview with Philip Polgreen

 Philip Polgreen, M.D., an associate professor in the Department of Medicine at the University of Iowa Carver College of Medicine, and his colleagues published a study in the May 4, 2011 issue of the scientific journal PLoS ONE showing that Twitter can be used to track influenza activity. Support for the research was provided in part by the Robert Wood Johnson Foundation’s Pioneer Portfolio. Previous work by Polgreen and Forrest Nelson, Ph.D., an economics professor also at the University of Iowa, includes the development of an electronic prediction market that could help public health officials forecast the timing, severity and spread of seasonal influenza and other infectious diseases. In this post, Polgreen answers some questions about the current study’s findings and implications for the future

 

Q: Why did you look at Twitter and influenza activity?

 

A: Right now, public health officials report suspected cases of the flu to the Centers for Disease Control and Prevention (CDC), but that process can take several weeks, a lag that gives the flu an opportunity to spread. When reports of the H1N1 virus that causes swine flu started increasing, we wondered if we could tap into the Twitter stream to find evidence of an upswing in cases of the flu in real time. Twitter is a micro-blogging service that allows millions of users to send and read “tweets” on all kinds of information, including, as it turns out, useful information about people suffering from fever and other flu symptoms.

 

Q: Your team also found that Twitter could be used to track the rapidly evolving public sentiment with respect to H1N1. How did the team come to that conclusion?

 

 A: We collected and stored tweets containing key words such as “H1N1”, “influenza”, or “swine flu” that were sent at the start of the outbreak. At the start of the outbreak in April 2009, we saw a flurry of tweets, including some expressing fear about the virus. But as time went on, public health messages indicating that the H1N1 virus was not as deadly as expected kicked in and we saw a gradual decline of tweets talking about such concerns.

 

Q: The study also found that public interest in hand-washing seemed tied to public health messages aimed at slowing the spread of the flu. Can you explain why that finding is important?

 

A: If this method proves accurate, public health officials may one day use it to find out whether people understand key messages aimed at flu control and prevention. If not, they can tailor the messages to increase the knowledge of, say, the importance of hand-washing, a habit that can protect people from the flu and can contain its spread.

 

 Q: You also did a second analysis that used Twitter to track disease activity. Can you explain what your team found?

 

A: We analyzed tweets that contained the words “fever”, “flu”, “muscle aches” and other symptoms, finding that Twitter data could be used to estimate incidence of the flu in real time. In addition, we found that Tweets from people experiencing flu symptoms tracked closely with the information collected by the CDC (data that comes out two to three weeks after people report feeling sick) in both time and location. If this method of tracking disease is confirmed by additional research, public health officials could use it as an early warning of a potential uptick in flu cases in a specific geographic area.

 

Q: Why is early warning a critical part of protecting the public?

 

A: Public health officials need as much information as they can gather in order to combat the flu and other infectious diseases. With early warning that a flu strain is particularly virulent in some part of the country or is spreading rapidly in others, public health officials can ramp up production of a vaccine or push out public health messages urging people to line up for a flu shot, which can turn down the dial on the outbreak.

 

Q: Does this have the potential to accelerate the progress we’ve made in protecting people from the flu or other infectious diseases?

 

A: Yes. This is one of the first large-scale efforts to investigate if data from Twitter can be used to predict the flu or to track public interest in a disease like H1N1 influenza. Additional research will need to confirm the accuracy of this method and extend it to other infectious diseases. But if all goes well, public health officials may one day be able to tap into the Twitter stream to get real-time information that could pinpoint an outbreak’s location and show when it is starting to spread to other areas of the country. This method will not replace current disease-tracking methods but could augment existing approaches to surveillance.

 

Accentuating the Positives: Positive Health

What comes to mind when you think of medicine? If you’re like most people, it is preventing disease and treating them when they are sick.

But health is more than the mere absence of disease. So what if there were options for medicine beyond the prevention, diagnosis, treatment and cure of disease?

Researchers who work in the emerging field of Positive Health are exploring the possibility that people have and can develop positive health assets that keep them healthier and help them recover more quickly when they are sick. The research, supported by the Pioneer Portfolio, is taking an empirical approach to developing the field. Positive Health research explores associations between health assets -- including subjective factors like optimism, functional factors like stable marriage, and biological factors like high heart rate variability – and people’s health.

The research is starting to gain traction in health and medical literature.

• Health Psychology published a study finding that positive psychological well-being – defined as emotional vitality and optimism – was associated with lower levels of risk for heart disease. The study re-analyzed existing data from a survey of 7,942 middle-aged men and women over five years who were measured through their responses to statements about purpose in life, mental energy and the expectation of more good things than bad to occur in the near future. Positive psychological well-being was associated with a modest, but consistent reduced risk of fatal heart disease, first heart attack or first definite angina. 
• The European Heart Journal published a study stating that higher levels of life satisfaction were associated with lower risk of heart disease. The study re-analyzed existing data from a survey of 7,956 British civil servants who rated their satisfaction with eight domains of life: love relationships, leisure activities, standard of living, job, health, family, sex life and self. Four of these life domains—job, family life, sex life and self satisfaction—were independently associated with a 12 percent reduced risk of heart disease, as was higher overall life satisfaction.
• The journal Stroke published a study linking higher levels of optimism to lower risk for stroke. The study assessed 6,044 American adults for optimism and tracked their incidence of stroke. Participants rated items such as “In uncertain times, I usually expect the best” on a six-point scale, resulting in an overall score between 3 and 18. Each unit increase in optimism correlated to a 9 percent decrease in stroke risk during a two-year follow-up period.

Positive Health changes the way we think about health and health care—it reframes the goal of our health care system from treating and preventing disease to building more robust health. This  innovative approach to health and well-being  promotes people’s positive health assets—their strengths that can help protect against disease and lead to a healthier, longer life. The focus is not on prevention or treatment of disease, but instead on building an individual’s “good” assets that are desirable in their own right.

With the support of the Pioneer Portfolio, Martin Seligman, Ph.D., project director and director of the Positive Psychology Center at the University of Pennsylvania, and a team of researchers are working to identify these assets. If identified and validated, the next step would be to design potent, low-cost approaches to enhance well-being and help protect against physical and mental illness.

Support for this research is provided by the Robert Wood Johnson Foundation’s Pioneer Portfolio through a grant, “Exploring Concepts of Positive Health."

Follow the growing research this team is building on Positive Health.

 

The Perfect Job – For You or Someone You Know! Pioneer Team Seeks Communications Officer

Our team, the Pioneer Portfolio of the Robert Wood Johnson Foundation, is hiring a Communications Officer. This is an exciting opportunity to help lead a dynamic, diverse team focused on seeking out and supporting ideas that have the potential to transform health and health care and accelerate change, leading to dramatic improvements in people's lives. The full job description is posted on our website. This person will also play a key role in our enterprise level programming efforts at RWJF.

As followers of Pioneering Ideas, we thought you might know people who embody the "Pioneer" spirit – strong candidates who can help ensure Pioneer succeeds in supporting ideas that change the way we think about health and health care. We'd be grateful if you could share the news throughout your networks — email it, tweet it, post it to your Facebook page, or call that perfect candidate whom you would like to personally recommend. All applications are due by August 10.

New Journal Represents Leap Forward for Health Video Games

Recently, we were thrilled to learn about the launch of a new peer-reviewed publication focused on health video games in the fall. Exploring how video games can be used to drive positive health outcomes for millions of people is something we’ve invested in for quite some time, through both our Health Games Research national program and the annual Games for Health Conference, which just wrapped-up its seventh conference last May.

According to Pioneer Senior Program Officer Paul Tarini, the launch of this journal represents a big step forward for the field: "There's an increasing number of people who are interested in the question of whether games work, how well they work, and what makes them work," Tarini said in a post on NewsWorks. "If we weren't beginning to see a critical mass of people who are interested in those questions, we wouldn't see somebody saying. 'I think it's time for a journal.' "

As the first-ever peer-reviewed publication that focuses on this emerging field, Games for Health: Research, Development, and Clinical Applications (G4H), published my Mary Ann Liebert, Inc,  will help build an evidence base of effective interventions,  which  developers can use to build the next generation of health video games. As stated on the blog Gamification  by Health Games Research National Program Director Debra Lieberman: “The Journal will be a starting point for anyone interested in the research and design of health games that integrate well-tested, evidence-based behavioral health strategies to help improve health behaviors and to support the delivery of care.”

Lieberman and several other Health Games Research grantees will serve on the journal’s editorial board and will help shape its direction. Their years of experience studying the impacts of video games on health and deep knowledge of the subject matter will greatly benefit this groundbreaking publication’s body of research.

How do you think video games can impact health? Are there any specific topics you would like to see the journal provide more insight into? Leave a comment and let us know your thoughts. 

 

Drug Facts Boxes Featured in New York Times

Last week, the New York Times published an op-ed by the Dartmouth Institute’s Steven Woloshin and Lisa M. Schwartz that discussed the critical need for a redesign of something that can empower consumers to make informed decisions about their health care – the information that accompanies prescription drugs. As stated in their own words: “Bombarded with pharmaceutical ads listing what seems like every conceivable side effect, American consumers might think they are already getting too much information. But they — and their doctors — are not getting what arguably matters most: independent, plain-English facts about the medication.”

Prescription medication labels are hard to read, confusing and often leave out crucial information contained in Food and Drug Administration (FDA) review documents. Major side effects or potentially dangerous drug interactions can be hidden to patients on their medication packaging. By giving drug packages a simple makeover and creating a standardized, easy-to-read drug fact box—akin to what’s currently required for nutrition labels—information that is critical to enabling an individual to make the best health care decisions possible will be readily available to all.

Woloshin and Schwartz are leading the charge on the effort to develop these “Prescription Drug Facts Boxes.” Recognizing the opportunity for a simple design change to create better access to information and have a big impact on how people engage with their health care, we have been supporting their efforts since 2008. You can read more about that support here. This idea was simple and powerful enough to be included in the health care reform law.

Policymakers say that an additional three years of study are needed before beginning to implement the facts box. To me, it’s unclear what more they will learn in those three years. I don’t think it’s the lack of an evidence base. Woloshin and Schwartz have done a number of good studies about the efficacy and adding to them should not take three years. I don’t think it’s figuring out how to operationalize the production, a hand book is easily developable. I do think it’s a combination of two important factors: an underrepresented constituency and an overly strong concern for the potential adverse impact of any change.

The underrepresented constituency is the consumer. We are already given information about the intent of the drug and the dangers. The perception is then that the only thing the drug box adds is the ability to make a more informed choice. And that’s not seen as very important. Given that, it’s easy to see why the potential downside of the change needs so much study. If you don’t weight the value very highly, you need to be very sure that there are no “adverse events”.

That’s wrong. We’re being told (and in some cases, compelled) to take more individual responsibility for our health. Being denied access to clear and actionable information is wrong.

 

Noodles of ODLs

By Steve Downs and Patricia Flatley Brennan 

On the heels of a recent meeting with our Project HealthDesign teams, we’ve been thinking a lot about how this Pioneer-funded national program has the potential to affect the way providers and patients share information that has personal and clinical relevance – and what that information may include. It’s interesting stuff.

 

Patients participating in Project HealthDesign studies are using technology to track personally meaningful information about their daily feelings, thoughts, moods and behaviors – or observations of daily living (ODLs) – and sharing this information with providers. Currently, nearly all of our project teams are beginning the testing phase, recruiting patients and providers to participate in the studies. Part of their task is to figure out which ODLs are relevant to share; another job is to share them in ways that are meaningful to all involved. We think the work of the teams may spark innovations in the patient-provider relationship and improve the management of chronic disease.

We’ve already learned that ODLs have the potential to provide clinicians with a richer picture of a patient’s overall health—addressing the entire continuum of care, not just acute episodes of illness.

 

We’ve also noted the complexities of tracking patient behavior and engaging clinicians to look at and act upon ODL data.

 

As we continue to track each team’s progress, we anticipate results that will help patients, technology leaders, policymakers and health care experts plan and implement new initiatives that put individuals and their needs at the center of the nation’s health information technology infrastructure.

Follow the work of our research teams as we report on their major breakthroughs and challenges, and learn more about the exciting work our Project HealthDesign teams are undertaking here. 

 

Project ECHO: A Game-Changer for Patient Care?

Note: This post originally appeared on The Health Care Blog June 14, 2011

By BRIAN QUINN, Pioneer Team Director

I met Sanjeev Arora as part of the RWJ crowd at TEDMED last year and was pretty impressed with his approach–especially given the lack of access to care in poor and minority regions. Now there’s proof his approach works –Matthew Holt

On June 1 the New England Journal of Medicinepublished a study about how primary care providers can treat very sick patients who previously did not have access to specialty care.  The piece described Project ECHO, a disruptive model of health care delivery based on collaborative practice that has the potential to transform health care.  Supported by Robert Wood Johnson’s Pioneer Portfolio and based at the University of New Mexico Health Sciences Center (UNMHSC), Project ECHO was developed by Sanjeev Arora, M.D., a hepatologist at UNMHSC and leading social innovator.

The ECHO model organizes community-based primary care clinicians into disease-specific knowledge networks that meet through weekly videoconferencing to present patient cases.  These “virtual grand rounds” are led by specialists at academic medical centers who train providers to provide specialized care, share best practices and co-manage complex chronic illness care for patients with the local care team. Under this model, primary care providers treat patients in their own communities – burdens on academic center capacity are reduced, poor access to care is eliminated  (patients are no longer limited by geography when seeking quality care), and the health care systems’ capacity to provide high quality care to more patients, sooner, is dramatically expanded.

In the NEJM study, patients with hepatitis C treated by primary care clinicians working through Project ECHO achieved results that were identical to patients treated by UNMHSC specialists.  The evaluation also showed that the ECHO model can reduce racial and ethnic disparities in treatment outcomes.

Project ECHO offers promise as a game-changer for how patients with complex illnesses are treated.  Dr. Arora describes the power of ECHO’s knowledge networks as a “force multiplier,” which “transforms the dynamics and the capacity of health care delivery and the spread of best practices.”

In an accompanying editorial, Thomas D. Sequist, M.D., associate professor of medicine and of health care policy at Harvard Medical School and Brigham and Women’s Hospital, said Project ECHO “represents an important step forward” in addressing barriers to accessing specialty care.  He notes that the NEJM study raises several issues, including the need for  adequate health information technology to implement the ECHO model successfully, the critical role of academic medical centers in supporting the model and the potential for meeting local community health care needs by extending the model to additional chronic diseases.

Sequist makes excellent points, and Project ECHO is already addressing them head-on.

The ECHO model harnesses communications technology to form truly collaborative provider partnerships that permit care in home communities.  It connects the wealth of knowledge and expertise housed at academic medical centers and the desire of primary care providers to do more for their patients.  And although the findings from theNEJM evaluation focus on hepatitis C, the Project ECHO model has spread to include asthma, mental illness, chronic pain, diabetes and cardiovascular risk reduction, high-risk pregnancy, HIV/AIDS, pediatric obesity, rheumatology and substance abuse.

ECHO represents a fundamental rethinking of how we use our limited supply of physicians, how we engage a full care team in chronic disease management, how we teach best practices and how we provide access to quality care for all.  We know we have physician shortages, an aging population and 32 million more Americans who are going to become insured in the coming years.  Dr. Arora has developed a disruptive innovation that addresses these challenges.

Through ECHO, providers – not just doctors, but nurses, nurse practitioners, physician assistants and community health workers – are teamed to work together to the benefit of patients who receive accessible, high quality care.

Isn’t that what we all are striving to deliver?

 

A New Hope? (…but what about that pesky death star?)

Picture a version of the Star Wars opening crawl:

A long time ago in a galaxy far, far away. . . . It is a period of enormous change and worry. The challenges are great. The status quo of poor health care quality and crushingly high costs is bearing down on the people—but that enemy is also under attack. A growing band of folk from all parts of the galaxy are attempting to bring every imaginable force—technology, market, government, people power—to the cause.  No one’s certain how it will all turn out… 

Now, cue ominously Darth Vader’s imperial march theme… (Fade out).

On June 9th I participated in the 2011 HHS/IOM Health Data Initiative Forum and self-styled “Data-Palooza”.  It was exciting.  Lots of dynamic leaders attended —from the government, the software development world and other industries—lots of Twitterati—social media personalities.  The place buzzed, literally.  (It was just missing the Tatooine bar music.)

I couldn’t help but flash back to last year’s markedly more freshman, inaugural meeting and compare.  The differences one year later were striking—even startling at times.  The obvious progress could make one pretty hopeful.  The vision of creating tools that use previously moribund federal (and other) data in unique ways to solve real problems is already bearing some remarkable fruit.

During the “Data-Palooza” plenary session, a parade of app developers demonstrated technology that mines and harnesses data for very cool, practical purposes.  High points: PatientsLikeMe;  Asthmapolis; and Multistate Foodborne Disease Outbreak Investigation System  (catchy name…).  The whiz bang, jaw dropping technology of these, and other, examples was impressive.  Last year, one really had to suspend to imagine how all this talk might actually have a major impact.  This year it could seem as if the vision isn’t keeping up with the technology.  In fact, perhaps we should be bolder, much bolder.

But, then, the enormity of the challenge brings one right back down to Earth—or rather—Endor.  In spite of the great hope all this vibrant creativity inspires, one wonders about the potential, even cumulatively, of these new app tools to make a dent on our high cost, low value care problems.  In the closing session, Tim O’Reilly pointedly noted that unless we find ways to move the embedded status quo health care incumbents aside just a bit—or at least find ways to open markets so that new approaches can take root, thrive, compete—all this work will be terrific—but ultimately not game changing.  The status quo will soldier on, as always.  In my daydream (read nightmare) I started worrying that these new technological wonders would, rather than triggering imperial defeat, instead end up being like Ewok wooden spears bouncing ineffectually off the usual huge armored imperial Walkers.

But all is not lost, of course.  As we know, the rebels did ultimately destroy the death star and defeat the empire.  They did it by working together and not relying on any single silver bullet (er, blaster) or group or approach.  The new technology on display last week that helps people practically use data to solve tough health and health care problems is incredibly important.  We just need to make sure that we’re also simultaneously doing all the other necessary things—like improving market information, adjusting payment to reward high value, waking up the sleeping health care consumer and supporting our Jedi health professionals—to allow innovation to do what it should be doing for us.  That is, we need to create the conditions that will allow creativity to help us rapidly achieve sustainable high value care focused intensely on and built entirely in partnership with the patient and consumer. 

Cue epilogue theme.  (Roll credits.)

 

Putting It All Together

I've just spent two stimulating days in DC, first going to the HHS/IOM Health Data Initiative meeting (aka "Datapalooza") and then at an HHS/Kaiser-sponsored Health Innovation Summit (see #futurehealth on Twitter).  What's clear is that this is an exciting time for innovation:  we're seeing companies pledging to enable patient downloads of their data (I heard "bluebutton" used as a verb for the first time); more releases of federal population-level data; and a gaggle of companies leveraging these data to offer terrific wellness apps.  The future's bright, indeed.

In thinking about how the pieces come together, the challenge seems a bit different now.  A few years ago, a key question was how to leverage the data in one's own personal health record to build apps that would help people take care of themselves.  An insight of the Pioneer-funded Project HealthDesign was that the data needed to drive those apps came not so much from the medical record but rather from the flow of life: observations of daily living (ODLs) about diet, exercise, sleep, mood, pain and more.  So apps needed a platform that would integrate both medical record data and this new set of patient-generated ODLs. 

Now, as I look around, I see multiple categories of data that one might want somehow integrated:  in addition to medical record data and ODLs, there's the population-level data that HHS and others are releasing (that can provide useful context and benchmarking), environmental data (mashing up your own geo-location data with data sets about the environmental factors associated with those locations), genomic data, and, of course, if you're the competitive type, comparative data from your social network.

What I've observed is many siloed apps.  I've got devices and web sites that either capture data (like the treadmill to the iPod to Nike+) or give me the opportunity to enter data (like putting my weight into Google Health), but nowhere that stores it all.  That doesn't bother me so much because at one level, where it's located isn't all that important as long as I'm confident that it's secure and reliable.  Missing are the abilities to a) present all of these disparately gathered data in some context that gives them meaning and b) to analyze these data to give me insights about patterns and correlations that would help me understand how to be healthier.  Where are the apps that will crawl across the different data stores and pull it all together? And what will they need to work? 

I'm curious to hear of companies that are trying to make this happen.  What are the best examples people have seen?

 

Self-Trackers Collaborate at 2011 Quantified Self Conference 2011

In a recent blog post, we told you about a group of pioneers who are making and using tools to track quantifiable qualities about their own bodies, habits, emotions and symptoms. They use this data to better understand how their decisions impact their health and other aspects of their lives.  

We had the pleasure of spending Memorial Day weekend with just about 400 of these self-trackers at the inaugural  Quantified Self Conference 2011. We also brought along a few invited guests to help us explore, collect and share ideas with those on the cutting edge of the self-tracking movement, and to provide us with some additional perspective as we seek to understand the potential self-tracking may have to transform health and health care.

You can read more about the conference and the potential from the perspective of one of our guests, Ethan Zuckerman with the Berkman Center for Internet & Society, who blogged prolifically throughout the weekend. Also, the San Jose Mercury News penned a great overview of the event. And the conversation is still going on at #QS2011.

We'll share more about our thoughts from the conference soon, but in the meantime, check out the first product to come out of our grant to Quantified Self and the Institute for the Future: The Complete Quantified Self Guide to Self-Tracking. This online resource guide, which is still currently in beta, aggregates all available tools for self-tracking. Each tool, app, and project is tagged, rated and reviewed by users, making it easy for beginners and self-tracking experts alike to harness the power of their own personal data to improve their lives.

We invite you to try out this new resource, or just take a closer look into how the Quantified Self community is tapping into the power of data to drive positive health outcomes. Then let us know your thoughts by leaving a comment or connecting with us on Twitter (@PioneerRWJF). Happy tracking.

 

Live HHS, IOM webcast tomorrow: Harnessing the Power of Data to Improve Health

Watch the Health Data Initiative Forum 2011 live webcast:  http://www.hhs.gov/live/

Tomorrow, Thursday, June 9 at 9 a.m. EDT, the Department of Health and Human Services and the Institute of Medicine will hold a day-long forum bringing together more than 500 people to explore how health data can create tools and applications to support more informed decision-making by consumers/patients, health care systems, and public health and community officials.

The discussion, “Harnessing the Power of Data to Improve Health,” will be shared via a free webcast. Tune in for an exciting announcement from our president and CEO, Risa Lavizzo-Mourey at 4:45 p.m. RWJF Senior Program Officer Michael Painter will be a panelist at on the “Health Data in the Era of Accountable Care” discussion taking place at 1 p.m. ET. 

Other featured presenters include, Aneesh Chopra, US Chief Technology Officer; Tim O'Reilly, O’Reilly Media; Matt Miller, NPR; Harvey Fineberg, IOM President and Todd Park, HHS Chief Technology Officer. Detail on the full agenda and featured speakers can be accessed here. You can also join in the discussion on twitter through the following hashtag: #healthapps. 

The event is part of the Health Data Initiative, a public-private collaboration that encourages innovators, entrepreneurs, startups, data geeks, community activists and policy makers to utilize health data to develop products and applications to raise awareness of health and health system performance and spark action to improve health. The RWJF/University of Wisconsin-funded County Health Rankings project is a good example of how data can be used to help people improve health every day.

• See the Agenda (The full day will be webcast live)

• Attend a Viewing Party near you

• Read an interview with Todd Park on NewPublicHealth about how government data is being liberated and leveraged to improve health.

 

Project ECHO: Transforming Health Care Education and Delivery

Findings from an evaluation of Project ECHO published June 1 online by the New England Journal of Medicine demonstrate that primary care providers can be trained via videoconferencing technology to manage complex chronic conditions formerly outside their expertise – in this case, hepatitis C – thus expanding their ability to treat very sick patients.

Project ECHO (Extension for Community Healthcare Outcomes) is a disruptive model for health care training and delivery that shows how health care providers everywhere can work collaboratively to provide better care. 

In the NEJM study, primary care providers across a variety of settings in New Mexico were able to treat – and even cure – patients with hepatitis C who previously couldn’t get treatment.  In fact, cure rates for patients treated through ECHO were the same as those for patients treated at a university medical center.  Project ECHO’s videoconferencing clinics also address asthma, mental illness, chronic pain, diabetes and cardiovascular risk reduction, high-risk pregnancy, HIV/AIDS, pediatric obesity, rheumatology and substance.

Risa Lavizzo-Mourey, M.D., M.B.A., president and CEO of the Robert Wood Johnson Foundation (RWJF), calls the model “the future of health care for those who aspire to excellence.” Project ECHO, she says, “demonstrates how health care providers everywhere can—and should—work collaboratively to provide better care.”

With the support of a three-year grant from RWJF’s Pioneer Portfolio, the ECHO model is spreading across the United States.  Replications of ECHO are already underway in Washington state and Chicago, and other potential sites are actively exploring the model.  Several government agencies have expressed strong interest in ECHO, as well.

To learn more about the study and Project ECHO, we encourage you to read some  of the excellent coverage on nextgov and HealthcareITNews.

 

 

How do we get health games to help millions of people?

By Brian Quinn, Pioneer team director

I attended the Games for Health Conference last week in Boston.  It was a great introduction to the gaming field and all of the work that’s being done in this space to try and improve healthy behaviors and increase healthy outcomes.  In addition to several of our Health Games Research grantees, I saw interesting presentations and demos on Kairos Labs’ livn.it, HopeLab’s Zamzee and Firsthand Technology’s game to promote better oral health habits among children.

One of the themes running throughout the conference is now that we’ve got all of this experience and evidence about how to use games to improve health, what are the next steps for the field?  That is, how does Games for Health get taken to scale to have an even broader impact?  The field has a lot of demonstrated success, energy and activity behind it, but health gamers face a unique challenge.  Successful health games need to simultaneously meet three requirements: 1) they need to make sure that the games are fun and entertaining; 2) they need to make sure that they have a real and measurable impact on health; and 3) they need to be marketable and revenue-generating.   Tackling all three goals simultaneously creates a unique set of challenges. The good news is that the field seems energized to take it on.

As we think about how to take the next step, the field needs to first consider what factors are necessary and sufficient for success.  Is it more research?  Is it better connections with providers?  Is it better inroads with non-gamers who would benefit from health games, such as seniors?  What can we learn from other fields?  What thoughts do you have?  How do we get health games to help millions of people?

 

 

Thoughts from Games for Health 2011: Sensors, Opportunity, Scale

Here are a few of my initial ideas from the 2011 Games for Health Conference, put on by Ben Sawyer and Beth Bryant:

1. The sensors are coming, the sensors are coming.  Sensors and the software to collect and analyze the data are on the verge of becoming retail products.  Green Goose is one company hoping to grab this market.  What does it mean for health games?  It means that soon we will be able to turn lots of things into data collection and data input devices.  So think about games that use household objects instead of, say, a wii remote.  You could turn your house into the playing field for a game.

2. Better seeds and more fertile ground.  The quality of health games—the game mechanics, the theory underlying design is getting better.  At the same time, the context in which we can use games to improve health is expanding.  We can now embed games in social networks, so think about linking someone’s facebook friends in with their game efforts to lose weight or manage their diabetes.

3. There’s likely more than one way for a game that has an impact at scale.  When we got into this space at RWJF, we were thinking about games as therapeutic interventions for individuals—one person with one game addressing one condition that a lot of individuals have.  But building off item 2 above, given what Nicholas Christakis and James Fowler are showing with their research on transmission of health behaviors through social networks, you could design a health game that requires social networks—teams—to play.  Still another level up is a game that could target a health problem that was a function of a system problem.  That is, a game that targeted a health problem that resulted not from someone’s genetics, but from set of processes and systems that are outside of any one individual’s control.  Imagine a game that’s designed to get some producers to make healthier food.