Pioneering Ideas

Brainstorming TECH Conference, Day Two

Day two of the Fortune Magazine Brainstorming TECH conference started with an unforeseen development. Jeff Bezos, president of Amazon.com, and I have something in common: we both choose to attend the Future of Gaming roundtable. The roundtable brought together about 20 people, including folks from Electronic Arts, Phillip Rosendale, president of Linden Labs (creator of Second Life) and Bezos to discuss the future of gaming. I wonder if Amazon will get into the gaming business? Imagine, you could buy your book while you game (and maybe it could even be a game for health…that would be very interesting).

The most compelling part of the day centered on the social web. Sheryl Sandberg, COO of Facebook.com, spoke about the way Facebook is propelling the social web forward. If Marc Benioff is correct, and the future of the web moves from collaboration to innovation (see my first post), creating a place for end users to connect will be invaluable. What I find so powerful and dynamic about Facebook is its ability to bring groups together around a particular issue or interest, and recently I’ve noticed Facebook’s role in bringing individuals together for social change. People are able to talk about what is important to them: from politics, to media, to being green.

Could health care advocates work together via Facebook for health care coverage, public health, and better quality of care? How could we use Facebook, and sites like Facebook, to support innovation in health and health care?

Here’s one possibility: Esther Dyson, who blogs on the Huffington Post, mentioned during a breakfast roundtable about web and relationships that she was going to make her personal health record public. This led me to think about whether people could place their personal health records on Facebook and friend (with certain privileges) their health providers.

A funny tidbit, when the audience was asked who had a Facebook page, almost everyone raised their hands. It looks like leaders in technology see the value in Facebook and are trying to integrate it into the success of their businesses. Is the health care industry next?

New RWJF Podcast Series Looks at the Power of Personal Health Records

RWJF's Larry Blumenthal, a Senior Communications Officer here at the Foundation, tells us:

Ralf Beach is an unlikely poster boy. At 70-years-old, he has survived a heart attack and quadruple by-pass surgery, has chronic lung disease and insulin dependent diabetes. He is also an acknowledged hypochondriac. Yet he is a shining example of the potential for bringing patient’s medical records online in the form of personal health records (PHRs).

As part of an experiment by researchers at the University of Washington, Beach is managing his diabetes and his health online. From an island in Puget Sound, he has access to his entire medical record. He delivers his blood sugar meter readings digitally – by-passing a three-hour trip to Seattle - and communicates with his doctors’ offices electronically. He’s a happy user of his PHR.

Ralf Beach is just one example of the potential for PHRs examined in a recently launched podcast series by the Foundation.

Advocates say PHRs could dramatically improve health care delivery, decrease medical costs and make it easier for all of us to manage our health over the course of our lives. With more than 130 million Americans – nearly half of the U.S. population – living with chronic conditions, the potential is obvious. To tap that potential, RWJF has been supporting, along with the California HealthCare Foundation, Project Health Design. Project Health Design has been working with nine multidisciplinary teams that are designing PHR-driven tools and applications that put patients’ needs and priorities first.

Of course, there are some challenges to overcome before PHRs reach that potential. There are concerns that PHRs shift too much of the burden of health care onto the patient. There are technology hurdles. Currently, there is no universal language or data format for health care information. Perhaps the biggest issue is concerns over privacy.

To delve into the potential — and the potential obstacles—RWJF worked with WGBH in Boston to produce this four-part series and the first two installments are up on the Foundation website, here.  The first segment features discussions with Project HealthDesign Director Patti Brennan, Project HealthDesign grantee James Ralston of the University of Washington, David Lansky of the Markle Foundation and Deborah Peel, founder of Patient Privacy Rights. You’ll even hear from Ralf Beach himself.

Segment 2 looks at some PHR work already underway at the Palo Alto Medical Foundation and Kaiser Permanente. The last two segments will be posted in the coming weeks; segment three digs into what Microsoft, Google, RevolutionHealth and others in private industry are working on. And the fourth and final segment features a roundtable discussion that wrestles with the intriguing potential of PHRs and the challenges ahead in implementing them. Please take a listen to this series and let us know what you think.

The Road to Innovation (It's All About the End User)

To say that I feel like a fish out of water would be the understatement of the week. I am sitting here at my first Fortune Magazine Brainstorming TECH conference, feeling a bit out of place, but hearing themes that resonate strongly with me and how we approach our work at RWJF. I might be one of five folks from nonprofits or foundations here (perhaps a bit of an overstatement, but not much so), but the conversation on the first day of this meeting directly relates to our work on the Pioneer team. The major theme this morning: how do we incorporate and work with the end user to create a better product? It is all about the end user. That is how you get to innovation.

The meeting kicked off with a conversation about the evolution of the web. Marc Benioff, president of salesforce.com, Inc., gave his perspective on how the internet has evolved over the years: transact (where it began), collaborate (where we are now), and innovate (where we are heading). We are moving from collaboration (web 2.0) to using the internet as a platform for innovation. The critical element for this transformation is the evolving role of the end user.

The speaker that really brought the idea home was Brad Smith, president of Intuit (developers of Turbo Tax and Quicken), who made me think about how his conceptualization of the end user could translate to the world of philanthropy and health and health care. He spoke to the questions that he asks himself as he thinks about the future of his company:

• Are we paying our employees today to do work that our customers could do for free?
• Are we sitting on the gold mind of data (end user expertise)?
• Could we create more value for the end user?

So let’s think about Pioneer’s work in prize philanthropy and our various Changemakers competitions that others and I have spoken of before.  What are we doing with these if not having our “customers” add their expertise to ideas that could benefit from RWJF’s support? The same is true for Ruckus Nation and much of Project Health Design.  (BTW, speaking of Intuit, it’s getting into the health management personal health record business with quickenhealth.  You trust your taxes to them, would you trust your personal health record?)

Changemakers, with its open source collaborative competition model, brings the end user in to every part of the competition experience: the judges and the applicants are end users and, therefore, the end user has a voice and a platform to put forth ideas that can address health and health care problems and judge ideas that have been set forth. In Ruckus Nation, the end user was the center of a competition for ideas that could get youth more physically active. The ideas sourced through Ruckus Nation came from end users, youth! And finally, Project Health Design incorporates the experiences, needs, and concerns of patients to inform project development for personal health record applications.

So even though I started feeling like a fish out of water, by the end of the first day I had found my place. There are transferable lessons from how the for-profit world thinks about end users and how Pioneer thinks about transforming health and health care.

Here’s the big question, is health care ready to bring the end user into the equation? If so, why and if not, what would help the integration of the end user into shaping health and health care?

More to come… In my next post I will let you know what Jeff Bezos, president of Amazon.com, and I have in common.

Opportunities for Disruption? A Forum on Disruptive Innovation in Health Care

The Innosight Institute, the non-profit think tank founded by Harvard B-School Professor Clayton Christensen, put on a conference last week called, A Forum on Disruptive Innovation in Healthcare.

Prof. Christensen developed the theory of disruptive innovation and is currently working on a book on the subject. One of his co-authors is Jason Hwang, MD, MBA, who served as a judge for the Disruptive Innovations competition Pioneer sponsored through Changemakers. Those of us at the meeting were treated to a glimpse of the still-being-drafted book, which was pretty interesting. I’m keen to read the final version.

Elliott Fisher, MD, of Dartmouth Atlas fame, set the stage for the forum by taking us on a flyover of "everything that’s wrong with health care in America." Fisher then presented seven causes, which I thought was a pretty succinct list:

1. There’s a lack of clarity in the US on the aim of health care;
2. There’s inadequate evidence to evaluate the effectiveness of both biologically-targeted interventions and delivery systems. Fisher asserted that the current discussions around comparative effectiveness were not paying nearly enough attention to the effectiveness of different types of delivery systems;
3. There’s a public assumption that more care is better care (Fisher has published results demonstrating that more care can actually lead to poorer outcomes);
4. Medicine is practiced (and taught) in a model of professional autonomy and authority that is outdated;
5. There’s a lack of accountability for capacity, quality and costs;
6. Current quality measures reinforce fragmentation, in that they’re too focused on performance within individual care settings and don’t track quality across the continuum of care; and
7. Payment incentives are flawed.

Wow.

Another big chunk of discussion focused on the development of more precise diagnostic tests, how they will drive the move to personalized medicine and disrupt the current paradigm of “trial and error medicine,” according to speaker Mara Aspinall, former president of Genzyme Genetics, which provides diagnostic services. As example of new precision, Aspinall noted that we can now diagnose 38 different types of leukemia and 50 different types of lymphoma. That increase in diagnostic precision tracks with the increase in five-year survival rates.

Looked at through the lens of Disruptive Innovation, what you see is a technological innovation—increased diagnostic precision—commoditizes expertise. The growing development and use of more precise diagnostics moves us closer to rules-based—and evidence-based—practice.

More From Gary Cohen: Challenges Now, and Hopes for the Future

Yesterday's discussion with Gary Cohen introduced us to Health Care Without Harm and the recent achievements of the green hospital movement in the United States. Today, Cohen speaks about green health care internationally, outlines the challenges facing the green hospital movement, and offers his both short- and long-term predictions for the movement's future.

Health Care Without Harm is part of a global movement; what lessons do you think the US health care system can learn from the international community?
Right now we’re learning a lot from Europe. A typical Northern European hospital uses half as much energy as a typical US hospital. That’s a very significant issue, because as we are entering into a period of global climate crises and reducing reliance on fossil fuels for health care is a public health imperative (this sentence needs better structure). There are very direct links between a hospital’s energy sources and community health; we have evidence that shows if a hospital is reliant on coal fire power plants, there will be increases in asthma, respiratory problems and increased hospital visits. This also offers the opportunity to move to renewable sources of energy.

Another reason hospitals in Northern Europe are using less energy is because of hospital room ventilation. In a typical US hospital the ventilation duct is at the top of the room and pushes air into the hospital, into the patient room, and it circulates out and then it goes back up. So it actually circulates a lot of the germs, and it goes against gravity. In Europe, the intake of the ventilation of the room is at the sidewall level. And so the air comes up and then goes out the top. As a result, you need 30 percent less energy to run such a system. And now there’s research to evaluate whether this type of ventilation actually decreases infection rates in the hospital. Instead of recirculating the air and reinfecting people, the Northern European systems draw the air up and out the top. If changing the ventilation in hospital design reduces infection and reduces energy it is a big win both for patients and for the environment.

What are the biggest barriers and challenges facing the green hospital movement in the US?
The health care systems that have made the most comprehensive changes always have buy-in from the executive level. Once the CEO says that we’re going to make this change happen, then the rest of the system gets in alignment and people are given a mandate to implement change, whether it has to do with their built environment or their purchasing or their operations.

Where we don’t have that high-level buy-in, we might have a lot of champions, either nurses or facilities managers or environmental coordinators. Their efforts are critical, but they are swimming upstream, against the priorities of the system. And while those champions may be doing great things in their small corner of the hospital, it’s hard, though not impossible, to diffuse those changes system-wide. The Luminary Project of HCWH has seen the power of nurses as change agents and is telling the stories of nurses who are working to human health by addressing environmental health.

Cost analysis is another barrier. Where we’ve been able to showsome intervention saves money or is cost neutral, it’s been very easy to make the case for green solutions. The places where it’s very cost competitive is around reducing waste, reducing water use and reducing energy use. There are immediate positive financial impacts and environmental impacts with those kind of interventions. We’re also in the midst of developing a business case around sustainable health care building. We are seeing that there’s quite a small differential up front for some of the pilot hospitals, in the neighborhood of 1-2%. But because it’s going to save over time we’re now trying to measure how quickly that investment’s recouped.

The medical education system in the U.S. does not address the links between environmental exposures and disease or health impacts, and this continues to be a significant barrier for our work. A typical doctor may get four hours of environmental education in four years, and that will include issues around smoking and diet. And yet the science suggests that there are incredibly strong links between a very specific set of illnesses and diseases and very specific set of environmental exposures. The science is way ahead of the medical education, and that’s a real impediment to the transformation.

Conversations with Pioneers: Gary Cohen of Health Care Without Harm

Last month, we kicked off Conversations with Pioneers, a series of interviews with Pioneer grantees. The series continues this week with an interview with Gary Cohen (photo at left), executive director of Health Care Without Harm.

Health Care Without Harm hosted its annual conference, Clean Med, last month and Susan Promislo and Theresa Kanter both posted updates from the conference. Working to drive environmental sustainability in health care, Health Care Without Harm has been on the forefront of efforts to accelerate the development, use, and diffusion of environmentally preferable products and practices in the health care system.

Abbey Cofsky spoke with Cohen recently about the organization and its work:

Health Care Without Harm’s mission is to transform the health care sector --why have you chosen to focus your efforts on the health care industry?

We’ve chosen the health care industry for multiple reasons. Increasingly it’s clear that in order to prevent diseases in the general public, we need to understand the environmental links to those diseases and do whatever we can to reduce environmental exposures. And of all the sectors of society who should understand this growing science, it should be the health care sector --they’re in the healing business. And they have a responsibility to clean up their own house. We think that one very important objective for the 21st century is ensuring health care facilities operate with the least amount of environmental exposure as possible, and to move to a model of a high-performance healing environment – an environment that actually promotes healing, as opposed to contributing to further disease or exposure or infection.

The second important reason to focus on the health care sector is because it’s such a big part of the economy. Health care is 16 percent of the gross domestic product and quickly increasing as the baby boomers get older. Transforming the way that hospitals build, buy and operate their facilities will have a broad transformative effect on the economy. That’s really important, because we need our general economy to move away from oil and chemicals made from oil. We’re approaching the end of the petrochemical age, and we need the health care sector to be a leading force in ushering in a new economy that’s based on green materials, green chemistry and green energy to promote healing and sustainability on the planet.

The third big reason that we are focusing on health care is because our society trusts health care leaders. And so by having nurses and doctors and hospital leaders serve as leading advocates for the larger transformation we need in our society, they’ll be increasingly important social change agents.

How have hospitals begun to adopt environmental sustainable changes and what successes have you seen?

When we started Health Care Without Harm in the mid-‘90s there were over 4,000 medical waste incinerators in the country. And the Environmental Protection Agency was reporting that medical waste incinerators were the largest source of dioxin emissions in the country. Dioxin is probably the most dangerous human-made chemical with known links to cancer, neurological damage, immune suppression, reproductive problems, diabetes and a whole host of other problems. In the last 10 years almost all of those incinerators have been shut down -- there are probably less than a hundred medical incinerators left in America today. Many hospitals have reduced their waste generation significantly and moved towards safer treatment technologies for their waste, and they’ve saved money in the process.

Mercury is another great success today. When we started Health Care Without Harm, the health care sector was seen as responsible for 10 percent of all mercury air emissions and a significant contributor to mercury in wastewater. And that was because hospitals were dumping mercury fixatives down the drain. In the last 12 years or so, more than 5,000 hospitals in the country have started to move dramatically toward mercury elimination across the board. All the major pharmacy chains in the country have stopped selling mercury thermometers. The European Union recently banned mercury thermometers, and they’re looking to do the same on mercury blood pressure devices. We are now working with the World Health Organization and the United Nations to support a global ban on mercury-based medical products. This is an example that exemplifies how it starts with a simple effort. This mercury initiative began with a simple thermometer exchange and education day at Beth Israel Hospital in Boston. We paid for a couple of hundred digital thermometers, and told hospital administrators that they should be educating people around mercury. We gave them replacement thermometers to share with their staff and encouraged them to educate staff about the dangers of dumping mercury. From that moment, the initiative mushroomed and cities across the country started to ban mercury thermometers and started instituting their own exchange programs.

Save the Date - New Frontiers in Personal Health Records

Mark your calendar now -- we're pleased to announce that details have been set for "New Frontiers in Personal Health Records: A Report Out from Project HealthDesign and Forum on Next-Generation PHRs."  Here's the logistical info:

Date: September 17, 2008

Time: 8:00-5:00

Location: Westin Washington, DC City Center

RSVP: Erica Garland, GYMR Public Relations

We hope you can join us to explore the vast potential for personal health records (PHRs) and related technologies to help consumers take charge of their health like never before. The event also provides the opportunity to showcase the array of next-generation, user-centered PHR applications developed by grantees of Pioneer's Project HealthDesign program.

Project HealthDesign grantees have pushed PHRs far beyond just providing consumers with access to their health information...these PHR tools are designed to meet people's varied and specific health needs, interpreting their health data and delivering customized feedback that can guide their daily health decisions. In addition to highlighting what Project HealthDesign has learned in the process of developing these tools, the Showcase will feature panels and discussions with leading health IT pioneers, policy makers and industry experts. At the event, you will have the opportunity to:

* Participate in an open dialogue about the prototypes and the future of PHRs, including lessons learned from user-centered design and policy directions to support continued growth and innovation in the PHR arena.
 
*  Engage in discussions with key experts on a variety of topics, including future directions that key industry players may take in this arena.

* Hear lessons coming out of Project HealthDesign and how they might influence emerging PHR services.

* See the prototypes that Project HealthDesign innovators developed to demonstrate the practical applications of PHRs to improve people's daily health.

* Learn about the functional requirements and common platform components developed by Project HealthDesign and explore how they could have broad application across the PHR field.

Please spread the word to others that may have interest in this event - we'll be posting back regularly with updates on the agenda and speakers.  We hope to see you in September!