Pioneering Ideas

Engineering Errors Out of Health Care

In my first month as a new communications associate with the Foundation’s Pioneer team, one of the many glaring items on my task list has been to gain a solid working understanding of the power of disruptive innovation and what it takes to achieve it. While this may take a while, thankfully Susan Promislo has given me a stack of project briefs and proposals that illustrate different aspects of this equation in a pretty straightforward way.

 

In one intriguing new effort, a team led by Peter Pronovost– professor of anesthesiology and critical care medicine at Johns Hopkins and renowned patient safety expert – is looking to a collaborative model that has yielded huge improvements in commercial aviation safety, and testing whether the application of a similar method could do the same for hospital patients.

Hospitals have engaged in noteworthy work to improve quality and safety, but other approaches are needed to accelerate improvement. Pronovost’s project is honing in on a public/private partnership model that has been highly successful in preventing aviation deaths and disasters.

 

Between 1995 and 2003, 2,261 people died in “controlled flight into terrain” (CFIT) plane crashes. Based on recommendations from the White House and Congress, the formation of Commercial Aviation Safety Teams (CAST) has drawn on the knowledge of key leaders from all sides of aviation – major manufacturers and airlines to the FAA and DOD. One of CAST’s first major recommendations led to the commercial adoption of a “terrain awareness and warning system” for all airplanes registered in the United States, and an altitude warning system for ground radar. In 2004 there were no CFIT airplane crashes, and all such accidents since then have involved planes without the warning system. 

 

From Health 2.0: Re-Imagining the Doctor-Patient Relationship

Several themes and memes emerged from the Health 2.0/Information Therapy conference over the last several days. One theme is the need to re-imagine the relationship between patient and doctor in order to prepare for a Health 2.0 world. In the past, doctors were the primary, if not the only, source of health information. Doctors defined what was relevant to patients' health (e.g. blood pressure, blood tests, height and weight), and they were responsible for collecting it whenever the patient came to their office. In the Health 2.0 world, patients seek information that is relevant to them ("given the pollen count today, do I need to take an extra dose of my allergy medication?"). This new dynamic views patients as sources of health-relevant information, much of which is collected outside of the clinical setting. Patients are no longer passive subjects, but "info-mediaries," as some attendees called them, in their own right.

 

Paul Wallace of Kaiser Permanente  and the Center for Information Therapy and Jamie Heywood of PatientsLikeMe debated the question during the session entitled "What is the Future Role of the Doctor?". Certain ideas and phrases -- in other words, "memes" -- filtered throughout the discussion, shaping the participants' efforts to rethink the relationship between patient, doctor and data. In order to get their minds around what this new relationship might look like, the panelists and members of the audience employed a few metaphors. These analogies quickly morphed into memes, and conference attendees referred back to them to summarize and simplify their perspective on the future relationship between doctor and patient. Here's a sampling:

1. Football: The doctor is the quarterback. She is the leader of a team, calling the shots. Perhaps she gets direction from the care coordinator (the coach). Where is the patient in this model? The patient is the all-important ball -- the object of coordination among different health care providers as they move it up the field.

2. Banking: The health care system is the banking system. Patients can access and control their health data via an online health management portfolio. The portfolio includes myriad tools, geared to different types of patients. In this model, the doctor is like a financial planner - she helps patients navigate the system.

3. Organization: The patient is the CEO of her body, and her doctor is a hired consultant.

While similar in that they place increased importance on the patient, these metaphors also reveal very different visions for the future role of the doctor.

Reporting Live from Health 2.0

I arrived at the Health 2.0 Conference bright and early this morning. At the urging of this very tech-savvy community, I joined Twitter and issued my first-ever Tweet. (For complete coverage of the conference, check out the 600 + following at #heatlh2con). Next, I popped into the Health2.0 Accelerator pre-conference meeting, where (among other things), we learned about how the Accelerator and Project HealthDesign will collaborate going forward. Afterwards, I spent some time fielding questions about the next round of Project HealthDesign at our expo booth. All before the conference officially kicked off at 1:30pm!

The first session initiated the debate over whether Health 2.0 and Information Therapy (Ix) are in tension or in synergy. We heard from Don Kemper, CEO of Healthwise, that Health 2.0 and Ix are the yin and the yang of translating data into information, information into knowledge, and knowledge in to behavior change. Matthew Holt, founder of Health 2.0, countered that a “shared understanding is not necessarily enough to support a marriage between Health 2.0 and Ix.” Given the candid format and the diversity of the crowd here, we can expect more “great debates” to follow.

Check back for reflections on tomorrow’s sessions, including “The Future Role of the Doctor,” and “User-Generated content vs. Expert: What’s the best approach to Knowledge Creation?”

The Landscape of Health, Green, and Everything in Between

Last May we introduced grantee Health Care Without Harm in a feature on Gary Cohen, Director of HCWH, as part of our “Conversations with Pioneer” series. You can also check out this new short video highlighting Health Care Without Harm and its mission to build the evidence for green interventions in the health care system.

The video also illustrates what is truly pioneering about Health Care Without Harm: their vision for sustainable improvements that also result in direct benefits to patient health and safety. For example, substituting hospital disinfectants for “greener cleaners” can arguably improve the long-term health of the population through indirect environmental effects. But these environmental advantages accrue incrementally over long stretches of time. 

Health Care Without Harm sees the momentum behind the Green Movement as the catalyst for direct and immediate improvements for patients and nurses. In the case of greener cleaners, this could mean reduced rates of asthma and other respiratory illnesses for patients, nurses, and hospital staff.

The Pioneer Team has a keen interest in this concept of the “triple win” – for the planet, long-term population health, and direct benefits to patient health. We recently conducted a field-mapping exercise to explore the intersection between Green and Health. Our purpose was to uncover similarly innovative and effective projects, and to examine the contours of the intersection itself. This discussion raised some interesting questions. Each team member had their own take, and now we would like to hear from you:

1. Is the union of green and health just a fad? The Green Movement has expanded into many new fields in recent years. Is its foray into health and health care substantial, authentic, and pioneering, or is it just an outgrowth of a short-lived trend?

2. Creating real-time benefits for patients through green initiatives is a key component of the “triple-win”. What ideas or opportunities for improving patient outcomes are out there for pioneers working in this space?

3. Broadly speaking, what does the common path of Green and Health look like for the foreseeable future?

We look forward to receiving and reading your comments.

Power Meters for Health?

Google has established itself as a player to watch in many arenas, including the field of personal health records. We’ve written about Google Health on this blog before, but today I’d like to discuss another innovation by Google that may have significant import for anyone working on personal health records.

Google PowerMeter is a beta (or trial) program underway at Google.Org, the company’s philanthropic arm. It is built around the premise that one component of the energy crisis is a lack of feedback connecting decisions and energy costs. Consumers heat their homes, use appliances, turn lights on and off, and at the end of the month they get an energy bill. Not only are energy bills often confusing and opaque, they do not contain any information about what contributes to fluctuations (or escalations) in cost. According to Google, this lack of transparency presents an opportunity to change behavior through awareness and information.

How much electricity does it take to power my vacuum? How much will I save if I lower the thermostat one degree? Google PowerMeter aims to deliver answers to questions like these to consumers in near real-time, coupled with suggestions for how to conserve energy and save money. Google also plans to analyze this data for trends and insights – such as whether running the dishwasher at 2am as opposed to 7pm could reduce energy consumption and lead to cost savings.

Does any of this sound familiar? Much of the impetus behind Project HealthDesign’s work on personal health records is that decisions about health-related behavior often rely on delayed and disjointed feedback (e.g. determining the relationship between exercise, diet, and chronic pain). Google PowerMeter’s efforts to decrease energy consumption through awareness and instantaneous feedback parallel Project HealthDesign’s key objective: empowering patients to make healthier choices by providing them with tools to visualize, interpret and manage their health information.

 

The next phase of Project HealthDesign funding will explore how health data from everyday life—observations such as diet, sleep, exercise levels, pain episodes and even moods—can be collected, interpreted and integrated into the clinical care process.

RWJF's Expanding Social Media Presence

You can now follow new content from the Robert Wood Johnson Foundation via multiple social media platforms.  We've launched a new YouTube destination, where you'll find more than 30 video stories on the work of the Foundation and its grantees.  The featured story posted now is Pioneer's own Health Care Without Harm-- check out the ways in which Boston's Brigham & Women's Hospital is adopting more environmentally sustainable practices that have meaningful benefits in terms of worker and patient health and safety.  Lots more will be coming online from our Broadcast Health Series and other video efforts.

RWJF also has an active Twitter stream that just topped 600 followers - it issues near-daily updates on reports, announcements and new developments happening across the Foundation and its universe of grantees and interest areas.  Click here to sign up.

And, we're happy to announce that Pioneering Ideas now has a sibling with the launch of The User's Guide to the Health Reform Galaxy, RWJF's blog providing insights on key things driving today's reform debate.  The blog is part of a dedicated section of our Web site that goes in depth on issues that shape reform prospects: health care coverage, improving the quality of care, strengthening public health, etc.  Interesting posts have been published on health IT, the impact of the nursing shortage, social determinants of health and so on, and you'll hear from a range of staff and grantee voices.  Check it out and take us up on our sincere and open invitation to add your thoughts to the conversation. 

Nortin Hadler Lecture - Personal/Social/Policy Barriers to Wellness When it Comes to Low Back Pain

Next up, the Penn Positive Health Lecture Series features Dr. Nortin Hadler speaking on "Backbone: Personal, Social and Policy Consequences of Low Back Pain."  Nortin Hadler M.D., MACP, FACR, FACOEM, is professor of medicine and microbiology/immunology at the University of North Carolina at Chapel Hill and attending rheumatologist at UNC Hospitals. Having analyzed the "illness of work incapacity," his most recent book is "Worried Sick: A Prescription for Health in an Overtreated America."  

The lecture will consider backache as a human predicament, a profound social problem, a medical issue, and a vexing public policy challenge.  Basing his critique on an analysis of the most current medical literature as well as his clinical experience, Hadler argues that regional back pain is overly medicalized by doctors, surgeons and alternative therapists who purvey various treatment regimens. Furthermore, the design of "health," workers' compensation, and disability insurance schemes thwarts getting well. For the past half-century, says Hadler, back pain and back pain-related disability have exacted a huge toll on modern societies, in terms of pain, suffering, and financial cost.

Here are details:

Date - Wed., April 22, 2009
Time - 12:00-1:00 p.m.
Location - Dunlop Auditorium, which is in Stemmler Hall at the University of Pennsylvania School of Medicine, Philadelphia
Free and Open to the Public

2nd-Round Project HealthDesign CFP Targets "Observations of Daily Living"

RWJF launched Project HealthDesign in 2006 to stimulate innovation in the development of personal health record (PHR) systems by transforming the concept of PHRs as data collection tools to PHRs as a foundation for action and improved health decision-making.

 

The first round of funding resulted in a range of applications that addressed self-management tasks ranging from a cell phone-enabled medication-management system to a personal digital assistant that collects and supports self-reported pain and activity data and provides a fuller picture of patients’ everyday chronic pain experiences.

 

In the second round, RWJF will award up to $2.4 million in grants to as many as five grantee teams for 24-month demonstration projects that will assess and test how “observations of daily living” — data on experiences such as meals, sleep, exercise, pain episodes and even moods — can be collected and interpreted such that patients can take action to better manage their health and clinicians can integrate new insights into clinical-care processes. 

 

Brief proposals are due on June 3.

 

Lygeia Ricciardi provides more details over on the Project HealthDesign blog.

An App Store for Your EHR? Why Not?

Up on the Project HealthDesign blog, Lygeia Ricciardi calls attention to Ken Mandl and Zak Kohane’s perspective article in the New England Journal on the need for a flexible information infrastructure in health care.  In the article, Mandl and Kohane offer a simple prescription – that the infrastructure be designed as a platform upon which many competitive, substitutable applications can be offered.  They cite the Apple iPhone as an example where this has worked successfully:

 

“The platform separates the system from the functionality provided by the applications. And the applications are substitutable: a consumer can download a calendar reminder system, reject it, and then download another one. The consumer is committed to the platform, but the applications compete on value and cost.”

 

The idea of separating the infrastructure from the applications has been vital to innovation in the computer industry and was the key to our approach on Project HealthDesign (see my post introducing the program).  We were focused on personal health records, but the notion of applying the idea to the design of the infrastructure that supports the business of health care is getting some attention.  Peter Neupert, who leads Microsoft’s health solutions business, has been calling for this, which should be no surprise since Microsoft knows full well the value of a software platform.  The National Research Council (NRC) released a report in January on Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions, in which they also recommend that health care institutions “insist that vendors supply IT that permits the separation of data from applications.” (Disclosure:  Robert Wood Johnson Foundation was a partial funder of the report).

 

This discussion comes at a critical time for two reasons.  First, the American Recovery and Reinvestment Act includes approximately $19 billion in investments in health IT, so to the extent that the incentives work, we’ll see a tremendous amount of investment in health IT over the next several years.  Second, and perhaps even more importantly, we are on the brink of health reform, which suggests that health care institutions need to be poised for changes in the ways that they work.  Mandl and Kohane make the point that macro trends such as the aging population and work force shortages will put pressure on the system to adapt and therefore the information infrastructure needs to be sufficiently flexible.  The NRC committee, led by Bill Stead and shepherded by Herb Lin, noted that

 

“IT is often implemented in systems in a monolithic fashion that makes even small changes hard to introduce ...IT applications appear designed largely to automate tasks or business processes”

 

and recommended that