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Philip K. Howard, Founder & Chair of Common Good – a Pioneer Grantee – gave an engaging talk at TED 2010 on four ways to simplify the legal system. We encourage you to listen to the talk and then pop back over here and let us know what you think about his ideas.
You can also read more from Howard on RWJF’s Health Reform Galaxy Blog.
Since 2006, sepsis and pneumonia, two common conditions caused by largely preventable hospital-acquired infections (HAIs), have killed 48,000 patients and have cost the health care system a staggering $8.1 billion – this according to a new study in Archives of Internal Medicine by researchers at Extending the Cure.
To put this in perspective: the death toll from avoidable pneumonia and sepsis is higher than that from traffic fatalities. It's more than three times higher than that for AIDS, and roughly twice as much as annual deaths from firearms.
The study is the largest nationally representative study to date – Ramanan Laxminarayan, Anup Malani and colleagues analyzed 69 million discharge records from hospitals in 40 states – and the findings are generating a lot of buzz. Patients who developed sepsis after surgery stayed in the hospital 11 days longer and the infections cost an extra $33,000 to treat per person – what’s worse is nearly 20 percent of those patients died as a result of the infection. While patients who developed pneumonia after surgery stayed in the hospital an extra 14 days, cost an extra $46,000 per person to treat and 11 percent died as a result of the infection.
HAIs frequently are caused by microbes that defy treatment with common antibiotics. Co-author Malani said, “These superbugs are increasingly difficult to treat and, in some cases, trigger infections that ultimately cause the body’s organs to shut down”.
Another interesting implication is that Medicare’s decision to not reimburse hospitals by preventable so-called “never” events is not having much of an impact when it comes to HAIs. In a case of misaligned incentives, the study suggests that penalties may not be a sufficient deterrent to motivate stronger infection control if hospitals knowingly misclassify infections to avoid penalties. It also may be that problems documenting the infections prevent adequate enforcement. Even if the Medicare rules were fully effective, though, it wouldn’t matter…according to the NPR blog, “in an analysis that's not in the published paper, the authors looked at how many deaths could be averted each year…The answer: Fewer than 100.”
Check out other coverage from ABC News, the Wall Street Journal Health Blog and NPR’s Marketplace.
If you are interested in seeing what else Extending the Cure is working on, make sure to check out their blog and twitter account.George Whitesides, a chemist and the Flowers University Professor at Harvard, gave an elegant talk on simplicity at TED. Whitesides asserted that simple things have four qualities:
They are predictable and reliable; They are cheap; They have a high value-to-cost ratio; and They are stackable, that is you can combine them to build more complicated things.
The lowly transistor is a simple thing. It’s also the building block of modern electronic devices. Transistors enabled computers which enabled the internet which enabled, well, you get the picture. The point here is that simple things have emergent properties, that is, they enable complex systems to arise out of simple interactions. The next point is that you can never predict what results or complex systems will emerge when you stack a bunch of simple things together, snowflakes included.
What he’s talking about, clearly, are simple physical things. But it led me to two thought experiments I’d like some help with…the first: identify two or three simple things that could be combined to create some novel product, service, or experience that would significantly improve health and health care.
The second: can you deconstruct a complex aspect of our health care system and identify its most simple parts as a first step in re-thinking how things get done?
Being at TED last week led to some interesting conversations about data, health and the progress of health IT. One conversation in particular stuck with me – a computer industry executive pointed out that the pace of innovation in the computer industry is orders of magnitude faster than in the health IT industry. Orders of magnitude. As in 10, 100, 1000 times faster. A bold claim. But then think about some of the advancements shown at TED:
- Microsoft’s integration of Photosynth and Sea Dragon technologies to create a Virtual Earth experience where you can now do a street level fly through of a city neighborhood and see the facades of the buildings around you. And where there are web cams, seamlessly integrate live video into the view.
- A voyage through the Digital Universe, which is about what it sounds like – extending the Virtual Earth/Google Earth experience to all known objects in the universe.
- Google’s demo of an image recognition feature where the presenter took a photo of a postcard of a hotel with the Nexus One and Google (the omniscient Google – not the company) returned the name and address of the hotel. And speech-to-speech translation through the Nexus One as well.
- John Underkoffler’s prototype interface in which people can gesture toward a screen to “pick up” a document, then walk across the room and drop the document onto the screen of a different computer.
When you step back and think about it, it’s truly extraordinary. The gap between sci-fi and ship dates is closing rapidly. Magic abounds.
So where are we with health IT? Progress to be sure. Pockets of excellence. But as best as I can tell, we’re still struggling with threshold challenges around data exchange, interface design, workflow and deployment at scale. I’m still processing all this and I’m probably missing something, so I’d really like to hear from people on this question – is the pace of innovation in health IT really that much slower than in the computer and software industries? If so, then the implications for how we think about the integration of IT into health care are really serious.
Esther Duflo, a development economist at MIT, gave a thought-provoking talk at TED on using randomized controlled trials to study the impact of anti-poverty interventions in developing countries. Instead of trying to answer the big, controversial question, “Does (international monetary) aid work?” Duflo tries to answer smaller, local questions that provide insight to the big question. For example, mosquito nets are highly cost-effective for preventing malaria, but they’re not being used widely. Duflo wanted to know why and whether cost had something to do with it. Are poor villagers more likely to use mosquito nets if they have to buy them (at a low, subsidized price) versus getting them for free? Her research showed it’s more effective to give the nets away for free.
What’s most appealing about Duflo’s research is that she’s able to show what works (or doesn’t) and she can back it up with data. Randomized controlled trials are the gold standard- for example, the 1971 Rand Health Insurance Experiment is still cited today, yet, they’re not extensively conducted on U.S. social policy interventions (with the exception of education) primarily due to cost, ethical issues, and complexity of the research design. Knowing what works would ensure that scarce funds are directed towards those policies that have meaningful, lasting impact to improve the lives of millions of people.
Duflo’s talk raises some important questions: When is appropriate to conduct randomized controlled trials in U.S. social policy? Should we conduct more randomized controlled trials in health and health care to understand which interventions work and to invest in? Or are randomized controlled trials too controlled, localized, unrealistic and infeasible?
I particularly enjoyed the TED talk by Elizabeth Pisani, author of the book, The Wisdom of Whores. A former journalist whose work now focuses on drug users and sex workers, Pisani has a PhD in infectious disease epidemiology from the London School of Hygiene and Tropical Medicine and spoke on the second morning, one day after Princeton’s Daniel Kahneman, the father of behavioral economics.
Pisani voiced frustration during her talk about the mismatch between government policies and public health approaches and what influences the choices sex workers and drug users make. Her argument drew on the analytical framework behavioral economists like Kahneman have used so effectively to describe and understand the choices people make.
Pisani dismissed the field of public health as being limited by its reliance on a rational model to develop intervention programs. (TED likes iconoclasts.) In the case of sex workers, public health initiatives tell them engaging in unsafe sex with multiple partners can seriously compromise their health, presuming they will stop because it’s the rational choice to make. But Pisani argued that, in Indonesia, women become sex workers, in part, because they can make as much as five dollars a day when the average daily wage is 20 cents per day, a context that shapes their decision making.
I spoke with Elizabeth after her talk and asked her whether the field of public health could benefit from importing principles from the field of behavioral economics to improve analyses and interventions. She believes we need to focus on government and train political scientists in order to have better policy.
Thoughts?
Much is has been written about TED 2010, so I thought I’d just chip in with a quick list of my five favorite TED talks that I urge people to watch online once they’re posted. (We’ll let you know via Twitter — @pioneerrwjf — when they are.) Before I get to the top 5, though, I do want to plug the talks by two of our Pioneer grantees – Nicholas Christakis and Philip Howard. If you haven’t had a chance to hear Christakis take you through the discoveries he made about the role of social networks in obesity and happiness or Howard put forth his ideas on how to change the legal system (and with it the way we approach malpractice in health care), please check them out on TED.com.
In no particular order, my five faves were as follows:
Oh – and check out blippy.com – a site where you stream your credit card transactions to a social network, which sounds like the definition of conspicuous consumption but it might not be as crazy as it sounds – you could eliminate expense reports, for one thing.
All of the attendees of the Pioneer Portfolio-sponsored luncheon, "The Coming Revolution Data-Driven, Patient-Centered Health Care," tomorrow at TED will receive a BodyMedia Fit personal health monitoring device, courtesy of BodyMedia. The gracious folks at BodyMedia believe, as we do, that "getting to know your body better will help you make powerful, positive changes in your health."
The Pioneer Portfolio wanted to provide everyone who attended the luncheon with the opportunity to have these devices because we see it as a simple illustration of how personal health data can be used to make better decisions about diet, sleep and exercise, all of which could lead to better health outcomes.
At the event, Paul Tarini, Pioneer's Team Director and the moderator of the discussion, will ask each of the participants to — after they have used the device for a day — to visit Pioneering Ideas to share their experience with the device. We don't want to know if it clashes with their outfit or if they can't turn it on (although BodyMedia would be happy to provide them with technical assistance). What do we want to know? We want to know that — now that they have this information — what are they going to do with it? Is it causing them to adjust their diet? Is it compelling them to get more sleep? Is it providing the incentive they need to get up and get more exercise? Are they going to consider any of the data patterns and share them with their doctor the next time they have an appointment?
Come back and see what they have to say.
As Susan said, the Pioneer Portfolio is at TED this week.
In preparation for the event, we produced a video, "The Coming Revolution Data-Driven, Patient-Centered Health Care," calling on team members, other experts and Pioneer grant recipients to share their viewpoints on how actionable health data could transform the top-down, doctor-driven status quo of health care on its head.
The interviewees included the following:
TED2010 – the Technology, Entertainment and Design conference – kicks off today and runs through the 13th in Long Beach, CA, with the Pioneer Portfolio resuming its role as an event sponsor. There’s an amazing lineup of speakers, and we’re especially excited that two Pioneer grantees will take the main stage. Nicholas Christakis of Harvard Medical School will be speaking on Thursday about the power of our social networks to influence the spread of health and social phenomena, including obesity, happiness and smoking cessation. And Phil Howard, chair of Common Good and leading spokesperson for the work we have supported to test administrative health courts to overhaul our broken system of medical justice, will address the TED audience on Saturday.
They’ll be among impressive company, joining speakers and performers including HIV vaccine researcher Seth Berkley, molecular technologist George Church, Bill Gates, musicians David Byrne and Sheryl Crow, behavioral economics founder Daniel Kahneman, game designer and Pioneer friend Jane McGonigal, chef Jamie Oliver and former CIA operative Valerie Plame Wilson, among many others.
We’ll be leading two activities at TED – a luncheon on Thursday that will highlight the future of data-driven, patient-centered care. We’re teeing up the following questions – in a world with abundant, accessible, actionable health data, how will our level of engagement in our health and health care change? What expectations of doctors, nurses and other providers will we have, and what expectations will they have of us? If we have and use our data – both those logged in our electronic medical records and those generated in the course of our everyday lives – how might our decisions change? Behaviors? Demands?
It’s a fascinating conversation, and one that will feature Pioneer team director Paul Tarini as moderator WIRED executive editor Thomas Goetz and Beth Israel Deaconess primary care visionary and Open Notes grantee Tom Delbanco. Thomas is releasing a book called The Decision Tree later this month that explores this new approach to health in which patients harness their data and use decision trees – essentially health-oriented flow charts – to engage more meaningfully in health decisions and manage their care more intentionally, leading ideally to better outcomes. Tom will spotlight the role for providers to innovate in this space. He’s leading the way in making health data for the patient – not just about the patient – by placing the information doctors enter in our medical records and clinical encounter notes,directly in our hands and revolutionizing our role in our health care. We'll record the event and post it as a Podcast later in the week.
We’ll also be running an exhibit space all week, the centerpiece of which is a video drawn from interviews with a range of Pioneer staff, grantees and other experts on the leading edge of this data-driven, patient-centered vision. A big shout out to our partners at DDB Issues and Advocacy, who turned hours of telephone interview transcipts in to a beautiful, dynamic and thought-provoking brief video that makes text – and these ideas – jump off the screen and challenge you. I love this video and urge you to check it out and add your ideas and reactions on our YouTube page.
Pioneer will be live-tweeting from TED and we invite you to join us in the conversation on Twitter, where you can provide your answer to this: In a world rich with actionable health data, how will our relationship with doctors change? Use the #pioneerdata hashtag and spread the conversation online.
Finally, we’ll be blogging the sights, sounds and stories of TED this week, so check back frequently.
Last month we talked about the UCLA Family Commons, a Pioneer funded project that uses a retail-based model to deliver behavioral health prevention and early intervention services to families. Last Thursday, UCLA Family Commons officially opened to the community.
We asked Diane Flannery, director and co-founder of The UCLA Family Commons and the Global Center for Children and Families, to discuss her work and motivation for launching the project.
Describe the work Pioneer is supporting you to do.
With the support of the Robert Wood Johnson Foundation’s Pioneer portfolio, we are launching our first family coaching clinic in Santa Monica, California. Called The UCLA Family Commons, it offers an inviting space, in a convenient retail neighborhood, that inspires families to reach their highest level of well-being.
We see this as a new model of consumer-centered mental health care that gives families the tools they need to become agents of their own well-being. All of our products and services are based on the highest quality research about what promotes healthy child development, and they are delivered in ways that are fun, engaging, and easy to incorporate into family’s busy lives.
How will your work transform the future of health or health care?
We believe our model has the potential to become a disruptive innovation that transforms treatment and delivery systems for common childhood problems. We aim to shift public perceptions about the role of prevention and early intervention in mental health care and the role families play in promoting and sustaining their own well-being.
Our long-term vision is to bring this model to scale in a way that makes prevention and early intervention for mental and physical well-being accessible to families throughout California and, ultimately, the U.S. Whether it’s through a nationwide network of family coaching clinics – similar to the Minute Clinics or other retail-based health clinics – or through a line of appealing, evidence-based family coaching products that could be found in every Wal-Mart or Target, we want every family to have easy access to tools they can use to reach their highest level of well-being.
Why does it fit within the Robert Wood Johnson Foundation’s Pioneer portfolio? How is it “pioneering”?
Our model is based on three key features:
1) affordable, action-oriented coaching that gives families the tools they need to address common family challenges and normal developmental issues;
2) convenient, inviting neighborhood locations that make services easily accessible and reduce the stigma sometimes associated with mental health care; and
3) a science-based model that offers families reliable information and proven techniques to change their behaviors and take charge of their health.
What inspires you to pursue your work? Your own personal curiosity? Your desire to improve health or health care? Something else?
My work has two primary sources of inspiration:
1) From working at the UCLA Semel Institute Global Center for Children and Families, I have seen firsthand how much wonderful research is available to assist families in creating healthy lifestyles that give children the strongest foundation for the future. I have also seen that too much of this research fails to reach the wide public audience that it deserves.
2) I am an entrepreneur at heart, and I get excited by developing creative methods to deliver information or services. As a parent myself, I have firsthand experience of the need for a place like The UCLA Family Commons. To be able to have easy access to reliable information that will help me create a life of wellness for my daughter and myself is no small thing. And to be able to get this information, and participate in these activities, in a community of like-minded people, makes an enormous difference in being able to live the healthiest life I can.
Have you encountered any unexpected lessons learned or ideas during the course of your funded project that has changed the way you think about it?
Creating The UCLA Family Commons took over five years, from the time we first started working on it. Over those years, we encountered a wide variety of barriers and setbacks – some expected, some not. There were even times when it seemed easier to give up the idea altogether. But we chose to pursue it, and we continued to bring in new people and to seek ideas and information from a multitude of sources. In the course of this work, the idea continued to evolve, to unfold in ways that were different – and often better – than what we’d originally imagined.
I see this as directly parallel to the way we encourage families to work toward building healthier lifestyles. It’s rarely easy to change your behavior, but if you start small, stick with it, are willing to let it look somewhat different than you’d originally envisioned, and find a community of people who want the same things, you will succeed.
I wrote last year about consumer product, service and retail companies moving more aggressively into the health and wellness space and how their customer-focused approach could be a real challenge to the more traditional medical model which is still struggling to understand and operationalize patient-centered care. According to recent news reports in the Cincinnati Enquirer, consumer product giant Proctor & Gamble recently purchased MDVIP, the nation’s largest concierge care company. P&G reportedly purchased a small stake in the company a couple years ago.
"‘We see this as a learning venture as well as a business,’ said Nathan Estruth, vice president of P&G's FutureWorks unit,” the Enquirer reported. Here’s a link to their story.
The article goes on to say that P&G “does not plan to market its products through the physician offices but rather use the company as ‘an incubator for primary care medicine,’ allowing it to gather information about patients and physicians, service and prevention. In 2008, for example, MDVIP worked with California-based Navigenics Inc., which P&G owns a stake in, to test that company's genetic marker that can gauge patients' predisposition to cancer, diabetes, heart attacks and other conditions.
“It's also talking with General Electric to test some of GE's diagnostic machines, Estruth said.”
I find these developments fascinating and can only begin to imagine how they might change the nature of care delivery.
