Pioneering Ideas

Positive Deviance Research Continues to Impact Health Care System

We are proud to see that an earlier grant supporting research into how positive deviance can be applied to methicillin-resistant Staphylococcus aureus (MRSA) prevention in hospitals continues to influence the way health care systems approach and solve challenges.

An article in last week’s Centers for Disease Control and Prevention's Morbidity and Mortality Weekly Report profiles the AtlantiCare Regional Medical Center, which participated in the CDC Hemodialysis BSI Prevention Collaborative to reduce bloodstream infections (BSIs). The medical center implemented the positive deviance method, identifying individuals within an organization who have overcome seemingly intractable problems and spreading their solutions throughout, to engage staff members in BSI prevention interventions. For example, a nurse developed a mnemonic device to meet the hand hygiene compliance that she then shared with other nurses. The program found that collaborative interventions and the use of positive deviance were associated with significant reduction in BSIs. 

Curt Lindberg, project director on a 2006 Pioneer grant to Plexus Institute to study the effect of using positive deviance to prevent hospital-acquired infections, recently served as a positive deviance coach at AtlanticCare. In his earlier research, Lindberg and other investigators developed a pilot program at six hospitals to control and reduce the rate of MRSA, one of the most virulent hospital-acquired infections in the United States. The study showed that MRSA infections rates declined by 73 percent in four of the six pilot units.

Read more about the results of the grant and learn about Pioneer’s work researching the growing problem of antibiotic resistance.

Life Purpose May Help Reduce Heart Attack Risk

Evidence continues to emerge that our psyche influences heart health.

In a new study published in the Journal of Behavioral Medicine, researchers working under a Pioneer Portfolio grant found that having a sense of purpose in life may help protect older adults with coronary heart disease from heart attacks. The article, “Purpose in Life and Reduced Risk of Myocardial Infarction among Older U.S. Adults with Coronary Heart Disease: A Two-year Follow-up,” comes from researchers at the University of Michigan and the Harvard School of Public Health.

Researchers surveyed more than 1,500 older adults with coronary heart disease and followed up after two years to investigate the association between the occurrence of a heart attack and the degree to which participants had a sense of purpose in their lives, which is typically conceptualized as a person’s sense of directedness and meaning. The study found a significantly reduced risk of heart attack among participants who reported a higher sense of meaning, regardless of socio-demographic differences. Each unit increase in purpose was associated with a 27 percent reduction in the likelihood of a myocardial infarction.

This finding is notable because adults with coronary heart disease, which is the leading cause of death among Americans, are five to seven times more likely to experience a heart attack. Most research focuses on preventive and risk factors contributing to coronary heart disease, and not on resilience factors that help promote health and longevity. The study flows from our work in Positive Health, an emerging concept that explores whether people have health assets that can be strengthened and lead to a healthier life. In contrast, traditional medicine focuses on health risk factors for disease and treatment if it occurs.

In addition to life purpose, the study investigated the association of other positive and negative psychological factors, including optimism, positive affect, anxiety, cynical hostility, and depression with risk of experiencing a heart attack. The study found that all these factors were significantly associated with myocardial infarction rates, but the sense of meaning in one’s life exhibited a protective effect on cardiovascular health above and beyond the presence of these other factors.

Researchers also noted that when people have a strong feeling of meaning in their lives, their will to live may encourage heart health-promoting behaviors, such as exercising, healthy eating, adhering to medical advice, and abstaining from excessive alcohol consumption or smoking.  

Learn more about our work in Positive Health.

Meet the Innovations for Health Competition Finalists!

Last year, the Pioneer portfolio partnered with Ashoka Changemakers to launch the Innovations for Health: Solutions that Cross Borders competition to find health care solutions from anywhere in the world that have the potential to be applied in other countries to improve health and health care.

After nearly 400 entries from 73 countries, we’re pleased to announce the finalists, and share a blog post with more details from Ashoka Changemakers. Stay tuned for the winners announcement on April 16!

Feeling Optimistic after SXSW

On Tuesday I had the privilege and the pleasure of serving as a judge on the health panel at the South by Southwest Accelerator. It's a great gig, getting to hear pitches from three startup companies that had been winnowed down from a field of dozens. And the companies were terrific—each is tackling an important challenge with imaginative solutions and great technology.

First up was Simplee. Simplee is positioning itself as the Mint.com of health care expenses. They've developed a service that reads through your insurance company accounts and displays your medical expenses in dashboard form—how much each family member has spent toward their annual deductible, for example.  They also explain the unexplainable—the "explanation" of benefits (EOB) statements we always get from our insurance companies, showing you what insurance covers, what you have to pay out of pocket, and why.  I'm on record (at last year’s Heath 2.0 conference) as saying that if Simplee can pull this off, co-founder Tomer Shomal should get a Nobel prize. While maybe not getting to that level of hyperbole, anyone who has regularly waded through these EOBs can relate to what I'm saying. They're starting with this basic problem of tracking and explaining expenses, but have the potential to go much further—facilitating bill payments, offering context-sensitive preventive reminders, and, as they get enough data, enabling comparison shopping for medical procedures. Best of all, you can try it today—Simplee.com.

Ginger.io then came on. As I've written before, I believe that the data we can capture about our day-to-day lives (observations of daily living) can greatly inform the care we receive and, as researchers start to mine it, it will become the source of new knowledge about what makes us healthy or sick. (Pioneer's Project HealthDesign has been focusing on this opportunity for the last couple of years and will soon have some research results to share.) Ginger.io focuses on a particular slice of this data—the data stored on our smartphones. They can capture social activity (calls, texts), geographic movement (GPS) and physical movement through accelerometers. Their twist is that they're really smart about processing the data and finding meaning in it. They're able to establish a behavioral signature and then identify any deviations from it, which can be important feedback for the user but also potentially for a clinician trying to improve a patient's health. Ginger.io is a spinoff from Sandy Pentland's lab at MIT (see his Pioneer- funded paper on reality mining) and by focusing on the smartphone data, they're avoiding the challenge of getting people to record anything—it's all passively collected. Currently, they're working through researchers and early adopter physicians.

The third and final presenter was Medify, which is working to bridge the gap between very high health information resources like WebMD and the medical literature. They have a robust natural language processing operation that is "reading" (crawling?) all the medical literature and coding it (i.e. intervention, disease, study population, conclusions and other attributes). The user can then get a summary along the lines of 15 studies on a total of 3,000 subjects, five of the studies showed that the intervention was safe and four showed that it was effective. You can then drill down and look at more detail and other dimensions like freshness of the research. I'm not doing it justice with this summary— you need to see it for yourself to get a feel for it. The key is that it takes the complexity of the literature on any given condition and/or treatment and starts to tame that complexity, which, as anyone who has gone Googling in search of deeper medical knowledge can attest, is a big deal. Like Simplee, you can use Medify today at medify.com.

Three exciting companies—each with the potential to bring great value to important challenges in health and health care in very different ways. In the end, the winner was... Ginger.io. Congrats to Anmol and Karan for the win, but also to the teams at Simplee and Medify for their creativity, ingenuity and terrific progress so far. These companies, along with five other excellent candidates, are cause for optimism.

Congratulations to Scott Johnson, an Inspirational Innovator

BY NANCY BARRAND, SENIOR ADVISOR FOR PROGRAM DEVELOPMENT

Tonight in Washington, Scott Johnson, the CEO of the Myelin Repair Foundation (MRF), will be honored as the recipient of the prestigious Gordon and Llura Gund Leadership Award from Research!America. The Pioneer Portfolio congratulates Scott and the MRF on what has been truly pioneering and inspiring work.

Scott, an engineer by training, is a Silicon Valley entrepreneur who has lived with multiple sclerosis since 1976. His keen desire to improve treatment led him to start MRF in 2004. Though RWJF does not fund biomedical research nor focus on specific diseases, we saw MRF’s Accelerated Research Collaboration model as pioneering a new approach to biomedical research – one that had the potential to speed the process of discovery.

With the help of RWJF’s support, MRF piloted the Accelerated Research Collaboration model. The model re-engineers the painfully slow and siloed research enterprise into a collaborative venture to accelerate discovery and move more potential candidates into the pipeline for development of new treatments. From 2005 to 2008, MRF researchers produced 50 peer-reviewed articles, pinpointed 19 new pathways and therapeutic targets for myelin repair, identified 24 new tools for neurological disease research, and filed applications for nine patents, with eight additional applications in the works.

In the process, MRF’s work shifted the field of MS research to focus on myelin repair as the more promising avenue to slow progression of the disease and develop treatments. But as significantly, his fresh view of the biomedical research process – based on how it can and should work, not how it has been traditionally conducted – will shift the future.

The RWJF Pioneer Portfolio is proud to have supported such innovative and life-changing work, and we congratulate Scott Johnson on receiving this much-deserved honor.

Q&A with Freelancers Union’s Sara Horowitz on Modernizing Health Insurance

The Centers for Medicare & Medicaid Services last month awarded $340 million in low-interest and no-interest federal loans to three organizations sponsored by Freelancers Union, a Pioneer Portfolio grantee, to create three of the first seven Consumer Operated and Oriented Plans (CO-OPs) in New York, New Jersey and Oregon. Created by the Affordable Care Act, CO-OPs are consumer-governed health plans that use profits to lower costs for consumers, improve quality of health care, and increase enrollment or benefits based on members’ needs.

We caught up with Sara Horowitz, the founder and executive director of Freelancers Union, to gain some insight on lessons she’s learned, what it means to be truly innovative, and how to put the “health” back in health insurance. The nonprofit Freelancers Union, with 171,000 members nationwide, advocates on behalf of the 42 million independent workers in the U.S. The organization provides health insurance to over 23,000 New York freelancers and their families through its social-purpose Freelancers Insurance Company.

What gave you the idea for Freelancers Union?

I wanted to figure out the next form of unionism, because people had begun working in a completely new way. Thirty percent of the workforce now earns its living as freelancers, contractors and temps.

When I began speaking with freelancers and independent workers in the mid-90s, their biggest concern was health insurance. I came into the field with no health policy background and didn’t carry any baggage. I approached the problem of changing the health care system by trying to help working people get the health insurance they need. Focusing on our members has been my North Star when deciding which strategies could work and which won’t.

When did you decide to start your own insurance company?

What we really wanted was to merge the ideas of Kaiser Permanente with union benefit funds, bringing in the best ideas out there. We recognized that you can do the most if you’re responsible for the money, and that we couldn’t accomplish our goals without creating an insurance company.

What did you learn from talking to your members about what they want from health benefits?

The biggest lesson, which we haven’t solved yet but have made strides toward, is that our members want to get more value in what they’re spending on their health and well-being, and they should. Americans pay out-of-pocket for extra efforts they make for their health, whether that means going to the gym, taking a yoga class, or purchasing healthy foods. Our health benefits should integrate efforts that keep people healthy, not only physically, but mentally, emotionally and socially. In places like northern Italy, you don’t have to be rich to eat well. We need that kind of culture change, and I like to think we can help.

What did you learn from starting your own insurance company?

I learned that you have to know what you’re trying to achieve and understand that there are risks, even if you are unsure what the risks are. You have to build a great team that can help search for what you don’t know. You need a board that has wisdom and experience in all aspects of the field. You have to always strive to do the right thing. In the short-term, you’re making changes that are central to peoples’ lives. Sometimes, this will make them very anxious and even mad at you. You have to reaffirm that there’s no alternative and stay on course to make the situation better. If you continue to communicate and build relationships with your members, their trust and support will come back.

That’s part of what I love about the Pioneer Portfolio and the zeitgeist of social entrepreneurship. When you’re working on complex issues, change and success take time. In current politics, government officials don’t have the longevity to do that right now because we’re not giving them enough space. So, the nonprofit sector has to step in and have the patience to pioneer and experiment.

What spurred you to pursue the CO-OP?

As you can imagine, trying to plan strategically during the past year has been challenging. As we looked at health reform, we thought about the opportunities and challenges for freelancers. We started tracking the CO-OP regulations two years ago because it concerned nonprofit health insurance. When the regulation passed, we applied for funding and began working with Nancy [Barrand, senior adviser for program development for RWJF’s Pioneer Portfolio].

What difference did the Pioneer Portfolio grants make?

Whether or not you support CO-OPs, there was $3.2 billion of support available and Nancy was one of the only philanthropists who even paid attention. That’s another reason I love the Pioneer Portfolio. It has a strong point-of-view about its mission, but is open to different strategies for solving problems.

What makes this strategy a pioneering idea?

Much of the focus today is on individuals, whether they have to get insurance through an individual exchange or a policy carrier. But truly, insurance works best in groups -- always has, always will. It’s important to set up these nonprofits that understand their members, and that can tailor benefits to what people actually need and make dollars go so much further. We are introducing the ideas of affinity, solidarity, and other ideals from the mutual insurance industry that built up cooperatives. I think that mindset makes our work pioneering.

Do you think this is a “disruptive idea”?

Yes. We started with freelancers, a part of the market nobody wanted or had cared about up to that point. Now freelancers and independent workers make up a third of all employees, and the workforce is moving in that direction. So I believe we’ve made an impact on how people traditionally think about the makeup of the workforce, as well as ways to offer health insurance.

What’s next?

It’s important to understand that we are not done yet. We need to move away from the fee-for-service system, go back to medical homes with integrated care, and foster thinner, curated networks. I think it’s important that we start to collect and publicly share data with members, doctors and hospitals to solve problems with health spending. We also need to integrate alternative care structures that support healthy behaviors, such as proper nutrition and exercise. We’ve structured the health system with these as fringe benefits, when they should be mainstream benefits. Freelancers Union is trying to change the culture by offering affordable, stable benefits to independent workers—showing that it can and should be done.

For more information on how Freelancers Union is expanding health insurance choices, check out last week's blog post by Nancy Barrand, senior adviser for program development for RWJF’s Pioneer Portfolio.

Hack-a-Thon for “Unmentionable” Issues in Adolescent Health

Calling all app developers! On March 31, ISIS, TechSoup and Health 2.0 are teaming up for a free, live hack-a-thon event in San Francisco to design apps to address youth health-related “unmentionable” activities, including dating violence, depression, sexually transmitted diseases and substance use. The event, sponsored by an RWJF grant, aims to create apps that will excite young people to share honest, real-time, private information about their taboo, embarrassing or “unmentionable” activities with researchers and program experts who work with youth.

The hack-a-thon will bring together developers, designers, innovators and entrepreneurs for rapid development of progressive concepts and prototypes to be developed by the participating teams following the event and at future hack-a-thons. ISIS and TechSoup will partner in the future development and distribution of the concepts and designs. The grand prize winner will be revealed at ISIS’ annual Sex::Tech conference and take home $1,000 cash.

Interested? Register now.

Pioneer’s Commitment to Health Games Profiled in New Games for Health Journal

BY PAUL TARINI, SENIOR PROGRAM OFFICER, PIONEER PORTFOLIO -- @PaulTarini

I recently had the good fortune of sitting down with Bill Ferguson to discuss the Robert Wood Johnson Foundation’s pivotal role in health games research for the inaugural issue of the Games for Health Journal. In our talk, I detailed the Foundation’s early investment in the field, the challenges to advancing health games and some grantee findings to date.

Thinking about our conversation, I’m struck by how far the field has come since the early days of our health games support in 2004. Back then, there wasn’t much intersection between the games space and the health space, but Pioneer saw potential. So we worked with Ben Sawyer (@BenSawyer) of Digitalmill to do some community building within the gaming industry around health interests and funded the first-ever Games for Health Conference.   

Now, with seven conferences behind us and the eighth scheduled for June 12-14, 2012, in Boston, Pioneer can proudly claim we helped create and sustain a way for the games and health communities to come together. But we didn’t stop there.

Pioneer expanded its support to the Health Games Research national program, directed by Debra Lieberman at UC Santa Barbara (who is featured in a roundtable discussion of health games experts in the Journal), where we are seeing our 21 grantees test some fascinating ways health games can be optimally designed. They're exploring game features such as competition, collaboration, social comparison, social support, nurturing of characters, immersion in fictional worlds and alternate realities, interacting with a human-like robots to motivate exercise, using a mobile phone game as a substitute for a cigarette, and much more. And there’s more to come.

Health Games Research's work to identify a broad range of features that make for effective health games will help to further expand the creative horizons of future developers. Well-designed and well-implemented games can motivate and support prevention, lifestyle behavior change, and self-management of chronic conditions, and Pioneer is proud to be part of this work. We are excited to see a journal devoted to the research, development, and clinical application of games and health.

Check out the inaugural issue and read about the work of Pioneer’s grantees and others in this important field on the Pioneer Health Games homepage. Tell @pioneerrwjf or @gamesresearch what you think.

Pioneer travels to SXSW 2012!

In the spirit of continuing to discover pioneering ideas, RWJF’s Chief Technology and Information Officer and Pioneer team member Steve Downs is heading to Austin for SXSW, the annual music, film, and interactive conference taking place March 9-18.  

Steve is one of the judges for the Health Technologies session in the exciting SXSW Accelerator competition where finalists will showcase incredibly cool products that just might change the way people think about their health and health care. 

Watch the Health Technologies session streaming live on March 13 at 11 a.m. CST.

Follow Steve @stephenjdowns and Pioneer @pioneerrwjf. For up to the minute coverage, follow @SXSW. 

New Data Reveals High Death Rates From Clostridium Difficile (C. diff)

A new Vital Signs report issued March 6 by the Centers for Disease Control and Prevention shows rates of infection with Clostridium difficile (C. diff) are at historic highs and must be curtailed. C. diff can cause cramps, severe diarrhea and, in some cases, death.

Also on March 6, Extending the Cure—a project funded by the Pioneer Portfolio that studies antibiotic resistance—released a new analysis showing high C. diff death rates in parts of New England. In fact, the Extending the Cure analysis shows that as of 2007 Rhode Island, Maine, and Connecticut had the highest death rates for C. diff in the nation.

These top three states had death rates that were more than double the national average of 2.15 deaths per 100,000 people.  The trend is visualized using the interactive mapping platform of ResistanceMap, Extending the Cure’s online tool that tracks antibiotic use and drug resistance in North America and in Europe.

At the same time, the map shows that most Southern and Western states had death rates from C. diff that were below the national average. For example, Georgia, Colorado, and Idaho reported less than one death per 100,000 people from these infections in 2007. “The geographical variation points to the need for additional research to better understand the epidemiology of C. diff infections and highlight the most effective ways of preventing their spread,” says Ramanan Laxminarayan, director of Extending the Cure, the D.C-based research project funded in part by the Robert Wood Johnson Foundation’s Pioneer Portfolio.

While C. diff has long been linked to hospitals, the CDC report finds that patients can acquire the infection in all medical settings, including nursing homes and outpatient clinics. Those most at risk are patients who take antibiotics, which can wipe out the good bacteria living in the gut, allowing C. diff to thrive.

C. diff infections can be reduced by judicious use of antibiotics, according to the CDC, which notes that about 50 percent of all antibiotics prescribed are not necessary. Reducing unnecessary antibiotic use will not only help prevent C. diff infections, but also curtail the growing problem of antibiotic resistance.

Addressing the rising rates of C. diff infections will require a multifaceted approach.  In addition to promoting antibiotic stewardship, health officials must work towards better infection control and early diagnosis at hospitals and other facilities where C. diff and other health care-associated infections can spread from patient to patient or from one facility to the next.

 In addition, policymakers, researchers, and others can use visualizations, like the map from Extending the Cure, to identify regions of the country with the most serious problems and look for targeted solutions to the rising tide of C. diff and other disease-causing bacterial pathogens.

Check out the new data and let us know what you think: Do you have a story to tell about a solution to the problem with C. diff?

Follow @ExtendgtheCure on Twitter to track coverage of this study.