Pioneering Ideas

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.

Patricia Flatley Brennan Discusses Project HealthDesign at TEDMED

We had the good fortune of catching-up with Project HealthDesign Director Patricia Flatley Brennan while at TEDMED this year. In this video Q&A, Patti discusses how Project HealthDesign is redefining the way we fundamentally perceive Personal Health Records (PHRs), away from a repository for health information and towards a “platform for action.” This includes enabling patients to track their “Observations of Daily Living” (ODLs) to better understand the state of their health and create an impetus to action.

Check out our interview with Patti and let us know your thoughts on ODLs and the work Project HealthDesign is doing.

 

We're rolling!

Take a minute to check out our new blog roll, over in the right-hand column.  We've pulled together a list of  the blogs we link to most often, including those run by Pioneer grantees as well as those that cover issues near and dear to our hearts: innovation, social entrepreneurship, the world of philanthropy and, of course, health and health care.  Have ideas of blogs we should add?  Let us know!

Opportunities, from Alice Gosfield

Alice Gosfield, Esq.’s entire 34-year legal career has focused on health law. Ms. Gosfield served as Chairman of the Board of Directors of the National Committee for Quality Assurance and was President of the American Health Lawyers Association. She is currently Chairman of the Board of PROMETHEUS Payment, Inc., a not-for-profit national multi-stakeholder project to develop a new provider payment model. (In the spirit of transparency, RWJF’s Quality/Equality team has made a planning grant to test the PROMETHEUS model.) Gosfield told Pioneer:

It occurs to me that there are five types of issues, some of which are quite different from the types of things you have funded and which may fall into the breakthrough category:

1. Getting Guns off the Streets. If heroin, crack and meth addiction are a public health problem so is getting guns of the street. Using entertainment, video and completely different forms of communication to get guns out of communities and gunshot wounds out of the nation’s ERs seems an important issue that health care foundations are not addressing. There has to be a way of thwarting the desire to have the guns in the first place rather than controlling the selling of the guns...We are spending scarce resources in our health care delivery system on something that shouldn’t even exist as a problem.
2. Community Created Health Resources.For many years, the view of the emergency department as a source for care for non-emergencies has been decried as a waste of money and resources. Urgi-centers, whether owned by hospitals to lower the pressure on ERs, or as feeders for their physicians and services, have never generated much in solution. The advent of Redi-clinics and Minute Clinics speaks to the need to get convenient care to where people are. Why isn’t there a Habitat for Humanity for health care resources so that people in a community who work to design and build their local health care resource could develop a real stake in the ongoing process of receiving care much the way building a home creates a connection with maintaining it?
3. Resolving the Tension between Standardization and Innovation. How can we increase quality and expand access—where economies of scale actually arise in a capitalist structure—if we are focused on standardized medicine and centers of excellence? The tension between increased standardization to science for quality, and both innovation in clinical delivery processes as well as diffusion of resources to meet access and convenience issues, has not yet been addressed with breakthrough solutions.
4. A Fresh At Look Health Care Payment Systems. Today the poles in the health care payment world are defined as a government- sponsored universal health system or consumer driven health care, which often is code for high deductible, tiered health care network employee based insurance. There has got to be more creativity available on this. Everything I read is from the same guys from the same orthodoxies writing in the same journals complaining about the same stuff but not creating or proposing anything really new. More focus on payment mechanisms that engage customers of health care in their own care delivery without merely requiring them to be responsible for co-pays would give them a stake in the game. It would also advance us well beyond what the last 50 years of employer sponsored health insurance has created.
5. Regulatory Systems That Protect People and Foster Innovation.Patient safety is not adequately addressed in current regulatory mechanisms. The many ways in which licensure regulation impedes real quality is insufficiently known and some real breakthrough thinking would be interesting and would have impact on other issues including access, payment and consumer-engagement.

Opportunities, from Wylie Burke

Wylie Burke, MD, is an expert in the implications and appropriate use of genetic information in clinical and public health practice. Her research addresses the bioethical and health policy implications of genetic technology. She is currently Chair, Department of Medical History and Ethics, and Professor of Medical History and Ethics, University of Washington School of Medicine, has served on the NIH National Advisory Council for Human Genome Research and the Secretary's Advisory Committee on Genetic Testing, and is formerly the President of the American Society of Human Genetics.

Burke suggested several areas in which Pioneer could, she felt, play a stronger role:

Genomics

Given the claims currently being made for the transformation of health are by genomic technologies, it is striking that no project – at least by the descriptions given—seems to be addressing this area. The claims for genomics seem badly in need of critical and pragmatic assessment, so this might be an area for future investment.

Evidence-Based Medicine

This seems to be an area of under investment. There do not appear to be any projects in your portfolio that are looking critically at how evidence is used to craft practice guidelines, or what constitutes relevant evidence for health care practice. These questions represent important corollaries to investigations of patient-centered care, patient measures of health care quality and efforts to decrease the cost of health care.

Boundaries of Health Care

I think there is a need to explore the concepts of health and health care and their relationship to the obligations of health care providers and delivery systems; and to consider these issues from the perspective of emerging technologies. If we assume that decisions about the delivery of health care service should be based on evidence of outcome benefit and wise use of resources within the health care commons, how do we decide when an activity is part of healthcare or a covered service? How do different stakeholders approach the issue? What are the implications for innovative funding? e.g. of workplace prevention, residentially based health care, or delivery of screening in a consumer service model.

Social Networks and Structures at Older Ages

Recognizing that end of life care is an area of active research, there still seems ample opportunity for considering innovations informed by interdisciplinary thinking, in particular about how ideas in diverse areas like architecture, bioethics, public health, and preventative medicine might work together to promote high quality of life for low-income elders.

Needed Research

Many health care services are provided without a robust evidence base.  This problem speaks to several needs:

• Policy Analysis to identify the barriers and incentives for different types of research
• Rigorous assessment of the evidence need to justify different kinds of medical innovation. How can we make best use of less expensive methods of gathering evidence? When is a Randomized Clinical Trial necessary?
• Consideration of some problematic issues in research ethics: e.g. performing research without consent to address important health care problems (such as optimal management of patients in cardiac arrest or precipitous pre-term labor) building data repositories in clinical settings; public health interventions among disadvantage populations.

Opportunities, from Lewis Sandy

Lewis Sandy, M.D., is Senior Vice President, Clinical Advancement at UnitedHealth Group, where he leads efforts to promote efficient and effective health care, provide tools and information to doctors and patients to promote health and foster the growth of evidence-based medicine. He is formerly Executive Vice President of The Robert Wood Johnson Foundation where he led Pioneer at its early outset, and served as an internist and health care center medical director at the Harvard Community Health Plan in Boston, MA.

Sandy stressed the importance of Pioneer’s thinking of its areas of interest as questions, not as projects or programs. Questions he raised for us include:

• What impact will virtual communities and social networks have on health?
• Should there be a Public Health “Special Forces” that can deal with Andrew Speaker or pandemic flu?
• What would create a breakthrough in increased adherence rates to medical therapy and behavior changes, say to 90% over two years?
• How can health-improving actions be designed to create the same dopamine release stimulated by risky behaviors (drug use, eating, gambling, etc.)?
• What policy constructs would support defaulting to change (e.g. access expansion) rather than defaulting (as we do now) to the status quo?

Opportunities, from Martin Seligman

Martin Seligman, PhD, is currently Fox Leadership Professor of Psychology at the University of Pennsylvania. His areas of academic focus include positive psychology, learned helplessness, depression, and optimism and pessimism. He is well known in academic and clinical circles and is a past president of the American Psychological Association and the author of more than 20 books including his most recent, Authentic Happiness.
 

Seligman suggested that Pioneer think about a key re-framing of its focus.  As he put it:

It looks to me that you are about disease and not about health and you make the unwarranted assumption that health is the absence (or prevention) of disease.  Most Americans want better health and I do not think this equals wanting less disease.  Less disease is part of it, surely but we want more zest, fitness, reserve, vitality, and wellbeing.  By analogy, as a clinical psychologist, I occasionally helped my patients get rid of depression, anxiety and anger.  I assumed when I did so I would get happy people I did not; I got empty people and that is because the skills of fighting the disorders are almost orthogonal to the skills of positive emotion, engagement and meaning. Being disease free is not by analogy being physically healthy.

So I think you should get serious about health, not just disease, and support cutting edge research and health care practice (I decidedly do not mean “fringe” or alternative practices) in this arena.

How are we doing?

As Paul noted in his recent post, we’ve asked outsiders to review our portfolio of grants and tell us (1) their assessment of what we’ve been doing and (2) some ideas of opportunities that we should be pursuing. 

Today we’ll summarize their comments about our work so far; over the next few days we’ll also present the opportunities they suggest for Pioneer. As Paul has said, please let us know what you think.

For example, Martin Seligman, Fox Leadership Professor of Psychology at the University of Pennsylvania, tells us:

I am impressed with your taste in projects. Of the ten leading grants, a couple of breakthroughs (e.g. much better use of health records) seemed possible. While some grants are high payoff-low probability grants, none struck me as sure losers. And I like your reliance on entrepreneurial activity both in the market place and among academics. The latter group, so reliant on relatively dull next steps, needs goading toward more imaginative project, particularly in the area of health and disease.

While Lewis Sandy, MD, Senior Vice President, Clinical Advancement at UnitedHealth Group (and former RWJF VP), observes:

The current Pioneer portfolio appears to be serving two functions: First it appears to serve as mechanism to fund relatively conventional programs in areas not traditionally funded by RWJF. This may serve as “R &D” for the main foci of RWJF grant making and/or serve to support areas of interest to RWJF constituents and staff. Second, it appears to be serving as a means to invest in “experiments” in particular domains in health/healthcare and/or in novel approaches to changes.

Overall, while the Portfolio has a wider range of grantees, problem areas, and projects than is typical fro RWJF, it is fairly conservative for a “high risk” portfolio. In particular, the Portfolio overly emphasizes an analytic, fact driven approach to change (what is and how to get there), rather than alternatives, such as social, emotional or artistic approaches (what might be).

Wylie Burke, M.D., Chair, Department of Medical History and Ethics, and Professor of Medical History and Ethics, University of Washington School of Medicine, points out that:

The portfolio of past and present projects seems robust and usefully diverse, particularly taking into account how recently this initiative was founded. The currently funded projects seem to break down into about half that are potentially breakthroughs and half that provide an opportunity for incremental change. This seems like a good balance. I found some projects difficult to characterize by this rubric: for example, where to put a project to design a new healthcare garment for patients. It’s a great idea whether it is characterized as breakthrough or incremental.

And finally, Alice Gosfield, a health lawyer and Chairman of the Board of PROMETHEUS Payment, Inc. (a not-for-profit national multi-stakeholder project to develop a new provider payment model), warns:

I find the vast majority of the projects [in the Pioneer Portfolio] to be incremental. I don’t see much contrarian thinking or really radical propositions that generate – “yikes, that’s scary!” or “How in the world will they do that?” which is what creates real breakthroughs. Some of it is just minor testing of minor innovations. The projects, which I think offer real potential breakthroughs—the possibility for contributing to a truly, radically different reality, even if only in small ways, are the medical courts, video and computer gaming for messaging, creating new financial markets for social entrepreneurs, creating a medical research investment analysis service and the RWJF X Prize. The latter three also have the quality of potential seeding of yet additional breakthroughs. You may want to add a grant criterion: How will what you are asking us to support not be replicable itself but stimulate further breakthroughs?

Agree? Disagree? Other observations?

Pioneer: kicking off the new year with a bit of reflection

The Pioneer Portfolio is supposed to support novel, high-return ideas that may have a big impact on people's health and their health care in the future. We’ve been in existence for about four years now. Not long ago, our team spent a day to ask ourselves, are we doing what we’re supposed to be doing? Do the projects we have supported exhibit the breakthrough potential we hope to see?

We also asked a handful of outsiders the same questions and over the next several days we’ll be posting bloggified (a word I thought I made up, but which shows up with multiple hits on Google) versions of their response.

Reflecting on their responses (and our staff discussions), I was struck by a couple things…There is a sense that the projects we’ve supported have become more pioneering over the four years. That reflects, I think, our developing understanding of what we mean when we say, “this is pioneering.” There are two things to note here: first is the distinction between an improvement, an innovation within an existing business or social change model, and an innovation that could challenge an existing model. Raising a car fleet’s mileage by an average two miles per gallon would be an improvement. Using hybrid engines to raise fleet mileage by 10 miles per gallon would be an innovation within an existing business model. Building solar powered Segways and convincing people to use them on all trips under 20 miles would be an innovation that challenges an existing business model. We want to look at ideas that fall into that last space.

Related to this is that when we look at an idea in that space, we look to see whether there’s a plausible path from promising idea to broad adoption. If there are some steps along the path akin to, “and then a miracle occurs,” – where the components for widespread uptake are not in place for the idea to reasonably flourish – we’re unlikely to support the idea.

That plausible path also represents stages along a continuum of change. Looking back at our grants, we see they fall into three rough stages: Grants to Learn; Grants to Design, Develop and Validate an idea; and, Grants to Spread an idea. The majority of our grants to date have fallen into the second category. That makes sense. Too much money devoted to learning means too many ideas remain ideas on paper and don’t get a test in the real world. And if we focused the bulk of our funds on spreading, we’d only be able to support a handful of projects over longer periods of time. Our sense is that there’s more benefit to health and health care—and to RWJF—by having a portfolio that looks to nurture lots of potential breakthrough ideas, providing support at stages in an innovation’s life cycle that make the most sense given a philanthropy’s limited resources.

The second thing I was struck by is the yield we get from networking efforts vs. the yield we get from hoping good ideas reach us through our open doors. Generally, more grants result from our networking efforts than from ideas sent in cold. I don’t think that yield ratio means you have to know someone inside the Pioneer Portfolio. Currently, much of what gets sent in cold falls into the “raise a car fleet’s mileage by an average two miles per gallon” category. An improvement, to be sure, but not a breakthrough innovation.  Our staff—we hope—is getting better at finding innovation. But I also think that a lot of people with the kinds of ideas we’re looking for don’t always look to places like RWJF for funding. Over time, we’re hoping to change that so more people with pioneering ideas look to us as a valuable resource and potential partner.

It was extremely helpful to us to have outside individuals take a look and provide frank answers on how we’re doing. We’ll be opening up our grants, and our wider work, to outside scrutiny more regularly as a key way of understanding the impact we are (or are not) having. It’s useful to have the blog as a vehicle through which we can share this information with you as well – it’s a bit more rapid, flexible and open that our standard published evaluation reports. We hope you find the bloggified responses from the external reviewers to be of interest. Let us know what you think.

Pioneering Ideas Presented at CDC Learning Session on Blogs

Yesterday in Atlanta, I spoke on a panel at the Centers for Disease Control and Prevention aimed at informing CDC’s internal e-learning community of practice about how blogging can serve as an effective tool for public health communications.  It was an honor – with all that the CDC is doing to utilize new media, I felt like Pioneering Ideas had arrived in some small way…our foray in to blogging was gaining some degree of recognition and support among others who have been active in this space for some time.
 

The event was hosted by the CDC’s Division of E-Health Marketing – part of the National Center on Health Marketing, which started a blog called Health Marketing Musings, penned by director Jay Bernhardt.  Joining me on the panel were Craig Lefebvre, who runs a terrific blog on new media, social change and social marketing; Toby Bloomberg, who runs the Diva Marketing blog and consults widely on organizational social media strategies; and Marianne Richmond, who blogs on social media and word of mouth marketing here.
 

Most audience members worked in various CDC program areas and were contemplating whether and how blogs might help them deliver key health information to audiences that need it.  A couple of CDC divisions have launched blogs – I give them props, for the agency does not make it easy to gain clearance or use standard technologies to blog freely. I hope more folks at CDC get in to the fray – the information they have to share, informed by the highest levels of research and practice, plays a critical role as more and more people seek health information in the blogosphere.

Craig Lefebvre perhaps summed it up best when he said during the Q&A, “What if the post-9/11 anthrax scare happened now instead of then?”  If the CDC isn’t out in front in the blogosphere, owning that issue and guiding the public in how to interpret the threat and respond appropriately, other bloggers who might be less expert, but quicker to capitalize on the information vacuum, will command the blogging stage. 

Welcome, and an Invitation

Welcome to the Pioneer Portfolio’s blog. What, you might ask, is a Pioneer Portfolio, and why is it blogging?