Pioneering Ideas

C. diff Infections: Worse Than We Thought

BY RAMANAN LAXMINARAYAN, PROJECT DIRECTOR, EXTENDING THE CURE

Infections caused by the dangerous microbe Clostridium difficile, or C. diff, are much more prevalent in hospitals and health care facilities than previously reported, according to an investigative front page story in last week’s USA Today. This bug is most often seen in hospitals, nursing homes, and other medical facilities. It causes severe diarrhea and intestinal problems that can worsen and even be fatal. The story cites a scientist from the Centers for Disease Control and Prevention who says annual fatalities may be as high as 30,000 per year, more than twice as high as some recent estimates.

The article accurately points to many reasons for this problem. Many hospital infection control programs aren’t stringent enough and C. diff reporting rates are poor. Hospitals need to be more prudent in their antibiotic use. C. diff thrives when healthy bacteria usually present in the intestines are wiped out by certain antibiotics patients take. In the absence of these healthy bacteria, C. diff can take over. 

The problem is exacerbated by the overuse of antibiotics, often in place of effective infection control. All health care providers – in health care facilities and in the community –  must use antibiotics prudently in order to slow the rate at which these powerful drugs become ineffective against C. diff, MRSA, and other dangerous bacteria.

We know that the evolutionary battle with microbes is, by nature, a losing one. Bacteria will continue to become resistant faster than our efforts to stop them. So as current antibiotics become ineffective, we need new drugs at the ready. However, efforts to bring new drugs to market need to be coupled with plans to conserve their use to maintain their effectiveness.

In order to get to the root of a problem like C. diff, we need comprehensive solutions that address not just antibiotic overuse but also infection prevention (such as vaccination) and infection control.

Check out new research from Extending the Cure showing how overuse of certain antibiotics correlates with C. diff deaths and hospitalization rates in the United States.

Read about the economics of drug resistance in a recent cover story featured in the Milken Institute Review by Ramanan Laxminarayan.

Follow Extending the Cure on Twitter @ExtendgtheCure.

Ramanan Laxminarayan is director of Extending the Cure, a research effort that examines policy solutions to address the growing problem of antibiotic resistance. The project is based at the Center for Disease Dynamics, Economics & Policy (CDDEP) in Washington, D.C., and is funded in part by the Pioneer Portfolio of the Robert Wood Johnson Foundation.

Lightning Strikes Datapalooza

It didn’t appear on the lightning strike map, but lightning did indeed strike a young medical student inside the Washington Convention Center right in front of about 1,500 amazed spectators on the first day of The Health Data Initiative Forum III: The Health Datapalooza.  Everyone is fine—though our medical student may never be the same again. 

Actually, this story began long before Datapalooza, of course.  Fourth-year medical student, Craig Monsen, and his Johns Hopkins Medical School classmate, David Do, started collaborating on software applications soon after they met in first-year anatomy class.  Craig graduated from Harvard with degrees in Engineering and Computer Science and David from University of Minnesota in Bioengineering.  

They’re not quite Jobs and Wozniak—neither dropped out of anything—yet—although Craig, at least, is planning to skip or delay residency.  You see, after seeing the Robert Wood Johnson Foundation (RWJF) Aligning Forces for Quality Developer Challenge last year—they got very serious about bringing to life their vision of new applications that could help patients and consumers make great health care decisions. 

The RWJF Aligning Forces Challenge offered a $100,000 first prize in a competition to find the best application that helps patients make health care decisions using publicly available measures of health care quality from the RWJF Aligning Forces initiative.  Aligning Forces is the Foundation’s nearly 10-year, centerpiece initiative to help the leaders in 16 health care markets across the nation improve the quality and cost of their health care.  The winning application would basically walk patients through a decision-making process for accessing health resources in much the same way that TurboTax® guides users through the process of submitting a tax filing.  The competing applications would use data from the Aligning Forces sites.

RWJF announced this challenge last year at the Health 2.0 conference in San Francisco.  The competition ultimately drew 55 first-phase applicants.  A panel of judges from the Aligning Forces communities selected five semi-finalists for the second phase.  During the second phase semi-finalists worked with leaders in Aligning Forces communities to refine the applications and then presented their final applications to a panel of judges at the Aligning Forces national meeting in New Orleans in May.

On June 5^th at Datapalooza 2012, John Lumpkin, senior vice president at RWJF, announced the winners to the morning plenary audience.  First prize went to Craig and David for their Symcat application.  They designed Symcat to help cyberchondriacs—or people who search the internet about worrisome symptoms (i.e., most of us) —understand what conditions might be causing those symptoms but importantly also provide immediate, customized information for those searchers.  Symcat is both a web and mobile app and features an extensive symptom vocabulary, intelligent and dynamic question generation, machine learning to calculate probable diagnoses, and trusted medical information from MedlinePlus and AHRQ.  Symcat incorporated Aligning Forces performance metrics to help users find quality care personalized to the searcher’s medical needs.  Independent of the RWJF challenge, the Datapalooza organizers selected Symcat from hundreds of submissions to present their application on the main stage plenary session. 

Craig and David started their company in August 2011—and immediately saw the Aligning Forces challenge as a great opportunity for their fledgling effort.  Craig says that his parents weren’t entirely thrilled that he was taking time out of medical school for the company—or that he was pausing with his residency plans.  After receiving the $100,000 RWJF check, though, he says he felt some “justification.”  He noted that his “parents were really proud” and that he called them almost immediately after leaving the Datapalooza stage.  His colleague, David, was not quite as fortunate—apparently his brand new wife would not allow him to interrupt their honeymoon for Datapalooza.  Craig had to manage the Datapalooza presentation and collect the winning check on behalf of the Symcat team.

We really need people like Craig and David.  For some lucky reason, leaders and risk-takers like these two young inventors always seem to come forward just when we need them.  It makes one believe that given the right opportunities, the risk-takers out there will keep dreaming big—will step into the breach and try crazy, new and amazing things—crazy new things that become our next awesome solutions.

 

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.

Pioneer Grantees Named to HealthLeaders Media’s 20 People Who Make Health Care Better

HealthLeaders Media identified 20 individuals to tell their stories of how they are changing health care for the better in its annual HealthLeaders 20 issue. Two grantees of the Pioneer Portfolio are included in this prestigious honor.

Clayton Christensen is often referred to as the father of disruptive innovation, the concept that new technologies have the potential to turn an industry upside down—but they may be difficult for established organizations to adopt. In 2011, Christensen and his team at Innosight Institute published a Pioneer-funded case study series on disruptive innovations within integrated health systems. In the summary report, researchers investigated how the seven integrated health systems think, act and innovate differently.

Nicholas A. Christakis is a well-established name in the science of human connectivity and social networks. In 2011, Christakis’ innovative Pioneer-funded research looked into how humans interact and coordinate in response to the behavior of one’s social partners in an article published in Science and in this profile.

We’re proud to call these innovating movers and shakers part of the Pioneer family. They, like all of us, are working to make a difference in health care. We encourage you to congratulate Christensen and Christakis (through his book Connected) on Twitter.

New Case Studies in Innosight Institute’s Disruptive Innovations in Health Series

 Over the past several months the Innosight Institute, a think tank that applies Clayton Christensen’s theories of disruptive innovation to the social sector, has been exploring the critical factors necessary for facilitating disruptive innovation in health care in integrated delivery systems to achieve increased quality, reduced cost, and access improvements. The work, which is funded by the Pioneer Portfolio, has already produced five case studies, including recent additions that look at processes at Grand Valley Health Plan, Group Health Cooperative, and Presbyterian Healthcare Services.

To learn how Grand Valley provides a high level of access at a low cost of care, how Group Health is employing a successful Medical Home program and how scarcity became “the mother of invention” at Presbyterian Healthcare Services please check out the full case studies here.

 

What does mEvidence need to look like?

There is something magical that happens when talking about mHealth. People start believing all of the wonderful things that a phone, together with the right gadget, can do: remind me to take my medicine, monitor my vitals, inform my doctor when something goes wrong, just plain automatically keep me healthy. The last few years have seen a huge growth in cell phone companies, technology companies, governments, application and device developers rushing to deliver product in this space. Just look at the over 500% increase in attendance between the 2009 and 2010 mHealth Summit (with the 2011 meeting promising to be even larger.) Along with the hype and the hope, people are beginning to ask for evidence and to question the value of growing a collection of isolated gadgets and apps.

I’d say that mHealth is somewhere around the asterisk on the “hype cycle” model developed by Gartner.

With that as context, RWJF’s Pioneer Portfolio, together with NIH, NSF, HHS and McKesson Foundation, organized a one day event to begin the process of advancing the Science of mHealth. What does mEvidence need to look like? What are the right methods to accelerate the evaluation of the efficacy of mHealth technologies?   First steps to address this have largely been focusing on attempts to demonstrate value by using a traditional randomized controlled trial, which is often ill suited to testing the interventions that mHealth enables. (It’s interesting to note that on August 14, Paul Meier died. I’d be interested in knowing what he’d be thinking.) When we first started to plan this meeting, I wondered how interested the field would be. After all, this is the drier, academic side of mobile health. I was surprised! We had 106 responses to our call for whitepapers of which we were able to choose 23. The demand for attendance was such that NIH had to arrange for a webcast.  Perhaps looking at transforming the way conduct research [in light of new technologies] is not so dry after all. While the attendees were predominantly US-based, academic, international and corporate interests were represented. The outcome was even more surprising. The group agreed that this was a good and important direction, that we needed to have a collaborative, ongoing and forward looking agenda and that the Science of mHealth was critical to achieving a high enough plateau of productivity. The group will soon issue a statement of direction and commitment, publish the key outcomes of the meeting and develop a longer-term agenda. We are also developing an online community so that we can keep the discussion going. In a couple of weeks the webinar will be available for people who missed it and we will work to keep the groundswell moving.

I’d be remiss not to include the fact that closely aligned is the ideas and ideals of Open mHealth and the work of Pioneer grantees Ida Sim and Deborah Estrin. Not only were they and a number of people in the open mHealth area participants, they organized a second day to help formulate how they were going to develop and move forward.

This is important and people are paying attention. One way that you can help is to respond to the request from the NIH Director’s Common Fund, which is designed to fund transformative research that is of interest to the health community. The Common Fund officials are looking for the community (that is you!) to weigh in on new ideas for funding. Go here to add your comments.

 

Tim O’Reilly to Host ‘Unconference’ for Health, Tech Leaders

Today we announced a grant to O’Reilly Media  to  sponsor the Foo Health Camp in 2011, a cross-discipline, immersive, informal 'unconference' that will take advantage of a growing interest in applying Web 2.0 and open-source thinking in health care to spark ideas that can expedite changes in the ecosystem of health care services. This event is being announced on the heels of last summer’s O’Reilly Open Source Convention, where we helped sponsor the event’s first-ever health track. A full report of that event’s takeaways is now on our Web site.

The Foo Camp-unconference format was pioneered by visionary Web leaders Tim O’Reilly and Sara Winge of O'Reilly Media. O’Reilly Media is a leading technology publisher, conference organizer and supporter of the free-software and open-source movements (Foo stands for “Friends of O’Reilly). The format, in which attendees design the agenda on the spot, produces more brainstorming and group problem solving than formal presentations – which is clearly conducive to catalyzing the type of outside-the-box thinking needed to transform health and health care.

This health camp will be an invitation-only meeting, bringing together about 150 key players from health care and emerging technology, including researchers, funders, health care executives, software developers, entrepreneurs, journalists, policy experts, thought leaders and Robert Wood Johnson Foundation team members.

We will be sure to fill you in on more details as they become available, including how to participate in the conversation via social media.

For more on Tim O’Reilly’s vision on how technology will change health and health care – and why O’Reilly Media is jumping into the field – you can watch his interview with Pioneer Team Leader Paul Tarini below. Then leave a comment and let us know what you think!

 

 

Time to Accelerate Innovation: Takeaways from this Year's mHealth Summit

I just returned from the mHealth Summit in Washington, D.C. We’ve been sponsors of the event for 2009 and 2010 – both years it’s been held. Last year there were about 400 people who attended. This year there were about 2,500, including prominent guest speakers like Francis Collins, Bill Gates and Aneesh Chopra, among others. There was also a large hall with lots of exhibitors and an extensive poster session. I guess this means that means mobile health is coming of age.

I liked it a lot, but not for the reason you might think. At most of these types of events the presentations tend to expand on the great things that are going on in the field. Here there was a good, healthy dose of skepticism. And there’s a lot to be skeptical about. There are the “show me” skeptics, the ones that ask for evidence that it actually works. There are the regulation skeptics, the ones who know the problems in getting devices approved by the responsible government agencies. There are the “disruptive innovation won’t work here” skeptics. There are the “who will pay for it?” skeptics, not to mention the standards, open source, proprietary, silo, etc. skeptics. It makes my head spin and wonder how we’ll ever get there.

There are two reasons I’m still optimistic. First, in spite of all this, the field is growing and there are big players in the field. Second, many of the issues are starting to be formally addressed at what seems to be appropriate levels. That’s good. There is an area where I think more can be done, and that’s in developing better methods for validation and evidence. There’s still a huge emphasis on the traditional clinical trials model, which sets up a fixed and structured experiment, collects data over a period of time, consolidates and analyzes the data at the end of the trial, and, after a long period of time (maybe five years), reports the outcome.

The field shouldn’t have to wait five years to understand the effects of what by then will be an obsolete intervention. In addition, this is a field where there should be continuous improvement, where tinkerers thrive, where prototypes are the rule. It makes little sense to freeze development when you learn something that will make it better. One solution might be the type of adaptive trial that pharmaceutical companies are investigating. This is one where results at various stages in a trial can effect changes in the trial model. You might change the sample size, the target population, the delivery method, the formulation, etc., based upon analyzing data internal or external to the experiment. Analysis of this model is complex but can be manageable. In the end you should be able to deliver a safer, more effective product sooner.

That’s the germ of one idea for being able to develop an evidence base for mHealth quicker and better than today. These are my thoughts. I’m sure that there are smart and thoughtful people who have others.

Innosight Institute Explores Disruptive Innovations in Health Care

This week the Innosight Institute, a not-for-profit, non-partisan think tank, released the first of six whitepapersexamining how disruptive innovations in integrated health care systems are generating higher quality care at a lower cost. We funded this research to identify critical factors necessary for facilitating disruptive innovation in health care. We’ve been long-time fans of Professor Clayton M. Christensen, and are excited to work with him because we believe that the principles of his theory of disruptive innovation could lead to significant positive changes in health care delivery.

 

This first case study focuses on HealthPartners, America's largest consumer-governed, nonprofit health care organization. HealthPartners’ integrated health system acts as both insurer and provider of care. According to Innosight’s research, this system design, which includes functions such as ranking physicians, providing patients control over physicians’ schedules and incorporating dental services and coverage has led HealthPartners to deliver a high quality of care at a cost that is even less than Minnesota’s already low average (30 percent below the national average).

 

We will highlight the additional whitepapers – which will focus on other health organizations with integrated delivery models – as they launch in the coming weeks. In the meantime, we look forward to your thoughts on HealthPartners’ approach to delivering high-quality care at a lower cost. 

A landmark first for the Archimedes model

At the very end of March, study findings were released in the online edition of The Lancet indicating that it is more effective from a cost and detection standpoint to begin screening for Type 2 diabetes in people between the ages of 30 and 45 — 15 years ahead of what established guidelines had been recommending.  Subsequent screenings should take place every three to five years thereafter.

While this is an important result for the medical community, the most significant piece of this story, in our opinion, was not covered in the news.  What really caught our attention was the fact that this was the first time The Lancet has ever published a peer-reviewed paper for which the research was based entirely on a simulated population and treatment options existing within a mathematical model – in this case, the Archimedes model of human physiology, diseases, interventions and health care systems.

For the study, the researchers simulated a population of 325,000 nondiabetic 30-year-olds.  According to Archimedes President and CEO John Beasley, “This paper presents the results of an international study that would never have been possible using an actual clinical trial. It would have required enrolling and following more than a million people for 45 years; the cost would have been astronomical.  The study examined the criteria for deciding when to screen for diabetes and Archimedes was the only model that could conduct a clinical trial simulation at this advanced level.”

We’re excited to see validation of the strength of the Archimedes methodology at this level.  Watch the blog for more updates soon on the status of the ARCHeS project, which will make it possible for public and health policy leaders to access the model to conduct their own virtual clinical trials from their desktops.  The vision is that a wide variety of key decisions will be informed by equally strong results from the model’s predictive analyses, and the sharing of findings powered by Archimedes will become common practice in peer-reviewed journals.

Changing the Way a Clinician Views a Patient

Last week, Susan Promislo discussed the announcement of five new grantee teams selected in Pioneer’s Project Health Design second round of funding.  As she mentioned, the teams will be testing new ways to integrate patient-generated observations of daily living (ODLs) in the clinical care process.

 

Today, Steve Downs elaborates on the concept on The Huffington Post.  As Downs mentions, “wireless data networks, smartphones, low-cost sensors and minimal software distribution costs have created new opportunities to paint a person's health experience in vivid detail.” The teams will try different ways of analyzing, synthesizing and summarizing the data and they'll try to extract clinically significant information from all the bits and bytes. They'll share the information with the participants and pass information on to clinicians. In short, they will prototype a new approach to health care - one where trends can be spotted before they manifest themselves as problems, one where the effects of new treatment regimens can be readily observed and quickly adapted, one where the connections between behavior and health can be more easily demonstrated.”  

 

Is the ability for a clinician to access a patient’s ODLs a good thing? Will it enhance care or will any meaningful signals in that data be drowned out by the noise of information overkill? 

 

We want to hear what you think.  Are we on the verge of entering a new era? We encourage you to read the post and share your comments over at the Huffington Post.

 

Overshoots and Apps: Disruptive Innovation and Health IT

As Paul Tarini just discussed, we had a thought-provoking discussion with Clayton Christensen about disruptive innovations and health IT.  One idea that interested me in particular was the potential for electronic health record (EHR) systems that are offered on the Software as a Service (SaaS) model to serve as a disruptive innovation.

Let me back up for a minute. Christensen talked about looking at the pre-conditions for disruptive innovations. One of them is when companies “overshoot” the market in terms of performance. For example, their product adds more and more features (each of which adds value to fewer and fewer customers) and becomes very expensive. They target the high-end of the market, where they make the highest margins, and as a result, they offer more than the lower end needs at a price that the lower end can’t afford. They’re “overshooting” that part of the market. This then creates opportunities for new entrants, with a new approach – that gives them a cost advantage – to make inroads at the low end of the market. The dynamic that follows is what ultimately transforms the market: the incumbent happily cedes the low end of the market because they make higher margins at the upper levels, giving the new entrant some traction. The new entrant then seeks the next rung up in the market, which the incumbent again, gladly cedes so they can focus on their most profitable customers, and so on, until Toyota, which started with cheap subcompacts in the 70s, introduces Lexus and starts taking on Mercedes.

So that got us thinking about the EHR marketplace and especially small practices.  A lot of people experience real cognitive dissonance when they think of a three-doc practice installing a traditional EHR where they install and maintain the hardware and software on site.  Systems designed for larger practices (with dedicated IT support) can be cost-prohibitive for small practices.  Sounds like overshoot to me.  Enter SaaS-based EHRs, which, by offering a very different technical and business model and (presumably) a real cost advantage, ought to be primed to take on the low end of the market, away from which the incumbents might happily walk.

What am I missing here?  Is anyone seeing signs of this happening?  Are there SaaS EHR vendors that look particularly promising?

The other key Christensen concept that came into the discussion is the idea Paul mentioned that customers have “jobs” to do, as opposed to systems they need.  In my mind, “job” relates quite directly to “app,” as in “there’s an app for that.”  (There I go quoting Apple ads again.)  This gets back to my earlier post on EHRs and apps, which I won’t rehash other than to say that adoption of EHRs would likely be enhanced if they offered the apps that help providers do the many jobs they need to get done and that the best way to ensure that is to open up app development to 3rd parties.

Talking Health Care with Clayton Christensen

We met with Clayton Christensen yesterday, the Harvard Business School professor who originated the concept of Disruptive Innovation. He’s been looking at the health care delivery system for some time now, seeking to apply his model of Disruptive Innovation in order to improve care and reduce costs.  That effort culminated in the release earlier this year of The Innovator's Prescription: A Disruptive Solution for Health Care, which he wrote with colleagues Jason Hwang and the late Jerome Grossman. It’s a fascinating read.

 

He’s a superb, thoughtful and gentle speaker.  If you ever have the opportunity to see him speak, take it.

 

We spent the better part of a day with him, so I’ll note only a couple of items that were raised.

 

The nursing shortage: Christensen notes that our training institutions do not have enough capacity to produce a sufficient supply of nurses.  At RWJF, we have been funding work to enhance and expand nursing faculty as a way to address that issue.  He says that in the same way in which many companies have begun to bring management training and development in house, larger integrated systems are beginning to insource the training of medical professionals.

 

Wellness: Christensen says one of the important things you need to understand when thinking about how to improve a product or service is what job the customer wants that product or service to do for them.  He explains this concept by talking about people who “hire” a milkshake for breakfast in the morning.  Understanding what job someone is hiring a milkshake for—and why the milkshake does that job better than a bagel or a bowl of oatmeal—helps you understand how to improve the product.  He suspects that “wellness” may not succeed as a way to organize the business of health care because not enough people want to hire wellness.

 

Disrupting public health:  We asked him about whether something that wasn’t market-based, but which was a public good—specifically, the public health system—could be analyzed and improved using the framework of Disruptive Innovation.  He said he’d never thought about it, but was intrigued by the challenge.

 

We also had a pretty robust conversation with him about health information technology.  Look for a post later from Steve Downs that discusses some aspects of that discussion.

 

Finally, one of our colleagues noted that RWJF sometimes feels like a player in an industry that’s ripe for disruption.  Any thoughts about what might disrupt our “business model” in philanthropy?

Is the country ready for health reform?

Health reform seems to be on everyone’s mind these days – and why not? Our system doesn’t deliver great value overall, it is inequitable, and the economic crisis promises to make it much worse unless we can do something about it.

I came across two views of health reform Sunday – one by David Leonhardt and the other by Janet Rae-Dupree – both in the New York Times. Leonhardt placed health reform in the context of big picture economic strategy over decades; Rae-Dupree brought the lens of disruptive innovation to health reform. Leonhardt singles out health because it is such a daunting fiscal problem, even in the context of the worldwide economic crisis. The future unfinanced obligations under Medicare plus a distinctly inefficient system makes the future price tag of health reform bigger than the estimated bailout. That is not what most people have in mind when they think of health reform – they think of more people having insurance coverage and improving the care people get.

Rae-Dupree applies Clayton Christiansen’s concept of disruptive innovation to health care, drawing on his book The Innovator’s Prescription, and holds out this pathway for getting beyond the current gridlock of inefficiencies. She describes promising examples, some based on emerging scientific discoveries that point the way.

Both views underscore the need for fundamental changes. But I can’t escape the feeling that much of the country isn’t really prepared for the consequences of health reform that would address some of the basic problems with our system. Disruptive innovations replace existing business models, they would change the way care is delivered – when, who, how, where, costs, and perhaps even our very conception of health-improving services. Health reform may have to combine these two views, addressing the looming budget challenge and encouraging disruptive innovations. Figuring out what the country will do about future Medicare obligations may just require a system that fosters the benefits that disruptive innovations can bring. It will certainly test the country’s resolve to improve health through reform at a time when all of us will be called upon to sacrifice.

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.

Pioneer Invites 11 "Disruptive Innovations" Entrants to Apply

The competition on Disruptive Innovations in Health and Health Care was the first time that we intentionally used the Changemakers open-source competition model to scan the field for ideas that the Pioneer Portfolio might wish to invest in directly. Not knowing how the challenge of disruptive innovation would play out using this type of competition model, we were astounded by the response — more than 300 entries — and really impressed by the creativity and quality represented in the mix of innovations proposed.

We're happy to announce that Pioneer staff have completed their review of the full set of entries. We had some spirited discussions about the ideas that flowed through these entries — they stand to really shake up established ways of doing things in health and health care and trigger big gains for consumers. So, while it's taken us some time, we're happy to announce that we have invited 11 entrants to compete for grant funding, if they so choose. Many you will recognize as finalists and winners, while others were included because we were excited about the pioneering approaches they presented.

These entrants will be asked to demonstrate how RWJF funding could be used to further the development of the work represented in their respective Changemakers entries — either through demonstration, scale and/or replication. The total amount of grants made under this phase will not exceed $5 million.

All of us at RWJF continue to be inspired by the ideas and energy contributed to this competition, and we're grateful for the participation of the global community of entrepreneurs who entered, commented or spread the word about it. We'll keep you posted on future funding decisions stemming from the Disruptive Innovations competition.

The 11 entrants invited to compete for RWJF funding are:

Building ARCHeS to Precise Answers, Stronger Decisions…and Better Health

Yesterday, I had the pleasure to publicly announce Pioneer’s largest grant to date: a $15.6 million award that will enable Dr. David Eddy and his team at Archimedes, Inc. to build ARCHeS, a powerful Web-based interface and delivery system that will allow far more health and policy decision-makers to use the Archimedes simulation model. That’s somewhat of a mouthful, so let me break it down a bit to describe why this project is exciting and has potential to transform the way that we make health and health care decisions.

Archimedes

So, what’s Archimedes? Perhaps the best place to start is with the problem it addresses. David Eddy—a rock-climbing heart surgeon turned mathematician and health economist—is a visionary driven to tackle the enormity of what we don’t know in medicine. So much of what guides our actions amounts to little more than enlightened guesswork. Simply put, there have always been far more questions than answers when it comes to providing quality health care.

As a doctor treating patients, a policy maker and, now, a foundation leader, I know this to be true.  Even the best-intentioned, most diligent among us in this field—be they doctors and nurses, health care analysts, researchers or policy officials—are continually frustrated by the gaps in information to guide many of our decisions. All too often, we can’t say with reasonable certainty what treatment…which policy…what mix of approaches… really works.

Mathematical Modeling: SimCity for Health Care

For more than 10 years, David, together with co-founder Dr. Len Schlessinger, has worked to develop Archimedes, a remarkably powerful, detailed and realistic mathematical model of human physiology, diseases and health care systems. It’s unique in many ways—it is the only model of its kind that can simulate pathways down to the cellular level in human physiology and, in turn, predict outcomes at the population level. By plugging questions into Archimedes, health care organizations and policy leaders can determine, reliably and quickly, the health and economic outcomes of specific interventions and treatments for patients, providers and payers.

As David states it, “We would never build a skyscraper, bridge or airplane without using models to optimize their designs and ensure their structural integrity. Yet today, that is what health care providers and administrators are forced to do with patient care, resource planning and other critical health care decisions.”

Unraveling the Health Care Hairball: A Health 2.0 Conference Recap

I've heard the state of health care described in many compelling yet disheartening ways: broken, expensive, inconsistent, complicated. But today I like this one best: health care is a hairball.

Although Google suggests others coined the phrase before last Thursday, I credit Wayne Gattinella, CEO of WebMD, for introducing it to me and many of the 500 others attending Health 2.0: User-Generated Healthcare in San Francisco last Thursday. For all of us who hope the tools of the social Web might play a role in untangling health care's many problems, now we know what we're up against.

Health 2.0 was the brainchild of Matthew Holt of The Health Care Blog and Indu Subaiya, MD of Etude Scientific, and they delivered a conference with many thought-provoking product demonstrations (and yes, a product launch or two) and much food for thought.

Many bloggers covered the play-by-play better than I can, and I will mention a few, as well as posts by participants, after the jump. If I missed any, please e-mail me at eculbertson (at) rwjf (dot) org so I can add them. But here are a few of my observations and questions about how health 2.0 might affect patients and consumers:

Congratulations to the Disruptive Innovations Winners

You voted, and your top three entries in the RWJF/Changemakers competition, "Disruptive Innovations in Health and Health Care: Solutions People Want," are .......

• Project Echo: Knowledge Networks for the Treatment of Complex Diseases in Remote, Rural, Underserved Communities, University of New Mexico Health Sciences Center (Albuquerque, NM) – Project ECHO (Extension for Community Healthcare Outcomes) teams up an academic medical center with a network of rural health clinics, the New Mexico Public Health Service and the state Department of Corrections to deliver health care to patients residing in underserved areas who have common, chronic diseases. The key component is a disruptive innovation called a Knowledge Network, through which the expertise of a single specialist is shared with several primary health care providers, each of whom sees numerous patients. Telemedicine and Internet connections enable specialists in the program to co-manage patients with complex diseases using best practice protocols, case-based knowledge networks and learning loops.

• Family Coaching Clinics, UCLA Semel Institute Global Center for Children and Families (Los Angeles, CA) – The Family Coaching Clinics offer a new model of preventive mental health for children and families. Located in retail centers and focused on a variety of specific child-rearing issues, the clinics reach families who might never seek out traditional counseling services or might not do so until crises arise. The clinics provide coaching designed to give families the tools they need to resolve common challenges before they develop in to serious problems, by changing family behaviors in ways that have been proven to be effective.

• Instant Birth Control, Planned Parenthood of the Columbia/Willamette (Portland, OR) – Instant Birth Control provides women in Oregon and Washington online access to hormonal contraception such as birth control pills. Instant Birth Control patients receive all necessary health screening and monitoring to assure safe quality care. By providing access to contraception services online, Instant Birth Control empowers women to take charge of their reproductive health by providing access to primary care 24/7, in the privacy of their home. Because they can avoid taking time off from work, school or family commitments, as well as travel and waiting time to see doctors in person, patients can manage their contraceptive and sexual health care in ways that are far more convenient for their schedules.

Descriptions of all finalists' innovations are on the Pioneer site. 

One more day to vote!

The voting period closes at the end of Wednesday for the Disruptive Innovations in Health and Health Care competition.  The nine finalists, selected from more than 300 entries, are listed here, which is also where you can vote once you complete the quick Changemakers registration process.  We want to know which projects you think hold truly disruptive potential - cast your vote today (...and no later than tomorrow)!

And sincere thanks for participating in this competition - it has been amazing to see the quality and diversity of the entries submitted, not to mention the more than 700 comments that folks around the world have logged on the competition site.  They reflect incredible vision and passion in transforming the health and health care marketplace in ways that put consumers needs -- and the jobs they want done -- first. 

Congrats to the winners you ultimately select!

Disruptive Innovations Competition: Time to Vote!

The finalists for the Disruptive Innovations competition have been posted on the Changemakers site. Please take a minute to check out the finalists, and take a few more minutes to vote.

I had the opportunity to be a fly on the wall during the judges' deliberations to select these finalists.  While I can't reveal who said what about which project, I did want to share some thoughts about the judging for this competition.  You can share your thoughts on the competition and on the finalists here.

First, there are some incredibly cool ideas out there!  The competition drew in over 300 submissions and many were engaging proposals.  In the finalist group, there were some "far out" ideas, in terms of technology, behavior change, policy, and more.  I'm hopeful that some of these out-of-the-box ideas can become more common place, and displace the ideas that keep us in a rut of poor (or mediocre, at best) health.  I've been involved with many proposal selection panels, and there's a reason why some of them have elaborate coffee bars—to keep the reviewers awake!  But there was no caffeine at this judging panel.  I think you'll enjoy reviewing the crème de la crème of the competition during the voting phase.

The voting phase for a Changemakers' competition allows the community to be informed, engaged, and heard. Even though we're not part of the judging panel, we can support proposals we think are strong ideas with promising impacts. And, in truth, it is the community of social entrepreneurs, health providers, consumers, etc., who are the real authorities and in the best position to judge what's a disruptive innovation.

The last point I'd like to share about the judging for the competition is the continued dialogue and potential to refine an entry. After an entry is posted to the competition, the Changemakers community can comment on, or ask questions about, an entry. As the judges reviewed and discussed the top selections, more questions came up. In a typical review process, if a question cannot be answered by another judge, it remains unanswered. And, more importantly, the issue isn’t addressed. With a Changemakers competition, the applicant has an opportunity to respond to the questions of the community and of the judges. The answers can help to refine and strengthen an entry, which, in the end, improves the quality of the entry.

Again, please visit the site and vote - become part of the discussion!

Disruptive Innovations Competition - What's Coming In

We're about six weeks in to the second RWJF/Changemakers competition -- "Disruptive Innovations in Health and Health Care: Solutions People Want." We're glad to see that word of the competition continues to spread. Thanks to Amy Tenderich of Diabetes Mine, Lucy Bernholz of Philanthropy 2173, The HealthCare IT Guy blog, the folks at Nextbillion.net and others for connecting their networks with the competition. (Added 6/19:  thanks also to the Space Prizes blog, which covered this competition on Sunday 6/17.)

We hope people keep coming to check it out and, more importantly, enter the discussion and their ideas on Changemakers to propel disruptive change in the health arena. The general consensus we've heard going around is that it's time, and it's needed.

Thirty-two organizations from nine countries have entered so far.  Some recent entry titles are intriguing (I point these out solely because they got me thinking after an initial glance...I leave the assessment of their quality and competitiveness up to the competition judges):

• A Rules-based Engine for Healthcare Quality, Innovation & Productivity
• TimeBanking with CareShares: Consumers as Co-Producers of Health and Long Term Care
• Patient Opinion International, which proposes to use Web 2.0 tools to add the patient voice to evaluations of the care they receive.

Thinking about that last one, I spend hours poring over cNet user opinions in researching my next gadget purchase.  The consumer opinions posted on TripAdvisor have helped us avoid hotels whose Web sites look great...but never tell you that you can't sleep for the street noise, the elevator's always broken and the desk staff could care less about your faulty air conditioner.  Imagine tools that let me do similar snooping on the specialist my primary care doc just recommended I see.

Visit the competition site to see what these projects are all about and learn more about entrants'  visions for revamping health and health care in ways consumers want. If they trigger any reactions/questions/objections/new ideas, we and our partners at Changemakers want to hear them -- post a comment!

July 18 is the entry deadline.  We look forward to seeing what other exciting ideas enter the mix.

Making A Disruptive Innovation Even More Disruptive

In introducing the RWJF-sponsored Changemakers competition on disruptive innovations in health care, Nancy Barrand spoke of “Walk-in clinics opening in Targets, WalMarts and drugstore chains across America” as an example of just such a disruptive innovation.

These clinics are generating a lot of news.  For a start, the Times reported Thursday that Walgreens has just bought a chain of them. And earlier this week, The Wall Street Journal ran an Op-ed that strongly supported this type of health care, albeit primarily for economic, rather than clinical, reasons.

The Journal also sponsors a health care blog that referenced the Op-ed, and the response on the blog came fast and furious.  And here’s where it gets interesting, at least from Pioneer’s viewpoint. 

We had at least one commentor (“TCB, physician, economist and IT innovator”) claiming that:

“If I use my crystal ball in light of what is happening in medicine with the innovators in IT, I would see these clinics as ideal places to get a focused physical examination.”

followed not long after by “Primary Care Physician,” who countered:

“I believe that innovations in IT will make Minute Clinics obsolete. If a doctor knows his patient, he can do more in less time and at lower cost via communication with the patient over web site or telephone than the Minute Clinic can.”

Given Pioneer’s investment in IT as a change agent in health care, which will it be?  And what can we, at the Foundation, do to help find out?

Innovations from the Blogosphere Up

Many thanks to the NextBillion.net blog for writing about the Disruptive Innovations competition. NextBillion.net is a comprehensive online resource from the Development Through Enterprise initiative of World Resources Institute. Their description nicely captures how the Changemakers' competition model can open new doors for foundations to do their work differently:

"And that's what Changemakers is doing with this partnership - they are creating a pipeline of investible healthcare innovations from the bottom up (sorry, blogosphere, but we're the bottom in this case) and mapping them right to a funding source."

Disruptive Innovation Competition – Transforming Markets to Get the Jobs Consumers Want Done…Done

Back in January, RWJF and Changemakers launched the first of three open-source online competitions to solicit promising ideas from a worldwide network of social change agents.  The first competition – “No Private Matter! Ending Abuse in Intimate and Family Relations” – surfaced a remarkable 243 entries. I’ll say more about what this means for RWJF’s interest in this area below.

What we found exciting about this partnership was Changemakers’ model of sourcing novel solutions from enterprising thinkers and do-ers across the globe. When RWJF holds standard grant competitions, we have a well-defined idea of the problem and what types of solutions are likely to advance the program’s goals. Our timeline for converting a proposed idea in to a funded project tends to be slow, and the wider world has limited access to or participation in the decision-making process. Through this partnership with Changemakers, we are able to test a more transparent, interactive way of generating ideas to inform our thinking on the problem and possible solutions.
 

Next up is a competition that gets at the heart of what drives Pioneer – innovations that encompass and push far-reaching change in health and health care. From May 2 through July 18, enter “Disruptive Innovations in Health and Health Care—Solutions People Want," a competition to identify ways the health and health care marketplace can offer services, tools and choices that consumers want…but that are now out of reach because of cost or complexity (or maybe the right idea hasn’t come along).

We’re particularly excited about this competition because, in addition to the Changemakers cash awards that will go to the winners, Pioneer team members will review the panel of entries with an eye toward ideas that RWJF may support down the road. We have up to $5 million available to fund disruptive innovations that show potential to go to scale.

Philanthropy as an Agent of Disruptive Change

As I write this post, I'm about to travel to the Council on Foundations (COF) annual meeting in Seattle. This year, RWJF is helping to lead an exploration of the role of philanthropy in improving public health. This is one of the four big societal challenges posed to participants; other tracks focus on poverty, disaster preparedness and response, and the environment.  None of these challenges exists in isolation - issues of access, equity, education and empowerment infuse them all. Without question, we'll need bold visions and innovative solutions to secure a stronger, safer, healthier future across these dimensions.

It is in that spirit of forward-thinking and bold vision that I welcome COF attendees to Pioneering Ideas - many thanks to COF for featuring us in your list of foundation blogs on conference computers!  Pioneering Ideas was launched in 2006 by the Pioneer Portfolio, the grantmaking area within RWJF charged with scouting innovative ideas that may drive breakthrough improvements in the future of health and health care.  Pioneer looks to support unconventional, often higher-risk projects that go beyond incremental improvements to seek transformative change.  You'll come across several in browsing the blog - posts highlight projects that are redesigning the personal health records of the future, outlining new policy approaches to combat antibiotic resistance, and applying video games to improving health, to name a few.

Included under that umbrella of innovation is room to test new models of doing philanthropy.  For instance, you'll read above that we're launching the second in a series of online, open-source idea competitions with Ashoka's Changemakers initiative. "Disruptive Innovations in Health and Health Care: Solutions People Want," kicks off May 2.

Harvard Business School Professor Clayton Christensen coined the term "disruptive innovations" to describe a level of change big and bold enough to transform business, markets, populations - even entire societies. Recently he published an article applying these concepts to social change. It's not an abstract concept.  As a doctor, I witnessed first-hand how the home glucose monitor changed the lives of tens of thousands of diabetics. It wasn't that long ago when patients had to get dressed and drive to a hospital, where a health care professional would draw their blood, process it and them give them the result hours later. Today, these same people can take a reading of their own blood glucose in seconds, without having to interrupt their schedule.

I've blogged on disruptive innovation before - the area continues to intrigue me as ripe with opportunity for philanthropy. In my view, what distinguishes philanthropies from charities or government organizations is that we possess the vision, assets and staying power to drive this type of transformative change.  We also know from experience how to discover, test and leverage fresh "disruptive innovations" of our own.

This is philanthropy as it should be - summoning the forces of disruptive innovation and retooling to improve the health, health care and quality of life for everyone in America.

We enthusiastically welcome your participation in the competition, by entering and/or joining the active Changemakers discussion spaces.  Please also share word of the competition with colleagues, grantees or others who you think may be interested.  For more information, I encourage you to visit the RWJF Web site, click on E-Mail Services at the top of the page and sign up for content alerts from Pioneer.

We hope to build on our experience with blogging and running open-source competitions to connect with new audiences both in and outside the fields of health and health care, and to broaden participation in our work.  They provide dynamic new mechanisms for increasing understanding, fostering interactive dialogue, and advancing solutions that make a difference in people's lives.  We hope you'll participate in these new channels and add your thoughts and ideas to the mix.

How Do We Design Truly Disruptive Innovations?

What will be the next disruptive innovations in health care?  This is a question I find fascinating to contemplate. Harvard professor Clayton Christensen broke new ground when he defined this concept, and in a recent (December, 2006) Harvard Business Review article, he refined it to apply to the social and health care sectors.

What intrigues me about disruptive innovations is not the impact they have on markets, profits or industries, but how they literally can transform the lives of ordinary people. A truly disruptive innovation makes it possible for ordinary people to have access to something they want, more easily, inexpensively and without having to rely on experts to the extent they did previously.

As a doctor, I witnessed first-hand how the home glucose monitor changed the lives of tens of thousands of diabetics. It wasn’t that long ago when patients had to get dressed and drive to a hospital, where a health care professional would draw their blood, process it and them give them the result hours later. Today, these same people can get a reading of their own blood glucose in seconds, without having to leave home or even change out of their pj’s.  If you’re a diabetic and are juggling family, school or job demands, that convenience factor can make a huge difference.  That said, if you don’t care about getting your blood glucose measured without muss or fuss, then the home glucose monitor won’t be a disruptive innovation. In other words, innovators have to understand what people really want – what will really make a difference to them as they manage their health in the context of their everyday lives – in order to create disruptive innovations.

So I ask myself (and you)—when it comes to health, or innovations related to health, what do people want?