Pioneering Ideas

Happiness is Hot

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

Happiness is gaining currency today, particularly in relationship to health and medicine. That’s what we’ve been hearing ever since Harvard School of Public Health researchers Julia K. Boehm and Laura Kubzansky published their report “The Heart’s Content: The Association Between Positive Psychological Well-Being and Cardiovascular Health” in the Psychological Bulletin, under a grant from Pioneer. This is the first study of its kind to look closely at how positive psychological well-being—including happiness and optimism—plays a role in heart health.

The story was indeed hot – gaining attention from USA Today, The Huffington Post, TIME’s Healthland blog,WebMD, The New York Times’ Well Blog, ABCNews.com, MensHealth.com, ModernHealthcare.com, Oprah.com, and hundreds more – and being shared throughout social networks and on the web.

This review, which bases its conclusions on more than 200 studies, taps into a larger conversation going on in health care today about the role of wellness and prevention. So often in health and medicine, we look at what is wrong and try to fix it. But more recently, attention has turned toward what we can do to get and stay healthy before things start to go wrong.

Prior research has primarily focused on how risk factors, such as anxiety and depression, are associated with heart disease and cardiovascular events. This investigation is the first to establish that health assets—such as optimism and happiness—are also associated with heart health. This most recent study fits into a new concept called Positive Health, which seeks to demonstrate that people can use and strengthen these assets to achieve a healthier life. 

The intersection of happiness and health – where we flourish both mentally and physically – is where we all want to find ourselves. The findings of this study make intuitive sense: They tell us that happy people are healthy, active, and health-conscious. They also point us toward a new health care paradigm that focuses on making the most of our inherent advantages—not just on avoiding what’s “bad for us.” The next step in this field is to establish whether or not we can design interventions that help build these health assets to help people increase their chances of living a healthier, longer, and perhaps happier life.

Read more of Paul Tarini’s thoughts on the growing evidence for Positive Health.

Pioneer Grantees Top RWJF’s Most Influential Research Articles of 2011

BY BRIAN C. QUINN, PHD, team director and senior program officer, Pioneer Portfolio

And the winner is …

We were quite proud and excited by the recent news that the work of two Pioneer Portfolio grantees placed first and second in the Most Influential RWJF Research Articles of 2011, as announced by David Colby, vice president of research and evaluation at RWJF, in January’s Evidence Matters.  

Coming in at number one, The Use of Twitter to Track Levels of Disease Activity and Public Concern in the U.S. During the Influenza A H1N1 Pandemic, published in May’s PLoS ONE. Dr. Phil Polgreen and colleagues at the University of Iowa monitored disease activity during the H1N1 outbreak by analyzing public messages or "tweets" on Twitter. The study established a model for monitoring disease outbreaks in real time.

Second place went to Project ECHO’s Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers, published in June’s New England Journal of Medicine. Dr. Sanjeev Arora and colleagues demonstrated that through Project ECHO’s transformative model of health education and delivery, primary care providers can be trained via video communications and real-time, case-based learning to manage complex chronic conditions formerly outside their expertise, thus expanding their ability to bring better care to more people in their own communities. By putting the best available medical knowledge into the hands of everyday clinical practitioners, Project ECHO exponentially expands the capacity of the health care workforce to provide high-quality care in local communities.

Congratulations to these grantees for their influential and innovative work to transform health and health care. We’re proud to call you part of the Pioneer family.

And a big thank you to all who voted or helped spread the word about these and the other great research articles in 2011’s top 25 list. You can still join in the conversation by using #Final_5 on Twitter, Facebook, and LinkedIn to discuss the winners and congratulate all the grantees who participated.

While you’re reviewing the Most Influential Research Articles of 2011, take a look at the top three most viewed Pioneering Ideas blog posts from 2011:

• Focus on the Pig: RWJF Chief Technology and Information Officer Steve Downs recaps the visions of industrial designers to re-imagine the environments in which we live, work and play for better health.
• What Does mEvidence Need to Look Like?: Vice President of Information Technology Al Shar discusses the hype and hope of mHealth and the need to develop evidence that supports its potential.
• Despite Political Uncertainties, an Emerging Model Shows Health Care Transformation is Possible: John Lumpkin, senior vice president and director of the health care group, discusses how Project ECHO can help us do more through the “force multiplier effect” of knowledge networks that create a health care system “without walls.”

We look forward to exploring more pioneering ideas with you in 2012 and highlighting the important work of our grantees. Keep checking back or better yet, sign up to receive Pioneer’s content and funding alerts and future Pioneering Ideas posts.

OpenNotes: Mind the Gap

Last week, I contributed to The Health Care Blog about OpenNotes, a Pioneer grantee that is enabling patients to view the notes their doctors write after a medical visit. I wrote that it is a simple idea – but also a dangerous one.

OpenNotes recently completed a pre-survey published in the Annals of Internal Medicine that asked doctors and patients about their expectations of how the idea would play out in real life. What they found is fascinating. Doctors and patients are clearly divided. On a wide range of possible benefits, doctors are more skeptical than patients. But what really jumps out are the responses to questions of whether patients would find the notes more confusing than useful, and whether the notes would make them worry more. The gap is dramatic. In each case, most doctors said “yes” while less than one in six patients agreed.

Why this disconnect between doctors and their patients? Why the gap between what doctors believe their patients can handle, and what patients feel they are ready to see?

The post has generated a nice discussion on the blog, and in the comment responses you’ll find that the results of the survey are reflected in the dialogue. I recently added my own two cents to the conversation, and I’d love to see you post your thoughts, as well.

The survey results have also been covered by USA Today, MSNBC.com, and TIME’s Healthland Blog.

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.

The Potential to Solve Perplexing Health Problems

In October, RWJF’s Pioneer portfolio laid down a challenge. Recognizing that good health behaviors often require behavior change, but that making those changes is usually easier said than done, we asked the pioneering world of behavioral economics to come up with solutions—innovative ideas to help people make the “right” decisions for their health.

The results were unbelievable. We’re excited to announce that Robert Wood Johnson Foundation’s Pioneer portfolio received more than 330 responses—a plethora of ideas drawing on behavioral economics to address tough health problems—in reply to our recent call for proposals.

We received applications from a variety of institutions, including universities, business schools, schools of public health, medical schools, clinics, non-profits, and research organizations. Our hope was to discover new interventions and insights that have potential to transform health and health care. In particular, we stated an interest in experiments that test innovative solutions to the challenges of obesity and consumer engagement. More than 50 percent of the applications we received focus on problems involving obesity. Nearly one-third involve consumer engagement. We are eager to dig into these as well as the investigator-initiated topics and invite those with the most pioneering ideas to submit a full proposal later this month.

RWJF’s Pioneer portfolio supports unconventional approaches to difficult problems—visionary solutions that have the potential to change the way we think about health and health care. We are the only RWJF team that accepts unsolicited proposals; however, when we target an area that we think deserves more attention, we are often humbled and excited by the caliber of the results.  I extend my warmest thanks to those scientists, economists, physicians and big thinkers who submitted your pioneering ideas as an answer to this call and to all those in our network who helped spread the word.

Drug Facts Boxes Featured in New York Times

Last week, the New York Times published an op-ed by the Dartmouth Institute’s Steven Woloshin and Lisa M. Schwartz that discussed the critical need for a redesign of something that can empower consumers to make informed decisions about their health care – the information that accompanies prescription drugs. As stated in their own words: “Bombarded with pharmaceutical ads listing what seems like every conceivable side effect, American consumers might think they are already getting too much information. But they — and their doctors — are not getting what arguably matters most: independent, plain-English facts about the medication.”

Prescription medication labels are hard to read, confusing and often leave out crucial information contained in Food and Drug Administration (FDA) review documents. Major side effects or potentially dangerous drug interactions can be hidden to patients on their medication packaging. By giving drug packages a simple makeover and creating a standardized, easy-to-read drug fact box—akin to what’s currently required for nutrition labels—information that is critical to enabling an individual to make the best health care decisions possible will be readily available to all.

Woloshin and Schwartz are leading the charge on the effort to develop these “Prescription Drug Facts Boxes.” Recognizing the opportunity for a simple design change to create better access to information and have a big impact on how people engage with their health care, we have been supporting their efforts since 2008. You can read more about that support here. This idea was simple and powerful enough to be included in the health care reform law.

Policymakers say that an additional three years of study are needed before beginning to implement the facts box. To me, it’s unclear what more they will learn in those three years. I don’t think it’s the lack of an evidence base. Woloshin and Schwartz have done a number of good studies about the efficacy and adding to them should not take three years. I don’t think it’s figuring out how to operationalize the production, a hand book is easily developable. I do think it’s a combination of two important factors: an underrepresented constituency and an overly strong concern for the potential adverse impact of any change.

The underrepresented constituency is the consumer. We are already given information about the intent of the drug and the dangers. The perception is then that the only thing the drug box adds is the ability to make a more informed choice. And that’s not seen as very important. Given that, it’s easy to see why the potential downside of the change needs so much study. If you don’t weight the value very highly, you need to be very sure that there are no “adverse events”.

That’s wrong. We’re being told (and in some cases, compelled) to take more individual responsibility for our health. Being denied access to clear and actionable information is wrong.

 

Introducing … DATA!

Next Wednesday at the IOM, HHS will do a big unveiling of its Community Health Data Initiative.  It will be a pretty big deal – HHS Secretary Kathleen Sebelius, White House CTO Aneesh Chopra and HHS CTO Todd Park will all be on hand and the expectation is that major tech companies will unveil prototype apps built off of some of the data sets that HHS will be making public.

The HHS/IOM event will be web cast, so check it out.  Either of these links should work:

1.    http://www.hhs.gov/open/
2.    http://videocast.nih.gov/summary.asp?live=9347

It’s an interesting headline when you step back and think about it.  HHS is making a major announcement – not about a new research breakthrough, a new vaccine, a new Medicare benefit or even a new grant opportunity.  It’s about **drumroll** … **drumroll** ... data!  Seriously.  The bet here is that the thousands (and I do mean thousands) of data sets that HHS maintains could actually support some useful applications – applications we can’t even imagine yet – in the same vein that the weather data produced by the National Weather Service generates so many services and businesses.  To some extent, these data have been available before, but they’ve been hard to get to.  The difference here is that HHS is planning to make access to the data easy and beyond that, make them available in ways that most lend themselves to application development.  It’s a conscious strategy to enable others to add value to these government data.

At RWJF, we’ve had a hand in one of the first major apps – the County Heath Rankings – which plots community health characteristics – for every county in America.  Go to the site and you can find both health outcome data, like premature death, and the social, behavioral and environmental factors that lead to those outcomes, like obesity, unemployment and air pollution.  And you can see how each county ranks on any of those factors compared to other counties in your state.  And the County Health Rankings data has even spawned an irreverent take on the data – the County Sin Rankings – winner of the Sunlight Labs Design for America contest for visualizing health data.  Check out the other contestants, who all offered imaginative ways to present health data to the public.  The point is that the government is not best suited to come up with creative ways to help people understand the health of their communities or the quality of the medical care they receive.  But creative designers, developers and activists, when given access to the data, can do it much better.  Once there’s a good platform, we always get happily surprised by the apps.

I’d love to hear what people think are the most exciting apps that get announced on Wednesday.  And while you’re at it, can you think of a more exciting name than “Community Heath Data Initiative?”

What is the Role of the Physician in a Data Rich World?

Last week’s Project HealthDesign workshop, held at the Vanderbilt Center for Better Health in Nashville, focused on how clinicians could use “observations of daily living,” or ODLs – data associated everyday experiences such as diet, exercise, sleep and pain – to provide better care to people with chronic diseases.  The five Project HealthDesign teams are refining their plans to integrate ODLS into the treatment of premature infants and their parents, obese teens at risk for depression, adults with Crohn’s disease and its complications, adults with asthma and depression or anxiety disorder, and elders with mild cognitive impairment.

A presentation by Kevin Johnson, vice chair of the Vanderbilt University Medical Center Department of Biomedical informatics and the project director of a previous Project HealthDesign grant, raised interesting questions about how to present information captured through ODLs and who should interpret the information.  Johnson showed this graph, which represented a self-report of medication usage over a month’s period as compared with a schedule. 

Clearly, any of us can tell at a glance that the patient adheres to this medication schedule extremely well. The presentation conveys this information quite clearly and, frankly, it doesn’t take a great deal of clinical training to interpret the information. But consider two other cases.  First, if this chart showed a much poorer rate of adherence, the challenge would be to look for patterns in the missed, late and on-time doses to see if there were behavioral triggers or environmental factors that explained the results (e.g. a change in work schedule means the noontime dose is problematic, a Thursday evening softball game makes it unlikely to remember). In the second case, one could overlay on the medication chart other data, such as pain level, mood or even clinical signs like blood pressure and look for patterns that might lead to inferences about correlations and interrelationships.

In each of these three cases, one could ask what skills and training are needed to review, interpret and act upon the information (one can even take it a step further and ask which of the cases requires human vs. algorithmic interpretation). Of course, at some level, the answer is “it depends,” but thinking about the question gives some insight into the broader question we’ve been asking of late in the Pioneer Portfolio:  “What is the role of the physician in a data rich world?” I’m not a clinician, so I’m on shaky ground here, but it seems to me that only the third case requires clinical training – because it’s a case that requires integrating clinical knowledge into a pattern sensing activity. It’s a form of clinical problem solving. The second case doesn’t seem to require clinical knowledge so much as an understanding of some concepts from consumer behavior, design or even behavioral economics and an ability to motivate – to work with the patient to find a solution.  And the first case seems to lend itself to automated processing to determine if the behavior is within some predefined range.

The question gets even more interesting when one factors in the patient’s own engagement in these cases. One would hope that the patient is looking at the same data and developing her own questions and hypotheses. With whom should she discuss them?

What do these scenarios and questions imply for the way we currently primary care and the health professions that make up that enterprise? How will those professions need to evolve?  Will we need new professions? And are the right skills being taught to the right students today?

The Government Wants You to Play with Your Food

In a move that underscores the potential for digital games to improve health and healthcare, the US Department of Agriculture together with Michelle Obama’s Let’s Move initiative announced yesterday a competition for apps and games “that encourage children directly or through their parents to make more nutritious food choices and be more physically active.”

The Apps for Healthy Kids competition will award $40,000 in prizes in two categories: Tools and Games.  All entries will be judged on their

• Potential impact on target audience;

• Quality, accuracy, and content of message;

• Creativity and originality;

• Potential for further development and use; and

• Potential to engage and motivate target audience. 

Judges include Aneesh Chopra, U.S. Chief Technology Officer, White House Office of Science & Technology Policy; Eric Johnston, Senior Software Engineer, LucasArts; and Steve Wozniak, Co-founder, Apple Computer, Inc.

 

When USDA was thinking about this contest, they pulled together a group of folks for advice, including Debra Lieberman, National Program Director for our Health Games Research Program; and, Ben Sawyer, who runs the Games for Health Conference, which we support. 

Kudos to the USDA for seeing the value of games and to Debra and Ben for their contributions.

Simplifying the Legal System: Philip K. Howard at TED 2010

Philip K. Howard, Founder & Chair of Common Good – a Pioneer Grantee – gave an engaging talk at TED 2010 on four ways to simplify the legal system. We encourage you to listen to the talk and then pop back over here and let us know what you think about his ideas.

You can also read more from Howard on RWJF’s Health Reform Galaxy Blog.

‘Tis a Gift to be Simple

George Whitesides, a chemist and the Flowers University Professor at Harvard, gave an elegant talk on simplicity at TED.  Whitesides asserted that simple things have four qualities:

• They are predictable and reliable;

• They are cheap;

• They have a high value-to-cost ratio; and

• They are stackable, that is you can combine them to build more complicated things.

The lowly transistor is a simple thing.  It’s also the building block of modern electronic devices.  Transistors enabled computers which enabled the internet which enabled, well, you get the picture. The point here is that simple things have emergent properties, that is, they enable complex systems to arise out of simple interactions. The next point is that you can never predict what results or complex systems will emerge when you stack a bunch of simple things together, snowflakes included.

 

What he’s talking about, clearly, are simple physical things.  But it led me to two thought experiments I’d like some help with…the first: identify two or three simple things that could be combined to create some novel product, service, or experience that would significantly improve health and health care. 

The second: can you deconstruct a complex aspect of our health care system and identify its most simple parts as a first step in re-thinking how things get done?

Benchmarking Progress in Health IT

Being at TED last week led to some interesting conversations about data, health and the progress of health IT.  One conversation in particular stuck with me – a computer industry executive pointed out that the pace of innovation in the computer industry is orders of magnitude faster than in the health IT industry.  Orders of magnitude.  As in 10, 100, 1000 times faster.  A bold claim.  But then think about some of the advancements shown at TED:

 

- Microsoft’s integration of Photosynth and Sea Dragon technologies to create a Virtual Earth experience where you can now do a street level fly through of a city neighborhood and see the facades of the buildings around you.  And where there are web cams, seamlessly integrate live video into the view.

 

- A voyage through the Digital Universe, which is about what it sounds like – extending the Virtual Earth/Google Earth experience to all known objects in the universe.

 

- Google’s demo of an image recognition feature where the presenter took a photo of a postcard of a hotel with the Nexus One and Google (the omniscient Google – not the company) returned the name and address of the hotel.  And speech-to-speech translation through the Nexus One as well.

 

- John Underkoffler’s prototype interface in which people can gesture toward a screen to “pick up” a document, then walk across the room and drop the document onto the screen of a different computer.

 

When you step back and think about it, it’s truly extraordinary.  The gap between sci-fi and ship dates is closing rapidly.  Magic abounds.

So where are we with health IT?  Progress to be sure.  Pockets of excellence.  But as best as I can tell, we’re still struggling with threshold challenges around data exchange, interface design, workflow and deployment at scale.  I’m still processing all this and I’m probably missing something, so I’d really like to hear from people on this question – is the pace of innovation in health IT really that much slower than in the computer and software industries?  If so, then the implications for how we think about the integration of IT into health care are really serious.

The Need for More Randomized Controlled Trials in U.S. Social Policy Interventions?

Esther Duflo, a development economist at MIT, gave a thought-provoking talk at TED on using randomized controlled trials to study the impact of anti-poverty interventions in developing countries. Instead of trying to answer the big, controversial question, “Does (international monetary) aid work?” Duflo tries to answer smaller, local questions that provide insight to the big question.  For example, mosquito nets are highly cost-effective for preventing malaria, but they’re not being used widely.  Duflo wanted to know why and whether cost had something to do with it.  Are poor villagers more likely to use mosquito nets if they have to buy them (at a low, subsidized price) versus getting them for free?  Her research showed it’s more effective to give the nets away for free. 

What’s most appealing about Duflo’s research is that she’s able to show what works (or doesn’t) and she can back it up with data.  Randomized controlled trials are the gold standard- for example, the 1971 Rand Health Insurance Experiment is still cited today, yet, they’re not extensively conducted on U.S. social policy interventions (with the exception of education) primarily due to cost, ethical issues, and complexity of the research design.  Knowing what works would ensure that scarce funds are directed towards those policies that have meaningful, lasting impact to improve the lives of millions of people.

Duflo’s talk raises some important questions: When is appropriate to conduct randomized controlled trials in U.S. social policy?  Should we conduct more randomized controlled trials in health and health care to understand which interventions work and to invest in? Or are randomized controlled trials too controlled, localized, unrealistic and infeasible?

Behavioral Economics and Public Health at TED2010

I particularly enjoyed the TED talk by Elizabeth Pisani, author of the book, The Wisdom of Whores. A former journalist whose work now focuses on drug users and sex workers, Pisani has a PhD in infectious disease epidemiology from the London School of Hygiene and Tropical Medicine and spoke on the second morning, one day after Princeton’s Daniel Kahneman, the father of behavioral economics.

Pisani voiced frustration during her talk about the mismatch between government policies and public health approaches and what influences the choices sex workers and drug users make. Her argument drew on the analytical framework behavioral economists like Kahneman have used so effectively to describe and understand the choices people make.

Pisani dismissed the field of public health as being limited by its reliance on a rational model to develop intervention programs. (TED likes iconoclasts.) In the case of sex workers, public health initiatives tell them engaging in unsafe sex with multiple partners can seriously compromise their health, presuming they will stop because it’s the rational choice to make. But Pisani argued that, in Indonesia, women become sex workers, in part, because they can make as much as five dollars a day when the average daily wage is 20 cents per day, a context that shapes their decision making.

 

I spoke with Elizabeth after her talk and asked her whether the field of public health could benefit from importing principles from the field of behavioral economics to improve analyses and interventions. She believes we need to focus on government and train political scientists in order to have better policy.

Thoughts?

The 90-minute TED

Much is has been written about TED 2010, so I thought I’d just chip in with a quick list of my five favorite TED talks that I urge people to watch online once they’re posted. (We’ll let you know via Twitter  — @pioneerrwjf —  when they are.) Before I get to the top 5, though, I do want to plug the talks by two of our Pioneer grantees – Nicholas Christakis and Philip Howard. If you haven’t had a chance to hear Christakis take you through the discoveries he made about the role of social networks in obesity and happiness or Howard put forth his ideas on how to change the legal system (and with it the way we approach malpractice in health care), please check them out on TED.com.

 

In no particular order, my five faves were as follows:

 

• Michael Sandel – a master teacher takes the audience through the meaning of justice.  Warm, funny and profound.

 

• Mark Roth – a natural storyteller tells a captivating tale of scientific inquiry as he seeks to understand a new and surprising way of saving people’s lives.  You get such an authentic sense of Roth’s curiosity and the joy with which he pursues his work.

• Sam Harris – a forceful argument for bringing expertise, knowledge and discoverable facts about how communities flourish into discussions of morality and values.

• George Whitesides – a thought-provoking and highly functional interpretation of simplicity.  “Simple” components are reliable, repeatable and predictable – thus they can be “stacked” to create remarkable systems

 

• Jake Shimabukuro – a virtuoso ukulele performance that you have to watch with the screen maximized and the sound way up.  Pure exhilaration.

 

Oh – and check out blippy.com – a site where you stream your credit card transactions to a social network, which sounds like the definition of conspicuous consumption but it might not be as crazy as it sounds – you could eliminate expense reports, for one thing.

Join Pioneer at TED 2010 – Health’s Future, Powered by You and Your Data

TED2010 – the Technology, Entertainment and Design conference – kicks off today and runs through the 13th in Long Beach, CA, with the Pioneer Portfolio resuming its role as an event sponsor.  There’s an amazing lineup of speakers, and we’re especially excited that two Pioneer grantees will take the main stage.  Nicholas Christakis of Harvard Medical School will be speaking on Thursday about the power of our social networks to influence the spread of health and social phenomena, including obesity, happiness and smoking cessation.  And Phil Howard, chair of Common Good and leading spokesperson for the work we have supported to test administrative health courts to overhaul our broken system of medical justice, will address the TED audience on Saturday.  

 

They’ll be among impressive company, joining speakers and performers including HIV vaccine researcher Seth Berkley, molecular technologist George Church, Bill Gates, musicians David Byrne and Sheryl Crow, behavioral economics founder Daniel Kahneman, game designer and Pioneer friend Jane McGonigal, chef Jamie Oliver and former CIA operative Valerie Plame Wilson, among many others. 

 

We’ll be leading two activities at TED – a luncheon on Thursday that will highlight the future of data-driven, patient-centered care.  We’re teeing up the following questions – in a world with abundant, accessible, actionable health data, how will our level of engagement in our health and health care change?  What expectations of doctors, nurses and other providers will we have, and what expectations will they have of us?  If we have and use our data – both those logged in our electronic medical records and those generated in the course of our everyday lives – how might our decisions change?  Behaviors?  Demands? 

 

It’s a fascinating conversation, and one that will feature Pioneer team director Paul Tarini as moderator WIRED executive editor Thomas Goetz and Beth Israel Deaconess primary care visionary and Open Notes grantee Tom Delbanco.  Thomas is releasing a book called The Decision Tree later this month that explores this new approach to health in which patients harness their data and use decision trees – essentially health-oriented flow charts – to engage more meaningfully in health decisions and manage their care more intentionally, leading ideally to better outcomes.  Tom will spotlight the role for providers to innovate in this space.  He’s leading the way in making health data for the patient – not just about the patient – by placing the information doctors enter in our medical records and clinical encounter notes,directly in our hands and revolutionizing our role in our health care.  We'll record the event and post it as a Podcast later in the week.
 
We’ll also be running an exhibit space all week, the centerpiece of which is a video drawn from interviews with a range of Pioneer staff, grantees and other experts on the leading edge of this data-driven, patient-centered vision.  A big shout out to our partners at DDB Issues and Advocacy, who turned hours of telephone interview transcipts in to a beautiful, dynamic and thought-provoking brief video that makes text – and these ideas – jump off the screen and challenge you.  I love this video and urge you to check it out and add your ideas and reactions on our YouTube page.

 

Pioneer will be live-tweeting from TED and we invite you to join us in the conversation on Twitter, where you can provide your answer to this: In a world rich with actionable health data, how will our relationship with doctors change?  Use the #pioneerdata hashtag and spread the conversation online.

 

Finally, we’ll be blogging the sights, sounds and stories of TED this week, so check back frequently.

 

What Does Your Health Care Have to Do With Your Mouthwash?

I wrote last year about consumer product, service and retail companies moving more aggressively into the health and wellness space and how their customer-focused approach could be a real challenge to the more traditional medical model which is still struggling to understand and operationalize patient-centered care.  According to recent news reports in the Cincinnati Enquirer, consumer product giant Proctor & Gamble recently purchased MDVIP, the nation’s largest concierge care company.  P&G reportedly purchased a small stake in the company a couple years ago.

 

"‘We see this as a learning venture as well as a business,’ said Nathan Estruth, vice president of P&G's FutureWorks unit,” the Enquirer reported.  Here’s a link to their story.

 

The article goes on to say that P&G “does not plan to market its products through the physician offices but rather use the company as ‘an incubator for primary care medicine,’ allowing it to gather information about patients and physicians, service and prevention. In 2008, for example, MDVIP worked with California-based Navigenics Inc., which P&G owns a stake in, to test that company's genetic marker that can gauge patients' predisposition to cancer, diabetes, heart attacks and other conditions.

 

“It's also talking with General Electric to test some of GE's diagnostic machines, Estruth said.”

 

I find these developments fascinating and can only begin to imagine how they might change the nature of care delivery.

Making Decisions about Nurse Practitioners’ Scope of Practice

Dr. David Eddy, founder of Archimedes, recently visited the Foundation to present ARCHeS, a Web-based delivery platform that enables policy-makers and health leaders to use the Archimedes model to run their own virtual trials. Dr. Eddy demonstrated a prototype version of what users can expect to access via ARCHeS and previewed new functionality that will allow providers and decision makers to use the model to tailor care decisions for individual patients. Pioneer is supporting Archimedes to build ARCHeS.  

What struck me about ARCHeS was the opportunity it presented to make evidence-based policy decisions about nurse practitioners’ scope of practice that could potentially result in significant savings. Currently, those who advocate for nurse practitioners playing an expanded, autonomous role in delivering primary care point to seminal evidence showing comparable outcomes in patients randomly assigned to either nurse practitioners or physicians where nurse practitioners had the same authority, responsibilities, productivity and administrative requirements, and patient population as primary care physicians. Though this research is not without its critics, it has been used successfully to convince many to see nurse practitioners as part of the solution to expanding access to primary care.  

Nevertheless, the debate around whether and how nurse practitioners’ scope of practice should be expanded and standardized nationally requires evidence that digs deeper into aggregate results. Policy makers need access to evidence that elucidates what nurse practitioners can do as well as physicians vs. tasks/responsibilities that should be left to physicians.  

For example, in his presentation, Eddy showed how ARCHeS, using evidence about both the cost and outcomes of nurse practitioners, indicates that having nurse practitioners administer shots to reduce cholesterol has a striking impact on the cost per QALY for a treatment option. Funders, including NIH, could use these criteria to prioritize funding condition/procedure-specific randomized control trials (RCTs) and other studies.  

To learn more about the implication of ARCHeS, I recommend reading a special report from Business Week entitled “Trimming Health-Care Costs Without Reforming the System,” which implies that the Archimedes model, when made accessible to policy makers and other decision makers, could lead to better decisions that could save billions in health care costs.

Talking About Philanthropic Failure

In a new Communications Network diavlog (no, that isn't a misprint, it is an awkward attempt to combine dialog, video, and blog), Pittsburgh Foundation President Grant Oliphant talks about failure. It is good to see more attention to this topic. Paul Brest of the Hewlett Foundation and Jim Canales of the Irvine Foundation have been outspoken about the need to be more forthcoming about programs that don't work, and Robert Giloth and Susan Gewirtz from Annie E. Casey Foundation document the potential value of foundation mistakes in the Winter 2009 issue of Foundation Review. So the issue is beginning to get traction. The Robert Wood Johnson Foundation's recently released Anthology (Volume XIII) adds to the mix with four chapters on foundation failures.

In his remarks, Oliphant comments about good and bad reasons for talking about failure. Good reasons include not wanting to hurt grantees or the cause intended to be helped - i.e., do no harm. Bad reasons include foundation embarrassment.

I’d offer two more – one good reason to talk about failure and one bad reason.  The bad reason is fear – fear of being held accountable for using tax-protected dollars in ways that don’t lead to results.  That fear is understandable, but it undercuts the very role that foundations are in the best position to take: reasonable risks on potentially high-impact activities that are less likely to attract support in the business or public sector.

 

The good reason starts with asking the question: why does the topic of failure even come up in the first place?  After all, the performance of most organizations is the constant subject of many outside observers. But that is the point - foundations are not the subject of systemic observation, in part because they occupy a relatively powerful and independent status in our society. As I argue in the RWJF Anthology, it is this very independence that drives the need for foundations to themselves generate the honest, critical assessment of their performance that is so important to their missions.

 

Finally, do you know of foundations that expect failure? RWJF's attention to failure is tied to different levels of risk intended to be taken by different grant portfolios in the Foundation. As my colleague Paul Tarini, Team Director of the Pioneer Portfolio, noted here, Pioneer expects more failure than other RWJF portfolios because it aims to support highly innovative, high-risk projects. If you are aware of other funding efforts designed to be high risk, and expect more failure, please let us know so we can learn from each other.

This Is a Brainstorm

There is no such thing as a blank check — particularly in this economic climate. Resources are not endless; parameters exist. But the Pioneer Portfolio is dedicated to powering ideas that have the ability to truly transform health and health care and — to do so — we need to encourage people to THINK BIG.

From October 27-30, members of the Pioneer team will be in San Diego to participate in TEDMED2009. While we are there, we will ask other participants — if someone was to hand them a blank check — what they would do to transform the future of health and health care? What kind of problems do they see as being “stuck” and that, if solved, could bring about significant improvements 5, 10, 15 or more years down the road?  Where are the breakthrough opportunities?

But we don’t want to limit the conversation to the group at TEDMED; we want to take the conversation to Twitter and ask a broader audience for their ideas. Like you.
 
There is no blank check.
 
This is not a call for proposals.
 
This is a brainstorm.
 
We want to hear your ideas because they inspire us and because we hope you might inspire each other.
 
If you would like to participate in the conversation and let us know how you would transform the future of health and health care, please tag your “tweets” with the #blankcheck hashtag. We’ll “retweet” them to share with those who follow Pioneer on Twitter and we’ll share them with everyone at TED MED through a live feed we’ll have playing throughout the event. If you don’t want to share your own ideas, but want to see what other people are thinking, you can follow the conversation here. And please consider telling others about the #blankcheck conversation.

Better Informed Managers of Our Health

Most of what I read and almost all of what I believe is that we, as individuals, must assume primary responsibility for managing our health. I'm also told that I need to become a more informed consumer when making health and health care decisions. As a person who's spent a good part of my career doing research I think that I'm more ready than most to investigate, consider and make informed decision. However, no matter how ready I am, no matter how skilled I am at analytic reasoning, I can not make an informed decision if the information is not available to me.

I know that some of the data is hard to acquire and may be harder to analyze. It is difficult even for hospitals to predict the total cost to the patient of a hospital stay. For drugs used to treat many conditions it can be hard to understand the cost versus the benefit, especially where there are competing choices. The prescription drug situation is further complicated by the fact that there is so much direct to consumer advertising of patent medicines that almost never reveal enough data to make an informed decision.

The perspective article in the recent New England Journal of Medicine discusses the fact that, although the FDA collects and makes available what may be extremely important information about prescription drugs, it does so in a relatively haphazard way. The authors, Lisa M. Schwartz, M.D., and Steven Woloshin, M.D. have developed a format for a "Prescription Drug Facts Box" that has been shown to provide clearer, more actionable information to consumers. We funded an FDA pilot of the Facts Box and, most recently, the FDA's Risk Advisory Committee recommended that the FDA adopt these boxes as the standard for their communications. It seems to me that this is one relatively straight forward way that we can become better informed managers of our health.

Fun Behavior.

Earlier this month, Volkswagen launched a competition for ideas to help change people's behavior. The premise is that the best way to change behavior is to make things fun. They call it The Fun Theory: http://thefuntheory.com/.  One example: get people to switch from the escalator to the stairs by changing the steps into a working piano. There are three videos that will make you smile. The competition closes Nov. 15; first prize is 2,500 euros.

Are questionable dosing practices fueling antibiotic resistance?

This post comes to us from Patricia Geli Rolfhamre over at Extending the Cure.  More in-depth conversation about antibiotic resistance and the future of our nation's supply of antibiotics is happening on the ETC blog.

Are there ways in which we can reduce the spread of antibiotic resistance by treating patients more strategically? The dosing and duration of antibiotic treatment have been shown to be critical determinants of the likelihood of curing an infection and of the emergence of resistance.   Adjusting these factors to a patient’s individual condition instead of treating every patient with the same antibiotic regimen may be an easy step toward fighting resistance.

Research reports from the American College of Emergency Physicians annual meeting in Boston earlier this week revealed that doctors who work in hospital emergency rooms rarely adjust antibiotic doses for obese patients. The consequences are an increased risk of treatment failure and resistance development. Yet it is unclear how much this will spur the growing resistance epidemic. Given the fact that more than a third of the US population is obese - this trend is worrying. But solving the obesity problem or adjusting the doses for obese patients is only a part of the answer. The other important parameter for successful treatment and for which a one-size-fits-all approach has generally been applied is the duration of treatment.

The H1N1 Flu Prediction Market

As kids across the country are starting to go back to school this month, parents, health officials and school administrators are wondering whether or not we will see a resurgence of H1N1. While no one can forecast the future, we asked Phil Polgreen and Forrest Nelson, the directors of the Iowa Electronic Health Markets, to explain what they’ve learned so far from their H1N1 market, a pilot prediction tool, and discuss what their expert traders believe will happen in the fall. The Iowa team has been running prediction markets for avian influenza (bird flu) and for seasonal influenza for several years.

On Friday, April 24, some of the first news reports about a frightening new influenza virus surfaced here in the United States. That news prompted us to re-tool our prediction market for the bird flu in order to develop a market for this new strain. We immediately started working on the questions for the new market and recruiting traders.

We had already assembled a group of microbiologists, doctors, public health officials, epidemiologists and others that had inside information about influenza, including trends in seasonal and bird flu. We gave those experts $100 in virtual money (makeshift dollars that can be used to buy and sell shares on the market) and asked them to start trading. By April 28, the H1N1 market was up and running.

Right off the bat, most of our traders predicted that by the end of May, there would be more than 1,101 cases across the U.S., with a low the mortality rate. As it turned out, they were right: As of June 1, the Centers for Disease Control and Prevention had reported 10,053 cases of swine flu in all 50 states and the District of Columbia with 17 deaths at that time.

What’s remarkable about the forecast is that in late April, news reports played up the danger factor, reporting that the virus was killing young, relatively healthy people in Mexico. The fear was that H1N1 would spread rapidly in the U.S. too and be a formidable killer. Our expert traders didn’t buy into the hype, betting instead on a future that resembles the course actually played out by H1N1. In fact, the market predicted that H1N1 would spread widely and quickly but the mortality rate would be less than 1 percent during the first few weeks of the outbreak.

Can Green Cleaning Products Prevent and Control HAIs?

We’ve written several times on Pioneering Ideas about the impact of hospital acquired infections (HAIs) on lives and hospitals as well as the costly drain HAIs have on the health care system.  Simply increasing the use of cleaning and disinfecting products to tackle HAIs can create a host of other health hazards for both health care facility workers and patients – not to mention significant harm to the environment.

This conundrum has led to the development of wide range of green cleaning methods, but at this point there remains a need for more evidence of about the extent to which these programs meet infection control and prevention goals. In a recent white paper, Health Care Without Harm(HCWH), in collaboration with the Global Health and Safety Initiative(GHSI), explores whether there are cleaning strategies for the health care sector could effectively prevent and control infection in a way that would be both healthier and friendlier to the environment.

The paper, which was produced with support from Pioneer, does not present any final answers, but it does lay out some out compelling recommendations for “closing the knowledge gap.”  Please take a look and let us know your thoughts.

Now that’s Progress

1899

 

2009

 

My family dog, Chance, testing the latest prototype. 

Credit to my wife, Naomi, for the idea.

The back story: Chance is about seven months old. He learned to swim in a local creek the other day. Then, in his excitement, he jumped off a bridge and landed on ground 10 feet below. I think he figured if he could swim, then he could also fly. We spent a good five hours at the emergency room, most of it waiting. The vet on call wanted a specialist to see him. The specialist, a doggie ortho surgeon, thought they would need to operate—to the tune of $4,000.  Additional x-rays showed no broken bones, but some torn tendons. It was just like a visit to a human ER, only with a lot more fur. Chance should be ok in three or four weeks.  In the mean time, he claims to be receiving podcasts from New Zealand.

Can a Reduction in Hospital Acquired Infections Cut Health Care Costs?

There is no denying that hospital acquired infections (HAIs) are an expensive drain on the system and impact the lives of an estimated 1.7 million hospital patients a year – killing nearly 99,000 annually. Is it possible that simply instituting best practices in infection control can substantially reduce these infections and save the nation’s healthcare system billions of dollars a year?  Yes, according to an article in last week’s Roll Call by Ramanan Laxminarayan of the Extending the Cure initiative, a Pioneer grantee, and Ed Septimus from HCA Healthcare System.  Laxminarayan and Septimus propose several ideas and incentives, which they believe will reduce the rate of resistant HAIs and control the rise of antibiotic resistance. 

Are hospital acquired infections really the low hanging fruit that will benefit patients and cut health care costs?  Check out the article and then come back here and let us know what you think.   

 

Using Games to Support Children's Healthy Development: Opportunities & Challenges

We welcome Ann My Thai to our guest blogger series.

Ann My Thai is the Assistant Director of the Joan Ganz Cooney Center at Sesame Workshop and the co-author of Game Changer: Investing in Digital Play to Advance Children’s Learning and Health. Ann leads the Center's strategic partnership efforts with high tech and gaming industries, and oversees organizational growth and strategy. Before joining the Center, she served as a consultant for Education for Development, Vietnam, a nonprofit organization that develops informal educational programming for disadvantaged children in Ho Chi Minh City, Vietnam. Thai received her bachelor's degree in Political Science from Yale University and a master's degree in Business Administration from the Ross School of Business at the University of Michigan.

Readers of the Joan Ganz Cooney Center’s latest report, Game Changer: Investing in Digital Play to Advance Children's Learning and Health might be asking why we chose to discuss how digital games could advance both children’s learning and health in the same paper. Named for its founder, the Center’s roots lie in Sesame Street’s “whole child” approach, which encourages learning that supports many different aspects of a child’s healthy development—from literacy skills, to social and emotional development, to practicing healthy habits.  A solid base of research tells us that children who eat healthfully and are more physically active are also able to learn more easily.  It also tells us that children who suffer from health threats such as obesity do worse in school and are less successful later in life.  Given the inextricable ties between learning and health, and the parallel efforts in each field to harness the power of games, we wanted to address the potential role they might play in health and education reform together.

The idea that digital games might actually help improve children's learning and health is, in some quarters, a radical one, but for authors of the report, it is also a pragmatic one. The medium has a high penetration, with 97% of American teens playing computer or video games.  Furthermore, digital games are reaching children at younger and younger ages for longer periods of time.  The average child begins playing games at age 6, down from 8 years old a few years ago, and the amount of time a child plays on average more than doubles between age 6 and 9.  This level of play shows that it is no longer a question of whether we should enlist games in our learning and health efforts but how we may do so.  Game Changer aims to spark a productive dialogue about the opportunities and challenges of using games to support children’s healthy development.

To kick off this dialogue, we unveiled the report on Tuesday with the Woodrow Wilson Center for International Scholars at an event in Washington, DC.  It featured a panel of experts from industry, research, and policy and hosted nearly 100 participants and a web audience from these key sectors. 

A key insight raised at the event was the lack of training available to health researchers to engage in the type of multi-disciplinary game R&D requires. Dr. David Abrams, Executive Director of the Schroeder Institute at the American Legacy Foundation, which focuses on accelerating the reduction in tobacco use, especially for young people in the U.S. population, said that the health care sector has “not looked beyond itself” to consider the whole child in advancing children’s health. The current generation of health researchers is too often isolated from the broader perspectives or tangible incentives to engage in a multi-disciplinary approach.  

Some of the biggest challenges of the day—such as childhood obesity or the fourth grade reading slump—are too broad and complex to be addressed by the expertise of any one discipline.   These are problems couched in layers of social, economic and other environmental factors, as well as developmental factors distinct to each child.  Responding to these issues from a whole child perspective will demand greater investment toward funding and collaboration models and infrastructure that support multi-disciplinary collaboration.  Such investment is essential if we are to tap into the digital media that surrounds today’s children in a purposeful way.  

Marketing the Concept of Games for Health

We continue our guest blogger series with Nedra Weinreich. 

Nedra Weinreich is a social marketing consultant who helps nonprofits and government agencies strategically promote health and social issues through her company Weinreich Communications. She is the author of Hands-On Social Marketing: A Step-by-Step Guide, writes on social marketing issues at the Spare Change blog and is the director of Social Marketing University. Nedra has an MS degree in Health & Social Behavior from the Harvard School of Public Health.

Games for health intrigue me because they have such potential for achieving the behavior change-related objectives we in public health often struggle to reach - changing awareness and attitudes about an issue, educating people with key facts, building necessary skills, and even the holy grail of engaging in healthful behaviors during the course of the game. Health gaming shares the roots of its success with other entertainment education approaches (like health topic "product placement" in television plotlines) by engaging its players emotionally, embedding learning opportunities within fun activities, and allowing people to try out new skills (either vicariously or in actuality).

Forward-thinking people in the behavior change business know all this. Unfortunately, many others hear the words "digital health games" and either say, "Ho-hum, how exciting can a game about health be?" or immediately conjure up the negative stereotypes of video games as a cause of violence or sedentary behavior. Whether it's parents, teachers, children, health professionals, game producers or funders, all need to be on board for these products to be viable. Let's explore how to market the idea of games for health as a serious intervention for many different public health and medical challenges.

Good marketing is always based on research with the target audience, so a key first step should be to learn more about how each group views digital health games for children. What do they see as the key benefits? What would stand in the way of their adopting or supporting them? How might games for health best fit into their personal or professional lives? Clearly, each of the groups listed above would need different approaches to persuade them of the merit of these products. In fact, within each audience may be several subgroups; for example, parents of young children likely have very different concerns and experiences with digital games than those with teenagers. Teachers at each grade level have different learning objectives for their students. In any case, the more individuals from each audience are involved in the actual development of the games, the more likely they will be successful.

Let's look at the product itself. The way health games should be framed depends on to whom you are talking. For health professionals and funders, positive research results are the key. Focus on the games as an intervention that has demonstrated success (and work hard to accumulate the hard evidence to back up your claims). Parents and teachers will respond best to an emphasis on learning and skills building that will serve to help the kids stay healthy as they navigate through life. For kids? It's got to be all about fun. If it's not fun, the game needs at least to be interesting enough to capture their attention. And game producers will be concerned with one thing: are games for health marketable? The Wii and Wii Fit have been game-changers (pardon the pun) in their popularity and may open up many more doors in this direction.

We also need to determine the main barriers that stand in the way between each audience and its unbridled support and use of health games. Adults will need to give up their views of what games are and what they can be. Many may feel that information conveyed in the form of a game means that the importance of an issue is being downplayed, or may worry about these being just another video game with negative behavioral effects. Again, the way to break down these barriers is by emphasizing results in the form of health outcomes, compliance, patient satisfaction, or positive changes in other measures of knowledge, attitudes and behaviors. For kids, the kiss of death for any activity is if it's perceived to be boring, especially if it's billed as "good for you." Health games must be banana splits, not broccoli, and promoted to kids with the emphasis on "game" rather than "health."

From a marketing perspective, let's think about how best to fit games for health into people's lives. What are the times and places they will be most able and interested in playing or prescribing these games? Some key ideas, many of which are already being implemented, include making them portable so people can use them anywhere, making sure that the games fit with the consoles or equipment they already have, and finding ways to combine digital games with real-life situations. Health professionals need to know what games are available for various health conditions so they can match their patients with the right interventions, perhaps via a centralized database. And when the idea comes from their doctor, a parent can feel more comfortable with letting their kids play.

Promoting the concept of health games will also have to be targeted to each audience. Perhaps they will become more acceptable as a health intervention as more "clinical trials" of their outcomes are published in peer-reviewed journals. Skeptical parents, teachers and children may become more convinced of the benefits of games when given the opportunity to try them out themselves. Many a person has been convinced of the exercise value of the Wii after trying it out at a friend's house and realizing their muscles are sore afterward. Game producers may need specific incentives from funders or investors to move into what they perceive as less robust markets until they see the demand from consumers.

Working with organizations and public agencies to craft policies friendly to these new interventions can help create fertile ground for health games to bloom. For example, when certain games have been proven to improve health outcomes would health insurers extend coverage for purchasing them with a doctor's prescription (and send a Wii-fund as reimbursement)? Can we increase the number of school districts that have incorporated Dance Dance Revolution into their physical education curriculum?

Finally, building partnerships that reach across categories will be beneficial to all involved. Working with trusted organizations or familiar characters creates games that start from a strong position with consumers in all categories. Thanks to the Robert Wood Johnson Foundation for cultivating these alliances with key partners and building the foundations for games for health to emerge as a pillar of health interventions.

Fun, Kids & Evidence-Based R&D = Games for Health Success?

We continue our guest blogger series with Richard Tate of HopeLab.

Richard Tate is the Director of Communications and Marketing at HopeLab and a blogger on Sticky Notes, HopeLab’s official blog. 

HopeLab, maker of the groundbreaking Re-Mission videogame for teens with cancer, is an innovative nonprofit harnessing the power and appeal of technology to improve the health of young people. Their evidence-based, customer-focused development process delivers fun, effective products that measurably improve the health and quality of life of adolescents and young adults.

More than 30 years ago, Joan Ganz Cooney began to build the evidence base for entertainment technology as a tool for good in the lives of young people. From Cooney’s work, the groundbreaking program Sesame Street emerged, and the show quickly demonstrated the incredible power of harnessing the appeal of TV technology to achieve specific goals in children’s educational, behavioral and social development. The approach worked, and TV producers, critics and generations of viewers were persuaded.

Can we do the same for digital games? Most definitely. What will it take to get there? The Sesame Workshop’s Joan Ganz Cooney Center released a new report offering a roadmap forward. Based on my work at HopeLab with our Re-Mission video game for cancer and my own experience as a kid watching Grover and Big Bird after school, three things come to mind as essential components: fun, kids’ input and evidence-based R&D.

Focus on Fun: There’s a reason 97% of American teens play computer or video games (hint: it’s not because they’re looking for educational opportunities). It’s because games are fun. And “fun” doesn’t have to mean “pointless”. Quite the contrary. The creative freedom afforded by today’s game technology gives us an opportunity to produce content that’s immersive, highly entertaining AND targeted at specific outcomes in the “real” world. But if games aren’t fun, kids won’t play. And if kids won’t play, we can’t achieve the outcomes we’re after. That’s where many “serious game” projects seem to stumble. Looking back, I didn’t watch Sesame Street because I wanted to learn the alphabet. I just had a blast singing “C Is for Cookie” with Cookie Monster.

Kids First: How do we know what’s fun for kids? We don’t – unless we ask them. Too often, the fun factor – the essential ingredient for games – is forgotten when adults begin to layer education and learning opportunities into entertainment media based solely on academic research. The best, most reliable way to gauge what’s truly engaging and fun for kids is to engage them directly. In our experience at HopeLab, kids are great at generating ideas and honest with their opinions when given an opportunity to contribute. It’s why we invite them into our development process and incorporate their feedback every step of the way. Talking to kids is the best way for us all to ensure we’re on track to deliver games that are fun and effective in improving kids’ lives.

Evidence-Based R&D: Commercial video games for entertainment are largely developed based on the creative vision of industry experts. Games that aim to do more than entertain require both creative vision and evidence to inform objectives and validate outcomes. Data – scientific evidence that games work – has been the critical missing piece in catalyzing broad, systemic and sustained engagement in digital games development for health and education. For example, demonstrating through research that games can enable patients to better manage their health and reduce healthcare costs is essential to engaging the healthcare industry in creating games as tools for consumers.

Research also provides insights to the field on how to create games that work to achieved desired benefits.  Advances in health games research and development have largely been driven by the commitment and financial resources of major foundations like the Robert Wood Johnson Foundation, and individual philanthropists, like HopeLab founder and board chair Pam Omidyar. The government also has funded development of leading-edge, game-based virtual technology for training soldiers. HopeLab has generated compelling data on Re-Mission and how it works to improve kids’ health, but more needs to be done in the field. RWJF’s Health Games Research Project aims to do just that. It would be great to see others come forward in the public and private sectors to support more evidence-based development of health and education games in the coming years.

Games are a tremendously powerful part of our kids’ lives, and it’s within our control to make them tools for good. The new Cooney Center report is a timely assessment of how digital games might advance our efforts to improve the health and learning of young people. Wouldn’t it be great to look back on this time as the point at which digital games, like television, became a medium that both entertained us and improved our lives?

Developing and Sustaining Health Games—A Losing Battle?

We welcome Melanie Lazarus as part of our guest blogger series.  

Melanie M. Lazarus, MPH is the Director of Marketing for Archimage, a serious game developer with titles including Escape From Diab and Nanoswarm: Invasion from Inner Space. She is also editor of healthGAMERS, a blog designed to educate the public about the games for health field, and author of Monster’s Blog, the corporate blog for Playnormous Health Games. Melanie has a B.S. degree in Microbiology from UT-Austin and an MPH in Health Promotion and Behavioral Science from The University of Texas Health Science Center at Houston.

The video game industry is an influential one -- $13.5 billion influential. Improving the health of children through a messaging medium this big seems like an obvious idea. Unfortunately, as a developer in this space for several years, we’ve found that obvious does not always translate into easy.

Archimage began work in 2003 on two National Institutes of Health-funded video games for the prevention of obesity and type 2 diabetes in children: Escape from Diab and Nanowswarm: Invasion from Inner Space. Since then we have moved into the relatively unexplored area of online casual games for health with our subsidiary Playnormous Health Games. From our perspective, there are three significant barriers to the proliferation of health video games in today’s marketplace. I’m sure there are many more challenges to choose from, but the following have been the biggest we’ve faced.

Getting funded

Although there is strong interest in exploring video games for health among government funding agencies like the National Institutes of Health, many grant reviewers are not as committed. Video games for health use entertainment to deliver its medicine. The words “fun” and “games” are not universally appreciated in the medical and scientific research academies. We have been literally told (though the trend now seems to be on the decline) not to use those words in association with serious topics like “health” and “disease.” The press is full of negative comments about video games as both the cause and effect of teenage violence. Similar sentiments can be found in the hearts and minds of some grant reviewers. Getting funding for the creation and research of video games for health may be an uphill battle for some time.

Sustaining funds

As Director of Marketing for a serious game design firm, I always find it interesting to talk with decision makers about the health games market. More often than not I’m told, “Market? What market? No one can make money on these things. Why don’t you just try to get on Oprah? I bet she’d like health games.”

Indeed, Oprah probably would. But a market beyond grant-based video game research is a topic worth discussing in the business community too. No question about it, an economic foundation beyond grants must be found to sustain the video games for health movement. A working commercial model is also needed to provide the researchers and developers with health game experience with the means to produce ever more effective games. There can be huge funding gaps between formative research, product development, and the clinical trials required to get a video game tested and ready for market. This industry needs a commercial basis and viable distribution models. On a positive note, investors such as health insurance companies, pharmaceuticals, and the food industry giants are starting to look beyond the feel-good messages health games can provide. Unfortunately, that’s not the same as viewing video games for health as critical influencers on the lives of their patients, customers, and constituents.

Knowing what works, and why

The literature on how and why video games for health work is rather thin. Clinical efficacy trials are few and far between. There is no real history to give game developers the X + Y = Z formula needed to develop medically and cost effective health games. Some research has been conducted on how the brain reacts to violent games versus non-violent games via functional MRI studies, but what about other aspects of health games? Very little research has been done on what is fun, let alone how fun translates into positive health change. I hate to sound like a researcher, but more research needs to be done on this. And research takes funding.

Light at the end of the research tunnel

Investigators are starting to report their data on the effectiveness of health games, including Diab and Nanoswarm, which should be available in the next few months.  An increase in positive evidence for health games in the literature could underpin new rounds of funding, commercial interest, and venture capital support.  Furthermore, it is encouraging to see large institutions like the Robert Wood Johnson Foundation and the Joan Ganz Cooney Center showing an interest in the use of technology for the improvement of child health. The days of health games sitting on researcher back shelves may soon be over. Let’s move beyond initial formative research and start getting these games to market.

Guest Blogger Series: Views on Increasing the Use of Digital Games for Health

We started June off with a look at games for health in preparation for the 2009 Games for Health Conference. We attended, we tweeted, and we shared updates on some of the incredible developments that took place this year. Now we’d like to end the month by looking at the opportunities that games have in creating positive health outcomes among children.

Yesterday, the Sesame Workshop’s Joan Ganz Cooney Center released a new report on the power that video games can have in addressing some of the most pressing health challenges facing America’s children. The report outlines some strong evidence that games can make a positive impact on the health of our children – a great step. However, we also recognize that there is still work that needs to be done to increase the use of digital games for health.

With that challenge in mind, we posed a question to a panel of guest bloggers and invited them to share their point of view:

“There is a growing consensus that digital games can be deployed to support learning and behavior change for positive health outcomes among children. What do you think needs to be done to increase the use of digital games for this purpose?”

Over the next week, they’ll be posting their thoughts right here – we encourage you to leave your comments and take part in the conversation. 

Catalyzing the app store for EHRs

Posted by Steve Downs and John Lumpkin, Senior Vice President, Health Care Group

Recently, Steve posted about the idea, floated by Ken Mandl and Zak Kohane, that EHRs (or health IT more broadly) could move to a model of competitive, substitutable applications running off a platform that would provide secure medical record storage.  In other words, the iPhone app model, but, for example, you could have an e-prescribing app that runs over an EHR instead of the Yelp restaurant review app on your iPhone.  We’re thinking about the provider side of the market here, as Google Health and Microsoft HealthVault are already doing this on the consumer side.

It’s nice to ponder these “what ifs,” but we’re a bit more action-oriented here and we’ve turned our attention to asking what it would take to make this happen.  It seems that there are two things that are needed. First, we need the platform.  Some of the most notable platforms started out as proprietary that were then opened up.  The IBM PC comes to mind as an example. Some were designed from the beginning to be open platforms with limited functionality until the market started developing applications.  A recent example is the development of iGoogle and the tons of applications that are available for free.  Finally, there was the purely public domain development from the beginning to end that we've seen in the Linux world.  Or perhaps we don’t need a common platform and maybe what is needed is to stimulate the market for health IT products that have open application programming interfaces (APIs) that allow for third-party application development?  Several ideas come to mind.

Engineering Errors Out of Health Care

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

 

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

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

 

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

 

Update: Positive Deviance & MRSA Reductions on NYT Lede Blog

Kevin Sack interviewed the CDC's John Jernigan about the effects of the Plexus Institute's positive deviance MRSA prevention partnership and wrote a post on the New York Times "Lede" blog.  Check it out and comment away, either there or on Pioneering Ideas.   

Keeping an Eye on Prize Philanthropy

McKinsey & Company’s recent report on prize philanthropy is a useful overview of the field. Titled “And the winner is . . .capturing the promise of philanthropic prizes”, the report is available here. Kudos to McKinsey for conducting a broad scan of an important philanthropic tool, and to the John Templeton Foundation for initiating the idea, sponsoring the work and sharing it with the field.

Why is this report useful? It puts prizes in historical perspective and explores the reasons for the recent increase in their use. It combines a review of the scholarly literature with insights gleaned from the leading practitioners in the field. And it develops a set of categories that go beyond the useful, but limited, distinction between recognition prizes and inducement (or incentive) prizes. The report’s six prize archetypes point to important traits that anyone considering using prizes should carefully review.

 

I was particularly interested in this report because RWJF, and the Pioneer Portfolio in particular, has worked with many of the organizations featured in the report. We have worked with Changemakers on a number of competitions, and are continuing to do so. We worked with Hope Lab on the Ruckus Nation competition and with Idea Crossing on its Innovation Challenge for MBA students around the world. And we worked with the X Prize Foundation in its efforts to develop a health prize. These experiences influenced my thinking as I read the report, and prompt two suggestions for future work on prize philanthropy.

 

The first is to work towards a clearer sense of the boundaries of this field. Prize philanthropy, when viewed broadly (as this report did), covers a huge territory. This makes it difficult to distinguish from a whole host of other strategic (goal-oriented) philanthropic approaches. For example, the report lists four important lessons about how to create and deliver effective prizes (p. 35), but none of these lessons is unique to prize philanthropy; they apply to any type of strategic philanthropic activity.

Freakonomics Blog Sparks Debate On "Designing for Better Health" Competition

Major thanks to Steven Levitt of the New York Times Freakonomics blog (and co-author of the book by the same name) for publishing a post on the new Changemakers competition, "Designing for Better Health."  The competition, which seeks innovative "nudges" that can influence people to make healthier choices for themselves or others, has kicked off a really interesting string of comments among Freakonomics blog readers.  Add your perspectives, either there or on the Changemakers competition site.

Posting from TED: Bacteria May Be The World’s Best "Risk" Players

According to Dr. Bonnie Bassler’s TED presentation on Friday, bacteria operate inside your body in way that’s similar to the game of Risk.  Bassler’s a molecular biologist at Princeton and she studies the way bacteria communicate with each other.  She said they’ve found that bacteria send out a simple chemical signal that can only be read by bacteria of the same type.  When there’s enough bacteria sending enough like-minded signals, the bacteria launch an attack (technically, it exercises a specific behavior it’s genetically programmed to exercise…in some cases that could be good for the host, in others, such as with MRSA, it could be really bad).  This communication is called quorum sensing.

It’s more complicated and more elegant, though.  Bacteria have a second simple chemical signal they send out.  This one can be read by all bacteria.  It tells a particular type of bacteria what other types of bacteria are in the host and how much of it is there.  Too much of bacteria Y, and bacteria X won’t launch its attack/exercise its behavior.

In Risk, it was always one thing to get control of Australia and another to gain enough reinforcements to successfully attack another piece of territory.  And the question of whether to attack was always informed by the size of your opponent’s army.

Bassler’s work is more than just a game.  It suggests a new approach to dealing with bacterial infections, one that involves interfering with the communication mechanism of the bacteria.  This may open up whole new avenues for pharma companies working to fight infections in this age of intensified antibiotic resistance.  In a related vein, policy changes that could facilitate the development of new antibiotics were outlined in the report "Extending the Cure: Policy research to extend antibiotic effectiveness," produced under a grant led by Ramanan Laxminaryan. 

Posting from TED: Health, Design and Game-Changers

Sorry for the lapse in TED posting…never have I seen an event program as packed as this.  It’s made getting back to the hotel a challenge, and throw in some tenuous wireless connections…well, you get the point.  But here’s a recap of RWJF’s luncheon at TED, held Thursday. 

We had a packed room of 60 TEDsters--including the creators of Del.icio.us and hotornot.com, heads of design schools, the president of user experience design firm Adaptive Path (developer of the Charmr, from an earlier Emily Culbertson post), execs from venture capital and game development firms, David Pogue (technology columnist for the New York Times and one of my favorite writers) and the founder of DNA Direct (a genetic testing and management company)—with about 30 who lined up to attend, but unfortunately we couldn’t accommodate due to space limitations.

Pam Omidyar, founder of HopeLab gave a great recap of the inspiration behind and clinical outcomes linked to Re-Mission, the video game developed for kids battling cancer.  There were cheers when she showed the results, which demonstrated that kids who played the game had higher levels of treatment adherence and more knowledge about their disease ,and were more empowered to fight back.  She showed amazing MRI imagery that showed players’ brains on Re-Mission.  Areas tied to emotional processing lit up, which was key to internalizing the lessons underlying the challenge and excitement of the first-person shooter game.  We were honored to have Taylor Carol and his dad, Jim, with us – Taylor is now in full remission from leukemia, played the game during his six months in the hospital, and is the star of our promise story on Re-Mission. 

John Maeda, president of RISD, outlined distinctions in mission and change vision between designers and artists, and called on more designers to apply their skills, thinking, creativity and ingenuity to save the world.  Having given some of the more popular TED Talks in years past, he provoked the group to think differently about the potential of this space.

The group then turned to the game jam, led by Ben Sawyer and game designers Noah Falstein and Larry Holland.  The crowd first decided to tackle the issues of chronic disease, and then refined the challenge further to focus on actions and behaviors.  Some of the ideas they proposed that seemed promising to the game developers included:

• Addressing metabolic syndrome, using a game approach to help navigate the different associated conditions and co-morbidities, trade-offs among treatments, and patients’ abilities to manage aspects of their condition.
• Developing a realistic, action-based approach to the immunization debate that can inform decisions around vaccine safety.
• A game focused on how to manage depression…when asked why that intrigued them, the developers replied, “Because it seems hard.”  
• Helping patients better navigate health care systems and services.

Noah and Larry continued to work through these possibilities in to the evening on Thursday and all day Friday.  The results of their concept development will be unveiled at our TED Lab exhibit space this morning.

We’re grateful to Pam, John, Ben, Larry and Noah for joining us and shining a spotlight on the potential for games to spark big change in health and health care.  I think people came away with a sense for that potential to touch people’s lives and help them pursue health goals and make informed decisions in uniquely powerful ways. 

Ben and his team are going to see where these ideas may go from here, so let us hear your input on how this exploration can lead to the next breakthrough health game.

Posting from TED: the Raw or the Cooked?

In the afternoon session of Day 1 at TED, Tim Berners-Lee, credited as inventor of the World Wide Web, made a simple request, one he’s trying to build a movement around: put your data on the web.  In Berners-Lee’s view, data held in the hands of the few is a lost opportunity.  It’s like the complaint leveled against the researchers who held on to the Dead Sea Scrolls for so long and wouldn’t let other researchers work with them or analyze them…only we’re talking about digitized data, not papyrus-based data.

Putting data on the web in a format that allows linking would open it up to all manner of exploration and analysis.  “When you connect data together, you get power,” he said. This spirit is what’s behind our support of Rapid Learning, which is being championed by Lynn Etheridge.  Rapid Learning proposes to link patient data bases from various provider organizations for research purposes.  It’s also embedded in our support for ARCHeS, the effort to build a user interface for the Archimedes model that would enable more people to harness its power to answer questions.

Berners-Lee pushed the idea of putting data on the web to its limits, leading the audience in a chant of “Raw Data Now, Raw Data Now.”  For some people, looking at some kinds of data, the idea of just posting it on the web is disconcerting.  Assuming one takes proper steps to assure privacy and confidentiality, should all data be open for mining and analysis, or are there limits to what should be shared in its raw form?

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.

Where's the revolution?

In Sunday’s Washington Post, Health Reporter David Brown wrote a very interesting thought piece, We All Want Longer, Healthier Lives. But It's Going to Cost Us. He outlines the “steady, predictable, relentless growth” we’ve seen in health care costs since the end of World War II. He says the time of cheap innovations that can produce the longer, healthier lives we all desire—clean water, vaccines, antibiotics—is past. Citing work by David Cutler at Harvard, he writes, “In the 1970s, it took $46,870 to add a year to the life expectancy of 65-year-olds. By the 1990s, it cost $145,000.” The next gains, Brown suggests, will come at even greater price.

There are some things we could do to shift the curve down, to save some money. Bringing down administrative costs, for instance. Or prevention, thought he notes prevention hasn’t been demonstrated to be any cheaper in the long run. Ultimately, though, on our current path, “We are on a collision course between our wish to live longer, healthier lives and our capacity to pay for that wish.”

Unless…

Brown suggests the current collision course sounds similar to that proposed by English Parson Thomas Malthus in the 18th century. Malthus published "An Essay on the Principle of Population as It Affects the Future Improvement of Society,” in which he projected a point in time where population growth would outstrip food production capacity. His analysis made a lot of people nervous.

But there were two things Malthus failed to imagine: “The first was that scientific agriculture would eventually double, triple and quintuple crop yields,” Brown writes. “The second was that when industrialization pulled huge numbers of people out of poverty, infant mortality fell, women became more educated, and the value of their labor rose. The net result was a huge decline in birth rates. This is known as the "demographic transition," and virtually every region of the planet has gone through it.”

We need a similar revolution in healthcare to avoid the collision between our desires for long and healthy lives and what those lives will cost, Brown says. Where it will come from, he doesn’t know.

So: Where will that revolution come from? Advances in genomics? Proteomics and diagnostics? New business models ala Clayton Christensen’s recent book, The Innovator’s Prescription? Any and all thoughts welcome.

Amplyifying how my body talks to me (and others)

It doesn’t take much insight to know that the current method of delivering (and paying for) health is broken and not sustainable. Making changes at the margins won’t work. Aside from current (and obvious) inefficiencies, we have a population that’s living longer, has more medical conditions and more methods for treating them. Even if you believe your personal health care support is doing OK, you have to know that there’s a crisis in the future. If you believe we’re already in a crisis, you know we’re heading for a catastrophe.

 

There is a school of thought that crises have a way of solving themselves. There’s a great story about how at the start of the 20th century, with the growth of the telephone, there was a fear that the number of switchboard operators needed for manual switching systems would soon exceed supply, and that the problem was solved (just in time) by the invention of automated switching systems. This story was repeated as recently as 1998 in a letter to the NY Times. Unfortunately, this story is not true. The first automatic switch was invented in 1889 by Almon B. Strowger who developed it because he believed the operator was deliberately routing calls to his competition. In fact, as late as 1920 Bell in Atlanta continued to use operators and only changed when there was an operator strike.

Recognizing, therefore, that most crises are not self-resolving, and at our request, the Center for Future Health at the University of Rochester convened a diverse group of thought leaders interested in real-time personalized health monitoring. They came to discuss how people might benefit from personalized self-care systems, how such systems might enable people to take more responsibility for their own health and what RWJF might do to advance the field. What we learned is that there are amazing things taking shape that hold the promise of technologies that are both useful (in terms of their ability to improve our health) and unobtrusive, that there are lots of single point experiments and that there are major obstacles to coherent development. The challenge remains finding activities that can be transformational in accelerating the field while avoiding, or at least mitigating, some of the costly dead ends.

Positive Deviance named an "idea of the year!"

The New York Times Magazine for Sunday, December 14 contains its 8th annual wrap-up of the ideas that "helped make the previous 12 months, for better or worse, what they were." The ideas are listed alphabetically, and there among the "p"s is an idea Pioneer's been exploring for some time, Positive Deviance.  In fact, Curt Lindberg, of our grantee Plexus Institute (also noted in the Magazine's short essay), wrote an introduction to P.D. here on the blog back in July, 2007.  Faithful readers can now say they knew it when...   

Vote Now: Two Pioneer Reports In the Running for RWJF's Top Research of 2008

Every year, David Colby, RWJF's vice president for research and evaluation, showcases 10 RWJF-supported research projects that have contributed to greater understanding of an issue or can help inform policy discussions.

This year, he's doing things a little bit differently. He's opened up a poll on RWJF.org so people can cast their votes for the most influential RWJF-supported research of 2008.

We're pleased he's included two papers supported by the Pioneer Portfolio among his 25 finalists:

The Collective Dynamics of Smoking in a Large Social Network
Using data from the Framingham Heart Study, Nicholas Christakis and his colleagues reconstructed the social networks of more than 12,000 individuals and found that smoking cessation occurs in network clusters. The study, published in The New England Journal of Medicine, also concludes that the chances of continuing to smoke decrease significantly for an individual when a spouse, friend or even sibling quits smoking.

In a blog post, "The promise of social network analysis," Lori Melichar wrote about this study and the potential for social network analysis:

Christakis’ research findings have the potential to drive a fundamental rethinking of health policy, clinical care, research and evaluation, and public health campaigns. If social network analysis continues to produce promising new results and becomes widely used – and if it helps us to think differently about how we design health interventions and health campaigns that ultimately achieve greater success – then we will have achieved a key breakthrough in the health and health care of all Americans. 

Most recently, Christakis and his colleagues published a study in BMJ about the social spread of happiness, which Susan Promislo blogs about here.

Administrative Compensation of Medical Injuries: A Hardy Perennial Blooms Again
In this article, published in Journal of Health Politics, Policy and Law, a team from Common Good and Harvard School of Public Health looks at the history of administrative compensation proposals over the last 30 years and examines the success of the administrative compensation model in fields like worker's compensation, vaccine injuries and automobile injuries. The authors conclude that establishing pilot projects, particularly through a voluntary or contractual approach, is likely the most practical way to realize the potential of this model for medical injuries.

Abbey Cofksy wrote a blog post about the latest work from this project in October:

Common Good and their collaborators at the Harvard School of Public Health continue to build the research base and policy consensus for a new system of specialized administrative health courts. An innovative alternative to our nation's current medical liability system, health courts would apply rational, consistent standards to resolving medical liability claims and compensating injury patients.

To vote for the top 10 RWJF-supported studies, visit the RWJF Year in Research 2008 poll. Voting is open until December 23.

RWJF will announce the winners in the new year through an RWJF Content Alert. To receive notification of the winners, subscribe to one or more of RWJF's Content Alerts.

(And to see what's been highlighted in the past, read the 2007 Year in Research here, which featured the work of Pioneer grantee Extending the Cure).

Systems and the risk of failure

As the ripples of the financial meltdown continue to spread, I’ve read a handful of articles that discuss the contribution that networks, interconnections and dependencies made to the problem. Essentially, they assert, if we hadn’t had this highly evolved, interconnected international financial system, the damage would have been much less, contained to one sector or one country.

It got me thinking about our health care delivery system and the long-standing observation that our system isn’t a system and that it needs to be more of a system to achieve better outcomes. And I wondered whether achieving more system-ness in health care delivery, that is, a more networked, interconnected and interdependent system, might produce greater possibility of significant breakdown and failure along with the efficiencies it also produces.

I e-mailed a couple folks—Ramanan Laxminarayan, PhD, a natural resources economist and senior fellow at Resources for the Future; and, Steven Weber, MD, PhD in political science at UC Berkeley. Ramanan has a grant from Pioneer to develop solutions to the problem of antibiotic resistance by treating antibiotics as a resource that need to be managed; Steve has been involved in some scenario planning the Pioneer Portfolio has done. Below are some excerpts.

Ramanan Laxminarayan:

“There is connectivity in the system – that’s the reason why we are able to forego paying for health insurance for the poor but rely on emergency rooms for primary care. This ability to pick up slack elsewhere is the main reason the system works (kind of). But it all depends on Medicare keeping things moving through carrot and stick. Once their reimbursement rates drop below a threshold beyond which its not worth being the health care business, that’s the beginning of a possible end…I suppose a collapse could happen in a number of ways leading to a rapid escalation in the price of health care and the inability of small and medium businesses to pay for employee health care (most are doing serious cost-sharing anyway). A collapse scenario could involve a wave of hospital and ER closures, exit from the system by medical professionals, escalating health care costs (which would happen because of fewer providers) etc.”

Steven Weber (who did some reading on this topic a couple years ago):

“There’s lots of work in different disciplines, most of which seem not to fully know that other disciplines are doing the same thing, on this simple but profound question: are highly interconnected systems more fragile (call it the contagion hypothesis) or more robust (call it the diversification/redundancy hypothesis)…[M]y conclusion after reading all this stuff is that we are probably asking the question the wrong way…[We should be] looking for parameters of systems that can be measured in advance, that tell us when interconnection yields fragility through contagion and when it yields robustness through diversification.  I suspect there are as yet untheorized characteristics of the connectivity itself that account for these effects, but that there will not be good generalizations that move across different kinds of systems (i.e. the explanation for the brain will be different from that of financial markets will be different from that of interconnected health systems).  

That said, here is one constructive takeaway that I do try to keep in mind:  whenever I see anyone argue that a system is more robust and redundant by virtue of its high connectivity, I ask myself, ‘What is the shock or where is the threshold that makes it the opposite -- i.e., that makes it come crashing down together,’ and I ask exactly the opposite when I hear the 'fragility' claim.”

These e-mails lead me to three questions:

1. Would more system-ness leave the health sector more vulnerable to collapse?
2. If we had the amount of system-ness in the health care system people think we need (use your own standard here), what shock would cause it to collapse?
3. What would a collapse mean?

Live-blogging from Health 2.0 Conference

We weren't able to go to the Health 2.0 conference, which kicked off yesterday in San Francisco.  The agenda had some sessions that looked great, including ones on patient social networks, Health 2.0 platforms for patient-provider communication, how the field is moving ahead in Europe and Asia, and how the issues of privacy, confidentiality and security will shape consumer confidence in Health 2.0.

Luckily, Lygeia Ricciardi is blogging live from the event over at Project HealthDesign's blog.  Her first post is up and she'll be publishing a few more over the next day or two.

Interesting things, here and there...

Thanks to Jerry Michalski of Sociate for telling us about a massively multiplayer online game hosted by Institute for the Future called Superstruct.  The folks who do IFTF's 10-year forecasts put together a game in which anyone and everyone can figure out what life might be like in 2019, and help invent the future of society as it relates to 5 different scenarios.  One is directly about health -- the QUARANTINE category states that outbreaks have become a common element of our existence.  It focuses on a respiratory infectious disease called ReDS and challenges players to consider all the implications and figure out how to respond.

The other game scenarios have important implications for health as well, as they immerse you in envisioning a world in which we're:

• RAVENOUS - the food chain is broken and we have to reinvent ways to feed ourselves
• in a POWER STRUGGLE - the world is caught up in "Alternative Fuel" wars over what will take the place of oil
• facing GENERATION EXILE - our neighbors have become climate and economic disaster refugees in search of new places to live, or
• an OUTLAW PLANET -- In 2019, the mobile internet and sensor networks we rely on to hold our societies together are being hacked, griefed, and gamed.

The site today reports that there are 4,905 players with a collective score of 4,911.  What this means is that the current survival horizon, based on all of these superthreats and how we deal with them, is through 2047.  The game started on Oct. 6 and runs for 6 weeks -- check it out and sign up to play.

Another item worth reading is eFuturist Douglas Goldstein's take on the future of video games and health, posted today on The Health Care Blog.  He has this to say:

"It may be surprising to some that the health care industry has been among the first to recognize the ‘game-changing’ potential of games in business and other environments.  Leaders in the health care sector are now embracing video games as an integral part of a digitally enabled health culture."

He also points to an October 2008 market report from iConecto that identifies health games as a growing field.  Right now, they estimate that the health games market stands "at approximately $7 billion during the next 12 months including the markets for brain fitness ($267M), exergaming ($6.4B+) and other Health eGames on the consumer and professional side ($250M+).  An expanded executive summary of the report can be obtained here.

Business and Philanthropy: Meeting in the Middle?

Traditionally, in looking at the continuum of types of organizations, for-profit businesses intent on increasing the wealth of their shareholders appear at one end; and not-for-profit philanthropies intent on giving money away appear at the other. But is this, in fact, true in our current world?

A recent article by Matthew Bishop in CFO.com highlights the most recent trends in businesses’ adopting philanthropic practices. Google is exhibit A, with their one percent rule – one percent of profits, of equity, and of employee time are allocated to doing good. Wal-Mart is exhibit B, with their post-Katrina efforts and sustainability programs.

And, over the past decade, philanthropy has increasingly adopted concepts and techniques from the business sector. A strong emphasis on strategic planning is one good example.

But this current tug on philanthropy towards a more for-profit, business-like approach – towards the middle of the continuum – is, in fact, rooted in greater attention to two facts: 

·         Most of the funds in philanthropies’ endowments have not been invested in assets that can then be used to further a philanthropy’s mission, 

·         The capital needs of nonprofits have been largely neglected. 

These facts are generating significant exploration into using foundations’ financial assets, including endowments, for new purposes like capital investment that can be tied directly to a philanthropy’s mission.

These investments differ from traditional grants and can take many forms, such as loans, loan guarantees, or equity investments. Meyer Memorial Trust in Portland Oregon has used these financial tools to support affordable housing, economic development, and environmental protection projects. Mission-related investments, or MRIs, has become the umbrella term to describe these many alternatives to traditional grantmaking.

Now that the dynamics of cross-sector exchanges of organizational genetic material between business and philanthropy are in full swing, some fascinating questions are likely to emerge. They may also trigger innovations that make both sectors more effective, or not. There is a lot to learn.

Which brings us back to Matthew Bishop, who has co-authored the book Philanthrocapitalism with Michael Green, due out next month. Bishop is a keen observer of the philanthropic sector (subscription required to read full article), so I expect the book will help us all put these new developments in perspective. I, for one, am eager to see what the authors think.

Brainstorming TECH Conference, Day Two

Day two of the Fortune Magazine Brainstorming TECH conference started with an unforeseen development. Jeff Bezos, president of Amazon.com, and I have something in common: we both choose to attend the Future of Gaming roundtable. The roundtable brought together about 20 people, including folks from Electronic Arts, Phillip Rosendale, president of Linden Labs (creator of Second Life) and Bezos to discuss the future of gaming. I wonder if Amazon will get into the gaming business? Imagine, you could buy your book while you game (and maybe it could even be a game for health…that would be very interesting).

The most compelling part of the day centered on the social web. Sheryl Sandberg, COO of Facebook.com, spoke about the way Facebook is propelling the social web forward. If Marc Benioff is correct, and the future of the web moves from collaboration to innovation (see my first post), creating a place for end users to connect will be invaluable. What I find so powerful and dynamic about Facebook is its ability to bring groups together around a particular issue or interest, and recently I’ve noticed Facebook’s role in bringing individuals together for social change. People are able to talk about what is important to them: from politics, to media, to being green.

Could health care advocates work together via Facebook for health care coverage, public health, and better quality of care? How could we use Facebook, and sites like Facebook, to support innovation in health and health care?

Here’s one possibility: Esther Dyson, who blogs on the Huffington Post, mentioned during a breakfast roundtable about web and relationships that she was going to make her personal health record public. This led me to think about whether people could place their personal health records on Facebook and friend (with certain privileges) their health providers.

A funny tidbit, when the audience was asked who had a Facebook page, almost everyone raised their hands. It looks like leaders in technology see the value in Facebook and are trying to integrate it into the success of their businesses. Is the health care industry next?