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.

Thoughts from Games for Health 2011: Sensors, Opportunity, Scale

Here are a few of my initial ideas from the 2011 Games for Health Conference, put on by Ben Sawyer and Beth Bryant:

1. The sensors are coming, the sensors are coming.  Sensors and the software to collect and analyze the data are on the verge of becoming retail products.  Green Goose is one company hoping to grab this market.  What does it mean for health games?  It means that soon we will be able to turn lots of things into data collection and data input devices.  So think about games that use household objects instead of, say, a wii remote.  You could turn your house into the playing field for a game.

2. Better seeds and more fertile ground.  The quality of health games—the game mechanics, the theory underlying design is getting better.  At the same time, the context in which we can use games to improve health is expanding.  We can now embed games in social networks, so think about linking someone’s facebook friends in with their game efforts to lose weight or manage their diabetes.

3. There’s likely more than one way for a game that has an impact at scale.  When we got into this space at RWJF, we were thinking about games as therapeutic interventions for individuals—one person with one game addressing one condition that a lot of individuals have.  But building off item 2 above, given what Nicholas Christakis and James Fowler are showing with their research on transmission of health behaviors through social networks, you could design a health game that requires social networks—teams—to play.  Still another level up is a game that could target a health problem that was a function of a system problem.  That is, a game that targeted a health problem that resulted not from someone’s genetics, but from set of processes and systems that are outside of any one individual’s control.  Imagine a game that’s designed to get some producers to make healthier food.

 

Are We The Source of Knowledge?

Are We The Source of Knowledge?

We started hearing about it a couple years ago: an ALS member of Patients Like Me had seen (and translated—it was in Italian) a medical conference poster with results showing lithium carbonate could slow the disease’s progression.  That study was a single-blind trial of 16 treated patients and 28 controls.  The results spread through the ALS community and soon, patients began talking their physicians into prescribing lithium carbonate off-label. PLM soon had 348 members reporting on the effects of their use of the drug.

 PLM realized they had an opportunity to study the experience of their members who were—effectively—experimenting with the drug.  PLM couldn’t randomize, so they developed an algorithm and matched 149 treated patients to 447 controls based on the progression of their disease course.

 On Sunday, the journal Nature Biotechnology published PLM’s findings showing after 12 months of treatment, lithium carbonate had no effect on disease progression.  PLM reports that subsequent clinical trials reached similar conclusions.

 What’s important here is to recognize the potential to conduct research using patient self-reported data from an online social community.  PLM’s sweet spot is social communities for ambiguous diseases (that is, diseases we’re still learning about, diseases that don’t have clear, effective treatment protocols) where the patient does a lot of care at home.  To be sure, PLM is a pretty sophisticated community, but it’s intriguing to think about where we might be in 10-15 years.

A couple of us met last week with PLM’s Jamie Heywood and Dave Clifford.  We had a ranging discussion—hard to avoid with Heywood—that included linking patient self-reported data with clinicians, conducting research with this data, and business models.  A fundamental question Heywood is exploring is “whether it’s faster to get to learning health system through the current confines of the health system or through something like PLM.”

Given the growing ability and inclination of patients to capture and share details on their own experiences, how powerful a role is there for the analysis of this sort of data in our efforts to accelerate the discovery of new treatments for disease?

Got Game? Apply for an SBIR Award!

The National Institute on Drug Abuse is looking to support a video game targeting relapse prevention in youth with substance use disorders.  See page 91 in the recently-released solicitation from the NIH and CDC.

Here’s the brief description:

Despite advances in the development of treatments for adolescents with substance use disorders, relapse remains to be a concern. This contract topic will support research to develop a video game targeting prevention of relapse for youth with substance use disorders. Video game platforms of interest include computers, handheld devices, and video game consoles. The video game can be used as a single modality or as part of a continuing care program. Phase I will support the development and feasibility testing of the video game for use with adolescents with substance use disorders. If feasible, Phase II will support further development based on Phase I findings, and pilot testing of efficacy in post-treatment adolescents. The proposed project should be theory based and designed to assess the hypothesized mechanism of action of the intervention (e.g., maintenance of skills learned in treatment or motivation to abstain). This innovative technology is intended to attract and engage adolescents in programs designed to maintain treatment gains and prevent relapse.

What Inning Are We In?

I was at the Games for Health meeting in Boston last week. This was the fourth year Pioneer has supported the meeting, which has come a long way since its inception.  When I first attended, most of the conversation I heard was an effort by gamers and health practitioners to each understand the other.  From one side, you heard questions that asked, essentially, “What makes a good game?” From the other side, you heard questions that asked, essentially, “Help me understand diseases, therapies, and how health care works. 

 

And from both sides, you heard, “When you say X, what exactly do you mean?”

The conversation this year was significantly different.  Instead of talking to each other, people were talking with each other, trying to figure out how to solve problems. Attendees were frequently working off a common language, though some are more fluent than others.

Given that much of the conversation has moved from discovery to collaboration, it has me wondering what’s needed now to move the field along?  The funding we provided under ourHealth Games Research national program focused on establishing efficacy and exploring game design principles.  Does the field need more of that?  Some of the ideas I heard at the Games for Health conference of what was needed now included research to demonstrate cost-effectiveness and the establishment of a journal devoted to the field of health games research.

Any opinions?

When is it all fun and games, and when is it manipulation?

Note: See yesterday’s post to learn more about what the Pioneer team has been working on lately with Debra Lieberman and the Health Games Research program.  

Earlier this week I tweeted a link to a piece on VentureBeat featuring Norwest Venture Partners’ Tim Chang thoughts about the “game-ification” of life.

I shared the link with Debra Lieberman, national program director for our Health Games Research program. Debra is a passionate researchers who’s devoted much of her career to understanding how and why games can be effective and useful tools. She had some very thoughtful observations:

“I have noticed for a long time that many aspects of life are already made into games...with reward points for frequent flying and incentives for customer loyalty at all kinds of retailers (discount coupons, gifts). I am often asked to respond to surveys with the enticement that I will be entered in a sweepstakes as a reward. Contests are everywhere as an incentive to get people to share ideas. I like Tim Chang's observations that teams and a sense of loyalty to them can be very motivating.

The "gamification" of life can get us to do things just to gain rewards and avoid punishments (such as the taxes on junk foods, as the blog describes). But we must not forget the importance of intrinsic motivation. In the past it seems to me that we chose to do things because, at least to some extent, they were inherently valuable to us and our motivation came from internally-driven needs and interests, not from external rewards, points, and prizes. We need to help our kids figure out what they want to accomplish so they can reach for their own goals...and not be so manipulated by the extrinsic rewards offered with coupons, reward points, and prizes...and extrinsic punishments.

Health games can be designed to focus on and bring out the player's intrinsic motivation. Research tells us that people who are intrinsically motivated are much more engaged and interested in the task (e.g., developing the knowledge and skills they can gain from the game) than those who are trying to figure out a way to win the prize. An interesting experiment would be to compare one group in which each individual set their own healthy eating goals and developed their own plan and were shown the health rewards they were actually getting this way...versus a group that was given healthy eating goals and was spurred on by external rewards (e.g., pay them to do it). Then, see what happens when the study ends and the external rewards go away. I bet the people in the rewarded group will revert back to old eating habits while those in the intrinsically motivated group will be more likely to sustain the healthy eating habits.”

We hope developers take Debra’s insights into consideration when designing games that encourage healthy living habits. External rewards can lead to a temporary shift in behavior, but to create lasting change, motivation must come from within.

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.

‘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?

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?

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.

What Will You Be Attending in 2010?

Hello folks,

On the Pioneer Team, we’re thinking about our travel plans for 2010.  A lot of our travel is related to specific grants and projects, but we have a budget for meetings and conferences.  We’re building a list of events we might attend.  What we’re looking for are meetings and conferences where we might meet interesting and innovative people, find unconventional and future-oriented ideas.

To prime the pump, I asked a couple folks for their ideas.

From Susannah Fox at the Pew Internet & American Life Project:

• Health 2.0 – April 6-7, Paris (with apologies to Vernon Duke and Yip Harburg)

• Gov. 2.0 Expo 2010 – May 25-27, Washington, DC

• SXSW – March 12-21, Austin, TX

• TEDMED 2010 – October 26-29, San Diego, CA

• Medicine 2.0 – September 17-18, TBD

From Vijay Goel, Sr. Director, Healthcare Prize Development at X PRIZE Foundation:

• World Healthcare Innovation & Technology Congress – November 8-10, Washington, DC

• Milken Global Conference - April 26-28, Los Angeles, CA

• Versant Ventures Innovation Conference – TBD  

• TED2010 – February 9-13, Long Beach, CA

• Clinton Global Initiative – September 21-24, NYC

• TechCrunch50 2010 – TBD

• TiECon (The Indus Entrepreneurs) – TBD

From Jim Cashel, Chairman, Forum One Communication

• SXSW – March 12-21, Austin, TX

• Forum One Online Community Summit – TBD

• NTEN’s Nonprofit Technology Conference – April 8-10, Atlanta, GA

• TED2010 – February 9-13, Long Beach, CA

• Web 2.0 Expo – May 3-6, San Francisco, CA

Pulse + Signal Blogger Andre Blackman keeps a list of upcoming events here:

Other events we’re aware of include:

• PopTech – October 20-23, Camden, Maine

• Skoll World Forum on Social Entrepreneurship – April 14-16, Oxford, England

• The Feast – October 15, NYC

• Push the Future—TBD

• Mayo Clinic Transform Symposium—September, Rochester, MN

• Cleveland Clinic 2010 Medical Innovation Summit—November 1-3, Cleveland, OH

• Games for Health Conference – May 25-27, Boston, MA

We will compile all the submissions, add web links and share the results with everybody.

An “exaflood” of Observational Data

Today’s New York Times has a book review of THE FOURTH PARADIGM: Data-Intensive Scientific Discovery.  It’s a collection of essays edited by Tony Hey, Stewart Tansley and Kristin Tolle from Microsoft Research.  According to John Markoff’s review, “The essays focus on research on the earth and environment, health and well-being, scientific infrastructure and the way in which computers and networks are transforming scholarly communication. The essays also chronicle a new generation of scientific instruments that are increasingly part sensor, part computer, and which are capable of producing and capturing vast floods of data."

This is an area we've been interested in for awhile...our program, Project Health Design: Rethinking the Power and Potential of Personal Health Records is exploring how people with chronic conditions can improve their health and wellbeing by capturing, understanding, interpreting and acting on information they capture from the patterns of their everyday lives - Observations of Daily Living. It's also looking at how that information can be fed back to clinicians and integrated into their workflow.

Time for New Behavior Change Models and All Things Neuro

We had a really interesting meeting.  It was provocative and wide-ranging; I can’t begin to do it justice in the format of a blog.  Look for a more thoughtful and informative report in the weeks to come.  Also, we’ll work to set up an on-line space where people who are interested in these questions can come together.  In the meantime, here are just a few ideas and thoughts to come out of the meeting:

 

Do we need a next-generation model for behavior change?  The models we have for behavior change have enabled impressive gains and powerful programs, but they were largely developed 20 years ago when our ability to understand what is going on inside someone’s brain was much less developed.  Technology that didn’t exist 20 years ago provides a much more detailed picture of what influences decision and behavior, enough of a new picture that it may be time to re-evaluate our current models of behavior change.

 

Watch for increased use of the prefix “neuro.”  There’s neurotech, neuroplasticity, neuromodulation.  There’s neuroimaging, neuro-oncology, neurogenetics. and neurofeedback.  But when you seek to understand an experience at the neurological level—and you have the technology to do it—you can go anywhere: neuroaesthetics takes a scientific approach to understand perceptions of art and music.  At the other end, look for increased use of the suffix “ceuticals.”  We heard about the possibility of cognoceuticals that improve people’s capacity to learn (This has been happening for years, caffeine and nicotine, for example.  For five or six years now, there’s been the occasional story about use of Ritalin and Adderall as study aids.); emotoceuticals that could in a much more targeted way address emotional disorders or enhance certain emotional states; and, sense-ceuticals that could improve your sense of smell, touch, hearing.

Finally, monitoring your brain’s wellness could become a new responsibility for primary care providers.

Connecting Revolutions in Neuroscience with Health and Health Care

As a national leader in health and health care, the Robert Wood Johnson Foundation is continually searching for opportunities to generate greater impact. One of the charges of the Pioneer team, the most explicitly future-oriented of RWJF’s program areas, is to identify and investigate areas where transformative breakthroughs feel most possible.

In line with this charge, working with the Monitor Institute, we’ve invited a provocative group of academics, researchers, physicians and industry leaders in neurotechnology, neuroscience and behavioral health to step to the ledge of current innovations in these fertile and promising fields – and then step beyond it – begin to anticipate what near-term and distant innovations in these fields could mean for health and health care.  

On November 11-12, this group, along with staff from the Foundation and Monitor, will engage in a series of highly iterative, forward-looking discussions that will culminate in a wrap-up that integrates the thinking across all three disciplines and outlines connections and implications for the future of health and health care.

This event is a new approach for Pioneer. It is not connected with any prospective funding initiative. Rather, we play the role of convener, focused on bringing together the experts who hold the key to identifying and advancing the next generation of innovations in this space.

I, for one, can’t wait to see what everyone has to say. If you would like to follow the conversation about the Forum on Twitter — leading up to, during and following the event — please use the #rwjfneuro hash tag.

Interested in more information?

Pre-read

Participants

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.

Seeking Disruption? Look for Delight.

The New York Times' John Tierney recently wrote an article in the New York Times and posted on his blog about a paper by Samuel H. Preston and Jessica Y. Ho of the University of Pennsylvania titled, “Low Life Expectancy in the United States: Is the Health Care System at Fault?”

 

Tierney wrote that Preston and Ho found “no evidence that America's health care system is to blame for the longevity gap between it and other industrialized countries. In fact, [they conclude], the American system in many ways provides superior treatment even when uninsured Americans are included in the analysis. ''‘The U.S. actually does a pretty good job of identifying and treating the major diseases,’'' says Dr. Preston, a demographer at the University of Pennsylvania who is among the leading experts on mortality rates from disease. ''‘The international comparisons don't show we're in dire straits.'”

 

This is not big news.  And it’s not big news that the formal health care system—on the whole—has struggled to do prevention well and is only beginning to pay attention to wellness. The question I’ve been thinking about is where will the innovation come from that produces a system that is not only more efficient in what Preston and Ho assert it currently does well— detecting and treating disease—but that also does prevention and wellness well.

 

In their book, The Innovator’s Prescription, Christensen, Hwang and Grossman suggest integrated, fixed-fee systems, such as Mayo, Kaiser, and Geisinger are likely candidates because in highly fragmented industries, such as health care, disruptive innovations can be accelerated when there is an orchestrator of change that is integrated across multiple pieces of a system.

 

I think there is another source for big innovation in health and health care that’s worth watching: consumer product companies and retail chains. Think Procter & Gamble, Best Buy and Wal-Mart. When you move the focus from detection and treatment to prevention and wellness, there are lots of opportunities to develop products and services and relationships that improve health, extend life and don’t require medical professionals. I can imagine a whole bunch of consumer products and services that focus on wellness. And once established in that market, it’s not too big a step for these companies to begin to offer products and services that do require medical professionals…it’s already happening with minute clinics.

 

The big difference would be the way consumer product companies and retailers approach this space and the experience they would offer.  Karl Ronn from P&G gave a great talk on the perspective a consumer products company brings to this space at a recent conference put on by the Mayo Clinic’s Center for Innovation.

 

In his talk, Ronn discusses that consumer product companies seek to create products and experiences that “delight” consumers. The closest health care gets to “delight” is “patient-centeredness.”

 

Ouch.

 

Given a choice between a health care experience that was a delight and one that was patient-centered, most people, I suspect, would choose to be delighted.

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.

A Declaration of Our Rights to Health Data

If you enjoyed Steve Downs’ recent post about the Open Notes project, here’s a group with related interests. Health Data Rights, a group of organizations, corporations and individuals, is calling for a people’s right to have and share health data. They assert, in part, that -

“We the people:

• Have the right to our own health data;

• Have the right to know the source of each health data element;

• Have the right to take possession of a complete copy of our individual health data, without delay, at minimal or no cost; If data exist in computable form, they must be made available in that form; and

• Have the right to share our health data with others as we see fit.”

The group includes Dossia, GoogleHealth, FasterCures, Microsoft and PatientsLikeMe. The rights have been endorsed by Adam Bosworth, David Kibbe, Esther Dyson, Tim O’Reilly, Steve Case and nearly 300 other individuals.  If you’re interested in learning more, here’s their site: http://www.healthdatarights.org/

The Pioneer Portfolio team and the Robert Wood Johnson Foundation have been interested in liberating health data for a long time, as we think that liberated data enables innovation.

If you’re interested, you can follow the conversation about Health Data Rights on Twitter.  

Winning Nudges Announced in "Designing for Better Health" Competition

The winners of the "Designing for Better Health" competition we held with Ashoka’s Changemakers have been announced.  The competition was inspired by the book Nudge, which was written by behavioral economics experts Cass R. Sunstein, J.D. and Richard Thaler, Ph.D.  Nudges are simple pushes that can induce someone to change their behavior.  My favorite entry didn’t win.  If you tracked the competition, it was “Just an Idea.”  This entry suggested a way to help more women conduct their monthly breast self-examination—put a reminder symbol in birth control pill packages on the optimal exam day.  I thought this idea was elegant.

There were 285 entries from 29 countries.  The three winners were all international:

• GOONJ (India) - GOONJ (means “echo”) collects donated cloth and creates clean sanitary pads that it then distributes to women, while at the same time bringing out in the open the taboo subject of menstrual hygiene.

• San Francisco Saludable (Peru) - This unique waste management program nudges people to change their traditional habits to improve their health by producing compost for family gardens. 

• Fundación Boca Sana (Venezuela) - Children are nudged to better oral health because they receive training to act as scholar/promoters who share what they have learned about proper oral hygiene and care with other children, parents and relatives. 

After reading through all of the entries, I came to the conclusion that nudges, as conceived by Thaler and Sunstein, are a subtle concept.  The folks at Changemakers tried hard to explain the concept on the competition site and, to my eyes, they did a good job.  But looking at the entries, a lot of them weren’t even nudge-ish.  In designing the concept of nudges, Thaler and Sunstein were trying to walk a fine political line to come up with an approach to policy that would be acceptable to the right and the left—Libertarian Paternalism, they call it.  One thought as to why a good nudge is hard to find is that it requires a lot of discipline on the part of the designer.  You set up the nudge and then stand back.  If people aren’t nudged to do the right thing, that’s it...you get your answer pretty clearly as to whether it worked.  For people who are driven to solve problems, that may be a very hard stand to take.

That said, there were some wonderful entries and I offer my sincere congratulations to the winners—well done!  Also, I thank Changemakers for their good work and my fellow judges for their efforts.  We’re glad to have sponsored the competition and we hope those who entered, commented and otherwise participated continue to explore the power that well-designed nudges can have in driving better health decisions, behaviors and outcomes.

Talking Health Care with Clayton Christensen

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

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: 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?

Announcing our newest Pioneer/Changemakers competition (nudge, nudge...)

People can be so…so…so stubborn. They know the right thing to do—eat servings of fruits and vegetables every day—they just don’t do it. Or they don’t get around to doing it. Or they do it for a little while—exercise for 30 minutes every day—and then they stop doing it. Or their environment creates barriers to doing it.

One way to think about it is that, often, life gets in the way doing the right thing. The kids, the job, the economy (“What the hell? Where did my 401k go??) all compete for time and attention. And sometimes, it’s not life, but the choice itself that gets in the way. Any of you who spent time trying to help an older parent figure out what choice to make under Medicare Part D knows what I mean when I say some choices are just too complicated. When faced with making a complicated choice in real life, many of us end up making choices that aren’t the best ones we could make.

We’ve launched a global competition looking for “nudges,” innovative little pushes – that help people make better decisions regarding their own health and the health of others. The competition is co-sponsored by Ashoka’s Changemakers project and is based on the ideas put forth by Richard Thayler and Cass Sunstein in their book Nudge. Here’s an example of a nudge focusing on wearing motorcycle helmets: instead of making helmet-wearing mandatory, you permit people to ride without a helmet…but only if they qualify for a special helmet-less motorcycle license. To qualify, they’d need to pass a class that improves their riding skills and they’d have to carry an extra amount of insurance. The goal is not to remove someone’s ability to make choices, but, rather to “nudge” them in the direction of the better choice.

If you think you have a good nudge, you can enter the competition here. 

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.

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?

Opportunities for Disruption? A Forum on Disruptive Innovation in Health Care

The Innosight Institute, the non-profit think tank founded by Harvard B-School Professor Clayton Christensen, put on a conference last week called, A Forum on Disruptive Innovation in Healthcare.

Prof. Christensen developed the theory of disruptive innovation and is currently working on a book on the subject. One of his co-authors is Jason Hwang, MD, MBA, who served as a judge for the Disruptive Innovations competition Pioneer sponsored through Changemakers. Those of us at the meeting were treated to a glimpse of the still-being-drafted book, which was pretty interesting. I’m keen to read the final version.

Elliott Fisher, MD, of Dartmouth Atlas fame, set the stage for the forum by taking us on a flyover of "everything that’s wrong with health care in America." Fisher then presented seven causes, which I thought was a pretty succinct list:

1. There’s a lack of clarity in the US on the aim of health care;
2. There’s inadequate evidence to evaluate the effectiveness of both biologically-targeted interventions and delivery systems. Fisher asserted that the current discussions around comparative effectiveness were not paying nearly enough attention to the effectiveness of different types of delivery systems;
3. There’s a public assumption that more care is better care (Fisher has published results demonstrating that more care can actually lead to poorer outcomes);
4. Medicine is practiced (and taught) in a model of professional autonomy and authority that is outdated;
5. There’s a lack of accountability for capacity, quality and costs;
6. Current quality measures reinforce fragmentation, in that they’re too focused on performance within individual care settings and don’t track quality across the continuum of care; and
7. Payment incentives are flawed.

Wow.

Another big chunk of discussion focused on the development of more precise diagnostic tests, how they will drive the move to personalized medicine and disrupt the current paradigm of “trial and error medicine,” according to speaker Mara Aspinall, former president of Genzyme Genetics, which provides diagnostic services. As example of new precision, Aspinall noted that we can now diagnose 38 different types of leukemia and 50 different types of lymphoma. That increase in diagnostic precision tracks with the increase in five-year survival rates.

Looked at through the lens of Disruptive Innovation, what you see is a technological innovation—increased diagnostic precision—commoditizes expertise. The growing development and use of more precise diagnostics moves us closer to rules-based—and evidence-based—practice.

Crowdsourced blogs for Council on Foundations annual meeting

Sean Stannard-Stockton has organized a group of bloggers to cover the Council on Foundations annual meeting.  Their posts are just beginning to appear on his blog, Tactical Philanthropy.  For those of you interested in the ideas coming out of this meeting, these posts will give you an early glimpse.

In the long run...

Last Friday, in his thoughtful blog, Tactical Philanthropy, Sean Stannard-Stockton, wrote about the often-missed opportunity philanthropies have to focus on the long run.  Stannard-Stockton directs the philanthropy practice at Ensemble Capital Management, a position which informs his perspective, as you’ll see in this excerpt from his blog:

It is human nature to want results as quickly as possible. But to achieve success, we must match our investment decisions to our time horizon. If we want to fix a local school because our child will be attending starting next year, then it might make sense to focus on short-term solutions. But most donors fund issues because they want to have a sustained impact on a situation. The techniques that might reduce crime in a bad neighborhood the most over the next month are unlikely to be the techniques that will have the largest, permanent impact on reducing crime rates over the next couple of decades.

Financial market participants are often short-term focused. They often focus on metrics which describe short-term conditions, but do little to illuminate long-term trends. But great investors and great philanthropists must focus on the information that matters to the long-term success of their projects.

On the Pioneer Portfolio, we’re interested in understanding those long-term trends, because they are driven by forces and create conditions that make today’s radical ideas tomorrow’s successes.

Recently, we’ve been watching trends of patient empowerment, IT/communications technology, and data mining/rapid learning.  What trends are you watching and what implications do you think they have—long term—for health and health care?

Engaging end users

I was a judge in the Grand Prize round for the Ruckus Nation competition.  And I have to say, the selection process they used felt a lot different than the selection process we use.  One of the reasons was that we were looking to select just one winner, instead of a slate of 10-15 as usually happens with RWJF national programs.  This meant that as we ruled some entrants out, the remaining ideas got additional focus.  When we were down to the final two, we had covered a lot of ground and were able to have a conversation that easily moved between granular operational issues, e.g., “Would this thing break if you threw it?,” and values positions, e.g., “This one cuts the link to the screen and gets kids outside.”

But I think the biggest influence was the addition of youth to the judging panel.  Three pretty fearless kids, aged 11-15, poised and articulate, kept us grounded with their frank observations.  It reminded me that keeping end users in mind when designing a program is a good starting point, but that engaging them in more aspects of programming—from planning to selection—can make for a richer, more authentic program.

Everything old is new again

I was at a meeting last week, called Caring for Aging Adults: The Future of Geriatric Care. It was hosted by HealthTech, a non-profit group founded by Molly Coye, MD, MPH, that develops technology forecasts, decision-making tools and facilitates a learning network of experts and health system leaders. They do this work for the exclusive benefit of its partner organizations, which include healthcare systems, hospitals, safety-net providers and government agencies.

For this meeting, HealthTech had convened a group of national experts in geriatrics to help them strengthen a scenario they are building about what the five- and 10-year future of geriatric care will look like in this country. The charge to the experts was to question, challenge, accept or reject a set of assertions on the basis of what they think is likely to happen, as opposed to what they think needs to happen. HealthTech had seven broad areas of focus to frame its scenario:

1. Clinical care
2. Care setting and facilities
3. IT & communications
4. Cost & coverage
5. Workforce
6. Patient experience; and
7. Regulations & standards

Given the proprietary nature of meeting, and the fact that I was there by invitation, I can’t get into exquisite details about the specific predictions. However, there were some themes that ran through the discussion that led me to want to pose four questions to our blog readers.

There was a lot of discussion about the role of social support as someone ages and the potential role for virtual social networks with this population. But in a discussion on robotics in care settings that touched briefly on whether you could use robots to regularly turn bed-ridden patients, one expert noted that the richness of human contact and conversation you could have while turning a patient was as important to long-term outcome as the physical turning. That led me to Question 1: Are there some social supports that cannot be delivered sufficiently through virtual networks or technological implements and need to be delivered in person?

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

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

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

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

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

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

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

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

Another Perspective on Failure

The New York Times recently carried an article, Foundations Find Benefits in Facing Up to Failures, by Stephanie Strom (note that registration may be required to view the article). The piece discusses efforts by a number of philanthropies “to disclose and analyze their failures.” This is a trend, she reports, driven by a new generation of foundation leaders and new foundations founded by high-tech entrepreneurs who brought a culture of accountability with them from the for-profit world.

“Failure” in philanthropy is an interesting concept, one that is not as stark as the black-and-white bottom line of the for-profit world. Goodness knows, philanthropy can benefit from the rigor and accountability of the for-profit sector. But social problems are not the same as business challenges. Importing unquestioned the concepts of “failure” and “success” from the business world risks a grave misunderstanding what philanthropy does and how hard it can be to, say, improve a failing public education system.
 

Not all “failures” are created equal. “Failures” that result from poor planning or poor execution are not good things. But in some cases, a “failure” can be a very good thing.  It can contribute incredibly valuable information that brings the next effort that much closer to success. The point should not be whether we “face up” to our failures. Rather, it should be whether we learn from the work that we support and whether we share those lessons as broadly and clearly as possible. For this, philanthropy should be accountable; not doing so would be a failure at the enterprise level.

On the Pioneer Portfolio, we have yet another perspective on “failure.” From a high-level perspective, “failure” for us is a measure of success. Our charge is to look for highly innovative, high risk projects that have the potential for high pay offs—in our case, projects that may create dramatic improvements in health and health care. If all of the projects we support “succeed” to some extent, then we aren’t pushing the envelope hard enough.

Finally, I’ll note that RWJF has since the 1970s funded independent evaluations of its major programs and encouraged the evaluators to publish their findings in peer-reviewed journals. We also have a Grant Results unit that publishes reports on the outcomes of our grants (more than 2000 are available online). And finally, for 10 years now, we have published an annual volume, To Improve Health and Health Care, which features independent, long-form articles that discuss our work.

Making Sure Disease-Fighting Drugs Work - Now and in the Future

There's a bit of a story behind our support for the "Extending the Cure" effort, which released its Phase I report today. The original proposal came to Pioneer through the mail from someone who had never approached the Foundation before. Ramanan Laxminarayan, an economist with Resources for the Future, was requesting support for a paper that would present a way to tackle antibiotic resistance by re-framing the problem.

He suggested that if the nation thought about antibiotics as a valuable but scarce natural resource, then we could develop new policies and incentives that would help turn the tide on the growing problem of antibiotic resistance. You could come up with new ideas, he suggested, because you'd approach the problem not from the more traditional framing that seeks to control antibiotic prescribing and use, but from a natural resources economist's framework, which seeks to optimize the effectiveness of a scarce common societal good. Taking such a perspective would lead you to look upstream from the point of use and consider issues related to the development, production, regulation and management of antibiotics.