For people with complex health conditions like HIV/AIDS or diabetes, getting good medical care can be the difference between life and death. And for those who are poor or live in rural areas, finding that care can be a challenge.
Project ECHO’s solution to the lack of specialty care: using online videoconferencing to link primary-care doctors, nurse practitioners, and physicians’ assistants with specialists to train them in how to treat complex conditions.
Sanjeev Arora, a professor of internal medicine at the University of New Mexico, started the training program in response to the state’s dearth of hepatitis C specialists. Now, he says, doctors in rural areas are curing patients at the same rate as those at the university’s hospital.
The program won nearly $5-million from the Robert Wood Johnson Foundation’s innovation arm, the Pioneer Portfolio. Since 2004, Pioneer has awarded more than $120-million to bolster smart, unconventional solutions to tough health-care problems.
“We look across the health and health-care spectrum for new and innovative ideas that have the potential to be breakthroughs,” says Brian Quinn, the senior program officer who leads the Pioneer Portfolio. “We are looking for transformational improvements, not just incremental ones.”
Pioneer has tackled a wide range of subjects, often supporting ideas drawn from other disciplines. The fund made a grant for an experiment with more than 19,000 patients to see if giving them access to their doctors’ notes affected their involvement in their care. (It did: Patients said they were more likely to take their medicines as prescribed.) It has supported experimental “health-prediction markets,” modeled on futures markets, that collect expert opinion to predict the spread of infectious diseases like the H1N1 flu virus and awarded grants for a series of research projects exploring whether insights from behavioral economics can be applied to help people make better health-care choices.
The grants made as part of the Pioneer unit have achieved impressive successes. But they have also taught the foundation just how tough advancing large-scale change can be—and how long it takes.
“Sometimes we’ll support a project, and it doesn’t catch on right away,” says Mr. Quinn. “That doesn’t mean it’s a bust. It might just mean that we were ahead of the game a little bit, and we need to wait a little while for the rest of the health-care world to catch up.”
The Robert Wood Johnson Foundation wants to share what it’s learned with other grant makers that want to foster new ideas for tough problems. In late November, Pioneer will bring together roughly a dozen grant makers who run innovation programs to discuss their work, share their accomplishments, and tackle challenging issues, such as how best to help new ideas accelerate.
To try to increase the odds of success in its own grant making, Pioneer has become more systemic about its work, starting with how it identifies projects.
“For a long time we, used a 'we know it when we see it’ approach to evaluating the types of projects that we want to support,” says Mr. Quinn.
He says that while intuition still plays a role, Pioneer has developed clear criteria that lay out what it’s looking for: projects that are original, unconventional, cross-disciplinary, and have the potential to expand widely. The fund has also developed indicators to assess progress in its grant making.
“We’re trying to strike the right balance between being open and flexible on the one hand, while also being disciplined and rigorous on the other,” says Mr. Quinn.
A hallmark of Pioneer’s grant making is its support of projects that take ideas from other fields, such as finance, design, economics, and entertainment, and apply them to health care—which is why the fund turned to an environmental economist to tackle antibiotic resistance.
Medical professionals see the source of the problem as doctors prescribing too many antibiotics, which builds microorganisms’ immunity to them. But to Ramanan Laxminarayan, director of the Center for Disease Dynamics, Economics & Policy, the effectiveness of antibiotics looked like a natural resource, not unlike a forest or fresh water, that was under threat.
He and his colleagues studied the problem from the points of view of multiple players, including doctors, patients, and insurance companies, and But researchers at the Center for Disease Dynamics, Economics &amp;amp;amp;amp; Policy, after consulting with doctors, patients, and insurance companies, concluded that the healthcare system it would get better faster short-term results by trying to prevent infections than by persuading doctors to prescribe fewer antibiotics.
Different disciplines have developed their own approaches to thinking about problems, and in many cases, they can be transported from one field to another, says Stephen Downs, who was Pioneer’s first leader and now serves as the foundation’s chief technology and information offer. He says someone who’s coming to a problem fresh often looks at it differently than someone’s who’s been enmeshed in the issue for a long time.
“When you’re really looking for breakthrough thinking and ways of shaking up the system, it’s so easy to be blinded by your expertise,” he says. “It’s so easy to be blinded by your sense of what’s feasible and what’s not and the way things are done.”
One of the biggest grants Pioneer ever awarded was for a project designed to accelerate research examining the influence of genetics and environment on health.
The Kaiser Permanente Research Program on Genes, Environment and Health won $8.6-million to build a large, diverse biobank of DNA samples from consenting members of the health plan. In a single database, the project links 200,000 participants’ genetic information anonymously with their health records and connects that information to geographic details about environmental factors like air quality and the number of parks in members’ neighborhoods.
With all that information in one place, scientists can skip the time-consuming, costly step of assembling those data sets on their own, says Catherine Schaefer, director of the Research Program on Genes, Environment and Health.
“Research takes a long time,” she says. “So if you can reduce part of that time, you can make the wheel of discovery turn faster.”
Ms. Schaefer says she values the big-picture perspective her program officer at Pioneer provides on how the biobank fits into the larger public-health landscape.
“I can get very focused on what do I need to do to make this program a success, or what are we trying to achieve in terms of this particular scientific issue,” says Ms. Schaefer. “She helps me to broaden my vision to what are we trying to do here that really could make a difference in terms of people’s health care.”
Grantees say they appreciate the Pioneer Portfolio’s willingness to back projects that don’t fit easily into typical foundation priorities. But they say Pioneer’s support goes beyond writing a check.
Among its projects: Health Games Research, a program at the University of California, Santa Barbara, that finances research to see if digital games that carry health lessons actually change behavior. One study the program financed found that blowing into a mobile phone’s microphone as part of a game can help reduce tobacco cravings in smokers who are trying to quit.
The seal of approval of the Robert Wood Johnson Foundation lent credibility to a new area of study, says Debra Lieberman, director of Health Games Research. She recalls when her program officer from the Pioneer Portfolio traveled to Maryland and introduced her when she made a speech at the National Institutes of Health.
“The fact that he was there made people more interested in attending my talk and made them take notice,” she says. “The foundation was really setting a new norm that health games are really an important tool in the toolbox for health promotion and that the research has something to teach us.”
Philanthropy has an important role to play spurring innovation, says Mr. Quinn, of the Pioneer Portfolio. Because foundations don’t need to earn a financial return on their grants, he says, they can take risks that investors in the business world cannot.
“We face big problems, whether it’s in health, whether it’s in education, whether it’s in the environment, the aging of the population,” says Mr. Quinn. “Those big problems are going to require big solutions.”
Pioneer Portfolio Grants: a Sampling
Archimedes Health Care Simulator
Purpose: To build a Web-based tool that gives policy makers and nonprofits access to high-powered mathematical modeling, which can be used to analyze health-policy questions and compare treatment scenarios, outcomes, and costs.
Beth Israel Deaconess Medical Center
Purpose: To study whether giving patients access to their doctors’ notes affects their involvement in their care.
Kaiser Permanente Research Program on Genes, Environment, and Health
Purpose: To build a biobank of DNA samples that links participants’ genetic information anonymously with their health records and environmental data, with the goal of accelerating research on the impact of genetics and environment on health.
Project ECHO (Extension for Community Healthcare Outcomes)
Purpose: For Web-based videoconferencing that links primary-care doctors, nurse practitioners, and physicians’ assistants with specialists who train them on how to treat complex conditions, such as hepatitis C and diabetes.
University of Michigan School of Information
Purpose: To study whether people who publicly announce their physical-activity goals are more likely to follow through on them.
University of Pennsylvania School of Arts and Sciences
Purpose: To identify “health assets,” factors such as optimism or a stable marriage, and determine whether promoting them can protect against physical and mental illness.