From The Field F E B R U A R Y 1 7 , 2 0 1 4 A World of Darkness: What If Thomas Edison Had to Write Grant Proposals to Invent the Light Bulb? JEFFREY BRENNER, MD Executive Director and Founder, Camden Coalition of Healthcare Providers, and Medical Director, Urban Health Institute at Cooper University Health Care A s Thomas Edison began to write his grant report he ment of truly stunning academic health care institutions that cringed. Despite trying over 2,000 different materials have applied the scientific method on a massive scale, but to create a light bulb that could bring light to every these same institutions have grown dependent on delivering American, he felt no closer to a solution. The bulbs he had unnecessary care through the misapplication of the technology built required too much power and would only stay lit for a they have created. They have grown their inpatient hospital few hours. His inputs, outputs, timeline, and logic model all bed and specialty care capacity, while leaving the fundamental made sense on paper—but still no light. questions of equity, justice, and beneficence for these tech- Cobbling together over 12 grants to build his team was nologies broad application unresolved. stressful. He was building the world’s first industrial labora- How do we ensure that every American benefits from these tory, had discovered a way to record and playback sound, and health care advances? Or, more precisely, how do we industri- was on the verge of building a motion picture machine, but alize our health care system, spreading these advances while he worried perpetually that he might lose his grant funding. simultaneously driving down the costs, expanding access, and Would he have to lay off his staff? He marveled that his team ensuring quality for every patient, every day? was willing to work in his workshop, when he could not The innovations in productivity that have occurred in almost guarantee their jobs. He needed to report progress on the light every other segment of the economy have left health care bulb and there was none, at least not yet. behind. While we are dazzled by the drugs, devices, and proce- Since 1945 the National Institutes of Health (NIH), a fed- dures of health care, the structure of our health care delivery eral government agency that funds medical research, has spent system, the way we organize work, the way we analyze data, $547 billion dollars to cure disease and push the frontiers of and the way we train our professionals have become obsolete. medical knowledge. This spending has been supplemented by Our health care delivery system has been very slow to change funding from private foundations. Sadly, despite all of this and embrace industrial methods pioneered in the 19th and 20th spending we have little understanding of how to deliver better centuries by other sectors of the economy. Techniques like care at lower cost to every American. At best, in the field of standardization, protocolization, segmentation, workflow population health, we have a few light bulbs that stay lit for an redesign, task shifting, change management, and modern lean hour or two, but we lack even basic knowledge to drive this principles are only beginning to be adopted in health care. field forward. The scientific revolution of better care at lower cost will not With 85 million baby boomers in the midst of retiring and a be led by academic health centers alone because they have too health care system that consumes 18 percent of our economy, much to lose. The underpinnings of their financial model it is not a small problem. We do not understand the funda- would collapse if their unneeded bed capacity went unoccu- mental drivers of health care utilization; the basic rules for pied. Instead, the cutting edge of population health is being designing and implementing effective interventions; the best built at the periphery of the system, sometimes far from our ways to use data to plan, implement, manage, and evaluate traditional academic health care institutions, in places like interventions; nor how to train staff to run and lead these south central Alaska; Albuquerque, New Mexico; Danville, interventions. Why the lack of progress? Pennsylvania; Doylestown, Pennsylvania; Grand Rapids, As executive director and founder of the Camden Coalition Michigan; and Camden, New Jersey. In all of these communi- of Healthcare Providers, a nonprofit organization committed ties, urban poor or rural underserved, doing more with less is to delivering better care at lower cost in Camden, New Jersey, a core social value. one of America’s poorest cities, I have spent a lot of time The barbarians at the gate for population health will be thinking about these questions. Finding a path forward will nurses, social workers, project managers, and health coaches require new leadership from private foundations and a armed with new analytic models, real-time data from Health different way of funding population health initiatives. Information Exchanges, and tools borrowed from behavioral The last 60 years of research funding has driven the develop- health like motivational interviewing and trauma-informed care. Rightsizing our nation’s biomedical infrastructure and shifting led by communitywide, nonprofit organizations with broad 18 percent of our economy will be no easy task, but it is a task stakeholder and community support. Local hospitals, that philanthropy was intended to solve, to be a counterbalance providers, and insurers must be committed to delivering better to systems that have become obsolete and need to change. care at lower cost regardless of the potential impact on their At the heart of the problem is the importance of identifying business model. the field of population health as a unique and distinct disci- A population health laboratory would need to have full access pline, which combines skills, knowledge, and perspective to real-time, patient-level data; legal infrastructure to enable from public health, medicine, sociology, psychology, anthro- easy data sharing; a stable communitywide governance model; pology, business, engineering, biology, and computer science. the ability to conduct mixed method and randomized control To borrow a word from the famous scientist, E.O. Wilson, studies; the capacity to analyze, visualize, and learn from data; population health is a discipline that requires consilience— business skills in project management, workflow redesign, a synthesis and recombination of many existing fields of performance improvement, and strategic planning; and a deep knowledge into a new and distinct set of knowledge. bench of clinical outreach staff and project managers. Population health works to ensure that every patient These laboratories would act as hubs for highly qualified receives high-quality, effective, and timely health care at the researchers in diverse fields to access data and participate in lowest cost every day. To accomplish this goal means under- designing and implementing population health research standing the quarks, protein folding, and e=mc2 of human studies. A strong commitment to testing interventions with behavior as it relates to delivering and utilizing health care randomized control trials would be essential; there have not services with the goal of creating an industrial revolution in been enough quality ones done in this field. health care delivery. Edison’s work and Xerox Parc were funded through the Current public and foundation funding streams are inade- commercialization of new technologies. I do not believe the quate to solve this problem. An NIH research grant will fund field of population health and the proposed laboratories should the research team but is not enough to fund the clinical be funded by commercialization of their discoveries. Delivering teams. A foundation grant will fund the clinical team, but not better care at lower cost is too important to our society, and the data or legal infrastructure. Population health requires commercialization will slow down the pace of discovery and significant infrastructure: data management, data analysis, dissemination. Their sustainability plan should be planned legal, public policy, project management, quality improve- obsolescence—when they cease to provide important knowl- ment, finance, social work, behavioral health, nursing, edge for mankind they close down, instead of patenting, pharmacy, medical, and more. copyright protecting, and selling things like patient screening There are two historical examples that can illustrate a tools. Open source tools can drive innovation more quickly. pathway forward—the creation of industrial laboratories by I fervently hope the Camden Coalition gets smaller as the Thomas Edison and Xerox at Xerox Parc in California. work we do becomes a mainstream part of the health care sys- Thomas Edison gathered a team of machinists, chemists, and tem and the knowledge we have discovered becomes a part of engineers to solve the most challenging technological prob- everyday health care services for Camden residents and patients lems of his age. With over a thousand patents his team all over the country. Our vision will be realized when we developed the phonograph, motion picture camera, long- become obsolete. For this reason, we have put our contracts, lasting light bulb, fluoroscope, and carbon microphone, and training manuals, workflows, screening tools, and other deployed a system for distribution of electricity in parts of materials on-line and made them freely available. I hope New York City. Entire industries were created or changed by someone takes them and creates even better innovations. his work. Under one roof he assembled an enormous array of Fortunately, Edison did not need to cobble together multiple human talent and resources. grants and file grant reports to support his work. I am not sure Xerox Parc brought together engineers, scientists, psycholo- we would have the light bulb; it took Edison another 1,000 gists, and anthropologists to change how humans interact tries before he stumbled upon a carbonized bamboo filament with computers. In a short period of time they created the as the best filament to create a low-cost, long-lasting, commer- mouse, GUI computer interface with icons, laser printer, cially viable bulb. optical data storage, word processing, and the Ethernet. The Camden Coalition has had the support of foundation Their work paved the way for the modern desktop computer. partners willing to fund the core infrastructure necessary to I am proposing the creation and support of industrial grow our work in an entrepreneurial and flexible way. Our population health research laboratories in several locations in funders include: The Nicholson Foundation, Robert Wood America supported by private foundations. Small community Johnson Foundation, Merck Foundation, Bristol-Myers health grants disseminated to under-resourced community Squibb Foundation, The Commonwealth Fund, Campbell programs across the country will never solve the bigger health Soup Foundation, The Atlantic Philanthropies, Pincus care problems of our time. The articulated purpose of these Foundation, and the Aetna Foundation. smaller grants should be to find population health innovators capable of building and leading population health projects, to find communities with broad alignment around population health goals, and to find health care systems ready to change. Views from the Field is offered by GIH as a forum Industrial population health research laboratories should be for health grantmakers to share insights and experiences. If you are interested in participating, please contact Osula Rushing at 202.452.8331 or orushing@gih.org.