My framework and perspective on measuring “pioneer-ness” has been radically altered by what I have seen and heard at TED.  What began as a traditional academic exercise of collecting data to examine a hypothesis and testing fit of predictions has evolved into a task of discovery – a quest to discover the “pioneering” genome.

Jim Hornthal gave a memorable talk in TED university (a series of short talks held in a smaller theater than the official “TED TALKS”) about the importance of pattern recognition, a quality another speaker said that only humans, not computers, possess.   

Pattern recognition can help us discover useful information we didn’t know we were looking for. Jim talked about several ways humans seek assistance when making a decision. 

• Rely on experts
• Rely on friends
• Check with crowds
• Use algorithms to understand complex data, such as what’s currently being done in genomics

We’ve used the first two to examine the Foundation’s Pioneer Portfolio.  We will embrace the third once open proposal is launched .It is the fourth that intrigued me…. a strategy that I encounter daily in my entertainment life, but had not considered in my work.

Similar to the iPod app Pandora, which predicts what kind of music an individual will like based on the fundamental properties of the songs they have indicated they liked in the past, I am intrigued by the challenge of discovering what it is about the Pioneer team’s projects that makes them pioneering, in order to predict projects and ideas that the team should seek to support.

To turn patterns into information, I’ll start by going through the notes I took at TED, the words my colleagues shared, and the characteristics the other meeting attendees supplied: infrastructure, unconventional, unpredictable.

I’ll also go through the two years of data we've collected in our quest to objectively score our portfolio's success at attracting and supporting successful pioneering ideas/projects.  Even our crudest measures, such as when we just ask our examiners, "Is this pioneering?" why?  What is pioneering to you?

Through all of this, I’ll look for clues to the building blocks of the pioneering genome, then see how we can use that information to gain knowledge.

I'm thrilled to attend TED this week. In addition to being open to new ideas that might morph into fundable projects for RWJF, I’ll be expanding and refining my thoughts about measuring “pioneer-ness.” This means trying to distill a core definition of "pioneering" and validating this definition – seeking, in the end, a scale and/or indicators rwjf staff and others can use to objectively score the ideas we support.

I plan to collect data by having each RWJF program officer here rate presentations as "pioneering, innovative, interesting, or not that interesting" and by interviewing fellow attendees about how they make determinations about the ideas they're hearing.

As the week goes on, I may find I have a checklist I can use to score each idea.

 I may not.

If I had to answer the question today of "what is pioneering”—and how you measure it – I'd say, without taking credit for the language: 

“Pioneering ideas have potential for breakthrough solutions to emerging or persistent problems."

If I had to answer the question today, how do you make decisions about pioneering (vs merely innovative) ideas, I'd say:

“RWJF pioneer team members seem to know it when they see it.”

If I had to answer the question today of  "how do you measure ‘pioneeringness,"  I’d say:  

“I don't yet have good indicators, but a scale to measure "pioneer-ness" would surely include elements of newness, unexpectedness, risk (carefully defined),and  the potential for a leap in progress. These projects also have the potential to transform health care with out-of-the-box solutions.”

I'm not sure if I would include the elements of elegant or simple, but I'm expecting to be most blown away by ideas that I understand but never would have come to me.

I hope a few new ideas will come to me as well.

Update to original post: I’ve been asking each of my colleagues (and TED attendees I’ve interviewed) to rate the ideas presented as Pioneering/innovative/interesting.

I found that scale limiting, and have expanded to: Pioneering/innovative/important/interesting. Though something can be innovative, but not important technically, so I’m going to work with this scale until it breaks down.

Here are some words and concepts that are being associated with the concept of pioneering:

• (un)Predictability: However, it’s not always clear what’s better in terms of impact. Julie Taymor talks about the value of not knowing where you are going to end up, so I think that having a project that allows for unpredictable outcomes will have  more pioneering potential.
• Simplicity
• Understandable
• Done before?
• Tried before: This is a real challenge. I’ve started with a score of pioneering for more than one idea, until speaking with others and finding out that someone else has done this before.
• Redefine rules?
• Suggest an infrastructure?: This is likely to result in lasting social change (no need to define the type of change..maybe that’s unpredictable)
• Hypothesis driven?
• About discovery?

I’ll continue to hone this scale throughout the remainder of TED and will let you know how things shape-up after the conference. 

Last week, I went to Key Largo, Florida to attend the 8th Triennial Invitational Choice Symposium, hosted by the University of Miami and the University of Technology, Sydney.  Pioneer has had an ongoing interest in behavioral economics – also called choice architecture or “nudges” – which explores ways to influence people to make healthier choices.  You’ll recall that we sponsored the “Designing for Better Health” competition with Changemakers last year to identify health nudges. The conference convened researchers, psychologists, marketing folks and behavioral economists from around the world to meet together in small groups for three full days to present and discuss whatever they wanted. 

At the Invitational Choice Symposium, there were about 15 different groups that discussed topics ranging from marketing and politics to the intersection of perception, learning, thinking and feeling. My group, which was simply called “improving medical decision making,” brought together researchers with expertise in psychology, financial incentives, nutrition, law and economics to discuss how to improve medical decision making.…by physicians, nurses, patients and other actors in hospitals, medical offices, minute clinics, schools, at home and in the workplace.

Being that I work outside of the academy, I was invited by Dan Ariely and Ziv Carmon to join Kevin Volpp, Brian Wansink, Anup Malani, Barbara Kahn, Peter Ubel and others to provide a real-world perspective to the conversation. When the academics get too high up in the clouds, I was told, you should bring us down to think in a more focused way about how incentives can result in improved health and health care through improved policy or other tools to motivate and sustain favorable behaviors of providers, patients and others.

I don’t want to speak for the others, but I assume they were as gratified as I was for having the opportunity to spend so much time thinking and learning with those who had some of the missing pieces of the puzzles we were attempting to solve. We talked about LOTS of problems (conflict of interest, patient comprehension, adherence to medication) and lots of potential solutions (requiring cash payment, default second opinions, videos to change norms). The main issue that ran through the three days was adult obesity.  Though we  tried to leave the issue aside because we worried about wasting time on an issue that even Oprah can’t surmount, the fact remained that it was such a thorny behavioral problem that we couldn’t escape it.

In our discussion about how to address adult obesity, we talked about needing to understand why and how obese people become obese. Are they eating a lot at meals? (in which case, restaurants offering to serve half portions at 2/3 the cost of a full serving could provide a partial solution). Are they eating a lot when they are with their obese friends (then targeting interventions at social networks sounds promising). Are they eating the foods that are cheaper? (a fat tax could help). Are they eating the same amount as non-obese people, but just have a worse metabolism (need a miracle drug)? Are they eating because they don’t know how bad some things are for them or how good something are for them (calorie counts and other informational materials could help)?

The discussion dug in deeper to get at whatmight work to change eating habits.  Rules and restrictions? Financial incentives? Financial incentives to people’s friends?  Virtual incentives like those provided through the Farmville game? Points for good behavior redeemable the way frequent flyer/spender miles/points are? Making the world a Canyon Ranch? Limiting serving size by law? Shrinking plates?  Hiding appealing-looking food? Taking away people’s “heavy clothes” and buying them a new wardrobe to incentivize weight loss and maintenance?

Here is one idea that I feel enough ownership to share, though it was born of the insights of others: I think that a lot of people screw up their “good” day by eating something they didn’t really want.  Though I think that people who bring sweets to work and leave candy on their desk for people to nibble on have the best of intentions, free food is hard to pass up and good-looking food is a good way to start your day on a slippery slope.

What would it take to change the culture? To have co-workers consider it a rude thing to do to bring in cupcakes,  donuts, or cookies to a meeting, or put out chocolate when it is potentially damaging to someone else’s health? Would signs in the bathroom stall or conference room doors be enough?

At the conference, I accomplished the goals I set out to accomplish: to learn more about cutting-edge behavioral economics and decision science, and come away with an idea with “breakthrough potential” for possible future development by Pioneer.

I’ll expand more upon these ideas on future blog posts.

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.

Nicholas Christakis’ new study on social networks and smoking cessation was published in yesterday’s New England Journal of Medicine. Using data from the Framingham Heart Study, 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 also concludes that the chances of continuing to smoke decrease significantly for an individual when their spouse, friend or even sibling quits smoking.

The article, funded in part by the Pioneer Portfolio, is garnering a lot of attention in the media and stimulating many dinner table discussions. While the findings provide valuable lessons for those working in the field of smoking cessation, the study has implications well beyond smoking. Christakis’ work, reflected in this study as well as in the results he published last year on the influence of social networks on the spread of obesity, opens up a whole new way of exploring health behavior. I expect that over the next few days, weeks, months and years, policy makers and those advocating for social change will discuss how these findings can shape interventions and policies and researchers will clamor about how this innovative approach will expand the arsenal of tools used to help us understand and address some of our nation’s most challenging health problems.

Our grant supports Dr. Christakis’ and his research team’s efforts to create new data sets and develop innovative statistical methods that may allow health researchers to track and analyze the spread of health outcomes and behaviors – both good and bad – within complex, real-world social networks that evolve across time. The Foundation was willing to invest in developing these methodological tools because of an up-to-now unproven suspicion that the social network of relatives, friends, co-workers, neighbors, health providers and others can have a strong influence on an individual’s behaviors. And we believe that social network analysis can help us better understand the relationship between healthy or unhealthy behaviors and social linkages. Can we do a better job of improving health behaviors if we work at the level of the social network, instead of only the individual?

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.