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

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

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

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

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

RWJF's Larry Blumenthal, a Senior Communications Officer here at the Foundation, tells us:

Ralf Beach is an unlikely poster boy. At 70-years-old, he has survived a heart attack and quadruple by-pass surgery, has chronic lung disease and insulin dependent diabetes. He is also an acknowledged hypochondriac. Yet he is a shining example of the potential for bringing patient’s medical records online in the form of personal health records (PHRs).

As part of an experiment by researchers at the University of Washington, Beach is managing his diabetes and his health online. From an island in Puget Sound, he has access to his entire medical record. He delivers his blood sugar meter readings digitally – by-passing a three-hour trip to Seattle - and communicates with his doctors’ offices electronically. He’s a happy user of his PHR.

Ralf Beach is just one example of the potential for PHRs examined in a recently launched podcast series by the Foundation.

Advocates say PHRs could dramatically improve health care delivery, decrease medical costs and make it easier for all of us to manage our health over the course of our lives. With more than 130 million Americans – nearly half of the U.S. population – living with chronic conditions, the potential is obvious. To tap that potential, RWJF has been supporting, along with the California HealthCare Foundation, Project Health Design. Project Health Design has been working with nine multidisciplinary teams that are designing PHR-driven tools and applications that put patients’ needs and priorities first.

Of course, there are some challenges to overcome before PHRs reach that potential. There are concerns that PHRs shift too much of the burden of health care onto the patient. There are technology hurdles. Currently, there is no universal language or data format for health care information. Perhaps the biggest issue is concerns over privacy.

To delve into the potential — and the potential obstacles—RWJF worked with WGBH in Boston to produce this four-part series and the first two installments are up on the Foundation website, here.  The first segment features discussions with Project HealthDesign Director Patti Brennan, Project HealthDesign grantee James Ralston of the University of Washington, David Lansky of the Markle Foundation and Deborah Peel, founder of Patient Privacy Rights. You’ll even hear from Ralf Beach himself.

Segment 2 looks at some PHR work already underway at the Palo Alto Medical Foundation and Kaiser Permanente. The last two segments will be posted in the coming weeks; segment three digs into what Microsoft, Google, RevolutionHealth and others in private industry are working on. And the fourth and final segment features a roundtable discussion that wrestles with the intriguing potential of PHRs and the challenges ahead in implementing them. Please take a listen to this series and let us know what you think.

To say that I feel like a fish out of water would be the understatement of the week. I am sitting here at my first Fortune Magazine Brainstorming TECH conference, feeling a bit out of place, but hearing themes that resonate strongly with me and how we approach our work at RWJF. I might be one of five folks from nonprofits or foundations here (perhaps a bit of an overstatement, but not much so), but the conversation on the first day of this meeting directly relates to our work on the Pioneer team. The major theme this morning: how do we incorporate and work with the end user to create a better product? It is all about the end user. That is how you get to innovation.

The meeting kicked off with a conversation about the evolution of the web. Marc Benioff, president of salesforce.com, Inc., gave his perspective on how the internet has evolved over the years: transact (where it began), collaborate (where we are now), and innovate (where we are heading). We are moving from collaboration (web 2.0) to using the internet as a platform for innovation. The critical element for this transformation is the evolving role of the end user.

The speaker that really brought the idea home was Brad Smith, president of Intuit (developers of Turbo Tax and Quicken), who made me think about how his conceptualization of the end user could translate to the world of philanthropy and health and health care. He spoke to the questions that he asks himself as he thinks about the future of his company:

• Are we paying our employees today to do work that our customers could do for free?
• Are we sitting on the gold mind of data (end user expertise)?
• Could we create more value for the end user?

So let’s think about Pioneer’s work in prize philanthropy and our various Changemakers competitions that others and I have spoken of before.  What are we doing with these if not having our “customers” add their expertise to ideas that could benefit from RWJF’s support? The same is true for Ruckus Nation and much of Project Health Design.  (BTW, speaking of Intuit, it’s getting into the health management personal health record business with quickenhealth.  You trust your taxes to them, would you trust your personal health record?)

Changemakers, with its open source collaborative competition model, brings the end user in to every part of the competition experience: the judges and the applicants are end users and, therefore, the end user has a voice and a platform to put forth ideas that can address health and health care problems and judge ideas that have been set forth. In Ruckus Nation, the end user was the center of a competition for ideas that could get youth more physically active. The ideas sourced through Ruckus Nation came from end users, youth! And finally, Project Health Design incorporates the experiences, needs, and concerns of patients to inform project development for personal health record applications.

So even though I started feeling like a fish out of water, by the end of the first day I had found my place. There are transferable lessons from how the for-profit world thinks about end users and how Pioneer thinks about transforming health and health care.

Here’s the big question, is health care ready to bring the end user into the equation? If so, why and if not, what would help the integration of the end user into shaping health and health care?

More to come… In my next post I will let you know what Jeff Bezos, president of Amazon.com, and I have in common.

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.

And the ability to use rules to guide activity—care—is an important pre-condition that permits a Disruptive Innovation. Once you have evidence-based rules that determine a course of action, you don’t need someone with the highest level of training to take that action, because you don’t need as much judgment and intuition. In the case of health care, this means less expensive caregivers can do more complicated things.

Then came Christensen’s discussion of how Disruptive Innovation can transform the health care system. Christensen’s take is that the network effects of the existing health care ecosystem (the relationships among hospitals, providers, plans) make it impossible for our current system to change sufficiently to solve the problems we have with health care today. I think he would assert that the current system simply can’t improve its way out of its current limitations, so the only way to fix the problems we face is through disruptive innovations.

The cool part came when Christensen reframed of the current business models in health care in such a way so as to identify opportunities for disruption. I don’t want to steal the thunder of the forth-coming book, so just when this blog is getting interesting, I need to stop. But suffice it to say, I plan to read this book carefully when it’s published.

Yesterday's discussion with Gary Cohen introduced us to Health Care Without Harm and the recent achievements of the green hospital movement in the United States. Today, Cohen speaks about green health care internationally, outlines the challenges facing the green hospital movement, and offers his both short- and long-term predictions for the movement's future.

Health Care Without Harm is part of a global movement; what lessons do you think the US health care system can learn from the international community?
Right now we’re learning a lot from Europe. A typical Northern European hospital uses half as much energy as a typical US hospital. That’s a very significant issue, because as we are entering into a period of global climate crises and reducing reliance on fossil fuels for health care is a public health imperative (this sentence needs better structure). There are very direct links between a hospital’s energy sources and community health; we have evidence that shows if a hospital is reliant on coal fire power plants, there will be increases in asthma, respiratory problems and increased hospital visits. This also offers the opportunity to move to renewable sources of energy.

Another reason hospitals in Northern Europe are using less energy is because of hospital room ventilation. In a typical US hospital the ventilation duct is at the top of the room and pushes air into the hospital, into the patient room, and it circulates out and then it goes back up. So it actually circulates a lot of the germs, and it goes against gravity. In Europe, the intake of the ventilation of the room is at the sidewall level. And so the air comes up and then goes out the top. As a result, you need 30 percent less energy to run such a system. And now there’s research to evaluate whether this type of ventilation actually decreases infection rates in the hospital. Instead of recirculating the air and reinfecting people, the Northern European systems draw the air up and out the top. If changing the ventilation in hospital design reduces infection and reduces energy it is a big win both for patients and for the environment.

What are the biggest barriers and challenges facing the green hospital movement in the US?
The health care systems that have made the most comprehensive changes always have buy-in from the executive level. Once the CEO says that we’re going to make this change happen, then the rest of the system gets in alignment and people are given a mandate to implement change, whether it has to do with their built environment or their purchasing or their operations.

Where we don’t have that high-level buy-in, we might have a lot of champions, either nurses or facilities managers or environmental coordinators. Their efforts are critical, but they are swimming upstream, against the priorities of the system. And while those champions may be doing great things in their small corner of the hospital, it’s hard, though not impossible, to diffuse those changes system-wide. The Luminary Project of HCWH has seen the power of nurses as change agents and is telling the stories of nurses who are working to human health by addressing environmental health.

Cost analysis is another barrier. Where we’ve been able to showsome intervention saves money or is cost neutral, it’s been very easy to make the case for green solutions. The places where it’s very cost competitive is around reducing waste, reducing water use and reducing energy use. There are immediate positive financial impacts and environmental impacts with those kind of interventions. We’re also in the midst of developing a business case around sustainable health care building. We are seeing that there’s quite a small differential up front for some of the pilot hospitals, in the neighborhood of 1-2%. But because it’s going to save over time we’re now trying to measure how quickly that investment’s recouped.

The medical education system in the U.S. does not address the links between environmental exposures and disease or health impacts, and this continues to be a significant barrier for our work. A typical doctor may get four hours of environmental education in four years, and that will include issues around smoking and diet. And yet the science suggests that there are incredibly strong links between a very specific set of illnesses and diseases and very specific set of environmental exposures. The science is way ahead of the medical education, and that’s a real impediment to the transformation.

Are there specific things you are looking to accomplish in the next 5 years?
In the next 5 years we’re hoping to get to change the way that hospitals operate so that they’re moving toward being toxic-free, carbon-neutral, with minimal waste and dramatic water conservation measures. To that end, we’re going to be helping hospitals develop their health care footprint, so they can measure where they are now, and then work with them over time to dramatically reduce that footprint.

We are working hard to link sustainable health care design with what’s called evidence-based design. Used by the Center for Health care Design, evidence-based design integrates patient and worker safety into the design process. Linking sustainability and evidence-based design to make green and healthy building practices the absolute standard in all future health care construction is a short-term goal for us. And it will be important for us to document how those changes in design and construction affect patient outcome and worker health and safety.

We also hope to collectivize the purchasing practices of all the major hospitals in the country to drive the marketplace for safer and healthier products across the whole sector. I think there is an enormous opportunity for the health care sector to define an economy and a society that is places health at the center of it all. We need to transform our society to one that supports healthy people, healthy communities and a healthy planet.

We are also going to be working with the UN and the WHO to eliminate mercury from health care globally and to use that as leverage for a globally binding treaty to eliminate mercury completely.

If the health care sector really decides to move in the green direction, what impact is it going to have 10-15 years down the line?
We will see that changes in the health care industry become a driving force in our society, it will help us move away from our addiction to oil and petrochemicals, it will move us toward preventive medicine and we’ll begin to see reduction of diseases in our society.

Now, we’re working on a wedge of a larger problem. The larger problem is that we need to be providing health care to everybody who needs it. And at the same time it needs to be as environmental responsible and supportive of safety as it can be. We are part of a larger confluence of consciousness in the planet around the need for health care and the kind of health care that will keep us and our planet healthy. It’s exciting and we’re happy to be part of this movement.