There’s Wiki Government, so what about “Wiki Public Health”: Public Health Innovation III

I recently read Beth Simone Noveck’s Wiki Government: How Technology can Make Government Better, Democracy Stronger and Citizens More Powerful as part of my research on rethinking public health and innovation in public health. From the outset Noveck hits a chord with me in asserting that it is time to rethink democratic theory and the design of governing institutions to bring them in line with the age of networks. Or as I like to put it, we’re constantly struggling in a world of analog institutions and practices embedded in network societies. Public health, a laggard in my opinion, is rapidly falling behind other disciplines in thinking about socio-technological change and the implications for the field despite the tremendous growth in interest in mobiles and social media widgets at the CDC. These are merely the tip of the iceburg.

Noveck begins with some examples of how networked platforms and practices are changing industry. From IBM’s World Jam that enables employees from all over the world to work collaboratively and create proposals for new projects which the CEO has allocated $100 million to implement the best ideas, to InnoCentive’s success as an open innovation platform (she illustrates the success with the following antidote–a difficult to solve chemistry problem (in industry) was solved in four hours! by a lawyer), we’re seeing some networks perform quite well in providing solutions to problems. That is, provided they are managed and constructed in the right manner. And this is where Noveck’s work is quite useful to the health practitioner who wants to innovate.

If you’re not familiar with Joy’s Law it might be time to acquaint yourself with this axiom that states that no matter who or where you are, most of the smartest people work for someone else. This then begs the question of how do I tap their knowledge and expertise to accomplish my goals. Recognizing this is not difficult for many in government, and in my experience, public health. We’re too accustomed with one-way communication channels and how often have you raised the issue of user-generated content and the health expert hands go up immediately to question laypersons’ knowledge claims? But face it, health experts no longer have a monopoly on health knowledge, particularly as our knowledge of the social determinants, environmental determinants, etc. grows. Noveck points to political theorist Roberto Unger’s notion of “institutional fetishism” whereby many institutions believe that only a select and known group of ‘experts’ can assess science and citizens are only really capable of expressing values and opinions, is clearly one of the hurdles we face in the new realm of what I prefer to call “open health”. Philip Tetlock observes that historically expertise has not translated into an ability to make better forecasts (eg. he uses the example of Gandhi who in 1940 greatly underestimated the violence that Hitler would bring to Europe).

Noveck provides a tour of the examples out there where government and industry have taken Joy’s Law to heart and actually built platforms to innovate in the public sector. Her main example is the one she was mostly intimately involved with “Peer-to-Patent” the US Patent Office’s platform to innovate around the process through which patent claims are examined. I won’t go into details here but would rather focus on the insights and bring this to how we might use these insights in health. One of the interesting examples she found in the public sector was Bridgeport, Connecticut’s CityScan (pdf) that was a platform city government created to work with local communities to rescue derelict land-use sites. Citizens worked with the city to rehabilitate, map and document the rehabilitation process. We’re now seeing a proliferation of platforms similar to this take off in the past year. Check out SeeClickFix that enables citizens to identify an issue in their community that needs remedied and then crowdsource responses and make the invisible visible through civic participation and engagement with community leaders.

What we’re seeing is a growth in tools that enable us to visualize problems and data which in turn can facilitate action. Platforms such as Many Eyes and Swivel as well as the open API of Google maps enable people to begin creating and using data. There’s even an open data movement in the UK that is working toward making taxpayer funded data sources in government more widely available and accessible. Rather than the traditional database/knowledge management ethos we’re accustomed to, we need to begin to think about the social life of information. Or, as Noveck puts it, we need to think of every piece of information as a potential community. To illustrate this point she looks at the policies of Vivek Kundra, the former CTO of Washington, DC who became the CIO in the Obama Administration due to his work on opening up data and building applications for citizens to engage with data. He made every agency in the DC government create feeds from their websites that alerted the public to new data sources. In essence, he was creating a “digital public square” and was recognized for the work he did in creating Apps for Democracy that enabled citizens to frame a problem and then programmers could submit software solutions. This co-created mode of governance produced over $2 million worth of software for $50k in prize money (see first round winners). When Bob Riley, the governor of Alabama recognized that the fragmentation in the DHS crisis information was going to be an impediment, he created the Virtual Alabama Platform that enabled greater sharing of data, mapping and aggregation situated in a cloud computing context rather than in localized databases. This took $150,000 and 10 days to create a system that works across multiple sectors. Some of the other tools that the public health community should be aware of and consider using are:

Freebase: an open database projects
Public Resource: enables people to buy public information and then post it freely on the web (goal is to make data searchable and usable)
Urban Institute’s National Neighborhood Indicator’s Partnership: an effort to democratize information that can be used at the local neighborhood level for policy-making and community building user-generated input on problems at the neighborhood level documenting bike lane violations to make cycling safer
F** This! via the blog, The Infrastructurist, a version of

We need to think what the public health analogs of these platforms might look like? How can we make them available on mobile phones? How can we aggregate feedback on platforms to build policies collaboratively with publics? These are all data points for where innovation in public health, in my opinion, is going. Noveck points to these platforms as modes of organizing for innovation.

The challenge is to translate information into knowledge that people can work with and the growth in tools and thinking about infographics and visualization tools has been dramatic in the past year. Once again, thinking about how to make the invisible visible and build actionable data and platforms that can empower citizens and communities to use data, build policies, act on the data, change behaviors and environments.

One of the key challenges is the tasks of collaboration and cooperation and this is particularly relevant to public health. Policy wikis are one of the tools being developed to engage communities and work across silos. For example, rather than issuing a directive to the public as the final product one can create a wiki early on in the policy development process that contains relevant background materials, underlying research claims and then allow the public or selected members, depending on circumstances, to comment. Reputation systems and rating systems such as Digg-like tools can be used to rank or rate user contributions (these can help filter and prioritize ideas). Noveck views efforts in this space to be something akin to the IBM World Jam or “civic jams” to strengthen democratic institutions and input. We can use these internally with various public health partnerships where the growing complexity of issues and stakeholders represents a challenge to efficient collaboration. What about building a policy wiki for community benefit partners with non-profit hospitals, for example? Suggestions for best practices, innovative approaches and programs can be posted to seed the wiki and visualization tools could be created to compare approaches, impact and introduce transparency so that community benefit programs begin to share data and experiences with an eye to optimizing impact of investments. Visualization tools are also helpful in assisting organizations to reduce duplicity of services and to develop metrics and benchmarks for impact. Once these tools become used effectively the same institutions will have better data and a better facility for demonstrating benefits to the public and government.

So what are the lessons that Noveck learned from her work with “wiki government” in the past few years? She provides ten important lessons:

1) Ask the right questions: as with any open innovation process, asking the right question is central to success. You just can’t build a platform and people will come. You need to break problems into manageable chunks and provide the tools and resources for people to solve the problem

2) Ask the right people: there is a facile populism out there around ‘crowdsourcing’ and other open innovation models that can prove counter-productive. Just opening things up to a cast beyond the usual cast of characters does not automatically translate into new innovations. You still need to think about the standards of participation and who to open the process up to and when.

3) Design the process for the desired end: groups need to know what is being asked of them and you need to break processes and problems down into discrete steps.

4) Design for groups not individuals: here it is important to recognize that people often work in short bursts of time when working in groups. Participation needs to be enjoyable and engaging and reward in ways that working alone does not.

5) Use the screen to show the group back to itself: people need to see themselves as part of a group or “mini-movement” when they’re working at a distance or in virtual communities. There are visual tools for people to see who is doing what and to enable individuals to nudge one another toward desired outcomes. Mapping tools can be very helpful.

6) Divide work into roles and tasks: Parcel work into small tasks. People can assign themselves roles. A good example is Scratch developed at MIT Media Lab is a tool created to help students to write software by giving them visual building blocks, similar to Lego pieces. In other words, just as social movements have a division of labor, so do online communities.

7) Harness the Power of Reputation: most good collaborative platforms have ratings systems that enable participants to rate each other’s submissions. Many of the collaborative, open innovation websites use these tools to filter and prioritize. Here are some examples: Dell’s Ideastorm, Ameritocracy, Knol, White House 2.

8) Make policies, not websites: It is not just the technology, stupid! You need a systems-based approach that looks at the problem as a whole and look at policies and practices and how they must change to become more collaborative. Know where you have expertise and where you need help.

9) Pilot new ideas: Networks are experiments and probes. Not everything you start will succeed but you need to be able to, as they say in Silicon Valley, fail early and fail fast. Make it clear to participants when you’re piloting. I often hear public health folks wanting to get on the train now that these platforms are taking off and they scratch their heads why no one shows up to the wiki or blog. It takes some work and time so you need to try out new things, get over the build the site and they will come attitude and figure out who is going to be the idea gardener(s) for whatever approach you take.

10) Focus on outcomes, not inputs: Have a clear idea of what you want to accomplish. Is it legislative outcomes, community impact of programs, ideas for new approaches to a problem?

Public Health Innovation II

To continue with the Health Policy Innovation review and discussion, part II will focus on innovation systems and platforms that Kickbusch et al propose. We’ve all heard of the Personal Health Record, the elusive holy grail of “the next big thing” in health care. Now what would the public health analog of this be? The authors here point to the concept of a “Personal Health Information System” that forms the backbone of a public health innovation system that has shared, co-created aspects that distinguish it from the PHR. The goal is to use the PHIR as a “community-centered collaborative innovation system”. The old model of public health was one that focused on educating people to behave in a healthy way and the public health system will offer protection from epidemics, safe access to food and water, and access to medical care. We’re now shifting to a model where patients in the health care system are increasingly considered co-producers, citizens rather than consumers, and we’re seeing the creation of bottom-up health commons (a common theme in this blog).

The traditional model of biosurveillance and epidemiological models are more command and control types of regimes that are now shifting to what the authors call “integrated health governance”. This means a new vision of health services that is less vertically driven and fragmented to a more value-based, citizen-driven model based on health networks. This is where the PPPP model, of public-private-partnerships that are “people-driven” come in. In order to facilitate this model we’ll need to think about how to develop platforms that offer the tools, often co-created with citizens, that could promote desirable changes in behaviors. There are some interesting working examples of this way of thinking and doing innovation and one of the most impressive examples is NESTA in the UK which has been one of the leading centers for rethinking public services through the broad lens of open innovation, co-creation, design.

NESTA and the Young Foundation’s Health Launchpad could provide interesting conceptual approaches to what I have in mind with the “Public Health Innovation Center” concept I’m working on at the moment. This could be the basis of a node for the ePHIS mentioned above. This system, as structured in the Kickbusch volume, would bring together the health policy sector and the need for health information governance, to a market-driven sector that provides technology platforms, to localities where specific health strategies are generated, to professional health provider networks. The citizen health information node is at the center and provides the platform for each piece to feed in for health innovation through health knowledge networks (I’ll add a diagram at a later point that makes this easier to visualize). A model based on this concept has already been deployed in a rural community in Barreiro, Portugal with high diabetes rates. A community of 1050 with 65% prevalence rate of diabetes became the site of the iCitizen, a citizen-centered health information system that contains both PHR and ePHIR with a focus on digital literacy and participatory research was begun in 2008 to test the concept.

I’ll be adding part III of this series through a discussion of “Wiki Government” and soon to be followed by an analysis of transparency policies to create the building block of a more robust picture of Public Health 2.0.

Public Health Innovation I

I’ve been focusing on pulling some thoughts together to inform the creation of a new health innovation center and along the way I’ve been reading some interesting new books that have been quite helpful. I’m going to provide some nuggets from each and how they might be brought together to create something quite useful.

The first piece is Ilona Kickbusch’s edited volume “Policy Innovation for Health”.41oj-wTFujL._SS500_ Kickbusch begins by recognizing that we have undergone a transition from acute care to managing chronic diseases that must now be approached through a broader multi-sectoral lens (yes, we hear this all the time but can you find more than a handful of interventions that actually do it or do it well?) and, news for the public health community, we have to do this through partnerships with the private sector. Innovation in this new context will revolve around the following variables: affordability, quality, and efficiency. The problem with what we call innovation in the health sector has too frequently been about short-term reorganization of health care systems that lack any kind of long-term perspective. The OECD perspective on health innovation is rather typical–genetics and biotech remain the focus or framing disciplines/sectors for where innovation lies (OECD should really take a hard look at the numbers for biotech, they’re actually not that impressive to date). Framing health and health innovation is an important first step and to do that properly we must recognize that the boundaries of health are fluid and that most attempts at thinking about health innovation remain within the health system.

The organization of health is increasingly separated from the management of disease and illness so we’ll need to think about the health impact of policies ACROSS the policy spectrum (ie. transportation, agriculture, built environment, etc.). Most health professionals who still do not exist in the paleolithic age get this, but doing it is another thing. There are some examples such as the Canadian Index for Well-Being that have tried to create frameworks for putting this broader approach into place. And I like what this means for how we need to rethink what we mean by innovation (or what I am increasingly referring to as social innovation). Or, Kickbusch and colleagues term the “innovation of innovation”–health innovations change society but the societal processes of innovation in health changes the nature and characteristics of innovation. Or, as science and technology scholars may have it, innovation and health are mutually constituitive.

Open innovation as a paradigm for health is coming fast but faces some hurdles in the health sector. Even though we have a culture of peer review in medicine, medical organizations are far from transparent. This will get interesting in the US as the Obama Administration tries to bring more transparency to all sectors of government. We’re bound to hear the old story of how health is different and the privacy flags will go up to try to stop the conversation dead in it’s tracks. Nevertheless, open innovation demands a more networked governance model, greater attention to social determinants of health and greater reliance or partnerships (or I prefer networked models over traditional partnerships). And we do see some interesting efforts to put this into place such as the “Nordic Region as a Global Health Lab” project that aims to focus on prevention and build strong civil society organizations, open data, innovative science environments, and user-led innovation platforms to drive innovation in the health sector.

I’ve been working on the open health paradigm for the past several years and appreciate the attention this book gives to the proliferation of new sensors, diagnostics and mobile devices that are increasingly creating the tools and ability to create platforms for user-led innovation in the health sector. Recently I’ve been thinking about how we can build on the AppsforDemocracy.Org experience and build something akin to “AppsforHealth” to solve citizen-generated problems, for example in the Healthy Cities format. These authors point out that a focus on building health literacy will be important. However, I think this is going to have to be a two-way street–health professionals need to learn a lot more about actually existing and lived experience of chronic diseases and their broader context through, what the authors of this book view, PPPPs, that is, public-private partnerships with PEOPLE. Through true partnerships we can begin to build greater transparency and understanding of the social and environmental determinants of disease and give people the tools to see the connections. We talk a lot about the concept of “dashboards” in sustainability, such as the mpg dashboard in the Prius, or smart grids for the home to monitor electricity consumption. What would these look like in health given the rapid pace of development in the mobile health/bluetooth device space in health?

Networked governance and what the authors refer to as “Virtual Reorganization by Design” are going to be central to innovating in health in the future. First on the table is how to build networks across sectors and build trust, commitment and share risk are some of the issue that will need to be developed. And there are also different types of networks in terms of structure and function that will need to be considered. Some of the key competencies required to design and maintain these networked structures will range from the ability to manage non-hierarchical domains, managing interdependencies of stakeholders and having the ability to manage multiple roles and accountabilities across time and space. Furthermore, networked organizations require a change in thinking from one that focuses on inputs and outputs to a perspective informed by thinking in terms of investments and outcomes. Managing the white spaces in networks becomes extremely important since this is often where new innovations are discovered.

Much of the thinking about innovation in health has been about technologies. Witness the interest in social media and mobiles in health at the moment. But it is important to recognize that even in these areas, innovation is not just about the technologies. I don’t know how many mobile health conversations I’ve had of late where the consensus has been that we need policy innovation desperately for this space to take off and have the impact that we’re hoping for. Kickbusch et al. are correct to point out that innovation in health is not about technology, but rather creating value in a knowledge society. What this means in mobile health/health 2.0 and then some, is that we’re in a historical moment when we need to think about managing the mass customization of health information and creating tools to enhance health and digital literacies that lead to citizen (not that ridiculous health consumer fantasy) empowerment.