 Great, so welcome everybody and a special welcome to Rebecca. Rebecca is one of our new Berkman Fellows this year, part of the new class for 2014-2015. In addition to that, she's also an assistant professor at the Harvard Medical School and the faculty director of the Global Health Delivery project in which we have a couple staff members here, in addition to many other accomplishments and titles, but we're so pleased to welcome Rebecca and take care. Thank you. Excellent, thank you. I actually asked to be one of the first contenders here and Kavya, Gretchen and I went to college together way back. And Gretchen said, why did you decide to go first? And actually the reason why I wanted to go first is that I actually desperately need your help. So I'm an outlier in the system and I'm learning all this new vocabulary. I didn't know what Linkrot meant. I didn't know what an SNI was, server name, indication, and I'm like cataloging all the new vocabulary that I'm getting from being part of the Berkman community. I'm hoping I'll have a new, a few new vocabulary words for some of you who may not be healthcare-related. And so what I'm hoping to do is spend about 12 minutes on our central problem and three different products that we've developed at the Global Health Delivery Project. And then actually my main question for you all today is how do we design digital badges for healthcare implementers? And understanding that ecosystem, which I think many of you are within, are in proximity to, how best we incentivize our healthcare professionals for continuous learning. So this is whom we're going to be serving today. So this is my friend Lorenzo Dore. He's a 50-year-old physician assistant in Liberia. He has four children and a grandchild and he just left the capital, Monterey, Liberia, the Western African country, to move to a rural area where they've identified one case of Ebola. He's now the only healthcare provider for 300,000 people. He's actually also our student in 2012 and we gave him an introduction to management, strategy, supply chain, and he is now in a sense responsible for containing this virus. I think many of you may know this is what Ebola looks like or seen it yourself. You need a PCR to actually identify and there's two PCR machines in the entire country of Liberia. The New England Journal has been an extensive series. It's all posted online. Ebola and a stew of fear and I just highlighted here quarantine. So this is the new technology we're using to contain this virus. Quarantine the word from Italian, I don't know if anyone knows what it's name, when it was developed. No. So this is for the plague in the 17th century that when people came off a ship, they needed to wait for 40 days before they could actually be released on land. And we're using basically the same technology that we're using from the plague. So my first question for us all to think about is how can we contain a virus? You can see some of those in the answers below. So I'm an easy teacher here. So vaccines, a PCR machine, how we diagnose software, right, which we'll talk about healthcare professionals and then all of the above. And I think y'all can see some of the metaphors here. Okay, so our central problem of the global health delivery project is what we call the implementation bottleneck that we know upstream. There's been tremendous investment in the discovery, the basic science of disease, development, the new tools, so the products, the diagnostics, as well as the therapeutics needed for healthcare delivery, but less investment in the gritty business of delivering those products and services to change the health outcomes of populations. And that sounds like a grand theory, but that's actually the ROI, the return on investments that most people assume these products have. And there's been massive investments right on that second piece, the development of new products. This list here that I've listed in microbicides, malaria, and TB diagnostics checklist, the major new funder in the space has been the Gates Foundation. And so they are now questioning after 20 years of investment, what has been the change in the health outcome of populations? So our team's argument here is that the lens on healthcare delivery has been, in a sense, too narrow. And with Michael Porter's advice at Harvard Business School and his mentorship, we've taken about this notion of value-based healthcare delivery, and values defined as health outcome over cost. And that should encompass the discussions that are having about access to healthcare, equity, and quality healthcare. So one of our suggestions that we began about seven years ago is how do we create a pedagogy in value-based healthcare delivery? And we kind of leaned on Mike Porter at this point who had developed this for microeconomics of competition. He had created a series of curricula for advanced healthcare economies that we followed him suit, and we created a series of Harvard Business School case studies. There's now over 30. They're at no cost to the users, both the faculty members and the students, and we iterate and teach them in our classrooms here. The reason why I kind of show you the site is I actually hope you all will go and download and if you're interested in read some of the cases as well as the teaching notes behind it. But the reason why I'm showing you this at the Berkman Center is when we actually put the cases up, we broke Harvard Business Publishing's website for 24 hours, I'm pleased to say, because when you put something in the shopping cart at Harvard Business Publishing and the price is zero, it didn't work. Aka is the first time, right, this academic publishing house had given something away for free. That took probably longer than writing some of the cases, right? So the second product line we do is courseware. So we offer our courses both during the academic year as well as the summer. We have a mid-level management course called the Global Health Delivery Summer Intensive where we have students from about 40 countries join us. We've also used our case studies in an edX version called Global Health Case Studies from a Biosocial perspective that went up earlier this spring. And I think in this room, I know there's been many discussions about MOOCs and evaluating and monitoring the MOOCs. We also had that significant drop-off after the first month and they're thinking through how unicents create continuous learning on an online platform. The last piece of kind of our product line I want to just end here for a moment is we created frameworks. How do we inform professionals today to generate value-based healthcare delivery? And for any of those who are interested and pleased to walk you through this theory, we connect the theory to our case examples so that the new professional can actually understand how to deliver value-based healthcare. But as an academic, I can tell you that this is insufficient. This is retrospective work that doesn't help you anticipate the problems ahead, nor does it actually help Lorenzo as he's trying to contain Ebola today. So our team thought through the types of questions our healthcare professionals have and as we've discussed, I think in this room, the fire hose effect of information that has created this complex maze. And we watch our healthcare professionals put into Google anti-territual vial therapy or resistance or I need to a new diagnosis for tuberculosis and get millions of hits. And so we thought through how could we be that navigation through this maze? So we launched almost seven years ago now, GHDOnline.org, it's a series of professional virtual communities, and our team decided that they needed to leverage wisdom of the crowd with these four characteristics. Diversity of opinion, independence of thought, decentralized, and then we needed to aggregate this in some way that can make this consumable for the newcomer to GHDOnline.org. So this is where we ended up in the aims of the communities. First, they would clearly have a global perspective to healthcare delivery. There'd be crowdsourced insights. We would actually have the discussions be moderated and this related to the quality of the content that we helped in a sense transmit to our users and then the archives needed to be searchable. So this is seven years ago and DECA helped us create the back end for our search and who's in a sense are relatively new phenomena, especially for our global health colleagues. And today this is kind of where we at. I don't like to necessarily show quantitative numbers because it doesn't necessarily show the depth of conversation. But we have had a daily post for the last two years. Every day someone has posted something. And I think that shows actually virology in some ways going back to a good form of virus. Now, not all viruses are bad. The hundred and eighty two countries is pretty significant. We don't know how we got there. So those of you who like to map out connections and understand networks, we would love your help. There's been no marketing scheme. There's no emblem. No one's getting paid, aka the users and there's no subscription fee to join. Just to mention on the side, so this is a series of photographs of our moderators. Some of you may notice Paul English here from Kayak and now Blade was a tremendous inspiration for us in the beginning of GHD online. And what we do in many ways is not only bring academics and implementers, but we actually try and attract our users who become super users to serve as moderators over time and help build that capacity and the capital in country. We have 40 extra moderators to date, 42, 30 are from advanced economies and 12 are from research limited settings. Here is just to give you a sense of kind of the communities that we actually host. A significant number are in the private. You need to be invited by the moderator to join those communities and the rest you can see are within the public realm. Our first four communities were tuberculosis infection control and just want to highlight that for a moment. So this is a community of engineers, architects, tuberculosis docs who are trying to understand how to decrease the transmission of tuberculosis in both a hospital and the community based setting. So this includes the vendors for your lighting, right? The masks that you need to decrease the transmission and clearly when new healthcare providers are seeing not only multi drug resistant tuberculosis, but XDRTB extremely drug resistant tuberculosis. They're technical features of what you should be wearing and how you should in a sense both identify that first case and then contain the resistance if possible. So as we are building all these communities, we realize we were in a sense, unfortunately reproducing what we do in academia all the time is great silos of knowledge and information. And sitting in an academic hub at the medical school. I see I don't even know some of my colleagues at the medical school because we're not necessarily sitting in the same department or seeing patients on the same floor of the hospital. And so we clearly wanted to create some bridges across these communities because we knew these professionals not only did not know each other in person, nor did they know each other virtually. So our team experimented on the notion of an expert panel, which is an asynchronous conference that runs for four business days. And they're moderated by panelists who bring a new expertise into these panels across several of the communities. So an example here is one on connected health and there's two communities involved. We then summarize them into what we call discussion briefs, which are two page PDFs that all members can download. Another example here is that point of care diagnostics. So there's a group that received a large grant to think through point of care diagnostics for cancer care and control. And they wanted to learn how this was done for HIV, right, the test, the CD4 test, and then we actually went back and in this discussion we actually talked about the pregnancy test. And some of the ethics of the development of the pregnancy test and obviously the manufacturing distribution distribution of the pregnancy test within the home setting. We've also tried to look at how we create a global community and this is something else we would love your help with. This is one visualization that we try and understand who begins a discussion on GHC online, who's answering the discussion. And if we can find some of our bridge professionals, which I know Zuckerman's spoken about within these countries. So for example here in Chile, all the orange, these are the outward lines. This is someone starting a discussion in Chile and if they're answering it, a U.S. question and a Chilean is answering it, then the color is responding there. So there's a very active exchange and dialogue happening with our Chilean colleagues and then there's several of our colleagues who we realize are only asking or generating a discussion and are less maybe willing or able to answer. So a lot to dive in here and interesting data. If anyone's interested, we'd love your help. Okay, so let's go back to Lorenzo because he's on my mind on a daily basis. So right now if you think of the trajectory of Ebola, in March the first case was identified in Guinea and people thought this is going to be an isolated epidemic. And that has happened previously that we've had other outbreaks in the Congo and Sierra Leone and they've been able to be contained. And now I think many of you know there's a use case in Nigeria and the capital of Nigeria. There are two Americans, Aravac to the United States and given some serum. This is a very complicated international discussion and why people are now projecting that there will be 20 to 25,000 cases of Ebola within this calendar year. That is, we're on the wrong part of the exponential curve right now. And Lorenzo is struggling, how do I manage to contain this virus as a physician assistant and how can we get him some of those answers in that brain trust that we have access to? So here's Lorenzo, just wanted to show you this is, he is with us in 2012 wearing his Liberian garb every day an avid learner. He needed to learn how to use Word, Excel, PowerPoint, all the rest of it while he was sitting with us and now it's quite active. And we need to in a sense maintain his sense of continuous learning even in the midst of this emergency. So this is kind of the question for today is what are the right carrots to set up for Lorenzo and not only in the midst of this emergency right over the course of his career that we're struggling with. And what we see for many of our colleagues in resource limited settings there aren't the carrots that we have in advanced economies where I am required as a physician to maintain continuing medical education points and my nursing colleagues maintain their continuing nursing. They are actually paid and you are responsible for maintaining a portfolio. In addition, we find for many of our clinicians they are now in roles as managers. They are managing people, products and money with no training in how to do this and how can we leverage the expertise we have within our own brain trust here as well as our colleagues on GHD online to ensure that they are prepared for their roles ahead. So our premise that we'd love to get your ideas on how do we create this digital badge that is on Lorenzo's profile on GHD online. So you can see this is where how many times he's contributed the communities that he's contributed in and we'd love to start seeing him stack his badges on his GHD online profile. Just to take a step back what our team did was look back on how other badges were developed both for products for buildings and for professionals and there's also anyone in this space with expertise. This is really why we're coming to the Berkman Center to understand how to do this well. I think many of you probably drank a cup of fair-trade coffee this morning. I don't know if there's any DEA agents in the room but kind of intimidating when someone puts out their DEA badge when I'm in the hospital I have to wear my badge right here right so all the patients know who I am what my role is whom I'm taking care of and how can we do this for our healthcare providers. So this is kind of what our team is thinking through and breaking down is if we took on the role of being the issuer of this badge and the earner was Lorenzo and our colleagues on GHD online we'd hope the consumer would be governments and multilaterals that the Global Fund for AIDS to Be in Malaria would say I want 10,000 managers in every country badge at level blue for example and that they would generate the demand. The value of the credential would have to be set by a group which I think we could actually collaborate with and then the stackability portability issue would be this would actually be not only on your LinkedIn profile but also within the Ministry of Health's requirements for professional education and this is where we've since generated some demand that we have new ministers of health interested in this idea they want to say this is part of the responsibility of healthcare providers but we need to figure out how to build it right. So our hope is that Lorenzo will not only be a student and a collaborator with us but now he will be a recognized professional. So my question kind of to lead to start the discussion off here is how can we optimize skill-based credentialing and a few easy answers that I could come up with but I need your help for the others is what I do every year I in a sense attend CME so I go to a session I get a CME credit I also do this online with an evidence-based body called up to date. I don't read the New England Journal cover to cover I read my New Yorker cover to cover earning digital badges and then things I'm trying to keep up with is read all the posts on our listserv I don't know if anyone else is keeping up here but the massive fire hose effect of being part of a community and how can we sort this through so I'm gonna leave us with that and just last point so Julio Frank I don't know if anyone follows but he was the previous minister of health in Mexico he's serving as dean he's a wonderful mentor to us at the at the project and this is why he thinks this is the work of us and this is an interdisciplinary effort to think about health improvement and health systems. So in our turbulent world health improvement can be a bridge to peace and prosperity and antidote to intolerance and a source of shared security so I just want to acknowledge this is the efforts of many including Abby and Angie and our massive team of community members on ghd online and our advisors and hoping to start the discussion to fuel our efforts thank you maybe I'll go back to this anyone wants anyone has an easy answer to this I work I'm Amy Zhang and I am I'm a fellow here but I also work for NTIA department of commerce and we funded curriculum development in New York City high school which basically built a platform for badging to be used with high school so the incentive was not was not only sort of not a replacement for grades but just sort of this like um continual kind of reward for and recognition for learning skills so skills included things like posting on a blog um contributing to a forum that sort of thing so it wasn't so much necessarily formalized as well as some people are using it to go get through a online class or something like that so it just seems like there's a good parallel between education you know with love and instruction okay the skills you need to do your task and then the skills you need to get the information you need to do your task and it feels almost like language acquisition grammar versus vocabulary that that you having one helps you get the other and then there's sort of a ladder there's an interesting way of you know we almost take for granted the tools we need to get the information because it's we're so fluent in them yeah absolutely so an analogy I've been just thinking about so um I have a second grader at home and he has a spelling test every week and on Mondays he gets a pretest where the teacher dictates a set of words then he has to self correct he can see the list on Wednesday he has to write a sentence for every word and on Friday is the spelling test and very so I mean I think his notion of actually even also being able to self correct is something quite powerful um and I'm trying to think of the second grader's been doing this secondary teacher's been doing this about 45 years did a lot more experience than I do in pedagogy yes yes that's what we've noticed as well yeah I'm glad petition has been on on the list well American Elms are dying so that yes that's what other people yeah yeah but this type of expertise is I think definitely one element that we're looking for um and obviously the internet literacy and being able to participate um because we see many of the people that we want to be completing the MOOC right are unable to participate for some of the I would say prerequisite reasons you may need to be a consumer really grateful to have you here and collaborate just as well um this is by way of context I think an important moment also for the Berkman Center so we may not have all the answers that that you hope we would have but I think it's a very important moment for us to as a community really build these bridges as so many areas and health being a core area of course are embracing digital technology to solve very hard problems as you described it and that itself seems to be a very important effort um I think Berkman has for many years focused on on digital and the internet and online stuff but obviously what you're describing here is is an environment where where is that is still pre-digital or where we don't immediately think about you know broadband or Facebook but where the tools are becoming part of a solution for global problems so I'm very excited that we can start this conversation in many respects one of the things I hope we can offer as a community is to to think about some of the lessons learned we've seen in in what we've been studying in the online context over the past decade or so and there are a couple of things that come to mind so the first that perhaps comes to mind is how incentives have been uh what we what we've learned in terms of incentives creating incentives for for collaboration in large groups so for instance if you look at open source software there's been a there's a lot of research actually um how how that has created incentive structures for people to participate and contribute code to a shared pool of knowledge and if you go back to your wonderful slide with the Chilean participants right you you may may see some similarities of okay who are power contributors and and how can we motivate them for instance by them becoming uh uh building reputation within a community and how can we leverage such reputation effects to maintain incentives to be a collaborator at least another and and and a contributor right so that's kind of I think one possible angle where we can contribute to the conversation the second one that comes to mind is of course around the question of skills so as as we already heard this is a interesting blend of multiple types of skills required you told the story of your of your friend right to at first to learn the basic computer literacy and like how do you use powerpoint or word doc so there's definitely what you're building here has some sort of requirements of at the first level that you can use the tool right and so we've been engaged in effort how do we think about digital literacy and and these kind of basic skills that are required that you can use the tools later on so that's one level and then of course you have the medical skills and I know the higher level skills that that you hope to get across so building on Bruce comments but so at this deeper level I think we have some some ideas and then further up the stack the third area where we hopefully have connection points and they hope Polina can weigh in we're thinking about this batching question a lot we think about that more in the digital skills context but there's a very rich discussion and and Polina is is a ed school graduate and may have ideas too what we can take away and potentially translate so this is a bit a longer statement but I want to make sure that we get the framing right here as you volunteer to present early on so there are a number of things I think we can can connect and I'm excited to have a question and sorry I came a little late to answer it um what is the motivation are your main motivation behind the badging is it a to motivate people to do things or is it more of a being able to see on the network who has expertise on what topic so which or are they both or what's more important right um so I learned from my dear friend Abby Campbell to set a goal and set some metrics so she we did 1,776 push-ups from June 1st to July 4th I never would have done them unless Abby had been tracking doing 50 push-ups a day and so there's something that breaking down a task right and being monitored for it and if you want having that peer-to-peer relationship that I knew Abby had done her push-ups and not we do this in medicine all the time right I'm actually comparing I know I need to have 100 points for my CME at the end of the year we don't compare necessarily physician to physician but it's been something I need to submit and for our for many of our providers nurses midwives physician assistants physicians in the settings that we're talking about there is no continuation of their graduate medical education after three and this is an undergraduate degree in nursing or medicine so this tends to be someone in the early 20s who then in a sense is not having that continuous arc of how do I develop as a professional anybody here who's interested in this and this is really interesting and I certainly agree with her it's about the importance of it this Friday at 12 30 there is a open sort of semi-unconference on using social media as a way of disseminating good information to affect health care outcomes especially in the developing world and disseminating is not even the right word since it's intended also to include conversational interaction so if you're interested in this topic you should be coming to that and this would be fantastic to raise there this is so okay so the plug aside in the sort of badging that I can if I think of badging the sorts of things that I think of are pretty straightforward and yours is not unfortunately pretty straightforward often because the consequences of the badging are way more trivial much less depends on them and because it's being done primarily within the online world where the the achievements the metrics that can be the achievements can be accomplished online and thus the badging is automatic so to what extent do you intend do you think that your badging system can be what extent does it have to involve offline activities which will make it more complicated but not you know but perhaps way more useful and important right excellent question I think what we're hoping is some of the early um capacities that we could build are actually ones that are the quantitative side so supply chain management finance and accounting HR those get measured by online activity or by somebody testing online activity the second element that we'd like to incorporate in which we use on the clinical side this is to be in parallel with your clinical medicine is we use a simulator in medicine all the time so I practice running a code on a patient and there's a video watching me my temperature increases my heart rate goes up right my saliva and then I'm why I rewatch that video and review the mistakes that I made with my residents and my fellows there so they're actually learning as I am managing that code the first part because the second part it seems easier because you have the data right so that's that really helps um supply chain management yeah um how is Lorenzo how are you going to know that he's mastered right right so that's what you're asking us yeah that's an idea so we've been trying to talk to folks who build question banks right how to frame the right questions so we know for example if we give a community health worker 40 different products they may have difficulty figuring out which product to get to which patient but for Lorenzo side we need to know that he has the skills to understand how to project which products will go out of stock right to understand his population size his burden of disease the shelf life for example the the complexity of the cold chain and so we actually have a simulator where he puts in those numbers and can he create the right projection but a lot of work to do in that frame but that's actually almost the easier side I say the harder side with all things in health care is the human resources side it's how do you develop human capacity in a group of individuals organized to deliver care to patients that is I agree with you the size that needs that you can award a badge meaning right that will be quite difficult and that is the question you're asking us yeah so I'm asking really the first is how to at least do we do the first part well so I'd say the non-clinical piece of health care delivery which is the management of people so actually job descriptions in general um HR 101 accounting finance logistics and how to design that pedagogy well this follows up on Amy's question about what actually you're training people for but it looked what I was hearing was that underlying all of this you're trying to build trust in in Lorenzo and others and uh that's we've learned through bad experiences quite hard to do um the bad experiences I have some familiarity with her in the online e-commerce space what one plans what one sets up to do to build trust frequently doesn't work for a whole variety of reasons so all I this looks pretty straightforward in some sense I don't know why you would find bad actors in this context it's shameful on the other hand I think it's when you're building trust it's it's something to keep track of because you can lose trust with one one bad actor build those courses I mean I would assume that there's some online courses and resources for those sorts of things that's very excellent point no what we'd rather actually build is the pretest choose your own adventure algorithm right and then the way in which we certify and we in a sense leverage the expertise and a bit of the brand that we actually have here at harvard to do that but I agree we have actually have a list there's hundreds of courses out there already we need to review and ensure that they're decent and then figure out how to create that question bank and so even looking into the pedagogy of what does testing do to prime your knowledge acquisition once I go back to my second grader spelling test is that we realize even in the act of testing and obviously if you even read your why your answers were wrong even better you actually reinforces the learning cycle so anyone who has colleagues that this is really in the ed school arena we'd love to meet with them to get a sense of how to even structure these multiple choice easy when I give you guys the answer interesting when I flip the answers people focus a little bit better or you misspell one of the answers people actually think that that one is wrong I mean these are all kind of tricks people are using in the pedagogy and we find especially for adults to maintain your attention when doing an online question bank which is utterly boring there are some of these tricks may be helpful ensure completion of your accounting I mean there's there has to be some and there are tons of like very basic courses that have you know those you don't even have to figure out the I mean that they have the completed and all that stuff built in so yeah the exercises may need to be healthcare related okay in the end but absolutely the archival community has recently constructed its own certificate system for a digital archive specialist a series of online courses and go from there and we faced a kind of chicken and egg situation is that people are doing this in part because they want to they think it'll make them more employable get higher salaries things like have the the employers support it and yet until it's established and and they're aware about it what's doing it one of the things that surprised me is that there is has been a tremendous take up just on the part of the individuals have a desire to learn and establish their credentials and I think you've done a having the the badge is a really neat idea we've we've seen this in so many areas the Wikimedia editors who like to be the super editors and and other people and so that you've got really done really well there but what about on the flip side the idea of sitting down and saying Lorenzo is going to get more money because he's gotten your certification and and and the badge carries some weight with it administratively yes no I think our team internally think that is our job to actually sell this to the ministers of health that we can ensure you that x percent of your managers will have the capacity to manage people products and money and that they should then and since their salaries should be upgraded likely I think we'll need to have a third-party payer into that realm so it's the multilateral generating that demand maybe pep for the presence emergency plan for AIDS relief for the presence malaria initiatives saying I want this many managers at this level and I think we can all understand if we have one stock out and you're using one set of emergency funds so you're needing 200 million dollars of extra dollars to get the malaria bed and that's there on time obviously the ROI of training managers is there so everyone understands the expense of having people not trained as a cell but the expectation that physicians and nurses and midwives know how to manage especially products for example is is not what's taught in medical school or nursing school that's just going to be resource and more are there going to be like smaller badges within it right I think absolutely so you're a few levels I think we'll probably start in one arena and then see if we think of someone who's going to end up running a district level hospital how far along the continuum but yes I think we'll have to be multiple stages because we some folks who are managing a hundred community health workers some people are managing a community health center and then the district level hospital is you're managing a catchment area of 300,000 people it's a different set of skills have you thought about having this may be a bad idea but have you thought about having two categories of badges ones that are more likes play the role of a certificate we've taken more seriously there's been some excuse me and then to accomplish some of the other aim which I forgot who said it can't be to provide an incentive as well as so heavy participation blogged you know champion blogger blog five times a month or this many connections or answer that many questions those also that be a separate category so that the certificate ones have more weight right no we definitely we just don't we're not sure how to do this well so we want people to be encouraged we have an engagement period of tracking our members and we don't want to encourage people just to write four or five words right we want there to be a quality content so we have a recommendation button and all the things that people are you raise of tuning tuning that so it's not merely posting but yeah posted that got comments or got picked up or whatever the metric is but I was trying to make a distinction between in fact why not take the badges that are the more serious ones where there's a set of qualifying things need to do and call them certificates or something since you want them to have a lot of weight and badging shows up primarily in my experience primarily as often anyway as a as an incentive and as a it's like a badge I mean that's you know it's like you give a kid a badge good in school today or yeah yeah it's a it's a it's a starring system whereas you I think want at least some of these to be not just yay good job but right you can trust this person for the skill set that she gets that's excellent thing about participation versus expertise and where testing will be needed to show the knowledge that's been acquired internet access is this a phone um right a mobile phones um so people asked this so five years ago I would not have said I wouldn't be this confident but now to be honest I mean we see how our healthcare most people who are graduating from medical school around the globe the first thing that they want is a smartphone 10 years ago they wanted a motorbike 20 years ago they wanted a leather jacket and they don't even want a motor but they don't even care they actually just want a connected smartphone and honestly many of our providers are actually much more used to moving mobile money for example minutes are very important to them we have Nathan Eagle a close colleague I'm sorting through that whole market so I'm actually much less worried about the hardware at this point because people are very used to hacking systems to get the video that they want and so I think people get used to participating even if the hardware is more limited in the beginning the second piece I think that we're seeing is so much of healthcare the equipment is coming with it so the fourth principle values healthcare deliveries as people are investing in healthcare infrastructure which is both water electricity and the internet they are stimulating economies in this area so I do think that it will come with the aid that is coming to many of these regions not as fast as I'd like but I'm much more optimistic than I was five years ago assumption that the curriculum and the things that you put out the training modules will be you'll be able to do on a phone basically um well some may be on a phone some may need to be at a kiosk some of the hardware actually the the laptops and the desktops are coming to the healthcare center so in the same way when I'm on call for 24 hours I have a couple hours where I'm not doing as much right I could actually do my continuing life education during that time on a hospital computer or a clinic computer so Lorenzo has access to and Lorenzo has access to a computer to a computer right interesting might be as good as your computer you want that's good um at um Cornell we ran the teal started the teal project which was agricultural literature that was sent to third world countries primarily african on cds on the assumption that most people didn't have internet access and it's now gone to the uh an online version and uh has joined henari and um oari and the research for lights initiative but there's still demand for the um the cd version as well so uh I'm you know and that you we hear all the time about places that where you can't guarantee four hours of electricity a day not to mention internet uh so I'm glad to hear that at least the medical community is more connected it's it while it goes on and off if you can cash it in a local area um not perfect but it's much better any uh cultural differences in some of the things you're aiming at I mean this occurred to me when we're talking about certificates and badges and stars um recently I was told that you look at reputation websites in the United States that use stars americans always want five stars british are satisfied with four stars but badge means almost nothing to me certificate means a lot to me testing with our users of what and obviously if things get translated what we've seen I agree with you with our students so they come from 40 different countries as they want a printed out certificate which abby creates for them with the dean signing it at the end of our summer course and we know and the people have taken pictures that they frame these certificates and it's up on the wall of their office and it has a Harvard emblem on it um by you know we have permission from the provost and the dean to do that and that has tremendous meaning um I don't necessarily if I believe in the brand and that means you're actually well qualified but yes I think culturally we're seeing with your rights that that is quite important to pay there's something to the paper document and does that mean you've in a sense accrued x number of both badges and a certificate that we send you a print out um um we'll have to do but excellent there's definitely some cultural norms here that that we need to do abby is that many of the students to their employers ask and require it that if they're gone they weave their position their post for a month to come to Boston and learn from us and they want to see that and employers often will subsidize or pay for completely their tuition which isn't cheap unfortunately um for credit for the school public health and so it is a big piece um this is a simple piece of paper but it's for a lot of people means they get their tuition please they can come back they can take a month of the I haven't seen anyone anyone being settled on ebay yet so then i'll know we've made it yes participants from your summer course become champions within this community yeah yeah absolutely so we have over 200 graduates this is our we'll be at our seventh summer of running the summer course at this point and to absolutely we've written cases with our summer um mid-level managers one of our mid-level managers became the head of the national aid program in Kenya for example we wrote a case about him and his experience and they actually helped bring students bring their colleagues um from their studies and show the why it's worthwhile absolutely so I think it's because we're doing both or we have kind of this virtuous cycle that we have this touch point in person we have a virtual communication and way to maintain that um and now kind of our how do we ensure all these early adopters are incentivized to both participate and learn with us yeah I mean I think that some of its virology that I haven't mapped out necessarily we have a relationship we're also developing courseware for new ministers of health um with dean frank so if you're a minister of health um so earth becomes better here you're actually miss or 18 months and so you're a very high level physician typically in your country you have no management expertise but maybe your family's politically connected and so dean frank and others train you here at harvard if you'd like um and so we get to meet those ministers of health as well but I think most of it's honestly person to person we get people recommended um and there's a group uh within the harvard community that helps us um get the word out yeah exactly so you could accrue that's what we'd love to be able to do for this summer is that you'd actually in a sense achieve some of that badge level in the summer course right to show its stackability over time um and so the course that I run management global health delivery could do that for example for supply chain management we do those simulations within the courseware well I like putting out these messy hairy problems they don't say a fine I think two pieces that I've just pulled out is both um the lexicon and I'd say the digital literacy piece of where our global health implementers need to learn and how we can learn from this community where to get the best training of that and then in the sense how do we ensure the incentives are leading to true certificates right that certificate has meaning over time um so those are two pieces yeah there's a lot of peace I think that's also obviously very much a conversation that currently happens at the provost level um with peter bowl the question as you know harvard offers more and more course online what's our comfort comfort level to give out certificates which is very political for obvious reasons so I think there is a lot of thinking and also a lot of research happening there and to tap into these conversations if you haven't done so already I would encourage you to do that and I know you guys are very plugged in so but that to me is is perhaps the the right venue also to get some of the latest thinking although not institutionally but they're also looking what competitors are doing that to me seems the language I was just kind of I'm personally I'm less interested in the batches me personally but I'm very interested what I see on this chart so um you because that's kind of you could see that's the new Wikipedia for for medicine on a global scale that that's what this picture is about so David lumen ball is the president of common law fund thinks that we are crowdsourcing yeah the healthcare Wikipedia and how to keep doing that well and incentivize people right is to ensure that the content is quality so that you're learning the right content and it's not static content because you you're dealing with all tech levels at once because access to resources is going to be so all over the map so you need the answer for every century up to now and what's the best answer with 15th century technology yeah quarantine right so um well two things one our colleagues at Hinari have done just a tremendous job this is the WHO affiliation for the major publications that are made available um and a good friend of our archival community um is running that and then the second is we have a long-standing partnership for five years with up to date which is the premier evidence-based clinical uh evidence source and so 160 all right I'm trying to think how many of our providers have it about 10 000 providers from our g h and like they have free access to up to date so we've been able to convince the commercial enterprise to participate in this and now actually I have another project if anyone's interested is that up to date is willing to donate subscriptions to every single african medical school we want to do africa first that every dean of every medical school in africa has access to up to date I need now a sales force to figure out how to generate that demand and I'd love to get your take on this because the um analogy I use which I don't know if it's right but it's lexus nexus that law students decided that this is such a very important tool that they knocked on the doors of partners and said I need this I can't do my work I will not work a hundred hours a week without it and partners are like what's this is this important and then they started buying it and obviously lexus nexus saturated the market well similar to up to date there is no resident or medical student especially in the Boston area and in this country it's saturated about 93 percent of the American market that doesn't use up to date on a daily basis and so software it's scalable it's free you can use the lexus nexus business case to explain this to african medical school deans I think would be just transformational for this generation it's free you said uh so no it's very expensive it's about so it is free if you're in a resource limit setting you can apply for a free subscription through ghda online we assure that you're from a resource limited setting and then they give you free access but if I was paying for my own individual subscription per year it'd be a thousand dollars per year likely for me as an individual subscriber but this is what you're building here to your open source version of it um so I would say this is in parallel so up to date is there's 40 000 randomized control trials that come out every year and they are ensuring every six months that every form of pathophysiology is updated versus we're doing the non-clinical side the management of disease the management of systems which there isn't enough to date for I think our points here about the importance of having a resource limited setting button is that the randomized control trials are based on being able to run a clinical trial having that level of human resources products right in the healthcare system around it and how do you then inform those who have one antibiotic not a hundred or one form of a cast for a patient not seven so and the discussions are mostly centered around these managerial issues so to speak correct or is it the blend also then it's a blend it's mainly the management of multi-juggery system tuberculosis not how do I clinically diagnose it but once I have the PCR machine how do I train people to use the PCR machine how to ensure I have the right supplies well this has been tremendous for us and I appreciate it I know as with the lecturers many people are thinking things on a very meta meta scale as I was watching some of them from last year and I think on a daily basis we think about our users and it's Lorenzo who keeps me up at night it's our medical students in these countries that we know in a sense are trying to prepare themselves and contain this disease and I think if you are interested in following the Ebola response this is so emblematic of what's happening in our industry of global health is that people are shipping the product they're being airlifted and sent in with no human resources no understanding how to use these products and we still use systems from the 17th century to quarantine patients I'm hoping unfortunately though it's such an acute situation that this will bring about some of these issues and we'll have a more global conversation had a combat Ebola and be prepared for the next epidemic I know that that was a very nice sort of wrap up and I still want to ask a question though well it was a little bit either now or perhaps on Friday at Friday's meeting these discussions are among healthcare professionals or non-professional but dedicated you know people yeah are there do you think about ways have you tried or would you like to discuss now or on Friday ways in which this can be expanded out so the information that's developed here can reach out to counter some of the misinformation for example about Ebola is that something that's already you are already doing because this is yeah no we'd love to connect and we'll definitely participate on on Friday we start an Ebola response community which is mainly for people trying to figure out who wants to volunteer and what resources you need prior to volunteering for example and some of the clinical issues to prepare nurses and physicians who are going into the field but actually I mean I think we're all understanding that all the data that's out there is not necessarily good and that leads to fear but it's better for in this situation we're trying to how do we attract healthcare workforce who want to volunteer to get there and be properly funded and and resourced thank you thank you ever