The Art of “Muddling Through”

Twelve years ago, few could have imagined that funding a small grant to explore the concept of rapid-learning in health care would lead to a critical component of President Obama’s national “moonshot” initiative aimed at eliminating cancer.

Yet that’s exactly what happened, and it’s a great example of what’s often called “emergent strategy”—strategy that, instead of being built around pre-determined deliverables and benchmarks, evolves opportunistically over time. Business theorist Henry Mintzberg, an important proponent of this approach, compares it to a potter crafting her work in front of a wheel. In a 2014 article, John Kania, Mark Kramer, and Patty Russell wrote that emergent strategy allows “funders to be more relevant and effective by adapting their activities to ever-changing circumstances and engaging others as partners without the illusion of control.” 

In a conversation with health care researcher and analyst Lynn Etheredge, who previously served as health director for the White House Office of Management and Budget, he jokingly referred to emergent strategy as “the art of muddling through.” But there’s more to it than that, as Etheredge’s own story shows; emergent strategy is the art of imagination, collaboration, and iteration.

In 2004, the Robert Wood Johnson Foundation (RWJF) was getting its new pioneer portfolio off the ground and looking to fund breakthrough, transformative ideas. Etheredge approached the foundation with a proposal to explore a new way of thinking about medical research. He described a vision for a rapid-learning national health system that would support “real-time reporting of clinical experience for millions of patients to national databases” and how such a system could address “groups that are frequently under-represented in clinic trials, such as racial and ethnic minorities, women, children, seniors, and persons with multiple chronic conditions.” What Etheredge envisioned was nothing short of revolutionizing the national clinical research enterprise as a way to increase health care value.

RWJF awarded an 18-month grant to George Washington University (GWU) to enable Etheredge to delve into this new idea, renewing his funding three more times through 2012. Etheredge cited the foundation’s flexibility in allowing him to “connect, evolve, and work with expanding networks of key people over several years”—that is, to develop an emergent strategy—as critical to the success of his work.

With the foundation’s funding, Etheredge began by bringing together experts from different fields in a series of small meetings to define the critical elements of his proposed system, identify parts already in place and parts in development, and imagine what should come next. He then started to weave together these ideas, engaging a broad range of collaborators in a continuous feedback loop. In 2007, Etheredge and several other experts “infected” by his idea published articles in a special issue of Health Affairs themed around rapid-learning health systems. They covered issues ranging from health information technology and infrastructure to how best to reshape patient care for diseases like diabetes and cancer.

Etheredge himself first addressed the idea of rapid-learning for cancer care in a Health Affairs paper in 2009, arguing that the “war on cancer” had not made sufficient progress. He cited a 2008 statistic that an estimated 5 million Medicare enrollees were living with a cancer, with an estimated 750,000 newly diagnosed that year. (The problem persists: Total US medical expenditures for cancer are expected to reach at least $158 billion in 2020.) Etheredge believed that evidence-based cancer care could advance more swiftly by integrating rapid-learning networks into a new national system of quality reporting and improvement.

Around this time, Etheredge began working with pediatric oncologist and cancer researcher Sharon Murphy, who became a scholar-in-residence at the Institute of Medicine (IOM) in 2008. Inspired by Etheredge’s work, the IOM’s National Cancer Policy Forum convened leading oncologists to examine how they might apply the concept of a rapid-learning health system to fight cancer. At the workshop, Etheredge noted that “only a very small percentage of cancer patients today have their key clinical data captured for research purposes,” but that new technology, such as electronic health records, held the potential for “capturing the key data from virtually every patient and feeding that into a learning system to try to learn as much as possible.”

Etheredge’s proposal to break down the walls between clinical research and patient care caught the attention of Allen Lichter, CEO of the American Society of Clinical Oncologists (ASCO). The association subsequently committed to developing and testing a prototype for a revolutionary health information technology platform called CancerLinQ. The platform collects and analyzes patient data with the goal of enabling any oncologist to spot trends among millions of patients for almost every treatment, tumor type, and genomic profile; use that information to make better treatment decisions for their own patients; and add information about the experience of each patient to the database to further accelerate cancer research. ASCO launched the CancerLinQ prototype in 2013. To date, 58 practices in 39 states and the District of Columbia have joined CancerLinQ, involving 1,000 clinicians and collecting 750,000 patient records.

In January 2016, when Vice President Joe Biden announced the National Cancer Moonshot initiative, he cited ASCO’s CancerLinQ as a model of what was needed to “break down silos and bring all cancer fighters together” in a concerted effort to eliminate the disease. Since then, ASCO has worked closely with Biden’s office to support the initiative. At ASCO’s June 6 national meeting in Chicago, Biden asked attendees to work to “expand CancerLinQ so that it can meaningfully and seamlessly connect with other project networks … in pursuit of a national and international flow of data.” As part of the initiative, CancerLinQ will connect the nation’s leading clinical, genomics, and biomedical informaticists, academicians, and data scientists with the oncology community to help develop an even bigger and deeper rapid-learning health system for cancer.   

If you trace CancerLinQ’s origins, you’ll find a winding path that started with Etheredge embarking on a journey to explore what rapid-learning could mean for health and health care, moving on to envision what that system would look like, and then conceptualizing how such a system might actually work in the field of cancer.

So what would have happened if Etheredge had approached RWJF in 2004 with a proposal to build a platform that essentially would enable every cancer patient to participate in his or her own personal clinical trial and contribute data to the greater good? And what if he had requested $50 million to prototype that platform—for which the technology did not even exist, and with no proof of concept or clear path for developing it further? It’s impossible to know for sure, but we probably would have turned him down.

We could not have predicted that supporting exploration of a rapid-learning health system would lead to the development of CancerLinQ, or that 12 years later it would be the right tool at the right time to collide with the right set of circumstances: the National Cancer Institute’s creation of a blueprint for the future of cancer science, genomics, and personalized medicine and the President’s cancer moonshot.

RWJF supported Etheredge’s work because we were inspired by his vision. We renewed his funding every two years, because we could see the project’s progress and its continuing potential. Etheredge built an ever-expanding network of collaborators and leaders to bring the idea of a rapid-learning health system to reality, and he is now helping to develop more rapid-learning systems in health care, agriculture, education, and other fields around the world.

Philanthropy often seems more comfortable funding conventional, planned strategies with defined goals and deliverables, and providing short-term grants that do not obligate funders to sustain long-term relationships. It seeks predictability as a way to mitigate risk. 

Michelangelo, who was perhaps the greatest practitioner of emergent strategy, said: “The greater danger for most of us lies not in setting our aim too high and falling short; but in setting our aim too low and achieving our mark.”

Emergent strategy is about envisioning a better future and investing in the big ideas to take us there. It is the art of muddling through. It is the art of imagination, collaboration, and iteration that lie at the heart of philanthropy.  

Read more stories by Nancy Barrand.