How Digital Technology Can Personalize Health Care

Orignal Source:    http://www.huffingtonpost.com/ralph-snyderman-md/health-technology_b_2689845.html?utm_hp_ref=email_share  February 15, 2013

Digital technology has transformed virtually all aspects of how we live and now it’s ready to revolutionize health care.  In The Creative Destruction of Medicine, Dr. Eric Topal makes a convincing argument that the digital revolution will deconstruct how health care is delivered.  For example, hand-held digital devices will provide precise diagnostic information virtually anywhere and transmit it instantaneously wherever needed.  Smart phones and e-tablets will give individuals access to applications allowing them to understand and manage their health or disease.  Inefficient, inconvenient, and expensive physician office or hospital visits will be far less necessary as distant monitoring goes online.  The power of digital technology in health care is clear; but what hasn’t been described is how such devices can be used to facilitate the creation of a better health care system. 

A major flaw in health care today is that it’s focused on treatment of disease events after they develop rather than on preventing them.  This approach is partly responsible for the massive increase in preventable chronic diseases.  Digitalizing today’s “fix what’s broken” approach to health care would be akin to adding GPS to a horse and buggy.  While improved technologies can enhance the effectiveness of treating disease events, the real opportunity lies in using them to create a new approach to care that enables individuals to improve their health, diminish their chance to develop preventable diseases, and minimize the consequences of diseases if they occur.  A more rational model of care is within our grasp and digitalization can make it far more effective.  This approach is termed Personalized Health Care.    

To understand how it works, let’s start with the basics.  Each individual is born with a unique set of genes which, in combination with their environment, determines their health and their risk of developing diseases.  Diseases develop over time with symptoms frequently not evident until damage is considerable. Our current medical practice is to intervene after symptoms have manifested using “one-size-fits-all” treatments.  With digitalization and ongoing medical breakthroughs, we can change health care to be personalized, predictive, preventive, and more effective as individuals become central players in their care.  Personalized health care recognizes the dynamics of how diseases develop, the uniqueness of individuals, and what can be done to maximize health.  With personalized health care, the annual medical visit, which is currently acknowledged to be of little value, is redesigned to identify the patient’s immediate and long-term health risks and establish goals and actions to decrease risks and improve health through a personalized health plan.   

Imagine the annual physician office visit with personalized health care in the digital world.  No longer will there be a cursory visit with the physician entering information into a laptop without ever looking the patient in the eye.  Prior to their visit, the patient will complete an easy, yet comprehensive health questionnaire electronically on their smart phone or e-tablet.  Relevant laboratory tests and other diagnostic information will be obtained at home or in the local pharmacy using point of care tools coupled to a smart phone or similar device.  This information will be analyzed electronically in a format designed to support the physician’s assessment of the patient’s health status and risks at the time of the visit, and to facilitate discussion of the best options to enhance the patient’s health over the course of the year.

During the appointment, the physician will have access to powerful digital diagnostic devices to refine the clinical evaluation far more accurately than with current instruments, such as the stethoscope. Cost-effective digital technologies in the physician office will greatly reduce expensive and inconvenient visits to other health care facilities.  Discussions between the physician and patient now will focus on creating a joint understanding of the patient’s health needs.  A clear-cut plan with measurable objectives for minimizing disease risks and enhancing health will be developed collaboratively thereby enhancing the patient’s engagement.  The personalized health plan will be linked securely to the patient’s smart phone and during the course of the year, relevant data such as weight, blood pressure, laboratory tests, lung function, and electrocardiograms will be collected via smart phone applications or similar devices.  Other tests will be available at local pharmacies or supermarkets.  This information will be analyzed and transmitted to the patient and health care team and progress will be tracked largely through mobile devices.  Communication with the physician or health coach will occur conveniently through digital means without unnecessary utilization of health care resources.  At appropriate intervals, the plan will be updated to meet the patient’s evolving needs.  Of course, if disease events or emergencies occur, physician offices, urgent care clinics, emergency rooms, and hospitals will be available along with access to the data contained in the personalized health plan.

Personalized health care on a digital platform can reconstruct our current expensive and inefficient sick-care approach into a cost-effective, health-enhancing system with individuals at the center of their care.   While the practice of personalized health care is in its infancy, “ObamaCare” is encouraging its adoption through reimbursement for preventive care and financial incentives for better outcomes, rather than more procedures.  Importantly, as technologies enable individuals to become more informed and empowered about health care, they will be a major force for insisting on care that is designed to improve their health personally. 

Dr. Ralph Snyderman Wins AAMC David E. Rogers Award

Dr. Ralph Snyderman will be awarded the AAMC’s David E. Rogers Award on Saturday evening, November 3, 2012, in San Francisco.   The winners of this year’s awards were announced by the AAMC yesterday.

The Roger’s Award is based on a collaboration between AAMC and the Robert Wood Johnson Foundation and is given annually to recognize major contributions to improving the health and health care of the American people. 

AAMC TO HONOR NATIONAL AWARD RECIPIENTS
Nine individuals, one medical school to receive recognition at association’s annual meeting

Washington, D.C., October 25, 2012—The AAMC (Association of American Medical Colleges) will award national recognition to nine individuals and one medical school for their outstanding contributions to academic medicine. The awards will be presented on Saturday, Nov. 3, during the association’s annual meeting in San Francisco. Information: https://www.aamc.org/initiatives/awards/2012awardsrecipients/

2012 David E. Rogers Award

 

Ralph Snyderman, M.D., Duke University School of Medicine

Recognized as the father of personalized medicine, Ralph Snyderman, M.D., has played a pivotal role in improving the nation’s health over the past 40 years. Chancellor emeritus at Duke University and James B. Duke Professor of Medicine at Duke University School of Medicine, Dr. Snyderman also serves as director of the Duke Center for Research on Prospective Health Care. Through the center, Dr. Snyderman leads the development and implementation of what he terms personalized health care—a rational way to engage patients in their own personalized, predictive, and preventive care. He seeks to transform care from the disease-oriented approach to one that personalizes health. In 2002, the U.S. Centers for Medicare and Medicaid Services partnered with Duke to develop a personalized care model that tracked the health of patients. In 2003, Duke expanded the model and began offering prospective health care to its employees. 

During his 15-year tenure as chancellor for health affairs and dean of the school of medicine, Dr. Snyderman led the development of the Duke University Health System (DUHS) and served as its founding president and CEO. He established an overarching mission for DUHS to design innovative models of health care delivery. “Societal impact was a fundamental goal at Duke, and a commitment was made to become a new kind of academic institution,” says E. Albert Reece, M.D., Ph.D., M.B.A., vice president for medical affairs at the University of Maryland, John Z. and Akiko K. Bowers Distinguished Professor, and dean of the school of medicine. With Dr. Snyderman at the helm, DUHS “emerged as a leading national and international force in creating initiatives that are transforming how health care is delivered,” Dr. Reece adds. 

Dr. Snyderman also led the creation of the Duke Clinical Research Institute (DCRI), the largest academic clinical research institute in the world. “One of Dr. Snyderman’s major accomplishments was the conceptualization and development of the infrastructure to support clinical and translational research,” says Dr. Reece. “The DCRI is capable of conducting any clinical research project, from the smallest pilot to truly global trials.” 

Always committed to research ethics, Dr. Snyderman chaired the AAMC Task Force on Clinical Research from 1998 to 2000, and his 2000 Science article, co-written with Dr. Ed Holmes, advocated establishing guidelines for the protection of human subjects in clinical research. “This document formed a strong foundation for the actual rules implemented by the U.S. Department of Health and Human Services Office for Human Research Protection,” Dr. Reece says. 

The programs Dr. Snyderman initiated to bring personalized health care to Durham, N.C., regardless of the ability to pay, include Promising Practices, Just for Us, and Latino Access to Coordinated Health Care. “These initiatives focus on cardiovascular disease, obesity, and asthma, and are led by members of the Duke and Durham community to substantially reduce the burden of disease in economically deprived areas,” Dr. Reece says. 

Dr. Snyderman was a member of the AAMC Executive Council from 1997 to 2004, serving as chair from 2001 to 2002. He is a former chair and administrative board member of the AAMC Council of Deans.   

Dr. Snyderman earned a B.S. degree from Washington College and an M.D. degree from Downstate Medical Center of the State University of New York.

THE SUPREME COURT HAS RULED, BUT WHAT REALLY MATTERS IS REFORMING HEALTH CARE DELIVERY!

The factious debate regarding the constitutionality of the Accountable Care Act (ACA) is over.  The Supreme Court has ruled that the law is constitutional, including the health insurance mandate which was judged to be a tax.

Health care reform will now be elevated to a major political referendum in the upcoming national election.  Virtually all agree that we need a health care system that is accessible, affordable, and effective in providing quality health care.  Whether the best route forward is through the ACA or other legislative-directed approaches is far less certain than the need to change our underlying approach to health care delivery.

We must move from our current reactive, sporadic approach, using expensive technologies to treat late-stage preventable disease-events to a coordinated preventive, personalized model of care.   Personalized health care addresses the specific health needs of individuals at any time in their life and utilizes predictive technologies to evaluate health risks and employs planning to provide the care most likely to be effective.  This approach to care is personalized, predictive, and preventive and involves an engaged and enlightened patient.  A great barrier to innovation in health care has been a reimbursement system that handsomely rewards high cost intervention for late-stage disease and punishes prevention and coordinated care.  Reimbursement models that reward successful outcomes will help unlock innovation.  As a consequence, personalized health care will be embraced by more and more enlightened providers, employers, and insurers.  So, while the heated debate will focus on legislation, the real work of resolving the problem will occur through fixing health care reimbursement and developing and adopting health care approaches that work.  There is a great degree of creativity being deployed to create the most effective models for care.  New technologies are enabling increasing personalization and are putting capabilities in the hands of consumers and lower cost providers.

With a more rational approach to health care, access and affordability will be attainable.  Absent changes in how care is delivered, health care legislation will do little more than drive up costs and add to the burden of an already struggling economy. The solution to affordable quality care is attainable but the solutions will need to occur outside the partisan health arena.

AVOIDING A HEALTH CARE BUBBLE

The recent report from the Department of Labor showing that the United States economy added just 69,000 jobs in May was met with surprise and disappointment and has had an immediate effect on the presidential campaign as well as the stock market.

What was lost in this news, however, is that almost half of the job growth came in the health care sector. Thus, health care provides a large underpinning for our economic growth, but is this a good thing? Currently, health care expenditures are quickly increasing beyond what individuals, employers, or the government can afford. Ironically, what is gained by these increases in employment may be offset by the burden of rising health care costs on the overall economy. This raises an important question. Is the expansion within the health care industry a good thing for our economy and nation or is it an emerging bubble that will inevitably burst?

Over the past decade, national health care costs grew from an already large $1.6 trillion per year and 14% of the GDP in 2002 to $2.6 trillion per year and 18% of the GDP currently. This growth has been fueled by increased costs of treating chronic diseases with expensive specialty and hospital care. Such expenses are driven in part by investments in technologies and new facilities which often rival the opulence of five star hotels. According to the Health Care Cost Institute, price increases and costs of hospital admissions grew nearly three times faster than inflation. Despite the drag on the economy from the rising cost of health care, preventable chronic diseases have continued to grow. Consequently, the increased expenditures have not led to an improvement in the health of the nation.

What is frightening is the parallel between the growth in the health care industry and the recent experience in the real estate market. In real estate, the American dream to own a home was seen as laudable. Unfortunately, the financial market could not sustain the growth of the housing market and it ultimately collapsed. In health care, access for all Americans is at least as important a goal and should be achieved, but it must be done in a way that is effective and affordable. The current approach, in my view, is neither effective nor sustainable. Fortunately, there is a solution to this dilemma. Health care expenditures must be focused toward health promotion, prevention, patient engagement, and coordinated care rather than the current emphasis on high cost, sporadic treatment of disease events which are largely preventable. We know how to make the approach to care far more effective and less costly.

Personalized, predictive, and preventive approaches, with intense patient engagement, are already proving to be far more effective than the current reactive treatment of disease events. At the center of effective care should be the individual (who at times is the patient) who is engaged, informed, and involved in their own health. Coupling the engaged individual with a health care system designed to meet personalized medical needs overtime is the model that we should move toward. Health care sector growth within a system that actually improves health and minimizes preventable diseases will be cost effective, sustainable, and a true boost to our economy. Absent this, growth in the health care industry is a mixed blessing.

Electronic Health Records and Prospective Health Care

Last week Don Berwick announced his resignation as Administrator of CMS. In his parting speech, Dr. Berwick listed his top 5 reasons as to why there is so much waste in the US health care system.

These five reasons were as follows:
1. The over treatment of patients
2. The failure to coordinate care
3. The administrative complexity of the health care system
4. Burdensome rules
5. Fraud

In a post on this week’s Health Care Blog, Dr. John Halamka argues that a common solution which would at least in part address each of these issues is the electronic health record. I think the point he is making is on the right path but that it would be better served taking it one step further: an electronic health record in the context of Prospective Health Care. Prospective Health Care is a coordinated approach to health care and wellness which involves personalized health risk assessment and the development of a personalized health care plan to ensure maximum patient involvement and engagement in their care. IN this model, the personalized health plan is coordinated between the patient, a health coach when appropriate, and the provider system.

By focusing on an electronic health record itself, we risk missing its necessary precursor – a strategic approach which addresses the needs of each patient by tailoring their health care plan to meet their individual needs. An electronic health record is a tool which would help implement and optimize this type of approach, but would be insufficient on its own.

In the context of each of Dr. Berwick’s five reasons for waste, Dr. Halamka suggests that electronic health records would mitigate each of these factors.

To address over treatment of patients, Dr. Halamka suggests that EHRs could automate alerts and reminders as to what his patients need. If such alerts and reminders are not tailored to the specific health and wellness needs of individual patients in the context of their personal health plan, one could see how these types of systematic alerts and reminders could potentially exacerbate over treatment rather than curb it.

In terms of coordinated care, EHRs will certainly allow multiple providers greater ease of access to a patient’s health and treatment information and provide the opportunity for improved communication between different providers working with the same patient but unless the patient in question has a personal health plan in place to drive the strategic approach to their individual care, there can be no guarantee that these different providers are working with the patient towards a common goal. If providers are not working in tandem the opportunity to reduce waste is missed.

Dr. Halamka also gives examples as to how the next three contributors to waste, complexity, rules, and fraud, could be mitigated by EHRs as well – mainly by streamlining some of the administrative complexities of the health care system by having EHRs that automate care plans, provide feedback at the point of care, and process payments based on measured outcomes. He also suggests that the data generated by ERHs would allow analysts to look for patterns of care that are outliers and thus potential indicators of fraud. For each of these instances it would still be important for EHRs to be utilized in the context of personalized health planning to ensure that patients are receiving and providers are being reimbursed for providing patients optimal care for their individual health and wellness goals.

While EHRs are an important tool to help drive appropriate treatment of patients, coordination of care, and reductions in administrative burdens and the potential for fraud to help eliminate waste, they can only do so optimally in the context of prospective health care.

Hats Off to Sanjay Gupta – A Strong Voice for Personalized Health Care

I have spent almost 40 years as an academic physician involved in research, teaching, practice, and administration. During this past decade, I have become increasingly convinced of the need to change health care from its current disease event-oriented approach to one that is personalized, predictive, preventative, and focused on personalized health planning with an engaged, empowered individual at the center of their care.

I have written, spoken, organized symposiums, and created model delivery programs. Yet, my overall impact on fostering change, if any, dwarfs in comparison to the power of the mass media to gain the public’s attention. Dr. Gupta’s August 28, 2011 show on CNN entitled, “The Last Heart Attack”, while presenting some controversial views, clearly portrayed a powerful message to a vast audience. The number one killer of adults in our country is largely preventable. To do this requires personalized planning and intense engagement on the part of the individual (patient), hopefully in collaboration with an enlightened care delivery system. This is what personalized health care is all about.

True health care reform requires far more than what can ever be legislated. It requires a change in how one values health and, therefore, acts accordingly. Health is amongst our most important resources. It can be managed and enhanced but to do this most effectively, care should be personalized, planned and supported by coordinating clinical infrastructures.

When directed by enlightened individuals such as Dr. Gupta, the media can play a major role in leading health care reform by gaining the public’s understanding and support. While politicians are embroiled in issues such as health insurance and mandates, true reform requires a change in the delivery model itself. To do this appropriately, the public needs to understand the stakes and become involved.

Hats off to Sanjay Gupta and others for bringing this story to the public. As for this academic physician’s attempt, you may want to read my piece from the Huffington Post.

Personalized Health Care Drives Progress in Cancer

The American Society of Clinical Oncology is the leading professional organization committed to conquering cancer through research, education, prevention, and delivery of high quality patient care. Its Annual Meeting provides a forum where major advances in cancer are presented to its members consisting of over 30,000 physicians involved in all aspects of oncology. The meeting is also well attended by the press as well as members of the pharmaceutical, biotechnology, diagnostic, and investment communities as it provides a rich source of information about progress in cancer.

This year’s ASCO meeting, which is still in progress, has already demonstrated that personalized medicine is impacting virtually all aspects of cancer care and that its benefits are just beginning. In his presidential address, Dr. George W. Sledge, Jr., considers genomic advances will rapidly “change our understanding of cancer biology; it will identify new targets and previously hard to treat diseases, and will explain the causes of drug resistance.” In other presentations, tremendous progress in the treatment of metastatic melanoma, lung cancer, prostate cancer, sarcomas, breast cancer and others gives hope that improvement in cancer survival and remission rates will be occurring rapidly due to the application of personalized medicine to this group of dreaded diseases. A major basis of optimism in the war against cancer relates to the development of personalized approaches such as targeted therapies directed toward the specific abnormality responsible for the patient’s cancer, the use of companion diagnostics to identify the specific abnormalities, the ability to test tumors for their chemosensitivity in vitro prior to using a therapy, the availability of predictors of potential adverse outcomes of treatment, and the identification of surrogate end point biomarkers to determine whether therapy is working. These are all applications of personalized medicine tools to the treatment of patients with cancer.

Personalized health care is built on the development of a personalized health plan which identifies an individual’s specific health care needs based on a multiplicity of factors including their inherited genome as well as the impact of a lifetime of environmental factors leading to their current health status and care needs. The approaches of personalized health care work well to enhance health and well-being, to support primary care, and to personalize the treatment of chronic disease. It is in the field of cancer, however, where the importance of personalization is not only obvious, it has already contributed greatly to the quality of care and has received tremendous interest from multiple constituencies.

This year’s ASCO Annual Meeting in Chicago once again indicates that personalized approaches to care are not only the wave of the future in rationalizing and improving care, they are already being applied successfully to amongst the most dread diseases experienced by humans.