Welcome to the Blog of the Duke Center for Research on Prospective Health Care

The mission of the Duke Center for Research on Prospective Health Care is to support the development and implementation of prospective health care, a personalized, predictive, preventive and participatory approach to care that is based on the integration of three key elements: (1) personalized health planning, (2) coordination of care, and (3) rational reimbursement. On this blog we discuss current issues in prospective health care and personalized medicine, including ongoing research and outreach in the Center, the work of other leaders in the field, and innovations in science and technology that can promote this model of care. We invite you to this important conversation and look forward to your thoughtful comments and ideas.

The views, opinions and positions expressed by the authors and those providing comments on these blogs are theirs alone, and do not necessarily reflect the views, opinions or positions of Duke's Center for Research on Personalized Health Care.

Tuesday, May 31, 2011

On-the-job health care clinics – the near future of Prospective Health Care?

A recent story in the Washing Post reported that an increasing number of employers are starting to implement on-the-job primary care clinics for their employees. These clinics typically offer free or inexpensive primary care onsite for employees during work hours, in addition to usual health care benefits. The goal of the large employers offering these clinics is to save money by reducing lost wages and health care costs by providing improved and convenient evidence-based preventative primary care. The article gave several interesting anecdotes about how these clinics affect the lives of employees, including one employee who was discovered to be having a heart attack that would have otherwise gone undiagnosed.

The article highlights an import ongoing trend – as we become more concerned about rising health care costs and health care concerns, the best answer isn’t to restrict services. In fact, these companies offer these clinics on top of their existing health care benefits. This evolving arrangement highlights the potential benefit of rational care over rationing care. I believe that this trend will only grow stronger with time. Businesses are starting to realize that they can improve the health of their employees, reduce lost wages, and reduce health care bills – all through being proactive and providing more health care, not less. Perhaps the most exciting consequence of these at-work clinics will be that they provide the environment in which prospective health care can both provide value and be improved upon. Employer-based clinics offers a system where both the patients and payers are on the same side, which provides a stark contrast from the fee-based incentives that currently encourage procedures over prevention and stifle rational delivery of health care. It seems like there could be a real opportunity here for academic and non-profit institutions interested in promoting prospective health to partner with industries implementing this on-the-job model to learn how we can best implement the most effective and efficient models of prospective health care.

Wednesday, May 18, 2011

False competition: an obstacle for prospective healthcare

By Sanjay Kishore

This past week I traveled to DC with 10 other undergrads passionate about health policy. During my visit I had the intriguing experience of visiting Housing Works, a prominent homelessness and HIV/AIDS advocacy organization famous for its history of activism, social justice, and civil disobedience. While we thought we were going on a simple tour, I soon realized that I would walk away with much more perspective on the state of health policy than when I entered.

As it turns out, the Washington Post had published an article the previous night quoting a local councilwoman who said she was considering reallocating HIV/AIDS funding to other obesity-related medical conditions affecting her district – none other than primarily diabetes, heart disease, and hypertension. Since she was the swing vote for passage of the budget, it was likely her demands would be included in the final bill. As I stood in the office of Housing Works, I saw the HIV/AIDS lobby begin to mobilize. Conference calls were made, frustrations exchanged, talking points drafted, and responses strategized. As student aides for the day, we too played a part. Our role? Drafting a letter to the councilwoman forcefully explaining that HIV/AIDS funding could not be cut by a single penny. And write we did, composing a message to be used as a call to action that would surely fill the legislator’s inbox.

To Housing Work’s credit, their rationale was this: instead of distributing money to different diseases (take from HIV, give to diabetes, etc.), why not create a better health system that addresses all of these health problems holistically? This seems completely rational - yet, there was a caveat. To accomplish health system strengthening, they wanted more overall funds devoted to health without reallocating money away from HIV/AIDS.

This example speaks to the challenges prospective health care faces as it encourages policymakers to combat chronic disease. Perhaps these funds would have helped eliminate “food deserts,” improve access to community exercise facilities, and allow free physicals in disadvantaged neighborhoods. But it would have been at the expense of helping individuals with other health needs. The reality is clear: in the midst of a $3 trillion deficit, governmental resources for health are limited. And paying more for one disease (in this case obesity) means paying less attention to another (HIV/AIDS)

Is this a false competition? Perhaps. Though we all stand for health as a human right, over-specialization may be hindering our collective progress. Can students play a role in facilitating collaboration and uniting narrow interest groups? You bet. Creating a stronger health system is not just a talking point – it’s a solution that will require compromise and force us to seek common ground. One thing is clear: it’s going to be a lot harder to de-politicize a movement to alleviate chronic disease than perhaps anyone of us youth ever thought.

Thursday, May 12, 2011

Paul Krugman Gets It Wrong: The Consumer Should be the Boss in Health Care

In a New York Times editorial of April 21, 2011, Paul Krugman writes, "Patients are Not Consumers" then derides proposals to voucher Medicare as he feels this would turn patients into consumers. While not addressing the wisdom of vouchers for medicine, I strongly object to his contention that considering patients as consumers demeans patients and is a bad thing for health care. The opposite is true! The patient is the consumer of care, and the lack of attention to this fact on the part of the patient, the physician, and the delivery system is a major reason why health care in this Country is so dysfunctional.

By any definition, patients are consumers of health care services, and they should and do have choices and rights. They should demand the best of care and service from their provider. They have the right to be informed and empowered to make reasoned choices and to participate in their care. The fact that many patients don't get sufficiently involved in their care and blindly relegate decisions to their providers works to their disadvantage and diminishes the value of health care. In virtually all medical decisions, there are choices, and it is outrageous to think that the patient as the ultimate consumer of the therapy would not be entitled and expected to learn about and weigh in on those decisions. Moreover, for all but the most emergency-type care, the patient's active participation is essential for maximum therapeutic success.

The failure of providers and delivery systems to recognize and respect the patient as a valued consumer is amongst the greatest flaws in the system. In my professional career, in addition to having led a major academic health system, I sat on the Board of one of the world's most successful consumer-product companies. The motto of the Company is, "The consumer is boss." This isn't an empty slogan. It is at the very heart of the way the company does business. The company’s success depends on understanding and meeting the needs of the consumer. Only in health care, perhaps followed by the airline industry, do we find such an egregious neglect of the rights of the consumer.

I have often pondered why in health care does the patient (e.g. consumer) not play a far more dominant role in demanding the best in care, cost, and service? The usual explanations are that the patient rarely pays the bill directly and that issues related to health care are too complicated for the lay person to understand. While both explanations are plausible, they are increasingly less valid. Health care costs are a financial burden to all either directly or indirectly and charges are increasingly being directly borne by the patient. This trend will continue. Health care is complicated, but not incomprehensible and more and more resources are being provided to patients to allow them to weigh in on clinical decisions. Importantly, it should be incumbent on providers to provide more comprehensive patient information on their clinical options and costs of various decisions.

The health care industry must recognize that the patient is a consumer with rights and free choice. As patients become more involved in their own care decisions, they participate more in doing the things they need to do to lead to better therapeutic outcomes, greater patient satisfaction, and likely lower costs. Only recently has the medical profession begun to recognize the centrality of the patient in good clinical care. "Patient-centered care" is a new mantra and long over-due. Personalized health planning focused on prevention and active patient engagement is a great hope for meaningful health care improvement. Understanding the value and necessity of the patient as a valued partner in their own care is becoming basic to medical education and enlightened medical practice. The reason for this goes beyond the rights of the patient -- it creates better outcomes.

Thus, in medicine as in business, it is critical to understand that the patient is the consumer, the consumer is boss, and fostering this will be a good thing for health care.

Thursday, May 5, 2011

The Future of Health Care Intelligence and Personalized Healthcare

Last Wednesday, Duke’s Fuqua School of Business and the Duke Center for Health Informatics hosted the second annual informatics conference on “Business Intelligence in the Health Care Age.” The conference hosted a number of high profile members of academia and industry who discussed several topics regarding the ongoing transformation of how we use and protect our health care data. Talks and panel discussions described past, ongoing, and future attempts to obtain meaningful value from patient health care data.

The conference provided a snapshot of our current ability to standardize patient data to allow for useful, automated analysis to inform health care recommendations. A common theme that emerged was that many innovation efforts are being initially driven by mandates in the HITECH act, which extends personal health information disclosure requirements to electronic health care records. Although compliance with these new standards bear the relatively low-hanging fruit of improved health care information technology, additional efforts to provide an interactive, learning health care system would provide a real value in the future. In terms of what to expect in the near future, both Asif Ahmad and Jeff Ferranti suggested that accomplishments in improved health information technology which have up until now focused mostly on compliance, are now starting to address quality improvement, and will in the future be able to perform risk prediction and help provide personalized medicine.

Perhaps one of the biggest challenges towards the automated personalization of medicine is that dictated or free-text information currently composes about 80% of the medical record. At present, few efforts have been made to address how such information, which is highly variable between specialties and from physician to physician can be usefully incorporated into the electronic health record. How to standardize and automate the crux of what makes a medical record personalized will be an ongoing challenge in how we merge the benefits of health informatics, personalized medicine, and prospective health care in the future.