Posted on | January 21, 2015 | No Comments
Ralph Snyderman M.D.
In a January 10, 2015 editorial in the NewYork Times, Dr. Ezekiel Emmanuel derides the annual physical exam as a multi-billion dollar waste of time. The exam in current practice is indeed ineffective in preventing disease and reflects the inadequacy of a reactive approach to health care which costs almost $3 trillion/year of which two-thirds is for treating preventable chronic diseases. Not only is the current annual exam a waste of resources, it is more importantly, a waste of an opportunity to fix a bigger problem – our health care system’s expensive focus on treating established diseases, most of which are preventable. Rather than a cursory look for disease with inadequate tools, the annual physical could be made to focus on three health enhancing activities: first, assessing the patient’s specific risks of developing diseases; second, enhancing the patient’s awareness of their health risks, the value of their health to them and their ability to impact their health through what they do and; third, developing shared goals and a yearly plan to promote their health and prevent diseases to which they are susceptible.
This approach, termed “personalized health care,” is being developed at Duke University and is a proactive strategy that is taking hold as a far more effective way to deliver health care. Rather than treating established disease, it proactively provides personalized disease prevention with the engagement of individuals as partners in improving their health. Capabilities to measure each individual’s risk of disease, track its development, and treat it specifically are becoming available through advances in genomics, digital and biotechnologies.
Sophisticated health assessment tools, along with a deeper understanding of the need to truly engage patients in their care are leading to the modern version of the annual checkup that can foster health promotion and disease prevention. An annual physical, using the personalized health care approach, could be the key to promoting the nation’s health, preventing chronic diseases, and reducing needless health expenditures.
Unlike the current “worthless” annual physical, the personalized health care annual exam or approaches like it could be the linchpin for preventing diseases and the waste of our precious health resources. Health, after all, is a terrible thing to waste.
Ralph Snyderman, MD is Chancellor Emeritus at Duke University, former president and chief executive officer of the Duke University Health System and director of Duke’s Center for Research on Prospective Health. His analysis above appeared originally in his Prospective Health blog.
Posted on | January 19, 2015 | 2 Comments
Today is Martin Luther King Day. On the government site that honors this federal holiday, it says: “Dr. Martin Luther King Jr. once said, ‘Life’s most persistent and urgent question is: What are you doing for others?’ Each year, Americans across the country answer that question by coming together on the King Holiday to serve their neighbors and communities.”
How do you serve others, and in so doing, serve yourself? And how can human beings preserve their own dignity and honor their own full human potential through non-violent actions? I found the answer to this in a teenager, attempting to recover from the loss of his father, while be taunted and bullied by cruel classmates. In a courageous attempt to support her son, his mother moved him to a new school and hoped for the best.
Over the years, I’ve called attention to the danger and damages related to bullying – especially in schools. The AMA Alliance alerted me to the issue now many years ago. They and other groups have worked tirelessly to highlight the issue and mobilize a response.
But in all those efforts, I doubt that anyone has done as much good as the young man featured in the video above. Please give it six minutes of your time and then share it and pass it along. Here’s where social media can really help in promoting Public Health. And it is a perfect way to remember Martin Luther King’s spirit and legacy.
Foe Health Commentary, I’m Mike Magee.
Posted on | January 16, 2015 | No Comments
The White House Conference on Aging has announced the five regional forums that will lead up to the summer 2015 conference.
The regional forums will take place in the following cities:
Tampa, FL, February 19th
Phoenix, AZ, March 31st
Seattle, WA, April 9th
Cleveland, OH, April 27th
Boston, MA, May 28th
Read more from Cecilia Muñoz, Assistant to the President and Director of the Domestic Policy Council, here.
To get involved, visit the WHCOA website here and submit your comments and suggestions to the team.
Posted on | January 12, 2015 | 4 Comments
Mike Magee, MD
We are rapidly approaching a 2015 White House Conference on Aging. It will mark the 50th anniversary of Medicare and Medicaid, and the 80th anniversary of the Social Security Act. (1) A decade ago, in preparation for the 2005 event(2), and as a commissioner on the National Commission on Quality Long Term Care, I chaired the Commission’s technology subcommittee, and some months later wrote a summary. As is often the case, it can take a decade for events to catch up with vision. But for planners of the 2015 meeting, the summary below provides a useful framework for discussion.
“Traditionally, the area of greatest interest had been in the application of technology for the management of disease and disability to assist older Americans in their ability ‘to age in place.'(3) But as the Conference approached, and an analysis of aging Boomers with high functionality and high expectations came front and center, the vision expanded and raised the question, ‘How might technology extend independence, productivity and quality of life for our nation’s oldest citizens?'(4) Since the Conference, and as part of the work of the National Commission for Quality in Long-Term Care, the exploration has both broadened and sharpened its focus.(5) The question today is ‘How might technology be applied to re-engineer homes for health and assure maximum connectivity to support aging citizens as part of the multigenerational family, the community and a preventive oriented health delivery system?’
This insight, that the technology should not be limited only to fourth and fifth generation Americans, but rather, in an integral way, be applied to assist as well the three generations below them – their children, grandchildren, and great-grandchildren – reinforces the concept of technology applications as both assistive and transformational. In supporting our most senior citizens in home design, care team connectivity, mobility, cognition, entertainment, learning and employment, might we reorient our support for citizens and their families around a more home centered approach that reinforces independence, productivity, connectivity and efficient application of limited resources?
Such a vision focuses on healthy bodies and health minds. It assists memory as well as mobility. It harnesses software and hardware to not only improve individual quality of life, but to also advantage family, community and societal goals. For example, extending workplace involvement can be extraordinarily beneficial to the overall health of an elder citizen. Coincidentally, harnessing the knowledge, skills and experience of these citizens can positively impact the success of a community and all of its citizens.(6)
Independence also implies responsibility centered on individuals and their networks of support including family, friends and caring professionals. As citizens we have differing capabilities and needs, and these change as we age. We must help each other. But to do so efficiently, we must advantage virtual connectivity and a full range of technologic applications that unlock our fullest individual and collective human potential.(7)
The revolutionary strength of modern information and scientific technologies is that ‘they ignore geography.’ In so doing they allow us to reorient and connect beyond the limits of a range of barriers whether they be physical, social, financial or political. The danger is not in over-reaching but in under-reaching. Our vision must be sufficiently forward looking and expansive to challenge technology innovators. Where are the ‘killer applications’ that would allow lifespan planning to move us ahead of the disease curve? How can we target technologic advances in health to first reach our citizens most at risk? How do we, in powering the health technology revolution, broaden our social contract to include universal health insurance? How do we unite the technology, entertainment, and financial sectors (previously locked out of the health care space) with the traditional health care power players, and incentivize them to work together to create a truly preventive and holistic health delivery system that is equitable, just, efficient, and uniformly reliable? How can each citizen play a role in ongoing research and innovation, and help define lifelong learning and behavioral modification as part of good citizenship? What can corporate America do to advance health in the broadest sense of the word, and in ‘doing good,’ do well financially, serving Main Street as it serves Wall Street?
Individuals, families, corporations, universities, health caregivers, and government entities all have a role to play. Technologies can enable, operate, connect, instruct and assist. But to do so logically and efficiently they must conform to a vision that is both generalizable and customizable. Technology offers the flexibility and fluidity to pursue health, independence, mobility, financial security, social engagement and cognition in hundreds of thousands of uniquely different environments simultaneously, while also pursuing a single unified and collectively committed vision for our nation.(8)
The vision for technology must be integrated into a broader and more transformational quality of life model. IT must equally serve 4th and 5th generation Americans as it addresses the needs of 1st, 2nd, and 3rd generation Americans. It must address variability of services, and be broadly inclusive, and universal in coverage. It is not so much about Aging as it is about Living, and doing so to our fullest human extent. Technology has the power to assist us in healing, providing health and keeping our nation and global family whole. But it’s capacity to delivery on this promise is dependent on a vision for health that is both broad and inclusive.”
The 2015 White Conference on Aging offers a unique opportunity to explore a range of issues that impact elder Americans. But to “heal” them, we must create a health care system that provides “health” while keeping the multi-generational family “whole”. If we can do all that, that would be a “holy” thing.
For Health Commentary I’m Mike Magee.
- 2015 White House Conference on Aging.http://whitehouseconferenceonaging.gov/about/index.html
- Office of Technology Policy of the Commerce Department’s Technology Administration, “Technology and Innovation in an Emerging Senior Boomer Marketplace.” 11 December 2005,http://www.civicengagement.org/agingsociety/WHCOA_generalmaterials.htm
- Mann, WL. Editor. Smart Technology for Aging, Disability, and Independence: the State of Science. Wiley Interscience, July 2005.
- Pew, RW and Van Hemel, SB. Editors. Technology for Adaptive Aging. Board on Behavioral, Cognitive, and Sensory Sciences and Education. National Research Council of the National Academies of Science.2004, http://books.nap.edu/openbook.php?record_id=10857&page=1, (20 September 2006)
- National Commission on Quality of Long-Term Care.http://www.newschool.edu/ltcc/reports.html
- Boehm, EW. “Healthcare Unbound Meets the Digital Home.” Healthcare Unbound 2005 Meeting. Boston, MA.http://www.tcbi.org/files/brochures/TBCI_HU2005_Brochure.pdf
- “America’s Aging Workforce Posing New Opportunities and Challenges for Companies to Utilize Mature Employees.” Conference Board. 19 September 2005,http://www.agingworkforcenews.com/2005_09_01_archive.html
- Dishman, E. Inventing Wellness Systems for Aging in Place. Computer. 2004;37:34-41.
Posted on | January 2, 2015 | 2 Comments
Three enormous health databases are in the process of going virtual or electronic. The first of these is the Clinical Research Database or CRD. On the back end of the Vioxx withdrawal, conflict of interest concerns, and legitimate health consumer desires for early access to discovery information, major research databases moved toward open transparency. For better or worse, the public demanded access to the vast majority of positive and negative results of studies at the time of completion. These results are now electronic and readily transferable, far and wide. (1,2)
The second database is the Continuing Medical Education or CME database. It, too, is going electronic. In fact, projections are that 50% of all U.S. CME will be electronic by 2016, and eCME has been demonstrated to be effective. It is likely that within ten years, the vast majority of CME will be virtual and will be applied in real time rather than in episodic segments. Handheld devices are increasingly standard medical equipment in caring encounters, providing immediate database support to the patient/physician relationship during the evaluative and joint decision making process. This allows experts to quite confidently predict that in a preventive health care system where information is overwhelmingly the dominant health care product, CME will be inter-changeable and indecipherable from the care itself. (3)
And this brings us to the third database, CCE or Continuing Consumer Education. The consumer movement continues to evolve from educational empowerment to active engagement and inclusion in the health care team. 80% of Internet users in 2010 already accessed health information on the web. (4) Patients and their families will increasingly demand access to the same hand-held hardware and information software that the other care team members are using. This will help avoid any confusion that might arise from multitracked information and accelerate the need for simple and well- designed educational products. By using the same devices and educational platforms, issues of standards and problems of incompatibility that might compromise the primary “home to care team to home” loop will melt away.
Two Translation Gaps
Three large growing databases – CRD, CME, CCE – have going virtual and are increasingly accessible. What remains are two translation gaps. (5) The first is between CRD and CME, and it ensures that discoveries will take many years to penetrate and inform clinical practice. If, for example, a study reveals that it is safer and better for mother and child to provide epidural anesthesia at 2 cm rather than 5 cm dilation, and that doing so not only does not increase Csection rates but ensures safer, more comfortable labor and better Apgar scores for the baby, under our past system, this knowledge transfer to practice would be a multiyear affair. With virtual CRD and CME, there exists the ability to collapse those databases upon each other and almost immediately affect practice behavior changes coincident with a new discovery.
If CRD and CME will collapse upon each other, CME and CCE will in many ways become one and the same. Thus, the frantic efforts to develop Personal Health Records on the one hand and Electronic Medical Records on the other are already raising entrepreneurial eyebrows. Are these not, after all, one and the same? Does not all clinical data originate with the people? Do they not loan this data to the people in whom they have the greatest trust and confidence – their physicians, nurses, and other caregivers? And if our records are one and the same, should we not also use the same informational resources to support our joint decision-making? Wouldn’t this be the best way to help us stay on the same page and avoid any chance of miscalculation, misinformation, or mistake?
As we move from intervention to prevention, health care will be an information dominated product or service, and this product will be anchored by three massive, collapsing databases – discovery (CRD), medical (CME) and consumer (CCE) – with primary ownership residing where the data originated, with the people, and provided primarily to the people caring for the people.
Killer applications that allow health care to move from intervention to prevention to strategic health planning will emerge on the consumer side with health care professionals moving toward the people to support confidence, trust and relationship building. By utilizing the same software, information will double connect the people to the people caring for the people, rather then serving as a double check on each other.
For Health Commentary, I’m Mike Magee
1. Greener M. Drug Safety On Trial. EMBO Reports. 2005. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1299263/
2. PhRMA Statement Supporting Enhanced Transparency. Aug. 2, 2010 http://www.phrma.org/media/releases/phrma-statement-supporting-enhanced-transparency
3. Harris JM. The growth, characteristics, and future of online CME. The Journal of Continuing Education in The Health Professions
4. Fox S. Health Digital Divide. Pew Research Center. Feb. 1, 2011. http://pewinternet.org/Reports/2011/HealthTopics.aspx
5. Haynes B and Haines A. Getting research findings into practice: Barriers and bridges to evidence based clinical practice. BMJ 1998; 317: 273,1998 http://www.bmj.com/search?author1=Andrew+Haines&sortspec=date&submit=Submit
Posted on | December 31, 2014 | 1 Comment
Massachusetts has just announced that its physicians will now be required to demonstrate competency in Electronic Health Records.(1) But the potential for good in a marriage of Medicine and Technology goes far beyond individual acceptance and competency. I call that potential, “Techmanity”.
Back in 1983, Dr. John A. Benson, Jr., then President of the Board of Internal Medicine, voiced these words when questioned about technology’s impact on the patient-physician relationship. ”There is a groundswell in American medicine, this desire to encourage more ethical and humanistic concerns in physicians. After the technological progress that medicine made in the 60’s and 70’s, this is a swing of the pendulum back to the fact that we are doctors, and that we can do a lot better than we are doing now.” (2) He accurately described the mood then, and for most of the 20th century, of clinicians toward technology, a complex love-hate relationship that has rejoiced and cheered on progress, while struggling to accept and master change in a manner that would avoid driving a wedge between them and their patients. (3)
It is fair to say that, as the health consumer movement has matured over the past 30 years, and physicians have moved away from paternalism to partnerships and team based approaches to care, that outright resistance and abject fear of technology has progressed to and beyond grudging acceptance. In part the people, and the people caring for the people have developed computer skills together, pursued broadband and wireless connectivity together, and discovered the value of personalized and customized computer search engines together.
Medical Informatics Meets Consumers
As this has occurred the specialty of Medical Informatics has risen to legitimacy within the Medical hierarchy, and its leaders have reinforced the need to advantage technology and informatics in support of humanistic care. (3) One such voice is that of Warner V. Slack, who heads the Center for Clinical Computing at Harvard Medical School. No “Johnny-come-lately” to the field, his first published paper in Medical Computing appeared in the New England Journal of Medicine in 1966. (4) His book, Cybermedicine: How Computing Empowers Doctors and Patients for Better Health Care, is considered a classic, and argued, as Health Informatics expert Kevin Kawamoto said in 2003, that “Computers can be mutually beneficial for both the patient and the health care provider”. (5)
If we have managed to move as caregivers from resistance to acceptance of technology in health care, we have not moved far enough. The technology sub-committee for the National Commission for Quality Long Term Care states: “In embracing technology in Medicine, we must view it as both assistive and transformational.” (6)
The revolutionary strength of modern information and scientific technologies is that they ignore geography. In so doing they allow us to reorient and connect beyond the limits of a range of barriers whether they be physical, social, financial or political. The danger is not in over-reaching but in under-reaching. Our vision must be sufficiently forward looking and expansive to challenge technology innovators. Where are the “killer applications” that would allow lifespan planning to move us ahead of the disease curve? How can we target technologic advances in health to first reach our citizens most at risk? How do we, in powering the health technology revolution, broaden our social contract to include universal health insurance? How do we unite the technology, entertainment, and financial sectors (previously locked out of the health care space) with the traditional health care power players, and incentivize them to work together to create a truly preventive and holistic health delivery system that is equitable, just, efficient, and uniformly reliable? How can each citizen play a role in ongoing research and innovation, and help define lifelong learning and behavioral modification as part of good citizenship? What can corporate America do to advance health information infrastructure and in “doing good,” do well financially, serving Main Street as it serves Wall Street?
Moving Beyond Acceptance and Addressing the Empathy Gap
Health Information leaders of the 21st century need to be more revolutionary. Were they to achieve at their full capacity, our health care system would transform and re-center around relationship-based care, cementing the people to the people caring for the people. If we were to do that we would see improvement on 10 different fronts simultaneously: empathetic access, efficiency, team care coordination, multi-generational family linkages, inclusion of informal family care givers in the health care team, targeted interventions for vulnerable populations, informed mutual decision making, lifespan health planning, evidenced based personalized care, and palpable presence of physicians, nurses and care team members in the home.
Paul Dinsmore, in the AMA Book of Project Management said, ” … designed properly…technology can be a great gift to humanity.”(7)
We no longer can afford to simply accept technology. We must embrace techmanity for all it is worth.
7. Dinsmore, Paul C. and Jeanette Cabinis-Brewin, Eds. AMA Handbook of Project Management. AMACOM, New York. 2011.
Posted on | December 24, 2014 | No Comments
I was recently asked about the Medical Journalism Code of Ethics referenced in JAMA in 1992. One of the grounding documents on which that Code was based was the original Positive Medicine Credo which I wrote in 1986. Rereading it now, some two decades later, I believe it remains relevant as a series of guide posts for caring individuals of every persuasion who believe that their choice to respond to others in need involves “a higher calling”. I offer it to you in this Giving Season as an opportunity for reflection and a starting point for renewed commitment in 2015. Happy New Year!
POSITIVE MEDICINE CREDO:
PATIENT-CENTERED: As health professionals, we are committed to a patient-centered, pride-filled approach to the organization and delivery of healthcare.
PROFESSIONAL COLLABORATION: We promote collaborative processes based in shared education, language, and tools.
COMMUNITY LEADERSHIP: We are community servants who believe in equal access to health information and healthcare for all.
CONTINUOUS IMPROVEMENT: We recognize our imperfections and constantly strive to improve our performance, seeking humanistic and scientific solutions that ensure positive and coordinate outcomes.
PROFESSIONAL POSITIVITY: We are committed to personal revitalization, recognizing our responsibility to provide hope and reassurance to all those we serve and to promote courage, strength and positive attitudes