Posted on | February 22, 2009 | No Comments
Too much medical, not enough home
As we listen to thought leaders and experts in medical education, public health, chronic disease management, global health and the dual burden of disease, wellness and prevention, and alternative health, two things are clear. First, change is in the air. Second, our thought processes are converging, even as our readiness for change remains in doubt.
If I have one concern, in light of the mega-trends that have enveloped us, it is this: I do not believe that our vision is sufficiently forward-facing and powered to exceed the change curve and to capture the imagination of the people or the people caring for the people.
I maintain a strong bias in favor of relationship-based health care. In this regard, I am in agreement with the values embedded in the current "Medical Home" concept as laid out in their recent joint statement.1
3. Mutual decision making
5. Holistic coordination
6. Facilitated information exchange including technology
7. Quality, safety, evidence
9. Personal relationships
While I embrace these values, it must also be said that the “Medical Home” is significantly underpowered to manage the future health needs of this nation. My concern, stated simply, is: too much medical, not enough home.
Much of the difficulty can be traced from the starting point. Here is an example of a model called "home-centered health care:" Her name is Anabella. She is 8 years old, the eldest of of our 6 grandchildren. Is she healthy? First off, what do we mean by that question? For me, it means, “will Anabella reach her full human potential?”
We must look out over a 100-year horizon at the many influences and to the people who will influence her decisions day by day, and year after year. We must plan ahead and consider her uniqueness, socially and scientifically. We must be where she lives.
"Home" is where Anabella lives. But let me stop for a moment here, and clarify what I mean by home. For me, home is both a geographic and virtual term which defines a place where one feels safe and secure, supported and loved, and washed, if you will, in social capital. And while one’s geographic home may change more than once by necessity, choice, or need; the state of feeling "at home" should ideally follow you. This concept of home should be where the heart is, as it is for so many Americans, whether they live in a trailer or a McMansion . But it isn’t currently where the health is.
So much has changed all around us that perhaps we could be excused for having overlooked the home as a logical destination and cornerstone for a health system. Misreading the significance of trends compounds the problem.
Three quick examples.2 First, for most people, aging is associated with statistics (how many people are over 65, 85, etc.). But aging is not just about numbers. It is about complexity. Before our eyes, the typical American family is growing from three to four to five generation complexity. Health solutions must efficiently and effectively address this complexity.
Second, the internet. A remarkable tool, when combined with broadband and wireless, pushing massive information at lighting speed. But what is it’s true significance? The Internet ignores geography, and in doing so breaks all the rules. Who do you wish to connect to whom, and who and what will be the center of your future health universe?
Third, health consumerism. Three decades of health information empowerment. Doctors, nurses, hospitals agree “The best patient is an educated patient." Paternalism must give way to partnership. Teams over individuals. Mutual decision making. All are good. But health information is given way to health activism. This is led mostly by informal family caregivers – family members, almost all third generation women age 40 to 70 – managing frailty above and immaturity below –now laboring as both providers and consumers of care in nearly 25 % of all American homes. They often go without formal support or even acknowledgment. For them, it’s not lack of information that’s literally killing them, it’s the lack of a system.
A sufficiently powered vision then must advantage complexity, connectivity and consumerism.3 Let’s look at what we have in the simplest terms. Here’s the center loop of today’s health system, little changed in the past 100 years – a loop from office to hospital and back to office. The home is an after-thought. If you have a health concern, you must generally find your way into the loop.
Now, let’s dream for a moment, and dream big.4 What if we were to decide that the center of our new health care system would be a loop that went from home to care team and back to home? This new system would provide a rich array of information – personalized, customized, with vital signs, diagnostics, motion data, planning milestones –transmitted automatically and wirelessly in one direction to the care team. Data analysis, advice, support and coaching 24/7 would be coming back to the home from the care team. Other valued and needed services revolve around the home, rather then the other way around. All would be part of a system committed to efficient connectivity, rather then bricks and mortar.
Although such a vision has serious policy challenges, it still builds on our strengths. Let’s consider a few: Americans greatly value the concept of "home"- a space where you are loved and sheltered, and people believe in you and root for your success. Americans abhor homelessness, yet have learned to accept healthlessness. Yet, can we ride the home to health, and health to home, improving both in the process?
Second, our society is signaling support for universal health care. Yet with this right must come responsibility. Readiness to define roles and responsibilities of individual, family, and community in return for universal care could provide multiple societal benefits.
Third, the people caring for people have moved from resisting technology to (at least grudgingly) accepting it. They must now take the next step toward fully advantaging its capacity to humanize, plan, connect, and bring order and sense to a segmented and broken enterprise. As for resources, health care workers might consider partnering with sectors – currently locked out of health care – that have significant financial resources, tremendous IT expertise, and existing positions in the home including those in the financial, home technology and entertainment industries.
Fourth, many are beginning to appreciate that instead of technology creating a socio-economiic digital divide, it may do just the opposite. Connectivity can be targeted at those who need it the most, whether that be an 18-year-old pregnant single mother of two in West Philly, or a Montana farm family 200 miles from the nearest hospital, or the only daughter of a widowed mother living alone three states away.
Finally, embracing the trends may allow us to efficiently and effectively manage existing chronic disease burden on the one hand, while simultaneously building a truly preventive system that will serve not only Anabella, but her children and her grandchildren as well.
What’s missing and where do we begin? I will leave the second question open for discussion, but will end my remarks by describing one missing “killer application” under development by everyone from Google to Microsoft to Intel, and hundreds of entrepreneurs in-between. I predict this application will be ubiquitous on all new computers within 5 years. It will supplant personal health records (PHR’s). It will come from the consumer side, with or without support from clinicians. This single "killer application," I believe, will be the “tipping point” for a truly preventive health care system.
I call this application an LPR, for Lifespan Planning Record.5 It is a graphically pleasing, highly powered, software application, capable of “sucking-up” automatically a wide range of individual, family, community and environmental and scientific data. It converts that data into a personalized, predictive, preventive and participatory prospective, and strategic health plan, as described by doctors Snyderman and Yoediono6. We can adjust this plan in real time to outcome inputs, modifying the plan, and inputing targeted information in support of adherence. With what we know today, Anabella’s 100 year plan would already be embedded with thousands of targeted inputs, 10 years from now, hundreds of thousands.
Medical Home’s values are not wrong, but it’s destination currently is. But that could, and I believe, must change. If we are to preserve relationship-based health care, we must embrace the trends and lead with a vision sufficient powered to excite the imagination. That vision must embrace complexity, connectivity and consumerism – while reinforcing the social capital embedded in relationships between the people and the people caring for the people.
For Health Commentary, I’m Mike Magee.
1. American Academy of Family Physicians (AAFP), et al. Joint Principles of the Patient-Centered Medical Home. March 2007.
2. Magee M. Connecting Healthy Homes To A Preventive Healthcare System: Leveraging Technology For All It Is Worth. Harvard Health Policy Review. Fall 2007. Vol. 8:2, 44-52.
3. Magee M. Home-Centered Health Care. Spencer Books, New York, NY. 2007.
4. Magee M. 7 Visions For Health Reform. 2008.
5. Magee M. Health Records of the Future. Health Politics. 16 Nov. 2006.
6. Yoediono Z, Snyderman R. Proposal for a new health record to support personalized, predictive, preventativeand participatory medicine. Personalized Medicine. 2008. 5(1), 47-54
- Seven Visions for Health Reform
Read more about Mike Magee’s ideas about what aspects are crucial for reforming the health care system.