Summit On Integrative Care
February 12, 2009Mike Magee MD
Medical Home: Too Much Medical, Not Enough Home
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 layed out in their recent joint statement. (1)
3. Mutual Decision Making
5. Holistic Coordination
6. Facilitated technology
7. Quality, Safety, Evidence
9. Personal Relationships
While I embrace the values of “Medical Home”, it must be said that it is significantly underpowered to manage the future health needs of this nation. My concerns in 6 words: “Too Much Medical, Not Enough Home”.
Much of the difficulty can be traced from the starting point. Here is where I begin in 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, and 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 forces and individuals who will influence her decisions day by day, and year after year. We must plan ahead, consider her uniqueness socially and scientifically. We must be where she lives.
Here is where Anabella lives. This is her home. And her home may where the heart is – as it is for so many Americans whether in a single wide drafty trailor or a McMansion . But it isn’t currently where the health is.
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, washed, if you will in Social Capital. And while ones geographic home may change more than once by necessity, choice, or need; the state of feeling “at home” should ideally follow you.
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 has compounded the problem.
Three quick examples. (2) First, for most, Aging equals numbers (how many over 65, how many over 85). But Aging is not about numbers. It’s about complexity. Before oue eyes, the American family is moving from three to four and five generation complexity. Health solutions must address this complexity efficiently and effectively.
Second, the Internet. A remarkable tool, when combined with broadband and wireless, pushing massive information at lighting speed. But 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 good. But health information is given way to health activism, led mostly by informal family caregivers – family members, almost all 3rd 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, 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, comnnectivity 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 a marginalized 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 – 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, and data analysis, advice, support and coaching 24/7 coming the other way. Other valued and needed services revolve around it rather then compete with it, all part of a virtual system committed to efficiency, connectivity, and mobility rather then bricks and mortar.
Now such a vision has serious policy challenges. But it builds on our strengths. Let’s consider a few. Americans highly 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. Could you 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 the people have moved from resisting technology to at least grudgingly accepting it. They must now take the next step toward fully advantaging it’s capacity to humanize, plan, connect and bring order and sense to a segmented and broken enterprise. As for resources, they 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 sectors.
Fourth, many are beginning to appreciate that – rather than technology creating a socio-economiic digital divide, it may do just the opposite. Connectivity can be targeted at those who need it the most first – whether that be an 18 year old pregnant single mother of 2 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 Anabella, her children and her grandchildren on the other.
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 100’s of entrepreneurs in between. I predict this killer application will be ubiquitous on all new computers within 5 years. It will supplant Personal Health Records (PHR’s), and it will come from the Consumer side, with or without support from clinicians. This single killer application 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; converting that data into a personalized, predictive, preventive and participatory prospective, and strategic health plan as described by Dr’s Snyderman and Yoediono (6); and adjusting 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 ionputs, 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 inrelationships between the people and the people caring for the people.