Exploring Human Potential

AMA President’s Forum Speech – March 12, 2006

Speech delivered by Mike Magee, M.D.
Turning Silos to Vapor:  How the New Health Populism Will Transform Medicine As We Know It
March 12, 2006 Washington D.C.
AMA Presidents’ Forum

Let me begin by saying thank you to the AMA and to you, its leaders, not simply for the privilege in addressing you today, but also for the many kindnesses you have extended to Trish and me over many years. You have been a presence in my life through my father since I was a young child, and have been there though every stage of my development.

Thirty-three years have passed since I received my medical degree, but not one year has passed in which I was not proud to be a doctor, and not one moment has passed when I was not honored to be a member of the American Medical Association. My biases are strong and well known to you. I offer them at the outset with no apology.

The first is that the world is a better place today for having developed and supported strong, enduring patient-physician relationships. This is not simply a function of the nuts and bolts health care that this relationship provides, in full vision day in and day out. But also for those things
it has reliably delivered over many decades around the world, quietly below the radar screen.

The first of these, as a collective, is the management and processing of a population’s fear and worry, which, absent our efforts, would accumulate to destabilizing effect.

The second is a subtle and rational reinforcement of important societal bonds as and outflow of personalization of care. The importance of this second contribution was best highlighted by the great Cardinal Bernardin, who shortly before he died said to several thousand AMA physicians, “There are four words in the English language that have common English roots. They are heal, health, whole and holy. I tell you this today to remind each of you that to heal in a modern world you must provide health; and to provide health you must keep the individual, the family, the community, and society whole. And if you can do all that, why that is a holy thing.” The third mostly invisible contribution that the patient-physician relationship makes to society is hopefulness; a quiet confidence that most problems can be managed, most mysteries solved, and that, absent a cure today, there remains hope for a discovery tomorrow. That deep seated optimism, embodied in an individual whom you trust, have confidence in, and believe in, is transferable. And so together, as a collective each day, and every day, we help create a reservoir of good will, a belief that life is worth living, that risks are worth taking, that loving and being loved is possible, that dreaming, imagining, purchasing a home, getting married, having children are all worth the effort.

So it is my firm belief that if tomorrow all patient-physician relationships were to disappear, stable civil societies would immediately notice the difference. Our populations would be more fearful, less trusting, less tolerant, less connected, less compassionate, less productive, and less committed to the future. My second bias is that negative leaders, who view change with fear and leverage that fear as a currency to control a population in order to reinforce existing and past power silos; who attempt to segregate us one from another to maintain the status quo, deserve our contempt. They not only draw down the reservoir of good will locally and globally, but ensure our medium and long term failure. While their highly effective tactics can lock a quivering public in check, they cannot stop the world from changing around them. And so for negative leaders, success is short term, for they are rapidly overtaken by each other, and by environmental events.

Contrast these with positive leaders for whom visioning, rather than fear, is the currency. Where one excludes, the other includes. Where one reinforces the status quo, the other makes constant incremental adjustments. Where one plays by the old rules, the other makes the new rules. Where one segregates, the other congregates. Where one reinforces silos, the other builds islands of common stewardship.

It is within the context of these two strongly held beliefs that I address you today, at a moment in time when relationship-based care is at a great risk and requires the aggressive support of positive leaders to ensure its survival into the future. Some two and a half years ago, I launched the weekly webcast program, Health Politics. The goal was simple: using aggressive new media advocacy, to simultaneously support the information needs of the people and the people who care for the people. As we approached our 100th anniversary show and were wondering what subject would be appropriate, I received several e-mails questioning whether Health Politics was an appropriate title for the program. I decided to devote our 100th program to answering the question, “Why Health Politics?”

I quickly realized that this would require answering two questions: First, “What is health?” and second, “What is politics?” For me, it was easier to define what health is not, than what it is. Health is not the health care system. Health is not the elimination of dis- ease. Health is not science and technology. And health is not intervention in all its varied shapes and sizes. Health is a state of well-being that involves mind, body, and spirit. Health is well defined in the eyes of a mother, who gazes down on her newborn baby, and hopes and prays that her little girl will one day have the opportunity to reach her full human potential. Health is, as Gro Brundtland said from the global platform of the World Health Organization in 1998, “part goodness and part fairness.” “Goodness” in the sense that our professionals are well trained and qualified; our institu- tions well outfitted and safe; our processes engineered to perfection; our teamwork a reflection of training and excellent communi- cation. “Fairness” in the sense that these skills and capabilities are fairly and equitably distributed to the broadest population possible.

Now for the second question, “What is Politics?” For some, politics is an apparatus of government, fundamentally top-down and elitist. A few govern the multitude. But for others, politics is the power to support the needs of individuals, families, communities, and soci- ety. For these, politics is bottom-up and populist. But is health political? Clearly the answer is yes. First, the social determinants of health – employment, housing, transportation – are themselves political. Second, health is multifactorial and integrated. For example, clean water – which is vital to health – is a function of agricultural, energy, and urban policy. Third, health involves critical resources that are unequally distributed. Fourth, most now agree that health is more than a market commodity and is increasingly understood as a human right. And finally, health clearly intersects at the crossroads of economic, social, and political theory. So once again, in the spirit of full disclosure: For me health is a human right; politics is about the people; and health politics is, in fact, health populism.

Within that context, I would like to now describe five mega-trends that I have been following for over two decades, which are increasingly colliding, synergizing and accelerating each other. Together they are releasing a wave of transformational forces that will ensure the near term actualization of all, or a portion of the three visions that I will soon share with you. The first trend, of course, is aging. Approximately 50% of all 60 year olds in the Untied States today have a parent alive. This means that the four-generation American family is commonplace. By the year 2050, more than 1 million Americans will be over 100. This means that the five-generation family will be common place. Thus the three-generation family is rapidly being supplanted by the four- and five-generation family with enormous implications for multigenerational health management complexity. Approximately 25% of these complex U.S. families have an informal family caregiver in place. 85% of these caregivers are family members, and almost all are third-generation women, aged 45 to 65. They are simultaneously managing parents and grandparents on the one hand, while supporting children and grandchildren on the other. They are generally isolated, poorly supported, unfunded, unorganized, and at risk. But, they are unable to avoid what they increasingly see as an ethical imperative, even if they must pay a significant price. And pay a price they do. 17% leave their jobs, 20% take anti-anxiety or anti-depressive medication, and 42% of those caring for a relative with dementia in one study were clinically depressed.

The second trend is health consumerism. It is difficult to fully appreciate that this movement only really began to take off in and around 1983, as part of the Civil Rights movement. People collectively woke up one day and confronted Health Emancipation. “These are our bodies,” they said, “and we should be responsible for managing our own health.” To the great credit of physicians, nurses, and other caregivers in the U.S. and around the world, we agreed. What immediately ensued was two decades of health information empowerment with transfers of the scientific lexicon and the knowledge of basic organ function, the processes of chronic disease and the beginnings of how to best prevent these diseases. Today 90% of doctors and patients in America agree the best patient is an educated patient. So in two short decades we have moved from emancipation to empowerment, and now find the movement morphing once again into active engagement. On the leading edge of this second wave of change are those third-generation women family caregivers I just referenced, who, confronted with managing the complexities and inefficiencies of the current system, have had enough, and are demanding that health care transform to better service their multigenerational needs. As they seize control, we are seeing increased focus on chronic disease management, palliative care, aging in place, and issues of death and dying. But we are also seeing our third-generation partners, as they reflect on their image in the mirror of parents and grandparents, examine their own and their children and grandchildren’s likely futures. The net effect is a growing emphasis on lifecycle planning and lifespan management.

In many ways, the people and people caring for the people are discovering this new approach in tandem in the public square. Consider osteoporosis. On first glance, it is a problem of the fourth and fifth generation. After all, there are over 1.5 million fragile fractures in elderly women in the U.S. each year. But, on second glance, studies show that in women age 50, 52% already have early bone loss and 20% have silent clinical osteoporosis. So perhaps this is a third-generation disease. But then there is the disturbing fact that by age 20, 98% of a woman’s skeleton is formed. Now we’re into the second generation. But then again, we have clearly established that fitness, nutrition, exercise, and avoiding smoking all contribute to skeletal formation in the first decade of life. And so it is with all chronic diseases: As we walk down the generational ladder, we arrive at preventive strategies and the need for advanced lifecycle planning. The point to remember is that health consumerism has today became increasingly activist and focused on the concept of multigenerational health.

The third major trend is the evolution of the patient-physician relationship. Studies over the past nine years in the U.S., U.K., Germany, South Africa, Japan, and Canada have demonstrated that citizens in all of these countries value this relationship second only to family relationships. They see their relationship with their doctors as far more important than financial, spiritual and co-work- er relations. As consumers have evolved, so have their physicians. They have moved away from paternalism to partnerships, from individual to team approaches, and from clinical leadership to clinical, educational, and social leadership. Both patients and physicians define their relationship not in scientific, but in social terms as compassion, understanding and partnership.

The fourth major trend has been the emergence of the Internet. For most, of course, the Internet represents a globally distributed information system with extraordinary reach and penetration, armed now, as well, with the capacity to encourage and facilitate personalized research. But for me, the most revolutionary element of the Internet is its capacity to ignore geographic boundaries that confine and define human populations. The Internet, if broadly accessible, has the potential power to eliminate geographic prejudices. For those who are disabled, elderly, poor, forgotten and socially isolated, the Internet provides reason for hope, for it decreases our ability to isolate peoples and problems, whether local or global. The Internet reveals the truth and places a glaring spotlight on inequities. So we are able to see in real time the juxta- position of a member of the Masai tribe in Africa surviving on four liters of water per day in the shadow of the Los Angelean citizen consuming more than 500 liters of water per day. We are able to see and better understand that the developing world’s exportation of infectious diseases – such as HIV/AIDS, SARS, and H5N1 bird flu – to the developed nations has been quickly returned in kind by the developed world’s exportation of heavily marketed tobacco, poor nutrition, the weapons of war, and, today, war itself, which rapidly morphs into chronic disease and disability. So together, the Internet forces us to acknowledge that our global failures have created – for developing and developed world alike – a common reality: a shared dual burden of disease.

On an economic and political scale, the Internet is equally transformational. Its combination with overnight delivery undermines geographically defined markets and market pricing. Markets represent a social agreement. For example, Canadian citizens accept somewhat decreased access to new health products and services in return for somewhat lower pricing, compared to their neighbors, for those entities. But with the Internet, each global citizen has the potential power to create his or her own market, cherry picking the best quality and most advantageous pricing from the comfort of home. More than this, most licensure and certification is geo- graphically governed. Thus, in the U.S., physicians, nurses, and pharmacists practice with the blessing of state bodies, in spite of the fact that Internet-based health commerce regularly crosses both state and national boundaries in today’s virtual world. Finally, the Internet provides a single platform for the people and the people caring for the people to debate the pressing policy issues of the day. The Internet has the ability to accelerate consensus and to expand insight as events, exploding on different sides of the world, inform each other. It matters little in the end whether it’s a tsunami or Hurricane Katrina. Bad policy is bad policy.

The fifth and final trend that bears mentioning is the emergence of non-governmental organizations, or NGOs. The first recorded NGO was the International Red Cross and Red Crescent movement, which sprang to life in Switzerland in 1863. Nearly 40 years later, it formally arrived on U.S. soil. For most of the following century, there was little growth in members or size of non-government associations. All of that began to change in the 1980s, for two critically important reasons. The first was the Internet, which resolved the nagging problem of limited resources that had plagued these fledging issue-driven organizations. With the arrival of the Internet, NGO leaders quickly realized that they had been handed an incredibly efficient tool to solicit, organize, communicate, witness, advocate, and execute on a global scale. The second enabling force was media perception. As the 80s became the 90s, traditional broadcast and print media turned toward NGO leaders and away from governmental, business and academic leaders as credible sources and spokespeople for issue-oriented information and comment. Media credibility ratings of NGO leaders exceeds 50%,while media credibility ratings of government and business leaders languishes below 20%. The ability, then, of NGOs to execute off of a new media platform, while circling back to capture the power and impact of traditional media, created an explosive combination so that by the turn of the century, the number of NGOs had exceeded 20,000. This occurred as the waves of consumer-driven populism gained strength, reinforcing the strategic positioning of hard-hitting advocacy organizations over the more traditional, andsome would say elitist and paternalistic, governmental, business, and educational institutions.

So in a short 25 years, we have seen the pressing demographics of aging with companion emergence of multigenerational complexity and the creation of the informal family caregiver movement; the birth of health consumerism and its evolution from emancipation to educational empowerment and now to active engagement; the transformation of the patient-physician relationship to support partnerships, team approaches, and joint decision making; the emergence and massive expansion of the Internet, which refuses to play by the rules or pay homage to traditional power bases; and finally, the explosive growth of a new type of leader, perfectly aligned with a populist public that is more than prepared to answer the question, “What have you done for the people today?”

Let me now share with you three visions that I believe will play out within the next 10 years. The first is the re-emergence of home-centered care. It has now become clear to most that nearly 100% of the assets we currently define as our health care system – the bricks and mortar of our hospitals and our patient offices; our human resources as embodied in our training, roles, responsibilities, and payment incentives; our educational curricula; and our continuously reengineered processes targeted at in-patient safety and efficiency – have little to offer us, in their current form, to assist the build-out of a preventive health care system. Rather, these elements are original, or second or third iterations of a century-old interventional care system that stubbornly survives largely in its original form because we have been unsuccessful in managing and executing the creation of a truly preventive health care system.

Prevention is grounded in education and behavioral modification. It begins before birth and extends beyond death. To be successful, a preventive health care system must advantage multigenerational relationships to provide multiple, repetitive inputs in real time that allow micro-adjustments in one’s daily life.  Such a system de- mands intimately informed, highly motivated, deeply committed individuals willing to gently prod those under their charge toward health and wellness. Prevention presumes guiding hands and 24/7 presence, multigenerational linkages, and the ability to efficiently lay out lifecycle plans and execute lifespan management. All of this is 180° apart from what we
have traditionally termed health care.

In centering the build-out of such a health care system, there is only one place that is both geographically identifiable and political- ly viable as a candidate. That is the home. And while homes vary widely, from cardboard containers constructed hastily to shield the rain to “McMansions” that consume more than they provide, homes of all varieties share a special place in our hearts. But while home may be where the heart is, it is most certainly not currently where the health is. That could change. GE recognized the “moldability” of the home when it launched its remarkable exhibit called the “Carousel of Progress” at the World Fair in New York in 1964. As a 16 year old, I remember sitting in the revolving theatre and witnessing the six decades peel away with the last look peering 20 years into the future. At the end, I had to admit that, in improving our toasters and refrigerators, GE had truly improved our lives.

It is fair to imagine, then, that the same could be done with health. If we were able to equitably re-outfit, and at least partially improve the health of homes, by leveraging technology – informational technology, diagnostic and imaging technology, engineering technology, financial system technology – could we efficiently re-center our health care system around the home? As it turns out, others have been asking this same question and have been actively at work, below the radar screen, developing a wide range of product offerings that Forrester Research forecasts will find an explosive growth market beginning in 2010. These firms include Intel, GE, Philips, Semens, Disney, Best Buy, and many others. They also include a large number of academic engineering powerhouses such as MIT, the University of Rochester, Carnegie Mellon, and the University of Michigan. What is surprising, however, is the relative absence of the patient-physician relationship, care teams, and multigenerational prevention in the home health planning visions of these groups. Rather, the emphasis has been on the use of consumer health electronics to support independence and aging in place at home.

In 2005, in partnership with leaders from Intel and the American Association of Homes and Services for the Aging (AAHSA), a new and fuller vision emerged. At the center of this vision is the home. The primary health information loop would not be from hospital to doctor’s office and back, as is currently being advanced on the federal level, but rather from home to care team and back to home. Informal caregivers would become fully enfranchised members of physician-led, often nurse-directed care teams. These family caregivers would not only be linked virtually to their multi- generational families and to their care teams, but also to other informal family caregivers effectively addressing the profound sense of isolation that comes with these roles. A wide range of secondary loops would evolve from generalist to specialist, from clinician’s office to hospital, from care team to insurer or pharmacy. But the primary loop, where data would originate and from which privacy access would be granted, would be home-centered. The data flowing out of the home would be rich, varied, real-time and virtual. It would include vital signs and diagnostic and imaging results sent wirelessly to care teams. But beyond this, the healthy home would have pervasive, low-cost sensors able to track motions, actions and interactions. Data emanating from these sensors would be interpreted by on-site intelligence software and measured against predicted healthy living plans. The results would be fed in a continuous stream to the care team. Coming the other way, in the feedback loop, supported by a 24/7 connecting inter- face, would be a human team partner communicating through a friendly interface of your choice – wristwatch, phone, radio, TV or computer – a guide and companion who might remind you to bathe if you’ve forgotten; to increase fluid, alter diet, or exercise; to take your meds or vary your dose today; or to call your daughter as you had promised.

Physician-led teams would be reimbursed for managing complexity. Informal caregivers would become home health managers, rewarded with lower health insurance premiums or tax benefits for accomplishing healthy family outcomes. Nurses’ roles as coaches, educators, and behavior modifiers, would expand with the full sup- port and encouragement of physicians. Offices would see much less traffic, as most care could be accomplished without a visit. Yet doctors would make a good living, and even have time to visit their patients, from time to time, in their own homes.

The second vision, flowing once again from our five intersecting mega-trends, I call “collapsing databases.” 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 are moving toward open transparency. For better or worse, the public will soon have ready access to the vast majority of positive and negative results of studies at the time of completion. These results will be electronic and readily transferable, far and wide. The second database is the Continuing Medical Education or CME database. It, too, is going electronic. In fact, nearly 20% of all U.S. CME is already electronic and 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. Hand-held 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 interchangeable and indecipherable from the care itself.

And this brings us to the third database, one I call CCE or Continuing Consumer Education. As the consumer movement continues to evolve from educational empowerment to active engagement and inclusion in the health care team, patients and their families will 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 multi-tracked information and accelerate the need for simple and well- designed educational products. By using the same devices and educational platforms, issues of varying e-standards and problems of incompatibility that might compromise the primary “home to care team to home” loop will melt away.

So these three large growing databases – CRD, CME, CCE – have gone virtual and are widely accessible. What remains are two translation gaps. 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 C-section 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. But 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?

So the second vision is that, 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.

The third and final vision I call “silo vaporization.” Rigid silos are not unique to health care, but in health care they have been raised to an art form. Silo rigidity is a function of strongly held ideological positions or policies reinforcing backward-facing command and control systems. Fear of territorial intrusion, fear of erosion of financial resources, and fear of change have created ideal conditions for negative leaders and the development of these silos. Yet during periods of rapid evolution, as we are now experiencing in health care, negative leaders are poorly positioned for long term success – and their carefully constructed silos are about to begin buckling below their feet. Eventually, they could vaporize completely.

Let me explain how, starting with several recent developments that have quietly altered the health care landscape:
• Just three years ago, United Health Care purchased the first insurer-owned bank. Late last year, Blue Cross/Blue Shield announced its own “Blue Healthcare Bank,” giving its members a place to save and withdraw money for health expenses.

• Also last year, roughly 300 of the worlds’ largest banks and financial institutions entered the health care service sector because they saw a unique opportunity for profitability in the form of Health Savings Accounts.

• This year, 150 additional entrants will likely join the Health Savings Account bandwagon, seeking out the opportunity to leverage their vast information technology, investment expertise, and system management skills to simultaneously manage an investment portfolio of $75 billion while managing millions of daily transaction points off a health debit card, each with a fee.

• And over the space of the last several years, 400 of the largest multinational electronic, computer, and media firms, seeing the future of prevention, joined together in a single national advocacy organization called the Center for Aging Services Technologies in Washington D.C., with long-term care industry providers and the prevention and wellness community working together to drive health into the home, with or without a care team.

Now let’s fast-forward 10 years. It’s 2016. The national medical organizations and the national nursing organizations are locked in place. They have successfully check and check-mated each other on the issue of who writes the prescription, an important issue since the prescription has meant a visit, and the visit has always meant a fee. The ideological face-off has generated enough heat and fear on both sides to reinforce their backward facing silos and has so preoccupied them as to prevent either from noticing the changes all around them. Yet they opened the doors of health care a decade earlier to new industries – financial institutions, technology firms, entrepreneurs – that knew how to build-out something brand new, and were not burdened by a century of ideological baggage.

So it’s 2016, and nursing and medicine stand face to face, engaged, puffed up, pens drawn, ready to write the best prescription. But there are very few prescriptions left to write. Prescriptions have given way to lifecycle planning, where adherence management has automated long-term therapies and consumer coaching has transferred many of the decisions. Most of the health databases are now merged, and a new health care system has appeared. The people are still there, but the people who care for the people – who processed their fears and worries, who reinforced their ties to family and community, who pointed them toward a hopeful future – are strangely absent. You see, they were not part of the build-out. For nursing and medicine, the battle is over. The reason for the battle and the reason for the silos is no longer relevant. They have awakened in 2016 and POOF! Their silos have vaporized into thin air, overtaken by a new reality created and driven by new entrants.

This is what could happen, not what must happen. The alternative to vaporization is constructive transformation. And that’s still possible. Much is at stake, and it’s essential to have the people and the people caring for the people work together on a build-out of a preventive home-centered health care system based on the concepts I have discussed with you today. So that you might not consider me delusional, please understand that I know that many of these concepts represent an idealized version of the best we might hope for in a resource rich, affluent American home. But know, as well, that these concepts – a primary loop from home to care team to home; physician-nurse partnering; informal family caregiver inclusion; automated family centered data outflow; 24/7 assessment and coaching feedback; advanced medical communications with elimination of discovery to clinician to patient translation gaps; and active targeting of our most vulnerable populations, whether they be elderly in Florida, rural in Montana, or poor and disabled in Tucson or West Philadelphia – are both sound and achievable if we are willing to serve and if we are willing to lead.

Make no mistake: The trends that I have shared with you today will continue to accelerate us toward a home-centered health care vision – with or without physicians. The point is that, without us, the vision can never be truly complete. Absent mutual advocacy – with the active voice of physicians at the forefront — consumer- ism points toward an entirely different – and more hollow – set of end points. Knowledge and public confidence will still rise. Financial and technology vendors will still succeed in the creation, marketing and sales of products that transform our homes. But relationships will fall away, and along with them the confidence and trust in each other to pursue the best for health. Under these circumstances, our double-connect to each other becomes a double-check on each other. The bright promise of health populism reverts to the dead weight of health siloism – an outmoded concept that serves no one.

In closing, let me share with you the 10 rules of health populism, as I believe they must guide and instruct our future actions:

1. When confronting a decision, ask two questions, in this order:

a) Is this good for the people and the people caring for the people?

b) Is this good for the organization?

If the answer to the first question is “no,” don’t ask the second question.

2. Never pursue a strategy, even if short term and profitable, if it undermines the patient-physician relationship.

3. When “building-out,” build to the future and not the present.

4. The 90/10 rule: When seeking allies, embrace those with whom you share 90% value alignment. Have the discipline to embrace the 90% that connects you,
and the prudence to avoid triggering the 10% that separates you.

5. Behave more like an NGO and less like a professional, educational, government or business association.

6. Be transparent. Never speak through radical idealogues. Speak for yourself.

7. Stick up for the people. Make informal caregivers part of your health care team.

8. Embrace new media and circle back to traditional media.

9. Advocate that the primary health information highway go from home to care team to home. Links from hospital to office are secondary, not primary links.

10. Get into the home…Get into the world.

Thank you.

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