Healthcare reform has once again surfaced as the number one domestic issue. But what is missing is an organizing vision for today’s complex and unruly healthcare landscape.
Time for Transformation
Nearly 100 percent of the assets we currently include in our definition of the healthcare 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 in the build-out of a truly preventive healthcare system. Instead, 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 more inclusive and anticipatory healthcare system.
Prevention is grounded in education and behavioral modification. It begins before birth and extends beyond death. To be successful, a preventive healthcare 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 demands intimately informed, highly motivated, and deeply committed individuals willing to gently prod those under their charge toward health and wellness.
The practical institution of a preventive system would necessitate guiding hands and a pervasive presence, family and community linkages, and the ability to efficiently lay out lifecycle plans and execute lifespan management on the one hand, and ensure adherence to palliative treatment plans for patients with chronic disease on the other. Unfortunately, these elements are not included in what we have traditionally termed “healthcare.”
Beginning with New Technology
In the build-out of such a healthcare system, there is only one location that is both geographically identifiable and politically viable as a candidate upon which to center the program – the home. While the home may be where the heart is, it is most certainly not currently where the health is, and in this way represents an opportune site for constructive change to take place.
General Electric (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. The GE exhibit convinced many that, by improving our toasters and refrigerators, GE had truly improved our lives. The same could be done with health.
America views homelessness as a social failure. The nation has now begun to view “healthlessness” in the same light. If we were able to leverage technology—informational technology, diagnostic and imaging technology, entertainment technology, and financial system technology to equitably re-outfit and at least partially improve the health of homes, we could efficiently re-center our healthcare system around the home.
As it turns out, others have endorsed this same strategy, and have been actively at work, albeit under the radar, to develop a wide range of product offerings for which Forrester Research forecasts will find an explosive growth market by 2015.(1) Thousands of technology, entertainment, and financial firms are now investing in the parallel build-out of preventive home-centered health. In this effort, they are working side by side with governments and municipalities, and with major academic engineering powerhouses such as MIT (2), the University of Rochester (3), Carnegie Mellon (4), and the University of Michigan (5). What is surprising, however, is the relative lack of discussion of the patient-physician relationship, care teams, and multigenerational prevention in these groups’ home health planning visions. Rather, the emphasis has been on the use of consumer health electronics to support independence, aging at home, and chronic disease management, when the true opportunity lies in multigenerational lifecycle management. (6,7)
Moving into the Home
At the center of this vision is the home: the primary health information loop would not travel from hospital to physician’s office and back, but rather from home to care team and back to home. Informal caregivers would become fully enfranchised members of physician-led, yet nurse-directed, care teams. These family caregivers would not only be linked virtually to their multigenerational families and to their care teams, but also to other informal family caregivers, thereby 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. (8,9)
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. Beyond this, the healthy home would also have ubiquitous, low cost sensors able to track motions, actions, and interactions. The data produced by these sensors would be interpreted by on-site intelligence software and measured against predicted healthy living plans.(6) The results would be fed in a continuous stream to the care team. The feedback loop, which would be supported by a connecting interface, would consist of a human team partner communicating through a friendly interface of one’s choice—wristwatch, phone, radio, TV, or computer—a guide and companion who might remind one to bathe if you’ve forgotten; to increase fluid, to alter diet, or to exercise; to take medication or vary dosage today; to schedule a mammogram; or even to call one’s daughter as one had promised.(7)
While specific roles for physician, nurse, and other formal and informal caregivers would need to be defined, it would be possible to reorganize the workflow using a clearly defined system of incentives. For example, care teams could be reimbursed for successfully assuring the health of their patients, for managing patient databases and the appropriate sharing of that data, and for providing coaching, development and oversight of lifespan health records. Patients and their families could be rewarded with lower insurance rates for adherence to their plans for health, and meeting health outcomes.
Changing Roles
As a result of this shift, 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 support and encouragement of physicians.
Offices would see much less traffic, as most care could be accomplished without a visit. Yet physicians and nurses would make a good living, and even have time to visit their patients, in their own homes. (10,11) Hospitals and specialists, along with their advanced diagnostics and special interventional capabilities would remain a necessity. But with the success of an anticipatory preventive health care system properly incentivized to financially reward health, one would expect these services to become more centralized and concentrated, and for less services to be required per capita. The surviving services would see higher volume and would be expected to deliver better and more uniform outcomes. (12)
This shift would require caregivers, traditionally suspicious of technology for fear that it will dehumanize their relationships with their patients, to confront their aversion to technology and embrace it. The initial steps must be to develop openness to new and innovative partnerships, and a deep commitment to advance, encourage and utilize virtual connectivity to reinforce the physician/nurse – patient relationship.
These concepts together define a new era of “health enlightenment” – a primary loop from home to care team to home; physician-nurse partnering; informal family caregiver inclusion; automated, family-centered data outflow; continual 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 supported by transformative leadership.
Alternate Pathways
The trends that are transforming healthcare – an increase in aging populations, consumerism, the Internet, broadband reach, expansion of family caregivers, and globalization – will continue to accelerate the healthcare system toward a home-centered healthcare vision, even absent the participation of physicians, nurses and other healthcare professionals. (13) Yet without the active participation of caring doctors, nurses, and health professionals, the vision can never be truly complete.
Without the active voice of clinicians at the forefront, consumerism points toward an entirely different outcome. Knowledge and consumer involvement still rise. Financial, technology, and entertainment vendors still succeed in the creation, marketing, and sales of products that transform our homes. However, supportive relationships decline further, resulting in greater consumer isolation.
Under these circumstances, our envisioned “double-connect” to each other (technology that provides a permanent, constant connection between the people and the people caring for the people) becomes a “double-check” on each other (technology used by consumers to perform second opinions on the people and institutions with whom they traditionally shared confidence and trust).
The bright promise of health populism reverts to the dead weight of health siloism, an outmoded concept that serves no one. Technology, one way or another, will transform healthcare. If traditional leaders in healthcare are able to rise to the challenge, have the wisdom and insight to see the opportunity of technology for what it is, they will embrace traditional and new healthcare partners around a new health value proposition, and collaboratively and deliberately build-out a home-centered healthcare system. (14)
The Ideal Scenario
Beyond home health care for our aging population, home-centered health is a vision for the not-so-far-off future that would use technology, advanced information systems and a new, more team-oriented medical approach to share responsibility for efficient, high quality health fulfillment.
Ten realities would be skillfully integrated into this calm and well-organized vision of a healthy home:
1.A home health manager, previously the informal family caregiver, would be designated for each extended family.
2.Health insurance would cover nearly all Americans, and a medical information highway constructed around the patient, with caregivers integrated in, would support knowledge transfer.
3.The majority of prevention, behavioral modification, monitoring and treatment of chronic diseases would take place at home.
4.Physician-led, nurse-directed virtual health networks of home health managers would serve as community-based, 24/7, educational and emotional support teams.
5.Health care insurance premiums for families would decline due to expert performance of the home health manager, as reflected in outcome measures of family members.
6.Basic diagnostics, including blood work, imaging, vital signs, and therapeutics would be performed by the home health managers and transmitted electronically to the physician-led, nurse-directed educational network, which provides feedback, coaching, and treatment options as necessary.
7.Sophisticated customized behavioral modification tools, age adjusted for each individual, and funded in part by diagnostic and therapeutic companies that have benefited from expansion of insurance coverage and health markets, would become available.
8.Primary care office capacity would grow as nursing scope of practice expands and doctors apply their advanced knowledge, skills and leadership most effectively. Most care would not require a visit. Physician reimbursement would increase in acknowledgment of roles in managing clinical and educational teams and multigenerational complexity. Nursing school enrollment in all bachelor RN programs would increase in support of expanded and appropriate clinical roles as educational directors.
9.Family nutrition would be carefully planned and executed; activity levels of all five generations rise; weight goes down; cognition goes up; mental and physical well being are also up.
10.Hospitals continue to right size – they’re more specialized and safer, with better outcomes. And scientific advances have allowed customized and personalized early diagnosis and more effective treatment, making the need for hospitalization increasingly rare.
REFERENCES
1. Forrester Research, “Healthcare Unbound: Early Self Pay Market,” July,1,2005, http://www.forrester.com/rb/Research/healthcare_unbounds_early_self-pay_market/q/id/36802/t/2
2. House Research Group, Department of Architecture. Massachusetts Institute of Technology, http://architecture.mit.edu/house_n/
3. Center for Future Health. University of Rochester Medical Center, http://www.urmc.rochester.edu/future-health/
4. B. Spice, “Enhancing Quality of Life —and Saving Billions,” Carnegie Mellon Today, December 2006, http://www.carnegiemellontoday.com/article.asp?Aid=376
5. M.E. Pollack, “Assisted Technology for Cognition” and “Constraint-Based Temporal Reasoning,” University of Michigan, http://www.eecs.umich.edu/~pollackm/distrib/agingtex-preprint.pdf
6. E. Dishman, “Inventing Wellness Systems for Aging in Place,” Computer. no 37 (2004):31-34.
7. D. Yach,et al., The Global Burden of Chronic Diseases: Overcoming Impediments to Prevention and Control, JAMA, no. 291, (2004):2616-2622.
8. M. Magee, The Re-Emergence of Home Health Care: A Holistic Response to Aging and Consumer Empowerment in Medicine of the Person. Chapter 13 in J Cox, Campbell AV and Fulford (eds). Medicine of the Person: Faith, Science and Values in Health Care Provision, (United Kingdom: Jessica Kingsley Publishers, 2006).
9. M. Magee, Home-Centered Health Care: The Populist Transformation of the American Health Care System. (New York: Spencer Books. 2007). http://spencerbooks.com
10. Personal Medical Home Tops Agenda for AAFP, Wellpoint Meeting, 20 December 2006,http://www.aafp.org/online/en/home/publications/news/news-now/professional-issues/20061220wellpoint.html
11. R.B. Doherty, ACP Observer, “Can the medical home model solve health care’s woes?” American Academy of Family Physicians. 20 December 2006,http://www.aafp.org/online/en/home/publications/news/news-now/professional-issues/20061220wellpoint.html
12. D. Nash, M.P. Manfredi, B. Bozarth, S. Howell, Connecting with the New Health Care Consumer, (New York: McGraw-Hill Publishing Co,2000).
13. Expert Panel, “Personal Health Records and Electronic Health Records: Navigating the Intersection,” American Medical Informatics Association, Bethesda, MD, 28-29, September, 2006.
14. M. Magee, “Qualities of enduring cross-sector partnerships in public health.” American Journal of Surgeons. No.185(2003):26-29 http://www.thecmafoundation.org/projects/pdfs/rxwellness/Cross Sector Collaborations.pdf