2. Disruptors and Demands
Global Recession-recovering
US Health Care Costs Out of Control
Polarized politics and culture
US Govt. operating on a Continuing Resolution
Partially resolved Fiscal Cliff on Jan. 3 2013
Sequester delayed 2 months
College and Medical School Costs Growing Faster Than Healthcare Costs
Rising costs of Research and Uncertain Federal Research Funding
Uncertain Future Support of GME Funding
Healthcare Reimbursements to Decline
10,000 Baby Boomers become M’Care eligible per day
Personal Financial Instability
4. Where the Jobs are
new us jobs in healthcare and all other industries
He
Healthcare is a major US jobs program!!
5. Academic Health Center Challenges
The current clinical and academic environments continue to become
more complex and challenging to manage.
PPACA challenges us to make a step change in the way we care for
patients
Mechanism/resources/incentives to develop leadership and
management expertise are required to develop a clinically and
academically successful department, school, business unit, AHC, etc.
Market and regulatory pressures continue to threaten the cash flow of
the healthcare system.
Pressures on operating margins and cash flow creates tension between
the academic and clinical enterprises.
Research which is critical to advancing healthcare loses money
6. Academic Health Center Challenges
Difficulties in effecting timely decision making and communication
Cultural -- Need to eliminate barriers to new thinking and practice:
“This is the way it has always been done.”
Academic and clinical silos and the separateness of professional
schools/training
Old facilities that get in the way of progress, innovation, new practices
Rebuild The Public Trust of HC Providers
All of the relevant environmental issues must be identified and addressed.
8. Physician Issues on Horizon
• Changes to geographic adjusters in payment
• Quality reporting mandatory for physicians
• Public reporting (‘physician compare’)
• Sunshine Act
• Physician pay ‘value’ modifier
• Medicaid payment rates
• Hospitals are now major employers of physicians
• Primary care vs. specialty reimbursement
• No ‘fix’ for SGR
9. Opportunities
Significant unmet needs
Aging demographics
Large underserved populations
Evolving science leading to new medicines
and predictive, personalized and precise
solutions
Innovation and value creation for patients
and health care systems
10. Yet Science and Technology Drives us to a new era
High throughput science
Metabolomics
Genomics
Proteomics
Computational biology
Systems biology
Bioinformatics
Synthetic biology
Molecular imaging
Regenerative science
“Generic”predictors
Social Networks
Big Data
It’s a Wireless World
12. The new biomedicine
P
redictive
rospective
reemptive
ersonalized
reventive
articipatory
13. Predictive Health
THE CHALLENGE AND THE OPPORTUNITY
As many of us as possible should age with grace and die with
painless dignity of natural causes
Jeanne Calment 1875-1997
14. Two-Pronged Approach
Apply what we know, translate new discovery
Predictive Health Institute
Center for Health Discovery Biomarker Science Discovery
and Well Being And Validation
• Health assessment • genomics
• Personalized health plan • proteomics
• Clinical/translational research • metabolomics
• structural biology
• computational science
15. The Health/Disease Continuum
Normal Normal Pre Early Late
Low risk High risk disease disease disease
D
H Predictive Health I
E S
A E
L Contemporary Medicine
A
T S
H E
16. Determinants of
Health You live here
Environmen
Genomics/ t Population
Metabolomics/ Biology
Proteomics Genetics Behavior
Molecular Imaging Systems Biology
Generic Pathways
Bioinformatics Ethics
Technologies Immunology and Disciplines
Inflammation
Nanomedicine
Development Public Policy
Oxidative
Quantitative and
Stress Finance and
Senescence
Medicine Economics
Novel Other Generic Regeneration Education
Therapeutics Pathways and Repair
Cardiovascular Specific Diseases Cancer
Diseases
Diabetes
Chronic Lung
Diseases
Neurological
Diseases
17. A Model for Predictive Health Based Research
Biomarker identified
and/or gene identified
(Discovery based research)
Predictive health Health care Identify people “at risk”
New targets research provider
(genomics/metabolomics)
Healthy
Person(s)
Pharmacologic intervention Environmental/behavioral
intervention
New drugs
(high throughput molecular screening)
Lifelong health 17
19. April 7, 1948 WHO Definition
Health is a state of complete physical mental and social well being
and not merely the absence of disease or infirmity
21. HEALTH VIS-À-VIS DISEASE: MOVING THE TARGET
So much for the theory and the tools---existing or soon to come--- that
will make Predictive Health possible. But what would it look like in
practice in the real world?
22. Center for Health Discovery and Well Being
The Center design embodies a new
approach to healthcare:
Non-clinical atmosphere
Customer oriented
High tech
23. Assessment: The Surveys
Surveys collect information about
Mental, Emotional & Spiritual health
Health Symptoms, Exposure, Behavior &
Physical Activity
Nutrition, Supplements & Medications
Stress, Anxiety, Depression & Sleep
Patterns
24. Assessment: Instrumentation
Resting Blood Pressure and Heart Rate
Anthropometrics & Body Composition
% body fat
Lean Body Mass
Bone Mineral Density
Treadmill Fit Testing
Vascular Testing
Arterial thickness
Arterial elasticity
Central Blood Pressure
26. The Predictive Health Partner
E3PO
• Engage A Health Partner is a professional
• Educate who will integrate the personal
• Empower health plan material, explain
• Promote results from testing, and provide a
• Observe process for both creating the
Action Plan and for supporting and
encouraging you on an ongoing
basis.
27. How are we doing?
% of participants
Base 6 mo Year Year Year
line 1 2 3
Well Being 96 98 99 100 100 BDI less than 19
BMI 35 38 37 42 53 BMI less than 25
Physical Activity 96 96 97 97 95 Met moderate
guidelines
Blood Pressure 48 56 56 56 56 120/80 or better
Cholesterol 58 63 64 59 69 Less than 200
Stress 38 54 56 60 71 PSS below 18
Glucose 88 86 86 91 83 Below 99
Sleep 81 83 82 83 91 Epworth less than 10
28. Moving care outside of the hospital
The 6 R’s: Connect ALL of the Dots
• the RIGHT CARE at the RIGHT TIME for
• Care must be integrated
• the RIGHT PERSON by the RIGHT HEALTH PROVIDER in
• the RIGHT PLACE for the RIGHT PRICE • Primary care does not stand
alone
The Health Home will be in the Home • Starts with self care
• Smart Algorithms replace retail clinics • It takes a team
• Primary care avatar takes your cc and hx and you do • Hand offs at the right time can
your own physical exam be critical
• Wireless measurement and monitoring of multiple • Transitional care becoming the
physical parameters at home feed in to your virtual norm
health universe
• There is a health care universe
• Most common diagnoses made and treated right in your
home
29. There is a consumer revolution in healthcare
• Internet is the leading source of health information.
• Expansion of health, not just conditions, but also wellness
• Evolution from patient focused to consumer focused
• Health is becoming continuous rather than episodic
• Consumers are now influencing the behavior of doctors and hospitals
• Better health encourages sharing
30. The Future is now
» Personalized – emphasis on collecting more health data to better customize care
» Wherever – portable devices will help bring care to you
» Whenever – health care will no longer be confined to the doctor’s office
» Participatory – consumers will be actively involved in managing their health
» Crowd sourced - real-time access to aggregated health data
www.patientslikeme.com
31. Death is 100% Guaranteed Life is a fatal condition!
100%
H
E
A
L
T
H
S
T
A
T
U
S
0%
31
33. But how do we get to this new vision?- Incrementally
Integration is key
•Able to Clinically Integrate
•Multiple disciplines within one
Enable high priority organization
programs to grow as •Creative mindset
patient centered • Strong research base
•Capacity to foster (and direct)
care models are key collaborative, interdisciplinary
to future success research on a large scale
AHC have a starting •Catalyst for translational
research – integrated basic
advantage if they science, healthcare, public
take advantage of health, and other necessary,
their position supporting disciplines
•Objectivity about national
economic issues
•Organized voice in national
debate
34. How I See It
» Integration of the AHSC is more important than ever given the trends
that are seen in the PPACA bill. Today we see more and more
physicians coming together into large multi-specialty groups and an
increasing numbers of hospital mergers. Further we are seeing
physicians seeking employment by hospitals as an increasing trend
well demonstrated by the migration of cardiologists from independent
group practice to hospital based practice.
» If AHSCs are to be successful moving ahead as leaders in clinical care
they must bring the missions of research and education into this new
environment and learn to adapt to the changes ahead. Bringing
translational research and the science of health care delivery into the
next decade will call for careful attention to organizational structure as
well as physical structure. The central core medical center with
distributed satellites of multi-disciplinary clinics and ambulatory
services (e.g. imaging and sophisticated laboratory testing) will bring
the AHSC clinical care and its translational research to the community.
Efficiency, quality, integration and connectedness will be critical
attributes of a successful AHSC
36. Objectives of a New Model in Many AMCs
These restructurings are typically occurring in anticipation of health reform’s implementation to enable:
A unified strategy linking clinical and academic success including:
A single face to the Increased efficiency: Streamlined decision-
market: making:
• Integration of
• Consistent, high quality, • A unified management
administrative and clinical
seamless patient care structure
functions where possible
• A single brand image • Availability of information
• Allocation of resources to
• A unified approach to across the enterprise for
optimize overall
payors and referral sources better decision making
performance
including bundled payments • Reduce regulatory and
• Integration of care across
• Development of integrated compliance risk
settings
service lines
37. Building for Convergence
Governance Structure/Organizational Culture Must also Support Convergence
» Changing traditional culture
entails at least three major
factors, which are
challenging in any
environment… and
particularly in Academia:
38. Goals for a New Organization
If we agree with the AHSC characteristics of aligned organizations,
we can use these characteristics to evaluate whether potential models advance the
organization’s ability to achieve these goals
• Contribute to success across all missions and leverage the unique capabilities enabled by
being an AHSC
• Ability to create a unified clinical vision and to implement that vision
• Ability to align incentives and invest funds in the areas of highest priority
• Eliminate or minimize redundant overhead and streamline administrative processes
• Engage and involve the faculty in creating a highly successful enterprise
• Ease of implementation
• Likelihood of success
39. SYSTEMS ABLE TO DEVELOP EXCELLENCE IN CORE CAPABILITIES
WILL BE SUCCESSFUL IN ANY FUTURE SCENARIO FUTURE IN IN
40. The Question for the Future
• The question is not:
• “What will medicine look like in 20 years?”
• The questions are:
• “What can medicine be in 20 years?”
and
• “What can we aspire to be as leaders in
fulfilling that vision?”
Editor's Notes
Some days I do feel like I am in the movie “Ground Hog Day”. The movie in DC keeps playing the same thing over and over again he world is challenging us in many ways and while we feel the challenges we laso have many opportunities. The new BIG goal is to achieve Predictive Health and the Square wave life. We are making small steps forward here at Emory but this is a transitional process and in order to continue the transition we have to respond to the changing health care environment not by abandoning our commitment to our mission but by responding to the changes in healthcare and in order to do that integration is essential.
Every one in this room is familiar with these stressors that continue to add uncertainty to our daily work This next one was orignally assembled by Carnegie Mellon University professor Paul Fischbeck – and reported by Mark Roth of the Pittsburgh Post-Gazette (December, 2009) – and highlights our Per Capita Healthcare Costs by Age as compared to four other countries (Germany, the U.K., Sweden and Spain).
the good (and bad) news is that it is probably the strongest sector of our economy. Needed disruptive change in the healthcare sector will create disruptive change in the overall economy. How do we balance it? The health care sector added 290,000 jobs last year through November, according to Bureau of Labor Statistics data compiled by the Advisory Board, http://i.huffpost.com/gen/894539/original.jpg There appears to be an inzatiable appetite for healthcare. The care has never been more sophisticated and more expensive
Over the last five years, health care job growth has outpaced employment trends overall. Health care jobs account for one out of every six of the jobs created in 2012 so far, Employment rose in the health care industry over the last six years, even as jobs disappeared overall during the Great Recession and have reappeared slowly since. Indeed, when the U.S. hemorrhaged jobs in 2008 and 2009, health care companies continued hiring. The health care sector added 290,000 jobs this year through November, according to Bureau of Labor Statistics data compiled by the Advisory Board, http://i.huffpost.com/gen/894539/original.jpg
Having been in leadership in two AMCs over the last 20 years…
The HA article shows that the implementation of some increasingly popular operational changes in the ways clinicians deliver care—including the use of teams or “pods,” better information technology and sharing of data, and the use of nonphysicians—have the potential to offset completely the increase in demand for physician services while improving access to care, thereby averting a primary care physician shortage. shortages could be averted with physician "pooling," effective use of nurse practitioners and physician assistants and technology that reduces the need for face-to-face visits. "Furthermore, if we include the impact of diverting a fraction of patient appointments to nonphysician professionals or of addressing some of the demand through electronic com-munication channels, the predicted physician shortage essentially evaporates," the authors wrote, citing a 2009 Kaiser Permanente study that found that primary-care visits decreased 25.3% after implementation of an EHR that encouraged electronic communication with patients—rather than in-person visits—pertaining to management of chronic con-ditions.
It is not like there are no opportunities in fact there are many but they require us to respond to the new dynamic. And BioScience and Bio Technology shows us the way to a new Vision of Health Care
we see the beginnings of bespoke medicine, which makes what we are doing now feel like prêt-à-porter. Mike Snyder and his colleagues at Stanford ventured beyond the concept of genomics-based personalized medicine to introduce the iPOP , an integrative personal omics profile . On information overload We are drowning in data. But we don't have enough ability to analyze it. The more data you throw at something, you will find correlations—but correlation is not causation. What we now have is a demand for statisticians to shrink down the correlations to things that can be tested. Because if you don't, you're going to end up chasing mirages.
We are all leaving trails of DATA DUST Perhaps jobs in this sector can offset some of the jobs liost http://www.intelligentfingerprinting.com/#
People thinking and writing in this area have become enamored of alliteration---an ever-lengthening list of P words is used to describe this new biomedicine. Here are four of those words—we have chosen Predictive Health as a theme because it emphasizes discovery of markers that have predictive value and the focus on health as opposed to disease We could add here Professionalism as a seventhP. And some now like Precision. Along with enormous potential for good, new knowledge brings ethical and moral challenges that must be addressed.
“ The ONLY wrinkle I have I sit on”” Calment
This slide illustrates the basic concept of our institute. We propose, in parallel, to both deliver what we know now and conduct basic science research aimed at discovering new predictors and new ways to keep people healthy A Center for Health Discovery and Well Being will engage cohorts of healthy people in a program of detailed health assessment upon which to base personalized health plans. This will also be a demonstration project that will enable rapid translation and validation of new discoveries The basic science component of the Institute will be a broadly interdiscipinary activity that will aim to create new information that will help to understand human biology and provide both rationale and tools for translation to caring for human beings
THERE ARE TWO CONCEPTS HERE---ONE IS THAT a. HEALTH AND DISEASE ARE A CONTINUUM, NOT A DICHOTOMY AND THE OTHER b. IS THE CONTRAST OF EMPHASIS OF CONTEMORARY MEDICINE AND PREDICTIVE HEALTH
Our institute is assembled in this way The basic determinants of health interact to affect Processes that also interact and may be early indicators of an unhealthy state prior to development of end organ failure—i.e. disease. We will concentrate on the upper part of this scheme We will focus both basic science and technologies and the range of other disciplines that will be essential to implementation of a new system on the processes that determine health
The integrated activity is diagramed here. Known and developed predictive measurements will identify people at risk for losing their health permitting early personalized health sustaining programs Predictive measurements will also define processes that will be new targets for novel interventions before disease develops. As processes are understood, more sophisticated health markers will be discovered and pharmacologic interventions will be developed that maintain the healthy phenotype For the most part, we now operate in a linear model that suggests unidirectional development from the basic laboratory to translational research to clinical trials to new therapy A circulating model may be more efficient where information resonates among the research laboratory, the clinic and health care professionals
THIS LINKS DISEASE BURDEN AND COST, SO NOT JUST THE COST SAVINGS BUT THE SAVINGS IN HUMAN MISERY TO BE HAD BY PREDICTIVE APPROACH PHC HAS POTENTIAL TO PROVIDE BETTER RISK ASSESSMENT AND PREDICTION, EARLIER DETECTION, EARLIER TREATMENT AND TARGETED TREATMENTS.
THE GOAL OF PREDICTIVE HEALTH IS NOT JUST TO BE FREE OF DISEASE BUT TO FLUORISH
We designed the center with the deliberate goal of creating a space that did not look and feel like a clinic and was welcoming to essentially healthy people. We worked with an architect who familiarized himself with the Predictive Health concept and translated the concept into a physical space. A basic need for the concept to work is to engage healthy people in caring about their health and we felt that the physical space was an important part of that.
Using validated questionnaires, we collect quantitative information about physical health, behaviors, environments and “well-being” that includes tendencies to depression, perceived stress, sleep quantity and quality, social support, familial relationships, and even spirituality.
Measurements physical health made in the center are non-invasive determinations of body composition as well as BMI, and ultrasound determinations of detailed functions of large and small blood vessels. Overall cardiopulmonary health is determined by a treadmill determination of maximum oxygen consumption, a standard measurement.
There are a number of biomarkers of the health of the bodys major systems that are available, but are not routinely made in healthy people. Our asessment of health include s an extensive battery of known biomarkers. But, a basic hypothesis of Predictive Health is that there are a few processes that are basic to normal function and that these can be measured. Oxidative stress, inflammation, immune function and regenerative capacity comprise these fundamental processes and can be measured using developing research methodology.
NOT EVERYTHING GOT BETTER, BUT A LOT OF THINGS DID AND IMPROVEMENT APPEARS TO BE SUSTAINED BDI, first published in 1961,[5] consisted of twenty-one questions about how the subject has been feeling in the last week. Each question has a set of at least four possible answer choices, ranging in intensity. . The Perceived Stress Scale was developed to measure of the degree to which situations in one’s life are appraised as stressful. Psychological stress has been defined as the extent to which persons perceive (appraise) that their demands exceed their ability to cope. The Epworth Sleepiness Scale is a scale intended to measure daytime sleepiness or their probability of falling asleep on a scale of increasing probability from 0 to 3 for eight different situations that most people engage in during their daily lives,
. INTERACTIONS OF EACH OF THES COMPONENTS OF THE SYSTEM ALL SUPPORTING DEVELOPMENT OF CORE CAPBILITIES.