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- 1. The Chinese Curse “MayYou Live In Interesting Times” Michael Johns MD January 31, 2013
- 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
- 3. 3 The Cost Conundrumand More
- 4. Where the Jobsare new us jobs in healthcare and all other industries He Healthcare is a major US jobs program!!
- 5. Academic Health CenterChallenges 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 CenterChallenges 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.
- 7. Shortage of 91kPhysicians in 9 yrs or maybe not?
- 8. Physician Issues onHorizon • 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 unmetneeds 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 andTechnology 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
- 11. Big Data-skilled analystsNeeded WSJ
- 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 whatwe 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 forPredictive 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
- 18. Opportunities for Intervention Cost/irreversibility Disease Burden Baseline Initiating Preclinical Disease Typical Risk Events Progression Initiation Current Intervention Time Adapted from R. Snyderman© 2005
- 19. April 7, 1948WHO Definition Health is a state of complete physical mental and social well being and not merely the absence of disease or infirmity
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- 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 HealthDiscovery and Well Being The Center design embodies a new approach to healthcare: Non-clinical atmosphere Customer oriented High tech
- 23. Assessment: The Surveys Surveyscollect 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
- 25. Assessment Laboratory Studies More than 50 different lab tests
- 26. The Predictive HealthPartner 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 wedoing? % 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 outsideof 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 aconsumer 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 isnow » 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 dowe 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 SeeIt » 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
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- 36. Objectives of aNew 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 aNew 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 TODEVELOP EXCELLENCE IN CORE CAPABILITIES WILL BE SUCCESSFUL IN ANY FUTURE SCENARIO FUTURE IN IN
- 40. The Question forthe 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
- #2 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.
- #3 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).
- #4 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
- #5 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
- #6 Having been in leadership in two AMCs over the last 20 years…
- #8 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.
- #10 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
- #11 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.
- #12 We are all leaving trails of DATA DUST Perhaps jobs in this sector can offset some of the jobs liost http://www.intelligentfingerprinting.com/#
- #13 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.
- #14 “ The ONLY wrinkle I have I sit on”” Calment
- #15 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
- #16 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
- #17 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
- #18 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
- #19 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.
- #21 THE GOAL OF PREDICTIVE HEALTH IS NOT JUST TO BE FREE OF DISEASE BUT TO FLUORISH
- #23 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.
- #24 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.
- #25 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.
- #26 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.
- #28 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,
- #40 . INTERACTIONS OF EACH OF THES COMPONENTS OF THE SYSTEM ALL SUPPORTING DEVELOPMENT OF CORE CAPBILITIES.