Personal Health Application

In this post, I propose the development of a Personal Health Application (PHA). It is a next generation consumer-centric information system that helps improve healthcare delivery, self-management and wellness by providing clear and complete information, which increases understanding, competence and awareness.

PHAs would:

• Incorporate sick-care data currently found in Electronic Health Records (EHRs) used by healthcare providers and Personal Health Records (PHRs), and add well-care data focusing on prevention, self-management, and emotional well-being


• Give a high-definition, big picture, whole-person view of a person's physiological & psychological risk factors, current health, health trends, and projected health status.


• Reveal the interventions that are effective for an individual by integrating and analyzing a lifetime of data about health status & quality of life, conventional and complementary & alternative medicine (CAM) treatments received, and the clinical outcomes of that care.


• Enable the exchange of patient data with providers' EHRs, as well as obtaining data directly from lab, pharmacy or hospital systems.
  

Whereas today's PHRs present narrow views of a person's general health information, PHAs would provide clear, comprehensive views of the whole person-mind, body, spirit and environment-showing risk factors, current health status, health trends, and projected one's future health status. Revealing such trends and predicting one's health condition under different scenarios can be powerful motivators for health living, as well as offering important clinical insights for healthcare providers.

Furthermore, PHRs do little to inform a person about treatment efficacy and the value of CAM approaches. PHAs, on the other hand, would provide this information by collecting and analyzing a lifetime of detailed health data to show what works for the person and what doesn't.

PHAs also bridge well-care and sick-care:

• Sick-care focuses on the treatment of diagnosed physical & psychological problems


• Well-care focuses on preventing serious illnesses and complications, and increasing people's well-being and quality of life through self-management and healthy lifestyles.

The objectives of a PHA are to inform, empower and enable consumers to make better decisions and act responsibly. This includes enabling consumers to:

• Be helpful and proactive in managing their health, rather than passive and reactive.


• Make wise decisions when agreeing to specific treatment options and living health lifestyles


• Carry out strategies for remaining healthy longer


• Comply with plans of care when ill to speed recovery, avoid complications, and achieve the best possible quality of life


• Deal effectively with personal problems and life stressor to maximize one's overall well-being.

Informing and empowering the modern consumer

My previous three posts discussed the daunting challenges facing today's "modern consumer." This post focuses on what is needed to inform and empower consumers, so they make good decisions and act responsibly when it comes to selecting the best treatments and adhering to them.

It's obvious that consumers need valid, understandable information about the risks, benefits and costs of different treatment options. But often that's not enough. Consumers also need the motivation, resources and skill to comply with chosen plans of care. In other words, they must be mentally, emotionally and physically able and willing to carry out their healthy living strategies, and do it effectively and efficiently.

Obtaining the needed information can be difficult because information found on different web sites, instructional pamphlets and expert opinions often offer conflicting, inadequate, irrelevant, unclear, and/or invalid information. Only 16% of online consumers searching for health information find what they were looking for. Although general search engines perform satisfactorily for generic searches, they may not do well for health queries. [1]

For example, much available information focuses only on conventional treatment options and ignores CAM (complementary and alternative medicine) interventions. Some information sources lack objectivity because they are influenced by advertisers sponsoring them. Some offer general information that is not adequately personalized for an individual's particular situation. And it's tough to find clear-cut information that lays out all reasonable options in terms of cost; risks (e.g., adverse side-effects, mortality rates, quality of life impairment, etc.); likely benefits; patient responsibilities; and so on. In addition, an individual's personal preferences tend to be overlooked.

Another problem is that the mind-body connection is often ignored, even though up to 50% of all visits to a primary care physician are for conditions with affected by psychological factors, and the relationship between emotional stress and physical disease is well established.[2] So, if a person is diagnosed with a physical problem, related emotional/psychological issues are rarely addressed, and visa versa.

Furthermore, consumers can be overwhelmed by having to navigate through web sites with hundreds of links, or read search engine returns that can easily total in the tens of thousands to hundreds of thousands.

And one more thing, consumers often need to have conversations with subject matter experts-including knowledable peers and professionals-in order to have their questions answered and to receive hands-on guidance and encouragement. Sometime reading written materials, listening to tapes, or watching videos isn't enough.

I suggest, therefore, that the best way to give consumers what they need is to implement a consumer-focused strategy with the following tactics-and do it in an easy, secure way that protects personal privacy:

• Perform comprehensive, lifetime health status and risk assessments that examine the "whole-person," including psychological and biological factors, environmental influences, and personal preferences and abilities.
• Use the results of the assessment to provide personalized "information therapy" that gives a clear explanation of people's existing conditions and risks, offers a risk-benefit analysis of both conventional and CAM treatment options, and gives instructions for adhering to healthy living strategies.
• Offer targeted, interactive, decision-support and problem-solving tools that assist people in making good choices and dealing with troubling issues likely to prevent treatment compliance, in order to replace stress, denial, depression, anxiety, etc. with effective coping skills and proactive behaviors.
• Focus on well-care (illness prevention, health optimization, recovery from health problems, and health self-maintenance).
• Connect people with vetted peers and professionals who share experiences and ideas, ask and answer questions, and give emotional support.
• Take the time to examine motivational issues and offer meaningful support and incentives.
• Offer alerts and reminders to increase awareness of what to do and when to do it.
• Make sure care is coordinated when multiple providers are involved (e.g., primary care and specialists).

What we need, then, are collaborating networks of peers and professionals who use a next-generation Personal Health Application (PHA), which differs considerably from today's personal health records (PHRs) and health information web sites. My colleagues and I are developing such networks and prototypes of such technologies; I'll have more to say about this in future posts.

[1] "Health Information Search Engines Emerge; Growing Consumer Demand for Health Information Increases Need for Better Quality, More Personalized Searches, Says Expert at 11th World Congress on Internet in Medicine." Internet Wire (Oct 18, 2006).

[2] WellnessWiki

Jake's Deadly Dilemma

My two previous posts about the plight of the modern healthcare consumer focused on Jane’s exasperating treatment decision and John’s health insurance ordeal. This post examines a life-threatening scenario any of us could face in a disaster.

As he regained consciousness after the explosion, Jake found himself pinned under a beam, unable to move; he was trapped in his office building. To make matters worse, he kept loosing consciousness. Thankfully, 1st responders (fireman, police, and emergency medical units) were arriving outside. Unfortunately, they didn't know where in the building victims were located, or which stairways, hallways and rooms were safe to enter.

Several 1st responders reached Jake eventually. Sadly, there were two "men down" from serious injuries during the search.

Jake's rescuers began to evacuate him, but they didn't know his medical history, nor could they determine the trauma centers best suited to treat his injuries. There was also difficulty maintaining communications between the 1st responders and trauma center staff since telephone and Internet services were sporadic. The ambulance driver ended up taking Jake to a nearby emergency room hoping it had sufficient beds, surgeons and other resources needed to treat him.

When they arrived, things were chaotic. Due to widespread devastation, the doctors and nurses in the ER were inundated with injured patients. When they got around to Jake, they had trouble delivering the care he needed due to problems allocating their medical equipment, directing their staff, and keeping track of their medicines and materials. Since Jake was unconsciousness and didn't have any identifying documents, the trauma team couldn't obtain important information about his allergies and pre-existing medical problems. They couldn't even notify family about Jake's condition, nor have someone with power of attorney make a life-saving decision.

What's the problem here?

Not enough is being done to equip 1st responders and trauma center staff with information they need to evacuate victims safely, transport them to the right trauma centers, and treat them effectively in the emergency room and beyond. In disasters, pandemics and terrorist attacks, an information system is needed that helps save lives and property through rapid response by enabling emergency preparedness and providing assistance for 1st responders and trauma center staff.

If the 1st responders assisting Jake had been using such a system, there may not have been any "men down." They would have known where Jake was located in the building and would have followed the safest path to him. That would have protected the 1st responders and got them to Jake more quickly. It would have also identified the trauma center best able to care for his injuries and would have instructed the ambulance driver to take him there. It would have also maintained communications between the emergency personnel at the scene of the explosion and the hospital staff. In addition, it would have been able to obtain Jake's medical history from any health record systems using "biometrics" (such as fingerprints and retinal scans). And it would have helped the nurses and doctors deliver the necessary care with minimal disruption and error.

My next posts will examine solutions for empowering and supporting modern consumers when making important healthcare and insurance decisions, and for helping victims by assisting 1st responders and emergency room personnel in disasters.

Click here for the next post in this series.

John’s Health Insurance Ordeal

Last time I wrote about Jane’s exasperating treatment decision. This time I focus on John’s health insurance ordeal.

It was time for John to choose a new health plan for his family and he wanted to do it right. So he spent weeks visiting insurance web sites, using online calculation tools, and talking to numerous insurance professionals and other consumers. He gathered tons of data on dozens of health plans and put it all in a big spreadsheet. It listed the deductibles, premiums, co-insurance, co-pays, covered treatments and wellness programs, ceilings on coverage, estimated tax-savings and other details.

What’s the problem here?

Nearly everyone agrees that skyrocketing healthcare costs in the USA—much higher than any other country—are putting our nation in danger of financial ruin! Those in the know are also aware that there are very serious quality and efficiency problems with America’s healthcare. There are over 45 million uninsured. Many businesses can’t afford to cover their employees. Hundreds of thousands of patients are hurt or killed each year by medical errors and deadly drug effects. The quality of care delivered in our country is rated below many other industrialized nations. And the enormous Medicare debt we’re pushing onto our children is shameful!

To deal with these serious problems and others, our country has recently been trying to control costs and improve quality by having consumers put more “skin in the game.” That is, they must pay more for their healthcare. The logic of this “consumer-directed healthcare” strategy is that by paying more, consumers will take control and drive down costs. For example, consumers will be less likely to request unnecessary care. They will manage their own health better by making positive lifestyle changes. And they will seek out providers who deliver the most cost-effective treatments and get the best results.

While this strategy may seem sensible, many critical questions remain unanswered. How are consumers to be certain when care is required? How can they determine the most cost-effective treatments and find the providers who deliver the best care? And how can they select the most affordable health plans that meet their current and future needs? Jane and John—being bright, educated and motivated consumers—did a great deal of research, got tons of information, but ended up with no clear-cut answers.

Bottom line: The consumer-directed healthcare strategy is dangerous! This is because the most important ingredient is missing: Consumers need easy access to accurate, relevant and understandable information about the quality and cost of providers, treatments, eldercare and health plans. This information is essential for making prudent choices.

What health insurance policy is the right one?

Not surprisingly, John discovered that policies with lower premiums and higher deductibles, while costing less, carried greater financial risk. Such plans would save him money as long as he and his family remained healthy. This meant he would have to make very accurate judgments about likelihood of family members getting sick and the extent of care they would need in the coming year. A miscalculation, incorrect assumption, or just bad luck, could send John into financial ruin.

Unfortunately, research suggests that consumers consistently underestimate their risk of being seriously ill. This is especially true for individuals who have not used healthcare services often, because they don’t have the knowledge they need to fine-tune their judgments based on experience [1].

And consumers’ decisions don’t stop there. After you chose a health plan, you must determine what healthcare providers deliver the most cost-effective care and, if you’re not feeling well, you have to decide whether your symptoms require a doctor’s visit.

What’s the problem here?

As a consumer, you need information about health policies that enable you to compare different plans. You also need a clear-cut way to estimate your future healthcare needs and your out-of-pocket expenses in different scenarios. You then have to become a good diagnostician, so you don’t seek unnecessary care or allow unnecessary tests … Just don’t err and fail to go to the doctor for something serious!

Putting it all together: The role of the modern consumer

So, as a modern consumer, it’s your responsibility to know when you’re sick enough to make a doctor’s appointment. It’s your responsibility to choose the treatments that will do you the most good with the least risk when you are ill, as well as finding competent healthcare practitioners and hospitals that will deliver that care safely and cost-effectively. It’s also your responsibility to optimize your health and manage chronic illness through the right lifestyle changes and adherence to the right self-management plans. In addition, you may be responsible for assuring that elderly loved ones receive the right care and have a good quality of life. On top of all this, it’s your responsibility to choose the right health insurance policy for yourself and your family.

As a modern consumer, therefore, you have the daunting responsibility of researching all your health care and insurance options thoroughly, while avoiding information overload. Where essential information is lacking, you must somehow get the knowledge you need anyway. And then you must gain a clear understanding of confusing technical data and conflicting professional opinions. GOOD LUCK!!!

Click here for the next post in this series.

[1] Based on ConsumerReportsMedicalGuide.org

First of 3 stories about the dilemma modern consumers face in this era of "personal responsibility."

I'm now going to focus on the dilemma modern consumers confront in this era of "personal responsibility." During this next series of posts, I'm going to present and then discuss three stories about the difficult position patients and other consumers face thanks to today's consumer-directed healthcare strategy.

• One has to make difficult treatment decisions when there are no clear-cut answers.
• Another has to decide on a health insurance policy from among dozens of confusing alternatives.
• And the third is being treated in a trauma center after a catastrophic event.

Let's start with a story about Jane's exasperating treatment decision.

After seeing countless specialists and six rounds of chemotherapy, Jane's ovarian cancer metastasized to her liver. This means she now has too many tumors for surgery. One doctor advised her to "Go home and think about the quality, not the quantity, of your days."

At 39 and the mother of two toddlers, Jane wasn't ready to give up; instead, she faced an excruciating decision. Three oncologists advised that she continue receiving chemotherapy, which showed some sign of working the last time. But two others thought she should first try cryosurgery, which starts by injecting liquid nitrogen into the tumors to shrink as many as possible. They then follow up with chemotherapy in hopes it would be more effective. The problem is, Jane might not survive the cryosurgery procedure.

When she asked a surgeon how to decide, he said that no one knows what she should do. He told her that she would have to make the decision based on here "own values" ... whatever that means!?!

Exasperated, Jane shouted, "I'm not a doctor! How am I supposed to know!?!"

Jane isn't alone. Many patients and other healthcare consumers face making daunting choices without adequate knowledge and guidance. Examples include prostate cancer, which gives patients the choice between watchful waiting and aggressive therapies like radiation or surgery. Breast cancer patients often hear conflicting advice from experts suggesting lumpectomy and others mastectomy. Heart disease patients may be told they need bypass surgery by one doctor, angioplasty by another, and a third says that drugs are all that's needed. And even for conditions that are not life-threatening-such as gout, back pain, mental illness, autism, chronic fatigue, menopause, dental procedures, and many others-there is little agreement as to the best treatment regimen.[1]

This is the bind more and more healthcare consumers are finding themselves in. Modern consumers now face a new world of "personal responsibility" and perplexing choices in a struggling healthcare system plagued with safety, quality and efficiency problems. Most are lost and confused when it comes to making important health decisions and taking responsible actions. It can be a lonely, frightening and overwhelming experience considering all the treatment options and medical uncertainty. It's like wandering around lost in a foreign land.

How is a consumer to know what's best?

Becoming more knowledgeable is important, but it can quickly become overwhelming; information overload is a real threat. For example, search the Internet for information on most types of cancer and you'll likely receive at least a million results. Not only is it impossible for a consumer read all this information or to understand it, but there are often conflicting recommendations and uncertainties. In fact, a Times/CBS poll reported that over half the time patients are given multiple treatment options with no clear best choice. Not to mention how difficult it is to figure which web sites offer accurate and unbiased information, and which are influenced by the self-interests of their advertisers and sponsors.

What about asking your doctor?

Sadly, few medical professionals have the time to sit with you and clearly explain all the data. Even if they did, it's unlikely that they'd have the breadth of knowledge to help you understand all the possible alternatives, including complementary and alternative approaches (such as dietary supplements, mind-body medicine, Chinese techniques, homeopathic and naturopathic medicine, bodily manipulation, energy medicines, etc.).

To make matters worse, an estimated half of all surgical operations and other medical procedures lack strict scientific evidence of their effectiveness and safety. In other words, healthcare providers often don't know what treatments work best for a particular patient. Despite all our medical advances, our country is way behind when it comes to tracking treatment efficacy and the outcome of prolonged medication use.

This means that consumers must now struggle to make treatment decisions that are beyond the knowledge of the experts!

Next time I'll tell the story of John's health insurance ordeal.

Click here for the next post in this series

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[1] Based on a New York Times article titled "Awash in Information, Patients Face a Lonely, Uncertain Road" Aug. 14, 2005. Available at http://law.wisc.edu/patientadvocacy/PDFlinks/NYTimes.pdf

Why many belief systems are so emotional

Continuing the topic of health and beliefs, I will now answer the questions: Why are certain belief systems so emotional? and What types of beliefs are associated with good health?

Why are certain belief systems so emotional? Certain belief systems come with strong emotions because of the way the brain works. The brain activity I mentioned above occurs in three regions (see, for example www.healing-arts.org/n-r-limbic.htm):

1. The “rational” part of the brain (neocortex) is where the cognitions/thoughts take place
2. The “intermediate” part of the brain (“limbic system”) control emotions
3. The “primitive” (“reptilian”) part of the brain activates self-preservation behavior.

So, when we have a thought reflecting a belief that something (or someone) is a threat to our well-being (i.e., appraisal of potential harm), our minds automatically trigger the “fight-flight” response by eliciting brain activity in its intermediate and primitive regions that make us feel upset and prepare us to deal with the perceived threat through release of adrenalin. While this process is vital to our survival, it can easily become maladaptive if our beliefs over- or under-estimate the likelihood and severity of the threat, as well as our ability to change or cope with it:

• Sometimes our belief systems accurately appraise a threat as being unlikely to cause us serious harm, but we realize it will, nevertheless, bring us disappointment, frustration, criticism, inconvenience, etc. When this happens, we will feel appropriately annoyed or concerned, and focus on the right things. This means we are in the best emotional and mental state to deal with the threat. And if we believe the threat can be eliminated by changing the situation in certain ways, and we believe we have the ability to make those changes effectively, then we are motivated to take responsible action to improve things and ourselves.
  

• Sometimes we exaggerate a modest threat because our irrational beliefs distort its severity. We then blame certain people or circumstance, correctly or incorrectly, for causing our problems (e.g., “This shouldn’t be happening to me …I can’t stand it … it’s their fault!!!”). When this happens, our negative emotions are exacerbated: Annoyance becomes anger and concern becomes fear.

• Sometimes our belief system accurately appraises a threat as serious. When this happens, the sensible response is to eliminate the cause of the threat if we believe the situation can be changed, or if it cannot be changed, to avoid the threat or accept and cope with it as best we can. In either case, having control of our emotions and reactions enable us to develop and implement a realistic plan of action with a clear head and focused mind, rather than being frozen with fear or attack with reckless hostility. Being able to keep our emotions and reactions in check means having a belief system that correctly attributes the causes and our abilities to change things. It also means avoiding irrational beliefs that distort the situation and exacerbate our negative emotions. So, if we believe we have the ability to ameliorate the threat by changing the things that create the negative situation, we are more willing to take a problem-solving approach. If, however, we believe the situation cannot be changed, we can still cope with the impending threat and its aftermath by, for example, leaning to deal with the unfortunate situation with minimal distress through rational acceptance, avoidance, etc.

• Sometimes our belief systems inaccurately estimate the severity or likelihood of the threat, incorrectly evaluates our ability to change it, and/or misidentifies the threat’s cause. When this happens, we are more likely to worsen a bad situation, or at least fail to make it better. We may, for example, (a) dismiss a serious problem as being inconsequential; (b) deceive ourselves that we can’t do anything to improve a situation, even though we actually can make difference; or (c) try to change the wrong things in the wrong ways. This, unfortunately, is the path humanity tends to follow …Our long-term survival requires a major shift in our belief systems and foci!

What types of beliefs are associated with good health? When it comes to managing our health, it’s critical that we have accurate beliefs about the severity of our risk factors and current conditions, their causes, and our ability to avoid health problems and improve our existing health status. We must have a level of emotion that motivates us to act sensibly and responsibly, and cope effectively. And, of course, we need a realistic self-management plan and a rational mind that keeps things in perspective.

Next time I’ll examine three other things that help determine how to change beliefs; they are: core relational themes, appraisal patterns, and action tendencies.

Why people develop persistent maladaptive beliefs

Continuing the thread of beliefs and health, I will now examine why people develop maladaptive beliefs systems and why they’re so difficult to change.

A belief is a type of thought (cognition, attitude, assumption, theory) that emerges as one’s mind converts patterns of electro-chemical brain activity into internal dialogue (“self-talk”), images in the “mind’s eye,” emotions, and behavioral reactions. Since this occurs automatically and unconsciously, we are typically unaware of these thoughts and feelings as they happen.

 

How do these beliefs develop and persist? The kind of beliefs I’ve been discussing—attributions, appraisals and irrational beliefs—are created by our experiences and cultural teachings. These belief systems (interrelated set of beliefs) function as mental/perceptual “filters” through which we view the world, the future and ourselves, which ultimately affects the state of our physical, psychological and spiritual health.

 

There are many reasons why humans develop and maintain maladaptive beliefs, and the negative emotions and behaviors accompanying them. They include the following (adapted from Albert Ellis’ book, “Reason and Emotion in Psychotherapy” pp. 381-414):

 

• We have a prolonged period of childhood during which time we are—relative to healthy adults—vulnerable, weak, ignorant, unintelligent, incompetent, highly impressionable, and over-emotional creatures. This is poor training ground and preparation for the kind of thinking, emoting, and acting we will have to do to live sanely and healthily as adults.
• We often have difficulty unlearning something, even as we learn new things that contradict it. So, once certain beliefs are acquired, it often requires constant work and practice to change them. In other words, beliefs become habitual.
• Inertia is the tendency of an object at rest to remain at rest, and of an object in motion to remain in motion. Changing an object’s motion by starting it or stopping it, therefore, requires extra energy. The same is true for people’s tendency to think, feel and act in ways we’re accustomed. It takes extra effort to modify the thoughts, emotions and behaviors familiar to us. Unfortunately, we tend to have trouble with sustained effort (as discussed below), so once a strong beliefs are in place, our inertia makes them resistant to change.
• People tend to be short-sighted and want their desires satisfied immediately (“short-term hedonism”), even when they would be better off postponing satisfaction or living without. Examples of things momentarily desirable, but undesirable or harmful in the long run, include consumption of alcohol, drugs and too much food. This is one reason why we find it so easy to believe we need what we want when we want it, without consideration of the long-term consequences.
• People have a tendency to be over-suggestible, which makes us prone to adopting the beliefs of our families our cultures, rather than rejecting conformity in favor of independent critical thinking.
• Humans tend to be overly vigilant, cautious and misfocused, which means, for example, that we focus too intently on certain things we wrongly believe pose a threat, where in fact we’d be better off concentrating on other things that pose a more serious threat to our well-being.
• Extremism is a human tendency that makes it very easy for us to accept radical beliefs, rather than taking a middle-ground view.
• People are prone to wishful thinking, which makes it very easy for us to have self-deceiving beliefs that minimize problems and that enable us to foolishly justify inaction (e.g., “No need to bother … everything will work out on its own”).
• Humans have (a) trouble sustaining their focus effectively on what’s most important, (b) difficulty organizing many diverse elements of one’s existence into integrated wholes, and (c) problem engaging in disciplined & sustained effort, especially when frustrated. Belief change, however, requires competence and will in all these areas.
• Our culture reinforces beliefs that over-emphasize guilt and blame, and make us prone to envy and jealousy.
• We have a tendency to over-generalize, which means we apply our beliefs about particular people or things to other people and things believe are similar, but that are, in fact, really quite different. When combined with “people appraisal,” this tendency is the foundation of racial, ethnic, gender and religious prejudice.
• It is easy for humans to exist with disturbed beliefs and the maladaptive emotions and behaviors associated with them.

And here are some reasons why people have trouble refuting invalid beliefs:

• We tend to have a form of “selective attention” that makes us focus on a specific aspect of an experience while ignoring other aspects, as well as “hindsight bias” makes us recall only certain things from memory. The problem is that the things we focus on and remember tend to support our preconceived beliefs (assumptions/theories), while ignoring contradictory evidence. Belief change, however, requires just the opposite, i.e., examining situations objectively, through critical thinking, by seeking out evidence that refutes our assumptions and hypotheses.
• We also tend to be overconfident in the accuracy of our attributions and appraisals. So, rather than fully investigating contradictory evidence, we develop and maintain beliefs based on judgments supported by insufficient and misleading information.

In my next post, I will answer the questions: Why are certain belief systems so emotional? and What types of beliefs are associated with good health?

Beliefs, emotions, behaviors and health: Examining 3 categories of beliefs

Last time I discussed how people’s beliefs affect their health. This time I dissect three common categories of beliefs associated with exaggerated negative emotions and self-defeating behaviors: They are attributions, appraisals and irrational beliefs.

 

Attributions are inferences (conclusions) people draw about causality (i.e., who/what is responsibility, at fault, to blame for a problematic situation); changeability (i.e., prediction of whether a problematic situation is changeable and within you control or intractable and beyond your ability to change).

 

Negative beliefs about the attributes of causality and changeability tend to be associated with feelings and actions such as (a) angry emotions and hurtful behavior (e.g., if you believe someone in particular caused your problems and you blame them for it); (b) shame/embarrassment, avoidant behavior or self-destructive actions (e.g., if you believe your problem is your own fault); and (c) depression or sadness, low frustration tolerance, anxiety or fear (if you believe the problem will never change). Not only does this increase one’s stress levels (which would have an adverse affect on one’s health), but it prevents a person from being an effective problem-solver, which, when it comes to dealing with one’s health problems, means poorer health and quality of life.

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Positive beliefs about causality and changeability, on the other hand, tend to be associated with optimism and hope, courage, assertive/proactive problem solving, persistence in the face of frustration and disappointment, self-respect, willingness to accept help from others, effective coping strategies, etc.

 

Appraisals are judgments about the degree of benefit (or potential reward) and harm (or threat) something or someone has caused (or will cause). If, for example, a patient believes a doctor’s advice won’t provide much help for his/her condition, the patient is unlikely to comply, and visa versa.

Another form of appraisal is what I call “People-Appraisals,” which involves measuring the amount of inherent worth and goodness people possess. 

 

People who receive positive appraisals (from themselves and others) are believed to have successful, competent, powerful, valuable, superior, important, precious, worthy, noble, good, moral, virtuous, righteous, pure, respectable inner-selves. They are called successes, winners, stars, or good people, saints, heros, gems, respectable citizens. They develop a favorable opinion about who and what they are; they have a positive self-image and high self-esteem.

 

People who have negative appraisals, on the other hand, are believed to have worthless, useless, unlovable, unworthy, good-for-nothing, flawed, defective, inferior, weak, or wicked, degenerate, rotten, detestable inner-selves. They are called failures, losers, no-bodies, louses, flunkies, derelicts, bums, jerks, turds, shits, bad people, bastards, bitches, skunks, rats, swine, animals, sinners, evildoers, devils, criminals, scum of the earth, dregs of society. They develop an unfavorable opinion about who and what they are; they have a negative self-image and low self-esteem.

 

Just like attributions, appraisals affect one’s emotions and behaviors in powerful ways, including being a foundational component of racial/ethnic prejudice, the “deadly sin” of pride and deservingness, suicide and murder, and more.

 

Irrational beliefs are erroneous assumptions and perceptions, which include exaggerations, overgeneralizations, dogmatic demands, minimizations, personalizations, selective attention, polarized (dichotomous, black & white) thinking, and the elevation of wants/desires into needs.

In my next post, I discuss why people develop persistent maladaptive beliefs .

Beliefs and Physical Health

How can a person’s beliefs affect one’s physical health? A belief, after all, is a type of cognition (thought) … it’s a mental phenomenon. So, why are beliefs important when it comes to the health of one’s body?

The answer lies in the relationship between beliefs, emotions and behaviors. Being a student of cognitive-behavioral and rational-emotive psychotherapy (Aaron Beck and Albert Ellis), I was trained in techniques of belief change designed to facilitate changes in people’s emotional and behavioral responses to situations they find distressing.

People who are stressed or upset may have certain types of erroneous beliefs, which exacerbated their distress levels. These beliefs include distorted/faulty (a) attributions (e.g., assigning the cause of the problem to the wrong person or thing, or believing that one is powerless to do anything about it) and (b) appraisals (e.g., making incorrect judgments about how bad a situation is, or prejudging certain people without adequate evidence). They are often expressed as irrational beliefs that are based on dogmatic demands that certain things shouldn’t happen; that elevate wants and desires into “needs;” that relate to a sense of “deservingness” or “deservingness;” that view things as black & white (e.g., all good or all bad) rather than in shades of grey); and that over-generalize, personalize, etc. When this happens, their negative emotions tend to be exacerbated, causing them to feel dread, stressed-out, hostile, hopeless depression, debilitating guilt or shame, etc. in situations where concern, frustration, annoyance, sadness, regret, etc. would be more appropriate emotions.

Instead of logically evaluating the situation with a calm and rational mind—looking for reasonable solutions and ways to cope—people maintaining these beliefs act in a self-defeating manner by, for example:

• Being overly passive and avoid dealing with problematic situations
• Having very low frustration tolerance and giving up quickly
• Being self-deceptive
• Feeling helplessness and hopeless
• Feeling ashamed and embarrassed
• “Eating themselves up inside” with stress
• Over-reacting by, for example, attacking, blaming and ridiculing
• “Self-medicating” with drugs and alcohol, over-eating, etc. in an attempt to lessen their emotional pain.

All these maladaptive reactions are self-defeating because they typically make things worse instead of better, or do nothing to improve the situation.
So, what does this have to do with physical health? A great deal! This belief-emotion-behavior connection is function of the mind-body connection. For example, many people do not follow their doctor’s advice to change their lifestyle (e.g., to exercise and eat better) because of beliefs that:

• Exaggerate how difficult it is (“I can’t stand doing it…it’s just intolerable!”)
• Minimize their own abilities (“I’m helplessness … it’s hopeless … I just can’t do it!”)
• Focus on how unfair it is (“This shouldn’t be happening to me … I shouldn’t have to change … it’s not fair!”), rather than focusing on what they must do to improve their health
• Blame others for their problems (“It’s my mother’s fault for over-feeding me …”) and seek to punish them (“So I’ll eat myself to death to show her”)
• Result in self-loathing (“I’m worthless and don’t deserve to get healthy”).

People with belief systems such as these are unlikely to be effective in self-management of risk-factors and chronic conditions. They may have low frustration tolerance and motivation, become easily discouraged, “bury their heads in the sand” and deny the problem, become hopelessly depressed and give up, angrily lash out at others trying to help them, and some may actually want to die.

Furthermore, many people living or working in high stress conditions feel strong emotional distress related to similar kinds of beliefs, e.g., they may think “I can’t tolerate this place … They shouldn’t treat me this way … I’m trapped and there’s nothing I can do about it … “). These beliefs are erroneous because:

• They ARE tolerating the situations, even though they are, no doubt, having unpleasant experiences
• Everything that happens has causes; just because someone doesn’t like it, it doesn’t mean those things “shouldn’t” happen
• People are never “trapped” in a bad ob or marriage; there are always alternatives, although they might not be comfortable and pleasant.

Beliefs such as these are likely to exacerbate negative emotions and stress levels, and there is ample research on mind-body medicine that demonstrates a strong connection between stress, negative emotions and illness.

They would all be much better off if they changed their beliefs, so they could think rationally and act responsibly by keeping things in perspective, evaluating options objectively, getting constructive feedback from others, developing a game plan and executing it assertively.

So, can a person’s beliefs affect one’s physical health? You bet!

The topic continues here.

Attending to patients' sense of security

I think one of the most important things to patients/consumers is to feel secure in the belief that they do and will receive the best possible care -- tailored to their particular needs, characteristics, and preferences -- which is delivered in a safe, timely, and efficient (cost-effective) manner.

This is an emotional issue related to having trust and confidence in (a) the knowledge and competence of their providers, (b) the safety of the healthcare delivery system, and (c) the ability for the system to be prepared and respond effectively in emergencies (bioterrorism, pandemics, natural disasters, etc.).

An informed consumer would likely feel quite insecure considering the knowledge gap problem, safety and quality problems, our insane economic and competition models, and the split between sick-care and well-care and between mind and body care, which reflect today’s healthcare environment.

If I’m correct, rallying the public first requires educating them about why feeling insecure about their health and finances is the most rational reaction to the current healthcare system. They then have to debate what changes are necessary to transform the system, which requires further education, along with good collaborative communication for discussing and evaluating ideas. Emerging from this dialogue would be a transformational model detailing the strategies and tactics necessary to make them feel more secure. It will likely include recommendations for policies, practices, models and processes designed to help their providers deliver continually improving care quality and reward them for doing it efficiently and effectively, to monitor populations for outbreaks and have responding to emergencies, as well as ways to make universal coverage a reality.

Supporting First Responders and Hospital Staff in a Disaster

One aspect of the healthcare continuum that should receive more attention is support for first responders and hospital staff in the ER and beyond. In a disaster situation, this involves complex processes in chaotic environments.

We’ve been studying this issue and developing an innovative way to use information technology systems to support all involved personnel by:

• Deploying a "man-down" device that detects when a first responder, such as a firefighter, is not responsive and needs assistance.
• Helping locate and extract victims from buildings in a way that minimizes risk to both the victims and the first responders rescuing them.
• Guiding first responders in selecting appropriate trauma centers by mapping victim needs to facility capability.
• Giving timely feedback about each victim’s health profile and condition to healthcare providers from first encounter through transport to the nearest trauma center equipped to handle the victim.
• Monitoring the availability of resources (including personnel, beds, medications, equipment, etc.) in the treatment facility and informing staff of shortages, so prescribed care is delivered with minimal disruption.
• Alerting clinicians when a patient’s plan-of-care orders are not carried out in a timely manner, in order to help avoid adverse events by speeding plan of care adjustments.

In a disaster, pandemic or terrorist attack, this system supplies ongoing critical feedback that (a) facilitates coordination of care between first responders, trauma center staff and other hospital personnel and (b) enables rapid response when problems arise. It includes new types of software systems that work in tandem with a Personal Health Record (PHR), Electronic Health Record (EMR) and Computer Physician Order Entry (CPOE) applications. It also support the Saint Francis University’s Center of Excellence for Remote and Medically Under-Served Areas (CERMUSA) ambulance of the future, which is capable of providing continuous voice and data transmission through a variety of communications links, and has the ability to transmit and receive live video through a satellite video conferencing system.

I think few would argue that we should be doing everything possible to prepare and support first responders and ER staff for large scale crises.

We have a document that shows how these technologies would be used in a disaster, pandemic, or terrorist attack. For a copy, please contact me (Steve Beller) at sbeller@nhds.com

Health Courts

I recently became aware of a proposal by Common Good to reform the medical practice system with “health courts.” Common Good Chair Philip Howard explains in a recent Wall Street Journal op-ed: “Fear of erratic jury decisions in medical malpractice cases has spawned a culture of fear, causing inefficiencies that infect every level of medicine.” It’s not just the $28 billion in direct malpractice system costs. It’s the billions in defensive medicine and the inefficiency in care when doctors have to document every action to "build a record" in case there's a lawsuit over a bad outcome. We need a reliable medical justice system in which providers don’t need to constantly look over their shoulders and instead do what they think is right. “The only way to overcome this distrust, and all its debilitating errors and waste, is to create a special health court that is trustworthy,” says Howard.

Their proposal is gaining strong momentum.

There’s still many details to be worked out, as well as challenges such as how to evaluate the appropriateness of care delivered in light of the knowledge gap, practice variation problem, and limitations of today’s practice guidelines.

Nevertheless, these folks are on the cutting edge and it’s worthwhile to read what they have to say.

Also, you may be interested in a live webcast on November 5th in Washington, DC entitled “Health Courts, Administrative Compensation & Patient Safety: Research, Policy & Practice,” which is available at http://www.fc-tv.com/webcast/commongood/11-05-07.asx.

Motivating people to change

How is one motivated to change one's behaviors … especially if the change requires physical and/or emotional discomfort or inconvenience; if it is expensive or difficult to achieve; if the person has no desire to change or doubts s/he has the ability to do what’s necessary; if there are incentives or other competing forces not to change; etc.? When it comes to one's health, this question is relevant to any preventive measures and plans of care because it affects patient adherence/compliance, engagement, and activation.

Information alone is typically not enough. Sure, people must know how to change and that requires good, understandable, readily available information. They also need ongoing feedback, i.e., information that enables them to know how well they’re doing and what adjustments they can make to promote their progress.

But all the information in the world won’t foster change unless people are motivated to make the changes, which includes having:

• Confidence in themselves and their healthcare providers/caregivers

• Resilience to persist when things get tough, frustration, disappointing

• Positive/adaptive emotions, such as love, joy, satisfaction, peace of mind, etc.

• Ability to manage negative/maladaptive emotions, such as high levels of anxiety/fear, disgust, sadness/depression, shame, guilt, etc. 

So, when people feel good about changing certain behaviors and feel badly when not making those changes, motivation is maximized and change is most likely to occur.

Well, what has to happen for someone to have (or not to have) such motivating characteristics? I suggest that our beliefs and values about ourselves, others, the world, the future, life-purpose, etc. are the primary triggers of these emotions. These beliefs are affected by our experiences, social surroundings, culture, religions, formal education, economic status, life opportunities, etc. Emotions are also influence by our physical condition and stress, and can be affected by certain medications, what we eat, and environmental factors.

As such, this is a very complex question, whose answer lies in a lifetime of complex mind-body-environment interactions.

It may be that comprehensive biopsychosocial assessments can help us to understand what's affecting a person’s motivation to change and to help us address these influences through some type of focused counseling and personalized social (peer/family) support. Rewards and punishments, may also be useful, as long as the negative underlying psychological/emotional issues are addressed and resolved. And finally, making the change process as simple, safe and affordable as possible would help.

But we have to accept that there's no way to motivate everyone to change, nor does everyone have the physical ability to make certain changes. It may be, for example, that the bodily mechanisms (e.g., metabolism) of some people may make behavioral change (e.g., dieting) largely ineffective even if the person is motivated. Should we expect these people to undergo gastric bypass surgery?

Alternative therapies – Beyond the myths

A special report in the Jan 2007 Consumer Reports on Health, titled “Alternative therapies – Beyond the myths,” had this to say about such therapies (note that herbs and supplements we not included in this report):

• Some people are resistant to hypnosis
• Acupuncture doesn’t hurt
• Most alternative techniques have very little risk because they rarely cause adverse effects when performed properly
• Tai chi can help joints damaged by rheumatoid arthritis
• Unconventional cancer treatment methods, such as mind-body methods, massage therapy, and acupuncture, are generally safe to use in conjunction with standard cancer care treatments
• Cognitive therapy can help prevent relapse of depression
  Spinal manipulation is no better than acupuncture, yoga, mind-body methods, and message for low-back pain
• Mind-body therapies are useful for chronic illness and for reducing the pain and recovery time of surgery
• If a patient’s doctor persistently disparages alternative treatment despite the patient’s efforts to discuss them and despite providing supporting evidence, the patient should consider seeking a different doctor.

See the PBS documentary “The New Medicine” for more about the value of complementary and alternative medicines (CAM).

Being trained as a clinical psychologist specializing in cognitive therapy, and having studied the mind-body connection for many years, I’ve been aware of the value of certain types of CAM therapies. Around 10 years ago, I attempted to promote the idea of “biopsychosocial healthcare” with little success, and I confronted extreme resistance from my mental health colleagues.

Have things changed enough in the past ten years to make CAM and well-care more accepted by mainstream medicine?

Sharing and playing with models: A practical example

In my last post, I discussed the value of sharing and playing with models in loosely connected networks of people. In this post, I’ll give an example of this process.

One type of model is a patient profile report (from an EMR/EHR). These reports may be designed to assist providers in making diagnostic and treatment decisions, as well as tracking treatment progress and outcomes. As such, providers in different healthcare disciplines require different information about their patients. A primary care physician, being a generalist, would benefit from a broad spectrum of information, covering biomedical, psychological, and environmental factors. While all providers would benefit from information about current medical conditions, medications being taken, alergies, vital signs, basic lab results, medical history, etc., a specialist would benefit from a more in-depth sub-set of information related to their area of specialization.

For example, a cardiologist would benefit from data related to heart functioning, such as location of chest pain, ST elevation or depression, Q waves or left bundle branch block, T wave inversion or hyperacusis, CKMB and Troponin T or I levels, and heart imaging studies, etc. A dentist would benefit from information about previous dental work done, dental x-rays, exiting medical conditions affecting teeth and gums, etc. A mental health practitioner would benefit from detailed information about the relationship between a patient’s thoughts, emotions, and behavior, as well as psychosocial data, etc. An integrative/integrated medicine practitioner would benefit from addition information about the mind-body connection, metabolic functioning, etc. And a personal health profile report (from a PHR) would benefit the patient most if it included risk appraisal and self-management information in lay language. And so on … Different models for different folks.

So, what’s the best way to decide what the contents of specific typpe of a health profile report model should be? I suggest I good way to do this is with loosely connected groups of individuals connected through virtual communities who collaborate to develop useful models. They would create, exchange, compare, discuss, debate and evolve the models, as I discussed in the previous post.

As way of example, here’s a link to a holistic (mind-body-environment/biopsychosocial) personal health profile report model I developed. Imagine how much could be accomplished if networks of loosely connected healthcare professionals and consumers were to collaborate around such models by ripping it apart, modifying it, and rebuilding it meet their particular needs.

Playing with models in loosely coupled social networks

In this post, I present two concepts which, when combined, have the potential to transform our healthcare system in profoundly positive ways.

The first is “loosely-coupled social networks” in which people from multiple locations and with different roles, responsibilities and experiences work together to make decisions beyond the knowledge or skills of any individual. Collaboration among people with wide diversities of knowledge, ideas and points of view provides a larger collection of intellectual resource, and offers access to a greater variety of non-redundant information and knowledge on which to base decisions. Compare this to a tightly-coupled network that limits participation to people within the same discipline, department, region, etc. and with people who have access to the same information sources and who share similar experiences. In the loosely-coupled social networks are the greatest opportunities for stimulating multifaceted discussions, out-of-the box thinking, and creative solutions.

The second concept is “sharing & playing with models.” There are many different types of models used in healthcare, including models for defining health problems/diagnoses (e.g., ICD and DSM codes) and treatments (e.g., CPT and ABC codes), for assessing and managing clinical and financial issues/risk (e.g., retrospective encounter and claims data analyses), for evaluating performance (e.g., variance analysis and risk-adjustment), for deciding the interventions to render and procedures to follow (e.g., clinical guidelines and pathways), for testing hypotheses and assumptions, for paying for care (e.g., HSA/HDHP and traditional indemnity insurance), for rationing care (e.g., QALY), and so on. When people share and play with models, they compare models and test them for their ability to reflect reality accurately; they manipulate the models to represent different scenarios, such as “what if” scenarios about the probability of future occurrences; and they discuss the assumptions and results the models produce. When they find models that disagree or generate invalid results, they examine the fundamental assumptions built into the models, looking for logical flaws and inconsistencies, questioning the authors' perception of reality, and debating about the assumptions and practical value of the model. By challenging their assumptions, useful counterintuitive insights often emerge, innovative thought is sparked, new questions arise, relationships are developed, the influence of an organization’s culture and politics are revealed, and compelling and unexpected management issues are discovered. This means that sharing and playing with models is an effective path to innovation, risk management, and value creation.

Conclusion: By encouraging people in loosely coupled social networks to share and play with models, radical innovation is fostered by disrupting of status quo, which enables the models upon which decisions are made to evolve continuously. The bottom line is that connecting diverse groups of people and giving them the ability to model-play would produce continually improving models; and using these models to support decision would result in safer, higher quality, more cost-effective care.

In my next post, I give a practical example of the value of exchanging healthcare models.

Why does American healthcare cost so much?

According to the NY Times Business (October 18, 2006) A Lesson From Europe on Health Care at http://www.nytimes.com/2006/10/1...9e7de8c&ei=5070 and http://economistsview.typepad.com/economistsview/2006/10/reducing_health.html:

“The most obvious difference between [European] health care systems and ours — that their governments provide universal insurance — certainly plays a big role in the cost differences. Look behind the receptionist at your doctor’s office, and you will very likely see a staff of people filing claims to different insurance companies. The insurance companies, meanwhile, employ a small army charged with figuring out how to avoid covering the unhealthy. The administrative costs of our patchwork bureaucracy eat up about 25 percent of health spending… Even in Europe’s single-payer systems, administrative costs account for about 15 percent of health spending, once everything is included, according to the Lewin Group, a consulting firm…. Medicare, which has administrative costs roughly as low as those of other countries’ universal plans. Younger Americans, by contrast, have private insurance, with all its inefficiencies. Yet elderly Americans’ share of national health spending is similar to that of the elderly in other countries, as Arnold Kling, an economist, has noted.”

“So something beside administrative costs is at work here, and it involves a basic cultural difference. Americans seem to be less willing to take no for an answer and more willing to try almost anything, no matter how expensive or how slim the odds, to prolong life. … It has made us obsessed with medical advances and turned this country into the world’s research laboratory. …But much of it is simply wasteful. Expensive procedures …are often no more effective than basic ones, according to research. Yet doctors can keep on getting reimbursed for the expensive ones. ‘Basically, anything that doesn’t kill patients is paid for by Medicare and insurance companies,’ said Jonathan Skinner, a health care researcher at Dartmouth College. …’We Americans tend to treat any rejection of a health claim as some conspiracy by insurance companies, the government, doctors and the pharmaceutical industry. In other countries, people have arrived at a better understanding that health care necessarily involves economic triage …’”

The comment section of the economistsview blog (link above) included a discussion of the higher cost of pharmaceuticals.

At the Economist.com, at www.economist.com/world/displaystory.cfm?story_id=5436968, they explain it this way:

“The Bush team argue that ‘fairer’ tax treatment will slow cost rises and enable more people to get basic insurance. The opposite is more likely. Bigger tax subsidies for health care are, if anything, likely to raise overall spending. Worse, since most tax breaks benefit richer people most, more tax incentives are likely to bring more inequality. They will also reduce tax revenue and worsen the budget mess. Mr Bush's health-care philosophy has a certain political appeal. It suggests incremental change rather than a comprehensive solution. It reinforces existing industry trends. And it promises to be pain-free. Unfortunately, it will not work. The Bush agenda may speed the reform of American health care, but only by hastening the day the current system falls apart.”

Others have argued that direct-to-consumer advertising by pharmaceutical companies also drive up costs because more patients demand from their doctors medications they don’t need. In addition, some make the case that by focusing costs are increased because our healthcare system rewards mediocrity through a “fix it and pay for it again when it breaks” process, rather than focusing on wellness/prevention and rewarding cost-effective sick-care.

In summary, the reasons given for the exceptionally expensive cost of healthcare in the US include: Waste, administrative overhead, Americans refusal to accept economic triage (take no for an answer), taking on the role of the world’s research laboratory, our attitude toward end-of-life spending, cost of prescriptions drugs, HSA tax-based incentives, direct-to-consumer advertising, and a system that rewards mediocrity rather than cost-effective care.

What do you think?

Is the "Moral Hazard" idea a myth?

I came across an interesting article about the way insurance is viewed, called The Moral-Hazard Myth at http://www.newyorker.com/fact/content/articles/050829fa_fact

The moral hazard idea — which states that insurance encourages risky and wasteful behavior by the insured person since the cost of consumption is paid by someone else — is considered a myth by some when applied to healthcare and is not a reason to assume Health Saving Accounts/High Deductible Helath Plans (HSA/HDHPs) or other methods of cost-shifting will reduce utilization and control costs by making people pay more out of their own pocket for care. They claim this is because, unlike other consumer goods, insured people don’t go to healthcare providers just because it’s free; in fact, most people don’t like to go to the doctor or take medications. Instead, what is most likely to happen when more costs are shifted to consumers is that they will forego routine preventive care and delay getting care for their health conditions. They way this will actually end up increasing overall costs because people will be sicker when finally going for treatment they needed all along. In addition, HSA/HDHPs, etc. replace the “social insurance” model of coverage, which equalizes the financial risk between the healthy and sick by having the well help pay for the care of ill people, with an actuarial model in which older and sicker people pay much higher premiums than the young and healthy who can accept bare bones policies.

What do you think?

Do we need profound changes now?

On another blog, I’ve been arguing about the need for profound changes in our healthcare system, and to make these changes sooner than later. I proposed is a multifaceted, consumer/patient/community-centered, knowledge-based, collaborative wellness strategy (defined in our WellnessWiki), which focuses on changing the current policies, processes, and practices that reward mediocrity and punish efficiency. This strategy takes a comprehensive approach that would implement a number of tactics that foster continuous improvements in care safety, effectiveness and efficiency by dramatically increasing our clinical knowledge and ability to use that knowledge with the ultimate goal of ensuring every person gets the precise sick-care and well-care needed when it is needed -- nothing more & nothing less -- and to make sure that care is delivered competently and cost-effectively. It is based on an attitude of forever seeking perfection. Executing this strategy would require spending money and time on a transformational process that (a) constrains wasteful, fraudulent and error-prone aspects of our current healthcare system and (b) expands aspects that generate high value, i.e., promotes excellent outcomes with the least necessary utilization of resources.

The main rebuttal to my proposed strategy is that there is no need for profound changes since our healthcare system is fine the way it is -- there is not healthcare crisis, it’s largely media hype. We should, therefore, let things change incrementally (step-by-step manner) as they have in the past. After all, we’ve made great strides in our healthcare technologies, medicines, and procedures over the years and will continue to do so if we just let market forces do their thing. And on top of that, our country doesn’t have the money to drive profound change with comprehensive strategies even if we wanted to do it. So, instead of discussing comprehensive strategies, we should limit our focus to a few tactics aimed primarily at controlling costs without spending a lot of money in the process. In terms of dealing with safety problems, it was suggested that we settle for now on getting rid of dangerous providers.

I will briefly discuss how I responded to each of these and look forward to you comments.

The vast majority of healthcare providers are intelligent and compassionate people who work very hard and do the best they can in a broken system that reward mediocrity and waste. Dedicated researchers have made wonderful breakthroughs in medicine, genetics, and medical devices that help keep us alive longer than ever with an improved quality of life. And health IT companies are developing ever better tools. Nevertheless, there is a healthcare crisis as discussed here and here.

While I agreed that changes should be done incrementally since we can’t do it all at one time, and while I agreed that we’ve made great advances over the centuries, I argued that the incremental changes should be accomplished whenever possible with leaps, not baby steps. The first leap would be to develop a “big picture view” of all the complex interacting problems with our current system. The second leap would be to use this broad & deep understanding to define and endorse a comprehensive strategy detailing all the changes necessary to solve the healthcare crisis in ways that bring the most benefit to the most people, including universal coverage and continuous quality improvement. The third leap would be to prioritize the tactics from most to least important and likely to succeed. The forth leap would be implement those tactics. And the fifth leap would be to learn from our successes and failures in a knowledge feedback-loop process that continually improves the strategy and tactics.

One reason for leaping ahead with a sense of urgency, imo, is that failure to do so will just prolong and exacerbate our problems by fostering inertia and complacency. I say this because our country has a tendency to seek superficial, short-sighted, failure-prone solutions designed to maintain much of the status quo; we tend to shy away from profound changes that “rock the boat.” Secondly, if we have the technical ability to make profound improvements in care safety, effectiveness and efficiency – which I claim we do – then why wait? Is it because we lack the will? Lack the money? Lack the leadership? Are afraid? All these things? Probably. So, shouldn’t we be focusing on ways to overcome these constraints, rather than giving into them without a fight?

Let’s assume for a moment that we have the will, courage, resources, and leadership to realize profound change. What might we focus on first so we can deal with the healthcare crisis in “bite sized pieces” rather than all at once?

Well, a majority of healthcare spending in the U.S. has been attributed to people with chronic (lifelong) conditions that can be especially difficult and expensive to treat, especially since patients do not always comply with the medical regimens, and because they may have multiple comorbidities for which evidence-based guidelines don’t exist, and there are difficulties coordinating care among many different providers working with the same patient. What should be done?

I suggested that one key factor common to dealing with all this is knowledge. Treating chronic and complex conditions safely, effectively and efficiently requires that we know a great deal about such things as: (a) patients’ problems, strengths, weaknesses over extended time periods, including physical and psychological signs & symptoms, genetic markers, attitudes and emotions, social support networks, etc.; (b) patients’ preferences (e.g., regarding quality of life issues as related to the consequence of treatments); (c) appropriate evidence-based guidelines and how to implement them; (d) self-care methods and motivators; (e) patients’ medical history; (f) what all the providers treatment a patient are doing so care can be coordinated across the entire healthcare continuum; (g) the effectiveness of care delivered through ongoing feedback; (i) whether medications prescribed are contraindicated (e.g., are likely to cause unacceptable side effects or and adverse event by interacting with other meds); (j) providers most qualified to deliver the care; etc.

Obtaining and using this knowledge effectively may require: (a) a commitment to ongoing clinical research; (b) development, evolution, and dissemination of evidence-based guidelines (including outcomes studies and consensus conferences); (c) cooperation and collaboration among healthcare professionals; (d) case management; (e) information exchange technologies (including interoperable EHR/EMRs); (f) next-generation personal health records (PHRs) that give patients ongoing feedback and reminders; (g) clinical decision support technologies (including diagnostic aids); (h) clinical guideline and outcomes research technologies; (i) patient education technologies; (j) methods for fostering patient compliance; (k) provision of mind-body medicine (e.g., http://www.thenewmedicine.org/); (l) transparency tools; (m) greater understanding of complementary and alternative interventions; (n) patient advocacy; and more. An enhanced disease management program would offer some this (see http://curinghealthcare.blogspot...-and-what.html/).

This is a comprehensive solution of profound changes. But not everything needs to be done at once, and not every patient needs it all. The objective would be to make it all available as soon as possible, so every patient could get what they need when they need it.

Some of the most pressing things to do, imo, are to administer comprehensive biopsychosocial diagnostic assessments, use and evolve existing evidence-based guidelines and develop new ones that address multiple comorbidities, enable better patient data sharing, provide ongoing feedback to patients about their health status and maintenance, learn how to motivate patients to comply with the medical regimens, develop and use effective decision-support tools, implement patient safety processes, supplement sick-care with well-care, and empower consumers to select the providers and health plans best suited to their needs.

I don’t see this as being biting off more than we can chew, but I do think it requires profound changes. Can our country afford to pay for these profound changes? Should we even bother discussing how to do it? Are there easier and cheaper solutions worth consideration? What do you think?

How to get the public involved in transforming our healthcare system

I've been having an interesting conversation with folks on two other blogs about how to get the public involved in transforming our healthcare system: One is on The Health Care Blog(toward the bottom of the comments section) and the other is on the Healthvoices.

Issues we've discussed include:

• How to define a sensible rallying point -- something the public can understand and support, and something that is powerful enough to withstand the push-back from the mighty self-interests gaining from the status quo who will resist such change.
• What must be done for patients/consumers to feel confident and secure in the belief that they do/will receive the best possible care when sick -- tailored to their particular needs, characteristics, and preferences -- which is delivered in a safe, timely, and efficient (cost-effective) manner.
• How to help the public learn about and understand the serious problems with our broken healthcare system and collaborate to come up with possible solutions.
• How to empower patients/consumers to have an informed and meaningful say in their own health and healthcare.

Feel free to share your thoughts.