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Connected Health and Meaningful Use

April 26, 2010

My colleague Tom Morrison, Founder of Navinet,  shared an interesting analysis with me the other day pertaining to physician compliance to demonstrate meaningful use.  In essence, he noted that about 41% of phase I criteria will have heavy reliance on patient behaviors, including medication adherence, adherence to care plan, trips to testing facilities and others.  I think it is fascinating that we are about to embark on an unprecented effort to accelerate the adoption of electronic health records by health care professionals in hopes of improving the quality of health care for our citizens, but there has been no attention paid to motivating the citizen or holding him or her accountable.  Stated succinctly by another physician friend of mine, ‘When are we going to have a pay-for-performance program for our patients?’

This opens up any number of intersting avenues to mull and debate.  One more time, lets run through the high level view of how health care works.  Unfortunately, at some point you are bound to get sick. Once you get sick you need care. Two things are important to note here:  once you get sick you are a victim – sickness is a random, bad-luck occurance. This is the reason we insure ourselves against sickness. The second is that sickness is far to complex for you to manage on your own. You need a relationship with an expert, an oracle – we call these people doctors (from the latin doctus– a teacher or learned one). We expect them to almost magically have access to millions of facts about our particular situation, make flawless decisions on our behalf, and most importantly carry the burden of getting us well again. After all, when you are a sick victim, you want someone to care for you and do the heavy lifting required to bring you back to health.

Of course, the medical profession has done its share of things to perpetuate this stereotype.  As you read this tongue-in-cheek description of what a doctor is supposed to do, wouldn’t you want that job? And as a recipient of such magic, wouldn’t you value the doctor’s input highly (i.e. make sure the doctor is well compensated)?

This model of thinking, while arguably over simplified and outdated, works reasonably well for those health issues that are truly accidents or the result of bad luck (e.g. the wrong genetics).  Think about the victim of a random shooting or the child born with a congenital heart defect.

So far, so good.

But what about chronic illness? Varying estimates of the burden of chronic illness all describe a Pareto principle ‘on steroids’.  I like the one that says 7% of individuals consume 70% of our health care costs as a result of caring for 6 chronic illnesses (coronary disease, CHF, asthma, COPD, kidney failure, and diabetes).  For the most part, these are illnesses that occur because of sustained unhealthy behaviors over time.  Another way to think of it; 50% of health care costs link back to unhealthy behaviors. The model of patient as victim, abdicating all decision making to the oracle does not work well for dealing with illness that is the result of unhealthy behavior.

However, our libertarian roots, combined with our mechanism for electing our government representatives make it almost impossible for us as a society to hold individuals accountable for their unhealthy behaviors.  Accountability can be viewed as reining in freedom and no politician wants to remind their constituents that individuals are in control of unhealthy behaviors. Its much easier to be in favor of programs that guarantee care to victims.

I’m curious if you have ideas on how to deal with this conundrum.  I have some and will detail them more in my next post.

13 Comments leave one →
  1. April 26, 2010 6:25 pm

    I take issue with the idea that asthma is the result of sustained unhealthy behaviors over time. The other health problems do have behavioral factors, so I can see why they are included.

    But I didn’t give myself asthma.

    It’s not my fault Advair came onto the market too late to save me from scarring and chronic prednisone use.

    My concern with posts like this is we’re going to go on a witch hunt when, at least in my situation, at least 50% (if not more) of my health issues can be related directly back to prednisone. I didn’t make myself fat; medicine did both in terms of medication and doctors who, to this day, persist in failing to understand what a high carb low fat diet does to someone with my medical history.

    Medicine still has a loooooong way to go before we start pointing fingers at patients. A really long way.

    When science has everything figured out, then we can start holding patients accountable, but I would argue we don’t know what we don’t know.

    We can displace blame all we like to make ourselves feel better, but it doesn’t fix the problem. I recently had a physician who, unable to find anything overtly wrong with my diet, nitpicked on the fact I use ground turkey. His premise? It was high in fat and would make me fat. He didn’t even know it was 97% lean, but being fat MUST be a personal responsibility issue? Right? Anything else is unacceptable. So I HAVE to be doing something wrong.

    I’m sure he felt better, having ‘properly’ blamed me for my problems, but I didn’t get any actual help. In my opinion, your post enables this kind of dynamic and isn’t really offering a solution.

    M

    • April 27, 2010 12:04 pm

      Points well taken. It is a mistake to lump asthma in with other chronic illnesses, from this perspective. Too often we think of chronic obstructive lung disease and its relationship to smoking, but again, that is no excuse for lumping in asthma. I appreciate the feedback and will take care to be more sensitive to this matter in the future.

  2. April 27, 2010 1:14 pm

    I cannot speak as personally as POP above (thank the Lord) but could give you three instances, off the top of my head, of relatives and friends whose chronic conditions had nothing to do with lifestyle but were due to damage from (separately) infection, a congenital condition aggravated by a minor accident and drug interactions or side effects. My brother (psychiatrist) spends a fair amount of his time on the medical side sorting out his (older) patients meds (if he can find them out from them–privacy, y’know) and making sure that what he is prescribing has a fairly low chance of adverse interactions (there is never NO chance, as he’s reminded me.) Also as you know psych meds have a host of side effects that often include weight gain–which aggravates other problems. So it is not as black and white as cast in para.1. Appreciate your thoughts on the subject and look forward to more.

  3. April 27, 2010 4:27 pm

    Frustration leads to wanting to assign blame and I quite understand the comments made. However, this aproach will not result in the outcomes we seek. How many years has it taken for society to recognize smoking dangers and accept limitations on their smoking habits?

    Many companies are now making efforts to encourage healthy lifestyles and rewarding or making it more costly for those who do not enter their programs. While it will take some years to accomplish these ends, I have to believe this will be the pathway to success even though we should never expect 100% compliance. And as someone noted, sometimes it’s luck of the draw; not all lung cancer is smoking related etc.

    • April 27, 2010 4:37 pm

      We think that achieving success through employers is logical, too.

  4. Jerry Bello permalink
    April 28, 2010 9:02 pm

    I read with great interest the issues raised in Dr. Kvedar’s April 26 posting. I also read the first three responses from POP, D. Cusano and J. Hutchinson. I am not a physician but I do understand that the cause of certain illnesses cannot be attributed to “unhealthy behaviors”. However, it seems the criticisms raised by the first two of those who posted responses from POP and D. Caruso arise solely from their own or their friends’ personal experiences and do not address those illnesses that are attributed to unhealthy behaviors.

    I was, at the age of 62, diagnosed with type 2 diabetes in October of 2007. It should be noted that my father was diagnosed with diabetes at about the same age. Shortly after this diagnosis, I was fortunate enough to be placed in a “diabetes group” which educated us regarding the nature of the disease and those “behaviors” which would exacerbate it. At the time, I was about thirty pounds overweight, but most of my fellow group members were 60 to 150 pounds overweight and most of them had been diagnosed with diabetes a year or two earlier.

    As the group progressed, it became apparent that only one other person and I would seek to alter our “unhealthy behaviors”, most of which consisted of a lasck of exercise and eating the wrong type and quantity of foods which produced high sugar levels. The other person (by virtue of his intellect) and I (by virtue of the fact that I am a stubborn Italian) lost twenty-five pounds or so as a result of changing our eating habits and diet. We followed the suggestions/directives of our group leaders, a diabetes nurse and nutritionist. As a result of this, my A1C readings decreased to acceptable levels and other readings which previously read outside acceptable parameters (e.g. triglycerides, liver, etc.) fell into the proper ranges.

    Other members of our group did not really change their “unhealthy behaviors” (as reported by them) due to a lack of willpower and, in many cases, an incomprehensible belief that a “magic drug” would be discovered that would allow them to eat anything they wanted, engage in no exercise and be cured of their diabetes. These beliefs seemed impregnable as the nurse, dietician and physicians who made guest appearances to our group explained that such a remedy was not realistic and that continued denial would lead to irreparable damage to their bodies. Based upon this and many other experiences, it seems to me that there are a significant number of people who fail to accept personal responsibility for their health.

    I believe that Dr. Kvedar had these types of incomprehensible “unhealthy behaviors” in mind as he opined on this subject. The net that he initially cast may have been too wide, but rest assured, there is much truth in what he said.

    • April 28, 2010 9:17 pm

      can’t do any better than to publish this from the hear testimonial

  5. April 28, 2010 9:41 pm

    @ Jerry– I agree and disagree with you 🙂

    1. With regards to the inertia you observed, I am of the belief that we need to do more at the High School health class level. People are not educated in meaningful ways about health. It wasn’t until I went back as an adult and took Biochem, A&P, and Patho that things clicked for me. Most people aren’t that driven to work that hard at their health, so we need to do a better job of meeting them where they are at.

    2.The thing I dislike about the personal responsibility argument is it ignores the enormous damage substances like high fructose corn syrup (HCFS) do to our bodies. HFCS is derived from corn, which receives large subsidies from the US Government. It is ubiquitous because it is cheap, it is cheap because it is subsidized–HCFS laces almost every food we eat and it has been shown to produce more weight gain than regular sugar.( http://www.princeton.edu/main/news/archive/S26/91/22K07/). Our own government contributes to the problem in a material way.

    Sure we can rant and rave about the people who are too “lazy” to do what’s right, but why not be sure we’re blaming _all_ the people/institutions who are guilty of perpetuating ill health in our country? There’s more than one culprit here, but we keep trying to hang the individual and ignore the society (Big Business anyone? Food lobby?) that enabled the problem in the first place.

    And the ADA diet is a crock–which is what most diabetics are ‘educated’ to follow. The amount of carbs in that diet would make me a diabetic for sure. But this is the ‘golden rule’ for diabetics all over and it is slowly killing them whether they know it or not. There are some people who speak out against the ADA, but the ADA is so entrenched in their authority, it’s difficult to make changes to the paradigm.

    Real change means moving past personal responsibility and toward global solutions that attack the multi-factorial root causes of the problem.

    We have to stop making it a blame game if we truly want to effect positive change. It’s not about laziness or bad habits, it’s about giving people the tools and support they truly need (you were lucky to get it in one class, some people need more and there is nothing wrong with that). Demanding change from our government. Pushing science to do better.

    The individual is not the only one with responsibility here. The individual is not the only one failing to do their share. Far from it in fact.

    M

    • Jerry Bello permalink
      April 29, 2010 3:06 pm

      Dear POP,

      I agree with you that much can and should be done to educate our youth regarding issues that affect their health. But consider this: if these students or others who receive the education do not take personal responsibility for the implementation of such education, how will such initiatives be of any value?

      You went on to state that “Most people aren’t that driven to work that hard at their health…”. Think about that please. Replace the word “health” with “job” or “education”. Would you be so quick to absolve them of their responsibilities in these areas of their lives? Would you be so quick to excuse them if they didn’t work that hard for their child who was diagnosed with a serious disease?

      I also agree that the government should prohibit certain foods or food additives that have proven to be injurious to our health, but I think we all know that any such measure would be met with stiff resistance from our fiercely independent friends and neighbors who object to any government intrusion on their lives.

      I strongly disagree with your statement that “Real change means moving past personal responsibility …”. While I do understand that there are certain illnesses or diseases that may not be improved or cured by personal action, I simply do not understand why it seems to be sinful or insensitive to advocate for the assumption of personal responsibility. Don’t we take personal responsibility for the work we do, the way we raise our children and the manner in which we conduct our lives in so many other ways?

      The real problem with your assertion that “Real change means moving past personal responsibility …” is that it provides a convenient escape for those people who truly aren’t that driven to work that hard at their health, but should be.

      • April 29, 2010 6:13 pm

        Good point. Let me clarify… personal responsibility is a piece of the puzzle and if we focus on it alone,we’ll never get the whole picture. That was my point. We need a broad spectrum approach and must acknowledge the other pieces of the puzzle so we don’t forget they exist.

        Poop rolls down hill. Who has the least power here? The individual. That’s how life works. The weak suffer the agenda of the strong. In this case, I think we need to push uphill. It can be done, but not if we’re too busy vilifying the individual.

        Clear vision is needed, not stereotypical tropes. We’ve been telling people to lose weight and eat less for a long time. It’s not working. Time to do something else.

        I wonder what the result would be if doctors stopped advising patients to lose weight, but instead asked them to buy fresh, local food and boycott High Fructose Corn Syrup and BPA (which appears now to be linked to obesity)? What if they passed out prescriptions for sites like Kayln’s Kitchen and prescribed those recipes? How long before all the individuals would hit critical mass? Not long I don’t think.

        I bet it would be faster than asking everyone to lose 50 lbs.

        M

  6. Chris Wigley permalink
    May 1, 2010 4:12 pm

    It also needs to be borne in mind that a lot of these “unhealthy behaviors” are in fact addictions and addictions in themselves are (and should be) considered diseases. I started smoking when it was not considered by society to be bad or dangerous, and I have worked in many places where atmospheric conditions are very poor (not always my choice of where I worked – I had to work to put ‘bread’ on my family’s table). I quit smoking ten years ago and now try (fairly successfully) to avoid unhealthy behaviors. However I now have severe COPD – we also know now that this would likely NOT have happened if I had a different genetic makeup.

    Treat those addictions as diseases and treat the chronically ill – there, but for the grace of God, you might be.

  7. Jerry Bello permalink
    May 2, 2010 1:10 pm

    Dear POP and Chris,

    This will be my final blog entry on this subject, so I want to set my record straight. I do understand that some diseases are caused by genetic endowment (as is most likely the case in my situation) and that there are numerous unhealthy additives in our processed foods. I also understand that some of us suffer from addictions that constitute or contribute to “unhealthy behaviors” and that such people face a very difficult uphill battle to overcome the addictions.

    But in each of these circumstances, it is the patient who has the ultimate responsibility for combating those behaviors that contribute to his/her health issue. The doctors, nurses, dietitians and other health professionals who provide diagnosis, counseling, education, and so on can perform their jobs well, but it is the patient who is the final decision-maker with respect to what foods they consume (in our home we avoid anything with HFC in it), whether or not they smoke, whether or not they exercise, and so on.

    So, on this point I disagree wholeheartedly with POP when he states the “Who has the least power here? The individual..” In fact, I believe that the individual has the most power over his or her health.

  8. Tom Morrison permalink
    May 17, 2010 5:39 pm

    There are two very different aspects to this conversation. First is the social and the public policy decisions that address personal responsibility for managing chronic conditions. Clearly, a very loaded and complex set of issues where there is unlikely to be any single approach that can address the variability inherent in personal behavior change and motivation.

    The second aspect is the HIT infrastructure itself. Recognizing that 41% of the meaningful use metrics will require patient behavior change to realize improvements in outcomes, is a critical factor in the design of an effective HIT infrastructure. Our evolving HIT infrastructure must be able to automate patient behavior change programs directly with a wide variety of capabilities that can meet the needs of individuals with chronic conditions. The current HIT focus on EMR adoption and clinical data exchange, while useful for addressing many meaningful use quality metrics, will have a very limited ability to address patient behavior change programs. Behavior change is driven by support programs not by data in an EMR.

    There are already many proven approaches to identify people with chronic conditions that can be used to begin implementing and automating behavior change programs. We need to develop a web-like HIT infrastructure capability that can support programs to help patients’ manage their conditions using tools like patient education, physician coaching, home monitoring, social networking, financial incentives for patients or their providers, etc. Experimentation in behavior change programs will be key to finding what does and doesn’t work for specific patients. Let’s get started now and make sure we implement the full range of HIT infrastructure capabilities necessary to improve quality and deliver the necessary cost reduction.

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