Duke Personalized Health Blog

“Father of Personalized Medicine” Dr. Ralph Snyderman Speaks to Duke Pre-Medical Students about the Past, Present & Future of Healthcare

It is a rare opportunity for an aspiring young physician to meet someone who has altered the course of medical history. Recently, 20 Duke undergraduates in Dr. Madan Kwatra’s course Pharmacogenomics had the opportunity to do just that. Kwatra, an associate professor of pharmacology and cancer biology, directs the Glioblastoma Drug Discovery Group at Duke.

In his course, he introduces students, many of whom intend to apply to medical school, to the emerging field of pharmacogenomics through case studies from his research on targeted therapies and guest presentations offered by esteemed physicians and researchers in the field.

An Introduction to Medical History

In his recent lecture, Dr. Ralph Snyderman, director of the Duke Center for Personalized Medicine, provided the students with crucial insight about how the study of pharmacogenomics, or how a person’s specific genome affects their response to drugs, is being leveraged to change the future of healthcare through the application of personalized medicine. He started by contextualizing recent discoveries within a brief overview of medical history, beginning with the prevailing pre-1900s “humoral hypothesis.” He commented on the early work of Ignaz Semmelweis who observed an outbreak of “childbirth fever” at his maternity clinic in Austria and noticed a higher rate of mortality among women who delivered in the hospital as compared to those who delivered at home. Microbiologists would later confirm that the disease was associated with microbial agents spread by the hands of physicians who had autopsied patients with the condition. Later, Koch offered key criteria for determining the causative agent of a disease and the field of germ theory, along with chemistry, physiology, pathology and physics, flourished, allowing for the identification of novel therapeutic approaches to many communicable conditions.

Dr. Snyderman described this as the first major transformation in healthcare – a scientific revolution that paved the way for the practice of modern evidence-based medicine. Snyderman commented that most physicians are trained in what he calls a reductionist approach to care, in which the role of the provider is to identify the underlying cause of an existing disease and to fix it.

“Predict it, Personalize it, Understand it”

However, Dr. Snyderman believes that we are in the early stages of the second great transformation in healthcare. Rather than reacting to the presence of disease, using new pharmacogenomic technologies, health care professionals are, as he said, aiming to: “predict [health], personalize it, and understand it.” Physicians working within the fields of pharmacogenomics and personalized medicine conceptualize disease as a dynamic process that could be detected and treated at any time point during its course of development.

Genomics, the study of the genome through next generation DNA sequencing techniques, as well as multi-omics, the study of the transcriptome, epigenome, and microbiome, give physicians important clues about an individual’s disease risk as compared to a pre- determined baseline risk. Dr. Snyderman imagines a future where individuals are empowered to make decisions about their heath alongside their provider using a variety of personal data sources. The students who eagerly listened to his lecture imagined the possibility of their own roles within this rapidly evolving field.

Ralph Snyderman is Chancellor Emeritus at Duke University, James B. Duke Professor of Medicine, and director of the Duke Center for Personalized Health Care. He served as Chancellor for Health Affairs and Dean of the School of Medicine from 1989 to July 2004.

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The Importance of Physician-Patient Relationships Communication and Trust in Health Care

“Medicine is an art whose magic and creative ability have long been recognized as residing in the interpersonal aspects of patient-physician relationship.”
                                                Hall et al.,1981

The physician-patient relationship is a foundation of clinical care. Physician-patient relationships can have profound positive and negative implications on clinical care. Ultimately, the overarching goal of the physician-patient relationship is to improve patient health outcomes and their medical care. Stronger physician-patient relationships are correlated with improved patient outcomes. As the relationship between physicians and patients becomes more important, it is essential to understand the factors that influence this relationship.

Frameworks for Physician-Patient Relationships

Throughout history there has been much debate regarding the “ideal” physician-patient relationship. In 1992, Ezekiel and Linda Emanuel proposed four models for the physician-patient relationship: the paternalistic model, the interpretive model, the deliberative model, and the informative model. (Fig. 1) These models differ based on their understanding of four key principles: the goals of physician-patient interactions, the physician’s obligations, the role of patient values, and the concept of patient autonomy.

Fig. 1 Models of the Physician-Patient Relationship

Factors that Influence the Physician-Patient Relationship

Although there are several factors that influence physician-patient relationships, the dynamic shared and sense of trust between physicians and patients are two critical components to their overall relationship.

Dynamic Between Physicians and Patients

The dynamic between physicians and patients refers to the communication patterns and the extent to which decision making is shared between both parties. Effective physician-patient communication is an integral part of clinical practice and serves as the keystone of physician-patient relationships. Studies have shown the approach taken by physicians to communicate information is equally important as the actual information that is being communicated. This type of communication incorporates both verbal and nonverbal interactionsbetween physicians and patients.iEffective communication has been shown to influence a wide array of outcomesincluding: emotional health, symptoms resolution, function, pain control, and physiologic measures such as blood pressure levels.iiWhen miscommunication occurs, it can have severe negative implications in clinical caresuch as impeding patient understanding, expectations of treatment, treatment planning, decreasing patient satisfaction of medical care, and reducing levels of patient hopefulness.iii

In addition to having effective communication, it is important that medical decisions stem from a collaborative process between physicians and patients. Decision makingis a process in which patients should be involved from the very beginning, and the result is a decision which reflects the physician’s medical knowledge as well as the patient’s values and beliefs.ivCollaborative communication and decision making have been correlated with greater patient satisfaction and loyalty. Working from a collaborative framework along with effective physician-patient communication can also strengthen a physician’s ability to utilize a personalized health care model through patientempowerment.v

Trust Between Physician and Patients

 “….‘patients must be able to trust doctors with their lives and health,’ and that maintaining trust is one core guidance for physicians…”
Birkhäuer et al, 2017

Trust is a fundamental characteristic of the physician-patient relationship. Patients must trust that their physicians will work in their best interests to achieve optimal health outcomes. Patients’ trust in their physicians has been demonstrated to be more important than treatment satisfactionin predictions of patient adherence to recommendations and their overall satisfaction with care.iStudies have also shown that trust is additionally a strong predictor of a patient continuing with their provider.iiTrust extends to many different aspects of the physician-relationships including, but not limited to: physicians’ willingness to listen to patients, patients’ believing that physicians value patient autonomy and ability to make informed decisions, and patients feeling comfortable enough to express and engage in dialogue related to their health concerns.

Physician-Patient Relationships Influence on the Future of Healthcare

The idea of viewing physician-patient relationships as a core element of quality health care is not something new, however understanding and assessing the factors that influence this relationship is just beginning. Effective physician-patient communication has been shown to positively influence health outcomes by increasing patient satisfaction, leading to greater patient understanding of health problems and treatments available, contributing to better adherence to treatment plans, and providing support and reassurance to patients.  Collaborative decision making enables physicians and patients to work as partners in order to achieve a mutual health goal. Trust within all areas of the physician-patient relationship is a critical factor that influences communication between both parties. As health care transforms into a more personalized and patient-centered model, the physician-patient relationship will significantly shape health outcomes. The personalized health care model encourages collaboration among physicians and patients in order to create shared health goals and the cultivation of a health plan to address identified problems. By understanding the factors that influence patient-physician relationships, in the future, health care providers will be able to address some of the barriers that prevent the adoption of more personalized approaches to health care.

 

Works Citied:

iLee, S. J., Back, A. L., Block, S. D., & Stewart, S. K. (2002, January 1). Enhancing physician-patient communication. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/12446437
iiStewart, M. A. (1995, May 01). Effective physician patient communication and health outcomes: A review. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/7728691
iiiHa, J. F., & Longnecker, N. (2010). Doctor-patient communication: a review. The Ochsner journal, 10(1), 38-43.
ivLee, S. J. (2002). Enhancing Physician-Patient Communication. Hematology,2002(1), 464-483. doi:10.1182/asheducation-2002.1.464
vStrategies for integrating personalized medicine into healthcare practice. (n.d.). Retrieved from https://www.futuremedicine.com/doi/full/10.2217/pme-2016-0064</font size=”-3″>

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Role of mHealth in PHC

createhealth.com. (2015, August 1). iOS Medical Apps on an iPhone 6 [Photograph]. Retrieved from https://www.flickr.com/photos/134647712@N07/20008817459

What is mHealth?
Mobile health, or “mHealth,” is used to describe any medical or public health practice supported by a mobile device2. A broad category, mHealth has traditionally encompassed mobile phones, personal digital assistants, and other wireless devices, relying on functionalities such as text messaging, GPS, data telecommunications systems, and Bluetooth technology2.

In the United States, mHealth is most recognizable in the form of applications designed for use on a smartphone. In 2018, almost 70% of Americans own smartphones – a number which is only projected to grow over the coming decade3. mHealth apps are becoming increasingly popular, representing over 95,000 of all apps available in the iTunes app store and over 105,000 of all apps available in the Google Play store, or about 3% of total applications4. A recent cross-sectional survey of smartphone owners across the U.S. found that over half reported using at least one health app, and of those, the majority used an mHealth app at least once per day. Tracking of nutrition and physical activity were the most common uses reported5,6, followed by facilitating communication with the medical system (e.g. appointment and medication tracking) and monitoring of medical conditions5.

Is mHealth effective?
Although the field of mHealth is still young, research has shown that health applications are already making a difference. Among the elderly, mHealth has been shown to improve self-efficacy, medication adherence, and the quality of health behaviors such as sleep, exercise, and diet7, making it an effective tool for disease prevention and management. A recent study using data from the National Cancer Institute found that users of health apps were significantly more likely to meet physical activity recommendations6, while another study found that mHealth apps were effective in increasing consumption of healthy foods8.

So what features make mHealth effective? Ease of use is important8. Taking too long to enter data and having an interface that is overly complicated are frequently cited reasons for discontinuance of app usage5. Equally important is the provision of positive feedback; apps that provide reinforcement and encouragement are more likely to create behavior change8. Findings are mixed on apps that include a social media, or “gamification” feature – although engaging with friends and family increases accountability and self-efficacy8, it also leads to concerns about the privacy of data among users5.

How can mHealth help personalize health care?
Provider coaching is associated with positive health behavior change8, but a high level of personalization is hard to deliver to a large volume of patients under tight time constraints. In this capacity, mHealth has the potential to connect patients and providers and deliver a level of personalization that would be otherwise impossible. Not only do health apps give providers access to a wealth of data about health metrics, they provide an opportunity for a provider to support and engage in a patient’s goals9.

Apps that are personalized to patients’ lifestyles or include a coaching element have been found to be most effective in changing health behaviors10. In trials at the University of California, San Francisco and Massachusetts General, researchers found that a combination of traditional primary care and additional coaching through an mHealth app led to more significant reductions in weight and obesity-related risk factors among pediatric patients compared to patients who used the app alone8. Apps aren’t limited to the patient, however – researchers at the Duke Clinical Research Institute recently created an app for providers that analyzes data from electronic health records to determine a patient’s risk for heart disease or stroke, making it faster and easier for providers to care for their patients11. While many mHealth apps were originally intended for patient use in private settings, apps developed for clinical settings are a high-growth subset of mHealth and an important area of future expansion.

Recommendations to providers and patients
mHealth technology is already transforming clinical workflows, a trend which will likely continue. In the personalized health planning model developed by the Duke Center for Personalized Health Care (Figure 1), after initial contact has been established between a patient and a provider, the patient completes an assessment of their current health status and risk behaviors in addition to a clinical assessment of health status and therapeutic needs. At these stages, a patient could benefit from a health application that allows for behavior tracking and goal identification, while apps intended for clinical settings could be employed to ensure efficient and thorough diagnostics. After completing their individual assessments, patients and providers work together to create shared health goals and a therapeutic plan called a personal health plan.

In addition to applying mHealth to track health behaviors and progress towards goals, providers can leverage mHealth to coach patients and reinforce the health behaviors identified in the personal health plan. In the care coordination and follow-up stage, the data tracking features of mHealth can be useful. Providers and patients would be able to concretely track progress towards goals, identify pitfalls, and easily communicate using mobile technology.

Figure 1
Duke Center for Personalized Health Care

Currently, a gap exists between usage of mHealth apps outside and within the clinical context. Although more Americans than ever are using some form of mHealth, one study found that fewer than 7% of users had learned about mHealth apps from their provider, and 70% did not feel it was important for providers to know of their use of mHealth9. By leveraging health apps to improve communication and behavior change, patients and providers can work together to create personalized, whole-health experiences in an efficient and effective manner.

Where do we go from here?
In today’s technology-driven world, not only is mHealth here to stay, it has the potential to revolutionize how care is delivered. Health apps are already being used to improve patient-provider communication, deliver preventative care, track health behaviors, and synthesize big data to predict a patient’s risk factors. However, economic barriers to accessing technology often limit the availability of mHealth, making equity of access a key concern as the industry continues to develop.

mHealth technology itself is evolving. While most apps available today are designed to track fitness, nutrition, and other personal health behaviors, a 2016 survey of mHealth professionals identified the categories of greatest market potential as those designed for remote monitoring and consultation, diagnostics, and managing medical conditions12. mHealth is becoming increasingly enmeshed in the clinical world, and as a result, a vision of personalized health care revolving around individualized health plans and shared patient-provider goals becomes clearer.

Works Cited:
1. Hunimed Web. (2016, December 20). How Technology is Changing the World of Medicine. Retrieved September 26, 2018, from Humanitas University website: https://www.hunimed.eu/news/technology-changing-world-medicine/
2. World Health Organization. (2011). Global Observatory for eHealth series: Vol. 3. mHealth: New horizons for health through mobile technologies. Retrieved from http://www.who.int/goe/publications/goe_mhealth_web.pdf
3. eMarketer. (n.d.). Smartphone penetration rate as share of the population in the United States from 2010 to 2021*. In Statista – The Statistics Portal. Retrieved September 26, 2018, from https://www.statista.com/statistics/201183/forecast-of-smartphone-penetration-in-the-us/.
4. Bol, N., Helberger, N., & Weert, J. C.M. (2018). Differences in mobile health app use: A source of new digital inequalities? The Information Society, 34(3), 183-193. Retrieved from https://www.tandfonline.com/doi/full/10.1080/01972243.2018.1438550
5. Krebs, P., & Duncan, D. T. (2015). Health App Use Among US Mobile Phone Owners: A National Survey. JMIR mHealth and uHealth, 3(4), e101. http://doi.org/10.2196/mhealth.4924
6. Carroll, J. K., Moorhead, A., Bond, R., LeBlanc, W. G., Petrella, R. J., & Fiscella, K. (2017). Who Uses Mobile Phone Health Apps and Does Use Matter? A Secondary Data Analytics Approach. Journal of Medical Internet Research, 19(4), e125. http://doi.org/10.2196/jmir.5604
7. Changizi, M., & Kaveh, M. H. (2017). Effectiveness of the mHealth technology in improvement of healthy behaviors in an elderly population—a systematic review. mHealth, 3, 51. http://doi.org/10.21037/mhealth.2017.08.06
8. Beaton, T. (2017, July 12). What Features are Needed to Make an mHealth App Effective? Retrieved September 26, 2018, from mHealth Intelligence website: https://mhealthintelligence.com/news/what-features-are-needed-to-make-an-mhealth-app-effective
9. Bauer, A. M., Rue, T., Keppel, G. A., Cole, A. M., Baldwin, L.-M., & Katon, W. (2014). Use of Mobile Health (mHealth) Tools by Primary Care Patients in the WWAMI Region Practice and Research Network (WPRN). Journal of the American Board of Family Medicine : JABFM, 27(6), 780–788. http://doi.org/10.3122/jabfm.2014.06.140108
10. Sharp, J. (2018, May 16). Are Health Apps Effective? The State of the Science. Retrieved September 26, 2018, from Personal Connected Health Alliance website: https://www.pchalliance.org/news/are-health-apps-effective-state-science
11. Wicklund, E. (2018, August 24). Cerner, Duke Develop mHealth App for Clinical Decision Support. Retrieved September 26, 2018, from mHealth Intelligence website: https://mhealthintelligence.com/news/cerner-duke-develop-mhealth-app-for-clinical-decision-support
12. eMarketer. (n.d.). Greatest market potential of mobile health app categories according to mHealth professionals as of 2016. In Statista – The Statistics Portal. Retrieved September 25, 2018, from https://www.statista.com/statistics/655148/market-potential-of-mobile-health-app-categories/.

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The Importance of Addressing Language Barriers in the US Health System

Lamen, D. (2016). Lost in Translation. [Online image]. Retrieved from https://isthmus.com/news/news/translation-services-enforcement-is-lax/

What the Scalpel is to the Surgeon, Words are to the Clinician…. the Conversation Between Doctor and Patient Is the Heart of the Practice of Medicine.
Woloshin S, et al., 1995

Currently, 1 in 15 people living in the US have Low-English Proficiency (LEP) and it is predicted that this number will increase to 67 million by 2050. As detailed by the Title VI of the Civil Rights Act of 1964, federally funded health institutions must provide interpreter services for LEP patients; however, due to financial restrictions, this federal requirement is not always enforced. As a result of language barriers, LEP patients exhibit a lower return rate for follow-up visits, which can result in poorer health outcomes. As the number of LEP people living in the US increases, the need for medical interpreters and bilingual medical staff becomes more essential.

Who are Medical Interpreters?
Medical interpreters serve as mediators for LEP patients and doctors to allow for improved communication between the two parties. There are medical interpreters that work over the phone and others who work in the physical clinical settings. According to a systematic review of the literature, the presence of a medical interpreter has shown to improve patient engagement, reduce medical errors, and facilitate efficient communication.

The Value of Effective Communication with LEP Patients
The benefits associated with the use of language services in clinics and hospitals include, but are not limited to, 1) increased quality of care, 2) improved patient safety outcomes and 3) lower utilization of costly medical procedures.

  1. Increased Quality of Care

Quality of care for LEP patients often is based on two factors: language and cultural values.

Language

With increased access to language services, many LEP patients are more likely to understand the significance of medical procedures and medications. A study by the University of California, San Francisco shows that there were differences between the rates of informed consent documentation of LEP and English-speaking patients. According to the article, such a discrepancy could be attributed to the lack of documentation of interpreter services during the consent process. As a result, LEP patients were less likely to contain consent forms in their charts than English-speaking patients, indicating a disparity in the implementation of informed consent for the LEP population. Another study conducted in 2007 showed that LEP patients who received no interpreter services were less likely to be aware of medical implications and were less satisfied overall about their medical care. With facilitated communication, patients will be more likely to be informed and able to make educated medical decisions.

Cultural Values

Increasing the quality of care for LEP patients also means taking into account cultural differences. Cultural values and principles may look very different for the provider and the patient. Figure 1 shows a list of the social, health and business benefits of providing culturally competent health care. By ensuring medical interpreters and providers are trained in cultural competency, the higher the likelihood that LEP patients will be able to understand and follow certain medical treatments. The National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care were created by the Office of Minority Health in the US Department of Health and Human Services. CLAS provides a baseline for health institutions to strive for and aims to standardize the quality of care provided in health institutions. With these endeavors in mind, it is important to realize the significance of a patient’s personal values. By doing so, this allows for culturally-appropriate personalized medical care that encourages patient engagement. By implementing such cultural cooperation, the provider is able to deliver precise and preventive medical care that contains realistic outcomes for the patient.

      2. Improved Patient Safety Outcomes

Patient safety can be improved for many LEP patients when there are sufficient language resources available. According to a study in 2007, 49.1% of LEP patients received some kind of physical harm as a result of a medical error. By documenting language disparities in hospital settings, the study shows that health institutions have the potential to improve LEP patient safety. In addition to this documentation, increasing awareness of language resources among medical staff and patients can help to ensure interpreter services are being utilized. Many LEP patients do not realize they have a right to request a medical interpreter and as a result fail to use these services. Therefore, having informed health providers who understand how to utilize language services can help ensure more doctors and LEP patients will be better equipped to prevent safety risks and promote effective care.

  1. Lower Utilization of Costly Medical Procedures

Even though it is not financially possible to have bilingual providers and medical interpreters in every language, there are cost-effective ways to meet the demand for these language services. A study conducted by UC Berkeley shows that by improving the efficiency of video conferences, call centers and an online presence, language services can increase the span of their services so that they can reach more people with an increased use of technology. The presence of a language barrier has been shown to be associated with higher rates of costly resource utilizations for diagnostic testing and increased emergency department visit times in a pediatric emergency department. When no interpreter services are available to overcome the language barrier between the patient and the health provider, medical staff must perform precautionary health measures to identify what the patient has without any context or patient history. By introducing medical interpreter services, there is evidence of reductions in emergency department visits and a decreased utilization of extraneous medical exams.

Conclusions

When you can’t speak to your patient in their native language, you do the best you can. No system of translation will ever be foolproof and you will never be able to duplicate that trust you establish when you speak the same language.”
Fein, New York Times, 1997

With a growing number of LEP people in the US, what does the future hold for LEP patients in the health care system? It is well understood by many providers the significance of being able to communicate effectively with patients; however, the issue lies with resources and funding of medical institutions. In an ideal world, medical interpreters would be widely available to interpret for a large population. Patients’ cultural values would be taken into account when helping to plan out their treatment options and health providers would ensure patients are properly informed on all aspects of their condition in their native language. However, due to financial restrictions, language services are not always available despite their proven benefits. As the health care system begins to become more personalized and preventive, it is important to push for the improvement of patient communication. By doing so, medical providers will be able to empower patients with medical knowledge that enables LEP patients to make realistic decisions on their health. As language barriers persist in the US health care system, policy makers and health care leaders must prioritize efforts to enable accurate and culturally-sensitive communication to improve quality of care, fortify patient safety and lower the utilization of medical procedures.

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Traditional Chinese Medicine and Its Clinical Potential to Fight Chronic Pain

As the burden of chronic disease continues to rise, patients and clinicians may seek additional treatment pathways to supplement conventional Western medicine. Trends toward holistic and patient-centered care models increasingly draw treatment-seekers toward non-conventional therapies with a history of use outside of Western medicine. These complementary and alternative medicines (CAM), as defined by the National Center for Complementary and Integrative Health (NCCIH), support or supplant previous treatment options:

  • Complementary medicines are non-mainstream practices used in conjunction with conventional medicine
  • Alternative medicine are non-mainstream practices that replace conventional medicine

CAM therapies sourced from a number of cultures include practices such a mindfulness-based interventions, yoga, and chiropractic manipulation, all of which have been largely embraced by the Western public. Similarly, Western health systems are gradually expanding

Traditional Chinese Medicine (TCM) services, namely acupuncture, tai chi, and herbal medicine. Western health systems’ reluctance to embrace TCM has been rooted in historical biases and deferred efforts to establish an evidence base for promising TCM therapies. The authority of Evidence-based medicine (EBM) has thus challenged traditional institutions like TCM to demonstrate clinical effectiveness before being fully embraced in the West. This has led to a promising and expanding field of research into exploring a diverse range of clinical applications for different TCM modalities.

One of the more notable researchers to bridge these cultural conventions, Tu Youyou, was awarded the 2015 Nobel Prize in Physiology or Medicine for her role in pioneering a new class of antimalarial drugs near the end of the Vietnam War. Tu’s team first introduced the scientific method and publication to Artemisia annua (qīnghāo青蒿), a type of wormwood known to TCM practitioners since the 4th Century as a robust treatment of malarial fever, and was lauded internationally for her proof of cross-system application for TCM. She and researchers like her have helped foster the gradual adoption of select TCM treatments by modern health systems and propelled greater scientific inquiry of its potential benefits.

This map shows VA Whole Health designated facilities.

Investigations into TCM’s ability to effectively manage chronic pain are of particular clinical relevance, though the exact analgesic mechanisms behind certain practices such as acupuncture remain a point of contention. Nevertheless, TCM services now occupy a rapidly growing space in holistic health assessment, preventive medicine, and disease treatment, particularly in populations experiencing chronic health outcomes. Active duty soldiers and Veteran populations have been among the most receptive to TCM interventions due to efforts to find low-risk CAM therapies to treat chronic pain. Chronic pain and subsequent opioid use as a treatment tool are significantly higher in soldiers than in the general population: 44 percent of recently returned active-duty American soldiers report chronic pain and 15.1 use some level of opioids for pain management. However, due to recent changes in opioid prescription standards, only half of these soldiers report the moderate to severe pain for which opioid prescription is now recommended. These changes reflect the heightened awareness of opioid abuse risk given the addictive nature of these medications. It is thus recommended that providers prescribe the lowest effective dose to reduce the risk of complications. In the absence of sufficient alternative therapies, some level of opioid use remains necessary for many Veterans given the higher prevalence of chronic pain in this population. When the risks outweigh the benefits of opioid therapy, it is necessary to pursue non-opioid and non-pharmacological alternatives.

CAM therapies used as part of a holistic treatment plan, which also includes conventional medicine, may help mitigate overreliance on and potential abuse of high-dose opioid prescriptions while facilitating lower-risk pain-coping mechanisms. Acupuncture (zhāzhēn扎针) is being largely embraced by these populations as the pressing need to reduce opioid use drives the VA and Department of Defense to invest $81 million in CAM and non-drug therapies over six years. Additionally, the VA’s Whole Health System (Figure 2), which seeks to transform the VA Health System to a patient-centered care model that emphasizes wellness and prevention, has expanded the availability of complementary and integrative services. These services include traditional acupuncture for its reported success in treating chronic pain and PTSD as well as battlefield acupuncture, a modified version of the TCM practice that may offer more immediate pain relief. The expansion of these CAM offerings coincides with an intentional decrease in opioid prescription rates constituting a 50 percent change at several dozen VA facilities since 2012.

Beyond TCM’s application to opioid management, TCM’s favoring of a holistic treatment of the body over specifically targeted medicines help fill in the diagnostic and treatment gaps left by conventional medicine. This is particularly true for diagnoses of exclusion, like fibromyalgia and IBS, for which we have limited understanding of the pathophysiology at the root of these conditions. Acupuncture and other TCM practices have yielded encouraging clinical results, including that the practice of Tai Chi (tàijíquán太极拳) has myriad benefits for patients of musculoskeletal pain, depression, and chronic heart failure. Patients with such chronic conditions may find greater validation in a holistic assessment of their health needs and greater relief for symptoms after exhausting conventional medicine options. TCM may also offer clinical researchers new practice patterns for diagnosis and treatment through pattern differentiation, the TCM practitioner’s procedure for making differential diagnoses and modifying diagnoses based on responsiveness to treatment. This methodology has been incorporated into studies as a promising tool to identify a subset of patients with Rheumatoid Arthritis (RA) who will be more responsive to biomedical therapy.

As Western health systems continue to innovate ways to employ CAM therapies to provide more personalized, proactive, and patient-centered care, it is important to avoid appropriative behavior by not laying claim to the conception of the medical practices themselves. TCM, like other CAM therapies with non-Western origins, is an ancient institution that is uniquely organized around its home culture’s values and belief system. TCM’s growing clinical applications should instead expedite greater synthesis of global health practices in modern health systems. Western providers and patients alike may feel empowered to consider TCM practices and holistic principles as part of their comprehensive solicitation for better health outcomes.

 

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Home-based Primary Care: A Personalized Solution for Aging Homebound Adults

As the baby boomer generation continues to age, older individuals will accumulate myriad chronic diseases that impact their mobility and leave them homebound. Therefore, it will be important to devise innovative and cost-effective means for delivering care to homebound individuals. Home-based primary care is one method to bring primary care to patients who are unable to participate in traditional office-visits. While it is important to talk about these innovative care models in theory, the actual implementation of these models is key to understanding how home-based services can positively impact homebound patients. This post will outline two successful home-based care delivery programs: one at Mount Sinai Hospital in New York City and the Center for Medicare and Medicaid Services Independence at Home Project.

Home-Based primary care (HBPC) is characterized by four traits:

  1. The provision of primary care in the patient’s home utilizing an integrated health care team.
  2. Frequent communication amongst members on the health care team. This ensures the patient can remain in his or her home and maintain a high quality of life.
  3. After-hours availability of health care team members.
  4. Focus on reducing emergency department (ED) visits.

This combination of services aims to integrate the patient into his or her care by bringing the primary care team to his or her home; in doing this, it is inherently personalized and patient-centered. Some evaluations of home-based systems have shown that participation in the program led to reductions in hospitalizations and emergency department visits. Such programs also provide caregivers with the support they need to care for ailing family members.

Mount Sinai hospital in New York City has operated the Mount Sinai Visiting Doctor (MSVD) program since the late-1990s. This program sought to bring primary care services to homebound patients in Manhattan. The idea behind MSVD was that bringing primary care to those who cannot participate in traditional office visits could encourage patient participation in their care plan. Using a multidisciplinary team, MSVD has been able to coordinate patient care and increase positive outcomes for patients who participate in the program. Evaluations of the program have indicated that MSVD has higher rates of vaccinations compared to ambulatory and nursing home populations, 80% for the influenza vaccine and 74% for the pneumococcal vaccine. They were also able to decrease the burden on individuals taking care of homebound loved ones. While MSVD has yielded these outcomes, its budget relies largely on hospital and philanthropic funds. Regardless of funding, it is an example of the impact that home-based primary care can have for individuals who are homebound.

In 2011, the Center for Medicare and Medicaid (CMS) announced the Independence at Home Project. This three-year project selected 15 practices to deliver home-based primary care tailored to the patient’s needs and to coordinate the patient’s care. Year two findings, released in January 2017, indicated that this model may be an effective means of delivering primary care services to chronically-ill-homebound patients. A press release by CMS announced that the Independence at Home Project was able to save the Medicare program more than $10 million ($1,010 per beneficiary). It also delivered quality care to these patients. This ongoing project provides health care providers with an innovative, cost-effective approach to implementing patient-centered care.

 

Ultimately the MSVD and the Independence at Home Project show that home-based care can be cost-effective and increase patients’ involvement in their care. These implementation experiences provide health care professionals with a foundation to begin utilizing home-based health care for patients who have multiple chronic disorders or other debilitations. With proof-of-concept complete, home-based care could be a setting for the implementation of patient-centered care models or interventions, such as Personalized Health Planning.

Preventing Unnecessary ER Visits Using Personalized Health Planning

Each year in the United States, there are 130.4 million visits to the emergency department. These visits, especially nonemergency visits, are costly not only to the patient, but also to the health system. The average cost of an ER visit is $1,233, approximately 40% higher than the average monthly rent in America, which is $871. Approximately 65% of all ER visits do not warrant a visit to the ER. Our current ER system fails to reduce reoccurring, nonemergency ER visits that could otherwise be addressed in a primary care setting. In addition, the current fee-for-service model does not incentivize health systems to prevent unnecessary visits. In the ER, our disease-focused model of care encourages providers to focus on the patient’s chief complaint, often neglecting other critical aspects of a patient’s case that may have led them to the ER.

Many ideas have been proposed to reduce nonemergency visits, including increased cost sharing to reduce the cost of preventive primary care visits. In addition, strategies should be devised to address the problem when it occurs, in the ER. Shifting towards personalization of care could reduce the burden of nonemergency ER visits by 1) using personalized medicine to reduce adverse drug events associated with chronic disease medications and 2) preventing reoccurrence of nonemergency ER visits by implementing personalized health care to develop personalized, coordinated health plans.

The most frequent reasons for seeking ER services are often avoidable and tend to be the result of chronic disease complications. Patients with chronic diseases like asthma, diabetes, chronic heart failure (CHF) and chronic pain, may experience adverse drug events (ADEs). Approximately $3.5 billion are spent yearly on the costs associated with ADEs, which account for at least 700,000 annual ER visits within the Medicare patient population. This could be a result of mismanaged care, low health literacy, or lack of patient engagement. Since sequencing the human genome in 2003, personalized medicine technology allows us to identify a patient’s genetic risk to certain medications using pharmacogenomics, preventing a physician from prescribing ineffective or adverse reaction-inducing medications. This information would allow for more accurate decisions on which medications and dosages will be most effective for the patient. To better address ADEs in the ER, the electronic medical record could be designed with built in clinical reminders for when an ADE could be triggered this is especially important in the busy ER setting.

To prevent the reoccurrence of nonemergency visits, a clinical workflow called Personalized Health Planning (PHP) could be used in the ER. PHP is a clinical workflow for developing a personalized health plan for the patient, centered on personalized, proactive, patient-centered care. PHP could be implemented using a dedicated PHP team, consisting of a physician or physician assistant, a nurse or nurse assistant, and/or social workers. The electronic medical record (EMR) could allow ER providers to refer high frequency patients (those with ≥ 3 annual ER visits) to the PHP team. The PHP team would then meet with the patient to begin managing the patient’s case and creating a personalized health plan with the patient. The EMR would enable the PHP team to monitor various aspects of the patient’s engagement, such as whether prescriptions have been filled and other medical visits have been made. The EMR would also allow PHP team providers to make referrals to the patient’s primary care provider.

In following the PHP workflow, the social worker or nurse’s aid would guide the patient in completing a personalized health inventory (PHI) to assess patient preferences and health goals. The provider would then assess the patient’s health risks and, with the patient, set shared goals that would engage the patient in considering how they could avoid the ER in the future. An important aspect of PHP in the ER is educating the patient to triage their own symptoms; it will be essential that patients know how to identify and categorize their symptoms as emergent or nonemergent. By the end of the consult, the PHP team would create a personalized health plan in the EMR for the PCP to see. Case management of nonnemergent ER users by the PHP team would be the first steps in coordinating the patient’s care, setting shared goals, and connecting them with their PCP for follow-up on their personalized health plan. Initiating PHP in the ER would be effective because it engages the patient in the process at the time of their ER visit, before their memory of the incident wanes of they are lost to follow-up.

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Fix Medical Billing by Reimbursing for Value

Dr. Ralph Snyderman responds to a recent article published in the NYTimes

In her NYTimes article, “Those Indecipherable Medical Bills? They’re One Reason Health Care Costs So Much“, Elizabeth Rosenthal amply describes the complex and arcane medical reimbursement system that drives up health care costs.  A far bigger driver of costs is the ¾ of medical expenses going toward high-tech treatments of episodes of chronic disease rather than for their prevention or effective management.

Health care follows the money and the current “fee for service” system rewards for volume of expensive procedures. Services requiring interactions with patients to encourage prevention or disease management lose money. Thus, the epidemic of preventable chronic diseases needing expensive treatment continues to grow.  Fee for service reimbursement is also responsible for the complexity of billing as payers want to justify what services they pay for, contributing to the coding maze.

A solution to this dilemma is to reimburse for the value of the outcomes of care rather than for volume. “Value based reimbursement” is designed to reward more effective care rather than volume of procedures. The switch from fee for service to value based care, being driven by the Centers for Medicare & Medicaid Services (CMS) is at its infancy but expedited implementation could help eliminate much of the perverse incentives that retard more effective care delivery and encourage the rigging of the system to maximize billing.

 

Ralph Snyderman, MD is Chancellor Emeritus, Duke University, James B. Duke Professor of Medicine, Duke University, and Director of the Duke Center for Research on Personalized Health Care.

Treating Congestive Heart Failure at Duke: A Case Study of Delivery and Payment Reform

With rising healthcare costs and a rapidly aging population, finding sustainable and cost-effective ways to address chronic illnesses is one of the most critical pursuits in health care today. One strategy that has demonstrated promising results is Personalized Health Planning (PHP). An example of its strengths as well as the barriers to implementation can be seen at Duke with a disease management program for patients with Congestive Heart Failure (CHF) that started back in 1998.

What is Congestive Heart Failure?

CHF is a chronic disease that occurs when the heart becomes weak or stiff and is unable to sufficiently pump blood to meet the body’s needs. CHF is common, costly, and potentially fatal.

Heart failure is common and potentially fatal.

Heart Failure Info from Novartis

According to the CDC, about 5.7 million adults in the US have heart failure, and the disease costs the nation nearly $31 billion each year in cost of health care services, medications, and missed days of work. This chronic condition accounts for one million hospitalizations annually, and is the leading cause of hospitalization among adults over 65. Moreover, readmission rates for CHF patients are high, due to recurrence of heart failure, as well as low medication adherence, self-monitoring, and follow-up. Strategies to improve CHF prognosis and reduce readmission rates should focus on patient engagement outside of the clinical encounter.

How can personalized health planning benefit patients with CHF?

PHP aims to make health care more proactive, personalized, and patient-centered through methods that engages patients in their care. In particular, PHP integrates wellness training and long-term planning into the traditional appointment model. Many patients with CHF suffer from multiple illnesses or co-morbidities, and need the support of different teams of health care providers (primary care, tertiary care, etc.) to effectively manage their health. PHP empowers the patient to take charge of their own health by engaging them in education and goal-setting through a tailored health plan. It shifts the emphasis of care away from high-intensity, expensive inpatient treatments to preventing, coordinating, and managing the illness in outpatient, or primary care settings. Furthermore, this personalized health plan allows for care coordination across clinical team members and across specialties within a health system.

What happened in the Duke CHF case study?

Duke set up the Duke Heart Failure Program (DHFP) based on the personalized health planning model. Protocols were developed for the management of medications, and a patient education manual was created that covered topics such as the importance of each medication, the potential adverse effects, appropriate actions to take if such effects occur, and resources available to CHF patients. Additionally, clinical teams maintained provider-patient contact through follow-up visits and regular telephone calls, while health coaches provided complementary support and education for each patient. The results were striking. Within two years, hospitalizations per patient-year decreased from a median of 1.5 to zero, and clinic visits significantly increased. The PHP approach improved health outcomes for patients and cut costs nearly in half. Empowered with education and clinical team support, patients showed active participation in the program and a desire to make positive lifestyle changes.

Why did the program get discontinued?

In the end, the CHF program reduced the average cost of treating patients by $8,600, or about 40%, by improving their outcomes and reducing their hospital admission rates. By shifting more of the care to outpatient settings, more money was spent on health coaches and clinics rather than treatments in the hospital. However, Duke faced an unfortunate paradox: the healthier its patients were, the more money Duke lost. Ultimately, it decided that this program was unsustainable because the hospital was losing too much money by reducing readmissions and therefore opportunities for billable care.

What are the lessons we’ve learned from that case study?

The current reimbursement system continues to primarily reward old models of care, and not more proactive, preventive models like personalized health planning. Alternative payment models are necessary to incentivize proper disease management, coordination of care, and activities such as follow-up calls that are currently not reimbursed in the fee-for-service, volume-based payment system. Models such as bundled payment and Accountable Care Organizations (ACOs) aim to shift payment in health care towards focusing on value and quality, rather than volume of services provided.

Today, Duke offers the Same-Day Access Heart Failure Clinic, which offers counseling, dietary management, and medical adherence support to CHF patients. Part of the motivation to establish this program came from the Centers for Medicare and Medicaid Services (CMS). In 2012, the CMS announced financial penalties for facilities with readmissions for the same condition, such as CHF, within a 30-day timeframe. To prepare for these changes, Duke established the Clinic to offer an alternative to the emergency room to avoid unnecessary hospital stays. Patients are taught self-management and given tools to promote successful transitions from hospital to home. Clinicians provide follow-up care consisting of phone calls 24-48 hours post-discharge and biweekly to weekly office visits until the patient is stable.

Since its initiation, the Duke University Health System has seen a 15 percent reduction in readmissions from CHF patients. Due to the CMS regulation, it is now financially feasible and necessary for Duke to establish programs that engage patients and improve outcomes, in order to avoid payment cuts incurred from high readmissions rates.

This program demonstrates the power of proactive disease management programs, and the necessity of financial incentives to establish these programs. Research and practice continues to show that preventive and personalized approaches are crucial to creating better outcomes for patients while controlling costs. Now we need to continue restructuring delivery and payment mechanisms to meet this imperative.

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Precision Medicine World Conference DUKE

The first East Coast Precision Medicine World Conference, the 12th PMWC, will be hosted at Duke University on May 24-25. The conference is co-chaired by Dr. Ralph Snyderman, Chancellor Emeritus, Duke University, and Dr. Geoff Ginsburg, Director of the Duke Center for Applied Genomics & Precision Medicine. The main focus of the conference is “translating the power of precision technologies into better health care.” Click here for a note from the conference co-chairs.

 

The conference will center around topics related to  data science to advance precision medicine, the importance of patient engagement, the impact of technology to drive genomics and medical practice, updates on data and regulatory policies, metabolomics in precision medicine, the emergence of single cell genomics, monitoring infectious disease, an update on the PMI, mobile health and how it is changing healthcare, liquid biopsy, the microbiome, and much more – for more information see the developing themes. Major speakers for the conference include Robert M. Califf, Francis S. Collins, Mark Levin, Chris Cournoyer, Kathy Giusti, Richard Klausner, Keith R. Yamamoto, and Janet Woodcock.

 

 

There is still time to register, so we hope to see you at PMWC DUKE in May!