Over the past few decades, the following first principles have emerged as touchstones for those who are trying to improve the delivery of healthcare and the associated clinical, health and cost outcomes. Many, if not all of these, were first developed by Dr. Lawrence Weed in the 1970s. These are more true today than they were then. Today we can design and implement the healthcare delivery system that many for decades have been saying we should have, as follows:
Confidentiality: Prosumer patient health related data and records are managed and stored to the highest security standards known today. Correspondence with health coaches and providers are conducted over private high security Prosumer email services to avoid prying eyes and data mining which are common with Gmail, Yahoo and other free email services.
Do No Harm: Unfortunately, under the multiple pressures of today’s medical practice, physicians and the teams of which they are a part do enormous harm to individuals who come to them for care. Depending on whose data you believe, preventable healthcare errors kill and injure millions of people each year.
Improve the Quality of the Inputs: There must be defined standards for managing medical information and implementation of these standards using information processing tools designed for that purpose. Every industry, except for healthcare, has standards that define the quality of the data and of the data analysis that go into the operating/production processes of that industry, which in turn determine the quality of the outcomes of those production processes. Ideally, the federal government would develop and enforce healthcare standards, as it does, for example, with generally accepted accounting principles and standards in the financial industry. However, lacking these standards in healthcare, there has been relatively little effort put into developing consistently high quality data and analysis of that data on a person’s health situation prior to nurses and physicians making decisions about what to do for that person.
Organize, Integrate and Manage Care and Health around Each Individual: An important reason why healthcare delivery in the US and elsewhere has been so inefficient and ineffective is that it has been working against the very nature of healthcare and health, which are by definition a singularly individual concern. The health of each person’s unique mind and body as a closed system of complex inter-connected biological systems is the raison d’etre of healthcare – not the financial solvency of providers. As such, we must organize, integrate and manage care around the health of each individual – not around different providers the way we currently organize care.
One Person – One Record: each person should have their own comprehensive problem oriented personal health record that contains all of that person’s healthcare and health data pulled together and integrated from all providers. There are many reasons why this is necessary:
The Human Body is a Complex System of Inter-Connected Biological Systems – as such every new health issue, acute or chronic, needs to be assessed in light of what else is going on and has gone on in that person’s body in order to arrive at the correct differential diagnosis, analysis of that differential, production of the best guidance options and selection of the best action/management plan for that person for that issue.
Problem Oriented Medical/Health Record - Instead, we have each provider keep the data on a given patient for a particular piece of a particular problem in separate silos with the result that we cannot get a comprehensive, horizontal picture of what is/has gone on with respect to that person’s entire experience across different providers for that problem. Problem Oriented Medical/Health Records within a person’s all- in-PHR solve this problem by collecting, analyzing and tracking the data from all providers working on a person’s particular problem so that the individual and all providers can receive a comprehensive, horizontal view ] and understanding of everything that has gone on with that problem.
The More Individualized the Data, The Greater the Accuracy of the Data - the more comprehensive the data is about an individual’s care and health and/or emerging problem and the greater the accuracy and precision of that data, the better will be the guidance options, decisions and management plans that were formed on the basis of that data.
Involve Individuals in The Management of Their Care and Health: individuals are the most underutilized resources in healthcare, but attempts to involve them in their care and health have been largely unsuccessful. We believe that these efforts have failed mainly because in applying a one size fits all approach medicine has ignored the basic reality that each individual has different circumstances of physiology, health, genetics, time, space, family, work, school, etc. Further, each person has unique preferences for the way they would like to become involved in their care and health. Studies have shown that when given the right data and tools as outlined above, individuals will become involved in their care and health in their own way by finding the path to engagement that suits their particular circumstances the best. Some will opt to have providers take care of them and not be very involved, some will use a family or friend surrogate to manage their care and health because they have physical and/or mental handicaps that make it impossible for them to manage by themselves, and many, studies have shown, will use their tools, virtual health coaches and home health monitors to manage up to 75% of their own care, without the intervention of a nurse and/or physician at same or better levels of quality and safety as current best practices.
Better Clinical, Health and Cost Are Possible: Chronic diseases account for over 75% of US total healthcare costs. When individuals have been able to manage their chronic conditions using these tools 24/7 via smartphones, they achieve their health targets (e.g. blood pressure, blood sugar, etc.) sooner, sustain them longer, reduce office and ER visits by 60% and reduce costs by 40% compared to best practices.
One-Stop-Shopping, All-In, Integrated Care/Health System: but right now because of the growing number and complexity of care venues, insurance plans, wearable devices, sensors, etc., this non-system makes it very difficult for individuals to engage in their own care in an efficient and effective manner. Instead, patients are now forced to jump in and out of different systems, devices, sensors, etc. that are not integrated with each other and are of unknown security, quality and/ or safety. Everyone wants simplicity and convenience over complexity and inaccessibility. We believe people will want a one-stop-shopping, all-in, fully integrated and vetted care/health system, that also again reflects the basic reality that each of their care/health issues need to be assessed in light of everything else that is going on in their body and their care/health and in the context of the relevant medical/health literature in order to arrive at the best possible guidance options, decisions and management plans. Patients should be able to go seamlessly from one part of their delivery system to another with the secure knowledge that no matter what the medical or health issue, all their medical/health information will follow them, all the appropriate questions will be asked and that the differential diagnoses, recommended tests or management options are derived from integrating that unique patients medical information with the best and latest medical literature.
Create a New Division of Labor: one of the reasons that healthcare has been so fraught with poor quality of data/analytical inputs, resulting safety problems, errors, delays, complexity, inaccessibility and exploding costs is that we have continued to work with an outdated division of labor in healthcare. This is also one of the reasons why physicians, more than in any other profession, have been experiencing high rates of professional burn out, substance abuse and suicide. We have asked nurses and physicians to do a job that is impossible to do.
Task Shifting – the New Providers – You, the Tools and Your Health Coach: With today’s advanced AI-driven, evidence-based clinical decision-support tools, it is possible to take most of the upfront data collection, asking of qualifying questions, preparing differential diagnoses, investigation, preparing guidance options and many other tasks off of the shoulders of nurses and physicians. We can give these tools to health coaches and the individuals/patients themselves. Health coaches and patients with these tools will do a better job of asking the right questions about symptoms and create more comprehensive and accurate differential diagnoses by matching symptoms with descriptions of possible diseases in large vetted, regularly updated databases with thousands of diseases in them. They will also collect better data on possible labs, tests, images, treatments and management plans for a given problem, and finally they will do a better job of documenting in real time everything that is done for a particular problem – e.g. who did what, what references were consulted, what questions were asked, what options assessed, what decisions were made, why, what management plan was decided upon, with what clinical, health and cost outcomes, etc. Higher quality inputs = higher quality outcomes.
Feedback Lessons Learned for Continually Improving Healthcare Processes: by changing tasks and the division of labor in this way, we would begin to address the growing shortage of nurses and physicians. They then could focus much more of their attention on the tasks they have been trained to do, such as taking more time with complex patients. They would also be able to analyze the new clinical, health and cost outcomes data for lessons learned and identification of best practices to be fed back up into the clinical/health decision support system for continuous learning and improvement of healthcare processes – something for which nurses and physicians do not have any training to do, but which they should start learning as a new course module in reformulated health (not medical) schools.
Support and value-based not Volume-based Payment/Reimbursement Systems: the US, through the ACA and other avenues is trying to shift from a costly fee-for-service system to a payment/reimbursement system based on quality, safety, clinical and health outcomes or on the value of what is done for a given individual. One of the barriers to making this shift is that we do not have good data on the quality, safety, health outcomes and/or on the costs associated with delivering those outcomes, and thus it is not possible in most cases to measure value. With the systems we have outlined above which are in existence, it is possible to produce both quality, safety and health outcomes data as well as associated cost data through the real time documentation capabilities of these systems described above.