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A New Approach for Sustainable Primary Care and Public Health Systems: 

Context: 

For decades primary care and public health in the US have been deteriorating in several ways – e.g. separation between primary care and public health, deteriorating public water quality and sanitation infrastructure, poor access to primary care with health and care disparities and inequities, clinician burnout, physicians leaving primary practice, shortages of primary care physicians and nurses, declining health outcomes for primary care patients as rates of chronic disease continue to climb, rising rates of preventable medical errors with rising associated morbidity, mortality, heart ache and preventable healthcare costs, and ongoing disinvestment. 

The terrible irony of this declining situation is that primary care and public health along with public education are the most important pillars on which a successful society is built and depends. Despite their importance, for many reasons we have allowed public health and primary care to become declining societal priorities. The onset of COVID-19, the higher incidence of COVID-19 among low income people, the mass demonstrations against systemic racism and inequality, which will only exacerbate the spread of the virus among low income people, have all further crippled our public health and primary care situations even more.   

A New System of Combined Public Health and Primary Care System is Needed: 

After decades of failed attempts to reform the US public health and primary care sectors, we do not believe that tinkering on the margins of the existing dysfunctional situation is going to work. Top down, population-based approaches, while important, do not reflect the physical reality and nature of public health and primary care, which are mostly community- and individual-based or bottoms up endeavors and continuous, not episodic, in nature.  

We need a new system that reflects these realities by integrating public health and primary care by giving each person their own Individualized Healthcare Delivery System or Individualized Health Platform (IHP) that leverages and brings together the significant advances that have been made in many domains such as HIT, AI-machine learning, health literature data capture, behavioral economics and psychology, the data, learning, decision, cognitive sciences and others. 

Tests of precursors of the 24/7 digital device accessible, evidence-based, AI-guided IHPs show that users working with their IHPS and their health coaches can take care of up to 75% of their acute and chronic health and care needs at higher quality and safety than current best practices without the intervention of clinicians; thus reducing utilization of traditional healthcare services by up to 60% and their associated healthcare costs by up to 40%. 

In the IHP world, public health gets turned on its head – e.g. rather than working only at the population level, community-based public health authorities could send individualized messages to citizens’ IHPs about outbreaks of the flu, other viruses, screening surveys for each individual to complete and send back, and data about testing services, and other health and neighborhood issues. And users could send data back to their public health authorities about their own individual health and care issues, neighborhood health issues, and each person’s social determinants of health. This is virtual care and advanced telehealth for an integrated public health and primary care system writ large. The data aggregation and analytic capabilities built into each IHP and its coded data make it possible for the results from each IHP to be aggregated and analyzed to conduct ongoing community disease surveillance and guidance about what needs to be done now proactively for earlier detection and prevention of disease spreading. 

For one example of how one of the tools in IHPs can act in this manner, see the online evidence-based, AI-guided COVID-19 symptom checker/checkup system at www.covid19checkup.net for earlier individual screening, risk stratification, testing and guidance during an emerging flu and/or epidemic relieving front line primary care clinicians from having to do these tasks. The individual, the primary care physician and that individual’s health coach all receive all the data, analysis and guidance from this COVID-19 checkup system before the telehealth call. The health coach then sets up the call between the individual and their primary care physician, who is now able to spend all of the time on the call in shared decision making about the results of the screening and what to do next, which the health coach helps the individual do right away. 

This is an example of how IHPs put in place a new division of labor in which primary care physicians have to do much less data recall, vetting, collection, analysis (which are the cause of many medical errors) and can thus spend more time in shared decision making and the patient receives more immediate, higher quality care and is able to follow up and close the loop sooner because of the encouragement of their health coach.  

In this way, the IHP also turns the delivery of primary care on its head – that is rather than insisting that a person come to this or that clinic or join this or that disease management and/or wellness program, IHPs take all of that person’s data, analytics, human support in the form of a health coach out to each individual in their own particular circumstances of life, family, work, health so that they can find their own path to health that works best for them.

In these and many other ways, IHPs can attack directly the underlying root causes and symptoms of our long running, multi-dimensional public health and health care delivery crises, all which COVID-19 has laid bare: 

• Standards for the Quality of the Inputs – the health care sector, including public health, is one of the few sectors which has no standards for the quality of data, analytical inputs, processes, auditing or tracking of outcomes. As a result, for decades one of the root causes of our multiple crises in public health and primary care and health care more broadly has been a lack of data on each individual such as on their diseases, diagnoses, labs, images, tests, treatments, quality, prices, costs and outcomes. IHPs have extensive standards for the quality of inputs, processes and outputs in the form of vetting, curating processes and range limits for each new piece of data that comes into an IHP from a wearable, remote patient monitoring device, etc. 

• One Person – One Personal Problem Oriented Health Record (POHR)– providing all of each users’ data in a problem oriented manner makes it possible for IHP users (or their surrogates), their health coaches and their PCPs to see what is going on and/or has been done to date to address each problem a patient has – e.g. their diabetes, their hypertension, their obesity, depression, anxiety, etc. – rather than the current EMRs which provide only some of each users’ data in vertical stacks of data for labs, tests, images, treatments etc. and not related to specific problems. POHRs include all a user’s data including data on behavioral health issues, if there are any. 
• Social Determinants of Health (SDoH) data in each person’s POHR are the most important data for measuring changes in that person’s health status – data that is missing in most EMRs. Coded, time and data stamped SDoH data operationalize the use of SDoH data by showing how each individual is doing right now but also over time as the individual’s situation changes with respect to these crucial variables, such as safety of their neighborhood, whether they have a place to sleep and if so is it clean and warm, does the person have a strong supportive social network, do they have access to fresh food and exercise opportunities, public transportation, etc. 
• Setting of health goals and care plans – from this data, the health coach and the user develop health goals and care plans that fit into and work with that user’s life circumstances, and thus have a better chance of being pursued, especially since the health coach is virtually present sometimes on a daily basis with texting messages of support to see how the user is doing with respect to their daily health and care activities, such as taking health measures with remote patient monitoring devices (RPM) for measuring blood pressure, blood glucose, weight and other key health metrics, medication management, nutrition and fitness activities and behavioral health.
• Better Access to Reduce Health/Care Disparities/Inequities – IHPs can give 24/7 digital device access to higher quality, safer care to millions of Americans who currently suffer huge care and health disparities and inequities at a much lower cost than is currently the case. Each user of their IHP has 24/7 access to their IHP through their smart phone and web ui apps on their tablet and/or laptop computer, making it much easier to access the data, tools and human support needed to deal with health and care issues compared to the existing fee-for-service (FFS) care systems. 
• Resources, Agency, Personal Responsibility, Engagement – IHPs finally give people the data, analytics, tools and human support – e.g. health coaches – that they need to have agency over their own health and care, and thus can take more personal responsibility and become more engaged in their health and care. Because of the relative ease with which each user (or their surrogate) can interact with their IHP’s smart phone and web-ui apps on a 24/7 basis, and because of this continuous interaction between the IHP user, their health coach, the user’s PCP and other members of their health team, the user has at their fingers tips all the time the tools and drivers of their care and health that they need to be able to engage in their health and care in a more efficient, effective, efficacious and thus enjoyable manner. 
• Individualized, Integrated, Interdependent, Holistic, Continuous – Rather than taking directions from distant providers and payors, who know little about our daily lives, IHPs reflect the way the human body, mind, behavior and care really work – e.g. they differ from one person to another, each of our bodies is a system of interdependent, integrated biological systems and care is needed when it is needed and sometimes with chronic diseases on a continuous, not episodic basis. Each problem is influenced by and influences other problems that a person may be dealing with – e.g. different chronic diseases influence each other, including behavioral health issues and/or acute symptoms that arise in an unpredictable manner.  
• Early detection, prevention, attenuation of disease progression – through RPM of blood pressure, blood glucose, weight and other key health measures, IHPs feed near daily measures from home health monitors to the IHP’s AI analytics engine which assesses the new data in the context of the all the rest of that patient’s data and in the context of the relevant health/medical literature to provide ongoing guidance options and alerts about nascent health issues as soon as they start to manifest themselves. 
• Screening Surveys – if as a result of this process, the AI analytics engine determines whether a new value is headed in the wrong direction for a particular health measure – such as for say blood glucose – the IHP will send to the user’s smart phone a list of screening questions about possible hypoglycemia from the peer reviewed literature, answers to which will again be assessed by the AI engine to provide immediate guidance options for the user and their care team. This earlier detection prevents the emerging problem from becoming worse, prevents those at risk from developing new chronic diseases and slows down the progression of existing chronic diseases. 
• Faster, More Accurate Response to Acute Issues – similarly, if a user has an acute care issue, they may immediately click on the issue from a list of acute issues in their IHP on their smart phone and then answer a set of questions coming from the best peer reviewed literature (not the physician). The AI analytics engine then assesses those answers in the context of all that user’s other data and in the context of the relevant literature to provide guidance/triage options for the user, the health coach and the PCP to discuss in a shared decision making call. Part of this assessment is the production from this data for this acute issue for this individual of an individualized differential diagnosis that tells the user and their care team what might be going on here without the cognitive biases that currently plague existing care practices and are part of the reason why there are so many diagnosis errors, delays and preventable expense. Again, standardize procedures and practices so that we can deliver individualized and thus more accurate care more quickly and for less money.  
• Closing the loop – for both chronic and acute care issues, the health coach will then immediately contact the user to make sure the user understands the guidance options and to provide any help the user might need to resolve the issue quickly and efficiently – e.g. sending data from the survey questionnaire and the resulting guidance options to the user’s PCP, setting up a telecom between the user and the PCP to discuss the guidance options, transportation, etc.. This immediate feedback loop in the Continuous Care Model begins to address one of the big problems with current more episodic models, which is that far too often, sometimes as much as 50% of the time, patients do not carry out the tasks they are supposed to do to address a particular heath issue. 
• Continuous Documentation, Learning, Process and Outcomes Improvement – each user’s IHP system documents everything that occurs on each IHP – e.g. who did what, when for what reason, with what inputs and with what outcomes, etc. As a result, each IHP learns what works best for its user – e.g. approaches, lessons learned and best practices that work best in that user’s life, schedule, preferences, interests, needs, etc. There is a constant feedback to the analytics engine of what works best and worst for each user. This documentation capability of the IHPs also relieves physicians of much of their documentation tasks which is one of their most burdensome activities. 
• Clinician Burnout and Shortages – IHPs enable a new division of labor through the shifting of data recall, collection, vetting, analysis, guidance and documentation from clinicians, who are ill-suited for these tasks, to patients/consumers, their IHP systems and their health coaches, who become three new primary care resources or force multipliers at a time of growing nurse and physician shortages and burnout. Because each piece of IHP guidance is based on the highest quality peer reviewed studies, users and their clinicians form a new partnership based on shared decision making around this evidence-based guidance. The evidence-based guidance also reduces errors, delays, inappropriate labs, tests, images and associated healthcare costs, and the use of defensive medicine and the threat of malpractice issues. 
• Moving from Fee–for-Service (FFS) to Value-based Payment Systems (VBP)-  by giving clinicians and patients/consumers the above data, tools and human support (health coaches) they need to improve individuals’ health outcomes and thus reduce the use of traditional healthcare services and associated costs, clinicians can now have the confidence that they will receive shared benefit payments to offset their loss of income from the reduction in the use and cost of traditional healthcare services, which is what enables payors to provide shared benefit payments to higher performing providers. (See separate paper on how IHPs can facilitate moving from FFS to VBP systems.)
• Positive ROI – many studies have shown that using IHP kinds of approaches can reduce America’s healthcare bill by about $1 trillion/year, while giving every citizen access to their own IHP would cost about $39 billion/year. 
• Establishing a Culture of Health – One Student at a Time – the alarming growth in the prevalence of childhood chronic diseases is overwhelming schools, parents, the children themselves and their pediatric primary care providers. IHPs can help all four groups by helping children learn healthy habits and life- styles at an early age while learning about the organ systems that are causing their chronic disease issues. 

We have organized a team of public health and primary care entities to carry out a series of pilot projects in different states to show how IHPs can improve each user’s access, quality, safety, engagement, health, care and cost outcomes. We would like to discuss the IHP concepts and their implementation with you. If you are interested, please contact: 

George Reigeluth at greigeluth@prosumerhealth.com and/or call us 860-794-4136.
www.prosumerhealth.com