Shifting the Focus From Disease To Health: Shifting the Focus From Disease To Health: A Paradigm Change To Achieve Patient-A Paradigm Change To Achieve Patient-

Centered Care Through TechnologyCentered Care Through Technology

Zsolt J Nagykaldi, PhDAssociate Professor, Associate Director of Research

University of Oklahoma HSC Department of Family & Preventive Medicineand the Oklahoma Physicians Resource/Research Network (OKPRN)

What Would What Would YOUYOU Do Do??

• LLong list of tasks• EEach compete for time and resources• EEach are important to complete• AAll are beneficial• TThe level of benefit varies significantly

> How would you solve this problem?

Congratulations! You are officially Congratulations! You are officially SMARTER than the U.S. healthcare system!!SMARTER than the U.S. healthcare system!!

A Real-Life Example: The Story of A Real-Life Example: The Story of Mr. Waldrin - Personal NarrativeMr. Waldrin - Personal Narrative

Mr. Waldrin is a 76 year old man of Northern European descent, married, a retired psychology professor who enjoys reading and writing (essays and articles for magazines). He is active socially, and also likes walking and traveling. His grown children and grandchildren are scattered throughout the country. Trips to visit them often involve driving long distances. He is a non-smoker and drinks only 3 glasses of wine weekly.

He states that, for him a substantially decreased quality of life would include permanent conditions that prevented him from thinking clearly.

The Story of Mr. Waldrin:The Story of Mr. Waldrin:Clinical & Biomedical InformationClinical & Biomedical Information

Mr. Waldrin has the following medical conditions and risk factors for adverse health outcomes:

Type 2 DM for 11 years, now on glipizide HTN for 20 years, now on HCTZ Dyslipidemia X 11 years, now on atorvastatin Osteoarthritis of knees for 8 years, on PRN Tylenol A family history of colon cancer (mother at age 70)

His current BMI: 32; BP: 150/90; A1c: 7.5%; LDL: 140; aerobic activity level: insufficiently active

Disease-Centered Guidelines Disease-Centered Guidelines and the Long “To-Do List” Problemand the Long “To-Do List” Problem

Considering only “A” and “B” –level evidence-based guidelines and only from USPSTF, ACIP/CDC, and AAFP, the relatively healthy Mr. Waldrin could receive a minimum of 20-25 (ongoing) evidence-based interventions to sustain or improve his health, including, for example:

Aerobic exercise 30 min 3 times/wk Reduce LDL cholesterol to 100

Take aspirin 81mg every day Take an ACE inhibitor

Reduce highway miles driven by 50% Take metformin

Yearly flu shot Pneumococcal vaccination

Reduce BP to 130 systolic Take a beta blocker

Lower A1c to 7% Do a screening colonoscopy

Another Real-Life Example: Another Real-Life Example: The Story of Mrs. SalinasThe Story of Mrs. Salinas

79 years old Hispanic/Latino female with moderate OP, OA, T2DM, HTN, and COPD

When pertinent single-disease guidelines are applied for only the 5 chronic conditions, the following clinical regimen can be suggested [*]:

12 separate medications taken at 5 diff. times and in 19 doses/day Estimated medication cost: > $400 per month 14 non-pharmacological interventions (e.g., patient education, labs) Min. 4 primary care visits and several specialist visits per year Important personal issues would remain unaddressed (15 min visits) Numerous drug and food interactions, some guideline conflicts, and potential patient preference conflicts

[*] Boyd CM et al, JAMA, 2005 (10)

Medicine On Unsustainable Course: Medicine On Unsustainable Course: What We Can Learn From Other ProfessionsWhat We Can Learn From Other Professions

Health/Disease Care Conundrum:

• Patients and practices are inundated by things to do• Number of “problems to fix” rises exponentially• Allocated resources per “fix” tend to decrease• Available time per “fix” decreases• Basic needs remain unmet or worse, we may cause harm

An Engineer’s Perspective:

• Take a step back and assess personal/shared goals• Prioritize actions based on their impact on reaching goals• Put a system in place to track outcomes and adjust the course of action iteratively

The Problem With Problem-The Problem With Problem-Oriented Medicine: Potential Self-Oriented Medicine: Potential Self-DestructionDestructionIf the ultimate goal of healthcare is to make everything “normal” by eliminating each individual abnormality, then:

We will never achieve our goals, since there is no end to discoverable problems

It creates an unsustainable course for healthcare (current) The ultimate solution would be to correct every genetic

abnormality which would result in a “perfect genome” However, species with an invariable genome could be

wiped out by the first major infectious agent due to loss of tolerance and adaptability

The Need For Personalization & Prioritization:The Need For Personalization & Prioritization:The Central Issue of 21The Central Issue of 21stst Century Medicine Century Medicine

• We have reached a point in the health care system where there are many more things that can be done than any patient is able to or should want to do.

• This will get dramatically worse once our individual DNAs can be mapped at birth (# of risk factors will increase substantially).

• Clinicians and patients must therefore learn how to prioritize available interventions.

But by what criteria should we prioritize clinical care?

Principal Goals of Health Care:Principal Goals of Health Care:Living Longer and Living BetterLiving Longer and Living Better

Development of healing relationships(Healing relationships are built upon trust that nourishes the inborn psychological/spiritual needs of individuals – SDT: Deci & Ryan)

Prevention of premature death and disability(The point of not preferring length over other aspects is individually different and changes over time)

Enhancement of current/future quality of life(Depends primarily upon the ability to do things that give life meaning which is individually different and changes over time)

Support of personal growth and development (Proceeds through a series of predictable stages, each one building

upon the previous ones)

Goal-Directed Care:Goal-Directed Care:Risk Reduction in a Holistic Perspective Risk Reduction in a Holistic Perspective

Patient-Centered Medical System: Patient-Centered Medical System: A New Primary Care Delivery ModelA New Primary Care Delivery Model

CCR

HRA

Wellness Portal

CCR

HRA: Health Risk Appraisal; EHR: Electronic Health Record; CCR: Continuity of Care Record PSRS: Preventive Services Reminder System

Risk Processor(HRA)

Prioritizes available interventions from

clinical guidelines by outcome and size of

effects

Prioritized Recommendations Lists

Wellness Plan

Decision Support Tool

Link to Resources

Task ManagerRegistry, reminder, and recall system (PSRS)

Lab results, consults and

referrals

Billing System,

EHR

Personal attributes,

values,goals,

preferences,constraints

ClinicianPatient

Wellnessnurse

Evidence-based guidelines and population statistics

Conceptual Model of Goal-Directed Conceptual Model of Goal-Directed Care: Care: READY–SET–GO!READY–SET–GO!

* Patient actively prepares for an annual wellness visit (“homework” assignment).** Includes primary, secondary and tertiary prevention.

Wellness Visit + Negotiated

Wellness Plan

Patient Activation

Personalized Wellness Plan

Emphasis On Healthy Behaviors

ImprovedHealth

Behaviors

Better Preventive Care

(**)

Education &Preparedness

Heightened Awareness

& Readiness

Quantification of Risks

Prioritization and Focus

Increased Life Expectancy & Quality of Life

Systematic Progress Tracking & Health Coaching

Goal-Directed, Pre-Visit HRA

(*)

“Ready” “Set” “Go”

Expanding the Construct of Risk FactorsExpanding the Construct of Risk Factors

All health conditions are associated with short-term or long-term adverse outcomes:

Conditions/problems can be considered risk factors for future adverse outcomes (e.g., MI, stroke, cancer, DM2)

All health care interventions are intended to improve short-term or long-term health outcomes:

Interventions/services can be considered strategies to mitigate the risk of adverse outcomes

This integrative model creates a more holistic approach for healthcare: a) no separation of acute and prospective care

b) disparate risks can be in the same model

The “The “My Wellness Portal”My Wellness Portal” Study Study(AHRQ (AHRQ 1R18HS017188-01; 2008 - 2011)1R18HS017188-01; 2008 - 2011)

Aims:

Develop, field test, and refine an innovative, goal-directed and practice-integrated e-patient wellness portal (2008)

Determine the impact of the Wellness Portal on patient-centered preventive care by examining the behavior and experiences of both patients and practices and the degree to which recommended services are individualized and delivered (2009-2010)

Disseminate the Portal technology and lessons learned from the Wellness Portal trial (2011-)

““Ready”: Feeding the Risk Engine Ready”: Feeding the Risk Engine From Clinical Sources (EHR/HIE)From Clinical Sources (EHR/HIE)

A 75-year-old white, non-Hispanic woman with diabetes (for 5 years), hypertension (for 10 years),elevated cholesterol, and painful osteoarthritis Has no recognized microvascular or macrovasculardisease and no symptoms related to hyperglycemia. She has attended diabetic education classesand modified her diet and activity. Her medications include glyburide, atorvastatin, hydrochloro-thiazide, acetaminophen, and aspirin. She has a family history of diabetes and cardiovascular disease. She has never smoked or used alcohol to excess. The review of her systems is unremarkable except for one recent fall, which occurred when she tripped on a throw rug in the bathroom. She was not injured. She is a retired teacher and widow, lives in her own home, values her independence, and has little interest in therapies that would increase her medical costs or change her daily routine. The arthritis limits her ability to exercise. However, she enjoys reading, sewing, sports on TV, and a little flower gardening. Her BMI is 29 (5 ft 4 inches 169 lbs); her BP is 154/76 mmHg supine but 132/70 mmHg while standing without lightheadedness. Her HbA1c is 8.4%, fasting glucose level is 150 mg/dL, total cholesterol 200 mg/dL, LDL cholesterol 110 mg/dL, HDL cholesterol 55 mg/dL, triglycerides 180 mg/dL, serum creatinine 1.2 mg/dL, and urine microalbumin < 20 mg/dL.

Factors in red can be picked up by the HRA risk engine

Feeding the HRA Risk EngineFeeding the HRA Risk EngineFrom Patient Contributions (Portal)From Patient Contributions (Portal)

215 health-related risk factors & preferences in 13 domains

Feeding the HRA Risk Engine Feeding the HRA Risk Engine HRQoL - Meaningful Life ActivitiesHRQoL - Meaningful Life Activities

Feeding the HRA Risk Engine Feeding the HRA Risk Engine HRQoL – Level of Existing DisabilityHRQoL – Level of Existing Disability

Under the Hood of the Risk EngineUnder the Hood of the Risk EngineLife tables & the Cox Proportional HMLife tables & the Cox Proportional HM

Baseline total risk calculated from appropriate population life tables

Log [Personal risk] = b1 x risk(1) + b2 x risk(2) + .... + bn x risk(n)

Total personal risk final probability of dying in each year

Cause-specific baseline risk componentsRisk adjustment coefficients (tailoring)

Breaking down total risk into components

Summing up individual risk components

Calculating personal life table values

Step 1.

Step 2.

Step 3.

Step 4.

(log relative hazard)

Life table conversion into Life Expectancies for each year

// //

Parametric estimates: (for clinicians)- ELE, EHE/DFLE, [RRI/RRR]

Visual-analog derivatives: (for patients)- RealAge, Wellness Score

Qualitative assessment:- Health strengths and challenges

Total health benefit:- Total life-years gained

Individual health benefit:- Estimated impacts of attaining individual patient goals

HRA ReportReport

PersonalizationPersonalization

PrioritizatioPrioritizationn

““Set”: Setting Goals and Set”: Setting Goals and Strategies (Wellness Plan)Strategies (Wellness Plan)

1) The HRA Report forms the basis of a more effective and clinically meaningful discussion

2) Areas that need improvement are stratified in the order of the magnitude of health impact (law of diminishing returns)

3) Considering patient readiness for change can be integrated into the process “organically” via goal setting

4) Status of heath and a sense of change in “unmeasurable” areas can be visualized and grasped: the needle moves

5) Report is just a starting point, the Plan can be further tailored (patient activation & empowerment)

““Go”: Putting Systems In Go”: Putting Systems In Place to Respond to NeedsPlace to Respond to Needs

1) Personnel are trained and dedicated to “clinical pathways”2) Office provides some patient outreach (proactive care)3) Reinstating annual wellness visits (e.g., Medicare AWVs)4) Patient retraining: “homework” must be done before visit5) Fostering a culture of patient accountability and participation6) Connecting to practice and community resources7) EHRs are augmented with registry/reminder/HRA and more

sophisticated clinical decision support technology8) Creative approaches implemented to fund these activities

(not leaving money on the table), a temporary measure

The “Clinical Pathways” or “Prevention on Rails” approach

A System Example: HIE-Level A System Example: HIE-Level Clinical Decision-Support Clinical Decision-Support

The Wellness Portal StudyThe Wellness Portal Study(AHRQ (AHRQ 1R18HS017188-01; 2008 - 2011)1R18HS017188-01; 2008 - 2011)

Aims:

Develop, field test, and refine a web-based patient Wellness Portal linked to an existing and tested practice portal (PSRS) in primary care practices (2008)

Determine the impact of the Wellness Portal on patient-centered preventive care by examining the behavior and experiences of both patients and practices and the degree to which recommended services are individualized and delivered (2009-2010)

Disseminate the Portal technology and lessons learned from the Wellness Portal trial (2011)

Results of the Wellness Portal RCT Results of the Wellness Portal RCT (N=422; 8 practices; 2009-2011)(N=422; 8 practices; 2009-2011)

• High level of “meaningful” utilization (73% of patients; 576 sessions)• Significantly improved uptake of preventive services (avg. 25% increase)• Despite lower average number of visits in Portal group (2.9 vs. 4.3)• Improved patient-centeredness of care (CAHPS-PCC10)• Substantially more community linkages established (OR=8.22)• More self-management support in Portal practices (OR=2.00)• More robust care delivery systems are established (OR=1.72)• Higher level of preventive care integration (OR=1.80)• Significant increase in patient activation (PAM 45 -> 47; 2nd to 3rd stage)• Considerable decrease in missed opportunities for preventive care (25%)• Rich and meaningful patient and clinician feedback about the process

Results of the HRA ImplementationResults of the HRA ImplementationTrial (Global Health Indicators)Trial (Global Health Indicators)

• The mean increase in Estimated Life Expectancy (ELE) across the intervention population was 8 months higher than expected based on a 12-month time difference and 6 months higher than in the control group (13 vs. 7 months; P<0.001).

• While the mean increase in “Real Age” was 7 months in the control group, it did not change significantly in the intervention group during the study period (P=0.03).

• “Wellness Score” showed a modest, but significant mean increase from 67.6 to 69.9 in the intervention group compared to control, where there was no significant change (P=0.03).

Results of the HRA ImplementationResults of the HRA ImplementationTrial (Qualitative Feedback)Trial (Qualitative Feedback)

Importance of personal goal attainment:• “The HRA helps me focus on maintaining healthy choices.”• “The website provides a roadmap to getting well.”

Heightened awareness of health impact:• “[The HRA] makes me look at what I am doing to my body.”

Convergence of patient & clinician goals:• “[The HRA] reminds me to go to the doctor more often and stick

to what he tells me to do.”• “It shows me what areas to focus on improving or minimizing to

make my life healthier.” (i.e.: evidence-based care options)

Suggested future improvements:• More response options and open-ended feedback• Reinforcing the perception of a “complete” personal record• Reminder for preparing personal information (e.g., blood

pressure readings, labs, etc) before HRA completion

https://mpsrs.us/WPortal http://www.okprn.org

ConclusionsConclusionsPersonalization and prioritization of care is one of

the greatest challenges of 21st Century medicineShared goal-setting is the best approach to bothRe-focus current disease-oriented care on personal

goals to achieve true patient-centerednessActivate and involve patients in their care via periodic

comprehensive HRAs, followed by shared decision-

making to generate tailored Wellness PlansPut systems (e.g., clinical pathways) in place to respond to arising needsContinually engage patients via systematic follow-up and health coaching Involve the entire community to improve health via goal-directed careMeasure quality at the personal and community level as the function of

strategic goal attainment

Acknowledgements & Credits Acknowledgements & Credits Funding Sources:

Key Contributors:

PSRS PDA Prototype AHRQ (Grant)PSRS PDA Prototype Testing OK Medicaid (Contract)PSRS Web-based Version OK Medicaid (Contract)Testing in Medicaid Population OK Medicaid (Contract)TRIP Prevention Project AHRQ (Grant)Prevention Nurse Model OCAST (Grant)Medicaid Implementation OK Medicaid (Contract)Patient Wellness Portal AHRQ (Grant, active)K08 Award (HRA development) AHRQ (Grant, active)

James Mold, MD, MPH (PI) Katy D Smith, MS (PEA)Zsolt Nagykaldi, PhD (Co-PI) Crystal Turner, MPH (PEA)Cheryl Aspy, PhD (Co-PI) Cara Vaught, MPH (PEA)Ann Chou, PhD (Co-PI) Eileen Merchen, MS (PEA)Robert Salinas, MD (consultant) OKPRN clinicians and patientsJohn H Wasson, MD (consultant) Portal Advisory Committee Members