Daily Archives: October 7, 2011

Market Potential for P4 Medicine

In a health care environment where an estimated 72 percent of first-line treatments for cancer don’t work for that first-line use, the time is right to improve upon that statistic by speeding the development of personalized medicine, says Gerald McDougall, partner in charge of the health sciences practice at the firm PricewaterhouseCoopers.

“We have to continue to invest in the underlying mechanism of disease and move away from reactive treatment of medicine,” he said.

PWC is an accounting and tax firm, but is also a consultancy; health care is its largest growing area. McDougall says the firm’s perspective is that health care is undergoing massive convergence, and as a result there will be many new opportunities for partnerships and alliances.

“Personalized medicine, we feel, is a driving force behind this convergence,” he said. Though some segments of health care still struggle to define personalized medicine, PWC assists in that effort. “The commonalities are health and treatment of illness,” McDougall said.

Scientific advancement and a culture of wellness are also converging to drive a huge and booming market for personalized medicine, he said. Currently a $232 billion market, it is projected to grow 11 percent annually to $452 billion by 2015. Diagnostics in particular “is an exploding area,” McDougall said.

How does PWC engage in this industry? The firm was involved in the design and implementation of TGen – the Translational Genomics Research Institute in Arizona. Key efforts included conducting a feasibility study and assessment; affiliation agreements with academic and clinical partners; business and financial planning; strategic, operations and facilities planning; overall operational implementation; and board development.

The broad reach of social media will have a role in helping establish partnerships and communicating successes, McDougall noted.

Personalized Screening for Athletes at High Risk for ACL Injuries


Timothy Hewett, PhD, FACSM; Director of Research, The Ohio State University Sports Health and Performance Institute. Dr. Hewitt specializes in researching ways to prevent ACL injuries in young women.

100,000 – 250,000 ACL injuries occur each year in the U.S. Females are between 2 and 10 times more likely to tear their ACL than men, especially women participating in high-risk landing/cutting/jumping activities. The ACL is a sensor full of mechano-receptors and the tissue senses the positioning of the knee joint in three-dimensional space. Once the ACL is torn, this sensor does not work properly. Deficient neuromuscular control may contribute to ACL injury risk.  Following an ACL tear, the ability to generate power is significantly reduced. The female athletes have a lot more force, with less power to control that force. Women have significantly less ability to balance on a single limb after ACL tear/surgery than men in a similar situation.

Once you tear one ACL, your risk of tearing another ACL is much more likely. Neuromuscular repair is limited once an ACL tear occurs. When athletes return to sports, post-ACL reconstruction, their landing force profiles are abnormal. Force on non-operated limb is reduced. 23% (1 in 4) women will tear a second ACL. Five times higher risk in women than in men for a second ACL tear.

Those with a second ACL injury had an internal hip turn when jumping and landing. A neuromuscular control loss will cause the non-injured side of your body to drop to equalize.

Coupled biomechanical studies identify risk of ACL tears in women. We need to evaluate a greater number of athletes to get more data. After evaluation, athletes go out and play as usual and follow-up is done with athletes if they at some point tear their ACL.

Physical therapy is changing to try and address potential issues in advance. Move toward technique progression, stability progression, single leg lateral progression, symmetry side to side, single leg rotator progression and lateral trunk progressions are being done with athletes in this study. The goal is to get athletes back to their sport, while also evaluating their movements.

ACL injuries are genetically based. Filing information in web portals is helping keep data in one place. “Understanding and Preventing ACL Injuries” is a great resource for additional information about preventing ACL injuries.

Would this screening ever be incorporated into school physicals?

Yes. We are hoping to get these studies incorporated into PPEs (already being done). Encourage your local study reviewer to support the grant to help get this incorporated into pre-sports physicals.

Transparency and Accountability in Genomic Medicine

Michael Millenson, president of Health Quality Advisors, calls himself a tourist in the world of personalized medicine. He comes from the health services world, and he has devoted time to exploring the information age, and specifically the world of genomic information.

“The question I want to answer for the health services world is what is happening in practice in the world of genomics that affects everyday care? Not what could be, what might be, what will be, or what should be, but what is happening …  that I should pay attention to?” he said.

He agrees with proponents of personalized medicine that it has plenty of potential to be beneficial to patients. But he believes some parts of the fledgling industry have strayed from reality by overpromising the potential or flat out misrepresenting – and overstating – how much authentic personalized medicine is actually practiced routinely in the United States today. In short, he says, there is too much hype.

“If you are in the business of promoting a technology for capitalistic purposes … you only talk about how people are not using enough of your product. If you’re in the … medical provision business, you try to be a little more objective,” he said.

His suggestions from a so-called tourist:

  • Change the signs: Millenson contends that personalized medicine is a marketing term and that it is inaccurate. He recommends “clinical genomics” or “personalized genetic medicine.”
  • Make the attractions clearer by offering more solid information and less boosterism.
  • Open the roads in both directions: Engage the mainstream health services, research and policy communities. “Let your enthusiasm and knowledge interact with their skepticism and fear,” he said.

“Everybody who does this has a passion for it. You wouldn’t do it if you didn’t have a passion for it. So let’s reach out to those communities, and have the road go in both directions,” he said.

 

Ohio as a Center of Healthcare Reform

Steve Allen, MD; CEO, Nationwide Children’s Hospital, Steven G. Gabbe, MD; CEO, The Ohio State University Medical Center and Gerald McDougall, head of the health practice for PricewaterhouseCoopers discuss the impact of healthcare reform.

In this time of health care reform, where in many ways providers are getting pressure to reduce spending with an expectation for more durable outcomes, what are our system needs to deal with this? What changes do you see on the horizon?

 Allen: In pediatric health care, the pressures are a little different from adult population. So much of what we do is related to Medicaid – in most pediatric hospitals more than 50 percent of patients are covered by Medicaid. Where we see challenges: We have to figure out how to provide care for a lower cost. We go through an initiative every year to cut our expenses so we can continue to support our mission. We have to learn how to manage the population’s health better. I feel very strongly that whatever direction health reform takes, we will be compensated on how well we manage clinical outcomes over a long period of time, not just acute episodes.

 Gabbe: The Affordable Care act is going to force us to do the right thing: look at health care longitudinally provide care of the highest quality and highest safety, while also reducing readmissions and assessing those patients at the highest risk. Another challenge in academic medical centers is that our bottom line is what we have used traditionally to fund our education, research and new program missions. That bottom line is going to be constrained. We’re going to get paid less for what we don’t do well, perhaps a little bit more for what we do well, but we’re going to have to find other sources of financial support for research, education and unique and innovative programs that we have developed and want to develop. Patient care itself, the pillar for funding sources, is not going to be there as it has in the past.

 McDougall: No matter what happens in political dynamics, structural shifts will occur and evolve. It’s important for policymakers and the public to understand the context of academic medical centers. Does Washington understand they approach $600 billion in our economy? What would Columbus be without Ohio State Medical Center as an economic driver? Sometimes the value of education and research is not realized as a unique asset.

 Gabbe: Columbus health care provides 36,000 jobs.

We hear about the need for better care coordination. How does that play out in improving the health of our population?

 Allen: We have 300,000 children for whom we are responsible for their clinical and economic outcomes. That has allowed us to change our behavior so we do more things to prevent them from going into the hospital and produce better outcomes. Infant mortality in this country is higher than in most developed countries and the No. 1 thing driving that is prematurity. It’s big business for children’s hospitals across the country. But it would be so much better for those babies and their families and our society if those babies didn’t arrive so early. We are partnering to prolong pregnancies and decrease NICU utilization. That is counter to economic interests of hospitals, but it is the right thing to do with society’s dollars allocated to health care.

 Gabbe: Most care we deliver has been episodic with very little interaction with the health system between those episodes. EMR is changing our ability to coordinate care. At Ohio State most patients we see for hospitalization are outside Franklin County. We need to make sure when they’re hospitalized that spend as much time planning for their discharge as we do providing their care. Patients need to go home to a welcoming health care environment. We should coordinate our efforts with the primary care community, make sure patients go home with right medications and know how to take them, ensure they see their primary care physician in a timely way. That’s how we’re going to impact readmissions and wellness once that patient goes home.

McDougall: Behavioral health is a big component of costs. We need to do a better job in behavioral health that I think we’ve been grossly underfunding for the longest time. Now we’re paying for it.

Governor Kasich is very interested in commercialization and owning the technology-based economy for the state of Ohio. How do you see this fitting into our plans? What types of partnerships might we see in the future, because revenue streams from the past may not be there as much as they have been in the past.

Gabbe: Ohio has seven medical schools, three of them have clinical and translational science awards from the NIH. Linking medical schools and medical centers to develop common IRBs, shared use of biorepositories and electronic medical records will help create clinical research organizations. Governor Kasich and we (at OSU) believe that we have a great opportunity to develop clinical research organizations in the state that can be the research basis for new drug development and technology transfer and new revenue sources for our medical schools.

McDougall: Need to have an organic strategy (very costly with great barriers to entry). This is still very important.

Retention – create an environment where companies are grown and retained.

Recruitment – Recruit companies at a global level. Role of the academic medical center in knowledge is a huge opportunity where a multitude of different funding sources that didn’t exist five years ago, exist today. Opportunities are endless. Execution of those opportunities is challenging. This takes a lot of patience, planning and alignment.

Gabbe: First Customer Concept – Agreement by a group of academic medical centers, that when an inventor comes up with new technology, we as a group of academic medical centers will do whatever we can to evaluate, refine and implement the new technology, leading to improved patient care.

Because of accountable care act and other requirements, we have a lot of hospital systems asking for assistance to develop efficiencies. Will we see more hospital mergers between academic centers moving forward to address these issues?

Jerry: Identifying how to develop coordinated care and also the health economics situation is a work in progress.

How do we cut our spending instead of preserving it?

Gabbe: We have to practice evidence-based medicine. We need to have difficult conversations about end of life care. 25% of medicare costs surround end of life care. There will be a big change around people’s expectations overall.

Where do you see things going?

Gabbe: Healthcare continues to attract the best and brightest people. Medicine has great rewards. Every day you pick up the newspaper and hear a story about healthcare, because that’s how we’re going to make this better and keep the conversation going. The future of medicine is very bright.

 

Creating a Consumer-Focused Environment for Participatory Health Care

Patient Engagement Through the Use of Information Technology

Ohio State University Medical Center created the OSUMyChart portal, which gives patients an online connection with their health care provider’s office, easing renewal of prescriptions and appointment scheduling. More than 21,000 patients use the system to read and compare test results, view their medical records, and communicate to the doctors and nurses from the convenience of their homes.

The portal has a feature called an e-visit that allows health care providers to use email to advise patients regarding minor symptoms. The system is also able to provide patient monitoring at home, as patients can upload results into the system. Online patient surveys also may be administered through the system.

“Patients responded very favorably to this, as did physicians. … Having patients engaged has always been important to me,” said Milisa Rizer, a family medicine physician and clinical director of EMR at Ohio State’s Medical Center.

Patients own their records and can take the information via a data format that’s transferable – allowing them to keep their health information available in the event that they need care while traveling, for example. The online collection of data also allows patients to provide some personal details – such as tobacco or alcohol use – without any embarrassment that some might feel in a face-to-face interview.

“It allows us to get much better data,” Rizer said.

Encouraging Patient Participation Through Social Media

Cleveland Clinic also uses MyChart, noted Kathryn Teng, director of the Center for Personalized Healthcare at the Cleveland Clinic. She described efforts to engage patients who are not already in the Clinic’s system.

Facebook is a good example of engagement, Teng says. It has a common theme: Users want to feel that they are special and unique, and want to share that with others. And it’s personalized. In health care, clinicians want to embrace that same concept by convincing patients that they are unique in their genetic makeup, environmental exposures and behaviors, and all that contributes to their health.

One strategy at the Clinic is linking personal uniqueness with family history and ancestry. Family history is the most accurate predictor for disease. “Knowing who we are genetically … helps us to make better choices when it is our turn to carry our family’s genes,” she said.

Statistics about social media use support the idea of using these tools to engage patients. The Clinic has an active social media strategy using Facebook, Twitter and YouTube videos. The Clinic prompts dialogue on Facebook about a health care topic and then directs patients back to Clinic websites for more information. Twitter is used to update live events and post daily health tips. The strategy seems to be paying off: Social media is ahead of word-of-mouth in generating brand awareness. Web visits, contacts and appointments are all up by about 25 percent.

The primary audience is patients rather than clinicians. When they are driven to the website, they might find Teng’s blog about personalized health care and what it can mean, or the main Personalized Healthcare site.

Employee Wellness – Ohio State’s Your Plan for Health Program

Gretchen Feldmann, benefits strategy & engagement manager in the Office of Human Resources at Ohio State, discussed how promoting health and wellness among faculty and staff is an important business strategy for the university.

The goals of Ohio State’s program, Your Plan For Health (YP4H), include: optimizing wellness and improving productivity among employees; maintaining and strengthening Ohio State’s “Employer of Choice” status by demonstrating culture of support; and reducing health care cost inflation – and allocating those savings to faculty and staff salaries and initiatives.

The university took a staggered approach; programs were rolled out gradually so “people could be comfortable with it, and could embrace it,” Feldmann said. Between 2006-09, the program was focused on three initiatives: faculty and staff engagement, health risks identification and management, and reducing barriers to obtaining health care. It’s now a comprehensive program offering multiple benefits and opportunities.

Risk stabilization or actual health improvement of continuously enrolled faculty and staff resulted in positive health change that represented approximately $3 million in avoided costs in 2008. Meanwhile, an 8 percent increase in health care costs between 2006 and 2010 can be attributed to an aging employee population, and the prevalence of chronic diseases in employees and dependents – making it critical to continue partnering across the medical center to implement P4 medicine and keep faculty and staff engaged in the way that works best for them.

“We’re able to … control our health care cost trend, and show our health plan utilization is being controlled,” she said.

YP4H 2.0, a second iteration of the program, represents the need “to take it to the next level,” Feldmann said. This program:

• Encourages making health/wellness social norm
• Focuses on engagement in a healthy lifestyle
• Approaches creation of a personalized model
• Educates faculty and staff about the relationship between health care costs and behavior

For 2012 and beyond, plans are to optimize plan design and funding, providing incentives that promote health and help associate member benefit costs with health choices; transforming health care delivery, allowing members participate in health-care decisions; and managing members’ care by reducing risk factors to optimize health and productivity.

Panel Discussion

Q: The patients you really need to reach the most are those who don’t have access to technology. How can they be engaged?

Teng: Patients with low socioeconomic backgrounds do tend to have powerful cell phones, if not more technology. We do need to go out to where people live and teach them about their health.

Rizer: My first question to patients is: Do you have computer access? Many say yes. But churches, libraries and other community resources offer that opportunity to patients. We need to know where we can identify opportunities for them.

Feldmann: Some employees do not have a computer at work. We go into colleges, departments and other units to schedule biometric health screenings, and have capabilities to complete health assessments at these events.

Q: As you increase number of patients that have MyChart, it seems that that would increase the time you spend following them. How much has that increased as a percentage of your time?

Rizer: It decreases my time spent on patient communication. Patients can get their labs easily, for example. My need to write a letter is now replaced by just a quick note that goes out in an electronic message. Electronic visits are things I would have had to answer on the phone, and this reduces the time I need to track down patients by phone. It has been much better for me from a time perspective.

Teng: People limit their comments when they communicate electronically, so it is much faster than talking on the phone.

Q: The amount of information on the EMR and the amount of email communication daily is a challenge. What other resources can we utilize? Most of these questions don’t need physician attention. When we launched a departmental Facebook page, I was enthusiastic to participate. But I didn’t want to be combining it with connections to old friends. What other resources do we need?

Teng: For social media activity, you need institutional resources dedicated to marketing communication, and specifically people who can advise the clinicians posting about the communication itself. Our Facebook is all at an institutional level and does not involve my personal account.

Feldmann: From a YP4H perspective, we implemented the biometric screenings to help with management of physician time. The results can be sent to a doctor and be done in lieu of an annual exam.

Rizer: Some emails can be routed to a pool of office staff who can do the first triage of messages to make sure those that require a physician’s input do go to physicians.

Q: How do we help patients find the right information from the right sources online?

Moderator Dave deBronkart: Patient communities are very good at suggesting reliable online sources.

Rizer: I think OSU should be out front in directing patients to sites that we think are meaningful and helpful.

Teng: Large hospital systems have a reputation in the community and patients trust what we’re telling them so we have to be careful about what we recommend. There must be a more systematic way to do this. In the medical community at large, that is very variable at this time.

Feldmann: Personalized action plans in YP4H will equip patients with how they can accomplish action items, including providing them with resources and information.

Making Connections to the Whole Patient

Ann Pendleton-Jullian; Walter H.Kidd Professor, Austin E. Knowlton School of Architecture, The Ohio State University, discusses the importance of creating complex and adaptive systems in health care.

Conflict exists between patient needs and insurance companies. Because of this, we need a new set of approaches and models different than what we have had up to this point. We are in a system of change and you cannot engineer for change because each moment of the system, changes the system.

Design has generally been deployed for designing things (content) and we need to begin thinking about designing contexts for human life to play out inside of it. Instead of just building spaces, buildings, cities, territories, we need to focus on building ecosystems. Design to date has been seen as embedded in business. Design sits inside of business, culture and nature. We have a responsibility to take on big problems whether they are environmental, poverty or healthcare.

Design by nature works on complex problems. In a learning healthcare system, you work and then calibrate, do some more work and then re-calibrate. You can try multiple paths and work on several things at once.

Disease is maladaptive aging. Medicine focuses on designing for change. Health is dynamic and is a complex, evolving condition. Ecosystems are alive and they are environments – everything feeds back into the system and affects the entire system.

Personalized healthcare must be a complex, adapting system.

Language is a socio-technical phenomenon. It is technical in nature – has science and linguistics structure, but serves the social function.

When defining complex systems, chaos is on one side and order is on the other side. Order can be 100% knowable and planned, but chaos cannot be. Complexity lies between order and chaos. Everything that is done, feeds back in and affects the entire system. For example: Every time you make a move in chess, you’ve changed the rest of the game.

You can do things to complex problems and move them to be just “complicated.” Some things will always stay chaotic, so you must move them before you do anything else, so they can be moved to a place where you can work on them. You cannot solve complexity or even model complex systems, because the system is the model.

Hotspotting Heart Health

600 of 65,000 people at OSU take up $80M of $250M (1/3 of the money, which is significant).

Work on the short term (the patients we actually see) to help patients work toward good health long-term.  Identify core principles, metrics, new mechanisms and means.

We need to identify new ways to look at the social side and new mechanisms of discovery and action for impact. Participatory is the most difficult of the 4 Ps. We need intrinsic motivations from birth throughout life. If you cannot solve the problem, then work toward positive change.

Things can be placed in the system to read the system, including genetic and epigenetic data, and implantable devices.

Micro-narratives are not about surveys or social scientists, but about the person giving you their story in their own words, from their perspective.

Methodological logic:

  • Start with a prompting question
  • Listen to the story
  • Doesn’t matter if story was true or not, because the person will act in accordance with the story they believe
  • Act on the signals

Our social networks have a lot to do with our own behavior. If the people in your network are obese, there’s a good chance you will be also.

How does your social network scaffold you?

Gamification

Modulators  are things you put in the system to affect change in the system.

Games and gamification provide a powerful, intrinsic motivation. How do you harness your social network and create a network of people regularly feeding into your system to help you get better (after brain injury, for example)?

Building a game layer on top of the world begins to be about influence and how to influence behavior. For example, World of Work Craft  is a motivational device to help people get healthier in the workplace.

The capacity to adapt and change to changing technological circumstances is critical. Technology has to be very sophisticated and very simple for users at the same time.

Q & As:

How will we recognize when we see core things coming out and identifying the core parts of this?

Certain things that scale. Things that scale are really valuable. Things within heart health will work with other things as well.

Principles behind gamification

Gamification often talked about as reward programs. Leveraging up is important, so you’re leveraging accomplishmenet and using it to move people forward. The “fun” factor is also important.

Where will change come from and what is the role of resources?

Change can be affected in several different ways. Understand the system you’re working on. Change needs to come from the top. The things ysou do begin to be exemplary for others. Work on the things people care least about first, so fewer people will be focusing on you. Many patients don’t feel empowered, so you need to create mechanisms that allow better comprehension and a feeling of empowerment for patients. You learn from every patient and every patient visit.