Rebooting Healthcare, Towards Personalized Quality Health
In his acceptance speech as he received his Nobel Peace Prize Award in Oslo on December 10, 1964 Martin Luther King said:
“I have the audacity to believe that peoples everywhere can have three meals a day for their bodies, education and culture for their minds, and dignity, equality and freedom for their spirits.”
I think of health in the same frame — I have the audacity to believe that everyone everywhere can have quality health! My journey through medical education, personal health, and working in the healthcare industry has taken me across different geographies and career areas. One of the key drivers of my continued commitment to healthcare is the belief in quality health for everyone. Optimistically, I still have this belief and think so do many others. We wake up each day hoping to leave a legacy of health better than we met it — at the individual, population, public, or global level. Realistically, this will require commitment from everyone because in one way or another we are stakeholders in health. The concept of ‘Health for All’ is not new and is a statement of equity — a genuine hope that all humans have access to great health regardless of what makes them similar or different to one another. It is one of the core parts of the WHO declarations of Alma Ata, from the International Conference on Primary Health Care, Alma-Ata, USSR in 1978, a subject of discussion during my medical education. More recently, the COVID-19 pandemic revealed that the fate of our health as a humanity is interconnected, the contributions of numerous factors to health and the impact of health on every other aspects of our lives.
For many across the United States, the month of March 2021 marked the one-year anniversary of major changes in lives due to the pandemic: stay-at-home order, work-from-home, school cancellations, social and professional event cancellations, medical and surgical visit cancellations, and so much more. In this period, individuals and families had to adapt in various ways to maintain health and livelihood. Businesses, corporations, and governments also had to adapt in various ways to sustain revenue and the economy. As a nation, we have gone through series of emotion — confusion, anxiety, loss — before the recent rays of hope with effective therapies and vaccines. Several publications (example) have described the impact of the COVID-19 pandemic on socioeconomic situations and highlighted its exacerbation of prior observed disparities. In response to the challenges, many industries including healthcare have responded with or doubled down on:
- Agile decision making,
- Acceleration of technology investment (most notably digital including telehealth),
- Deployment of new business models,
- Partnerships — even unexpected ones among competitors,
- Revision of data collection and standards,
- Streamlined data-sharing,
- Application of machine learning,
and much more, to reduce infection rates, death rates, and limit the impact of the pandemic on healthcare outcomes and revenue. This forced re-imagination of care provision and health is a great opportunity to reboot the healthcare industry from ground up. Consequently, I think we should not be focused on returning to ‘normal’ but on creating new ways of delivering care.
Though the pandemic revealed many weaknesses in care delivery, it also showed what is possible with willpower, innovation, and collective effort in public health and medical care. More than the rapid innovative strategies in workforce, technology, data & analytics, etc. to reach the desired outcomes for health, this period of recovery is the perfect time to redesign care with a foundation of equitable access, keeping the needs of each individual in mind. It is our collective responsibility to ensure that the knowledge of what makes individuals different, in-depth understanding of customers and identification of their unmet needs as well as deep motivators for health, is put into consideration at every point of care. It is time to translate the various findings from many years of research in health equity into action, incorporating it in health system operations, innovative product and service design, and program implementation.
Some of these considerations include but are not limited to:
- Age
- Sex at birth
- Race and ethnicity
- Functional status or disability
- Social and economic situations
- Psychological and behavioral conditions
Age
Age is an important factor to keep in mind for individuals, not only the clinical picture but also the specific needs, in research and care delivery. For example, for the elderly, special considerations need to be given to privacy, security, interest to age-in-place vs. community living, and the important roles that caregivers play. Opportunities here include a focus on education that formulate healthy behaviors in the young, health maintenance promotion in middle-age, and access to tailored healthcare important to the elderly such as management of polychronic conditions and advanced care planning.
Sex at Birth
In the absence of rare chromosomal variants, everyone has 23 pairs of chromosomes and differ on the sex chromosome — XX or XY. Ignoring this important distinction in the approach to prevalence, presentation, diagnosis, and management of disease conditions could result in poor outcomes. There are also diseases that are primarily found in either sexes or instances that one of the sexes have poorer prognosis.
Women
In medicine, some researchers have described women as being understudied, under-diagnosed, and under-treated. Male patterns dominate many clinical protocols and guidelines even in conditions where clinical presentation differ with sex, such as in cardiovascular diseases. For example, while the classic presentation of heart attack includes symptoms, like chest heaviness and pain radiating down the left arm, women may have more diffuse symptoms such as fatigue, mild discomfort, and even nausea attributed to underlying microvascular pathology in some research. Women are also more likely to have a silent heart attack, with no obvious symptoms.
Other medical areas of observed differences include stroke diagnosis, prescription / dosing, pain management, mental health (over-diagnoses), and hormone biochemistry. Current women’s health practices also need to go beyond pregnancy and issues with the reproductive health of women to include the research and application of current knowledge of the cellular and physiological differences that can be attributed to sex. Some of these omissions can be traced to clinical research and clinical trials in which women were not historically included or analyses along gender lines were not conducted.
Men
Estimation of life expectancy has shown consistently over the years that life expectancy of men is less than that of women. Men die younger than women, and they are more burdened by illness during life. They fall ill at a younger age and have more chronic illnesses than women. With the relative abundance of research on men health, the most actionable component will be the translation of findings into actions. Some recommendations for better men health include a focus on designing care in ways that encourage more men to access preventive healthcare including mental health, propagation of healthy habits and behavior, and social reexamination of masculinity with attention to safety and health.
Race and Ethnicity
The role of race in health has long been identified but has suffered being understudied especially for minority races in the United States. With the diverse races present, it is important to first understand and then tailor healthcare delivery in a way that advances the value of inclusion. This will include intentional efforts for clinical trials and research to account for all races as best possible. Several statistics that serve as indicators of health shows disparities in public health, individual health, and provision of healthcare services to minorities and minority communities especially Black / African Americans and Native Americans. Both individual and systemic racism (for example poor treatment of pain for persons from the Black race) has sown distrust and has persistently alienated black communities from access to much needed care. This in turn leads to lower utilization of basic and routine services, higher utilization of emergency services, statistics such as higher incidence and poorer health outcomes in Diabetes, Hypertension, Maternal Mortality to mention a few. Black, American Indian, Alaska Native, and Latinx persons and communities have also suffered the most during the COVID-19 pandemic and the uptake of vaccines among these individuals and communities require a more intense effort.
Functional Status or Disability
Functional disability types according to the CDC include mobility, cognition, independent living, hearing, vision, and self-care. CDC estimates that about 1 in 4 adults in the US have some type of disability and that disability is more common in the elderly, women, Non-Hispanic American Indians, and Alaska Natives. It also has implications for higher prevalence of certain clinical conditions such as obesity, smoking, diabetes, etc. Functional status can change or be exacerbated by new events for example, a fall that hurts the back. Each type of disability and a mix could result in difficulty in performing basic everyday tasks such as taking a bath or more complex tasks needed for independent living such as driving thus hampering attitude and access to care. Services and technology products need to be developed with accessibility accommodations in mind such as voice-over + braille for the visually impaired.
Social and Economic Situations
Several social and economic circumstances play a huge role in the attitude towards, adoption of and access to health. Some are addressed under the social determinants of health which in some research may contribute up to 80% health outcomes of individuals and communities. Some of these factors include obvious ones such as income, food, education, housing, objective and perceived social status, transportation, and neighborhood characteristics. The often-overlooked social constructs such as social support, broadband/digital divide, immigration status, trauma and violence, religion, language, gender identity, sexual orientation, racism, ageism, classism, etc. are all equally important components to consider in access to quality personalized healthcare, better health outcomes, and creating trust in the health system.
Psychological and Behavioral Conditions
In addition to the essential value of including mental health in evaluation of overall health, the last mile of adoption of healthy behaviors and seeking care lies in the activation of each person, using what works best for their situation. The struggle to implement safe, preventive and healthy practices during the pandemic is a great example of the challenges and opportunity in behavior modification. Many adults have previously formed opinions and attitudes to health which could be corrected or accounted for. Several behavior-modifying techniques and tools available from years of neuropsychologic and behavioral research such as gamification, triggers, and social connections can be better applied to continually engage, delight and captivate individuals on their healthcare journey.
Context for Our Thinking Going Forward
Transition to Digital Health and existing Electronic Health Records (EHR) has not kept up with the demands for health information needed for whole person care, consequent to the evolution of these factors in the society. Important patient data is either still not collected at all or is stored in notes and other areas of the medical record where they are not easily accessible for research, clinical operations, and social interventions. In the past few years, and accelerated by the pandemic, attention has turned to the importance of appropriately collecting these important pieces of information and opportunities to have them available to the care teams at various points of care (example Gravity Project), so they can provide the best care experience for patients. There is a general recognition of the importance of the awareness of health disparities, determinants of health, and creation of personalized treatment and management plans. However, a big question is how will care teams (physicians, nurses, PT, etc.) who are already stretched with the current data and operational situations of care, extend to accommodate the needs to achieve the lofty goal of personalized care? This is where carefully designed technology can support efforts of providers from collection of relevant data to the generation of clinically actionable insights. Current tools (such as for Remote Patient Monitoring (RPM) and the EHR) can be expanded to capture other relevant data points, algorithms responsibly created and trained with unbiased/de-biased data can be coupled with up-to-date guidelines for clinical decision support to supplement the efforts of health care providers at point of care. All with the inclusion of care teams and clients/patients in the development process.
Even though medical care contributes 10–20% to health outcomes, it sits at a very important position to identify needs and serve as a connector to resources that address other important factors necessary to improve health. This post-pandemic period is an opportunity to begin or continue to empower health systems and services to meet individual needs for health. In a few instances, it may be necessary to flip the typical approach of 80/20 rule over its head – where designing with the minority or underserved in mind may help get closer to meeting the needs of everyone. Recent experimentation with innovative ideas and shifts from ‘product or technology-focused’ to ‘human-focused’ or ‘human-centered design’, create many opportunities for progress. However, as legacy systems rethink offerings and new entrants into healthcare gain more prominence in creating solutions, it is imperative that these factors and important stakeholders are put into consideration when designing for health. Life does not exist in isolation — individuals at different points in time have an interplay of many or all the above listed factors (which is in no way an exhaustive list). For a successful transition, this renewed focus requires in-depth understanding of customers (patients, providers and consumers) and identification of their unmet needs — medical and social — as well as their deep motivators for health.
The goal of quality, personalized health for all is a collective responsibility, do you believe this? What are you working on in this direction?
About me: I am a Senior Director of Health Informatics at Optum. I was on the Fusion team as part of my experience in the Optum Access program. My three things are Health, Education and Equity, and as a Physician and Informatics Specialist, I employ those lenses in bringing value to various stakeholders in healthcare. I also enjoy empowering the next generation of STEM and healthcare leaders. Want to know more? You can find me on LinkedIn: https://www.linkedin.com/in/bilikisjumokeakindele/
A Fusion publication. We are employees of UHG and these views are our own and not those of the company nor its affiliates.
