Now please welcome Dr. Thomas Lee,
editorial board member of the New
England Journal of Medicine, Chief
Medical Officer of Press Ganey, and
a practicing internist and cardiologist at
Brigham and Women's Hospital. Thanks very much.
You know, welcome to the NEJM
Catalyst 2017 meeting on Patient
Engagement. Today we're going to hear
some terrific speakers give short talks,
but then interact with each other and
interact with you and hopefully create
some new knowledge about how we can get
the system to work better within
itself and to work better with patients
so we can improve their outcomes and do
so more efficiently. This meeting is
part of an ongoing effort by the NEJM Group
to try to help the health care
system move toward higher value more
quickly. In previous meetings over the
last couple of years our other themes
have included the new marketplace, care
redesign, leadership, but, at the end of
the day, it comes down to getting
patients to work together better with us
and with themselves so that they can
have better outcomes. So, this meeting is
really where the rubber meets the road.
We try to bring together, in NEJM
Catalyst, people that you might not run
into in the course of your daily life and
who might not run into each other. What a
catalyst is, I think many of you will
remember from high school chemistry, is
something that puts two things in
position with each other so that
reactions can take place faster than
they might otherwise would. That is very
much what we're trying to do today in
these three panels. The key theme for the
first panel is from two innovators who
have been working to try to make the
interface between technology and
patients better and more reliable. We
have two terrific young leaders. One's
leading the research on design at a
brand new medical school that only opened its
doors and took in its very first
students less than one year ago.
The other one's also young. Seven years ago
he was a first-year medical student who
was shadowing me for an afternoon in my
management roles, and now he's the
the CEO of a six-year-old startup,
which is doing exciting work that you'll
be hearing about, and was a terrific
afternoon shadow with me, obviously.
The second panel is going to focus on
understanding the worth and potential of
social networks and how that's coming
into play today. I think we all know that
the doctor/patient relationship remains
very, very important, but anyone who takes
care of patients or anyone who's taking
care of parents knows that there are
social networks on both sides of that
relationship now. Medicine is a team
sport. How clinicians work together to
take care of patients is really
important and the fact is that how
patients interact with the families, how
clinicians work with the families
surrounding patients, is also hugely
important. How those families work
together is important. We have two
folks who have been working on this kind
of question, on a variety of, from a variety of
perspectives; they both blend
perspectives. We have a leading primary
care physician economist from the
University of Pennsylvania and we have a
colleague who also studies interventions
for improving chronic disease but has
been doing that both academically but as
but also in Michigan and in the third
world and her real-world experiences
combined with the sort of thinking from
behavioral economics will be part of
what comes to life in the
second panel. The third panel is going to
focus on how we move providers from
loosely associated social networks into
real teams and so we can make
coordinated, compassionate care hardwired.
We're going to hear from the Chief
Medical Officer of an organization that
focuses on the most vulnerable and
complex patients in my hometown, Boston,
and also the key leader of one of the
largest and best integrated delivery
systems in the country. That delivery
system, Kaiser Permanente, is our host
today and provides the perfect place for
these discussions. KP Southern California
is our immediate host here and you're
going to hear from, in our third panel,
from one of its leaders who you've
already met, Nirav Shah, the
senior VP and COO for clinical
operations, someone who I think has been
one of the most important, effective
forces for improvement, both here at KP and
before that as New York State
Commissioner of Health. The work that he and
his colleagues at KP have been doing on
high-risk patients frankly makes me
jealous as an academic,
you know, jealous as a clinician.
You're in for a real treat today.
Now, our speakers won't be giving long
talks; they're going to be talking to
each other and with the moderators and
with you. I hope you'll silence your
beepers and phones so you can give
them their full attention.
At the end of each session, we'll be
taking questions from the panelists from
our live and our virtual audience.
For those of you in the room, you can submit
your questions via index cards in your
packet, and those of you who are online, you
can do it via the web. The full event's
being recorded and will be available in
a few days. We'll be live Tweeting this
event using the hashtag '#PatientEngage17.'
Now to open our meeting, we'll first
hear from the leader of the NEJM Catalyst
patient engagement theme, Kevin Volpp,
from the University of Pennsylvania.
I think many of us would agree:
among the very most important and
influential behavioral economists in the
country and a primary care physician.
He's performed so much great research on
behavioral change, in clinicians and in patients,
and he created the vision for
this NEJM Catalyst theme, patient
engagement, and this meeting today.
Ladies and gentlemen Kevin Volpp.
The US ranks first in health spending
and 26th and life expectancy. I think we
would all agree this is not a motto we'd
be proud of and we should be able to do
better than this,
so let's think about what we might do
about that in the context of heart
attacks, the number one killer of
Americans, imagine you wanted to prevent
as many heart attacks as possible in the
US over the next five years.
Furthermore, imagine you control all
research spending in the United States.
Would you put your budget into
A. developing more effective treatments
B. developing a vaccine
or C. increasing adherence to existing therapies?
Your answer to that question might depend on
your answer to the following question:
what percentage of patients take all
their cardiovascular medications in the
year following a heart attack? I found in
asking this question of various
audiences that very few people raise
their hands to option A. 85-100%.
People realize it's very
difficult to achieve full adherence to a
medication every day, particularly if
your condition's asymptomatic. A few hands
go up to option B. 70-84%, a lot more
hands go up for 50-69%, and,
depending on the audience, depending on how
cynical they are, depending how grounded
they are in the clinical literature,
either a small number or a lot of hands
will go up for 40-49% or below
40%.
Now let me pause for a moment
here and highlight for you that there's
perhaps no other area in medicine where
there's so many carefully done clinical
trials that really highlight the
efficacy of these therapies in both
preventing heart attacks and saving
lives. Yet, despite that, in a number of
studies, sadly, the answer is below 40%
and this is true even in insured
populations. So let's come back to this
question of where the US ranks
compared to other countries with which
we're commonly compared on life
expectancy and health spending.
It's interesting, when you look at this graph you can see
that in the 1970's we all started at about
the same place. Over time, health spending
has risen much faster in the US than
in other countries, but now, in terms of
life expectancy, we see we rank far below
countries in Europe, Asia, Australia,
Israel, New Zealand. So why might this be?
Clearly it's not because we don't have
access to the new therapies, the new
devices that all these other countries
have. Many of them are actually invented
in the US, but arguably we have much
bigger challenges in terms of social and
behavioral determinants in health and we
have to figure out: how do we get more
health for all the money we're spending on
healthcare? Let's think further about
reducing the risk of heart attacks.
Experts have estimated that with perfect
adherence, we might be able to reduce
heart attack risk by as much as 62 to 88%.
It's very unlikely we could ever
attain perfect adherence, but clearly it
seems like we should be able to do
better than 40%. Let's think about how we
might do this if we could do better
early detection, prediction of disease,
more aggressive prophylactic treatment
so that these heart attacks never
happen in the first place. Here's one
strategy for thinking about reducing
heart attack risk: we could do much
better in terms of predictive analytics.
I'll talk more about that in a moment. We
can use design principles, Stacey and
Shawn are going to talk more about that
in this session - about how we think about
putting the patients in the middle of
the healthcare system as opposed to the
provider. We could do much better in
leveraging people's social networks:
really tapping in to the reservoir of
goodwill and support that a lot of
people have, in terms of friends and
family. We could do much better in terms
of testing ideas on a continuous basis
and not accepting mediocrity in our
scaled up solutions, and then, furthermore,
we need to think about how do we design
a new service delivery model which
really is focused less on treating acute
disease and in preventing disease in the
first place?
So let's think about factors that put
people at elevated risk. Obviously what
people eat, how much they smoke, their
blood pressure, their cholesterol, we can
pull all that fairly readily from
clinical data now and come up with
reasonable predictions for who's at
elevated risk of having a heart attack,
but we can actually do much better than
that now and we're not consistently
doing that. We can use natural language
processing and really look through
electronic medical records and assess
people's social determinants of health.
We can look at what's revealed, in terms
of wireless devices and wearables, in
terms of people's behavior revealed on
social media, in terms of people's
interests and concerns, and, in essence, we
can come up with much better predictive
models than we typically do today where
we could much more systematically look
at who's at elevated risk in the future
and think more aggressively about how do
we keep their risk as low as possible
Next, let's think about Rapid Cycle
Innovation of pilot ideas. A lot of
organizations will prematurely scale
solutions which are either moderately
effective or modestly effective, but
think about the challenge at hand. We
have average adherence rates for very
high-risk patients of 40%. Clearly,
we don't want to scale up solutions that
achieve only modest improvements in that
we need to think about how do we
leverage what's been learned from the
technology industry? How do we look at A/B testing? Doing this much more
systematically, where we have promising
ideas and we're constantly testing them
against each other, constantly trying to
improve. We may not achieve a
breakthrough instantaneously, but that's
going to be the best path forward for
making incremental progress that
continues. Next, we can think about
leveraging social networks. Lots of
people have a family member or friends
would be very happy and, in fact, eager to
help them improve their health if we
only let them and there are a lot of
privacy rules which sometimes make this
different difficult, but with patients
approval there's lots of ways we could
think about pulling the patient's social
circle in in ways that could help
reinforce their behavior
or perhaps ,in some cases, with the use of
technology. That brings me to my next
point which is just really thinking about new
service delivery models focused on
prevention. Think about the typical way
we manage disease today. It's really
based on the fee-for-service financing
system; we focus on treating acute events
after they happen and we also, for
chronic disease, have patients come and
see a doctor every month, every three
months, perhaps every 12 months. At those
visits, the patient is asked to recall
everything they can about what happened
since they last saw their doctor. How
well people can do this obviously varies,
and it's also very difficult for people
to recall the details of what happened
four weeks ago, eight weeks ago, 11 months
ago. Imagine an alternative world in
which patients at elevated risk had
wireless devices and wearables to
monitor their smoking status, their
medication adherence, their physical
activity. These data could be seamlessly
uploaded into secure settings; we could
have automated algorithms that give
patients, or their social supporters,
feedback on how they're doing and then,
through an exception handling process, we
could have physician extenders reach out
to patients who are not doing so well.
Help them figure out how to better
navigate the system, help them figure out
how to improve their medication
adherence and you can see how that would
create both a more effective and more
efficient way of allocating healthcare
personnel. Finally, it's very important to
think about design, and Sean and Stacey
are going to talk a lot more about this.
I think there are a few important
principles to think about. One is really
having the patients in the middle. We
tend to set things up so it's at the
convenience of the physician as opposed
to convenience to the patient. Think
about the typical care delivery system,
where a patient will come in to see a
physician and wait. Sometimes they wait
ten minutes, sometimes they wait an hour,
sometimes they wait two hours.
Intermountain in Southern Utah is
building a new clinic, which I think has
a very interesting concept: there's no
waiting rooms at all. You arrive and
you're just brought to where you're
going to be seen,
and as I was talking about, with these
new service delivery models with
wireless devices and wearables, maybe in
many cases the patient doesn't even need
to be seen. If we're monitoring their
blood pressure, their cholesterol, their
medication adherence on a regular basis,
we can provide a lot of support to
people remotely from the convenience of
their own homes. They don't even have to
make the trip in to be seen, but not
without any sacrifice in the quality of
the support they receive.
Each year, about
735,000 Americans have a heart attack.
In our current system, we wait until
patients have a heart attack and go over
the proverbial waterfall, and then we
stop at nothing to try to rescue them
and that's appropriate, that we would try
to do that, but imagine if we could
divert the flow of water and really
prevent patients from having those heart
attacks in the first place. That would
obviously be much better for those
patients;
it would also obviously be much better
for our system in terms of trying to
improve our life expectancy.
As you'll hear more during this meeting,
there are lots of promising approaches to
designing a system that focuses on
keeping people healthy, that leverage
social networks in support of patients
and that provide whole person care and
address the social determinants and
behavioral challenges to preventing
disease.
Thank you.