Complex, Chronic Illnesses That Last A Lifetime

Our medical care system has developed around diagnosing and treating acute illnesses such as pneumonia, a gall bladder attack or appendicitis. The internist gave an antibiotic for the pneumonia and the patient got better. The surgeon cut out the gall bladder or the appendix and the patient was cured. But as the population ages, more and more individuals are developing what I will call complex, chronic diseases like heart failure, diabetes, chronic lung disease or cancer. These are diseases that remain with the individual for life and these diseases and patients need a different approach to care. These patients need long term care, not episodic care; they need a team-based approach where one physician serves as the orchestrater or quarterback and manages the myriad physician specialists and the other caregivers to allow for a unified, coordinated care management approach. And these diseases are very expensive to treat today; 70% of our medical care expenditures go to treat 10% of us, those with these chronic illnesses of health care costs in America. As I will describe in detail later, it will take a new approach to organizing the care of these patients to both improve care and reduce the costs. But the new approach actually exists in some locations – the need is to understand what works and then replicate it nationally.

America Has a Sick Care Not a Health Care System

We Americans like to pride ourselves as having the best healthcare system the world but unfortunately that is not the case. We have a medical care system, not a healthcare system. We give lip service to prevention and spend only about 3% of our $2 trillion in medical expenditures on public health. By many measures we do not rate favorably compared to many of the other industrialized societies. As citizens we have behaviors that are driving more and more illness, illnesses that at chronic, complex, lifelong and life shortening. That $2 trillion is by far more than other nations spend per capita and it is seriously and adversely affecting businesses, government and each of us. Meanwhile, we may be pleased with our doctor but not the delivery system as a whole. Quality is subpar, preventable errors are rampant and some 47 million of us are without insurance access to medical care – the only such industrialized country. Health care reform is now a topic of great interest but politicians and media focus on the access issues predominantly, cost issues somewhat and the quality, safety and prevention/ public health needs only rarely.
Let’s take a closer look at what we have today. The current system of care focuses on “disease and pestilence.” It is a disease oriented system and certainly not a health management system nor a patient-oriented system. Mostly, this is due to a reimbursement methodology that under-rates the generalists and tilts toward those that do procedures. That is not what we need; what we need is a payment system that rewards the generalist for working in rural or socio-economically deprived areas, for taking the time to listen to the patient, for being attuned to prevention and wellness management. Today, that is just not where we are in America. So we need a change to a system that is focused on disease prevention, health promotion and with ready access to primary care and providers. Then, when necessary, access to specialists, hospitals, rehabilitation and all of the other requirements for good medical care when disease or injury does occur.

Embryonic Stem Cells and the Future of Transplantation

Stem cell therapies promise to be one of those true scientific breakthroughs that will have an impact on health care in the future. Stem cells will bring us closer to the goal of personalized medicine, just as genomics is doing. With stem cells, projections need to be five, ten, even fifteen years out – because this is truly an emerging science. The course of a disease will change once we have the technology to insert stem cells into the human body to actually create a tissue. For example, a person with a heart attack will not go on to live the rest of his or her life with damaged heart muscle and resultant heart failure. Instead, stem cells will regenerate the heart and make it whole again. Similarly, a person with Parkinson’s disease will recover full faculties thanks to the ability of stem cells to regenerate the damaged area of the brain. The person with type I diabetes will be free of the disease because of the formation of new pancreatic islet cells. The athlete will play again because new cartilage will be created for the worn knee. This is the promise of “regenerative medicine.”
It is a promise that is already being kept with adult stem cells used for treating patients with immune defects, usually children, or those with some cancers. Sometimes doctors use the patients own stem cells to give the bone marrow a “boost” after intensive chemotherapy for cancer [called autologous transplants.] Or the stem cells of a closely matched donor are used for a leukemia patient to not only restore the bone marrow after aggressive therapy but also to attack any remaining leukemia cells [known as allogeneic transplants.]. And adult stem cells are being used today in research studies of patients who have had heart attacks leaving their heart muscle weakened.
The president has just created an important enablement to further research on stem cells. Yes, it is true that much can be done with adult stem cells but science so far suggests that embryonic stem cells hold promise for much more benefit. It will probably be embryonic stem cells that pave the way for replacing the islet cells of the pancreas with new insulin producing cells to cure diabetes or replace the damaged cells in the brain that are key to Parkinson’s disease. Some strongly feel that it is wrong to use cells form embryos. It is important to remember that these are fertilized eggs that were prepared for couples that could not conceive and so had eggs and sperm placed into a dish with special fluids. Experience has shown that success is better if the doctor implants a few embryos into the woman’s uterus rather than just one. But the doctor may have more than enough embryos and the extras will be discarded if the woman becomes pregnant. I look at it this way. Since the embryos will be destroyed anyway, why not use them for creating stem cells that perhaps many people with diverse diseases might benefit from. It is not dissimilar to transplanting the organs of a person who has died in a car accident rather than burying them in the grave. And there is no issue about “human cloning” – that is just not what is being done or proposed. And the embryo, made up of just a few cells, is disrupted so each cell grows independently. Now the cells can be stimulated to become heart cells, liver cells or what ever might be useful in treating a disease. It will take some years but there will certainly be major advances in how we can repair, restore or replace damaged tissues or organs.

Electronic Health Records

President Obama as part of his health care reform agenda is aggressively pushing the electronic health record [EHR]. will be a major improvement to medical care and to patient safety over time. But there are two major problems that need to be overcome before the EHR will ever be fully functional – interoperability and physician documentation. By interoperability I mean that each of the companies that produce the software do so in a proprietary manner. The result is that they cannot interact. So if a patient is discharged from one hospital today and goes to another hospital’s ER tomorrow, the information from the first hospital will likely not be accessible. This must change and it appears that the federal government is attempting to have standards established for all to follow. That will be a big improvement. There are issues however as to who should set the standards – government or a multidisciplinary working group. Either way, standards are needed.
The second obstacle is that physicians find that most of the current systems actually impede productivity rather than enhance it. This is because the software creators have not spent the time necessary to understand how physician work and are intent on making the document easy to manipulate by the computer. Here is an example. Say a doctor admits a patient with pneumonia. He or she might want to insert the following into the chart: “55 year old nonsmoking male, sudden onset of high fever, shaking chills, productive cough and pain at left lower chest with inspiration. Temp 103, pulse 94, BP 128/74, abnormal breath sounds and dullness to percussion in left lower chest. Chest X-ray shows infiltrate in left lower lobe and sputum exam shows gram positive diplococcic. Diagnosis – pneumococcal pneumonia. Treatment – antibiotic.” Sorry for some “doctor speak” but in essence this is a fairly classical description of a pneumococcal pneumonia. It takes about 30 seconds to say, the same to dictate and perhaps 60 seconds to write or type these words. But to enter it into the chart as per the dictates of the software takes much longer because it requires following a long branching tree of choices. You might liken it to using Word for a document that can be read later versus Excel for a spreadsheet that can be manipulated. Physicians really dislike the extra time it takes and the fact that it is not consistent with the way they “think” about the patient and his or her problem. So they rebel and will not adopt. But this problem, like interoperability, can be overcome.
Once these two issues are resolved, the EHR can become a reality, but not before.