A Broader Definition of Health

Eva Makvoort was 25 when she died. Eva Makvoort created a blog to communicate with her friends and growing community of followers as she struggled with the ravages of cystic fibrosis. It’s a beautiful blog and you can go to it by clicking here. You could tell that despite her physical challenges she loved life, appreciated each moment, and would give anything for a clear and unobstructed breath of fresh air.

We wrote about Randy Pausch in our July, 2008 Newsletter. He was the Carnegie Mellon professor who created a huge following with his talk to students at the university that resulted in his book “The Last Lecture.” Randy Pausch’s message to others was to always, fearlessly, pursue your dreams. He gave this lecture knowing his cancer was terminal and he died in 2007 not long after his book was published. Despite the physical challenges, the other aspects of his life remained strong. He maintained a positive perspective of life to the end.

These two individuals are examples of the idea that “health” is a much broader term than traditionally used in health care today. While we’re used to the diagnosis, prognosis, prescriptions, interventions, and measurement of the physical aspects of health we really don’t dive into all of the other areas of life that have an impact our overall health and well being as a standard part of the health care delivery process. The emotional health, spiritual health, intellectual health, and social health of a person can dramatically influence the way a person maintains when the physical health breaks down. They may also have some influence in determining what ultimately results to the physical health as well. We need to start paying more attention to these aspects in our definition of health as we change the paradigm in health care delivery from sickness to health.

The CDC’s latest report on the U.S. National Health and Nutrition Survey indicates almost half of US adults now have risk factors contributing to heart disease. We all know the obesity statistics. A study to be released in the Archives of Internal Medicine found that the lifestyle habits of a study population in Britain cut longevity by 12 years. We all know the simple lifestyle decisions made each day are contributing to the enormous costs of the care needed today and the care that will be needed tomorrow.

Reed Tuckson, M.D. of the UnitedHealth Foundation put it this way, “Unless there is urgent action across our society, our already burdened care system will be swamped by a tsunami of cost and demands from preventable chronic disease.” Our system simply can’t afford the lifestyles our society has embraced.

While Eva Makvoort’s and Randy Pausch’s physical health failed, the other aspects of their lives remained strong giving them the best quality of life they could achieve given the circumstances. Their physical options were limited.

But, most have a choice and have the opportunity to make the decisions we all know are necessary to improve both health and quality of life. We just need to make the commitment and do it and provide the support and resources along the way to help make it happen. While the physical health may remain the “standard marker” for defining a healthy person we’ll need to consider the emotional, social, spiritual, and intellectual aspects of health as well. They are all related.

One of Eva’s followers wrote, “I felt so selfish when I stumbled across your [LiveJournal] on here, because I’ve been smoking cigarettes for yours, taking my lungs for granted. You’ve helped me quit the worst habit I’ve ever had.”

Sometimes it just may take appreciating what you have to get started.

Checklists and Decision Trees

According to a study by PriceWaterhouse Coopers over $1 trillion of the $2.2 trillion we spend on health care in this country is wasted. While the definitions of waste in the study are pretty broad- defensive medicine, treating for lifestyle conditions, etc.; the point is made. There is a significant amount of waste in the system we have today.

Health care consumers and providers of care have pushed-back significantly when attempting to introduce protocols or decision making tools in the process. The thought being you cannot reduce something as complex as health care to a series of algorithms.

Two books provide some indication that the emphasis on standardized decision making in health care will not go away. The research cited, in-fact, provides credibility that by using simple decision making methodologies outcomes may improve, may cost less, and provides more transparency to varous stakeholders throughout the system.

The Checklist Manifesto, by Harvard surgeon and New Yorker staff writer Atul Gawande, M.D. introduces the simple idea of using “checklists” as part of the care delivery process. His premise is simple- no matter how much of an expert you may be, you can always improve your outcome with well designed checklists to guide you through the key steps of any complex procedure. Click here to go to Gawande's web site- he's got some cool checklists already developed.

While Gawande believes his checklist idea is applicable for many other areas of life, his experience in the health care field lends credibility to his argument for designing simple methods to assist in the decision making process resulting in better outcomes and lower costs over time.


Thomas Goetz, a journalist and Executive Editor of Wired Magazine presents a different approach- but this time for health care consumers.

His book, The Decision Tree: Taking Control of Your Health in the New Era of Personalized Medicine introduces a methodology to assist individuals in making health care decisions. Much like Gawande argues in The Checklist Manifesto, Goetz recognizes the decisions we make today are much more complex than ever before. Health care consumers are usually left to their own devices to acquire the information they need to make decisions concerning their health and are at the mercy of the health care system when confronted with it. The Decision Tree presents a method and device for individuals to formalize health care decisions and externalize the choices made in their health and health care they typically make without thinking. The studies he cites confirm the fact that those individuals who actively participate in the decision making process are more engaged, and achieve better results. Click here to go to the Decision Tree web site. Take a look at the video to get a better idea of the concept.

Our health care system has been fighting the battle of “protocols” and processes for many years. While one side recognizes the possibilities for improved efficiency the other side views them as barriers that obstruct the delivery of care and the relationship with the patient. Consumers are accessing and becoming overwhelmed with a growing body of research and information (both good and bad) from which to base their decisions- and have not always been welcomed when trying to participate in the decision making process.

With such a significant amount of money being wasted in our health care system the need to at least set a framework for making decisions by all stakeholders will only increase. Gawande and Goetz provide some food for thought with some simple ideas to consider with the support behind them to show that outcomes will improve, engagement will increase, and costs will go down.

They are certainly worth a good discussion at the water cooler.

OpenNotes and Medical Record Transparency

If there is one group of stakeholders totally confused by the health care system we have, it’s the individual consumer. The consumers don’t understand the legal jargon included in most health plan Certificates of Coverage (COC), they don’t understand how to navigate around the primary care/specialty care maze we send them through, and they don’t understand how the pricing and financial structure works. I’m not saying consumers are ignorant. They simply have not been provided the information they need to participate effectively. Our health care system has been very good at keeping information in silos. Consumers have had to rely on other sources to try to get the information they require to make the decisions they need to make. We can safely assume this lack of “transparency” impacts efficiency, cost, compliance, and possibly the outcomes associated with particular medical events.

The Journal of General Internal Medicine recently published an article highlighting the fact that consumers want full access to all their records and are willing to make some privacy concessions in the interest of making their medical records completely transparent. Consumers want more information than they are being provided today.

Through a $1.2 million grant from the Robert Wood Johnson Foundation and with the participation of 75-130 primary care physicians connected to Beth Israel Deaconess Medical Center in Boston, Geisinger Health System in Danville, Pa, and Harborview Medical Center in Seattle, a project is underway to answer a basic question: Can improving communication with the patient lead to better health care outcomes?

The answer seems obvious.

Through the OpenNotes project http://www.myopennotes.org/, health care providers will be using processes to provide patients with access to their primary care physician’s visit notes through an electronic medical record. While EMRs traditionally include such things as lab results, biometrics, and medication lists the office notes themselves are traditionally not accessible to the patient. This project is designed to determine if the office notes themselves can be repositioned to be “for the patient, instead of about the patient.”

Not all providers are enthralled with the idea. Some believe that providing access to the notes only adds to the possibility for misinterpretation and miscommunication. They believe the office notes are clinical and cannot be useful to the average consumer.

This argument highlights one of the more significant problems in health care- everybody is talking in different languages.

The OpenNotes project hopes to address the following:

1. Create a more transparent and democratic health care environment
2. Enhance patient-doctor communication
3. Improve the accuracy of provider notes- ultimately reducing the possibility for litigation
4. Increase shared decision-making and improve patient satisfaction
5. Help patients and families become more actively involved in follow-up and compliance
6. Improve patient recall after a visit.

The goals are admirable and the intent of the project is certainly heading in the right direction for the consumer and patient. Sometimes I just wonder if we need $1.2 million and a 12-month research project to do what we know is the right thing anyway.

Be Well

Will Wellness Incentives Work In Health Care?

Last year the average incentive paid to participants in an employer-sponsored wellness program was a little over $300 a year. Some employers paid a lot more- one paid $4,000 to employees just to complete an HRA- and some less, but the overall average increased over the previous year.

A lot of dollars are being thrown at employees to get them involved. Why is it that still only 11% of the employees actually are?

Daniel Pink’s new book “Drive; The Surprising Truth About What Motivates Us” provides an interesting perspective.

Pink delivers his argument from a historical perspective and simply comes to the conclusion that the way individuals were motivated in the past no longer applies today. He describes the historical way we have tried to motivate individuals as Motivation 2.0. Motivation 2.0 assumed “the way to improve performance, increase productivity, and encourage excellence is to reward the good and punish the bad.” It was the old carrot and stick model.

The carrot and stick model worked fine when the actions you were trying to change were repetitive and measurable and there was no consideration of external forces influencing an individual. If you produced more widgets, you were paid more. If you didn’t meet your quota, you might not have the job for much longer. The measurements were simple.

Pink argues that our culture no longer works that way. The dynamics of the workplace and the characteristics of our demographics are dramatically changing. He believes that we are moving toward Motivation 3.0. Motivation 3.0 “concerns itself less with the external rewards to which an activity leads and more with the inherent satisfaction of the activity itself.” Individuals don’t always respond to the carrot and the stick approach any more.

Individuals are looking for more in their lives (including their work) than they ever have before. Pink believes motivation to take action at any level is based upon an individual’s desire for three things: 1. Autonomy- the desire to direct our own lives; 2. Mastery- the urge to get better and better at something that matters; and 3. Purpose- the yearning to do what we do in the service of something larger than ourselves

Focusing on material incentives (money and gifts) may sometimes work to achieve short-term results but will probably not work to achieve the real goal of engagement and active participation. Actually, Pink cites examples where the carrot and stick approach worked in reverse. In health care, engagement and participation of the individual consumer is crucial. We can’t get much lower engagement than where we already are.

Getting employees engaged in this new health care world will require more than a carrot and stick approach. It will require creating the culture around the individual that meets their personal requirements of feeling they are in control of their lives (autonomy), continually improving their health because they know it matters (mastery), and participating because they know its not just about themselves (service).

Pink writes, “In our offices and our classrooms we have way too much compliance and way too little engagement. The former gets you through the day, but only the latter will get you through the night.”

If we can move to Motivation 3.0 in health care maybe we’ll have more than 11% of the individuals engaged in sponsored programs and we won’t have to pay $4,000 to get someone to complete an HRA.

Be Well.