June 28, 2016

The Empowered Patient, Part I

Mary MahoneyBY Mary Mahoney

J. Robinson Group Blog

This three-part series we will explore a big shift in health care: the empowered patient and new models of medical care. This first part explains how changes in the health care system are gathering momentum. Part II will explain the concept of the medical home, the challenges it faces and other new models for care and payment.  Part III will look at how physician practices are catching up to the digital age.

Patient Rights

For those of us who came of age in the late 20th century, i.e. those currently in the 50-80 age bracket, we took what doctors told us as gospel.  Some might have sought a second opinion before undergoing an operation. A rare few might even have changed family physicians. But the concept of becoming “co-authors of our own medical care” was unthinkable.

But there has been a sea change in the nature of the doctor-patient relationship, challenging the long-held tenet that “the doctor knows best.” Funny thing is, most people haven’t noticed.

Various groups have formed around the idea of patients’ rights and educating patients. One nonprofit group, the Empowered Patient Coalition, started after the death of the group founder’s young daughter and her experience with the hospital that treated her. The Society for Participatory Medicine  is another organization “devoted to promoting the concept of participatory medicine, a movement in which networked patients shift from being mere passengers to responsible drivers of their health, and in which providers encourage and value them as full partners.”

The internet, of course, has been the biggest, most pervasive force in patient self-education. But if ever there was truth to the cliché “a little knowledge is dangerous thing,” that certainly is the case with medicine. And good luck to the patient who tells his doctor, “But I saw something online about my condition that said …”

Certain changes in the health-care system just may open the door to better discussion, encouraging treatment options, informing patients about clinical trials and experimental therapies as well as sharing personal experiences with other patients.

What might this look like in the real world? Sometimes we are shuffled in and an out of our primary care physician’s office in just a few minutes. A PBS report on fee-for-service explains that such doctors get paid for each service and test rather than a salary. Most doctors don’t like this system, claiming it creates a syndrome with too many patients and not enough time or individual attention, according to an article published on June 8, 2016 in the Orlando Sentinel.

Additionally, many of us feel we give up all autonomy when we enter a hospital. CNN medical correspondent Elizabeth Cohen promoted the concept of the “empowered patient” and wrote a book about it, after her own experiences with her newborn daughter’s hospitalization.  In an article in The New York TimesCohen explains what you could do: “You shouldn’t have to fight, and most of the time you don’t. But sometimes you do. I think most people have a story of something that hasn’t gone quite right. You do feel small. Especially in the hospital. It’s their world, and you’re just visiting.

“But there are things you can do, and there are people out there who can help you. There are nurses — even if it’s not your nurse, there may be another nurse in the hospital who can help you. When you have insurance problems, there are agencies out there to challenge an insurance company denial. The people in your benefits office are there to help you. There are people to go to when things aren’t working out. You just have to know how to do it and how to think through your options.”

The idea of the patient as a proactive consumer, not merely a helpless bystander, was floated way before the arrival of WebMD. It was posited early on by Tom Ferguson,  physician, columnist, researcher and consumer advocate. Ferguson began writing on the subject in 1975, and by the mid-1980s was discussing online health resources for the layperson. In 1993 he organized the world’s first conference devoted to computer systems designed for medical consumers.

The site e-patients.net describes Ferguson as having coined the term “e-patients” to describe individuals who are equipped, enabled, empowered and engaged in their health and health care decisions. “He envisioned health care as an equal partnership between e-patients and health professionals and systems that support them,” the site says.

These advocates are not just a bunch of do-it-yourself, anti-establishment types railing against the status quo. Many within health-care admit the system could use improvements, both practical and philosophical. Indeed, stakeholders from numerous areas – patients, hospitals, primary care practitioners and the government ─ are exploring the idea that involving patients on different levels could result in better care, cost savings and a more rewarding experience for providers.

In the next blog we will take a look at new models of care and the challenges they face.

June 17, 2016

Hospital Food: Practicing What Doctors Preach

Mary MahoneyBY Mary Mahoney

J. Robinson Group Blog

Any doctor will tell you that healthy eating is a cornerstone of good health. Yet one of the hardest places to find a fresh, healthy meal may be at the very place many people end up as a result of a lifetime of bad dietary choices: the hospital.

Patient Receiving Food at Hospital

From patient menus of mass-produced meals often packed with sugar, sodium, trans-fats and other ingredients considered bad for even the healthiest among us to fatty-laced cafeteria offerings — even in-house fast food restaurants – hospitals are under increasing pressure to practice what their doctors preach.

Just like banning smoking and promoting preventive health and wellness practices, many say hospitals should be leading by example by setting high-quality nutritional standards.

Several hospitals across the country are responding with new programs that not only ensure healthier meals for patients, visitors and staff but also promote broader initiatives for fostering a healthier food chain, a better global environment and an overall culture of health.

In New Mexico, for instance, the state’s largest hospital system and insurer, Presbyterian Healthcare Services, recently joined the farm-to-hospital movement, which offers a new twist on the popular farm-to-table restaurant movement that focuses on serving fresh, locally grown sustainable food items.

According to a recent report in the Albuquerque Journal, Presbyterian Healthcare Services is seeking partnerships with New Mexico farmers and ranchers to buy fresh fruits and vegetables, meat and poultry products to highlight in its cafeterias, patient meals and catering.
Presbyterian officials say the effort is part of a larger community health plan, and in response to the Healthy Food in Healthcare Pledge it took as part of a national initiative of Healthcare Without Harm.

According to HealthCare Without Harm, hundreds of hospitals have taken that pledge. And more than 700 hospitals – or 10 percent of all those in the United States — have joined a similar effort, the Hospital Healthier Food Initiative, from the Partnership for a Healthier America, according to PHA’s web site.

Doing the right thing, however, can come at a cost – and put a hospital at odds with its fiscal and other responsibilities.

According to a report in the American Medical Association’s Journal of Ethics, adopting healthier cafeteria food options was the topic of heated debate at one recent hospital board meeting.

While one doctor on the board called what was being served in the cafeteria “simply unethical,” another said the hospital had no choice.

“When it comes down to it, it’s every person’s responsibility to make his or her own food choices,” the doctor argued. “Our main responsibility as the hospital’s representatives is not to change individual behavior but to serve the low-income population in our community—and to do that we must ensure the fiscal future of our institution. Our current food vendor is the only option that makes that possible.”

Overall, however, the Physicians Committee for Responsible Health Care, in its 2016 review of hospital food, says hospitals are making progress on the healthy food front.

“But there is still room for improvement,” the report says. “Disease-promoting meat and dairy products are the norm on most patient menus, and at least 42 hospitals still have Chick-fil-A, McDonald’s, Tim Hortons and Wendy’s fast-food restaurants.”

June 9, 2016

The Human Microbiome Project: Tiny Cells Unlocking Big Possibilities

Mary MahoneyBY Mary Mahoney

J. Robinson Group Blog

You may have heard of the Human Genome Project, the ground-breaking endeavor to map the human DNA. But have you heard of the Human Microbiome Project? Started in 2008 and now in its second phase, the HMP uses genome sequencing to identify microbes living in healthy adults and to define what constitutes the normal bacterial makeup of the body.

Microbe Word Cloud

Why is that a big deal? An article in Therapeutic Advances in Gastroenterology explains that “our gut harbors a complex community of over 100 trillion microbial cells which influence physiology, metabolism, nutrition and immune function. Disruption to the gut microbiota has been linked with gastrointestinal conditions such as inflammatory bowel disease and obesity.”

Microbial cells outnumber human cells 10 to 1, and the gut microbiota, if weighed together, would be about three pounds.

But until recently, the function and importance of this busy ecosystem inside our bodies was somewhat of a mystery because of the difficulty in growing lab cultures.

Now, advances in genetic sequencing are making it possible to identify and study the 1,000-plus bacterial species, and thus understand their significance to our health. Researchers are looking at ways to manipulate the gut microbiota for new treatment options, not only for chronic gastrointestinal illnesses but also for other diseases, including autoimmune maladies and cancer.

Indeed, the role of genetics in microbiology is expanding rapidly, and all kinds of new connections are being made. We each have a “signature” group of microbiota, but those can change due to diet, illness, age or environmental causes. For years the medical profession has puzzled over the increase in allergies, asthma, autoimmune diseases and obesity in more developed countries.

“In our modern environment, many people are not exposed to the microbiota of our evolutionary past. In the absence of appropriate microbial signals, the immune system does not develop normally,” said an article in the journal, Cell. Overuse of antibiotics, the presence of toxins and, ironically, better hygiene, may be contributing factors.

For example, a study reported in Diabetes Journals demonstrated “marked differences among populations in the U.S., rural Malawi and Venezuela. Non-U.S. adult residents had higher levels of Prevotella, whereas the differences between the Malawi and Venezuela populations were more subtle, with differences in the abundance of several species in the Clostridials order.”

Diet is also a factor. “In humans, microbes respond differently to dietary components, and long-term dietary habits have been linked to the abundance of microbial genera: Bacteroides correlates positively with a protein-rich diet, whereas Prevotella is associated with a diet rich in fiber.”

Additionally, we coevolve with our microbiota. A paper published in Therapeutic Advances in Gastroenterology explains that “there are age-related physiological changes in the gastrointestinal tract of older people that are characterized by a chronic low-grade inflammation, which can lead to a microbial imbalance in the intestine. The gut microbiota of older people is distinct from that of younger adults. This and other work has strongly implied that the GI microbiota is extremely important to the health and in the progression of disease and frailty in older people.”

Phase 2 of the HMP, the ongoing Integrative Human Microbiome Project, focuses on the interaction between microbes and hosts to study pregnancy and preterm birth, IBD and prediabetes.

Stanford University, one of participants, is using an even more advanced sequencing technique, called long-read DNA. It promises fascinating new insights.

“It’s like an IMAX movie,” says Michael Snyder, PhD, professor and chair of genetics at Stanford. “You can see the whole thing much more clearly than with what we do now, which is like an old black-and-white TV. The complexity we found was astounding.”

The National Institutes of Health, which has developed research resources for the project, likens HMP to “15th century explorers describing the outline of a new continent,” said NIH Director Francis S. Collins, M.D., Ph.D. in a press release. “It lays the foundation for accelerating infectious disease research previously impossible without this resource.”

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