Discovery

by Sherri Kirk

While politicians continue to argue about the best ways to reduce costs and improve care in America's hospitals and clinics, forward-thinking leaders at healthcare institutions like Ohio State are already testing innovative reforms that are bearing positive results. Electronic medical records systems, genetic testing, disease prevention services, and even changes in the way future physicians are trained – projects now in their infancy – will become the norm nationwide.

Health care is changing from a model once centered on the physician to one that places the patient at the center of the treatment plan. This is the result of several factors:

• research, which is revealing that prevention is the best medicine and that treatments can be as unique as the patients who need them; 
  
• policy, particularly in the form of the Patient Protection and Affordable Care Act, which seeks to increase access to care, reduce cost and reward quality care providers; 
  
• increased access to medical information, which has resulted in more educated, empowered patients; and
  
• choice, which has led hospitals and other healthcare providers to create a more consumer-oriented experience. 
  

According to experts at Ohio State and other leading healthcare organizations, the way health and medical services are delivered must become more predictive, preventive, personalized and participatory to better serve this changing landscape – a standard called P4 Medicine.

However, for this new philosophy to reach its full potential, more than the doctor-patient relationship must change. Everything, from the patient experience to insurance coverage, to medical education to the design of medical facilities and the very treatment plans developed for individual patients, must adapt.

The Ohio State University Medical Center and only a few other academic medical centers and health systems in the United States have begun to reorganize to accomplish just that. The OSU Medical Center's strategic plan, the College of Medicine's curriculum, and the University's employee health plan are realigning to prepare for P4 Medicine. These moves are several leaps beyond the guidelines set forth in federal healthcare reform legislation. This is an entire re-envisioning of health, health care and wellness in America.

Primary Care: Redrawing the Front Lines

The Patient Protection and Affordable Care Act, signed into law by President Barack Obama on March 23, 2010, focuses on reforms that improve patient outcomes and reduce costs. Care coordination, or the sharing of a patient's needs and preferences among providers, patients and families across a range of healthcare settings, will play a significant role in achieving these goals.

"Care coordination has been shown to reduce emergency room use as well as hospital readmissions, two areas of great expense and, if managed properly, it will be a major source of cost savings under the new healthcare law," says Randy Wexler, MD, assistant professor of Family Medicine at Ohio State.

Care coordination is central to a primary care concept called the patient-centered medical home (PCMH). PCMH is based on principles agreed to in 2007 by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians and the American Osteopathic Association:

• Each patient should have an ongoing relationship with a personal physician trained to provide first contact, continuous and comprehensive care.
  
• The personal physician leads a team of individuals at the practice level who collectively take responsibility for the ongoing care of patients.
  
• Care is coordinated and integrated across all elements of the healthcare system.
  
• Quality and safety must be hallmarks of the medical home.
  
• Enhanced access to care is available through systems such as open scheduling, expanded hours and new options for communication among patients, their physicians, and practice staffs.
  
• Payment appropriately recognizes the added value provided to patients who have a patient-centered medical home.
  
• The personal physician is responsible for providing all of the patient's healthcare needs or taking responsibility for arranging care with other qualified physicians.
  

The Ohio State University Medical Center's Primary Care Network currently has four certified Level 3 Patient Centered Medical Homes – CarePoint Gahanna, Rardin Family Practice, CarePoint East Family Medicine and OSU Internal Medicine at the Morehouse Medical Plaza. Level 3 is the highest level defined by the National Committee on Quality Assurance (NCQA), a private, nonprofit organization dedicated to improving healthcare quality. Additional Medical Center offices will be applying for certification by year's end.

Similar projects in other parts of the country have been very successful. A health cooperative in Washington state found that patient-centered medical homes reduced hospital admissions and improved quality. A similar group in North Carolina implemented a PCMH for Medicaid patients and reported improved quality of care for patients with asthma and diabetes, as well as reduced hospitalizations, lower costs, and declines in emergency department visits. Geisinger Health System in Pennsylvania formed several PCMHs in 2007, and in two years it saw significant improvements in treatment for diabetes and coronary artery disease.

Wexler says the care offered through the PCMH model is predictive and preventive. "The primary care setting is the ideal place to assess health risks and intervene or change therapy as necessary." Each member of a PCMH's multidisciplinary team has access to the same health information for each patient, allowing them to collaborate on a comprehensive care plan personalized to the genetic and behavioral needs of each individual, often using preventive therapies designed to head off disease before it manifests or worsens
.
This approach can include assisting women with genetic predispositions for breast cancer by starting preventive mammograms earlier, or giving pharmacists access to a patient's medical history and list of current medications so they can talk to patients about drug interactions and the importance of adhering to their treatment plan.

Other key elements of the PCMH model are the participatory role of the patient, and the support the PCMH provides to help them assume greater responsibility for maintaining their health. "The patient must be an active partner in their care to achieve maximum benefit," says Wexler. "That is the essence of the patient centered medical home model. The right care, for the right patient, at the right time: P4 Medicine."

Randy Wexler, MD, assistant professor of Family Medicine at Ohio State

Health Insurer as Prevention Agent

A stitch in time saves nine. Applying that maxim to a health insurance plan means supporting services that promote the health of members as well as the bottom line, which is easier said than done in a healthcare environment that still places priority on sick care.

The Ohio State University Health Plan covers more than 52,000 employees and dependents through a number of medical plans. Its leaders have worked closely with Medical Center experts to incorporate predictive tools into covered services and to develop a culture throughout the University that values preventive medicine. They've designed a number of personalized programs that focus on wellness and participatory care. Services help people change their health behaviors and stay out of the hospital.

In 2006, Ohio State's Medical Center, Office of Human Resources and the Ohio State University Health Plan formed a strategic partnership called Your Plan for Health (YP4H), a collection of personalized, preventive care and wellness programs designed to improve the overall health of faculty and staff while helping to stem rapidly rising costs. YP4H services include:

• health coaches, who help individuals achieve and maintain
  
• good health and manage chronic disease;
  
• medication therapies management, a comprehensive review of a patient's medications to help maximize effectiveness and minimize costs;
  
• reduced co-pays for individuals who participate in preventive treatment plans;
  
• annual personalized health assess ments; and
  
• biometric screenings.
  

Larry Lewellen, vice president of Care Coordination and Health Promotion at Ohio State's Medical Center, says he wants the University to be a national model demonstrating what health plans and health systems can achieve when they work together toward P4 Medicine goals.

Lewellen says that Ohio State, as both manager of a health plan and an academic medical center, recognizes that the goals of insurers and hospitals are not mutually exclusive: quality care need not be expensive, and reduced costs need not come at the expense of quality.

"P4 Medicine delivers the science that achieves the predictive and personalized aspects of health care," he says. "And through Your Plan for Health, the OSU Health Plan applies this knowledge to make care more preventive, more participatory and less expensive for everyone. It's a great partnership. Through YP4H and P4 Medicine, the Medical Center and the Health Plan are in perfect alignment."

Lewellen admits that participation remains a challenge. The current rate of participation in YP4H stands at about 55 percent. "I'd like to see participation at about 90 percent to be a true demonstration site for the effectiveness of applying P4 Medicine within an organization. Your Plan for Health is a great foundation, and as we move forward, we'll focus on ways to engage and empower individuals and make them feel like they're involved in a community."

Earlier this year, the University of Louisville earned national recognition from the College and University Professional Association for Human Resources for its "Get Healthy Now" program that helps faculty and staff lead healthier lives while containing long-term healthcare costs. The University of Michigan has also launched a similar employee wellness program known as "MHealthy."

The Digital Hospital

Although P4 Medicine promises to deliver care that is more predictive and therapies that are more preventive and designed to keep people out of the hospital, hospitals will always remain an integral part of the healthcare system, and personalized care will be just as important in hospitals as it is in primary care providers' offices.

A key to improving care at academic medical centers like Ohio State is giving everyone access to the same information. On October 15, the Medical Center launched its Integrated Healthcare Information System (IHIS), which includes a linked inpatient and outpatient electronic medical record. Patients who come to Ohio State will now benefit from all physicians, nurses and specialists working from the same patient records, eliminating needless duplications, improving the coordination of care, and reducing the likelihood of medical errors.

IHIS also gives patients direct access to key portions of their own electronic medical chart, allowing them to review lab results, manage physician appointments and renew prescriptions. This online connection between patients and care providers allows for better and more frequent communication, facilitating a personalized care plan.

This electronic medical record, in turn, becomes a digital treasure trove for personalized medical research. The Medical Center's Information Warehouse depersonalizes patient data, removing patient identities to leave only symptoms, diagnoses, treatments and outcomes. This medical data is then shared with networks of academic medical centers and research institutes across the country and the world, as they also share with Ohio State, giving researchers access to tens of thousands of patient interactions and a clearer picture of which treatments work best for certain patients and which may not.

This information can also be used to alert care teams to patients whose patterns of conditions place them at greater risk of developing infections or sepsis, or having complications with a specific medical procedure. It assists hospitals in taking the necessary precautions to protect the health of each patient and select the most appropriate therapy in a given situation.

 
The New School

Transitioning health care from a reactive model to a proactive one must begin with the training of future healthcare providers, including nurses, technicians and physicians. The Ohio State University College of Medicine has recently begun to thread the P4 model into its curriculum called "Lead.Serve.Inspire."

Stepping outside the traditional medical school model of two years of classroom study followed by two years of clinical experience, the new curriculum beginning in fall 2012, will get students out of the classroom much earlier in their education, and move the classroom into the clinical setting, where students will work alongside medical personnel to assess patients.

Current practitioners will serve as mentors, teaching students how P4 Medicine principles are already being worked into their daily routines, from entering data into an interconnected electronic medical record to consulting with genetic counselors to determine a patient's predisposition to diabetes and breast cancer.

This new curriculum model is being extended to other academic programs in the Health Sciences at Ohio State, including the Medical Scientist Training Program, which provides an accelerated education for students pursuing both an MD and PhD, and the School of Allied Medical Professions, which teaches occupational and physical therapists, among others, to translate health information and management systems into quality patient care.

In 2010, the College of Medicine introduced the P4 Scholars program, a course that focuses on health, wellness and preventive care in addition to personalized treatment for patients. Ohio State is the first institution to implement such an integrated program, paving the way for lower healthcare costs and improved quality care and outcomes for patients.

"The medical system of today emphasizes curative medicine," says Kandamurugu Manickam, MD, a geneticist at Ohio State's Center for Personalized Health Care and director of P4 Scholars. "Our program shifts traditional medical training from sick care to the practice of well care. We want students to think about how they would integrate the practice of P4 Medicine into their own future practices."

 
Self-Preservation

"Personalized health care is based on the premise that each individual is born with a unique genetic inheritance and that health or disease is a consequence of how this background is modified by environmental exposure over time," says Ralph Snyderman, MD, chancellor emeritus and James B. Duke Professor of Medicine at Duke University.

In addition to sharing detailed information about family history and social behaviors in the development of personalized care plans, patients may soon have primary care physicians combing their DNA for signals that lead to actionable items in their daily lives. Technological advances in molecular profiling are giving geneticists the ability to examine the tiniest of clues.

Seeing a mutation among interacting proteins, for instance, may be a predictor of ovarian cancer at its earliest stage. The ability to ascertain the likelihood of disease that far in advance of a diagnosis means that treatments will more frequently be preventive rather than medicinal – more about lifestyle changes than prescriptions – placing greater responsibility on the individual to manage his or her own care.

"An individual's behavior is often far more important for preventing or enhancing disease development than any specific therapeutic intervention by a healthcare provider," says Snyderman.

Preventing health problems before they happen will not only save lives but could also save the nation billions of dollars in healthcare costs. The Institute of Medicine, the premier entity that advises the nation on improving health, recommended measures for preventive care in its 2009 Prevention Report, including early intervention for emotional and behavioral disorders.

"It is very clear that from now on we should view mental health and physical health as inseparable," says Ricardo Munoz, PhD, professor of Psychology at the University of California, San Francisco. "Preventions for physical health, such as reducing early onset smoking or obesity, have enormous mental health consequences and, similarly, preventing depression or substance abuse has enormous physical health consequences."

 

Major P4 Projects in Progress
Mapping 100,000 Genomes
In 2009, The Ohio State University Medical Center partnered with the Coriell Institute for Medical Research, a leading biomedical research institution, to gather personal genetic information for what will ultimately be a database of more than 100,000 people. The project is called the Coriell Personalized Medicine Collaborative.

Healthcare providers will use findings from the study to develop tailored medical and therapeutic treatments for their patients.

Other partners on the project include Cooper University Hospital, Fox Chase Cancer Center, Virtua Health of New Jersey, and Helix Health of Connecticut.

Tailored Treatments
The Electronic Medical Records and Genomics (eMERGE) network was created by the National Human Genome Research Institute, part of the National Institutes of Health, to demonstrate over a four-year period whether genomic information linked to disease characteristics and symptoms in patients' electronic medical records can be used to improve their care.

So far, the eMERGE network has identified genetic variants associated with dementia, cataracts, high-density lipoprotein (HDL) cholesterol, peripheral arterial disease, white blood cell count, type 2 diabetes and cardiac conduction defects.

In the next phase, investigators will identify genetic variants associated with 40 more disease characteristics and symptoms, using DNA from about 32,000 participants in each study.

eMERGE network members include Vanderbilt University, the University of Washington, Northwestern University, Geisinger, the Mayo Clinic, and the Mount Sinai School of Medicine.

Virtual Patient
To develop the technological side of personalized medicine, researchers at the University of Manchester in the United Kingdom are using a massive computer network to create virtual patients. These computational patient models will contain genetic data along with traditional health metrics and will serve as prototypes of next-generation, easy-to-use health records for personalized medicine.

The Manchester team is part of the pan-European IT Future of Medicine initiative, a 10-year project that unites more than 25 academic institutions and industrial partners.

"Information gathered from sequencing an individual's genome or measuring the levels of certain chemicals in their blood will be used to create a unique mathematical model of that person, the virtual patient," says Daniel Jameson, project manager of the initiative.

Eventually, Jameson says, the project will produce a range of individualized models that physicians can query, along with an entire IT ecosystem that could support personalized genomic data in
the clinic.

P4 Medicine Spreads
Since the Personalized Medicine Coalition was launched in 2004 to promote new ways of thinking about health care, more than 200 entities have become members, including The Ohio State University Medical Center. Ohio State created its Center for Personalized Health Care in 2005 and continues to create, promote and facilitate the study and practice of P4 Medicine.

Other personalized medicine institutes have formed in recent years include the Cleveland Clinic Genomic Medicine Institute, the Duke Institute for Genome Sciences and Policy, Vanderbilt Personalized Medicine Initiative and the University of Utah's Personalized Medicine Coalition.

Johns Hopkins University is among the latest to join the trend. The Johns Hopkins Kimmel Cancer Center will use a $30-million donation from the Commonwealth Foundation for Cancer Research to fund a new Center for Personalized Cancer Medicine that will focus on genomics and personalized cancer medicine research.

Story Summary

• For P4 Medicine to reach its full potential, everything in health care must adapt, from the patient-physician relationship to insurance coverage, medical education, the design of medical facilities and the very treatment plans developed for each patient. 
  
• Ohio State's Medical Center and a few other academic hospital systems in the country are reorganizing in ways that are leaps beyond the guidelines set in federal healthcare legislation. These pioneers are entirely re-envisioning health and health care in America.
  
• The ability to ascertain the likelihood of disease far in advance of a diagnosis means that treatments will more frequently be preventive rather than medical – more about lifestyle changes than prescriptions and surgeries. This places more responsibility on the individual to manage his or her own health.
  

From Left: Larry Lewellan; Kandamurugu Manickam, MD; Ralph Snyderman, MD; Randy Wexler, MD