OBSERVATIONS - november 19, 2008

Personalized Care...Moving the Focus of Health Care Reform to the Patient

In Crossing the Quality Chasm, the Institute of Medicine (IOM) defines patient-centeredness as: Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.

On behalf of the Kaiser Permanente (KP) Institute for Health Policy, Brian Raymond and I recently hosted a roundtable discussion among several California and national experts to discuss patient-centeredness and health care reform. While the aim of “patient-centeredness” has been elevated with safety, timeliness, effectiveness, efficiency, and equity to the highest of strategic health system concepts by the IOM, it is not a prominent or consistent aspect of health care reform proposals. We reasoned this is a missed opportunity and projected that KP’s experience with designing and delivering individualized care can illustrate the value of this capability for policymakers.

The group we assembled viewed the role of the patient as an active and independent contributor to desired care outcomes. The full roundtable discussion and overall range of consensus will be reflected more completely in upcoming Institute communications.

As part of the meeting preparation we asked participants to react to the following assumptions:

The IOM’s definition of patient-centered care is reasonable and adequate.
Patient-centered care is a key dimension of a twenty-first-century health care system.
The IOM’s patient-centered system redesign principles are reasonable and adequate.
Maximizing health is imperative for health care reform.
Health care reform objectives are interconnected and cannot be solved in isolation.

The participants’ perspectives were diverse, ranging from researcher to regulator and from physician to patient. No one minimized the need for care to be more relevant to individuals’ desires about their health and health care services. However, participants’ overall reaction to the specific assumptions we offered was unexpected. Some actively discounted the IOM framing of “patient-centeredness” as an incompletely understood idea and the least developed of the “IOM 6.” In their experience, while used commonly and reflexively in healthcare since the IOM reports, the term had little consistency of meaning, perhaps most importantly with patients and their advocates.

The IOM definition of “patient-centered” was further criticized during discussion as an overly “medical model” concept. Objection was made to the definition’s unidirectional focus on providers doing things to and for patients while neglecting the active role and contribution of the patients themselves. A term with wider resonance to the participants was “personalized” care. Care personalization, as a reframed assumption and goal, helped to generate an interactive, creative, and productive discussion and yielded additional suggestions for linkage with reform.

A key extension of this feedback to design of system and payment reform is the need to move beyond exclusive focus on what can be done to and for patients by a health system. The emerging reform should systematically achieve broad patient engagement and consistently enable patients to understand, participate in, and direct their own care. Accordingly, credible, real-world examples of health system practices that personalize care could productively influence the reform debate. Some of Kaiser Permanente’s differentiating strengths that model engagement and personalization include:

Shared decision-making leading to care deemed appropriate by both the patient/consumer and their physician. Examples include low but clinically appropriate levels of preference-sensitive surgeries, management of pharmacy and new clinical technologies, and formal programs for shared decision-making through Avivia/Healthy Solutions.
Growing and evolving engagement of the member population through kp.org and MyHealthManager; and
Programs for Palliative and end-of-life care, requiring a highly personalized discussion and decision involving patient and family.

As a footnote, “personalized medicine” is increasingly identified with the concept that “information about a patient's genotype or gene expression profile could be used to tailor medical care to an individual's needs.”Ironically, this use of the term “personalized” is potentially highly prescriptive. However, I suspect the form of personalized medicine I have described here will have maximum impact only if there is a balance between specification based on genomic findings and active alignment with patient preference, values, and choice.

- Paul Wallace, MD, Senior Advisor, The Care Management Institute and Aviva Health, Fellow, KP IHP

past issues

OBSERVATIONS