Population Health, Stephen Shortell and ICT

Josep M. Picas

A few days ago, Jordi Varela published his editorial on "The health of the population beyond the integration of services" based on an excellent document from the King's Fund. The truth is that good news about the evolution of health models are rare, although it might be better to speak of "frameworks" in the field of health. The theme seems so powerful that, obviating the already mentioned conceptual aspects, I’d like to use it to bring forward some aspects related to information systems.

Progress in concepts such as Health Maintenance Organizations and Accountable Care Organizations have come together with the evolution of the great potential of information systems and data processing that has been developed in recent years, and here we find some of the best ideologues on health systems in these times, for example Stephen M. Shortell who, among other prominent curricular aspects, is emeritus dean of the School of Public Health at the University of California - Berkeley, discussing ICT tools and content. So I suggest reading two articles written by Shortell. The first, “A bold proposal for advancing population health” which was published as a discussion paper by the Institute of Medicine, develops the conceptual model and suggests the future development of the payment system and health financing towards one based on health and not on disease, more transversal between health care, public health and community services. Shortell emphasizes the problem of professionals’ cultural barriers when faced with this approach, as Varela said in the aforementioned article. In the second article, "A Proposal for Financially Sustainable Population Health Organizations", Yasnoff, Shortliffe & Shortell propose the creation of banks of health information that unifies, under the management of the patient themselves, electronic medical records – the individuals and population’s health, a surely trendsetting approach.

Against medical overuse, more primary care

Atul Gawande, a surgeon and author of the book "The Checklist Manifesto" and "Being Mortal" among others, has published an article in The New Yorker, "Overkill," which talks about the disproportionate clinical practices, especially those in their country, the USA. It’s a long and well-documented writing that I’d like to comment on in this post for two aspects I consider important because they can help fight the epidemic of overdiagnosis and medical overuse. The first question posed by Dr. Gawande is an organizational consideration of diversion of resources, and the second is a proposal to avoid mistakes when prioritizing budgets.

Preventive activity and daily clinical work

The case-mix seen in clinics today has changed dramatically with the impact of secondary prevention programs and the medication of risk factors. Now the doctors’ agendas and especially those of family physicians are filled with healthy people who are afraid of getting sick, a situation that not only uses up medical time but also diagnostic tests, medications and referrals to specialists (if you are interested in this issue don’t miss the book "The patient paradox" written by the Scottish family physician Margaret McCartney). Cost considerations aside, health resources are so busy in offering care for healthy people and invest so little effort in addressing the clinical complexity of some patients that what they need really is multidisciplinary work and integration of services.

Untangling the skein of frailty to leave the maze of disability. From detection to prevention

Marco Inzitari

Following on from Ariadne’s thread which was extended across the concepts of aging, complexity and disability, I will build this new contribution on my previous post entitled “Frail, cracked or broken?”. In that post, I defined as "frail" a person with apparent good health and overall functions but with concomitant alterations of different organs and systems, often sub-clinical, that increase the vulnerability to progress towards disability in case of injuries of a different nature (clinical, such as illness, or social, such as widowhood, etc). The main goal of the detection of frailty is prevention, because frailty and disability are reversible.

In this new post, I will try to move towards the exit of the maze, although this may be an even more complex task than Theseus’ challenge. The metaphor of frailty and, more generally, of aging as a "Minoan" maze, is not accidental: it’s a complex phenomenon where multiple systems and organs begin to be simultaneously altered, different pathologies appear and drug treatments are added. The social situation of the person and their environment can represent added elements of frailty. Besides coexisting, all these factors are interacting, determining an intricate tangle of threads of different colours that are really hard to discern. It’s as if the aging tended towards entropy, just like too many electric cables tend to become entangled. Given this complexity, it’s hopeless to pull a single thread and expect the skein to untangle. This is why "magic" recipes such as an alleged "pill" to combat aging, have failed so far. If we want different results we need a focus shift when looking at the classic "risk factor - disease - treatment".

The dream team of primary care in Europe

Tino Martí

The WHO Europe has published "Building Primary Care in a changing Europe". It is a very well prepared document written by a cast of first class minds (Kringos, Boerma, Hutchinson and Saltman) based on the information collected in the European project PHAMEU (Primary Healthcare Activity Monitor in Europe) reflecting indicators of structure, process and result of all the countries of the European Union provided by either accredited local points of contact (in Catalonia IDIAP). The project has been funded by the European Commission and supported by WHO Europe, the European Forum for Primary Care, the European Public Health Association and the European General Practice Research Network.

The paper analyzes the strengths and weaknesses of the existing multiple configurations of primary care in Europe, overcoming the usual classifications of Bismark versus Beveridge systems intended to relate their performance and results to develop rankings of countries. The systems reaching the top are considered as possessing an attribute of a "strong" Primary Care.

An interesting exercise based on the published information would be to design the most robust way for creating create a dream team of primary care settings in Europe.