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Healthcare Reform

HealthBiz Exclusive: A Conversation with TED Book Author Rishi Manchanda

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In the latest TED book The Upstream Doctors, Dr. Rishi Manchanda draws from his experiences as a primary care physician in south central Los Angeles to envision the future of community healthcare.

That future hinges on a small but growing group of people he calls “Upstreamists,” innovative leaders on the front lines of healthcare who understand that health begins in our everyday lives, where we live, work, eat and play. More than just prescribing pills and procedures to patients who will likely return to the healthcare system soon, these doctors, nurses and other clinicians use data and common sense to look upstream at the sources of illness.

These people leverage emerging technologies, build partnerships with patients and the community, draw on skills from outside of medicine and organize teams of healthcare professionals and community-based partners, he writes.

Manchanda talked with HealthBiz Decoded in detail about social determinism in health, the applications of data mining, and what providers can do now to change the system from the inside out.

The following has been lightly edited for length and clarity.

Q: What is an “upstreamist?”

A: It’s a term that I coined. The terms “partialist” and “comprehensivist” are not widely accepted yet, but they have been advocated by Paul Grundy (director of Healthcare, Technology and Strategy Initiatives at IBM) advancing idea of patient centered healthcare. Providers are more and more incentivized to know that they can be comprehensivists, that care can be coordinated with other practitioners, with the patient seen as a whole person. It’s an important step forward to see people as more than just a collection of diseases.

The term itself reflects a sort of approach and worldview that patients and providers can have, regardless of being in healthcare. It refers to ability to understand how healthcare is shaped by social and environmental conditions.

Healthcare is a very reactive process: we wait for the person to get sick, then we treat them. But there’s always been a thread of prevention in the community context as well, at a regional and national level. We know that clinical care accounts for maybe 10 percent of the variation in how people live, the rest is social and environmental conditions.

Q: What do you hope people will take from your book?

A: My central aim is for people to believe that healthcare can be better, particularly at this time when we consider the incredible transformation that’s going on in this country, my hope is that people come away with an understanding of how we can make things better.

Q: What tools can providers use to become comprehensivists or upstreamists?

[At my startup HealthBegins] we provide them a series of steps that allow them to quickly look at the social determinism of health, then we walk them through the process of how to quickly address those social forces. We’ve only been around since October and already 400 providers are signed up.

There’s a whole toolkit that we’ve put together, but we’re not the only ones taking these steps. We’re a “think-and-do” tank.

Q: What role do electronic health records play in moving medicine upstream?

A: There’s been an incredible and relatively rapid adoption. From my personal experience as a superuser in a community clinic, I’ve seen firsthand the transformation that’s been taking place. The last thing that you would want is to have your life or a person’s life in the hands of whether a person can read a doctor’s handwriting.

Right now the jury is still out on whether or not the adoption has been embraced fully by the provider community. Part of that is the intrinsic challenge of behavior change.

But also, there’s so much variety in EHRs, there are well over 1,000 solutions out there.

Q: How could those technical solutions be improved for community clinics like yours in L.A.?

A: The biggest challenge from my perspective is that very few of them really have the capacity to aid clinics helping patients with social needs. Some of them even lack the ability to prompt a provider to think about those things.

Merging the work that goes on outside clinic walls with EHRs is the real challenge. There are some really interesting examples of how some vanguards are tweaking their systems and using EHRs to investigate social needs.

Q: And “big data” will be key in the transition that’s already happening, from a high-cost, sick-care system of medicine to a low-cost, healthcare system, as you say in the book.

A: The future for us, if I’m asked to predict three or four years, is that we have the potential for all of us to leverage big data to improve social determinism of disease. It’s not too difficult to foresee a system in which all EHR systems are able to provide a standard set of social screening questions to health clinics that have most need.

With the rise of the quantified self movement and data tracking devices, usually those are used in a way that entirely removed from the healthcare industry, we haven’t built any bridges between the quantified self movement and healthcare in order to capture data as an aggregate.

At a community level we haven’t even begun to scratch the surface of the potential of the “quantified community.” We could collect aggregate data into a system that looks for clusters of folks who are experiencing problems caused by transportation, housing or pollution.

Q: How do you feel about healthcare reforms already in motion?

A: In my opinion and from my experience, the Affordable Care Act has been transformative for patients. Three or four years ago we were in a desert wandering through looking for some semblance of rationality in our healthcare system. We were operating in this space where nothing made sense as far as how we were caring for patients in an effective way. It was a different world.

I think history will look at these years as a really historic moment. Any reasonable person will agree that access to healthcare has improved. It’s a huge step forward, but it’s not complete.

Q: In the book you point to the Vermont Blueprint for Health, a state-led program launched in 2003. What makes that state in particular such a trailblazer?

A: Vermont is wonderful example of how a state has applied its creativity aligned with ACA. They developed the concept of a community care team responsible for bridging primary care providers and community resources.

The community care team idea is one of several examples of U.S. states taking this opportunity to push us even further to an upstream model.

It’s so essential that upstreamists be connected to healthcare, and that we provide training that speaks about concrete steps that clinics and hospitals can take to build patient centered medical homes.

I myself am a practicing physician and we aren’t interested in being armchair warriors.