In 1977 Dr. George Engel published a report that raised the specter of reductionism in medicine and advocated for a more inclusive scientific model, if, “physicians in the future are to apply the same scientific rigor to the approach and understanding of patients and their care as they customarily apply to the diagnosis and treatment of disease”. His recommendations were prescient, yet we have done little substantive towards their realization. The recent tsunami of programs addressing “social determinants of health” would be superfluous if we had taken Dr. Engels advice to incorporate behavioral dimensions and social factors into our model of care. Yet, even today’s efforts related to social determinants are simply an addition to the house of medicine, not part of its foundation, nor integral to its mental model.
In 1982, Drs. Ruth Stein and Dorothy Jessop published the first of a 15-year series of articles describing “a non-categorical approach” to chronic illness. Their insights, validated in subsequent research, defined the concept of ‘chronicity’ as a clinical entity, independent of diagnostic labels or etiology. The critical interaction of disease and quality of life are clear in their model, and the idea of a transcendent functional burden of illness has for 30+ years remained an unrealized opportunity for novel outcome-oriented intervention design.
In 1983, Dr. Robert Gordon, then Special Assistant to the Director of the NIH, wrote a brief report critiquing the traditional approach of classifying chronic illness prevention strategies based on ‘origins of disease’, proposing a new framework for “operational classification” of patient-focused clinical strategies. Gordon sought to define prevention strategies by their predictable outcomes, targeted to those ‘for whom the measure is advisable on a cost-benefit basis.” While his approach generated some interest related to mental health, a clinical operating model based on prevention did not get traction within mainstream medicine.
It would be easy to say that, at the time of these insights, incentives were not aligned to support their adoption. This, however, was not the case: with little of today’s scrutiny into physicians’ decisions and determinations of medical necessity, the medical community could have easily made these evolutionary leaps purely out of what was in the best interests of patients, as we did with Lawrence Weed’s SOAP notes.
To understand what went on then – and what remains today as a barrier to productive evolution of healthcare – let’s turn to another paper from that era by mathematician and physicist Elliot Montroll,who explores the concept of ‘social evolution’ and the calculus of social dynamics by tracking the evolutionary process of industrial replacement, with insights gleaned from our ‘social transition’ from rail to air travel.
We learn that in 1950, after almost 100 years of dominance of American transportation, the railroads had 7 times the intercity passenger-mile traffic of the then-30-year-old commercial airline industry. However, by 1970, airline services were carrying passengers 9 miles for every mile traveled by the railroads, which ended up bankrupt and nationalized. What happened?
Many forces influenced this change – the growing Interstate Highway System and the familiarity of returning WWII veterans with airplane travel were both factors – however, it turns out that the driving factor in the failure of the railroad industry was how they defined themselves.
The identity of “railroad people” was tied to the history and mythology of the railroads: rolling stock, rights of way, scheduling. They failed to consider that they were actually in the transportation business; this created an artificial barrier which put airplanes outside their operational frame of reference, and therefore ignored as a potential opportunity. If they had been more inclusive in their thinking, they might have invested in airlines and modified their rail service strategies based on market forces, allowing a more productive evolution; but hubris and legacy thinking blinded them to the reality of social dynamics.
This phenomenon was largely repeated 40 years later by “newspaper people” when the Internet emerged as a competitor to the print publishing industry; it now looms prominently over the American healthcare system.
The barriers to the productive evolution of our healthcare systems are not necessarily incentive-based; it may be that the traditional organizing principles of medical knowledge are insufficient to allow for adoption of problem representations that support truly integrated care.
Traditionally, the responsibility for the elements of any patient’s plan of care is apportioned independently among a patient’s “health resource-community” (primary care and specialist physicians, nurses, case managers, therapists, social workers, etc.) who, based on the operating model of their role, or the mental model of their professional discipline, contributes their perspective and associated insights, goals and the related orders or action items. Unfortunately, even when everyone is at the table (or facing the patient for that matter), integration in healthcare is often is no more real that the parallel play of toddlers. This ‘aggregation” model can result in conflicting priorities in terms of resource allocation, limitations on sharing knowledge and resources, redundancies, mis-communications, clashes in advice and counsel, and, sometimes, added risks due to conflicts in evidence, especially when judgements are made in isolation of other members of the patient’s health resource-community.
Architect and TED-conference founder Richard Saul Wurman is said to have conceptualized the discipline of “information architecture” (IA) as a method of creating “systemic, structural, and orderly principles to make something work”. As IA tells us, aggregation is not the same as integration; as such, creating a care plan without a rational overarching organizing principle won’t support effective downstream allocation of care delivery resources and subsequent tracking of their contribution to goal achievement.
In the symphony, orchestration is difficult without a common ‘score’ that integrates the diverse instrumental voices, and truly integrated care is impossible without a “single source of truth” for patient’s health-related goals and associated plans of care, collectively developed with the patient and shared among all the members of a patient’s health resource-community.
The building blocks of a universal framework for integrated, person-centered healthcare planning have been sitting in medicine’s front yard for decades. Remarkably, they haven’t rusted, and remain a fresh approach to the challenges facing healthcare today: including, but not limited to: prevention, social determinants of health, value-based care, clinical decision-making, medical education, the role of technology in healthcare, collaboration, and change management.
Integrating the work of Engel, Stein and Jessop into a revised Gordan Care Plan Framework provides us with an operational classification schema that places the judgments and recommendations of all the human and information systems that participate in a patient’s health resource-community into a central reference point — the “single source of truth”.
This can drive clinical performance that a) orients all the members of a patient’s health resource-community toward whole-person care b) accounts for all the possible goals that can be established to improve the patient’s quality of health, c) eliminates artificial boundaries related to the biopsychosocial determinants of the patient’s conditions or risks and d) sets up for collaboration and accountability across what might be otherwise unaffiliated members of a patient’s health resource-community.
Practically, operationalizing this framework will also organically support a more concrete shift to patient-driven care, by forcing all the members of a patient health-resource community to contribute to a central repository. My placing the locus of control for care planning with the patient we shift the figure/ground relationship between the patient and their health-resource community. The optimal model for this would be where the patient “owns” (controls, manages and approves) their plan of care, and distributes copies of it to all the respective member of their health resource-community. Any distant recommendations for change would be routed to the patient’s locus of control for discussion and/or approval.
The adoption and integration of such a framework would allow for a rational and individualized approach to intervention design and resource allocation, as well as enhance the capacity of a patient’s health-resource community to monitor and contribute to progress towards goal, while coordinating activities to assure a concordant, harmonious experience for the patient.