Tuesday, August 07, 2007

What Does People Centered Health Really Mean?

There's been a lot of talk about "people centered health," but my impression is that there's not a really clear definition of the term. In this post, I'm going to attempt to have a go at a defnitiion. Neverthleless, my attempt is really to solicit some opinions and help in defining this. I'm concluding this post with my take on what are the "revolutionary" components of people centered health in the hopes of soliciting comments that can clear this up for me and others.

Perhaps not a definition, but a recent article by Joe Flower for the Center for Health Design, sheds some light on the subject:

Most physicians and health professionals agree that Mr. Elswit’s perception is typical: Sick people are treated
in effect like prisoners in many health-care settings. The people-centered health-care movement responds to this chronic neglect of the patient experience by proclaiming a call to arms. Hospitals, say leaders of this movement, should never add to the pain and trauma of being sick or injured.

There is no shortage of low-cost opportunities to build a better patient relationship. Some peoplecentered
practices are clinical, including the enforcement of such fundamental (but too often forgotten) measures as having doctors and nurses wash their hands between treatments, installing better ventilation in hospitals,
and responding reliably to the call button. (In a 2004 study of hospital accidents, the Center for Health

Design found that a major cause was patients struggling out of bed, alone, to go to the bathroom because no one showed up to help them.) Other innovations provide simple dignity: giving patients hospital gowns with
Velcro closure tabs or straps, for modesty; or training staff to answer telephones by the third ring, to knock
before entering a patient’s room, and to introduce themselves and explain what they’re there to do.

My impression is that there's real ambiguity with respect to this term. The problem with this is that the term can be used to push programs or agendas, leading to cynicism. I've seen doctors roll their eyes when they here this term. Not because they don't want change (they do), but because they've seen initiatives (under this guise) which have very little to do with improving care and more to do with hidden agendas. Even though there've been committed efforts to define what this is, it's not easy to really get handle on the meaning of this term (or phrase). Fortunately, the World Health Organization recently had a go of defining the core values of "people centered health:"

The central role of the family and community in any process of development, and
An end to gender and all other forms of discrimination.

WHO goes on to admit that, "Despite its long history and increasing popularity, people-centred health care has not been satisfactorily and collectively enunciated at the health system level." WHO goes on to describe the characteristics of such a system from the viewpoint of each stakeholder:

For individuals, patients and their families:

Access to clear, concise and intelligible health information and education that increase health literacy;
Equitable access to health systems, effective treatments, and psycho-social support;
Personal skills which allow control over health and engagement with health care systems: communication, mutual collaboration and respect, goal setting, decision making, and problem solving, self-care; and
Supported involvement in health care decision-making, including health policy.

For health practitioners:

Holistic approach to the delivery of health care;
Respect for patients and their decisions;
Recognition of the needs of people seeking health care;
Professional skills to meet these needs: competence, communication, mutual collaboration and respect, empathy, health promotion, disease prevention, responsiveness, and sensitivity;
Provision of individualized care;
Access to professional development and debriefing opportunities;
Adherence to evidence-based guidelines and protocols;
Commitment to quality, safety and ethical care;
Team work and collaboration across disciples, providing co-ordinated care and ensuring continuity of care.

In health care organizations:

Accessible to all people needing health care;
Commitment to quality, safety, and ethical care;
Safe and welcoming physical environment supportive of lifestyle, family, privacy and dignity;
Access to psychological and spiritual support during the care experience;
Acknowledgement of the importance of all staff - managerial, medical, allied health, ancillary – in the delivery of health care;
Employment and remuneration conditions that support team work people-centred health care;
Organisation of services that provide convenience and continuity of care to patients;
Service models that recognise psycho-social dimensions and support partnership between individuals, their families and health practitioners.

In health systems:

Primary care serves as the foundation;
Financing arrangements for health organisations that support partnership between health practitioners and people accessing health care;
Investment in health professional education that promote multidisciplinary team work, good communication skills, an orientation towards prevention, and integrates evidence about psychosocial dimensions of health care;
Avenues for patient grievances and complaints to be addressed;
Collaboration with local communities;
Involvement of consumers in health policy;


I highlighted in red the items which, for me, are the clearest components that can provide a notable change in health care. First off is giving people (patients) access to quality health information. This is easier said than done for we need to define what quality means (e.g., not skewed towards the Pharma view, etc.). Secondly, there's a holistic approach to delivery of health care. This could be quite revolutionary if we include alternative medicine (e.g., herbal medicine, acupunture, etc.) as a valid component of health care delivery.

Teamwork and collaboration (as equal partners) among various stakeholders such as doctors, ancillary staff, etc. combined with a focus on continuity of care seems to me as something that easier to state and much, much harder to execute. Last but not least are transparency and recognizing the importance of Primary care in the whole process.

These concepts are easy to put in a blog post. Nevertheless, I've been around enough doctors (e.g., Dad and brother) to know that these changes are extremely hard to imagine. Why am I writing about all of this? The reason is that I really believe (am I naive?) that the web presents a tool that can really drive these changes. How exactly can this tool (web) drive something as complex as change in health care? I'll leave that for my next post. :)


Anonymous said...

I read your blog with great interest, as this is a topic that is increasingly drawing the attention of the health care community. I am concerned about the view of "people centered health care" as primarily one involving clinical care, in a health care DELIVERY system, such as a clinic or hospital. As a physician who has done both clinical and public health medicine, I truly believe that the concept should be applied more broadly, to encompass all levels of health care, including public health policy and program planning at the national/international level.

Thus, I see empowerment and participation/representation as vital elements of the definition, not just at the level of the individual patient, but also at the level of communities and populations that are so often, in this globalized world, marginalized in decision making regarding health care policy and population interventions. For instance, there are today so many international funds like the Global AIDS fund, but who gets to decide how and where the dollars are spent? Do the "target populations" ever have a say?


BigAl said...

Excellent point, amdavid.

My belief is precisely that, today, there's really no reason to not give these "target populations" a say. There's been enough of an advance in tools (e.g., social networking) to promote "participation" that this is not an obstacle.

The big question is "how" to enable this participation.

Anonymous said...

Great discussion.

I am a physician in a large multispecialty group in Wisconsin. We are making efforts to change the way we do business, guided, in part, by the principles of "people centered healthcare", as well as "coordinated care models", and care guided by "Evidenced Based Medicine". It's no easy task to translate principles into practice.

I am always struck by the tendency in the US to turn to novel business or marketing principles (which often sound more like slogans). It seems that we often start chanting these slogans at the expense of confronting and addressing key structural inadequacies within the system as a whole.

So, in the US, there is an obvious embrace of the concept of a "people centered" approach, but this occurs in a system that marginalizes over 40 million uninsured and a significant portion of the population that his underinsured. My criticism is not with the notion of a "people centered" approach; it's more with the fact that it telling stops short of requiring universal health care to work.

Of course, it's not completely fair to require that a new policy fix everything before accepting any of it. And the medical group that I'm working with right now certainly does not see this as an excuse to avoid working on moving toward a more "people centered" care delivery approach. Nevertheless, I think that the point is worth keeping in mind. Let's not fool ourselves that we can fine tune a system without ultimately addressing its major structural inadequacies.

Regarding international aid, Amdavid asks, "[W]ho gets to decide how and when the funds are spent?" This is not just an important question with international aid, it also directly affects medical research priorities in the US. Public funding has gone down in the past 20 years, and private funds largely dictate the direction of research. A patient centered approach to drug research would focus on comparison studies between traditional therapies and new therapies not placebo drugs. A patient should want to know whether a new high-priced drug (with an unknown safety profile) works better than an older tried and trud drug, not whether it works better than placebo. But this type of comparative research (between old and new drugs) is extremely rare these days. It's much easier for pharmaceutical companies to show a beneficial effect compared to a sugar pill than to a traditional therapy.

Let's look at another sector--medical imaging--that affects the possibility that we can truly transform our system into a people centered system rather than one focused on maximizing return on expensive technologies. Drug costs are still a major concern, but some headway has been made in taming this beast.

However, the cost of medical imaging in the US is exploding. Cardiac CTA is one area in particular that is seeing a rise in usage without proven evidence that it leads to better patient outcomes. Many of the studies are almost like advertisements, touting the high quality images that one can obtain. Intuitively, you would think that this would lead to better care. The reality is that the images are too good. That means that we find all sorts of "abnormalities" that, in the end, mean nothing. Of course, it takes further testing, including invasive biopsies to prove that these findings are insignificant. Another problem is that CT scanning is sometimes not good enough to give a clear answer, an so the patient has to undergo a heart catheritization (cath) to confirm that the patient is OK. The radiation doses for CT and for caths are very high so having both is a significant dose of radiation.

But patients see the advertisements in magazines, and many cardiologists are willing to order these tests even without hard evidence that they improve patient outcomes. (Over the past 20-30 years, US cardiologists and big business have had a "close" working relationship.) So what is a "people centered healthcare" movement to do? Are you going to tell a patient that they can't have one of those new cardiac scans that everyone is talking about?

Does this mean that we should take a nihilistic approach, and forget about people centered healthcare, or other improvements? Of course not. I'm just trying to put things in context. We definitely need to move in a better direction, and people centered healthcare captures some important issues that need to be addressed. It just doesn't capture everything.

- Phil