Predictive health: Could it be a new paradigm for quality?

Emory facility sees 'healthy' people in an attempt to avoid future disease

A new facility in Atlanta is turning the concept of "health care" upside down. Rather that treating sick patients, the health care professionals, called "partners," will see individuals, called "participants," who as far as they know are not sick at all.

Rather, they will conduct a series of surveys and tests to identify potential disease or existing chronic disease, and outline recommendations for either preventing or minimizing that disease. This approach, called "predictive health" by its proponents at Emory University's Predictive Health Institute, could represent a new paradigm for quality and may one day be an integral part of your hospital's offerings.

"We chose to call this predictive health [other terms in common use are 'personalized health' and 'prospective medicine'] because we talk about prediction vs. diagnosis, and health as opposed to disease," explains Ken Brigham, MD, associate vice president for predictive health at the Emory Health Science Center and director of the Emory/Georgia Tech Predictive Health Institute, which is overseeing the new Center for Health Discovery and Well-Being.

"Our approach is characterized by health, and by developing ways of measurement that are sensitive indicators of various early changes — or unhealth. The goal is to understand these processes and to develop new interventions to treat people before they become very sick."

Calling the individuals who are seen in the center participants "emphasizes strongly that this is a partnership," explains Brigham, as does calling the health care professional who follows them a partner. "The secret to getting people to implement healthy behaviors is engaging them in a partnership process, and to accept responsibility [for their own health]," he explains.

Affiliate with a hospital?

The new facility, which has just opened, is located in an office tower at Emory's Crawford Long Hospital, but at present is not part of Emory Healthcare. "We are calling it a center, not a clinic, to avoid some of the traditional language surrounding disease care," Brigham explains.

However, he says, "I do see it as being properly affiliated with hospitals. We are not under the illusion we will prevent everyone from getting sick — but we hope to minimize the incidence of disease and prevent as much as possible the need for traditional kinds of medical care."

He adds, though, in the process of defining health, his staff will no doubt identify people who need medical care and those people will be sent elsewhere for appropriate care — in this case, Crawford Long.

Down the road, Brigham hopes the center will help decrease admissions. "That's why hospitals should be thinking about actually owning something like this," he says.

Vive la difference

The center is even designed to look different from a traditional health care facility. "We worked closely with the architect, thinking carefully about what we'd want the experience of a healthy person encountering our system to be," says Brigham. The design is open, with a fountain in the entranceway, soft colors, and rounded walls. "The thought is that if healthy people encounter the system, it should be a pleasant experience for them — if not, they won't do it," Brigham explains.

When the participant arrives, he or she is given a series of screenings, including:

  • SF-36 — quality of life;
  • FACIT-Sp-Ex — spiritual/well-being;
  • CAPS — typical week physical activity;
  • Willett food frequency questionnaire;
  • Perceived Stress Scale;
  • Lunar iDXA Scanner — body composition;
  • ultrasound — carotid intimal medial thickness;
  • treadmill exercise fit test — estimated VO2 max;
  • hematologic profile;
  • metabolic profile;
  • nutrition profile;
  • glycomics array;
  • T-cell telomere;
  • DNA/genetic profile.

The first five are surveys administered on the center's web portal and designed by Georgia Tech. "The web-based series of validated questionnaires are completed on a computer tablet," explains Brigham. The iDXA scan, he continues, "is a very quick and sensitive measure of bone density and body composition." The ultrasound measurements include the thickness of the (carotid) artery in the neck, an indicator of artherocloseris, and the function of blood vessels in the arm, a surrogate for vascular function in general, says Brigham.

After the treadmill test, blood is drawn to determine a battery of measurements including routine tests such as cholesterol and sugar. However, adds Brigham, there are "some special tests of the four processes we believe define health and predict early deviations."

Four processes of discovery

While there is early evidence supporting the validity of measuring these processes, Brigham emphasizes that this is the "discovery" part of the clinic's activities. The processes are:

  • inflammation;
  • immune health (circulating immune cells in the blood);
  • regenerative health (the capacity of the body to heal itself, determined by counting the number of circulating stem cells);
  • measurements of oxidative stress.

"Such processes seem to underly a lot of disease," Brigham explains. "The individual will discover more about their health and we will discover more about human health."

"Part of the center's design is our discovery process," adds Matthew Rivera, RN, manager of the center, who has experience in disease management, staff training, evidence-based medicine, and benchmarking against national measures such as ORYX and HEDIS.

Longitudinal analysis to be done

"We will profile the participants, compare them to other population norms, and follow them longitudinally over time. We want to see whether or not meeting with health partners and getting them engaged in a health action plan will enable us to predict, based on the assessment, the kind of improvement we will make or not make."

Once the tests have been completed, Brigham continues, the participant goes into a private consultation room with the partner to receive a report that summarizes all available data. The partner will go over the results and help the participant design a health-related program that might include diet, exercise, stress reduction, and behavior changes. "They may even explore with each individual what kinds of things they are most likely to participate in that would be helpful — such as yoga programs," adds Brigham.

The health partner will stay in touch with the participant in agreed-upon intervals. Blood work will be available within 24 hours, and the participants will have secured web-based records and access with appropriate clearance. "That's also one method of communicating with the health partner," notes Brigham.

The health partners, he emphasizes, "are a new kind of health professional we are developing." They have at least a bachelor's degree, with a background in a health-related field, particularly exercise physiology or behavioral sciences, and are trained by the professional staff in the center, which includes a nutritionist, an exercise physiologist, and Brigham and Rivera.

Trend will grow

Rivera says the trend toward this sort of approach to health already is growing. "Other similar models are popping up at Duke and Ohio State, and several private companies are now doing full-body scans and health assessments," he says. "For our part, we are looking not only at physical health, but at mental health and social and environmental health as well."

This "absolutely" represents a paradigm shift in health care, he asserts, and "the benchmarks of evidence-based practices we develop will help other inpatient or outpatient facilities develop their own model similar to ours."

That's where the quality professional comes in, he observes. "One of our approaches, and part of our design, is looking at outcome measures," says Rivera. "The hospital quality manager would do that if their hospital were to set up a similar facility."

Brigham agrees. "There's absolutely a role for the quality professional in this," he asserts. "As this type of activity evolves, there will need to be a development of best practices and some sort of quality assurance program so initiatives are evidence-based and implemented appropriately."

Finally, he says, "hospitals ought to be thinking in this direction, because health care is shifting that way."

[For more information, contact:

Ken Brigham, MD, Associate Vice President for Predictive Health, Emory Health Science Center, Director, Emory/Georgia Tech Predictive Health Institute, 550 Peachtree Street, MOT, Suite #1850, Atlanta, GA 30308. Phone: (404) 686-6195.

Matthew Rivera, RN, MHSA, CPHQ, Manager, Center for Health Discovery and Well-Being, Emory/Georgia Tech Predictive Health Institute, 550 Peachtree Street, MOT, Suite #1850, Atlanta, GA 30308. Phone: (404) 686-6181. Fax: (404) 686-6193. E-mail: matthew.rivera@emory.edu.]