In this talk from Stanford Medicine X 2013, the University of Oklahoma's Dr. Zsolt Nagykaldi, PhD, discusses a paradigm shift at the heart of patient-centered care, from treating the unwell to maintaining the healthy.

1. Shifting the Focus From Disease To Health:Shifting the Focus From Disease To Health:
A Paradigm Change To Achieve Patient-A Paradigm Change To Achieve Patient-
Centered Care Through TechnologyCentered Care Through Technology
Zsolt J Nagykaldi, PhD
Associate Professor, Associate Director of Research
University of Oklahoma HSC Department of Family & Preventive Medicine
and the Oklahoma Physicians Resource/Research Network (OKPRN)

2. What WouldWhat Would YOUYOU DoDo??
• LLong list of tasks
• EEach compete for time and resources
• EEach are important to complete
• AAll are beneficial
• TThe level of benefit varies significantly
> How would you solve this problem?
Congratulations! You are officiallyCongratulations! You are officially
SMARTER than the U.S. healthcare system!!SMARTER than the U.S. healthcare system!!

3. A Real-Life Example: The Story ofA Real-Life Example: The Story of
Mr. Waldrin - Personal NarrativeMr. Waldrin - Personal Narrative
Mr. Waldrin is a 76 year old man of Northern European
descent, married, a retired psychology professor who
enjoys reading and writing (essays and articles for
magazines). He is active socially, and also likes walking
and traveling. His grown children and grandchildren are
scattered throughout the country. Trips to visit them often
involve driving long distances. He is a non-smoker and
drinks only 3 glasses of wine weekly.
He states that, for him a substantially decreased quality of
life would include permanent conditions that prevented
him from thinking clearly.

4. The Story of Mr. Waldrin:The Story of Mr. Waldrin:
Clinical & Biomedical InformationClinical & Biomedical Information
Mr. Waldrin has the following medical conditions and risk
factors for adverse health outcomes:
 Type 2 DM for 11 years, now on glipizide
 HTN for 20 years, now on HCTZ
 Dyslipidemia X 11 years, now on atorvastatin
 Osteoarthritis of knees for 8 years, on PRN Tylenol
 A family history of colon cancer (mother at age 70)
His current BMI: 32; BP: 150/90; A1c: 7.5%; LDL: 140;
aerobic activity level: insufficiently active

5. Disease-Centered GuidelinesDisease-Centered Guidelines
and the Long “To-Do List” Problemand the Long “To-Do List” Problem
Considering only “A” and “B” –level evidence-based
guidelines and only from USPSTF, ACIP/CDC, and
AAFP, the relatively healthy Mr. Waldrin could receive
a minimum of 20-25 (ongoing) evidence-based
interventions to sustain or improve his health,
including, for example:
Aerobic exercise 30 min 3 times/wk Reduce LDL cholesterol to 100
Take aspirin 81mg every day Take an ACE inhibitor
Reduce highway miles driven by 50% Take metformin
Yearly flu shot Pneumococcal vaccination
Reduce BP to 130 systolic Take a beta blocker
Lower A1c to 7% Do a screening colonoscopy

6. Another Real-Life Example:Another Real-Life Example:
The Story of Mrs. SalinasThe Story of Mrs. Salinas
79 years old Hispanic/Latino female with moderate OP, OA, T2DM,
HTN, and COPD
When pertinent single-disease guidelines are applied for only the 5
chronic conditions, the following clinical regimen can be suggested [*]:
 12 separate medications taken at 5 diff. times and in 19 doses/day
 Estimated medication cost: > $400 per month
 14 non-pharmacological interventions (e.g., patient education, labs)
 Min. 4 primary care visits and several specialist visits per year
 Important personal issues would remain unaddressed (15 min visits)
 Numerous drug and food interactions, some guideline conflicts, and
potential patient preference conflicts
[*] Boyd CM et al, JAMA, 2005 (10)

7. Medicine On Unsustainable Course:Medicine On Unsustainable Course:
What We Can Learn From Other ProfessionsWhat We Can Learn From Other Professions
Health/Disease Care Conundrum:
• Patients and practices are inundated by things to do
• Number of “problems to fix” rises exponentially
• Allocated resources per “fix” tend to decrease
• Available time per “fix” decreases
• Basic needs remain unmet or worse, we may cause harm
An Engineer’s Perspective:
• Take a step back and assess personal/shared goals
• Prioritize actions based on their impact on reaching goals
• Put a system in place to track outcomes and adjust the
course of action iteratively

8. The Problem With Problem-The Problem With Problem-
Oriented Medicine: Potential Self-Oriented Medicine: Potential Self-
DestructionDestruction
If the ultimate goal of healthcare is to make everything
“normal” by eliminating each individual abnormality, then:
 We will never achieve our goals, since there is no end to
discoverable problems
 It creates an unsustainable course for healthcare (current)
 The ultimate solution would be to correct every genetic
abnormality which would result in a “perfect genome”
 However, species with an invariable genome could be
wiped out by the first major infectious agent due to loss of
tolerance and adaptability

9. The Need For Personalization & Prioritization:The Need For Personalization & Prioritization:
The Central Issue of 21The Central Issue of 21stst
Century MedicineCentury Medicine
• We have reached a point in the health care system where
there are many more things that can be done than any
patient is able to or should want to do.
• This will get dramatically worse once our individual DNAs
can be mapped at birth (# of risk factors will increase
substantially).
• Clinicians and patients must therefore learn how to
prioritize available interventions.
But by what criteria should we prioritize clinical care?

10. Principal Goals of Health Care:Principal Goals of Health Care:
Living Longer and Living BetterLiving Longer and Living Better
 Development of healing relationships
(Healing relationships are built upon trust that nourishes the inborn
psychological/spiritual needs of individuals – SDT: Deci & Ryan)
 Prevention of premature death and disability
(The point of not preferring length over other aspects is individually
different and changes over time)
 Enhancement of current/future quality of life
(Depends primarily upon the ability to do things that give life meaning
which is individually different and changes over time)
 Support of personal growth and development
(Proceeds through a series of predictable stages, each one building
upon the previous ones)

11. Goal-Directed Care:Goal-Directed Care:
Risk Reduction in a Holistic PerspectiveRisk Reduction in a Holistic Perspective

12. Patient-Centered Medical System:Patient-Centered Medical System:
A New Primary Care Delivery ModelA New Primary Care Delivery Model
CCR
HRA
Wellness
Portal
CCR
HRA: Health Risk Appraisal; EHR: Electronic Health Record; CCR: Continuity of Care Record
PSRS: Preventive Services Reminder System
Risk Processor
(HRA)
Prioritizes available
interventions from
clinical guidelines by
outcome and size of
effects
Prioritized
Recommendations Lists
Wellness
Plan
Decision
Support Tool
Link to
Resources
Task Manager
Registry, reminder, and
recall system (PSRS)
Lab results,
consults and
referrals
Billing
System,
EHR
Personal
attributes,
values,
goals,
preferences,
constraints
ClinicianPatient
Wellness
nurse
Evidence-based guidelines and
population statistics

13. Conceptual Model of Goal-DirectedConceptual Model of Goal-Directed
Care:Care: READY–SET–GO!READY–SET–GO!
* Patient actively prepares for an annual wellness visit (“homework” assignment).
** Includes primary, secondary and tertiary prevention.
Wellness Visit
+ Negotiated
Wellness Plan
Patient Activation
Personalized
Wellness Plan
Emphasis On
Healthy Behaviors
Improved
Health
Behaviors
Better
Preventive Care
(**)
Education &
Preparedness
Heightened
Awareness
& Readiness
Quantification
of Risks
Prioritization
and Focus
Increased Life
Expectancy &
Quality of Life
Systematic Progress Tracking & Health Coaching
Goal-Directed,
Pre-Visit HRA
(*)
“Ready” “Set” “Go”

14. Expanding the Construct of Risk FactorsExpanding the Construct of Risk Factors
All health conditions are associated with short-term or long-
term adverse outcomes:
 Conditions/problems can be considered risk factors for
future adverse outcomes (e.g., MI, stroke, cancer, DM2)
All health care interventions are intended to improve short-term
or long-term health outcomes:
 Interventions/services can be considered strategies to
mitigate the risk of adverse outcomes
This integrative model creates a more holistic approach for
healthcare: a) no separation of acute and prospective care
b) disparate risks can be in the same model

15. The “The “My Wellness Portal”My Wellness Portal” StudyStudy
(AHRQ(AHRQ 1R18HS017188-01; 2008 - 2011)1R18HS017188-01; 2008 - 2011)
Aims:
 Develop, field test, and refine an innovative, goal-directed
and practice-integrated e-patient wellness portal (2008)
 Determine the impact of the Wellness Portal on patient-
centered preventive care by examining the behavior and
experiences of both patients and practices and the degree
to which recommended services are individualized and
delivered (2009-2010)
 Disseminate the Portal technology and lessons learned
from the Wellness Portal trial (2011-)

16. ““Ready”: Feeding the Risk EngineReady”: Feeding the Risk Engine
From Clinical Sources (EHR/HIE)From Clinical Sources (EHR/HIE)
A 75-year-old white, non-Hispanic woman with diabetes (for 5 years), hypertension (for 10 years),
elevated cholesterol, and painful osteoarthritis Has no recognized microvascular or macrovascular
disease and no symptoms related to hyperglycemia. She has attended diabetic education classes
and modified her diet and activity. Her medications include glyburide, atorvastatin, hydrochloro-
thiazide, acetaminophen, and aspirin. She has a family history of diabetes and cardiovascular
disease. She has never smoked or used alcohol to excess. The review of her systems is
unremarkable except for one recent fall, which occurred when she tripped on a throw rug in the
bathroom. She was not injured. She is a retired teacher and widow, lives in her own home, values
her independence, and has little interest in therapies that would increase her medical costs or
change her daily routine. The arthritis limits her ability to exercise. However, she enjoys reading,
sewing, sports on TV, and a little flower gardening. Her BMI is 29 (5 ft 4 inches 169 lbs); her BP is
154/76 mmHg supine but 132/70 mmHg while standing without lightheadedness. Her HbA1c is
8.4%, fasting glucose level is 150 mg/dL, total cholesterol 200 mg/dL, LDL cholesterol 110 mg/dL,
HDL cholesterol 55 mg/dL, triglycerides 180 mg/dL, serum creatinine 1.2 mg/dL, and urine
microalbumin < 20 mg/dL.
Factors in red can be picked up by the HRA risk engine

17. Feeding the HRA Risk EngineFeeding the HRA Risk Engine
From Patient Contributions (Portal)From Patient Contributions (Portal)
215 health-related risk factors & preferences in 13 domains

18. Feeding the HRA Risk EngineFeeding the HRA Risk Engine
HRQoL - Meaningful Life ActivitiesHRQoL - Meaningful Life Activities

19. Feeding the HRA Risk EngineFeeding the HRA Risk Engine
HRQoL – Level of Existing DisabilityHRQoL – Level of Existing Disability

20. Under the Hood of the Risk EngineUnder the Hood of the Risk Engine
Life tables & the Cox Proportional HMLife tables & the Cox Proportional HM
Baseline total risk calculated from
appropriate population life tables
Log [Personal risk] = b1 x risk(1) + b2 x risk(2) + .... + bn x risk(n)
Total personal risk final probability of dying in each year
Cause-specific baseline risk componentsRisk adjustment coefficients (tailoring)
Breaking down total risk into components
Summing up individual risk components
Calculating personal life table values
Step 1.
Step 2.
Step 3.
Step 4.
(log relative hazard)
Life table conversion into Life Expectancies for each year

21. // //
Parametric estimates:
(for clinicians)
- ELE, EHE/DFLE, [RRI/RRR]
Visual-analog derivatives:
(for patients)
- RealAge, Wellness Score
Qualitative assessment:
- Health strengths and
challenges
Total health benefit:
- Total life-years gained
Individual health benefit:
- Estimated impacts of
attaining individual
patient goals
HRA
ReportReport
PersonalizationPersonalization
PrioritizatioPrioritizatio
nn

22. ““Set”: Setting Goals andSet”: Setting Goals and
Strategies (Wellness Plan)Strategies (Wellness Plan)
1) The HRA Report forms the basis of a more effective and
clinically meaningful discussion
2) Areas that need improvement are stratified in the order of
the magnitude of health impact (law of diminishing returns)
3) Considering patient readiness for change can be integrated
into the process “organically” via goal setting
4) Status of heath and a sense of change in “unmeasurable”
areas can be visualized and grasped: the needle moves
5) Report is just a starting point, the Plan can be further
tailored (patient activation & empowerment)

23. ““Go”: Putting Systems InGo”: Putting Systems In
Place to Respond to NeedsPlace to Respond to Needs
1) Personnel are trained and dedicated to “clinical pathways”
2) Office provides some patient outreach (proactive care)
3) Reinstating annual wellness visits (e.g., Medicare AWVs)
4) Patient retraining: “homework” must be done before visit
5) Fostering a culture of patient accountability and participation
6) Connecting to practice and community resources
7) EHRs are augmented with registry/reminder/HRA and more
sophisticated clinical decision support technology
8) Creative approaches implemented to fund these activities
(not leaving money on the table), a temporary measure
The “Clinical Pathways” or “Prevention on Rails” approach

24. A System Example: HIE-LevelA System Example: HIE-Level
Clinical Decision-SupportClinical Decision-Support

25. The Wellness Portal StudyThe Wellness Portal Study
(AHRQ(AHRQ 1R18HS017188-01; 2008 - 2011)1R18HS017188-01; 2008 - 2011)
Aims:
 Develop, field test, and refine a web-based patient Wellness
Portal linked to an existing and tested practice portal
(PSRS) in primary care practices (2008)
 Determine the impact of the Wellness Portal on patient-
centered preventive care by examining the behavior and
experiences of both patients and practices and the degree
to which recommended services are individualized and
delivered (2009-2010)
 Disseminate the Portal technology and lessons learned
from the Wellness Portal trial (2011)

26. Results of the Wellness Portal RCTResults of the Wellness Portal RCT
(N=422; 8 practices; 2009-2011)(N=422; 8 practices; 2009-2011)
• High level of “meaningful” utilization (73% of patients; 576 sessions)
• Significantly improved uptake of preventive services (avg. 25% increase)
• Despite lower average number of visits in Portal group (2.9 vs. 4.3)
• Improved patient-centeredness of care (CAHPS-PCC10)
• Substantially more community linkages established (OR=8.22)
• More self-management support in Portal practices (OR=2.00)
• More robust care delivery systems are established (OR=1.72)
• Higher level of preventive care integration (OR=1.80)
• Significant increase in patient activation (PAM 45 -> 47; 2nd
to 3rd
stage)
• Considerable decrease in missed opportunities for preventive care (25%)
• Rich and meaningful patient and clinician feedback about the process

27. Results of the HRA ImplementationResults of the HRA Implementation
Trial (Global Health Indicators)Trial (Global Health Indicators)
• The mean increase in Estimated Life Expectancy (ELE)
across the intervention population was 8 months higher
than expected based on a 12-month time difference and 6
months higher than in the control group (13 vs. 7 months;
P<0.001).
• While the mean increase in “Real Age” was 7 months in the
control group, it did not change significantly in the
intervention group during the study period (P=0.03).
• “Wellness Score” showed a modest, but significant mean
increase from 67.6 to 69.9 in the intervention group
compared to control, where there was no significant change
(P=0.03).

28. Results of the HRA ImplementationResults of the HRA Implementation
Trial (Qualitative Feedback)Trial (Qualitative Feedback)
Importance of personal goal attainment:
• “The HRA helps me focus on maintaining healthy choices.”
• “The website provides a roadmap to getting well.”
Heightened awareness of health impact:
• “[The HRA] makes me look at what I am doing to my body.”
Convergence of patient & clinician goals:
• “[The HRA] reminds me to go to the doctor more often and stick
to what he tells me to do.”
• “It shows me what areas to focus on improving or minimizing to
make my life healthier.” (i.e.: evidence-based care options)
Suggested future improvements:
• More response options and open-ended feedback
• Reinforcing the perception of a “complete” personal record
• Reminder for preparing personal information (e.g., blood
pressure readings, labs, etc) before HRA completion

29. https://mpsrs.us/WPortal http://www.okprn.org

30. ConclusionsConclusions
Personalization and prioritization of care is one of
the greatest challenges of 21st
Century medicine
Shared goal-setting is the best approach to both
Re-focus current disease-oriented care on personal
goals to achieve true patient-centeredness
Activate and involve patients in their care via periodic
comprehensive HRAs, followed by shared decision-
making to generate tailored Wellness Plans
Put systems (e.g., clinical pathways) in place to respond to arising needs
Continually engage patients via systematic follow-up and health coaching
Involve the entire community to improve health via goal-directed care
Measure quality at the personal and community level as the function of
strategic goal attainment

31. Acknowledgements & CreditsAcknowledgements & Credits
Funding Sources:
Key Contributors:
PSRS PDA Prototype AHRQ (Grant)
PSRS PDA Prototype Testing OK Medicaid (Contract)
PSRS Web-based Version OK Medicaid (Contract)
Testing in Medicaid Population OK Medicaid (Contract)
TRIP Prevention Project AHRQ (Grant)
Prevention Nurse Model OCAST (Grant)
Medicaid Implementation OK Medicaid (Contract)
Patient Wellness Portal AHRQ (Grant, active)
K08 Award (HRA development) AHRQ (Grant, active)
James Mold, MD, MPH (PI) Katy D Smith, MS (PEA)
Zsolt Nagykaldi, PhD (Co-PI) Crystal Turner, MPH (PEA)
Cheryl Aspy, PhD (Co-PI) Cara Vaught, MPH (PEA)
Ann Chou, PhD (Co-PI) Eileen Merchen, MS (PEA)
Robert Salinas, MD (consultant) OKPRN clinicians and patients
John H Wasson, MD (consultant) Portal Advisory Committee Members