1 JUNE 2016 [ Major Revision # 1 ] [ Update # 2 of Major Revision # 1 10 APRIL 2019 – REASON : New Website / Aquarian ]
12 MacKinnon Place
East Lyme
Connecticut 06333 – 1533
USA
HEALTHspital © 6.0 + – Original Vision Expressed in THE FUTURIST MARCH – APRIL 2011
– Concept and neologism originated 1998
FRANK W MALETZ MD FACS
Web Analogy :
1.0 Place / Address
2.0 Search eg Google
3.0 Individuated / Preferences eg Amazon
4.0 Expert System Links eg BEST MOM s ( Moments Of Magnificence ) and POP s
( Pockets Of Perfection )
5.0 WELLBEINGULARITY ©
6.0 EMERGENCE / EMERGENT Phenomena – Washington DC World Future Society
50 th Birthday Convening / Summer 2016
+…………… TBD
PREMISE / PROLOGUE / RIGHT QUESTIONS :
- Are Health , Wellness , Well Being , and Healthful Productivity a COMMONS ( CPR – Common Pool Resource – as defined by Elinor Ostrom ) ? AND , if re – visioned thus , can a bold , abundant , new model be re conceptualized of nested micro – eco – logical systems , integrally interconnected and interrelated holistically ?
MY EMPHATIC ANSWER IS YES !
- Are Health , Wellness , and Well Being , by agreed definition and as conceptualized , the same as to general understanding , meaning , and for practical applications ( FWM – see essay ) ? I suggest NO .
- Are Health , Wellness , and Well Being human rights – accessible to all and equitable for all inhabitants of Spaceship Earth ? I suggest YES and NOT YET x2 .
Our NEXT step :
To co create , co design , AND deeply co llaborate in the actualization / realitization of –
A TRUE HEALTHCARE COMMON s AND PRACTICE OF GLOBAL HEALTH , WELLNESS , AND WELL BEING , CARE AND CARING + – CO OPERATIVE s BASED IN LOCAL COMMUNITIES – HEALTHspital s –
A NOVEL CO PRODUCTIVE VALUE ENHANCING AND GAIAN ENNOBLING HEcoSystem !
OUTLINE
- Prologue
- A Look Back : Goals / Hopes / Aspirations
1) IHI ( 2007 ) Triple Aims ( Institute of Healthcare Improvement )
– Improve the health of the defined population
– Enhance the patient care experience ( including quality , access , and
reliability )
– Reduce , or , at least , control , the per capita cost of care
2) IOM ( Institute Of Medicine ) : THE CHASM – A NEW HEALTH CARE SYSTEM
FOR THE 21st CENTURY
3) RANKING s AND EXPENDITURES – US comparisons
- Known Knowns
- Hospitals Today
- Pillars
1) THE HILL OF RIGHTS
2) LEAN / TPS / LOWN / WASTE , FRAUD , ABUSE / UNNECESSARY
REDUNDANCY AND DUPLICATION
3) CHRONIC AND COMPLICATED – Fragmentation
4) END OF LIFE
5) PRE s PRO s RE s CO s
- Community Integration ————> Scale eg MetaCommunity Of Communities ©
- Bumps and Barriers
1) TRADITIONS
2) CONVENTIONS
3) SUNK COST s
- My Current Steps :
1) CEO – STAFF – HOSPITAL
2) WEBSITE
3) WRITINGS
4) UNIVERSITY / ACADEMIA
5) “ SYSTEM “ PARTNERS
6) AFFILIATIONS
7) VENTURE CAPITALISTS ———–> ADVENTURE CONTRIBUTIONISTS ©
- Preparing for the NEXT world of Planetary Health which does not exist – YET
1) GEMS : Gedanken Experimental Mind Spaciousness
2) WEAK SIGNAL Identification AND Augmentation / Amplification – L Audible
3) SIGNAL / NOISE SIFTER AND SORTER
4) CAS ( Complex Adaptive System s ) ———–> Co Creative Adeptive Eco Logical
Eco System s
5) EMERGENCE : Co Facilitated Nudging——-> R – Evolution ( Thaler / Sunstein )
6) MATHEMATICAL MODELING :
– Bob Emiliani – LEAN
– Michael Porter – Harvard Business School
– University of Minnesota – Pesut / Potter / O’ Day / Anderson
– Plexus Institute – Easton
– Y Vodovotz Phd – Computational Modeling
7) Communities Of The Future – COTF 1.0 – Smyre / Richardson / Maletz /
Arrington / Baldwin / Bost / Damicis / Fleener / O ‘ Day / Bourcier / el al
8) DEMOCRACY COLLABORATIVE – Alperovitz / Speth / Howard
Is the practice and delivery of “ health “ care as presently offered to “ carees ” in the US and globally so broken , dislocated , disarticulated , fractured , and fragmented that it cannot be repaired , remediated , rejuvenated , reformed , or reorganized ? Should we tear down existing models with their respective infra – and super – structural elements and components and start anew , do – over , from scratch ? As a practicing Orthopaedic surgeon I have spent an entire career in the domain of “ internal fixation “ and re locating – helping to heal the fragments back into wholes , dys – ease back into optimal function and functionalities .
I am by nature NOT a Schumpeterian , and my response to the suggestion for total annihilation / decimation , the phoenix phenomenon , and “ creative destruction “ is an unequivocal NO . But co creative Re VISIONING is imperative . There are no exemplars , no perfect , perfected , or perfecting systems of integrated health and wellness currently on this planet . There are micro – and macro – systems and , definitely , many MOM s and POP s to be celebrated and scaled . There is no ECOSYSTEM , fully integrated in any locale , and , certainly , no global HEcoSystem approach to this vital practice ( Fritjof Capra / Pier Luisi – THE SYSTEMS VIEW OF LIFE ) .
Care is not “ delivered “ – like delivering a pizza – it is an ongoing “ practice “ . While “ practice makes perfect “ is asymptotic as an “ end “ , evolutionary events have no END , no end point . “ Perfection “ , therefore , is aspirational and motivational . And the path , the purposeful journey , toward perfection and its relentless pursuit is worth every incremental step AND monumental leap with momentum and robust diligence .
What does an Eco Logical Eco Systemic approach actually mean ? An ecosystem , more than the present ubiquitous buzzword “ system “ is a natural system , with known and identifiable inputs and outputs , precise and defined ingredients , constituents , and resources , and with integrated and sustainable feedback and feedforward loops which abide continual learning and iterative improvements within networked cycles and epicycles . There are controls and balances , checks and constraints . But more importantly , ecosystems allow for emergent phenomena to which adaptivity , adjustability , and accommodation can be evolved . AND most impressively , at their best , adeptability , novelty , and paradigm – launching breakwiths will be R – Evolved toward NEXT betters and bests . Perturbations ( natural and [ hu ] – man made ) and scarcities will impact , but a true ecosystem will respond with resonance damping re balancing and proportionate mechanisms relatively seamlessly and usually toward harmony . By this discussion it is crystal and with absolute assurance that we do not have YET a HEcoSystem in health and wellness practice !
Could one be conceived and co crafted ?
What are the essential l ingredients , components , players , species ( keystone and rivet ) for the totipotential EcoSystem ? :
-patients ( CAREES )
-providers ( CARORS )
-payors
–insurance / insurers
–individuals / families
–employers
–governments
-pharmaceuticals
–trade
–generic
-device manufacturers
-research and development
–corporate
–university
–private
-attorneys / legal
-supply chains
–distribution chains of goods / services
–marketing / sales
-informatics and analytics
Oh , what a tangled , networked web we have already woven. Add to this complicated list , needs ( met and unmet ) and wants , sunk costs and current investment portfolios , reputations based on predictions and projections ( whole academic and bureaucratic hierarchical careers – egosystems © ) . The terms GARGANTUAN / BEHEMOTH are not imprecise adjectival appellations to apply to the chaos / disarray / disorder at present . How do we move such a colossus? Again , a true EcoSystem utilizes its BEST s and adapts to change , relishes complexity and grander scale . If we alchemize human ingenuity to this fertile mix , an “ enginuity © “ is co created which will leverage , optimalize , and launch adeptively , reliably , this entity proposed herein .
We begin from a position of great strength and existing , triumphant accomplishments . Expertise is abundant at universities , research labs , and startups . In the US , our predominantly free – market economy , if unencumbered , ignites invention and innovation ( constructive AND disruptive – I make no distinction – innovation IS innovation ) – any encumbrances and unnecessary , layered complicatifications must be vigilantly monitored and streamlined or eliminated . Safety is assisted by oversight bodies like the US Food and Drug Administration , The Joint Commission ( TJC ) , accreditation and state mandated programs and agencies . Chaos and duplication reign in this arena as well . Research grants and public access to those projects are prioritized by the National Institutes of Health . Private foundations in the space , notables include the Robert Wood Johnson Foundation , Melinda and Bill Gates , and various institutes and think tanks , as exemplified by Plexus Institute , populate the external milieu with great pro fund ity and foresight . Social networking tools ( wikis , search engines , Google , Facebook , Doximity , LinkedIn ) proliferate awaiting Big Data coordination and convergence platforms into the health care and well – being space .
So , how are we doing thus far ? There have been some major signposts . The Institute of Medicine published CROSSING THE QUALITY CHASM : A NEW HEALTH SYSTEM FOR THE 21 ST CENTURY in March 2001.
The following recommendations were highlighted:
– Redesign care processes
-Make effective use of information technology
-Develop effective teams
-Coordinate care across patient conditions , services , and settings
-Use performance and outcome measurement for CQI and accountability
The next blueprint was promulgated by the esteemed Institute For Healthcare Improvement named THE TRIPLE AIMS.
– Improve the health of defined populations
-Enhance the patient care experience ( including quality , access , reliability )
– Reduce , or at least control , the per capita cost of care
Also , concurrent with these major templates , the Harvard Business School think tank has substantive tomes on CONSUMER – DRIVEN CURE ( Regina Herzlinger ) , THE STRATEGY THAT WILL FIX HEALTH CARE ( Michael E Porter and Thomas H Lee MD ) , AND REDEFINING HEALTHCARE ( Michael E Porter and Elizabeth Olmsted Teisberg ) . The word “ value “ has been similarly popularized , along with “ system “ in myriad publications . That term VALUE is defined as :
VALUE = Quality / Cost
But , these are all , I proffer , incremental , partial , siloed , patchwork , further fragmented , evolutionary , surface , micro – improvements , but improvements nonetheless , to the existing order , hypotheses , models , and designs . While I never disparage forward movement , lessons learned , and momentum , the facts still unequivocally show that each and every one of the above listed ideas or panels of ideas have failed in every measure of health quality and cost stabilization to move the needle , especially in the US . We are on track to expend $3 TRILLION per year / 20% of our GDP on “ healthcare “ and statistically have a worsened prognosis regarding a substantive return on that investment . We are seeing longevity ( a crude proxy for Health ) decline for the first time in over a Century in the US . Who is at fault in the omnipresent finger pointing blame game : patients ( demands and expectations ) , providers ( overtreatment , overtesting to reduce malpractice perceived risk , overdiagnosis ) , insurers ( playing doctor , rationing , administrative cost excesses ) , Big Pharma ( profit mongers , blockbuster seekers ) , device and product corporations ( voracious competition , mergers and acquisitions , Wall Street suitors ) , attorneys ( litigate everything ) , hospitals ( building and tower mania , top heavy administrations and compensation frenzies ) , government ( legislate every detail ) , professional organizations ( eyes off the ball , under representation ) ? In the chaotic vacuums , certainly some abuses and dysfunctions occur in many , if not all domains . What is blocking a true health Renaissance and which culprit is most to blame ? The answer , again unequivocally , is : we all are ( shared blame ) , fundamental barriers are co located at every level and in each silo and , to an impermanent but sticky degree , attached in combinations ( but these can be peeled apart ) . Because these are all human made “ systems “ and with layered upon layered complicatifications © , they can be unlearned , co re designed , and re purposed toward contemporary needs . And then which comes first “ chicken or egg “ , nature or nurture , wave or particle – YES .
To truly AND effectively ( efficiencies alone are insufficient ) launch toward a value exponentiating HEcoSystem we need to co create a new language leading then to new thinkings , cognitions , and musings in ideal space , co designing new models and blu – emerge – prints ( not static , conventional blueprints or rigid templates ) for pro actualizing prototyping and piloting to prove – the – concepts leading to a NEXT movement of bold , abundant , optimistic Health , Wellness , and Well Being – a FLOURISHMENT . This paper will ( has already ) introduce some of this new vocabulary as tools of brain creep and stretch , transitioning toward transformational thinking . Prototypes and mathematical modelling will work in the real AND gedanken spaces to re formulate the practice of “ caring + “ . The de facto quintessential STANDARD is care and caring + ( see Maletz concept paper on topic ) . Execution of and delivery of that measurable will be customized specifically based on demographics , experience , training , judgment , resource availability , local BEST practices , and electronic records , databases , and accessible expertise . The only acceptable measure of success is VALUE AND Continual Improvement , herein , newly defined as :
VALUE = Quality / Cost x Lifetime of the Caree
Short term quick fixes and improvement blips and Hawthorne micro steps are not defined as “ true “ successes by this definition . Health and Wellness and Well Being must become a WELLBEINGULARITY © : the totipotential combining of BEST practice , thinking , execution , and ALL tools and skill sets toward a future of planetary health , healthfulness , healing , and cure of all dys – eases and dys – functions long term and as a future legacy and launch platform for more learning and improvements .
KNOWN KNOWNS
FIRST : Prevention is much more cost effective than treatment , typically a late intervention , or crisis management .
SECOND : As longevity increases , multisystem chronic disorders take their toll – hypertension , diabetes , stroke , musculoskeletal “ degeneration “ and infirmities , organ and organelle pathophysiologies and imbalances – and with these physical deficiencies and insufficiencies come decreased life enjoyment and productivity . “ Management “ and coordination of subsystem care consumes major portions of “ healthcare “ dollars .
THIRD : Social and personal preferential determinants of individual health may dictate up to 80% of measured health benefit – the essential total of which is now outside the “ control “ parameters of our current non system ( See FWM The Terroir of Health © ) .
FOURTH : Death and dying are viewed as failure . Rather , death / dying is a natural and anticipated , normal and predictable outcome of lives well lived and memories of the good , the true , and the beautiful with attendant lessons learned and stories and anecdotes to be memorialized .
FIFTH : Cure , precision diagnoses , AND prevention are much more desired and effective , than control, maintenance , or palliation and endless prolongation. The status quo is no quo at all .
SIXTH : True healthcare is Big Data writ large and growing exponentially . This must be translated into Big Intelligence . ALL points of data must be interoperable , actionable , linked , constantly updated and refined , searchable , systematized , and available to caror / caree at each and every point of care – no exceptions .
SEVENTH : New Species © must be co architected to populate the new models : PreHospitalists , ParticiPatients , PreHabilitationists , ProLiving Navigators , Information Right Speakers and Translators – to name a few .
HOSPITALS TODAY
Hospitallers , hospitality , places of rest and rejuvenation on a journey date back to the
Crusades and have a history long before science and anything resembling a scientific method or an Enlightenment were added . A cool cloth and a warm blanket , a bed and a meal were soothing and comforting . Today ‘s hospitals , depending on the country and locale , co locate technologic wizardry and various levels of expertise / training primarily for intervention when sickness supervenes . Some are waystations for mass vaccination and screenings but usually they are buildings for :
-Emergency / crisis management
-Illness / disease intervention
-Vital sign and pathophysiologic and metabolic re balancing
-Symptom abatement and amelioration
-Advanced diagnostic and testing sources
-Major surgical corrections , ablations , amputations , and organ repairs and
enhancements
– Intensive care and resuscitation in single and multi system organ failure
-Full court press death prolongation and preparation
-Places of solace and social networking for all abuses , excesses , overdoses , reckless
behavior residuals , mental lapses and psychotic breaks , and houselessness ©
In the past century we have no excuses not to celebrate and acknowledge the triumphant discoveries and curational pathways that have been initiated and compiled – from the Curie ‘s /Roentgen ‘s x rays onto CAT / MRI / PET / DTI – radionuclide scans to antibiotics to mapping the genome and epigenome . The process of 3D printing , nano technologies , remote telemedicine and monitoring , robotic and minimally invasive surgeries , molecular and regenerative biology , genomics , metabolomics , proteomics , and microbiomics await fulfillment , application and further development . Add to this a deeper understanding and proof – of – concept in the alternative , complementary , Eastern traditions , and nutriceutical and nutrition sciences and the totipotential for global health and wellness is within reach , even in conventional hospitals .
“ Pipedreams “ you may say . “ Impossible wish list “ you may affirm . “ Who will pay for the gargantuan coordination task and herculean endeavor “ ? – is an appropriate question given all the published materials on accelerating cost curves and unsustainability . First , inclusion is a proposed budget – I have located $5. 8186 TRILLION per year globally for our consideration and re purposing ( see addendum ) . Therefore , even if I am off by a few billion or even tens of billions , there is money to utilize NOW. AND more than enough . Do , secondly , we have the will and are there enough Atlases to flex to lift the globe toward health – my answer is absolutely YES – if done together and with BEST leverage . My other philosophical inclination in this crucial arena is that to effect positive change ( nudgings AND more radical R – Evolutions ) we must , based on a well communicated literature of cognitive linguistics and psychology of mind framing , co create new model consilience and novel language toward NEXT spirals of growth and development on the upending and unending maturation continuum – all BEST s , enginuity , tools , resources , norms , mores , and imaginings – ALL – are applied to this convergence , this paradigm springboard launching a bold , abundant , optimistic , positive , and always looking forward flourishing , a Health EMERGENCE .
HEALTHSPITAL 6.0 + Proposal Update 2016
In the annual meeting of the World Future Society a theme was “ WHAT IF “ . My initial writing described 5 “ drivers “ of the proposed design . Subsequent revisions borrowed from the burgeoning EMERGENCE literature and HEALTHspital was reconfigured as a PLATFORM – not THE FINAL or END point – and onto that platform of health and wellness was constructed 5 pillars . These will be explained briefly here .
PILLAR # 1 A HILL OF RIGHTS
WHAT IF in our re visioning we got every step , every situation RIGHT . The RIGHT patient : so much more than right identification and right site for surgery – the fully prepared patient , ready and optimized for any encounter . The RIGHT provider : right training, background , and experience , right skill set for that right patient’s needs and expectations every time . RIGHT site for care / RIGHT setting – could be home , office , sports field , medical space , or present hospital , pharmacy , school , walk in minute clinics . RIGHT diagnostics , testing , analytics , and imaging . RIGHT price point – amount of testing and resultant care appropriate to the presentation . RIGHT differential diagnoses preliminarily with inclusion of ALL possibilities for care and intervening – no missed opportunities to be RIGHT . The right begins with all the RIGHT questions and all the implications and potential applications for care / for caring brought by each caree . RIGHT data can then be correctly entered into local databases , crosschecked by interested ParticiPatients at their respective “ medical home “ for accuracy then added to larger population databases with detailed demographics to further population studies and with the potential for deeper pattern constructions – goals for subpopulation predictive modelling . These are described as “ hills “ , not mountains , as these types of data handling and mining are far more manageable and accessible given ever improving artificial intelligence algorithms . RIGHT information becomes RIGHT intelligence which then frames NEXT questions and identifies potent new research topics . This pillar produces a feedforward loop of learning and iterative improvement .
Get it RIGHT and then execute it RIGHT the first time and every time is the new norm . Have the outcome stay RIGHT for the patient ’s lifetime – correct AND RIGHT . None of this pillar’s principles requires a substantive cultural leap for current carors . Virtually all practitioners I know , and have the daily privilege to work beside , in this current healthcare space , even when stress , frustrated , burnt out , or demoralized on any given day , are consummate professionals with “ doing RIGHT “ for fellow humans encoded in their DNA and hardwired into their chromatin , epigenomes , and neural pathways . In the face of all extraneous pressures and burdens of our non systems , the oaths , abiding inspirations , and original aspirations will be easily rejuvenated .
PILLAR # 2 WFA / OVER – / UNDER -TREATMENT AMOUNTS / DUPLICATIONS
Again exemplars for this foundational support and a vibrant literature exist already – LEAN , TPS , and variations specific to this topic . I understand “ bare bones “ and squeezing every last drop of efficiency out . But this pillar is so much more demanding than a simplified economic model generated by our bookkeepers , econs , and quants . This paradigm must exist at the point of care – each and every time . I suspect there is some outright , intentional fraud – carors purposefully trying to work the non system and the loopholes between the complicatifications . But if we have allowed flaws in the fabric of delivery and loopholes and unreasoned gaps and vacuums to exist , advantage will be taken by these very intelligent people , advertently or inadvertently . We get what we failed to prevent systemically . Sharon Brownlee’s focused book , PCO ‘s ( Patient Centered Orthopaedics ) group , and the Lown Institute have done yeoman’s work on overtreatment . But undertreatment requiring callbacks and re works , more visits and new diagnostic cycles , adding enormous costs and hand offs thwarting a true system ‘ s view . My start in the effort in 2010 was fueled by the Magna Carta of papers – Robert Kelley ‘s documentation for Thomson Reuters of $700 BILLION per annum in the US alone that is wasted , needlessly and unproductively . Elimination of this available surplus ( ⅓ of current US spending ) would instantly bring the US in line with many other developed nations who spend reportedly less and deliver better outcomes , consistently and repeatedly . The emphasis , as previously stated , must be on effectiveness which is so much broader and interesting than mere “ efficiency “ ever connotes .
PILLAR # 3 COORDINATED / INTEGRATED CARE
Think of the nested sub- and ecosystems in the human organism : gastrointestinal / digestive , reproductive , renal / urologic , cardiac , vascular , nervous / neurologic , musculoskeletal / rheumatologic , dermatologic , special sensory , endocrine / metabolic , pulmonary / respiratory , mental , microbiomic / commensal . As we use our “ Organism “ repeatedly , exposing it to myriad internal and external agents and forces and age and stress it , dys – eases , dys – functions , and dys – orders occur sometimes repetitively , cumulatively , or both . We know and categorize the single and some interactive pauci – and multi – system diseases and syndromes . My favorite example from my own practice was a patient with 7 nested systems involved . She was taking 28 prescribed daily medications ( excluding vitamins , supplements , and over – the – counter self medications ) . She was being actively seen by 11 different doctors , sub – and super – specialists . There is an obvious spectrum of disease and treatment , providers and associated monitoring required . The EHR has been touted as THE panacea . Big Data and the avalanche of real time patient specific data will make care connect . Providers will be enabled to coordinate and integrate care . The “ Quantified Self “ is a movement gaining traction . Not so fast ! Multiple proprietary EHR s and vendors with protected intellectual property and trademarking laws and privacy strictures prevent interoperability and true interconnectivity in records and record keeping . Ignorance is NOT bliss , but neither is a tsunami / avalanche of non sensemaking raw data . Also , is the RIGHT personalized data being recorded and accumulated . Lawrence Weed MD , an early and persistent pioneer has given us SOAP and POMR , moving on to Knowledge Coupling software . IBM and Watson have teamed with the Cleveland Clinic and its Lerner School of Medicine to inaugurate new interactive methods for bringing the world’s medical literature to the doctor – patient , caror – caree relationship , co – and inter – relating best current information with highly personal fact – finding interview and physical examination skills .
When then combined with integrated laboratory and imaging studies , so refined by such highly specific database collection , assessments and treatments can be specific and customized . Yes , personalized , precision medicine . And then subsequent encounters get better and better with each iterative learning cycle.
When local intervention points are restructured , the usable , truly functional , interoperable EHR then empowers a truer “ Medical Home “ actualization – for “ Home is where ( ever ) the “ CHART is . “ Dynamic Funnelization “ © allows “ universal capture “ of all potential “ ParticiPatients “ who then integrate into global “ universal caring + “ . A local ——–> global culture of caring + is born . The dynamic funnelization is an iterative , closed looping , flow diagram gathering ALL of the patients in a community population , person by person , then patient by patient , into an ever enriching and ennobling database . Evidence based medicine becomes Best Evidence Now (BEN ) medicine applied , then becoming Best Intelligence Next (BIN ) , and then ultimately leading onward to Universalizable Best Practices ( UBP ) . These also with new research and population experience can platform build toward planetary Health quality and improved Wellness for all . Thus , Private——–> Personalized ————> Public————> Population ———–> Planetary Health and fulfillment , productivity and Well Being – A WELLBEINGULARITY © . Individuals / elements become SubSystems ; SubSystems become micro – systems ; micro – system integration builds macro – systems ; nested ecosystems expand toward a HEcoSystem and bold new horizons AND novel co created realities .
PILLAR #4 DEATH AND DYING
We got badly off track and perturbingly off course with this topic . Death panels , Dr Jack Kevorkian , and “ rationing “ of sickness care in death preparation anecdotally caught our attention. But a quiet R – Evolution has begun . Heroes and heroines like Dr Ira Byock and author Katy Butler ( KNOCKING ON HEAVEN’S DOOR : The Path to a Better Way of Death ) have moved the needle toward true north with humane discussions of care and caring as life ‘s “ end “ approaches – inevitably and naturally . We get wrapped up and embroiled in ethical dilemmas – “ When does life begin “? and “ What constitutes death “? Is it the union of sperm and egg ( full potentiality ) or the ability to sustain vital functions outside the uterus ? Is the end when a heartbeat flatlines or brain wave EEG activity goes to zero ? We are actually quite fragile and vulnerable in between our birth date and demise certificate . How long can a human being survive without food / without water / in the raw elements without shelter , heat , air conditioning ? How long could a college student remain in school without parental checkbooks and bank loans and scholarship subsidies? How many would be without shelter if not for mortgages and long credit extensions ? Life and its living are TEAM SPORTS . We are all co ParticiPatients eventually . Birthing is highly intimate and, more and more , customizable . And while taxes may be modified and even evaded , death , to no one’s surprise , is for sure , a certainty , natural . Cells die and are replaced and recycled during the entire hyphen / DASH between birthdate and death date , our tombstone enshrined memorialization of our existence . But death is NOT an end . Lives well or poorly lived are teaching/ learning moments to be treasured , revered , precious . We should treat ALL alive , living , sentient beings with dignity , awe . This is the hierophany , the spirituality that metascends © formal religions , mores , norms , and cultural traditions.
We spend an enormous amount to “ keep “ patients , family , neighbors , “alive “ , often when all know , even the patient , that this will only fruitlessly , futilely prolong “ life “ often in a hospital , intensive care bed . We speak of “ quality of life “ . Dialogue could start much earlier – “ describe in your words your BEST death “ . “ How do you wish to be remembered , memorialized “? “What legacy and life points highlight your story “ ? Instead of the flashes of photographs in funeral parlors and graveside testimonials , quickly forgotten , the “ patient “ could write the narrative , co produce their notable and favorite moments and turning points , co create and co design remembrances , videos , storyboards , and essays . The Hospice approach and family care giver training could be coached – many “ terminal “ patients prefer to spend as much time at home , in comfort , surrounded by what they built , the familiar. Death is natural – it should be treated as such . Personalized medicine and preferential , culture attuned and sensitive traditions must be applied diligently to this domain . Death is not THE END , but a baton for future generations and a lasting legacy for NEXT s .
The “ death panels “ become “ family panels “ with a patient , caring epicenter . “ Rationing “ becomes rational . “ Funeral “ homes become “ celebratory community points of light and remembrance “. “ Departed “ becomes wisdom “ imparted”. The individual is returned after “ their time “ to the cosmological whole , never forgotten , always treasured , forever missed but remembered .
Life as legacy and Death as baton – for all – forever . Again , simpler , but not too simple for such a complex topic. BUT , by mind spaciousness and language change, this new thinking could make a re investible dent in the 80% of the Medicare budget expended in the last 6 months of life – futile becomes fertile , senseless becomes sensitive and sense making , “ death be not proud “ becomes “ proud to have lived , AND DIED ” , well !
PILLAR # 5 THE NOVEL – THE EXCITING – THE PRE s PRO s RE s CO s
PRE:
-Pre Emptive -Pre Dict
-Pre Vention -Pre Ference
-Pre Monitory -Pre Pare
PRO:
-Pro Active /Pro Act -Pro Gnosticate
-Pro Mote -Pro Pensity
-Pro Tection -Pro Spective
RE:
-Re Generative -Re Patriate
-Re Juvenate -Re Habilitate
-Re Store -Re Populate
CO :
-Co Design -Co Operative
-Co Create -Co Nnect
-Co llaborate -Co Mmunity
We have gained much from our Scientific Method. Evidence based medicine and surgical protocols have produced massive improvements in care toward cure . But individuals spend an uncoordinated “ fortune “ on products and methodologies marketed and hawked without the rigors applied to more traditional measurables and deliverables .
Nutriceuticals , supplements , alternatives , complementarities abound . Naturopathy , chiropractic , and osteopathy have long and rich traditions and highly trained practitioners. Who can “ play “ in the local HEALTHspitals and the larger HEcoSystem? Everyone , inclusively . Welcome ! BUT THE STANDARD IS CARE . Health and Well Being are the outcomes – for every specialty in this new Healthspace . Proof – of – concept and patient granularities must adhere toward cost effectiveness of that care for every true health outcome achieved – and be able to stand up to scientific scrutiny – validated and falsifiable – therefore , provable . Payors must also open their minds and checkbooks to attribute improved health and prevention to premium reduction and benefit re alignments for all dedicated co ParticiPatients . Remember this is a true ecosystem. This will never again be standard insurance modelled , zero sum game . This ecosystemic goal is win – win – win ……………..+ This is to be democratized , equitable , commoditized , collective , co operative , community based and facilitated , patient centric , UNIVERSAL CARE +. This can be accomplished in toto – as a Holarchy and NOW . Many of the pieces and parts already exist , my so – called MOM s and POP s. Pieces that fit this model can be integrated seamlessly and with immediacy . Pieces than can be modified should be – to fit . Discard the rest . Then co create and co design prospectively anything missing to fill out the needed totality , Wholistic Healthcare .
THOSE ARE THE 5 PILLARS
While I am a futurist , optimist , positivist , and neosynthetist , I believe I am also a realist . The following broad categories represent roadblocks , hurdles hills , mountains , and barriers in the Healthscape :
-LEGAL
-FISCAL / FINANCIAL
-POLITICAL / LEGISLATIVE
-EDUCATIONAL / TRAINING
-CORPORATE
-CONVENTION / TRADITION / CULTURAL
LEGAL
Many legal parameters will require re evaluation and modification. A major example will be in the area of information access , especially as data becomes more accessible , interoperable , fungible , analyzed for whole populations , and granular . To be useful at points of care , it must be available and seamless just like balance data and demographics on a credit card magnetic strip are now . Privacy is paramount to consider , of course . But new laws regarding non – discrimination when applying the analyzed , de identified population intelligence will be critical , not only for genetic information . Everything in cyberspace can be hacked , and all protections can be thwarted . Health and Wellness data , genetic propensities , family and social history , past history must always be directed and used for caring+ , to care . It must NEVER be misapplied to marginalize , segregate , de – humanize , prejudice , or discriminate against individuals or groups .
HIPAA will likewise require major overhaul . Anti – “ dumping “ requirements will need allowances for re triaging and re directing patients to RIGHT practitioners and RIGHT points of care provision , in timely and appropriate manner . I have personally questioned many of my patients about their willingness to allow me to determine to whom information will be needed in their care plan , care pathways . I have yet to receive a single “ No” , after literally hundreds of such permission requests . As we have learned from hundreds of billions of social media posts and blogs , people want their stories told , usually appropriately . To move from public to planetary health , information —————> intelligence ————-> wisdom IS the highway .
POLITICAL / LEGISLATIVE / LEADERSHIP
Is health and its care Democratic / Republican / Independent / Green ? Is this arena Conservative / Liberal ? Should it be characterized by democracy , communistic , or socialistic principles? Are we speaking to political agendas whether transparent or hidden ? My unequivocal answer is YES – all could be and should be considered because “ Health “ as expanded in this model is METAPARTISAN © , and is , therefore , a metascendent , phenomenologic emergence . “ HEALTHspital 6.0 + “ is a proposed model to be included in this overarching and bold undertaking I call “ Metapartisan Mars-shots and Stars-shots “ ( not Moonshot – we have already successfully accomplished that ) . Diversity in inclusion and inclusivity of all novel applications are eagerly sought to build upon these pillars and co create even more parallel constructive spin offs and spin ups. Does this require political will and co llaborative democratic and invested participatory leadership and championship ? YES AND NO .
Leadership , conventionally defined , is hierarchical , top – down , and the fruits of its profitability often siphoned to other domains of political promise and favoritism ( pork ) . Here defined , leadership is more leaderless , participatory , bottom spreading , like an autonomous colony of expansile self organization . But this is a principled algorithm based on contribution ( see CONTRIBUTALISM ) and , always , CARE + that ennobles this Mars-shot / Star-shot . The real question is : Can we muster the universal polis , political global will and willpower , to make Health and Wellness a priority in our Global Commons ? The answer is : We must !
FINANCIAL / FISCAL
As directed in Appendix A , there is copious money to be re directed and re purposed for investment in Health and healthfulness. Why should any ONE be energized to push for this re investment ? We will all – payor and provider , caror and caree , CEO and indigent , wealthy and houseless – ALL – at one point be dys – eased , a patient , and our ultimate destination is terminal . No one is excluded or will escape untouched . Of course , fiscal data sheets , measurables and intangibles , all determinants as well as proxies for health must be re conceptualized . Also key is that transparent bookkeeping must be open so that clarity of investment and re investment is sharp and crystal to all . If , for instance , Health and Wellness outcomes yield and generate decreased intervention expenditures in a given community , active participatients should be rewarded with premium rebates and a proportion of community wide savings re invested into those same communities for bike paths , green plantings , free seminars and health education , FitBits and real time monitoring for all , screenings , nutritious food co ops , and this list is endless . Healthy behaviors and attitudes are norms – normalized to every activity of thriving life – a sustainable “ thrivitality “ © . Folks who persist in smoking , drinking excessively , eating monumentally , failing to comply and adhere to recommendations and proscriptions , continuing to ignore warnings , and who call out “ sick “ , behave unsafely and recklessly will be nudged with higher premiums , co pays , and increasing divergence from those more happy , more productive , more fulfilled neighbors – in a free society all have their choice and choices . But the default – the path of least resistance – is Health . Their opt outs must be selected thoughtfully , for the negative reverberations will be significant . To diverge from this new norm is more costly , more negative , more inhumane to those expressing and selecting this preference . And should be .
EDUCATION / TRAINING
Learning in medicine / surgery is lifelong – CME – and should be expanded as such to all domains . Abraham Flexner was our ICONOCLAST as his biographer proclaims , but his model as synthesized is over 100 years old – an obsolete , anachronistic , dino – soured entity given our Information – Technologic – Interconnected new world . Why does organic chemistry , freshman calculus , or 4.0 GPA constitute our best , make – or – break crucible for practice ? A Google search and ask SIRI place answers at our screen fingertips . Curricula and textbooks are obsolete , virtually at printing . HEALTHspital librarians become the new navigators for providers and participatients alike – vetting BEST available research studies and evidence for questions of the moment – combining international expertise to local applicability raising the care bar instantaneously whenever and wherever breakthroughs and breakwiths occur . HEALTHspital nutritionists are also mission critical in community outreach to convert “ food deserts “ into “ nutrition oases© “ , conducting home and community garden training , food selection and cooking classes , and illustrating appropriate balancing with micronutrient attention . BEST research , BEST studies , and BEST evidence translate and transfer to the bedside , office – side , or home – side wherever CARE is needed or prevention opportunities abide . Information and its infinite fungibility interconnect , internetwork with the living HEcoSystem , moving and flowing in to treatments and then out to preventions . Outcomes are openly communicated and all “ boats “ rise . Better yet , the aggregation and analytical robustness permit planetary ranging studies , fully powered by adequate sampling size , yielding more granular questions for deeper and more expanding research curiosity . CME becomes CUH : Continuous Universal H – education for all curious and interested in exploring Health and Wellness even further . Education , as re framed , truly leads us out ( L . e ducere ) from our present paradigms .
CORPORATIONS / PARTNERSHIP
“ Conflict of interest “ – an interesting term . Also “ influence “ . It is the opinion of some that a company funded office luncheon or a representative supplied logo pen will swing a practitioner to utilize a pharmaceutical or device preferentially . While there are myriad examples of abuse and colossal misfeasance still requiring oversight beyond our present puny attempts at “ radical transparency “ and “ podium disclosures “ , let us never lose sight of the massive value supplied by true corporate partners in the health insurance , medical supply and services , Big and Small Pharma , and device manufacturing domains . As we re think and re vision the Commons and co design the HEcosystem these are critical keystone and rivet “ species “ : valued , value adding , and valuenabling . Their R AND D must be integrated with problems to be solved . Research questions must be aligned with funded research. Underfunded and unfunded mandates must be replaced by appropriately funded , programmatic , internetworked proofs and pragmatics . In this space pure academicians must be respected , but even more respected will be those pragmademicians © who translate pure bench science into Health and Wellness deliverables . “ Conflicts of interest “ must become “ Confluence of interests “ in the H – Commons . Recall always “ Caring is the Standard “. Corporate profits and sustainability in the new H – Space should be more transparent , re invested , and reasonable , not egregiously excessive to the few – and then distributed globally – to be determined and co llaboratively defined , not in silos and boardrooms behind closed doors , but interdependently . Co op boards could serve as models in the new H – Economy .
COME TOGETHER
Mechanistically how can we actualize and realitize this proposed concept . I personally have worked traditionally and conventionally since my MD degree was bestowed in 1978 – private hospitals , free hospitals , “ children’s “ hospitals , burn centers , military hospitals , State mental hospitals , University hospitals , and , most recently , a Hospital regional “ system ” . I have studied and reviewed international so called “ systems” , funded care , integrated , and socialized models . When all is said , there is no universal , all inclusive HEcoSystem – YET .
FIRST , we are all patients – therefore , with skin and other organs in this game , this space .
SECOND , there is much work to be done to reach planetary Health , Wellness , Well Being – a GLOBAL WELLBEINGULARITY .
THIRD , most current “ care “ is provided locally , person to person , community by community .
FOURTH , there is ample capital available , if re purposed .
FIFTH , ALL our models – Hospital , point of care , training/ education , delivery , funding , measurements , and oversight – are obsolete , archaic , anachronistic , antiquated , fragmented , siloed , evolutionary , incremental , partial , short term , unsustainable , and value compromising – a patchwork / mosaic / tapestry – at best .
SIXTH , the call is to utilize our present BEST s in art , craft , guild , science , technology , spirituality , and pertinent , relevant , and co designed combinatorics toward novel models of integration and value exponentiation – NEVER accepting status quo or regression but only humane “ caring “ with e – quality , effectiveness , and evaluations built in for BETTER BEST s to come .
Community HEALTHspitals require no investment in more bricks and mortar , aluminum and glass testaments to philanthropy . They are a simpler gedanken experiment with major impact when taken to scale . A HEALTHspital can arise by any insightful CEO AND Board by standard top – down directives and mapping . One year of prior data and one year of post implementation data will establish singular proof – of – concept after careful analysis of Community impact . OR individual pillars can be mathematically modelled and analytics and cost accounting applied to pre determine partial micro systemic impacts . OR an “ adventure contributionist “ with interest in this “ Mars-shot / Star-shot “ , this space , could fund a prototype / pilot . OR a self organizing community co – operative could envision a local hospital ————–> HEALTHspital conversion along the model of successful food – farm co operatives in existence .
My ultimate goal , hope , never ending aspiration is to co create , co design, and co llaboratively begin a R – Evolution , a Metascendence , taking us to new platforms of re visioniong HOPE , HEALTH , HEALING , HEALTHY , HEALTHFULNESS , WELLNESS , WELL BEING , AND CARING beyond the present moment toward a true HEcoSystemic COMMON WELL TH for the globe – GlobalWELLth © . The toolkits , skill sets , technologies , and minds already exist . A novel model is needed and proposed . Who is in ? Who wants to join ? Failure is an option . Band – aids and salves , poultices and pills , ointments and exercises , are all available . But WE are better together than these . And evolution has no END .
Let ‘s GO / Let ‘s DO this NOW !
Thank You
Looking Forward , Always Further ( LFAF ),
Frank W Maletz MD FACS
