The Man with the Health Care Plan

As he nears the end of his first year as executive vice president for health affairs, chair of Emory Healthcare, and CEO of the Woodruff Health Sciences Center, Fred Sanfilippo spends some time with Emory Magazine

What do you feel are the major strengths of the Woodruff Health Sciences Center?

One always needs to start with people because talented people and strong leaders are what make institutions great. There are many really remarkable people here—dedicated people, collegial people, collaborative people. At all levels, they make our progress toward transforming health and healing possible.

Another important strength is the way Emory’s governance and administration are aligned and work as teams. It’s relatively unusual to have such good synergy of the management and governance structure of an academic health center with the University as a whole. This degree of alignment allows us to collaborate rather than compete . . . to work together to leverage each other’s strengths and achieve our complementary and coordinated visions.

We also have a key strategic strength with our geographical location as the only academic health center in Atlanta. This has opened the door to some unique partnerships, and our collegial spirit has nurtured them into productive and mutually rewarding initiatives. Some of our collaborators include CDC, Georgia Tech, Grady, the VA Medical Center, Morehouse, and Children’s Healthcare of Atlanta.

These relationships are critically important to our momentum, as are our benefactors and community partners, such as the Woodruff Foundation, the Georgia Research Alliance, and the Georgia Cancer Coalition. Putting together complex alignments like these is hard to do, and Emory does it exceptionally well, both internally and externally.

Why and when did you first become interested in predictive health?

I’ve had a strong interest in predictive health for the past thirty years. In the late 1970s and early 1980s, I was doing basic and clinical research in immunogenetics and transplantation at Duke. A lot of my work focused on understanding why genetics did not always predict outcome in organ transplantation. In addition to biologic and genetic characteristics, one had to look at a lot of confounding factors and characteristics of the recipient as well as the donor.

It struck me from my background in math and physics that one should be able to use those methodologies to predict probabilities of different outcomes, as well as the effectiveness of different kinds of treatment. In the case of organ transplantation, the goal was to predict organ rejection and the effectiveness of different treatments on different patients. Over the past fifteen years, I’ve been interested in extending this approach to basic health care: how to accurately predict an individual’s risk of illness, response to illness, and response to treatment intervention.

Tell us about your work in predictive health before you came to Emory.

When I joined Ohio State University in 2000, a lot of my work was to help build up and align the component parts needed to execute personalized, predictive health, such as genetics, informatics, diagnostics, and decision support tools. We also engaged the institution in a desire to provide health care differently to our employees. We addressed predictive health from several perspectives—including basic, translational, and clinical research in many disciplines and across all major illnesses. It was such a high priority that we even developed our vision statement, as well as our brand promise, to focus on personalized health.

At Ohio State we administered our own health care plans, and over a two-year planning period with human resources, we developed and implemented many predictive health precepts into the health care plans for employees. For example, we were able to provide financial incentives to encourage employees to participate in personalized health assessments and maintenance. We developed ways for patients and referring physicians to access their electronic medical records, and for patients to get electronic consults with physicians. We also provided our employees with health coaches for health maintenance and chronic disease management. The beneficial results of these approaches were very gratifying.

The work at Ohio State illustrated the importance of addressing not only the science of predictive health, but also the health care delivery component. The ultimate goal is to use the most cutting-edge discoveries and technology—working closely with the patient and the key members of the health care team—to transform clinical practice from disease management to health promotion.

On a basic level, what are the most challenging ethical issues related to the practice of predictive health, and where do you think the answers might lie?

At the extreme, as in organ transplantation, once one really can predict outcomes, there arise challenging ethical issues about who receives what treatment. Moreover, as we become more accurate in predicting outcomes, we raise more questions about what to do with people who refuse to comply with health maintenance and restoration. Who should pay for their care? For example, many ask why the rest of society should bear much of the increased health care costs for people who choose to smoke or not comply with treatment.

Decisions around risk-benefit of different interventions may become harder as better accuracy improves our ability to predict the probability of success versus the risk of complications.

For example, how should the health care team respond to a patient who prefers an intervention with a lower likelihood of success in order to avoid a more defined risk of complications, or conversely, when the patient chooses the most risky approach because of a low, but better-defined, possibility of return to health?

We will also need to take into account the behavioral norms of society and what people are comfortable doing with all the information to which they’ll have access and may be asked to share.

Do you think predictive health will become part of the mainstream health care system? How can Emory lead that movement?

As health care becomes truly predictive, best practices will become defined more clearly, and patients and the public rightfully expect us to engage in best practices. At Emory, we can lead change by demonstrating that there are accurate predictive health approaches that improve outcome and by showing that the value of predictive health in both prevention and treatment is significant and provides real benefit to society.

An important aspect will be to not only develop the data warehouses and tools that can provide great decision support and predictive value based on an individual’s unique biology, behavior, and environment, but also to get the information from these tools into the hands of patients and health care providers to help them make decisions.

Predictive health is a university-wide initiative. What are some ways in which the Woodruff Health Sciences Center can work with nonhealth components of the University to advance predictive health?

Many aspects of predictive health are outside medicine and health science per se. Computational science and informatics are very important, as are social science, financial, business, and legal issues. When one looks at the parameters that predict health or disease, behavior and environment are two key contributors that in some cases are more important than biology. There’s a lot of research going on at Emory in the behavioral and environmental sciences. There’s also a significant subjective component to predictive health, which Emory, with its outstanding theology and pastoral programs, is in a strong position to address.

What were the advantages to partnering with Georgia Tech on the Predictive Health Institute? How is the collaboration working out, and are we considering other partnerships?

Georgia Tech’s significant strengths in the computing and engineering sciences are greatly helping our joint initiative to succeed. Georgia Tech Provost (and now interim president) Gary Schuster and I recently appointed a joint steering committee for the Predictive Health Institute, and from that group have formed a cabinet. We are focusing on next steps to move the initiative forward and are exploring programmatic areas beyond the Center for Health Discovery and Well-Being to identify our next area of focus. We also have formed a partnership with Ohio State University and are finalizing agreements with another university to complement this joint effort with Georgia Tech.

In your remarks to medical school graduates on Commencement day, you cautioned them to ensure that medicine remains a profession, not a business. Why do you think this is important?

In the early twentieth century, as a direct result of the Flexner Report, medicine evolved from a trade based on skill to a profession based on knowledge. In some regards, it’s now turning into a business based on revenue, margins, and market share. It’s essential that we in the profession—and especially those just joining the profession—are committed to keeping it focused on knowledge and education. If we don’t, the trends that are pushing medicine away from professionalism will dominate, and the benefits we provide to society will be diminished greatly. I believe our ability to successfully create a healthy society—through predictive health and other means—is dependent on knowledge creation, dissemination, and application as a measure of success, not how much money is made from providing care.