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 >>PENNY ROYAL
 Good morning.  Good morning.  Good morning.
 Welcome.  I'm Penny Royal (phonetic).  I think some of
 you saw me yesterday morning.  I'm from the President's
 Council on Physical Fitness and Sports.  Welcome to the
 second day of a great summit about prevention and being
 well, healthy and active.  Yesterday morning Denise
 Austin got us going.  This morning we have Reggie
 Freeman.  Reggie is a certified fitness instructor.  He runs
  TOROBICS in Washington D.C. where he leads by
  example.  That is Reggie's message to all of us.  We not
  only want to talk the talk, we want to walk the walk.  I
  don't know if Reggie is going to have us doing much
  walking, but he is going to get us moving today.  So let's
  welcome Reggie Freeman to get us started
  today.(Applause)
  >>REGGIE FREEMAN
  Thank you.  Thank you.  Thank you very much.  Good
  morning!
  >>AUDIENCE
  Good morning.
  >>REGGIE FREEMAN
  Good morning.  That's what I'm talking about.  My name
  is Reggie and I'm so happy to be here.  The main reason
  I wanted to speak with you to get bodies moving, the one
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 thing I haven't heard us doing at this summit is we're not
 talking about self love.  And before we can even do
 anything to improve ourselves, improve our bodies,
 improve our health, you have to love yourself so much to
 want to do it.  And that is so very important.  And I want
 us to live that message so that we can bring the message
 to everyone else.  I have a quick question.  Just by show
 of hands just let me know if you know the answer.  At
 3,000 miles, what do we do?  If you know the answer,
  raise your hand.  3,000 miles.  (off mic) Everybody say it.
  Oil change.  Everybody knows the answer, right?.  By
  show of hands, do you know what your resting heart rate
  is?  Good.  Do you know what your cholesterol level is?
  Good.  Do you know what your body weight is?
  Percentage of fat? Very good.  By the show of hands,
  that proves to me that you are starting to live by example.
  And this is the same type of message that we need to
  pass onto everybody.  Because everyone knows what
  we do at 3,000 miles.  And even if you don't have the
  cash in your wallet, what will you do?  You will use a
  what to pay for it?  A what?  Credit card.  But if you're
  feeling bad and need to go to the doctor on a regular
  basis, what do we do?  A lot of us make excuses and
  don't go.  So we take care of material things like
  automobiles and really treat those with the highest respect
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 to keep them running, but we don't do it for ourselves.
 And that's why I want you to live by example.  So now,
 this is called step to a healthier U.S.  When I saw that.  I
 thought of step to healthier us to help the U.S.  So that is
 my thinking on this message.  So to start that I want to
 get us all up and we're going to start moving.  And I want
 everybody up.  And if you have on a tie, men, loosen that
 tie a little bit.  If you have on a jacket and you want to
 take that jacket off, that's fine.  Excellent.  Maestro,
  please. [ music playing ] Inhale, exhale.  One more time.
  Deep inhale, exhale.  Press it up, up, up, up.  Reach, two.
  One other side and reach.  Good.  Up, up, reach.  Two.
  One.  Arms up.  Now I want you to just stretch.  Come
  on, come on, come on.  Step it up, step it up, step it up.
  Come on.  Keep it going, keep it going.  Four, three,
  two, one.  Now press it up.  Come on.  Keep it going,
  keep it going now.  Four, three, two, one.  Now march it
  wide, wide, come on, come on.  Volume, please.  Come
  on.  Here we go, here we go.  Come on, come on.  You
  got it.  Now one thing I do in my class.  I don't just stand
  up front.  Because everybody that's in the back always
  thinks that I'm not looking at you.  But in my class there is
  no back of the class.  And I'm going to show you why.
  Come on.  Come on.  Here we go.  Here is four, three,
  two.  Arms up, let's go.  Come on, come on, come on.
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 Make sure you breathe, make sure you're breathing.
 Inhale, exhale, inhale, exhale.  Four, three, two, one.
 Now press it.  Come on.  Keep it going, keep it going.
 Four, three, two, one.  Begin inhale.  Come on.  Exhale.
 Now lien to the left.  Left, right.  Come on.  You got it.
 Keep it going, keep it going.  Lean into it.  Lean into it.
 Lean into it.  Come on.  Lean into it.  Now press it.  Yes.
 Come on.  Press, press, press, press.  Come on.  Now
 whenever I say how you feeling?  I want you to reply
  "feeling good." Are you ready?  How you feeling?
  >>AUDIENCE
  Feeling good.
  >>REGGIE FREEMAN
  How you feeling? Reggie.  Come on.  You can do better
  than that.  Everybody say "Reggie, you're crazy."
  "Reggie, I'm lazy."  Come on four.  Three more.  You got
  it.  Come on, come on.  Now press it up.  Press, press.
  Lift up with that heel.  I want you to squeeze the
  buttocks.  Every time you lift the heels, squeeze that bun.
  You know why I want to you squeeze it, because every
  time you squeeze, there's a dimple that forms right there.
  So if you're not smiling at me right here, I want you to
  smile at me right now.  Come on.  Press, press, press,
  press.  Now hold it.  Every time when I point, I just want
  you to freeze.  Are you ready?  Whenever I point, I want
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 you to freeze.  Let me see you.  Hold it right there.  Now
 on this side, I want you to freeze.  Hold it right there.
 Now this side -- you follow direction good.  This time I
 want to you freeze right here.  Come on.  Oh my
 goodness.  I love it, I love it.  Both arms up.  Hang in
 there.  Come on.  Here we go.  Four, three, arms up in
 the air.  Let's party, you all.  Hey, hey, hey, hey.  Come
 on, come on, come on.  Keep going, breathe.  Breathe.
 Come on, come on, come on.  Hey, hey.  Keep
  breathing, keep breathing, come on, come on.  Hey, hey,
  hey, hey, hey.  Come on.  How many?  You all can't
  count?  Here we go.  Here we go.  Eight.  How many?
  Eight more.  How many is that?  Come on, louder.
  Everybody, everybody.  Come on, come on.  You got it,
  you got it.  Hang in there, you all.  Yes, yes.  To the right.
  One, two, three and four.  One, two, three and four.
  One, two, three, and four.  You got it.  Let me see you.
  Let me see you.  Come on, come on.  Now you know
  what, this is called the basic move.  But in my class we
  don't do it the basic way.  I want to you move those
  shoulders.  Come on.  Hey, hey.  Come on, come on.
  Hey, come on.  Get busy you all. Pump it up, pump,
  pump, pump it up.  Come on.  Pump, pump, pump it up.
  Come on.  Pump, pump, pump, pump it up.  Come on.
  Pump, pump, pump it up.  Keep it going.  Eight.  How
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 many is that?  Come on, come on.  Come on, come on.
 Come on, come on. How many is it?  How many is it?
 How many is it?  March it out, everybody turn to the
 rear.  Everybody back here didn't think I was going to
 mess with you, did you?  This is the front of the class, you
 all.  Everybody give them a hand.  Press, press, press,
 press.  Come on.  Come on.  Dig deep.  Dig deep.  Dig
 deep.  Dig deep.  Keep breathing.  Come on, come on,
 come on.  Volume, please, volume, please.  Oh my
  goodness, I got a stage up here too.  Lord, have mercy.
  Come on, come on, come on.  Let me see it.  Sweat.
  Give me those elbows.  Press.  Press.  Keep it going
  now.  Come on.  Eight.  How many is that?  How many
  is that?  How many is that?  Oh louder, please.  I don't
  hear it.  I don't hear it.  I don't hear it.  Big inhale. Come
  on.  Exhale.  Inhale.  Exhale.  Right leg is up.  Lift that
  heel.  Bring it down.  Good.  Stretch it.  Bring it out.
  Stretch.  Bring it around.  Heel is up.  Stretch it.  Hold it.
  Bring it out.  Stretch it.  Last inhale.  Exhale it out.  Big
  inhale.  Exhale it out.  Big old one, smile.  Have a
  wonderful day y'all.  Good job.  Give yourselves a hand.
  Yes. (Applause)
  >>PENNY ROYAL
  Good morning.  Thank you, Reggie, for starting our day
  with such fun.  Good morning, everyone.  Thank you all
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 for coming back to the Secretary's summit.  Second day
 Steps To A Healthier U.S: Putting Prevention First.  We
 hope yesterday was informative for you and you all had a
 pleasant evening.  This morning it gives me great pleasure
 to introduce to you Deputy Secretary of Health And
 Human Services, Dr. Claude Allen.  Unwavering
 commitment to addressing the health concerns of this
 country.  Not the least, which is as constant and
 passionate devotion to eliminate health disparities among
  racial and ethnic minorities across our nation.  The
  Deputy Secretary is also concerned with what we ought
  to be doing with prevention first, which is the use of our
  country, assuring we continue to promote healthy
  life-styles and make them available for opportunities for
  healthy choices as he did while he was the Secretary of
  Health And Human Services in the Commonwealth of
  Virginia. Secretary Deputy Allen helping young people
  avoid alcohol, drugs, sex, tobacco and violence.  To
  address the youth and assure they have prevention
  agenda on their plate, in this way we help them now that
  is the best foundation to prevention we can do.  It is an
  honor and privilege for me to work with our Deputy
  Secretary Allen but with formal introduction Dr. Allen
  confirmed Secretary for Department of Health and
  Human Services twenty-sixth of May in year 2001.  He
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 worked closely with Secretary Tommy Thompson on all
 policy and management issues as he served as
 department's Chief Operating Officer.  Prior to joining
 Dr. Allen was Secretary of Health And Human Services
 for the commonwealth of Virginia, leading 13 agencies
 and 15,000 employees.  He led Governor Gilmore's
 initiative new patient's Bill of Rights passed in 1989.
 Patients appeal for coverage decisions made by health
 plans and direct access to physician specialists.  Dr. Allen
  spearheaded reform initiative and provided leadership to
  overhaul the state's mental health community services.
  He was responsible for implementing the governor's
  insurance program for families offering lower health
  coverage for Virginians.  He holds degrees from
  University of Law school.  I present to you unique human
  being, Dr. Claude Allen. (Applause)
  >>CLAUDE ALLEN
  I would! You guys had a great start this morning.
  Privilege and honor to be here this evening.  Thank you,
  Christina, for the very generous and kind introduction.  It
  is an honor to come before you today and for me to talk
  with you a little bit about prevention and the need in this
  country for people to invest in themselves and take time
  to make healthy decisions for their lives.  Reggie Freeman
  certainly gave you a workout this morning.  I kind of wish
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 we had gotten here earlier to participate in that ourselves,
 but I had my workout before coming to work at 5:30 this
 morning.  It is important that little 15 minutes, 20 minutes
 of exercise can have tremendous impact on one's
 life-style, one's longevity in that sense.  And so I am sure
 that you can tell from yesterday Secretary Thompson is
 passionate about the issue.  He's a tremendous leader
 and example for all of us at the department.  He keeps all
 of us on our toes, to eat right, exercise and have regular
  medical checkups.  In fact, those of you who work in the
  department know that when you come downtown to the
  Humphrey building we have a little group that oftentimes
  goes out in front of the building and they will smoke.  And
  the Secretary when he comes out of the elevator he sees
  them out there, you see them all kind of scramble.  Well,
  just the other day I was coming downstairs to the first
  floor and coming out of the elevator, and there were a
  group of women out there.  And I looked at them and I
  just went -- kind of scurried away to deal with that.  The
  Secretary set a great example for us at the department in
  terms of eating right, in terms of exercising, making sure
  we take care of our own health.  When you consider the
  diseases and conditions we're looking at during this
  conference, diabetes, obesity, asthma, heart disease and
  stroke and cancer, the incidences can many times be
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 prevented by simple choices in life-styles.  We have the
 tendency in this country to focus on treatment and
 services instead of focusing on prevention.  In fact, when
 you look at our budget, it is way out of whack in terms of
 how much we spend on prevention versus how much we
 spend on treatment and care.  I heard Secretary
 Thompson mention oftentimes it is like waiting for your
 car to breakdown before you take it in for maintenance.
 Just as each of us probably takes our cars in for an oil
  change every few thousand miles or so, we need to make
  sure we're taking care of ourselves.  The human body
  needs preventative maintenance as well, just as our
  automobiles need preventative maintenance.  Steps to a
  Healthier U.S. is how we deal with healthcare in
  America, by dealing with causes of disease, we can focus
  our resources, our time and our energy towards
  preventing them before they ever have a chance to occur.
  Much of my time is spent at looking at this whole area of
  health disparities among minorities and how we can help
  use to make healthy choices in their own lives.
  Communities of color across this nation are being
  devastated by diseases we have been discussing.  You've
  probably heard the statistics, I'll share a few more with
  you today.  African American men under 65 years of age
  suffer from prostate cancer at nearly twice the rate as
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 white men.  While it is not comfortable, a simple test
 every year or so can detect this disease and treat it with
 high success rates.  American Indians suffer from
 diabetes at nearly three times the average rate with
 prevalence among some American Indian Alaska native
 tribes, as high as 50%.  Just a few weeks ago I was
 visiting tribes in Arizona and I could see differences very
 clearly Indians of the same tribe, depending which side of
 the border they lived.  The Indian tribal members on the
  U.S. side of the border have buried traditional diet and
  exercise and experiencing high rates of diabetes and
  obesity.  Just across the border members of the same
  tribe from the Mexican side of the border, however, have
  maintained a healthier diet and more physical activity as a
  result of their life-styles.  It is incredible when you look at
  these communities and see that the very same group
  because of what side of the border they live on, because
  of their diet and exercise habits have very different
  prospects for health outcomes.  When we look at Asian
  American community, recent study from C.D.C., Centers
  For Disease Control And Prevention, suggests that native
  Hawaiians are two and a half more likely to have been
  diagnosed with diabetes than white residents of Hawaii of
  similar age.  Again, many native Hawaiians have
  substituted traditional diets and customs for fast food and
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 sedentary life-styles.  Among African American women,
 49% reported that they did not participate in leisure time
 physical activity. This is one of the main reasons African
 American women are at high risk for obesity, heart
 disease and diabetes.  While cardiovascular disease is the
 leading cause of death within the U.S., Hispanics
 experiencing a rise in the prevalence of risk factors for
 coronary heart disease, including hypertension.  Again,
 African American women have the highest mortality rate
  from heart disease.  That's 147.6% 100,000 of all
  American women.  Of this population 34% have elevated
  blood pressure in contrast to 19% for Caucasian women.
  In a few minutes Dr. Julie Gerberding will be discussing
  some of the thing at H.H.S. to discuss heart disease and
  stroke prevention in particular.  Rest assured we're
  looking at all diseases in coming up with real solutions of
  how to end the disparities we see in health today.  All of
  these disease categories can be reduced significantly and
  prevented if we take a strong message to communities of
  color that exercise is important, good diet is essential and
  regular medical checkups are a necessity.  As a father of
  a ten-year-old, a six-year-old and soon to be
  three-year-old, positive youth development is something
  that is very important to me.  Just this last week we had
  the privilege, we have some of my great nephews and
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 nieces who live in the city, live in neighborhoods where
 they can't go and enjoy the outdoors and exercise.
 Whenever we have an opportunity, we invite them to
 come over, just across the border, into Virginia, northern
 Virginia and spend a few days with us.  And so earlier
 part of this week and since last week, we have had seven
 kids in our household and they have enjoyed venturing
 behind the yard to go down to the creek or going up to
 the basketball court to get out and to exercise and to
  enjoy that.  Well, we have a tendency in this country to
  dwell on the negative things some youth may be doing.  I
  don't think we give youth as much credit they deserve.  If
  we give them the very best information for them to make
  healthy choices, they will make those choices and make
  right and healthy decisions for themselves with the
  support of family and friends.  Majority of youth today in
  America are making good choices, making healthy
  choices.  We just need to affirm them and back them up.
  I know it is hard to believe sometimes, but children do
  listen to their parents.  That is why it is so important for
  parents to talk with their children not only about good
  eating habits, good exercise habits, but also about
  avoiding risky behavior such as alcohol, drugs, sex,
  tobacco and violence.  We need to realize each of these
  risk behaviors is connected and that when youth are
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 involved in one behavior, there's increase likelihood they
 will be involved in multiple behaviors. They're inner
 connected.  This is indeed a paradigm shift.  Risk
 reduction messages have met with very mixed results.
 When you have a clear message of risk avoidance,
 reduction is not necessary because you prevented the
 problem again before it even has a chance to begin.  And
 again, we're talking about preventative maintenance,
 talking about life-style changes.  In this case we're talking
  about good habits to protect young people into their adult
  hood.  We have to realize most important connection that
  youth have is that child's connection with his or her family,
  with peers, with school and with community.  These
  variables determine how youth respond to risk behaviors.
  When children feel connected to their families, they're less
  likely to smoke, less likely to use alcohol or drugs, less
  likely to engage in early sexual intercourse or less likely to
  engage in act of violence, experience emotional distress
  or even have thoughts of suicide.  Again, we're talking
  about prevention.  We need to create communities where
  youth can thrive and be involved in activities that promote
  positive life-styles away from televisions, away from
  computer games and away from junk food.  You heard
  yesterday of the Secretary's commitment of heart disease
  and stroke prevention.  When he launched action plan to
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 prevent heart disease and stroke.  It will chart a course
 national goals preventing heart disease and stroke over
 the next two decades and beyond.  This is incredible
 opportunity for all of us in the public health community to
 work towards reducing the burden of these leading
 causes of death.  The problem with getting America
 healthy, however, cannot be solved alone by government.
 We need partners.  It will take provider community, all
 communities, it will take the safe community churches,
  mosques, synagogues and government and all facets of
  daily lives making it a success.  Today you have an
  opportunity to continue meeting many of our partners
  here in this audience.  I hope that you will find your time
  here very informative and that you gain many of the tools
  that you will need to make prevention a part of what they
  do each day.  I want to thank you again for being here
  and look forward to working with you and making
  America a healthy place.  Thank you.  And have a good
  conference. (Applause)
  >>PENNY ROYAL
  Thank you, Claude, for your dedication and commitment
  to healthy Americans.  Thank you.  And now I would like
  to introduce to you on your packets -- on your table you
  have our plan.  Secretary got so caught up in his
  passionate speech that he forgot to introduce this to you
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 formally.  But this is our plan for cardiovascular disease
 and stroke.  It is a prevention plan.  It was collaborated
 by many, many parties, including the American Heart
 Association who joins us here today, but it is a
 collaborative effort between C.D.C. and I.H., different
 within the department, as well as many organizations,
 advocacy groups and other partners.  We hope that you
 will find it educative, as well as instructional.  This is
 incredible effort and many, many people worked very
  hard to get this.  And we believe it is an excellent
  beginning to start strategic plan to address cardiovascular
  disease in our country, which happens to be the number
  one killer of women.  So as you can see, these are
  concrete steps to deal with real problems.  I would like to
  introduce to you a colleague of mine.  She has been quite
  famous in the news lately with SARS.  I know it is not all
  that she likes to do.  Her passion is prevention.  The
  director of our Centers For Disease Control Julie
  Gerberding, we're going to give you a chance to talk
  about something else than SARS.  Welcome. (Applause)
  >>JULIE GERBERDING
  Good morning.  It is really a great location to talk about
  something besides SARS or terrorism.  I'm delighted to
  be here.  I'm very delighted to be able to introduce a little
  bit more information about the plan, public health action
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 plan to prevent heart disease and stroke.  Let me first say
 why we need such a plan.  Heart disease and stroke are
 epidemic in this country.  Every 29 seconds somebody
 suffers a heart attack.  And every 45 seconds somebody
 has a stroke.  So these are phenomenally common health
 problems for us and problems we have to treat with the
 same urgency and the same attention there as we utilize
 the much more visible problems like anthrax or SARS or
 West Nile Virus infection.  Truly constitute epidemics.
  These conditions represent the four most causes of death
  and disability in our nation.  They cost more than $350
  billion every year.  More than 140 billion of this has been
  lost earnings from the people who are prematurely
  disabled or die from these illnesses.  And I think
  importantly because of the excellence in our healthcare
  delivery system there are many survivors of these
  conditions, but survivors who are living with coronary
  heart disease, about 12.9 million of those people, 4.9
  million people living with heart failure and 4.7 million
  people living in rehabilitation from stroke.  So these are
  profound health issues.  Health issues and issues for
  delivery system and we need a coordinated, integrated
  approach to addressing them with the public health
  model.  This plan does that.  This represents about 16
  months of work.  Very hard work with number of
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 partners from across the nation and various systems and
 federal agencies.  I'm very proud of C.D.C.'s leadership
 in doing this. Although I can't take any credit myself.  I
 think hard work and disease center part of a lot of people
 including Darleen Debarth (phonetic), taking approach of
 group of experts and agencies and something that's truly a
 first step.  Every American will be called upon to take
 some action as a consequence of this plan.  We'll need to
 make healthier choices, we'll need to do more to enjoy
  physical activity.  We will need to get the health
  screenings that we need to identify -- identify problems
  early enough so we can do something about them.  And
  really working in partnership with our health agencies and
  our healthcare delivery system taking the healthy steps to
  prevent not only heart disease and stroke, but also
  mitigate the consequences for those people who are
  already at risk or who have already developed the earlier
  stages of the disease.  This first step is something that will
  be implemented through a variety of processes, but again,
  the actualization of the plan really does depend on the
  hard work and leadership of our state and local health
  departments and a number of federal agencies and
  professional organizations that have all come together to
  deal with this.  So it is a big challenge.  It is a great plan.
  I'm a little bit like Secretary Thompson.  I think plans are
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 great, but I'm especially interested in action.  So I really
 challenge all of you to become familiar with this plan, but
 then to actionize it by putting forward your ideas and
 working hard at whatever level in the plan you identify
 with to take the steps necessary to really develop a
 lasting chance that will make us healthier.  And really
 bring this number one killer of Americans much further
 down the list.  And I think that's an achievable goal.
 What we're going to be doing this morning is setting up a
  series of discussions and I'm very pleased this morning to
  have the honor of moderating this panel.  I think what I'm
  likely to do is ask the panelists to come up to the stage so
  I can introduce you as you arrive.  Good morning.  We're
  having a slight technical glitch, having to do with the fact I
  was in a traffic jam this morning and don't have my talking
  points in front of me.  While my speakers are getting
  nervous up here, I'll check the agenda to make sure you
  know how much time they're allotted to keep the session
  on time.  I wasn't sure whether you were going to be 15
  minutes or 45 minutes.  Get my act together now.  This
  panel is really representative of I think some of the hard
  work that went into creating this report.  Dr. Bonow is
  individual who has shown enormous leadership through
  his direction of the American Heart Association.  You
  notice that I'm wearing my Heart Association pin this
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 morning, as I've been indoctrinated into the organization.
 I'm likely to ask him to really provide a framework for the
 plan to probably give us more specificity why we need
 the plan and what's the scope and magnitude of what the
 problems are, but also what the American Heart
 Association is doing in support of this effort.  So thank
 you. (Applause)
 >>ROBERT BONOW
 Thank you very much, Dr. Gerberding.  Thank to Reggie
  also because Secretary Thompson will be happy to know
  I used 1/4 of my steps this morning, thanks to our effort.
  It is honor to me and on behalf of the American Heart
  Association not allowing me to participate in the panel but
  association playing a key partnership role with the
  department and all of you in developing this plan.  Clearly
  we need to thank the extraordinary leadership of Dr.
  Gerberding and C.D.C. for making this happen.  We're
  excited about moving this forward.  We have a blueprint
  and key now as to move beyond the blueprint to the
  building.  Dr. Gerberding told you, and as you know from
  your own experience, cardiovascular disease is leading
  cause of death in this country. Equal opportunity afflicter,
  including issue we need to bring preventative measures to
  bear on.  As you can see, nearly 62 million Americans
  have one or more forms of cardiovascular disease.  More
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 than 2600 Americans die from cardiovascular disease
 each day.  That's an average of one death every 33
 seconds.  During the time this panel will take place, you
 can do the simple arithmetic to notice how many lives
 we're going to lose.  This is not disease of old people.
 Half of 62 million individuals are under age 65 and 1/5 of
 the death, which is 500 per day, are under age -- as well.
 As Dr. Gerberding said, this is an annual cost of $300
 million per year.  Strictly speaking the American Heart
  Association has been at the fight against cardiovascular
  disease for many, many years.  Our mission is to reduce
  the disability in death in cardiovascular disease and
  stroke.  Stroke is very much part of the agenda.  As a
  result, the American Heart Association created a
  subdivision the American Stroke Association which has
  been really quite active in the last two years in the area of
  prevention and recognition.  Pushing the envelope for
  more research funding as well.  And getting messages into
  the community to improve awareness and outcome of
  stroke survivors.  The goal of the organization is by the
  year 2010 to reduce the risk of death and disability and
  risk by 25% for heart disease and stroke.  We put a
  number on this thinking that a number could drive us
  toward very aggressive programs, really try to achieve
  meaningful outcomes.  Rather than saying we want to
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 improve outcome, we thought 25% would allow us to put
 a target on this and measure outcome as well.  But in
 doing so we realize that we have enormous challenges in
 front of us.  Show you a few headlines.  These are --
 these have impact not only on healthcare community but
 also the citizens of the United States.  Obesity in
 America.  This results -- this is a headline related to the
 paper by coworkers from C.D.C. indicating 66%,
 roughly 66% of Americans are overweight, over 30% are
  frankly obese, 15% of children in teenage years are
  overweight or obese.  That's equally of greater concern
  what our children are doing.  In fact, what are our
  children doing?  They're getting mixed messages.  We tell
  them to eat healthy foods and yet in schools we have very
  poor nutritional programs.  Have school systems that are
  not only contributing to the ill health of our children but
  giving them wrong healthcare messages.  Of course, the
  obesity epidemic is fueling another major concern, the
  rise of diabetes.  This is not just a New York situation, as
  suggested by the headline, but New York Times
  indicated that the average statistics in New York what
  we're seeing nationwide.  8% of New Yorkers have
  diabetes, 13% of Hispanics have diabetes, and roughly
  ten or 11% of African American citizens in New York
  have diabetes.  We're seeing this nationwide.  And this
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 also gets into the disparity issue as Secretary Allen
 indicated.  Heart disease is a greater risk among African
 Americans.  This headline comes from one of my
 hometown papers in Chicago.  Illinois has third worst
 cardiovascular in any state.  Major issues regarding
 access to care.  Access to care issues we have two
 segments of population who are not getting access to
 preventative messages or preventative treatments.  More
 over, even when access to care is not the issue, even
  when we look at populations that have equal access and
  equal insurance we find that the healthcare as to be
  inferior among minorities as indicated by this particular
  headline which is result of the Institute Of Medicine
  report a year or so ago followed by the Kaiser family
  report foundation last fall indicating the same finding.
  Issues regarding communication, regarding trust in the
  healthcare system and we need to really work on these
  particular issues.  Behavioral issues as well as systems of
  care to break these wrongs.  What do we do?  As an
  organization we have historically organization that
  provides knowledge.  Discovering new science, funds
  research, both basic, clinical and population science now.
  Transfer the science to our meetings and publications,
  and we try to guide application of science through
  statements advisories and guidelines.  This is historically
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 what the American Heart Association has been about,
 but we realize this is not going to achieve our goals.
 Issues have occurred despite aspects of the organization
 but put numbers of 25 reduction by 2010 we need to be
 more aggressive.  Therefore change the fabric of the
 American Heart Association, the goal now is to increase
 awareness.  Change behaviors, change environment and
 change the healthcare system as necessary to achieve
 these goals.  We are very excited about what we have
  been doing, and we're very excited about the ability to
  partner with many other organizations to achieve the
  goals.  How can we provide credible information and
  changes in behavior to every community?  We think we
  are a good partner to consider the opportunities to work
  with because we can reach many segments of the
  community.  Through different means.  Through churches,
  through schools, through workplaces, through universities
  and medical centers.  Access to media, telephone,
  internet base systems as well.  Put information in grocery
  stores.  Now we're not all things to all people and certain
  communities, one or more of the particular means may
  work better and so therefore we can individualize what
  the opportunities may be to meet the given culture or
  system to be addressed.  And we believe we have some
  opportunities to help in these ways because we have a
.
Page 25
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 large organization.  In addition to national center and 14
 large reasons -- regional offices, we have volunteers and
 staff in the community.  We have 1500 local divisions,
 3,000 staff nationwide in every community.  Scientific
 councils which is scientific leadership of the organization
 involved 30,000 scientists, physicians and nurses.  And
 most important at the local level we have lay and science
 volunteers, numbering anywhere from 7 million to 20
 million, depending whether you count more dedicated
  individuals or the high school kids who do Jump Rope
  For Heart.  As an example at our Emergency Cardiac
  Care Committee meeting last week I learned that our
  organization has trained 260,000 trainers to teach C.P.R.
  throughout the country.  260,000.  Either training the
  trainers -- now trainers are going to go out according to
  our plan and train 20 million people to actually perform
  C.P.R. to deal with some of the issues.  This is kind of
  work force that we have potential to develop.  But even
  with the work force we realize quite clearly that we need
  to leverage our work.  We cannot do this alone as an
  organization.  This is why the partnership with the Healthy
  People 2010 community has been so important.  Our
  goal are in line with 2010 goals and we feel very proud of
  the relationship that we have developed thanks to Dr.
  Rosemary Robinson, past president and officer who
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 made it happen.  Have a strong partnership with the
 Department of Health and Human Services, including
 Office Of Disease Prevention And Health Promotion.
 N.I.H. agencies, C.D.C., Centers For Disease Control in
 prevention, Centers for Medicare, Medicaid Services
 and Health Services.  As a result we do see the final
 outcome of the partnership to date in the public health
 action plan, copy of which you have before you. We are
 very eager to move this forward.  In addition we have
  other strategic partners who nongovernmental.  American
  Department of Cardiology, sister to sister, campaigns,
  growing relationship at the state level with affiliate
  relationships within each state with the American Heart
  Association.  What can we try to bring to bear as an
  asset in partnership?  First of all, we have a large
  advocacy staff and work force.  Something we can do
  that federal agencies cannot do is to go to Congress and
  urge greater awareness, greater funding, two key issues
  each year have been greater research funding for N.I.H.,
  greater funding for C.D.C. to support the state base
  programs and that fight continues.  In addition as you see
  on this slide, number of other specific items that we have
  been dealing with, all of which focus on prevention that I'll
  go through very quickly.  First of all, get with guideline of
  hospital base program for patients in coronary care unit
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 with secondary guidelines.  We're all aware we have a
 major gap between the healthcare that we should have
 and the healthcare that we do have.  Patients are not
 getting effective secondary prevention measures after
 cardio infarction.  This program allows it to be
 implemented and is rolling out nationwide and will
 address some of the gender issues as one sees in care as
 well as some of the minority and ethnic disparities, help to
 level the playing field.  Program based on acute coronary
  care is also being modified to involve stroke, acute stroke
  care, and ultimately also heart failure.  In addition, you
  can see that what this allows to us do is go from
  developing guidelines which winds up on a book shelf to
  actually implementing them at the patient level within the
  community.  In addition we have program called Heart
  Profilers.  Individuals with disease or risk for disease can
  log on, get specific tailored information that is specific to
  his or her own individual characteristics based on
  sidelines to allow them to understand the disease process,
  understand the importance of prevention, ask the right
  questions of healthcare providers and seek healthcare
  provider that has not already occurred.  Problem with
  this, of course, is some of the people who need this
  information the most do not have access to a computer or
  internet.  So we need something else.  One thing we're
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 doing is This Is Your Heart.  It's a community based
 program in primarily in inner cities for the under-served
 and minority populations.  5,000 churches enrolled
 nationwide and through this particular program we hope
 to be able to begin to address some of the disparity issues
 in cardiac prevention.  This Is Your Heart has modules
 that teaches trainers to talk to members of congregations
 about stroke, about the importance of checking blood
 pressure, high risk for stroke, especially among African
  Americans and Hispanics and as Secretary Allen
  indicated, highest risk groups for obesity and metabolic
  syndrome tend to be women in minority, African
  American women and Hispanic women, diabetes,
  metabolic syndrome, it has tailored activities, healthy
  life-styles and healthy diet.  Another program is called
  Choose To Move.  I-village picked it up and had it on
  their internet site.  Hoping to move it in the community as
  well and maybe Reggie can help us do that because he
  got us moving so well this morning.  Finally, beginning to
  address the disparity issues, wish to frame the agenda for
  our organization that we can use in partnership for others
  regarding the scientific agenda as well as the community
  based issues, advocacy issues with conference in Atlanta
  first of October pulling together member of partnership
  organizations to help address this issue.  Finally I'd like to
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 recognize Dr. Tom Pearson (phonetic) who was one of
 the working member chairs of the Public Health Action
 plan who also chaired a task force within the American
 Heart Association dealing with community level
 prevention.  Of all prevention guidelines that we have
 published, I believe it is the most important one in the last
 decade or two.  Copy is out on the booth.  If you haven't
 seen it, you can pick it up at our booth or find it at
 Americanheart.org web site.  Telling individuals that they
  need to have cholesterol checked, blood pressure
  checked for doing healthy activities.  Most communities
  are not able to provide ability or information to and
  therefore need to become more active in the
  communities.  Many of us have taken the particular
  document to the town halls and shown it to our local
  legislatures about things that need to be doing.  For
  example, advocating for screening for cardiovascular
  disease, risk factors and stroke, same risk factors.  Need
  to be emphasizing communities with bicycle paths and
  walkways.  Is it safe at night for adults and children?
  Public schools with exercise facilities, why are they used
  at night and should be open weekends as well.  Physical
  education at school.  We feel these needs to be prime
  agenda on the list.  Healthy choices in school lunch
  programs.  These are two things we need to be doing for
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 our children to improve future cardiovascular health.
 Finally, I'd like to again acknowledge our great
 appreciation and admiration for the individuals who pulled
 this document together.  In fact, David Goff chaired this.
 He's very active in the American Heart Association as
 volunteer.  Look forward to continuing with all the
 partners to move this forward beyond the blueprint stage
 and implementation. Thank you very much for your
 attention. (Applause)
  >>JULIE GERBERDING
  Thank you.  That is a pretty impressive panel play of
  activities.  I don't think I really had a full appreciation of
  the Heart Association with C.D.C. until visiting a few
  months ago and peek view and really appreciate all that
  you're doing.  There are many partners -- actually more
  than 60 partners who have contributed to the
  development of the action plan and they obviously Heart
  Association has played a major lead in this.  But we
  couldn't have a plan or wouldn't be able to implement a
  plan without the full coordination of the health officials for
  state and local health agencies.  And the association
  office has been critical component of that.  Dr. Garcia,
  our next panelist is someone who is the President Elect of
  the Association of the State and Territory Health Officers
  but also the Health Commissioner in the State of
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 Connecticut.  I want to just make a very personal
 statement to him because throughout the past several
 months as we have come to grips with public health
 preparedness at the State level, Dr. Garcia has been one
 of the most rational contributors and supportive
 contributors in good sense.  We're pleased to have him a
 part of this panel and he's going to tell you what some of
 the partnerships that have gone through the states that are
 helping to address the issues of cardiovascular disease
  and stroke.  Dr. Garcia. (Applause)
  >>JOXEL GARCIA
  First time someone said I'm rational, that was a joke by
  the way.  What I want to do this morning is very simple.
  I want to present three things.  One briefly to present to
  you take me one minute.  After that what do we think and
  how we can use the action plan to change health in the
  United States.  Then third, example of three states that
  are implementing plans.  So you can actually benchmark
  what those states are doing or actually use that as a
  model and then modify that within your own state.  So
  with that in mind -- let me see if I can work this.  Yes.
  Association of State and Territories health officials,
  represent all the states, 50 states, territories and D.C. and
  headquarters are in D.C. as well.  And the mission is right
  there, formulate and influence sound, national policy, kind
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 of policy we're not going to be promoting but sound.
 And we are with the departments working to create
 change at the state level.  So what we think this is doing,
 action plan is doing.  I think we're going to be able to
 promote better health, prevent chronic diseases and help
 some of the factors.  Someone think we have to work --
 physical activity dealing with tobacco.  That way we can
 eliminate some of the cardiovascular disease and stroke
 issues affecting all our states, all our communities.
  Actually been doing for a long time.  That's why we're so
  excited with the document, with this action plan because
  it provides partners to opportunities with the federal and
  state government but also with our community in the
  private sector.  Essentially that's where we're looking,
  federal, state, local, private industry, healthcare system,
  communities getting it.  Using as action plan that can be
  used to change all the communities.  I think one of the
  things that we have to do is yesterday I like one of the
  lines of the Secretary used, he said there's lots of
  messengers.  When we come back to our communities
  start to think what we have learned not only from listening
  to the different presentations but talking with the different
  partners and create new partnerships because sustain we
  have to be -- we cannot think single we have to work in
  partnerships with everybody.  It has been long time since
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 we have energy boost from the federal government in
 terms to push for prevention.  Because I know the
 message we had yesterday we should not be thinking in
 terms of health system or healthy health system.  We
 should be looking at a health system.  That's essentially
 what the plan is going to try to accomplish and that's
 essentially what it wants.  These examples going to be
 giving, Texas, Rhode Island and of course my state of
 Connecticut.  Texas, they create strategic plan for
  prevention of obesity.  They have four goals. The first one
  is to increase awareness and they want to put in schools,
  communities to choose life-styles that can promote health.
  That way they think and they are -- data change
  cardiovascular affecting the states, communities and also
  the stroke affecting the communities.  Promotes change
  that support healthy habits.  Many, many policies can be
  pulled out, but if you don't give tools so change can
  happen, change cannot move forward.  Then very
  important four goals -- four goals they have as to
  monitor.  Because monitor the trends to see if the actions
  are there taking place are effective or not.  I think this is
  -- not only going to be used like Texas but can be used
  by other states and also other communities.  I have to say
  Dr. Sanchez (phonetic) who is part of the action plan,
  he's great leader in the state of Texas.  Rhode Island
.
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 Department Of Health, they have a process which I like a
 lot.  Sponsored by the Rhode Island Prevention
 Coalition, Department Of Public Health, American Heart
 Association of local business.  Walking initiative.  Sounds
 simple and actually I think significant change because
 communities, some towns, some cities and they have and
 marked them every half mile.  So people can actually
 start walking and find out how much they're walking
 every day and then try to accomplish their goals.  And so
  they can put some objectives and find out they have --
  and measure the objectives and find out if they reach their
  goal or so.  Yesterday the Secretary was talking about
  having a meter at your belt and interested in doing that in
  miles in state of Rhode Island.  They even have spring
  walking conference which essentially actually providing
  the monitors to people so they can actually measure what
  they were doing.  So it is a very proactive system that
  they have there.  It is a simple process.  Found a lot of
  partners and create change.  Now, the good thing I'm
  presenting I can have the better slide of my state.  As you
  can see.  I also have M.B.A. so marketing, called social
  marketing.  First thing I did when I came to my state was
  change the law.  Connecticut light house officially
  illuminating in the state of Connecticut with public health.
  (Applause) And this slide I have here pertains to the three
.
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.
 states and rest of the nation.  My state spent $3.6 billion
 in cardiovascular disease.  42% of all Connecticut deaths
 are associated with cardiovascular disease.  23% of
 hospitalization, just to give you some numbers, obesity
 rate, obesity rate in Texas and Rhode Island for adults is
 over 60%.  In terms of children school-age over 30%.
 That essentially pertains to all the states of the nation.
 Other things happening in all states is the change of our
 predicted growth of our people.  When I was in medical
  school, the data goes all the way to 65 years and older.
  Now the data is 85 years and older, and that's the fastest
  growing group in our state.  77.9% for 85 years and
  older.  Second group 65 years and older.  Line in my
  state 100% correct for all the states but may have better
  data, but I said to my -- when I speak in public, I said if a
  lady is 65 years and older and healthy and she's in the
  audience here today, she's probably going to live to 100
  years of age.  For the guys in the audience if you're
  healthy at 65, you're still going to die when you're 70 so
  -- have to change.  That's one of the things is
  cardiovascular disease.  Another thing that is changing is
  demographics of our state.  And that's happening across
  America and that's extremely important because
  American Heart Association already put presentations
  and C.D.C. put presentations, asked us, everybody put
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 presentations in terms of all the minority groups, different
 ethnic groups and affecting all of them.  So we do two
 things in the state, one is house calls with seniors health
 tour and other one is urban healthy initiative which we call
 door to door.  Very cost effective.  Again, this is with
 support in part by the federal government through C.D.C.
 and sometimes we do it by ourselves.  We got everybody
 involved.  Hospital association, we got community action
 groups, we got the local health departments, we got the
  public health community, we got the private sector
  involved.  I think essentially what we do we get partners,
  go, get data from my agency, go to the community, 30 to
  60 people, do this three times a week.  Essentially what
  we do is send data to them and ask them what do you
  think we should be doing to create change based in the
  notion that the communities know what is the best tools to
  work with them.  So in our state it works.  We're very
  Yankee state.  Local and territorial things but may be
  replicated in other states as well have created change.
  Survey pre-event and survey postevent.  Survey have any
  changes in the healthcare status, not only in the
  community but also have they accessed the healthcare
  system.  So to finalize and as you can see, I talk very fast,
  one of the things we think we can accomplish is the states
  working together with all the partners.  We have this --
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 each one of the states in territory so we cannot only work
 with the federal government but all the private sectors and
 create significant change. So that's why we need
 partnerships deal with communities, organizations.  This is
 with private sector and we have not only to educate the
 public, another thing we want to be able to do is change
 the healthcare system.  Some of the data we have -- now
 I know talking from another perspective but state of
 Connecticut sometimes healthcare providers are not using
  the tools that they should be using to create change.  For
  medications, processes that can be done after the patient
  has been diagnosed with the process.  So what we're
  trying to do is facilitate that and that's why we're looking
  at action to create change from the leadership perspective
  but also in terms of action perspective.  So essentially
  that's the brief presentation that we have and we're very
  thankful for the opportunity. (Applause)
  >>JULIE GERBERDING
  Thank you.  I have a question for the audience.  How
  many people in the audience are leaders or managers or
  supervisors of other employees?  Raise your hand.
  Okay.  How many of you who raised your hands have
  taken specific action steps to make your workplace heart
  happy or better, safer and healthier for your individuals?
  Not as many hands.  I have a challenge to all of you,
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Page 38
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 because it is a challenge I'm taking very seriously for
 myself, and that is just as you heard about opportunities
 in the community or opportunities in the home, I think
 each of us can think of opportunities in our own
 workplace to take steps to promote a healthier life-style,
 healthier work style for people.  At C.D.C., you know,
 we are the nation's lead public health agency for
 promoting healthier people.  It's unconscionable as to put
 highest priority within our organization.  When I started
  my role as Director of C.D.C. I thought I would walk the
  talk so I wanted to take the stairs up to the fifth floor.
  The building where my office is and the stairs were
  exactly where I didn't want to be.  They were very
  unattractive and some what hideous actually.  So I got on
  the stairwell and I did make it all the way up to the fifth
  floor without having any myocardial chest pain but I
  couldn't get out.  So I had to call on my cell phone and
  say please, let me out of the staircase.  So since that time
  in large part to the leadership of Dr. Jim Marks
  (phonetic) and Dr. Jackson who are interested in
  environmental factors in the workplace, we're initiating
  that in the workplace.  Proof of principle of simple things
  that can be done to promote more exercise or more
  steps.  We're engaged in the process at C.D.C. and
  C.D.C. has provided healthier stairwell at the Humphrey
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.
 Building so they can have a healthy staircase as well.  I
 would challenge you to think of small things you can do in
 your own workplace.  Have your staff meeting walking or
 turn off three of the four elevators.  That will get them on
 the stairs.  Anyway, I really thank my panelists for their
 contributions this morning and especially thank all the
 partners who contributed to the public health action plan.
 Really a terrific next step and we need your help and
 need your support and your commitment.  It is now my
  pleasure to introduce the moderator of the next panel, Dr.
  Elizabeth Duke.  She is a great colleague at H.H.S. and I
  think you probably latched onto the Secretary's
  comments yesterday and through the way the whole
  meeting is organized that we really are a much more
  integrated Department of Health and Human Services.
  That's the Secretary's dream, all one department, all
  H.H.S. and I think there's probably no person who better
  exemplifies that kind of integration and crossover
  between one agency and another than Dr. Duke.  She
  has been effective leader, and from my standpoint huge
  energy in bridging the gap between the public health
  system and healthcare delivery system and making
  seamless within the department but also seamless in the
  real world.  So Betty, welcome and I appreciate
  everything that you do to support public health.
.
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.
 (Applause)
 >>ELIZABETH DUKE
 Good morning.  I am just delighted to be here today.  I
 thank Julie for the gracious introduction.  It is actually a
 marvelous opportunity to work in the Department of
 Health and Human Services today with such incredibly
 energetic colleagues, and with some superb program such
 as those that we have introduced here at this conference.
 They asked me to talk a little bit about the agency I have
  because it is the one of the lessor known agencies.  I'll
  take a few minutes to introduce the agency, but not too
  many minutes because I want to get directly to the
  panelists.  Health Resources And Services Administration
  is a big budget small agency.  That is to say 7
  billion-dollar agency with about 2000 employees.  And
  our goal about which we're fairly passionate is to ensure
  that there is access to healthcare services for millions
  citizens who would not have healthcare were we not
  there.  In fact, we're the agency that provides services for
  the medically under-served.  We're the safety net and we
  work closely with the other elements of the department to
  ensure that we're providing quality service that is good
  healthcare for the poor in this nation.  One of the key
  elements of that is the Community Health Center
  Network which is part of our program.  The President
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 made a commitment in his first few months of service to
 expand that safety net.  And his commitment is a five year
 program to increase that healthcare safety net from 3200
 health centers at the beginning of his administration by
 1200 new sites to 4400 over a five year period. That will
 mean access to health care for 6 million additional people
 over that five year period so that we will be serving 16
 million people in 2006 and ultimately doubling to almost
 22 million.  In addition to that President has made a
  major presidential initiative.  And that's absolutely
  common sense.  Because if you're going to expand the
  health center network you're going to need physicians
  and doctors and nurses to run those centers.  Over half of
  the health service corps is involved in our community
  health centers at this point.  So that expansion is most
  welcome.  The health centers actually are the health
  providers for most of the poor of the nation.  10% of the
  nations uninsured are cared for by our health centers and
  30% of the nation's uninsured people of color, both adults
  and children are served through the health centers.  We're
  very aware of those statistics that you have seen all
  yesterday and this morning.  And then we are absolutely
  committed to ending the health disparities.  And one of
  the ways we're attempting to do that is through our health
  disparities collaboratives.  These approaches take a team
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 approach to treating chronic illness to ensure that patients
 are involved in their own care and they're organized
 specifically around the diseases we have been talking
 about for the last day and a half.  Diabetes, asthma,
 cardiovascular disease, obesity, H.I.V./AIDS and
 cancer.  We're working in 12 centers on cancer in a pilot
 and roll that out nationally over the next 12 months.  As
 we're increasing the number of health centers we're also
 increasing those who are involved in this quality initiative,
  the healthcare collaborative.  We believe that this is going
  to help us close that gap between the health outcomes of
  the population at large and minorities.  That's a little bit
  about who we are.  In one way we can look at it as we
  bring healthcare to those who need it.  It is my real
  pleasure this morning to introduce a marvelous panel.  I'm
  going to start by introducing Dr. Gerald Anderson,
  Director for Hospital Finance at Johns Hopkins, he's the
  Co Director for Medical Technology and Assessment.
  Director of Washington D.C. policy program, Professor
  and Associate Chair of John Hopkins Hygiene and Public
  Health.  Professor of National and Health and Medicine
  at Johns Hopkins School Of Medicine.  It is my great
  pleasure to introduce Doctor Gerald Anderson.
  (Applause)
  >>GERARD ANDERSON
.
Page 43
.
 Thank you.  This morning I'm going to be really wearing
 three hats.  One is professor at local public health school.
 I can tell you Johns Hopkins putting prevention first for
 almost 100 years ago now.  I'm on the third floor and I've
 been walking up the stairs for all 20 years at Johns
 Hopkins.  But as professor what I want to try to do is
 give you something new to consider today.  That's what
 my first responsibility is.  The second is that I'm a
 Director of a Robert Wood Johnson National program
  and the title of is Partnership For Solution.  And tag line is
  better lives for people with chronic condition.  Our goal is
  to improve lives of 25 million Americans who already
  have a chronic condition.  What our challenge today is to
  make prevention relevant to them.  And third, I have
  expertise in healthcare finance.  So what I want in the ten
  minutes or so that I have is present something which I
  think is financially viable.  The goal for me to talk about if
  people who already have chronic -- one chronic
  condition.  As I said, that's 125 million Americans right
  now.  The goal is to slow the growth to multiple chronic
  conditions.  The first thing we have to do is define a
  chronic condition.  What you heard about specific
  diseases.  We wanted to be more encompassing, a
  broader definition.  So what we did is we came up with
  three criteria for defining a chronic condition.  Something
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 that lasts or expected to last a year or longer and limits
 what you can do and requires ongoing care.  We're still
 working on this definition because people have suggested
 it fits other things as well.  Somebody, for example, said
 that's a great definition for a chronic disease but works
 equally well for marriage. (Laughter) We gave the
 American public that definition.  And we said do you
 have a chronic condition?  Cross-section of Americans
 and four out of ten Americans raised their hand and said
  yes, I have a chronic condition.  And that we found --
  well, that work with numbers that we thought people had,
  but what I found slightly more surprising and, you know,
  where prevention comes into account really importantly is
  the people that did not have a chronic condition right
  now, 2/3 of them thought that they were going to develop
  a chronic condition sometime during our life.  And that's
  even true for the 18-year-old boys who were concerned
  about chronic conditions.  So it affects everyone.  We
  ask the reincorporation how many people do you think
  have a chronic condition based upon C.D.C. and A.R.C.
  (phonetic) information and they told us in 2001 25 million
  Americans right now have a chronic condition using the
  definition.  The number by 2010 will grow by 16 million
  to 141 million Americans.  But what I want to talk about
  is people with multiple chronic conditions.  Right now
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 what you have on -- on the slide is the five most common
 chronic conditions in children.  And what you see
 fortunately is 2/3 of the children with a chronic disease
 have just that single chronic disease.  But 1/3 of children
 with chronic disease has two or more chronic conditions.
 So we start seeing the idea of multiple chronic conditions.
 When we get to people our age, then what we see is the
 single chronic condition is not the norm.  Only about 1/3
 of the people who are -- have one chronic condition.  2/3
  of them have two or more different chronic conditions.
  And then when we talk to the -- talk about seniors,
  people over the age of 65, you tell me one in ten seniors
  that just have a single chronic condition.  If they have a
  chronic condition, nine out of ten of them have two or
  more chronic conditions.  So designing programs that are
  just around single chronic conditions especially for the
  elderly does not make complete sense.  What we see is
  the number of people with chronic conditions according
  to the corporation is going to grow.  Right now we have
  60 million Americans with two or more chronic
  conditions.  By 2010 it is projected to grow to 70 million.
  Increase in 10 million.  What we need to figure out is a
  way to reduce those numbers.  It has -- having multiple
  chronic condition has many effects.  I'll show new --- a
  minute a lot higher healthcare utilization but also affects
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 you and your ability to work, ability to go to school,
 ability to do a variety of things.  One example ability,
 impacted on ability to do activities of daily living.  By the
 time you have five or more chronic conditions, you have a
 67% chance of having at least one activity of daily living
 limitation.  What I talk -- said I was going to talk about
 though is a little bit of financing.  And what we have is the
 more chronic conditions you have, the more expensive
 you are to the medical care system. So we don't all like
  to talk about dollars, we don't like to make financial
  arguments but this is the financial argument for prevention
  and especially prevention for people with multiple chronic
  conditions.  By the time you have five or more chronic
  conditions, your cost is a little over $10,000 a year to a
  health insurer.  If you stay at zero, it is $800.  One, it is a
  little over $2,000.  But what also we have to do is take a
  look -- it will switch in a minute.  Look at specific
  programs like the Medicare program.  And what we have
  is in the Medicare program it is -- you see that 67% of
  Medicare beneficiaries have two or more chronic
  conditions.  If you look at the dollars associated with
  those individuals, it is 96% of Medicare's budget. Now
  not all of that is for care of chronic conditions, but those
  people with chronic conditions in the Medicare program
  are 96% of Medicare's budget.  So if Tom Skulley was
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 here right now, what I would tell him is that Medicare is a
 program for people with multiple chronic conditions, but
 the way the system is designed today, he and the
 Congress just doesn't know it.  I take a look at the
 Medicaid program as well.  And what I see is 17% of the
 Medicaid beneficiaries have two or more chronic
 conditions, and they represent over 50% of
 Medicare/Medicaid spending in any given year.  And
 these people tend to be the highest spenders year after
  year after year.  So Medicaid is a program for people
  with multiple chronic conditions.  But it doesn't know it.
  So Tom Skulley, Medicaid directors, you got to design
  your program, got to design your preventative package
  around people with multiple chronic conditions. So how
  do we design prevention with a multiple chronic condition
  focus?  Well, we've got 125 million Americans already
  with a chronic condition.  They understand the limitations
  of having a chronic condition.  They don't want a second
  one.  We got to design programs that attracts them, the
  40% of our population.  The financial argument, and I
  deal a lot with financing is the key is to prevent the
  second, the third, the fourth chronic condition from
  happening.  Because that is a lot where the cost savings
  are going to be generated.  We have designed our
  programs around the first and that's critically important.
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 And I don't want to minimize that at all.  But if we're
 going to look for cost savings, going to make a case to
 private industry and other places, it is the second, third
 and fourth that are the most expensive, especially in the
 Medicare program.  Now, one of the areas is care
 coordination.  What we know is that the more doctors a
 person sees, the greater probability they're going to have
 of getting conflicting advice.  And people with multiple
 chronic conditions see an average of ten doctors a year.
  And they're getting different advice from each one of
  those doctors.  And what advice are they getting?  Well,
  there's a number of adverse effects that occur when you
  do not have good care coordination among the doctors
  and home health agencies and others.  You get
  unnecessary hospitalization.  When you have five or more
  chronic conditions, you have a 25% chance of having
  unnecessary hospitalization.  You also have a much higher
  probability of having drug interactions.  You have a much
  higher probability of being sent for duplicate tests.  But
  what does it mean for prevention?  Well, when we've
  looked at preventative guidelines, what we see is once
  you see more than four doctors, you're working with
  prevention guidelines starts going down.  People get
  conflicting advice.  And so what do we need?  Well, one
  of the things we might want to consider is to -- to identify
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 and to pay one clinician to try to coordinate all the
 preventative care services that people receive.  Get one
 person in charge.  It does not have to be a doctor.  But
 get one person in charge.  So that not everybody is telling
 you different things to do.  The area that we're talking
 about in insurance right now key word is disease
 management.  And one of the key and beneficial thing of
 disease management right now is that they promote good
 preventative care.  The problem as I see it most of the
  disease management programs are focused on a single
  disease.  And so if you focused on one disease and the
  person has four different chronic conditions, who do they
  listen to and so what we need is case management or
  care management, not disease management in a lot of
  these programs that we're working with these days.  So
  the person with two, three, four chronic conditions get
  one set of advice, not multiple advices.  And so my final
  message is prevention may be most important for people
  who already have one chronic condition.  And what do
  we -- what's the challenge for the near future is what do
  we do for the 125 million Americans who already have a
  chronic condition.  Thank you. (Applause)
  >>ELIZABETH DUKE
  Thank you very much, Dr. Anderson.  I will be sure to
  take your message to Tom Skulley about the nature of his
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 program. (Laughter) I would bring to your attention
 actually in Tom's behalf that he and the Secretary and
 entire Department of Health and Human Services have
 been working very hard in recent months around
 strengthening Medicaid and reforming Medicare and in
 both of those packages there is a tendency to issue of
 prevention which is linked again to financing.  So -- in the
 spirit of this panel, which is addressing problems and
 solutions, we'll continue to work on those and appreciate
  your help and guidance.  Now I'd like to introduce Dr.
  Ralph Snyderman, President and C.E.O. of Duke
  University Health Systems, Chancellor of Health Affairs
  and James B. Duke Professor of Medicine.  I assure you
  there's no relation.  Dr. Snyderman, please. (Applause)
  >>RALPH SNYDERMAN
  Thank you.  I see Reggie Freeman is still here.  I'm
  impressed and he started this morning by trying to get us
  to be involved in movement.  And I'm going to try to
  follow that same thing and talk about development of a
  movement to change the basic nature of healthcare
  delivery.  This is the first public health conference I've
  ever talked at.  And I am really so impressed alignment
  what we're trying to do, at least in some schools of
  medicine fits in so well with what you know from what
  you see in the communities that if we join together we
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 could really get something special started.  If we think
 about the practice of medicine -- see how this -- the
 practice of medicine has been identified as a profession
 since earliest recorded time.  But it is important to note
 that the introduction of science into the practice of
 medicine didn't occur until the very early part of the last
 century.  The accumulation of knowledge in a number
 different areas of science, biochemistry, very particularly
 microbiology, germ theory created tremendous
  opportunities for the care of people which at that time
  was very anecdotal and very unscientific.  This did not
  occur until about 100 years ago.  But the practice of
  medicine despite this robust creativity on the part of
  science was anecdotal, unscientific and regulated.  What
  happened in the early part of the 20th Century is that the
  Carnegie Foundation identified that the practice of
  medicine was not being impacted by the potential which
  was being created for it by the scientific fields.  Now this
  created a revolution in healthcare.  It began and Johns
  Hopkins was one of the models it used in appropriate
  School Of Medicine at that time putting research into the
  practice of medicine.  One of the consequences,
  however, was the understanding of the disease process.
  And the very heavy focus of the medical basis of treating
  disease by understanding the pathophysiology of disease.
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 This created a disease oriented approach to the teaching
 and practice of medicine.  Since World War II there has
 been an investment in the part of the federal government
 and industry of almost $1 trillion in biomedical research.
 This has given us tremendous understanding of human
 biology, the pathogensis of disease.  We heard yesterday
 or two days ago that the human genome project is just
 about complete.  99.9% accurate sequencing of the
 human genome.  The argument that I want to make is that
  similar to 100 years ago there is accumulation of
  knowledge which we are not using in the practice of
  medicine.  And in the practice of medicine today, as
  many speakers have already said, we have invested $1.5
  trillion for healthcare, and I believe everybody in this
  audience and everybody in this country will agree that
  we're not getting our money's worth.  And if we really
  think about it, we could design a better system.  That's
  what I want to talk about today.  One of the most
  important impacts of the genomic revolution will be the
  development of our ability to understand an individual
  susceptibility to disease before it occurs.  The focus of
  this meeting and the focus of Secretary Thompson and
  others in H.H.S. is prevention.  One can think of
  prevention generically.  But the capability that we're
  developing now is to think of prevention specifically as it
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 relates to any given individual.  And the ability to do that
 requires the ability to predict risk or to understand risk
 and to predict disease before it occurs.  And that is going
 to be a major impact of understanding the human
 genome.  But there are many other ways of understanding
 risk.  Within the next ten years most scientists working in
 the area believe that we will develop a risk profile
 analysis for the major common human diseases from
 Alzheimer's disease, all the way to schizophrenia.  Some
  people are talking about the evolution or the development
  of genomic medicine.  And that is from the time of birth if
  one understands genetic susceptibility, one could start
  thinking of an individuals risk compared to a normal
  population of developing again, for example, Alzheimer's
  disease, all the way through prostate cancer.  That is a
  very different way of thinking about the practice of
  medicine.  However, even without genomics, even
  without anymore information about genetics, look at how
  far we have come along in being able to determine risk
  for the major killer of Americans today.  And that is
  cardiovascular disease.  When I was an intern a number
  of years ago, we had a visiting professor at Duke leading
  expert at cardiovascular disease.  When we asked him
  how does one predict risk for cardiovascular disease,
  state-of-the-art in the late '60s was hair baldness
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 patterns, body type, thickness of the wrist, various other
 almost nonsensical factors such as that.  But now look
 where we are, generation and a half or so.  Family
 history, lipids, stress test, imaging and angiography and
 this is the beginning, all the interest in C.R.P. and
 tremendous ability to prevent.  Diet, exercise, aspirin, if
 necessary statins, beta blockers.  We are capable of
 practicing a type of medicine that is prospective.  This is
 new.  For the first time in our history we're capable of
  doing this seriously from the individual on out.  Medicine
  can be pro-active.  We can predict, we can prevent and
  fiction if we have to.  We have on the threshold of being
  able to develop healthcare planning, a healthcare system
  that is interactive with the patient and integrated similar to
  what we heard from the previous speaker so that there is
  a point of care.  So that the system is integrated.  But
  that's not what we're doing.  Sometimes I may ask what
  is wrong with the healthcare system today?  I say there's
  only two things wrong with the healthcare system today.
  How it is delivered, and how it is paid for.  So if we
  could figure out together how we solve those two issues,
  we could turn the delivery of healthcare on its head.  And
  I believe we actually have a lot of understanding as to
  how we could begin together to do this.  How it is
  delivered and how it is paid for.  Now, the practice of
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 medicine today, speaking from the physician, I can tell
 you it is reactive, we are still in most medical schools
 having our students think that for every disease there's a
 basic molecular defect or physical defect and the job of
 the doctor is to find it and fix it.  The intervention is
 sporadic, still heavily directed by the physician.  Our
 system is highly fractionated and is incredibly expensive,
 very wasteful.  Patients face dilemma, array of choices
 whether they do or do not have insurance.  As to whether
  they see primary care, urgent care, complimentary,
  specialists, internet, etc., etc.  The current medical
  record, any physician in the audience knows that this is
  what a physician does when you come to see him or her.
  The first question that they are asking themselves when
  you walk into the room is what is your chief complaint,
  why are you there?  What is your chief complaint, what
  are you going to be bothering me with today?  That is the
  initial approach from physician to patient.  Illness to
  differential diagnosis and plan.  Now that is a very good
  way to analyze a root cause analysis of failure.  That is
  what you do when a failure occurs.  And that is the way
  we practice medicine.  Now I would bet that everybody
  in this audience is beginning to think of a plan for their
  retirement.  A plan for their estate.  Planning for virtually
  every aspect of their lives.  But how many people in this
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 audience have a five year plan for their health based on
 what they are most likely to be susceptible to.  I would
 say probably none because most physicians don't
 practice this way. But getting to the point of my talk
 today, the practice of medicine, healthcare system has to
 be directed to the futuristic approach.  I believe that
 every American ought to be able to have, and we ought
 to be able to deliver this within years, individualized health
 risk assessment and health plan.  This is not beyond the
  reach of what we can do today.  A future health medical
  evaluation should have a health profile, current health
  status but a health risk analysis based on genetic
  background, what we know, environment risks, life-style,
  and then a one and five year plan.  Now where are we
  today?  Well, we have tools and we're getting
  increasingly better tools for risk assessment.  We are
  increasingly capable of developing early detection for
  coronary artery disease, diabetes, even certain forms of
  cancer.  And we are increasingly developing means for
  better prevention and early intervention when a disease
  occurs.  What we don't have yet is a delivery system that
  creates an individual health plan.  We don't have effective
  delivery systems so an individual with a plan knows how
  to fulfill that plan.  And we certainly don't have effective
  reimbursement systems.  Tom Skulley who was a very
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 close personal friend of mine, he and I talk a lot about it.
 And to some degree he is handcuffed, but he is fortunate
 -- we're fortunate to be within a leadership system that
 recognizes the problem and knows that we need to move
 from a reimbursement system, then in sense rewards
 intensive care, acute intervention chronic disease to a
 reimbursement system that rewards good outcomes and
 prevention.  And that is something that needs to be
 worked on.  Now you have already heard we have 125
  million people with chronic disease, many with multiple
  chronic diseases.  Every chronic disease, pick one in your
  own mind and think about it.  Whether it is coronary
  artery disease, whether it is diabetes leading to renal
  failure, develops overtime.  Coronary artery disease we
  know from many studies while heart attacks may occur in
  the 30s, 40s, 50s, 60s, coronary artery disease starts
  developing 20 years before.  Our healthcare system
  today is currently focused far on the right-hand side of
  that curve.  Where symptoms have already appeared,
  reversibility is low and cost is very high.  We are currently
  capable of intervening at the very earliest onset.  We are
  capable of doing that now.  We're not doing it.  And with
  genomics in the future, we're going to push the curve to
  the left.  Now what do we need to do this?  This is the
  bottom line.  Punch line and fits very, very well with what
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 I heard here already.  I believe we need to start with the
 individual.  We can start with the community and work in,
 but we also need to work with the individual and work
 out.  With good risk assessment tools which are being
 developed, we need to provide a risk assessment
 personalized health plan and then assign people --
 according to their risk those with low risk need to be --
 need to have available to them the best way of becoming
 educated about their own health and learning and getting
  motivated towards wellness.  The real focus, I believe,
  needs to be on those individuals that are very high risk for
  developing a major chronic disease or those individuals
  with early chronic disease in which intervention can
  prevent worsening of symptoms, signs and cost.  The
  elements for prospective care are primarily risk
  assessment tools.  I've already talked about many of
  these things.  Prospective medical record.  We need
  insurance and reimbursement and delivery system that's
  capable of doing this.  Prospective healthcare works
  primarily in forms of cancer, diabetes, and problem is
  system is not designed to do it, and the reimbursement
  system punishes it.  So in order to effect this, my mission
  and one of the reasons I am so honored to talk here as to
  try to recruit the interested parties to be 20 begin the
  development a healthcare system on prospective care
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 and I am going to close by saying that we have all the
 elements to do it right now starting from inefficiency of the
 current systems, negative factors and enabling factors and
 focusing well meaning people who have capability of
 delivering prospectus healthcare.  Thank you very
 much.(Applause)
 >>ELIZABETH DUKE
 Thank you, Dr. Snyderman focusing on pro-active
 medicine and thinking of ourself as individuals in need of
  individual health plan as well as focusing on system
  overhaul and integration of our systems.  We appreciate
  your insights.  Our third presenter on this pan and I have
  something in common, other than Dr. Snyderman share
  the name Duke a little bit.  Dr. Bob Harmon is in
  administration for Health Resources and Services.  Now
  he is the President of the American College Of
  Preventative Medicine and he's Vice President and
  National Medical Director for Optum/UnitedHealth
  Group company, which is based in McLean, Virginia.  It
  is my real pleasure to introduce Dr. Bob Harmon.  Thank
  you. (Applause)
  >>ROBERT HARMON
  Thank you, Betty.  Preventative medicine is hot topic
  these days.  It was mentioned by President Bush and the
  State Of The Union Message and mentioned by one of
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 the Generals at Centcom in Kuwait.  I'm pleased about
 all the publicity but I need your help. I have a request.  I
 need 1,000 messengers.  Please help me to eliminate the
 extra "ta" in preventative medicine. (Laughter)(Applause)
 I admit it is in the dictionary, alternative spelling but we
 don't -- it.  Let's streamline at preventative.  It is my
 specialty, as more than 7,000 physicians in the U.S.
 We're happy by the way to be the coordinating point by
 services recommended by Dr. Anderson.  My day job at
  Optum involves overseeing care of 23 million people.
  2/3 covered by UnitedHealth Group.  I'm speaking
  today, however, for the health plan sector which is
  represented by the American association of health plans.
  A.H.P. has more than 1,000 A.M.O. and P.P.O.,
  covering more than 170 million U.S. residents.  For
  several years I chaired A.H.P. public health committee
  which participated in several of the projects I'll be
  describing.  Thanks for A.H.P. for the data I'll be using.
  Now if we can go to the first slide.  Let's see.  I have that
  here.  Our target populations for preventative medicine
  health plans include health plan members, employers and
  employees such as for work site programs, clinicians such
  as through reminder programs and data sharing can.  The
  general public through community initiatives around things
  like immunization as well as leaders, educators and policy
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 makers.  At the local, state and national levels.  Our tools
 are many and varied.  We recommend national evidence
 based guidelines as well as coverage in health plans.  For
 example, nearly all H.M.O.'s and many P.P.O.'s cover
 U.S. preventative services -- clinical preventative services
 guidelines as well as C.D.C. immunization schedule.  I'll
 be talking about demand and disease management
 programs which are more and more prevalent.  Health
 promotion program are popular, including health risk
  appraisal and work site interventions.  Quality
  improvement measures programs such as mammography
  reminders and measurement programs.  Financial and
  other incentives such as reducing or eliminate copays for
  services as well as point systems and team approaches to
  prevention.  Cost effectiveness and R.O.I. studies such as
  one recently published by the partnership for prevention
  listing the priorities for clinical preventative services with
  immunization and smoking cessation at the top.  It gets
  the attention of chief financial officers.  E-mail and instant
  messaging and interactive voice response, automated
  telephone to get messages out and remind people about
  preventative services.  I wanted to mention demand
  management.  You can see the definition here.  Self
  management, decision support to help people to improve
  health and make appropriate use of medical care.  And
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 company I'm involved with uses multiple platforms and
 access points and channels such as telephone call centers.
 We have over 2 million calls a year through six call
 centers with telephone triage and health information and
 majority of health plan members now have this kind of
 service available.  In person through employee assistance
 counseling and work site programs, print, prevention
 news letters, self care books, audio tapes available by
 telephone.  As well as the internet which is the fastest
  growing area of self care and prevention messages that
  we deal with.  Now what are some of the guidelines in
  over reaching everything is healthy 2010.  Pay a lot of
  attention to that.  Mentioned services through A.R.C.
  Guide community services is also very important.  Taking
  program out into the community for diabetes,
  immunization, so forth.  A.H.P. has endorsed this as the
  best approach.  And the A.R.C. guidelines and smoking
  cessation and many others through its clearinghouse and
  very important the C.D.C. immunization schedule, A.H.P.
  has endorsed this, recommends it to member plans and
  most cover all of the C.D.C. immunization services for
  children, adolescence and adults as well.  I'm pleased to
  say there are a number of ongoing programs at A.H.P.
  Around immunization we have several grants and put on
  an award program with some impressive gains reported
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 by health plans.  There are news letters and there's a
 special effort to cooperate with immunization registries at
 the state and sometimes local level.  Around tobacco
 control thanks to R.B.J. (phonetic) have grants to pass
 along to do research about best practices in tobacco
 control and smoking and tobacco cessation.  There's an
 annual conference.  There are awards that again highlight
 impressive gains being made in that area.  Around
 maternal and child health, I'm pleased to say thanks to
  HRSA we have a grant and pursuing the promotion of
  bright futures guidelines and other best practices in
  M.C.H.  Through the C.D.C. the association has over a
  dozen ongoing research projects such as into vaccine,
  adverse events and other important areas.  Around
  disease management there are two major initiatives
  around diabetes and asthma which are at the state level,
  and involve broad partnerships.  I have mentioned the
  preventative services guidelines.  And around public
  health preparedness I'm pleased to say the association
  and Optum Harvard Pilgrim, Kaiser Colorado have
  bioterrorism syndromic surveillance grant from C.D.C.
  and begin reporting on these kinds of encounters at clinic
  and telephone call center by the end of the month.  My
  time is short so I just want to get into statistics and wrap
  this up.  I'll be using some data from the A.H.P. member
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 survey as well as N.C.Q.A, HEDIS, annual metrics.  The
 kind of things that are growing in the health plan sectors
 are things like access to discount memberships and health
 clubs which wasn't even measured in '97 but 2000 up to
 64%.  Stress reductions program up to 76 by the year
 2000.  We'll have newer data on this in few months by
 the way.  Exercise counseling up into the 86% range.
 Alcohol and substance abuse, prevention and treatment
 up to 70%.  And then reminder programs I mentioned,
  by the year 2000 prenatal care was at 23%.  I'm sure it
  will have grown a lot by '02.  Well child exam 62%.
  Adolescent vaccinations 60% and childhood reminders
  for vaccine 93%.  Other reminder programs flu vaccine,
  mostly for seniors, up to 92% of health plans had these
  kind of reminder programs.  Cervical cancer screening
  68.  Colorectal only at 17%, but I think it is rapidly
  growing.  Eye exams for diabetics, HEDIS measure well
  over 90% and mammograms for 50 and older over 98%.
  Now the disease management programs in 2000 survey
  that were two or more current programs reported by
  over 92% of commercial plans and 81% of Medicaid
  only plans, so a high prevalence.  And the most prevalent
  program were diabetes, asthma, C.H.F., coronary heart
  disease and high risk pregnancy.  So let's look at some of
  the results from '96 through 2002 and we're seeing good
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 progress on things like D.P.T. immunization up to 81%.
 Compliance. Varicella, chickenpox vaccine up now.
 Higher for M.M.R. for ages over ten at 89%.  Hepatitis b
 had grown rapidly to over 80% in the health plans
 responding.  Breast cancer screening up to 75% and
 footnote on breast cancer screening because that data is
 for '02, but for 2001 in Medicare plus choice H.M.O.'s
 for Medicare patients, mammography rate 75%, while
 comparative figure for Medicare fee for service only
  60%.  Showing being involved in organized system of
  care can give better rate of preventative services.  We
  have a lot more work to do on other areas.  Cervical
  cancer screenings doing well at 80% but chlamydia is
  only at 25%.  And advising smokers to quit I believe
  being dropped as HEDIS measure.  So what are our
  recommendations for health plans.  We certainly
  recommend using national evidence based guidelines and
  association has endorsed the once I mentioned earlier.
  To start with those that have the best effectiveness and
  return and we thank the partnership for prevention for
  that great study ranking the priorities of the clinical
  preventative services with immunization and smoking
  cessation on top.  Next partner with other organizations
  both public and private government, non-government,
  nonprofit, to get the best effect of the program, and use
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 the community as well as the clinical approach.  Let's not
 stop at the clinic door.  Let's get out into the community
 and reach everyone repeatedly with these messages.
 Measure our results, one of the best things happen in the
 health plan sector have been the HEDIS measure which
 measure H.M.O.  Have long way to go to measure other
 sectors because P.P.O. usually not Secretary to HEDIS
 and P.P.O. -- P.P.O. is the largest and fastest type of
 health coverage these days and of course, fee for service
  not much measured, although it is gradually changing.
  Remember marketing and incentives.  Big fan of that.  Be
  patient, stick with it and share the cost and credit.  And in
  closing, remember the words of Gertah (phonetic),
  knowing is not enough we must apply, willing is not
  enough, we must do.  Thank you. (Applause)
  >>ELIZABETH DUKE
  Thank you, Dr. Harmon.  It's helpful to see where the
  health plans are going and evidence on guide lines and
  emphasis on prevention progress through partnerships
  which is very helpful to us.  I want to thank Dr. Harmon,
  Dr. Anderson and Dr. Snyderman on challenges and
  solutions.  Working together we can make a difference.
  So I thank you very much for your help.  And now it is
  my great pleasure to introduce a colleague, Dr. Carolyn
  Clancy who will moderate the next panel with her panel
.
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 members. Dr. Carolyn Clancy is the director of the
 Agency for Health Research and Quality.  As Dr.
 Harmon was just pointing out, the author of evidence
 base guidelines that help us move this health system
 forward.  I introduce Dr. Carolyn Clancy. (Applause)
 >>CAROLYN CLANCY
 Thank you and good morning.  Looking out at everyone
 here I have to say I would for one moment.  Incredible
 summit.  No other word would suffice.  I'm very happy to
  be here this morning and introduce you to two terrific
  speakers who will present on technology tools for
  prevention which builds very logically on the points that
  Bob Harmon made about making the most of information
  technology to get the messages out to variety of
  audiences.  It is very significant at this conference that
  we're recognizing the potential of technologies for
  prevention, so I wanted to take a few minutes before
  introducing you to put this in context.  I think there are
  slides coming up.  No?  Here we are.  Bob Harmon just
  pointed out of course not all of prevention by any stretch
  of the imagination happens in clinical practice.  At the
  same time clinician have very important window of
  opportunity with many individuals.  So I thought I would
  start with a case.  Woman named Dorothy.  This is a
  made up name.  The woman is real.  Very obese
.
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 32-year-old who came in for a suspected urinary tract
 infection and found to have diabetes.  Her physician, that
 would be Dr. C, gave her information about diet and
 exercise, but was a little bit sill verdict by the challenge
 facing this woman who weighed close to 300 pounds.
 10 months later Dorothy came back having lost almost
 30 pounds and showed Dr. C how she was using
 customized application of the palm pilot to track progress
 with diet and exercise and changed Dr. C's with facing
  substantial challenges.  We know patients are incredibly
  enthusiastic about prevention.  If you were test most
  physicians, they're actually very up to date in evidence
  based recommendations.  Not only that, they believe their
  routinely providing services to the patience.  However,
  gaps in delivery of recommend services persist.  Bob
  Harmon showed areas we have been making progress.
  We have known what's on the slide for 20 years.  Now if
  you think about what are the barriers, there are a lot of
  barriers in typical offices.  I'll get to remind myself of them
  again this evening.  Big one delivery and follow-up for
  preventative services.  What happens a lot on
  Wednesday evenings is the patient and I agree on what
  the next step is and we fall short in terms of making sure
  that that next step actually gets executed.  And that's
  where information technology can help.  So this is a
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 bumper sticker.  If anyone wants one, please let me
 know, the wave of the future. As Secretary Thompson
 said we have wonderful technology but some grocery
 stores have better technology than some hospitals and
 clinics.  Potential of information technology is fairly
 obvious.  Decision support systems help overcome poor
 judgment, e-mail reinforce important communications to
 patients and the public and purchasers could become
 informed consumers by tapping onto web sites by
  performance information.  Maybe know which doctors
  are doing best job in preventing.  This slide gives you
  sense some of the power of clinical decision support for
  making informed care decisions to making the right
  choice easy in taking action, to making the right decision
  about what to do to making care better or in short
  making the right thing, the easy thing to do.  We know
  that information technology can improve the quality and
  safety of healthcare and many, many studies
  demonstrating that the effectiveness of care can be
  enhanced by reminder systems that enhance the delivery
  of preventative services.  In addition, it can enhance the
  timeliness of care as well as efficiency and equity of care
  and been a focus of this summit.  However, potential is
  what you have when you haven't done it yet.  This come
  from Darrell Royal, the Texas coach. So what we now
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 know ambulatory settings where a lot of preventative
 services occur, P.D.A.'s are widely used but E.M.R.'s
 are not widely adopted.  E-prescribing not widely
 adopted.  Now what I wanted to tell you about is one
 step that we're taking in the meantime, the department,
 which I find potentially exciting.  This is not the only step
 we can possibly take, but it is a step to take right now.
 How many six you use Hippocrates?  Good.  I hope by
 time I'm done more of you may sign up.  This is software
  for the palm pilot and other P.D.A.'s and essentially have
  network of 250,000 physicians and 700,000 health
  professionals in total.  We have been making use of the
  network to send people out updated recommendations
  from the U.S. preventative services task force of Bob
  Harmon just mentioned.  The reason people sync and get
  recommendations Hippocrates association has a lot of
  information and the information changes quite frequently
  that you can update.  That's all well and good but quite
  recently we started a new project with Hippocrates so
  the Secretary can get out important information about
  bioterrorism, infections or symptom clusters where it is
  not clear at the outset where this is potential bioterrorist
  event or new type of infection.  What we're doing is
  working with software vendor to figure out how to target
  the information and get it out.  This person has a pilot if
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 anyone wants to see it or get information, please contact
 him.  In this slide just makes the point that this is the kind
 of approach where we can actually use information from
 front line clinical providers to feed information to the
 public health infrastructure and back.  Whether it is about
 bioterrorism or prevention or other important health
 issues.  And I want to just close by quoting Secretary
 Thompson a couple weeks ago who said in modern era
 every century has had major advances brought giant
  steps forward and convinced the medical revolution of
  our children's lifetimes will be the application of
  information technology to healthcare.  And I have every
  expectation personally that prevention will be one of the
  first frontiers where we begin to get this right.  So now let
  me introduce you to Dr. Vic Strecher.  Research on
  effectiveness of interactive media has been widely
  published.  He founded HealthMedia in 1998 and serves
  as Chairman of the Board and Chief Science Officer and
  also professor at University of Michigan Public Health
  and speaking on tools for health behavior change.
  (Applause)
  >>VICTOR STRECHER
  Thank you.  Thank you so much, Carolyn.  I am so
  happy we're able to in this session drill deeper into the
  specific tools of health promotion disease prevention and
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 care management.  11 years ago my daughter had a heart
 transplant.  She is -- there was phenomenal -- there are
 phenomenal technologies that were used to save her life.
 As a result she now plays soccer, she's on the softball
 team that I coach, she's one of the smartest kids in her
 unbelievably expensive private school, and you know, I'm
 so happy that she's around.  And it is because clinicians
 have enormously powerful tools to treat disease.  They
 have enormously powerful drugs and enormously
  powerful medical instruments.  If they didn't, doctors
  wouldn't be as enormously powerful as they are.  But,
  you know, my colleagues in the medical school are
  continuing to develop very powerful tools to treat
  disease.  When they are creating something, and it may
  be in some ugly powdery form that has to be injected
  intravenously but it works, there are 14 drug companies
  waiting in the wings for that person, and waiting to apply
  about $250 million to make that ugly powder into a
  swallowable pill and do the marketing necessary to get
  people -- to encourage clinicians to use the medication
  properly to go through all the randomized trials, get
  F.D.A. approval, etc.  When my colleagues in the school
  of health create something cool, there are not 14
  companies usually outside the office waiting for $250
  million.  As a result our number one tool I would argue in
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 the public health field continues to be the pamphlet.  The
 pamphlet for 40 years has been chose not change
 behavior.  40 years.  Yet we have warehouses of them.
 The federal government has warehouses and warehouses
 of these.  I will certainly grant you pamphlets, videos,
 enhance information and knowledge but we also know
 and have known for 40 years, 4-0 knowledge does not
 predict behavior very well. We all know people have
 rotten health behaviors -- I'm beating.  I hate technology.
  We know people who have behaviors.  Behavior change
  is pretty complex to do.  Difficult to do.  We have
  pamphlets.  People passing pamphlets to passing people.
  Frankly I just got bored over this and didn't want to die
  and have on my headstone Vic Strecher published 200
  articles.  Allen Case said the best way to predict the
  future is to create it.  We didn't have everybody waiting
  to apply, we called HealthMedia to do this.  Now the
  business is doing quite well and has over 100 customers
  and trying to disseminate some of the work -- some of
  the more powerful tools in this field.  Other companies
  are doing the same thing.  One of the subtext of my talk
  though is I certainly help -- you know, a lot are from the
  federal government.  I hope we're getting much stronger
  federal government support for these tools so it is not just
  researched but it is disseminated in truly deep way
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 because we don't have drug companies out there, you
 know, ready to pay for all of this.  Now Dr. Snyderman
 talked about H.R.A.  Wonderful to learn about your risk,
 but we also know that is not the final step.  That is the
 first step.  First step to behavior change, learning about
 risk, wonderful but did not change behavior.  Couple
 randomized trials that have shown this.  Need other things
 to change behavior in addition to knowledge about your
 risk.  Now public health tools are interesting.  It is not like
  the Betty Ford clinic where you may have six people
  there, three people changing and go, great, we had 50%
  quit rate.  If you're in a hospital have 500 cigarette
  smokers.  If six people go to your clinical smoking
  cessation program and three quit, you don't have 50%
  quit rate.  Three out of 500 who quit smoking.  That's an
  important difference between medical model and public
  health model.  We must have high reach, we must have
  palatable programs if we're to, you know, create
  powerful public health behavior change tools.  Also have
  to be effective.  In other words, pamphlets don't do it.
  They're high reach but in effective.  Betty Ford clinic
  effective but doesn't get anybody there.  That's a big
  issue.  Conundrum, Rubik's cube we have to solve.  One
  high reach, second effective, third better be low cost.  I
  learned this from 25 years of experience.  I would rather
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 not say that but if not low cost, throw it out the window.
 Completely irrelevant in public health domain.  Has to be
 low cost, effective and high reach.  I spent the last 15
 years or so looking at idea of tailoring, interacting with a
 person or way interacting with people using computer
 technology.  It is cold, ugly, gland, not human, can't touch
 you and hold your hand.  Absolutely true.  All of those
 are true.  On the other hand people are far more likely to
 admit they're smokers, alcoholics, that they're engaging in
  anal intercourse if they're H.I.V. positive.  In fact, seven
  to 12 times more likely to say those things to computer
  than to trained counselor.  At Duke University Medical
  Center, I don't know if Snyderman is here anymore but
  switched out the candy salesperson in the front in the
  lobby at Duke with a candy machine.  Candy sales
  doubled. People are more likely to admit they have the
  little candy issue with the machine than they are to the
  human being.  In other words, computers may elicit more
  valid information and talk to them.  Also available 24/7
  which is a lot different than having to go to some care
  management or disease management group program that
  you have to drive to.  So there are tremendous
  advantages to the web right now.  72% of individuals in
  the United States have access to the Worldwide Web.
  Now I'm going to talk about two programs and two
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 methodologies for looking at the web.  So far what we
 have done is very clever.  20 years creating pamphlets
 and then internet came about and said oh, my gosh, the
 internet, this is great.  We can reach a lot of people with
 this.  What did we do, shoveled all our pamphlets onto
 the internet.  Doctorcoop.com was the world's largest
 pamphlet rack.  It was worth billion dollars.  Sold last
 year for $180,000 in fire sale.  Sold the pamphlet rack
 because no one cared about the pamphlet rack and it
  didn't work.  Plus all these ads for the pamphlets.  In
  other words, just shoveling pamphlets on line does the
  same thing than giving pamphlet does, enhances
  knowledge which is good, but in general it does not
  change behavior and known that for a long time.  Two
  other ways of doing this that are quite popular now.  Let's
  see if I can get this to move tailored online experiences
  that I can see be increasingly now.  One is user navigated
  and second called expert system. And so let's start with a
  user navigated system.  User navigated system means that
  a person goes to a site with a question and they go oh,
  boy I want to learn -- let's say this person wants to lose
  weight, manage their weight.  So they say oh, you know
  -- this weight management site has information on their
  health status, be able to say here is your B.M.I. and result
  of your B.M.I. are health risks.  Great.  Let's learn more
.
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 about your nutrition.  The person wants to learn more
 about nutrition -- get this forward.  Physical activity, etc.
 and on the basis of that, educational experience is created
 for that individual.  That's tailored but tailored by that
 individual.  We have found in our research in the past in
 HealthMedia research lab at University of Michigan that
 people tend to often go to the wrong places.  When --
 we offered kiosk systems and kiosk we had a smoking
 channel.  On the channel we put scare me channel that
  literally had the grim reaper on it, barriers to quitting
  smoking but if you want to be scared press this.  Three
  times as many people pressed the scare me channel than
  any other.  Not what the expert would have pressed but
  people pressing what we experts thought were the wrong
  thing.  Maybe that's fine.  Maybe we ought to be doing
  that.  That's worthy of test -- by the way, this is an
  example of user navigated system.  I'm not expecting you
  to read all this but certainly -- somebody signing.  That's
  so cool.  Are you keeping up?  I talk so fast.  You must
  be getting hand cramps.  Sorry. (Laughter) Okay.  In this
  program which is for KP online.  Kaiser Permanente.  8
  million members.  KP Online reaches millions of people.
  People who go to manage their weight can pick and
  choose what they want.  So they can literally go to
  different sections and identify what their needs are.  So I
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 want tools for change, etc. so pick out whatever they
 want.  This could be a very nice system and something
 we wanted to test against expert system.  Expert system
 is similar to what expert does. First asks questions so
 collect information from a person.  User data, v1, v2,
 variables.  Collect things from people, like why do you
 want to change.  Tell me about your motives for
 changing.  Intrinsic, versus extrinsic motives.  Do you
 want to do it for you, your kids, your doctor, what kind
  of health issues do you have, do you exercise I why do
  you, don't you, etc.  Collect the information.  On basis of
  that, human counselor, nutritionist, dietician, I can pick
  out from my brain, from my experience, research
  knowledge just what you need and generate a computer
  tailored, generate a program.  Tailored in between my
  ears.  So I use my knowledge and experience to build a
  program.  That's tailoring.  Humans are the best tailors.
  Try to put that into computer software and usually takes
  six months to build a piece of software that does
  something like this.  And you bring in experts and you ask
  them what do you ask patients?  How do you process the
  information in if 23 say this, what do you ask next?  What
  kind of feedback do you give, what kind of plan.  Talked
  to artist, talked to two Hollywood screen writers guild all
  the time in meaningful way.  That's what I'm going to talk
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 about.  In other words, expert system like person coming
 into your office with question and issue, ask them
 questions, get that information, you pull content, you build
 a plan for them, and you give that back.  By the way, the
 American Heart Association has programs right now that
 are tailored to the individual.  This is very rare and very
 cool that the Heart Association is doing this, because I
 don't know of other voluntaries who are doing something
 like this.  Also by the way the Center for Disease Control
  in my mind should be the Disney World of tailored
  information.  Kids should look to it to play games for
  injury prevention to get parents involved in something like
  this.  I don't know why they don't yet.  I mean I really -- I
  think this is an important area and love to see that. That's
  a subtext of mine -- my talk, I suppose.  I give you just an
  example here of what we mean by tailored organize.  This
  is just one paragraph.  Use data that's on the left-hand
  side for weight management and say something like
  certain amount of body fat is fine, but because your
  B.M.I. crept above 30 it is essential to reduce health risk,
  this is true of your family history of heart disease and --
  own history of diabetes, high blood pressure and high
  cholesterol.  Smoking and obesity combined because we
  know this person is a smoker.  Smoking and obesity
  combined increase risk of cardiovascular disease.  Tell
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 them what they're doing well.  This is a person by the
 way -- actually real paragraph that we send to individual
 who just in contemplation stage for managing their weight.
 Weren't totally ready so starting to sell them moderately
 on the idea of weight management.  One paragraph
 create half million versions of on the basis of 30 questions
 we create -- generated from the individual.  Take the
 person ten minutes to fill 24 out, half million of that one
 paragraph.  Of the whole guide on weight management,
  create one times ten to one hundredth power versions.
  To the point now online versions of this program are
  getting people writing e-mail back, thanking the author of
  the guide.  Even though the author was a computer.
  Okay.  So I'm going to talk about this one program we
  built.  Expert system called balance.  And balance you
  don't have to read this the idea balance focusing on
  cognitive issues, barriers and motives, perception of risk,
  focusing on physical activity and focusing on food, diet,
  nutrition.  Together it builds this in completely tailored
  manner.  Nobody gets same guide online and completely
  based on the information you give us.  We even warn
  you.  If you lie to us about your weight or lie to us about
  what you like or whatever, we lie back because we're
  just a stupid computer.  Okay.  So this focus on
  motivation, prior weight loss attempts, weight loss
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 methods, tried weight history, etc., set goals with you,
 follow-up, look at performance, reset goals on the basis
 of performance.  All of this we have known for 20 years
 works.  All of this is part of what is called cognitive
 behavioral therapy and something that's very readily
 programmable into computer technology.  So what we
 did was compare with Kaiser Permanente.  We're
 working with Kaiser.  Kaiser is the principal investigators
 on this study.  For obvious conflict of interest reasons, led
  by Jody Joyce (phonetic) is running this randomized trial
  of 5,000 K.P. members where KP Online if you want to
  lose weight click this button.  Once you click the button
  you're randomly assigned into expert system called
  balance, tailored programming or existing programming
  user navigated system.  For purposes here call it
  untailored, following at three months, six months and 12
  months to see if they lose weight and what they think
  about the program.  We have three month data with first
  five -- first 900 individuals.  Here is what we're -- by the
  way, to reiterate this is the user navigated program.  And
  then that's compared against the expert program.  Expert
  program called tailored here compared to user navigated
  program found three months later, 90 days later people
  more likely to have read informations are referred back
  to it, found it easier to understand, personally relevant,
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 they would recommend it to others and found material
 helpful. All of those are very statistically significant
 differences, very big.  In addition we ask people to rate
 the plan.  The dark blue bar is the user navigated
 untailored program, the light blue is the expert system.
 Term of satisfaction with this plan, people were much
 more likely to have rated -- to have highly rated the
 tailored weight management program 90 days later.
 Look at actual weight.  Divided this by B.M.I.  Three
  we're interested in 25 to 29, 30 to 34 and 35 and higher.
  25 -- 29 by the way in study done by Quisenberry
  (phonetic) at K.P. with members found no difference in
  cost in that population.  That's -- you know, overweight
  population.  No difference in cost over normal weight
  population.  The place that where cost started rising was
  in group started at B.M.I. of 30.  30 to 34 B.M.I. cost
  25% more than normal weight.  35 plus cost 45% more.
  Here we find significant improvement as a result of the
  tailored program.  In lower weight group didn't find any
  difference and didn't find much weight loss in general.  In
  the higher B.M.I. groups we did.  In fact, seems that in
  the sweet spot -- these data seem to be holding up.
  Sweet spot here is in this mild to moderately obese group
  of 30 to 34.9 B.M.I. Now one other question we ask
  people was whether they thought will power was an issue
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 in this.  Asking do you think will power holding you back
 keeping you from losing weight.  75% said yes.  Will
 power is just very common.  That's cognitive behavioral
 therapists crazy is because will power something you
 can't change, immutable and can't contribute to.
 Cognitive behavioral therapy spending a lot of time trying
 to recast the will power, matter of skill or skill power than
 will power.  So our tailored program really focused on
 will power as issue.  Here is what we find of 75% who
  said will power was issue.  All sudden we see much
  bigger differential.  We find the tailored program is really
  tailoring to the issue in helping people lose weight
  whereas untailored program did not do that.  One other
  thing I wanted to show you and that's motivation and self
  efficacy.  We're talking about building tool and how
  address those.  Two psychosocial concepts in every
  model, whether stages of change, health belief model --
  any of these models, self efficacy theory is motivation,
  how motivated am I to change and self efficacy which
  measure by different situations and see how did difficult
  would it be for you to -- how confident are you? You can
  manage your weight in this situation or in this situation?
  What we find by the way is if we just do a mapping of
  people, this is at K.P.  I know this looks like a mess.  On
  the x axis here, lower axis is motivation ranging from low
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 to high.  Y axis is self efficacy ranging low to hide.  Upper
 left hand quadrant is nobody.  These people say I know I
 can do it, just don't want to.  Don't get anybody in there.
 Duh.  Makes sense.  Top graphic map, which is what I
 created, vast majority lower return group.  In other
 words, I want to do this but I can't and find vast majority
 of individuals.  By the way, that's where this program
 worked the best and where we saw the greatest
 differential between the tailored and untailored programs.
  Look at it like actual mountain, actual same data but took
  airplane and flew over this mountain range would you see
  the vast majority of the mountain, in other words
  individuals fall in this I would like to change, like to lose
  weight but just can't. That's exactly the group we're hitting
  the most.  This is the nice part about tailoring through the
  internet, through computer technology.  Collecting data,
  follow people overtime, link this with cost data, link with
  other types of data, provide population feedback to
  individuals.  I would just ask that we start thinking about
  these programs more on a national level rather than at a
  smaller business level.  Thank you very much for your
  time. (Applause)
  >>CAROLYN CLANCY
  Thanks.  Which was terrific.  I want to introduce Fran
  Murphy.  I suspect many of you physicians that trained
.
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 V.A. and know from firsthand experience how terrific the
 health information system is and read about it in
 newspaper and all true.  She is Deputy for Health Policy
 Coordination for the Veterans Hhealth Administration in
 Department Of Veterans Affairs.  Serves as leader for
 Health Policy and Interagency Program Developments
 and serves as principal liaison for issues related to public
 health and patient safety and coordination of federal
 healthcare benefits.  It is pleasure to have the opportunity
  to work with her this past year.  Dr. Murphy. (Applause)
  >>FRANCES MURPHY
  Good morning, everyone.  It is really an honor to be here
  with you this morning.  I have a confession to make.
  Although I do a lot of I.T. and e-help, I'm a
  technophobe, so for all of you in the audience who think
  you can't do this, let me tell you that you can.  I'm the
  most enthusiastic supporter of the programs and these
  tools and I come to them with a lot of difficulty.  So with
  that let me just reiterate some of the problems of
  American healthcare.  The I.O.M. has pointed out we're
  really not good in prevention, secondary prevention or
  quality of care.  We don't do well in preventing the
  complications of diabetes, we provide inadequate
  secondary prevention for acute M.I. and less than half of
  the adults who should be screened for colorectal cancer
.
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 are screened for that condition.  So we have a lot of
 improvement that can happen.  And let me tell you about
 some of the programs in the V.A. that could be
 disseminated across the country that may help get us
 closer to where we should be in prevention.  We use
 electric health records and clinical reminders in the V.A.
 to improve prevention programs.  We also have a new
 pilot program that we call community coordinative care
 services that was developed in our Florida regional
  healthcare system and just about to implement throughout
  the nation and V.A.  So that will be the consent of my
  talk.  Those of you who haven't interfaced with us in the
  past, I just wanted to give you a sense of the scope of the
  challenges that we face.  We're largest integrated
  healthcare system in the country with full continuum of
  care and about 1300 sites of care across the country,
  183,000 healthcare employees in our system.  And we
  treat almost 4.5 million veterans every year.  Our patient
  population is older than the U.S. population.  About 45%
  of our patients are over the age of 65.  In the next decade
  the number of veterans over age 85 in healthcare system
  will increase by 200%.  Their incomes in general are less
  than $25,000 a year and about 1/3 of them have no other
  source of health insurance or healthcare.  A lot of
  challenges in that population.  Let's start by taking a look
.
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 at what we can do with the use of electronic health and
 reminders.  V.A. has comprehensive electronic system
 which was described by Institute Of Medicine and
 leadership by example report last year as one of the best
 in the nation, including the imbedded clinical reminders
 awe and performance measures.  This electronic health
 record is available at all sites of care, that includes
 smallest clinics and largest hospitals and nursing homes.
 It includes all of the things that you would expect to see in
  your paper record system, plus embedded images and
  diagnostic tests. These are just some of the components
  of the record system.  For those things that require a
  patient's suggest that can't be entered electronically like
  advance directives, we scan them and available on the
  P.C. in every doctor -- P.C. in every doctor's clinic,
  provider's clinic.  This is a screen shot of electronic health
  record.  This is the gooey interface.  It is a point and click
  system.  And you can see at the right middlesex of your
  slide that there are a whole series of clinical reminders.
  Some of them say do now.  And it is very simple during
  either a primary care visit or specialty care visit for the
  provider to identify which of the preventative measures
  have not been taken care of whether it is screening or
  immunizations and provide that during the visit.  In
  addition, if you're tracking some health problems, like
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 hypertension, you also have ability to graphicly look at
 that information.  The graph at the bottom of the screen
 has hematocrit but you can do the same thing with blood
 pressure or other measures that you're monitoring like
 white.  You can see on the left-hand side of the screen
 there are some imbedded colonoscopy images and chest
 x-rays which you can make full screen by clicking on
 them.  You can also view moving images like cardiac
 angiography on the desktop.  In the clinic and use that as
  patient education tool.  So what kind of results have we
  got went that?  Well, I can tell you there V.A. was not
  concentrating on preventative medicine and preventative
  health programs back in the early '90s.  But by providing
  a performance contract for all of our leadership that
  drove performance and by providing these tools as
  support to clinicians on the front line, we have made
  incredible progress.  You can see the V.A. 2002 results
  compared to the next best reported results.  And whether
  it is in cholesterol screening or diabetes care, or in cancer
  screening, we are in 16 of the 18 measures that we track
  the benchmark in the country.  And it is all because we
  hold people accountable and we give them the tools to
  perform.  This information can get fed back on a national
  level as I have done here with our national averages on
  regional healthcare level at the hospital level and to the
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 individual provider.  We're all very competitive people
 and nobody wants to be at the bottom of the list in their
 hospital, and they all want to do the best for the patients
 and these tools allow them to do that.  So what -- how
 do we get this performance?  We make it easy for
 people.  I showed you the clinical reminder system.  If
 something says do now, you can double click on that so
 the prompt reminds you to get it done, and then by
 double clicking it enters the order and puts the
  documentation in the record.  In two seconds you have
  got what used to take ten to 15 minutes to organize.
  When the order gets entered for any immunization, it gets
  electronically sent to the pharmacy and then it can be --
  the immunization can be delivered on the same visit.  It is
  incredibly efficient.  It works well.  And the clinicians and
  the patients love it.  We have seen dramatic
  improvements in our performance over the period of time
  that we have focused on this. In various areas of
  prevention our performance has improved between 130
  to 500% for the measures that we have been tracking.
  Our work isn't done.  We need to focus on new areas.
  We need to expand what we're doing and this isn't just a
  paper exercise or something that I can come before you
  and brag about because I'm very proud of what we have
  done.  But it makes a difference in the lives of patients.  If
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 you use the most conservative estimates in the literature,
 we have saved with vaccination program alone, our
 immunization program about 4,000 veterans lives, and
 that's a significant accomplishment.  Critical success
 factors.  Record system was developed by clinicians.  It
 is clinically relevant.  It is efficient, provides support and
 improves prevention and care.  It is flexible.  Each
 individual can customize the way the screen looks for
 them.  You can provide customized templates for
  recording in progress notes and it is integrated and fully
  functional and reliable. Very seldom goes down.  The last
  panel was an excellent introduction to the next area that
  I'd like to concentrate on that's our telemedicine
  telehealth program.  We moved out into veterans
  communities by increasing out-base clinics but address
  the needs of frail elderly population with multiple chronic
  conditions, we need to get further out.  We need to get
  into their homes.  We need to have continuous care,
  rather than episodic care, and we have done that in part
  through a pilot program that's called Community Care
  Coordination service.  It is a program that has continued
  the shift out into the community.  Disease management
  program so that individuals identified with diabetes,
  hypertension, depression, chronic -- chronic congestive
  heart failure, coronary artery disease and other chronic
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 conditions.  It is a system where coordination is the key.
 Technology is a tool that allows us to manage these
 patients on a continuous basis and we use multiple
 different types of innovative technology.  Used depending
 on the patient's needs and goals to improve care and
 healthcare utilization for the patients.  Six sites in Florida
 participated in the program and they range from large
 urban tertiary medical centers as site to small row of
 hospitals.  So it works in multiple different types of
  settings.  The population is a population of frail elderly
  with multiple chronic conditions.  It is a multiple
  --multidisciplinary team approach that is often either led
  by a nurse practitioner or in some cases a physician.
  After patients are identified as being eligible and needing
  this program, initial home assessment is done.  We take
  the equipment out.  It is installed, patient is trained to use
  it.  Takes very little time to actually train the patients
  because the technology is very simple.  And care
  coordination team interacts with the patient on a daily
  basis.  The patient is questioned daily and responds using
  this technology.  The technology is actually extremely
  simple to use.  And it does not require internet access or
  internet service.  It goes through routine good old
  telephone lines through eight hundred number and
  integrated.  Enrollment, the monitoring, the scheduling,
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 and the education tools are integrated.  Care team and
 patients again communicate quickly on a daily basis and
 flexible in customizable to address the individual veteran
 or patient's needs.  The patients answer questions on
 daily basis, provided in multiple languages.  Use Spanish
 and English.  They are -- the patients are asked to
 monitor their disease symptoms.  Their medication
 compliance, compliance with other monitors that have
 been set up.  And they're asked to increase their
  knowledge and participate in education activities.  The
  patients do have access to patient education materials
  through this system.  And their responses to the providers
  are categorized according to risk based on a system that
  has been set up.  This is what the -- one of the devices
  looks like.  Has four buttons on the bottom.  Question is
  asked, just need to press the button to give an answer.
  Also may have another device that has a keyboard if they
  want to type in a question.  This is a more complicated
  device.  You can see that this individual is measuring their
  blood pressure.  There's a screen they can communicate
  with the provider.  And it is a truly interactive process.
  The results, patients are extremely satisfied, they like the
  equipment, they find it simple to use, they like being able
  to have access to advice on a -- continuous basis.
  Quality of life as measured by S.F. 36v customized to
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 show either stable or immoving quality of life depending
 on the center.  Lake Center is small rural hospital and
 Miami is large tertiary care center.  Provider satisfaction
 is high.  Described the program is excellent and improving
 their ability to manage their patients can chronic
 conditions, and if I look at the outcomes, there's
 reduction in hospital admissions, bad days of care.  In
 prescription utilization and there are -- there are actually
 very, very good outcomes in just about any utilization
  measure that is included in this program.  There are
  differences interestingly in how patients respond to the
  technology.  You see that in Lake City the participation
  on a daily basis is over 1/3, 2/3 of the days they use the
  technology.  Not so good if urban population.  I'm not
  sure why that is.  But as we learn more about this, we're
  looking at individual characteristics and now we can
  improve patient participation.  So what are the lessons
  learned?  This program does provide great continuous
  care coordination for patients with multiple chronic
  conditions.  Patients like the system.  It does reduce
  healthcare utilization and improve the quality of life for
  these patients.  The providers like it and believe that it
  does help.  We're about to roll this out nationwide.  We
  have started four more regional pilots this year and we'll
  go nationwide in the next fiscal year.  And it really has
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 changed our ability to give continuous care to patients
 with chronic conditions.  So in conclusion, I just would
 like to say that technology really can improve not only the
 hospital care that we give but in fact can improve the
 home care and full continuum of care.  It can allow us to
 provide better preventative services to patients, provide
 better working environment for our healthcare providers
 and improve their productivity and quality of care.  We
 can no longer practice 20th Century medicine.  We need
  to come into the twenty-first century.  Healthcare needs
  to adopt technology that will help us address our patients'
  needs and help save lives.  We must become more
  patient centers and the healthcare system needs to be
  more accessible and accountable.  All of this can be
  accomplished in part by using technology as a tool.  It is
  not the sole answer.  The hearts and hands of providers
  are still important but we need to give them technology in
  order to let them accomplish the jobs they need to do.
  Thank you very much.  I know which was a quick
  summary. (Applause)
  >>CAROLYN CLANCY
  We are now going into a break and you'll have to figure
  out the math here.  I have about 10:53 and the concurrent
  session start at 11:00 and add steps to your pedometer
  (phonetic).  If you're feeling as exited as I am about the
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 past two presentations I wish the leaders of the sessions
 good luck, and please join me again in thanking our two
 presenters. (Applause)
.
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