Karen B. DeSalvo

Dietary Guidelines for Americans

This Viewpoint summarizes the updated recommendations of the US Department of Health and Human Services’ recently released 2015-2020 Dietary Guidelines for Americans.

Public Health 3.0: Time for an Upgrade

The authors reflect on public health in the U.S. and the need to upgrade it. They state the U.S. ranks 27th in the world in life expectancy despite spending almost three trillion dollars annually in health care, while life expectancy for the poor is declining. They describe what they call Public Health 1.0 and 2.0, and mention how the Affordable Care Act improved health care access for everyone and catalyzed the move toward value-based payments. They reflect on components for Public Health 3.0

Using Medicare Data to Identify Individuals Who Are Electricity Dependent to Improve Disaster Preparedness and Response

During a disaster or prolonged power outage, individuals who use electricity-dependent medical equipment are often unable to operate it and seek care in acute care settings or local shelters. Public health officials often report that they do not have proactive and systematic ways to rapidly identify and assist these individuals. In June 2013, we piloted a first-in-the-nation emergency preparedness drill in which we used Medicare claims data to identify individuals with electricity-dependent durable medical equipment during a disaster and securely disclosed it to a local health department. We found that Medicare claims data were 93% accurate in identifying individuals using a home oxygen concentrator or ventilator. The drill findings suggest that claims data can be useful in improving preparedness and response for electricity-dependent populations.

Broadening the View of Interoperability to include Person-Centeredness

O ver the past decade, through both deliberate policy and programmatic action, the nation has made significant progress in the adoption and use of health information technology (IT). The pace of this progress accelerated dramatically beginning in 2009 with the passage and implementation of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Prior to that time, though there were certainly aspirational programs and communities, the adoption and use of health IT sharing among and between key stakeholders, including clinicians, hospitals, consumers, and others, was only just beginning and was moving slowly. Since then, we have seen significant increases in the adoption and use of certified technology among eligible professionals and hospitals. Three-quarters of eligible professionals and nine in ten eligible hospitals have received incentive payments from the Medicare and Medicaid EHR incentive programs. This progress is the result of public-private partnerships supported through a set of grant programs such as the Regional Extension Centers and the Electronic Health Care Record Incentive Programs. HITECH has also supported advancement in the exchange of health information. More than six in ten hospitals have exchanged patient health information electronically with providers outside their organization, a 51 % increase since 2008. Seven in ten health care providers use an EHR to e-prescribe on the Surescripts network, and more than half of new and renewed prescriptions are sent electronically. The progress to date has laid a strong foundation, but there is much work that remains in order to achieve our shared vision of a world where patients and their care providers can access appropriate health information in an electronic format, when and how they need it, to save lives, make care convenient and well-coordinated, and allow for improvements in overall health. To build on this strong foundation, we are working with all stakeholders to develop a shared Interoperability Roadmap that charts a path to achieve progress in three, six, and ten years. We have structured our work along five critical building blocks for a nationwide interoperable health IT infrastructure:

An Environmental Scan of Recent Initiatives Incorporating Social Determinants in Public Health.

The foundational importance of social, environmental, and economic factors as determinants of health has long been recognized (1–5). Until recently, this recognition had resulted in few sustained, organized efforts to positively influence these determinants to foster health at the community level. In recent years, however, numerous efforts have arisen across the United States that explicitly seek to improve the public’s health by catalyzing collaboration across multiple societal sectors, with the goal of leveraging policy, systems, and environmental changes to drive sustained improvements in the public’s health. Many are using concepts such as “Health in All Policies” (6,7) and collective impact (8) to structure their efforts. These initiatives vary in scope and scale, and they address the challenge of multisector approaches to the social determinants in a variety of ways, often innovating as they evolve.

New Orleans Rises Anew: Community Health After Katrina

Ten years ago, I published a Perspective in Annals (1) describing our efforts in New Orleans in the aftermath of Hurricane Katrina. The mood during that complicated crisis was both urgent and hopeful as we faced the staggering challenge ahead of our city: to completely rebuild andif we had the couragereinvent our citys health care system while simultaneously providing services to people most in need. It was a difficult momentone where all of the things we take for granted as physicians, including our patients and basic health infrastructure, had been stripped away. A decade later, that memory of intense disruption, need, and opportunity is difficult to forget. I remember vividly standing on the streets, in the heat, alongside scores of volunteers, U.S. Public Health Service Commissioned Corps Officers, and federal supporters caring for some of our most vulnerable neighbors. We were addressing an urgent need; yet as we did that work, we knew we had a new patient to treatthe city itself. Since then, our new patient, the city, has not only survived, but thrived. The success came from being resourceful and working from the grassroots up and the grasstops downa real roll-up-our-sleeves effort that meant hosting clinics at folding tables, holding planning meetings in parking lots, and having policy meetings in gutted buildings. It meant we all had to leave behind our conventions of hierarchy. No titles, just professionals and volunteers working side by side. We built the system and the policy framework in a rapid-cycle, iterative fashionalways putting community at the center. We knew at that moment, we had a choice: We could go back to the way things were (a fundamentally flawed system full of hard-working people), or we could go in a new direction. At the time of the storm, nearly 3 in 10 residents lived below the poverty line and our state was dead last in overall health. We chose to redesign the system into one that would achieve better outcomesa system that the people of our community deserved. Because while Katrina was a tragedy, one where too many of our friends and neighbors lost their lives, their loved ones, and/or their property, it was also an opportunity. Looking back, I am not as impressed by our ability to work hard as I am by our determination to work smart. We chose to try something different, with 4 ambitious goals: to build a new health care system grounded in prevention and primary care; to ensure our entire public health system was enabled with a health information technology infrastructure, ready to take on day-to-day obstacles but prepared to face another natural disaster; to create a safe environment that fostered improvements in quality of care, both locally and at the state level; and to change the way residents paid for and financed their care by moving from fee-for-service toward the kind of team-based care that grows in the wild when you just allow talented medical professionals to do their jobs. Our progress is as remarkable as it is improbable. Over the past 10 years, New Orleans has systematically and thoughtfully reengineered its health system to meet the bold vision laid out in the wake of the storm. And while the work is far from complete, we have an encouraging story to tell about how vision, tenacity, and civic engagement can empower a community to make better, healthier choices for itself. We built new community health centers where the sites, decor, and even sometimes the staff were chosen by the community members themselves. Today, these health centers provide high-quality primary care and mental health services to some of our most vulnerable residents. We established a forum to work toward better quality and outcomes, and we worked to ensure that the health care system was supported by a robust health information technology infrastructure. Despite our success, there is still much work to be done. Although we have expanded access to both care and coverage, too many people in the New Orleans region face financial obstacles to getting the care they need. A patchwork of federal grants and support from the nonprofit and private sectors has helped cover those gaps, but there are real long-term concerns about those who are most in need and their ability to pay for the care they deserve. Along the way, we also learned a larger lesson: Although health care is necessary, it is not sufficient to create a healthy community. In New Orleans, we stopped treating patients and started treating community members. And that community-based approach has to continue if we are going to see progress. To achieve that, we need more than a strong health care infrastructure. A strong public health infrastructure, accountable to everyone who lives, learns, works, and plays in the communityan infrastructure connects the sectors of our societyis needed. Further, we must think about patients as whole people rather than a collection of symptoms or diagnoses to be addressed. In doing so, we can address the social determinants of health, knowing that excellent medical care will only take you so far if you lack basic necessities, such as a home, access to healthy and affordable food, and a place where your children can be safely cared for while you work. It is this lesson that I hold in my heart every day, and it deeply informs the work I do at the U.S. Department of Health and Human Services, encouraging every community to innovate and find better ways to build healthy neighborhoods from the ground up. It has been a decade filled with optimism, combined with an acknowledgment of the challenges facing communities throughout New Orleans, and I cannot wait to see what the next 10 years brings. With the right building blocks in place, I can begin to imagine how a healthy, vibrant community can expand and grow. I can also imagine the next chapter: one where New Orleans serves as a model rather than a cautionary tale.

Public Health 3.0: A Call to Action for Public Health to Meet the Challenges of the 21st Century

Public health is what we do together as a society to ensure the conditions in which everyone can be healthy. Although many sectors play key roles, governmental public health is an essential component. Recent stressors on public health are driving many local governments to pioneer a new Public Health 3.0 model in which leaders serve as Chief Health Strategists, partnering across multiple sectors and leveraging data and resources to address social, environmental, and economic conditions that affect health and health equity. In 2016, the US Department of Health and Human Services launched the Public Health 3.0 initiative and hosted listening sessions across the country. Local leaders and community members shared successes and provided insight on actions that would ensure a more supportive policy and resource environment to spread and scale this model. This article summarizes the key findings from those listening sessions and recommendations to achieve Public Health 3.0.

Bending the Trends

304 In this issue of the Annals of Family Medicine, Dr Johansen adds to our understanding that despite efforts to control health care costs over the past 2 decades, we are quickly approaching a reality in which health care spending subsumes one-fifth of our economy, which is well above our international peers.1,2 As Dr Johansen notes, this rising spending is the result of continued utilization of higher cost services such as specialty and hospital care, as well as increased prices. Increases in health care spending are not associated with better outcomes or more equitable health. The health status of the people in the United States continues to be burdened with high rates of chronic disease and for the first time in generations, life expectancy is declining.3 The Triple Aim has been the national call to action that drives the goals of “improving the experience of care, improving the health of populations, and reducing per capita costs of health care.”4 To date, the strategy for achieving the Triple Aim has been predominately focused on improving the health care system through the adoption of value-based payment design in lieu of fee-for-service payment models, and on reducing variability in health service delivery.5 Early results indicate that cost growth is slowing and that innovative delivery models are improving quality and safety of care and decreasing unnecessary utilization such as avoidable hospital readmissions.6

Prepare and Support Our Chief Health Strategists on the Front Lines

An introduction is presented in which the author discusses an article in the journal dealing with a framework for the competencies of Americas public health practitioners as of 2017, and it mentions how to prepare and support chief public health strategists in the U.S.

US Dietary Recommendations--Reply.

been shown to offer little additional advantage over regression models that have undergone rigorous goodness-of-fit tests.1,2 In addition, we agree that other unobserved confounders (such as socioeconomic status or education) may have contributed to some of the differences in outcomes observed across the cohorts, as acknowledged in the article. As is the case with all secondary analyses of administrative data, we were constrained in what we could adjust for based on the variables available in the data set.