Pioneering Idea: Your Patient’s Community Health Needs Assessment on the Desktop

Dec 21, 2012, 10:06 AM, Posted by

In medical school, we were taught an ahead-of-its-time curriculum called "Community Oriented Primary Care." It looks like now we're going to get to be able to practice it.

When I was with the Project HealthDesign (@PrjHealthDesign) team in Nashville earlier this year (see: A visit to Project HealthDesign and the patient voice, spoken through their observations of daily living | Ted Eytan, MD), we participated in an interesting exercise while wearing silly hats. It involved turning our thinking 180 degrees around about the future of health. Report

Mine was, "Medical care will get so good that it won't determine 10-20 percent of a person's health, it will determine 95 percent, making social action completely unnecessary." That was definitely a new way of looking at things for me.

Since that is in fact a 180 degree look at the situation today, I am completely inspired by a new community health assessment platform available online at This is available for everyone, at no cost.

There is also a customized version for the health system I work in, Kaiser Permanente, that includes information about our care delivery service area and facilities.

The platform has thousands of publicly available data layers attached to local, regional, and national maps. Some data is reported down to the census tract. What I can do, right now, is enter in the address where I live or work, and get a snapshot of all the community conditions that impact the health of the people around me. As someone interested in the causes of the causes of poor health, I would call this, "everything I was hoping for."

I ran some maps for the location around the Kaiser Permanente Center for Total Health, which is in Northeast Washington, D.C., ZIP code 20002: - High School Diploma - Poverty Rate - Premature Death - Years of Potential List Lost Before Age 75

As you can see, Washington, D.C. demonstrates extreme differences/disparities in health within it, and compared to the rest of the nation. The biggest meta-piece of data in this data set is the potential years of life lost from premature deaths—8,443, which is much, much higher than the national average, and much, much higher than for people living just a few miles away. When I walk with people in D.C., I say, "We're going to travel through 10 years of life expectancy in the next 60 minutes."

Now let's think about the future for a bit.

Imagine that a physician doesn't have to enter a patient's location into a separate website; imagine this system is attached to a comprehensive electronic health record.

When a physician or nurse reviews the medical record of the patient, the patient's community needs assessment is presented on demand. Your patient has not received her mammogram in two years? Maybe it's less because you didn't advise her to get one, more because she's trying to keep dying from other causes. What are those causes? Maps like this will start a conversation about them.

What if you discover that your patient is in a community cluster of patients who are not up to date on their preventive health interventions, because of their community conditions? How will this impact your practice? Will you still call/email/text/tweet every patient to get screened or will you discover that changing the community conditions that keep people from being healthy will be more efficient and more effective?

What if, while you do this, you discover that your role as a physician is changing, from being a health advocate to being a "health activist," not "for" your patient, but "with" your patient? And not just your patient, the broader web of community professionals already in this space, who are ready, willing, and able to partner with the profession to create lasting change.

Let's go out even further out into the future for a bit more.

What if the impact of individual physicians practicing clinical medicine AND community improvement is so profound that the structure of the medical profession itself changes?

If you've seen the concept of "diseaseomes" (see: Albert-László Barabási at TEDMED 2012 - YouTube), you understand that the idea of organ system-specific medicine may no longer make sense as the social network of cells is uncovered.

Think about this at the community level. Individual lifestyle-behavior change medicine may be overshadowed by an understanding of the social network of community conditions that contribute to poor health.

A class of physicians within a current specialty or a new specialty might be created that understands and treats individual human pathology as well as community pathology. They'll be experts in geospatial analysis and cell-cell interaction.

They will be concerned with effectiveness of care measures AND effectiveness of health measures, such as disability-free life expectancy or effectiveness of society measures, such as the Human Development Index. (See: Human Development Index - Wikipedia, the free encyclopedia)

And then...

...The health system won't go from being a sick care system to a well care system. It will become part of a human development system, designed to help all people achieve their life goals through optimal health of the individual, family, community, society.

Just a thought—let me know what you think.

Ted Eytan, MD, MS, MPH, is physician director at the Kaiser Permanente Center for Total Health in Washington, D.C., and an alumnus of the Robert Wood Johnson Clinical Scholars Program. You can find him online at @tedeytan or

This commentary originally appeared on the RWJF Pioneering Ideas blog.