Category Archives: Innovation

Issues related to development and adoption of healthcare innovations

Chronic Wellness Promotion v. Chronic Disease Management in Medical Homes

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One of the hottest health reform topics is Medical Homes: Medicare has Demonstration Project starting this year, several states have implemented, (or are implementing), medical home related initiatives, the Center for Studying Health System Change (CSHSC) released a great white paper titled “Making Medical Homes Work,” and the New York Times just had a story about how IBM is teaming up with United Healthcare to promote Medical Homes for their 11,000 employees and dependents in Arizona.

Definition of Medical Homes
One of the controversies in Medical Homes is the definition.  CSHSC and many others use the definition developed by 4 national medical societies which combines aspects of preexisting primary care and chronic care models with the goal of creating a primary care “home” that can more effectively address the needs of patients with chronic conditions.

Focus on Chronic Diseases – That’s Where the Money Is
This combination makes perfect sense since the majority of healthcare costs are used by the least well patients:  In 2003, 80% of health spending went for 20% of people in the US, and the Agency for Healthcare Research and Quality estimates that 70% of healthcare spending is for treating chronic diseases.

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[Source: Kaiser Family Foundation]

Emphasizing chronic disease management for Medical Homes reflects how most healthcare innovations, (including technologies, payment schemes, and care delivery changes), are first used in the most organized and intensive care settings -  such as hospitals – and then migrate out into primary care and preventive settings, including home use and patient self-management.  Thus Medical Homes’ focus on care coordination for chronic conditions parallels the decades old movement and growth in team-based care in hospitals.

Medical Homes and Wellness Care
Beyond improving chronic disease management, Medical Home capabilities should also help promote better wellness for all patients, i.e. the other 80% of people.  Patients wellness from better exercise, diet and other actions could be improved through Medical Homes providing more targeted counseling and self-management training.  Similarly, Medical Homes use of patient registries and reminder systems should increase compliance with vaccinations, prenatal vitamins, and reminders to follow-up on patient specific wellness interventions.

Long-Term Vision for Medical Homes
The long-term vision for Medical homes should include how they can improve clinical care for all people in a community – not just those with chronic or costly illnesses. As I work with payers, clinicians, and others about the desired characteristics of Medical Homes, this vision should help shape how payments for providing Medical Home services are structured and evolve, (e.g. PMPM for specific sets of Medical Home capabilities), and how additional compensation – such as bonuses – are constructed and modified to reward Medical Homes for achieving clinical and cost outcomes. Such a vision should also be part of our national long-term strategy for making healthcare delivery more efficient and coordinated, and transforming our delivery system’s culture to embrace the rapid adoption of change to provide greater clinical and societal value.

Advancements in Understanding Head Trauma and Preventing Long-Term Problems

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When I was training to become an orthopedic surgeon, one of the senior physicians said that the two best learning sources for orthopedic surgeons were football and war.  Over the past year I’ve been talking with friends and colleagues about another connection between war and football – how minor repetitive head trauma has long-term serious consequences.

It has become clear with the increasing reports about the neurological, cognitive and personality problems military personnel have experiences after repeated minor concussive events, (often from being inside vehicles hit by IEDs), that this is a real and serious situation.  While the VA health system has taken steps to understand the consequences of repetitive minor head trauma and work to provide appropriate diagnostic and treatment methods, I have been telling people that this new understanding of neuro-trauma will have implications for football.

There have been more than a few reports about former NFL players having neurological problems after retiring; In particular, former Patriot Ted Johnson, whose problems with post-concussive syndrome was reported 2 years ago in the Boston Globe.  And just today, the Boston Globe had an article about how the brain of an 18 year old football player, (who died from nonviolent causes), showed early signs of irreversible damage from repetitive head trauma – something that had not been documented in professional football players younger than 36 years old.

War is different than football: In war, the goal is to avoid head trauma and steps can be taken to avoid it or minimize its effects through better vehicles and helmets – and by taking people out of harms way after head trauma has occured.  Conversely, in football, the contact, hits and subsequent head trauma are essential parts of the game.  While helmets have been made better and players can be taken out of the action after even minor head trauma, football can’t be played with complete cushion suits like those sumo-style outfits used in late-night and reality TV shows.  Last summer I wrote about how professional baseball teams are becoming more aware of the lasting effects of concussions on their players – but baseball isn’t inherently a contact sport.  I wish I had a good answer for football and football players.  Unfortunately I don’t think switching to flag or touch is going to make it as an alternative to full contact football. I’m a fan, but I don’t have good suggestions, and understanding the long-term consequences of repetitive minor head trauma, often makes it difficult for me to watch a football game – professional, college or high school.

States Poaching Biotech Companies

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In the Boston Globe there have been a couple of articles and an ad that pointed out the challenges states have in promoting and keeping productive and growing companies in their states.

In today’s paper there is an article about how the Governor of Massachusetts  is going to the West Coast to “to network with executives at computer and energy companies that have large facilities here, aiming to shore up and even expand their employment and investments in Massachusetts.”  While this is presumably a very good thing for Massachusetts, it raises two thoughts:

  • When I moved to Massachusetts in 2002 people were talking about how the state had lost its lead in the computer industry in the 1970s and 80s to California
  • The article doesn’t mention biotechnology, life sciences or healthcare – industries where Massachusetts still has a leadership position

This second point is particularly important because Saturday’s Globe had an article about how state regulations scheduled to take effect July 1st requiring disclosure of industry payments to physicians may cut down on medical meetings in Boston.  While that is speculative, it could undermine one of the state’s major “industry’s,” i.e. academic medical conferences.  In addition, in today’s Globe, the New York Biotechnology Association took out a 3/4 page ad on page A5 that is clearly referencing these regulations.  The substantive text of the ad is:

Worried that government red tape is getting too much in the way of your life sciences work?

The solution is just across the border.

In New York.

In New York, you can run fundamental scientific practices without disclosing your confidential trade secrets to your competitors… or government bureaucrats. [emphasis added]

Like Massachusetts, New York has world-class hospitals, universities, research facilities and healthcare professionals.

It offers the perfect setting for advanced biomedical research.

In New York, you can conduct clinical trials where your royalty and licensing agreements are protected… and provide continuing medical education programs essential for life sciences professionals. [emphasis added]

In New York, government won’t get in your way.

It will be in your corner.

While the NY Biotech Association’s ad may be mostly saber rattling and fear mongering, healthcare, life sciences and biotechnology are very important industries for Massachusetts, and I hope that the state keeps them as priorities in their economic development agenda.  It would be too bad if just as the state is making dramatic progress toward universal insurance coverage – and hopefully taking productive steps towards containing the cost of healthcare – it looses out on maintaining its leadership in these industries which will be creating long term advancements in healthcare quality.

Improving Cancer Care and Medicare’s Cancer Coverage

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The New York Times and Wall Street Journal both had articles yesterday about a new rule clarifying how Medicare would decide whether or not to pay for off-label uses of medicines to treat cancer.  These articles describe controversies around Medicare relying on several compendia containing information about such off-label uses to make these coverage decisions, how some of the compendia may have industry connections, and how the new rule might increase Medicare spending.

I have a long history with this issue.  As a Legislative Assistant working for Congressman Sander Levin in the early 1990s, I was very involved in writing the legislation that first changed Medicare law to require Medicare Part B to pay for off-label used of medicines to treat cancer.  This change was seen as promoting both good medicine and good fiscal policy:  It promoted good medical practice because there was evidence that physicians were admitting patients to hospitals to give them off-label chemotherapy for cancer because Medicare wouldn’t reliably pay for it in outpatient clinics.  Thus, patients had to travel farther, and were potentially at risk for hospital acquired infections and other problems from being in the hospital when they didn’t need to be.  And it was good fiscal policy because Medicare was paying more for these patients to be in the hospitals than it would for them to get the same treatments as outpatients.  This is why the Congressional Budget Office estimated that this change to Medicare law wouldn’t cost Medicare any money.  (They estimated saving for Part A of Medicare, and some additional costs for Part B, with the net costs being essentially zero.)

What the Times and Journal articles don’t mention is that under Medicare law, off-label coverage for cancer treatments also occurs if there is “supportive clinical evidence in peer reviewed medical” journals that have been approved by the Department of Health and Human Services.  (See the language for the entire provision in Section 1861(t)(2) of the Social Security Act.)  The peer reviewed literature option was included so ensure that Medicare paid for appropriate off-label cancer treatments for very rare or unusual cancers and treatments that might never make it into the compendia, and to include the most up to date published information for making coverage decisions.

The 1993 law, and the subsequent refinements to it, were designed to improve Medicare’s coverage for cancer treatments.  With about 50% of people with cancer being over age 65, Medicare’s policies thus drive many decisions about cancer treatments for all Americans.  And despite the requirements for off-label coverage, being treated for cancer certainly presents huge medical and financial burdens for many people – something that the creation of the Medicare Part D outpatient prescription drug program was intended to help with.  However, because of a peculiar wording in the 2003 law that created the Part D program, the coverage for off-label cancer treatments under Part D was more restrictive than under Part B.  (Essentially, it was easier to get Medicare to pay for an off-label cancer treatment when the medicine was injected by a physician than if the medicine was a pill.)  Fortunately – after a lot of discussion and lobbying by patient advocacy organizations including the Medicare Rights Center – that situation was changed by Congress in the summer of 2008.  So as of January 1, 2009, the rules for off-label coverage for cancer treatments are the same under both Parts B & D – although I’m sure there will be some snags and bumps in getting all the Part D plans up to speed on how to appropriately apply these coverage rules.

Balancing Costs v. R&D Incentives
How to control the costs of such treatments while also providing incentives for the development of new and better medicines is a difficult public policy balance.  Higher reimbursement amounts for cancer treatments would increase the incentives for developing new and better treatments and cures for cancer.  But high reimbursements could also increase costs for patients and their insurance companies.  This balance becomes particularly difficult when a new treatment is much more effective than previous treatments, it doesn’t produce very unpleasant (and costly) side-effects, it needs to be taken much less frequently, or if it actually produces a cure.  In such cases, the new medicine’s very high per dose costs can be criticized.  But this analysis may look very different when put into the context of the value the medicine provides to the patient, and the overall costs incurred by Medicare (or the private insurer) and the patient.

Cost & Clinical Effectiveness Research
Such challenging balances and calculations are what biopharma companies, biomedical researchers, clinicians, insurance companies, government regulators and others struggle with whenever a new treatment is developed for a serious condition.  This is the essence of clinical and cost effectiveness research – an area of health policy that is beginning to be much more widely discussed:  It has been part of bipartisan Congressional discussions and was highlighted in last year’s Presidential campaign.  How the government and others increase their support for this type of research, (i.e. inside government or through some independent or semi-independent agency), how the information from this research is reflected in reimbursement policies, and how clinicians are educated about and use this information, could dramatically improve the quality and value of the health care we all receive for cancer and many other conditions.  Only time will tell if that happens, or if too many competing interests snarl up the process with cost savings being put before quality improvement, with the goal of cost containment pushing the information into reimbursement decisions before it is fully analyzed – or as someone once said, trying to get to the dough before the bread is fully baked.  (Yeah, I know, very bad dough pun.)

Quality of Care in Medical Practices – Size Does Matter

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The Journal of General Internal Medicine published a study last month that looked at primary care medical practices in Massachusetts to see how well they were able to provide the quality improving capabilities of Patient-Centered Medical Homes.  These structural capabilities represent process measures that assess the quality of care in medical practices.  However, these same measures could also help patients select their own primary care physicians.

Study Finds Larger Practices Have More Quality Related Capabilities
Not surprisingly the study found that larger practices, (and to a lesser extent those affiliated with larger networks of practices), provided more capabilities to improve the quality of patient care. The most significant difference in capabilities was seen in practices with 5 or more physicians, and these included:

  • Practice meets to discuss quality more frequently than every quarter
  • Practice regularly open to provide care on weekends
  • Use of Electronic health records that provide medication list, problem list, and electronic reminders

In addition, practices with 9 or more physicians were more likely to have specialty trained staff to assist with patient self-management, and there was an overall trend for larger practices to have reminder systems for preventive care:

Quality Improving Capabilities Increase with Practice SizeAsking Questions to Improve Quality
The questions used by the researchers in this study are clearly useful for assessing the quality relate capabilities of primary care practices, but additional research certainly it warranted to determine how well these process measures translate into actual improvements in clinical and economic outcomes. In addition, as such lists are developed and validated further, they could also be used by individuals looking for their own primary care physicians, and by patient advocacy organizations seeking to both promote quality improvement and to “grade” primary care providers.

The specific questions used in the study’s survey was:

Quality Capabilities for Primary Care Practices

One of the challenges for individuals or groups to effectively use any list of this type is that it needs to be customized because they will have different priorities and concerns. For example, the availability of translation services might be important for one family or advocacy organization, but less so for others.

Conclusion
Much has been written about using checklists to improve quality and reduce errors in hospitals – and particularly in the operating room.  But perhaps checklists could be derived from this type of Medical Home capabilities survey for use by individual patients and their advocates to assess outpatient clinical sites.   While the operating room checklist concept was based upon the airplane pre-flight checklist, maybe the checklist for assessing primary care practices could be likened to the checklist that home inspectors use to help home buyers understand the strengths and problems of a house. If individual patients and their collective advocacy groups regularly used checklists of this type, it could create a significant patient driven force for transforming the structure and operations of outpatient medical care in the United States to improve quality and control costs.

Making Physicians Better, and Making Better Physicians

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A few recent reports point to ways for improving the quality of physician delivered care that has little to do with technology or complex interventions.  The first involves how physicians interact with patients, and the second examines the work hours for physicians in training.

Etiquette in Medicine
The first article, by Dr. Michael Kahn in the New York Times, describes six recommended actions for physician to create a good rapport with hospitalized patients. Dr. Kahn collectively calls these actions “etiquette-based medicine”:

  1. Ask permission to enter the room; wait for an answer
  2. Introduce yourself; show your ID badge
  3. Shake hands
  4. Sit down. Smile if appropriate
  5. Explain your role on the health care team
  6. Ask how the patient feels about being in the hospital

Clearly these actions are all directed towards creating a stronger person-to-person connection between the physician and the patient as a step toward improved communications – which is the foundation for developing and effectively delivering a treatment plan to and for the patient.

Physicians Getting Rest
Another challenge physicians have in this process is being awake and aware enough to actually engage in those 6 steps. (Having enough energy also would effect their ability to engage patients empathetically – something I’ve written about before.)  [Also see the previous posting about napping being better than caffeine for improving verbal and physical memory and learning.]

How much sleep physicians need to act appropriately – and avoid making errors – is the subject of a recent Institute of Medicine report, (“Resident Duty Hours: Enhancing Sleep, Supervision and Safety”), that makes new recommendations for limits to the work hours for physicians in training:

  • Duty hours should not exceed 16 hours per shift; For 30 hour shifts there should be an uninterrupted five hour break for sleep
  • Residents should have variable off-duty periods between shifts based on the timing and duration of shifts to increase residents’ opportunities for sleep each day, as well as regular days off that enable residents to recover from chronic sleep deprivation.
  • Medical moonlighting, (additional paid healthcare work), should be restricted
    [A chart comparing the current and new recommendations is available here.]

While all these changes would certainly make for more aware and awake residents, the IOM also estimates that recruiting and paying professional staff to substitute for the work hours the residents would have been (over)working, would cost about $1.7 billion.

Besides figuring out how to pay for these new staff hours, one policy question for implementing these recommendations is how to find the clinicians to actually work these hours considering there is such a shortage of non-physician clinicians.

Anther policy question these recommendations raise, is why they should they only apply to physicians in training?  Why shouldn’t they also apply to physicians who’ve finished their training and are supervising, teaching, and mentoring residents and medical students – and of course are directly responsible for patients?  While it might be argued that most physicians don’t work these long hours, for some that may not be the case – particularly in hospitals without many residents.

Considering that many quality improvements for medicine have been taken from the airline industry – such as the pre-flight/pre-surgery checklist – then why shouldn’t the limits on pilot shifts and hours also be applied to fully licensed physicians?  [I suspect that this will not make me popular with some physicians, but I wonder how they will defend their right to treat patients round-the-clock without sleep?]

Conclusions
Perhaps work hours and etiquette should be other aspects of quality improvement and patient safety that are considered as part of health reform discussions at the Federal and State levels. Certainly well-rested, empathetic physicians trained to interact with their patients with etiquette should improve the quality of healthcare by reducing errors and making physician-patient communications more effective.

How to integrate all these “innovations” into physician training and practice will be a significant challenge, because teaching such skills and promoting their use is not very exciting or technological, and it will be hard for such behaviors to be tied to economic incentives – which are often the carrot or stick for quality improvement initiatives.  Hopefully, as health reform ideas move forward and become crafted into comprehensive packages and plans, they will expand beyond direct economic incentives for improving clinical processes, to include non-economic inducements to promote quality enhancing actions and attitudes for clinicians as well as patients.

Napping to Increase Productivity

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The New York Times had a great short report about a scientific study comparing a short nap to caffeine for improving a person’s memory.  The study found what many people have suspected for years – a nap is better than caffeine.

The benefits of napping are something that proponents of “power napping” have known for years. (Disclaimer: I’ve used the 20 minute power nap for years to re-energize and turn an afternoon impaired by a severe case of “the weakies” into several very productive hours.)

The study specifically found that naps were better for improving recall of a word list after both 20 minutes and 7 hours.  Naps were also better than caffeine for improving performance on a finger tapping task.  (This tested the ability to recall physically learned memories rather than the word list’s verbally related memories.)

The study also found that the caffeine group performed worse on the finger tapping test than the placebo group, and both napping and caffeine were better than placebo on a perceptual memory task of discriminating textures.

Questions Raised & Possibilities for More Research
Why caffeine is better than placebo for the perceptual task is an interesting finding?  Perhaps caffeine has some performance improving effect in peripheral nerves or nerve receptors.  This possibility could be examined by studying how caffeine effects other perceptual senses such as vibration and proprioception.

The statement from the study author in the New York Times that, “People think they’re smarter on caffeine,” points to the possibility that caffeine’s central neurological effects create false impressions of performance.  This might be another interesting avenue for research.  Particularly what does this increase in believed performance ability have on errors rates in important tasks such as flying an airplane or performing medical procedures?

Postscript: Reading this study also reminded me of a discussion I had many years ago with a corporate HR person about napping.  She had distributed information about identifying employees who had substance abuse or health problems that included “sleeping at work” as one of the warning signs.  The next day, the newspaper had an article about power-napping for productivity – which I sent to her, and she later confirmed that this was not what was meant by “sleeping at work.”

Baby Biotechs Treading Water

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Monday’s Boston Globe had an article about how smaller biotech firms are having to cut spending to stay afloat since the current economic environment has made it almost impossible to raise more cash.  This shouldn’t be surprising given that these companies spend years (and years) developing new treatments and technologies before they are ever able to sell anything – assuming that their R&D does produce something that can be sold.  And the investing/lending world is currently not very interested in such long-term and speculative prospects. The immediate result is that these companies are laying people off, reducing their office space and actually mothballing research projects.

But what will be the longer-term results?

The fact that companies are cutting back on research is of concern.  As the Globe stated, one company “recently elliminated some development programs to focus on its most promising potential drugs.” (emphasis added) While this is clearly a good business strategy for keeping the lights on, making these choices was probably not easy for the company’s management.  And I’m concerned because it is often research and development that initially is not seen as “most promising” that leads to some of the most significant breakthroughs.

Possible Longer-Term Outcomes
For companies that don’t manage to stay alive, there are several possible outcomes.  First, as their stock prices sink, they may be snatched up in a fire-sale by larger biotechnology/pharmaceutical companies.  However, that end of the industry spectrum may not be doing too well either -  Merck indicated today that their earnings and revenues would be below expectations.  (This was in part due to the strong dollar versus international currencies.)

Another possible outcome is that after companies go under, once the capital markets return, new biotech companies will form from their ashes as companies license in the the old data and patents – which presumably will be held by some creditors/old owners.

In either case, the best result will likely be a delay in the exploration of possible avenues leading to new treatments and cures.  The worst result would be that patents will run out on promising discoveries, making it unlikely that other companies will pick up where the fallen company left off.  To minimize either of these situations, let us hope that the economic downturn quickly turns around, so that these companies  looking for money to keep the lights on can refocus their energy on R&D.  That will clearly be the best outcome for the economy, jobs, and healthcare over the long-run.

Serotonin: Brains, Bowels, Bones and Beyond

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One of the fascinating aspects of medicine and biology is how one substance can have so many functions.  A recent article about the effects of serotonin on bone cells and bone formation in the New York Times illustrates this point. While this finding about serotonin and bone formation may be important for developing new ways to treat osteoporosis, it is especially fascinating because serotonin does so many other things in the body.

Serotonin is probably best known for how its levels affect mood – which is the basis for the medicines to treat depression in the class known as “Selective Serotonin Reuptake Inhibitors,” or SSRIs. Serotonin is also involved with the functioning of the gastrointestinal system – primarily as a neurotranmitter in the GI track’s nervous system effecting the peristaltic movement of the intestines. [Click here for a 2001 video from Novartis about serotonin and Irritable Bowel Syndrome.]

What the research article in Cell shows is that high levels of serotonin may inhibit bone formation as well. This understanding may be the basis for creating new treatments for osteoporosis – and is a new avenue for addressing this disease that hadn’t been considered before.  As the New York Times characterizes it, “Osteoporosis researcher were dumbfounded by the report.”

While this is very interesting in itself, as I stated at the start of this post, what is globally more enlightening is how one compound can have very different effects on the human body depending upon where it is found.  This is often seen in how medicines may have effects other than those they are intended to produce.  These are generally called “side-effects,” but really they may be seen as “other effects,” and sometimes they are used as the primary reason for using a medicine.  (To avoid giving what might seem like medical advice, I’ll refrain from listing specifics here, but would be interested if anyone has comments or insights into this.)

And of course, there are also the side-effects that turn out to be the primary effect for a new medicine.  Most famously, this is what led to the development of Viagra®, a medicine that was intended to promote blood flow in the arteries of the heart, but which actually caused increased blood flow elsewhere.

What this all means is that there are still many unknowns in biomedicine, and that many future discoveries will help us develop better treatments for many diseases by shifting our understanding of how the body works.  As I was told in a lecture on the first day of medical school, “Half of what we’re going to teach you is wrong – we just don’t know which half.”  I know that in the few/several/many years since I graduated medical school, biomedical research has discovered a tremendous amount of new knowledge about human health and disease.  But I also suspect that the percentage of what medical students are taught today which will need to be changed in the coming years hasn’t shifted very much, if at all, because more knowledge also leads to asking more questions – which, of course, are really the starting point for new discoveries that lead to better treatments…… and also require medical school professors to revise their lectures every year.

Engage With Grace

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Many bloggers are posting information today about a initiative to encourage conversation about a very difficult topic: How we want to die. This collective effort to prompt discussions about this topic at the beginning of the holiday season is very timely, and it is a good complement to my post last week about empathy and compassion in healthcare.

What follows is essentially the same text that appears on many other blogs along with a picture of the “One Slide” listing the 5 conversation promoting questions that are at the core of the Project:

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Engage with Grace: The One Slide Project is an astonishingly simple idea that literally touches everyone. Alexandra (“Alex”) Drane, whose sister-in-law died in the hospital, (at age 32 of glioblastoma – seven months post diagnosis – grab your tissues and see the backstory), has set in motion a talking/blogging/thinking campaign to get us to deeply consider how we want to die.

Alex’s one slide has five conversation-starter questions about dying, really simple stuff like: given the choice, do you want to die at home or in the hospital; do you want medical intervention or not…etc (see below) – and then she did the networking thing. Now bloggers have agreed to post her message about the campaign as a Thanksgiving project. We’re all posting the same message – with a lead-in of our choosing on Nov 26 – and leaving it up throughout the holiday weekend (yay! an enforced break from blogging – my family will be so happy).

The One Slide from the Engage with Grace Project

There’s also a great video with Alex explaining how she used the very best of networking principles to keep this really really simple. We make choices throughout our lives – where we want to live, what types of activities will fill our days, with whom we spend our time. These choices are often a balance between our desires and our means, but at the end of the day, they are decisions made with intent. But when it comes to how we want to be treated at the end our lives, often we don’t express our intent or tell our loved ones about it.

This has real consequences. 73% of Americans would prefer to die at home, but up to 50% die in hospital. More than 80% of Californians say their loved ones “know exactly” or have a “good idea” of what their wishes would be if they were in a persistent coma, but only 50% say they’ve talked to them about their preferences.But our end of life experiences are about a lot more than statistics. They’re about all of us.

So the first thing we need to do is start talking. Engage With Grace: The One Slide Project was designed with one simple goal: to help get the conversation about end of life experience started. The idea is simple: Create a tool to help get people talking. One Slide, with just five questions on it. Five questions designed to help get us talking with each other, with our loved ones, about our preferences.

And we’re asking people to share this One Slide – wherever and whenever they can.at a presentation, at dinner, at their book club. Just One Slide, just five questions. Lets start a global discussion that, until now, most of us haven’t had. Here is what we are asking you:

Download The One Slide and share it at any opportunity – with colleagues, family, friends. Think of the slide as currency and donate just two minutes whenever you can. Commit to being able to answer these five questions about end of life experience for yourself, and for your loved ones. Then commit to helping others do the same. Get this conversation started.

Let’s start a viral movement driven by the change we as individuals can effect…and the incredibly positive impact we could have collectively. Help ensure that all of us – and the people we care for – can end our lives in the same purposeful way we live them. Just One Slide, just one goal. Think of the enormous difference we can make together.

(To learn more please go to www.engagewithgrace.org. This post was written by Alexandra Drane and the Engage With Grace team.)

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P.S. – I just wanted to add that I have had several friends and relatives succumb to brain tumors, so I have a personal connection this story and this project’s goals.