40 ma­jor mile­stones in health­care

The se­quenc­ing of the hu­man genome rep­re­sents the most sig­nif­i­cant break­through in health­care over the past 40 years, ac­cord­ing to Mod­ern Health­care read­ers.

Modern Healthcare - - CONTENTS - BY JOSEPH CONN

That achieve­ment, cap­ping a 13-year, $3 bil­lion in­ter­na­tional ef­fort funded by the fed­eral gov­ern­ment, drew the most votes from the 728 re­spon­dents to a sur­vey that listed 60 health­care mile­stones achieved since Mod­ern Health­care was founded in 1976. The sur­vey asked read­ers to pick their top five choices from each of three cat­e­gories: science and tech­nol­ogy; health­care de­liv­ery; and pol­i­tics and pol­icy.

The top choice of the Hu­man Genome Project re­flects a grow­ing recog­ni­tion of its im­por­tance to ad­vanc­ing medicine, some­thing that wasn’t read­ily ap­par­ent when it was of­fi­cially com­pleted in 2003, said Dr. Fran­cis Collins, who ran the project for the gov­ern­ment and is now di­rec­tor of the Na­tional In­sti­tutes of Health.

“It’s not some­thing that im­me­di­ately changed health­care,” he said. “Shortly af­ter this process was com­pleted, there were a bunch of re­sponses that this was over­hyped. It was the big fiz­zle.”

But Collins said that when it comes to tech­nol­ogy, “Any ma­jor ad­vances al­ways have their con­se­quences over­es­ti­mated in the short run and un­der­es­ti­mated in the long run.” And the tide has turned on the per­cep­tion of ge­nomics, re­flected in its se­lec­tion in the poll.

“I think it’s a sense of the his­tor­i­cal na­ture of what this means,” Collins said. “For all of hu­man his­tory, we have la­bored with­out un­der­stand­ing our in­struc­tion book, and the hu­man genome pro­vided that. It’s like cross­ing a bridge.”

Collins was put in charge of the Hu­man Genome Project in 1993, three years af­ter its launch, when he took over as di­rec­tor of what is now called the Na­tional Hu­man Genome Re­search In­sti­tute from famed ge­net­ics re­searcher James Wat­son. “It will find its way into the prac­tice of medicine,” Collins said. “Maybe the case in five years (will be) that all of us be­ing pre­scribed a drug for a con­di­tion will want to have our genome checked to see that it’s the right drug for us”—part of what’s be­ing called pre­ci­sion medicine.

The se­quenc­ing of the hu­man genome, cho­sen 416 times by read­ers, nar­rowly nudged out the next most im­por­tant achieve­ment, mag­netic res­o­nance imag­ing, which drew 403 bal­lots.

Neu­ro­ra­di­ol­o­gist Dr. Wil­liam Bradley, for­mer ra­di­ol­ogy chair at the Univer­sity of Cal­i­for­nia at San Diego, be­gan work­ing with MRIs when they first sur­faced dur­ing his res­i­dency in the 1970s. “The work­horse of med­i­cal imag­ing right now is MRI,” Bradley said. “There’s no radiation and you have su­perb soft-tis­sue con­trast. . . . The idea of cut­ting things open to see what’s go­ing on is a thing of the past.”

‘Touched by health re­form’

The 2010 health­care re­form law, com­monly known as Oba­macare, topped the pol­i­tics and pol­icy cat­e­gory and ranked No. 3 over­all, gar­ner­ing 399 votes from Mod­ern Health­care read­ers. Plac­ing sec­ond in pol­i­tics and pol­icy—No. 6 over­all—was the Health In­sur­ance Porta­bil­ity and Ac­count­abil­ity Act, com­ing up on its 20th an­niver­sary in Au­gust.

Both Oba­macare and HIPAA have had broad ef­fects on the health­care in­dus­try, said Chip Kahn, CEO of the Fed­er­a­tion of Amer­i­can Hos­pi­tals. They “cre­ated tremen­dous change on the de­liv­ery side through Medi­care and Med­i­caid as well as the new plans that are avail­able to peo­ple,” he said. “Every hos­pi­tal­iza­tion is touched by health re­form.”

HIPAA has re­mained rel­e­vant for nearly two decades be­cause of its breadth and the ad­vent of health in­for­ma­tion tech­nol­ogy, which it sought to reg­u­late at a time when com­put­ers were mostly used in the health­care in­dus­try for claims pro­cess­ing and rev­enue-cy­cle man­age­ment. HIPAA was de­signed as a frame­work, with Congress com­ing back later to craft de­tails.

“But (it) never did,” said Kahn, who worked on the leg­is­la­tion as a top Repub­li­can aide on Capitol Hill. “It was too com­plex and dif­fi­cult.”

In­stead HHS agen­cies, em­pow­ered by HIPAA, im­ple­mented rules such as the re­cent switch to ICD-10 di­ag­nos­tic and pro­ce­dural codes. “It touches pa­tients day to day, every day,” Kahn said. “For every trans­ac­tion, there is some­thing that crosses that rule.”

Wip­ing out small­pox

In health­care de­liv­ery, the cat­e­gory win­ner was the erad­i­ca­tion of small­pox, ranked fourth over­all with 320 votes.

Af­ter nearly two cen­turies of pub­lic health ef­forts that started when English physi­cian Dr. Edward Jen­ner be­gan pro­mot­ing vac­ci­na­tion in the 1700s, small­pox was of­fi­cially de­clared dead by the World Health Or­ga­ni­za­tion in 1980. The elim­i­na­tion of small­pox in the U.S. had been largely achieved in the 19th cen­tury, but as re­cently as the 1950s, tens of mil­lions of peo­ple else­where in the world were in­fected with the virus each year.

Dr. Wil­liam Foege, who headed the Cen­ters for Dis­ease Con­trol and Preven­tion from 1977 to 1983, be­gan bat­tling small­pox as a con­sul­tant to a Lutheran health mis­sion in eastern Nige­ria in 1966 and con­tin­ued the fight at the CDC in the last en­demic ar­eas—In­dia, Bangladesh, and fi­nally, So­ma­lia in 1977.

“We’re now go­ing on about half a cen­tury with­out a sin­gle case,” said Foege, now a con­sul­tant to the Carter Cen­ter and the Bill & Melinda Gates Foun­da­tion.

Iden­ti­fy­ing the first case of ac­quired im­mune de­fi­ciency syn­drome, or AIDS, placed sec­ond in the health­care de­liv­ery cat­e­gory and fifth over­all. The mys­te­ri­ous out­break was first re­ported in the CDC’s Mor­bid­ity and Mor­tal­ity Weekly Re­port in July 1981.

At the time, Dr. James Cur­ran was chief of the re­search branch at the CDC, con­duct­ing tri­als on hepati­tis B, which was then “an epi­demic in the gay com­mu­nity.” The CDC be­gan re­ceiv­ing re­ports of a spike in an ad­vanced form of Ka­posi’s sar­coma, pneu­mo­nia and other op­por­tunis­tic in­fec­tions that re­sulted from se­vere im­mune-sys­tem sup­pres­sion.

Cur­ran was named to head up the CDC’s in­ves­tiga­tive task force. The agency dis­patched in­ves­ti­ga­tors to 18 cities to look back five years for sim­i­lar cases.

“We found more than 150 cases and they were in­creas­ing rapidly,” he said. While there was a strong link to gay men, one of the early vic­tims was a woman and a few oth­ers were self-in­jected drug users. An­other was an in­fant.

“A lot of us thought it was due to a new virus or a mod­i­fied virus, but a lot of other peo­ple didn’t think that,” Cur­ran said. “They thought it might be due to im­mune over­load. At first, peo­ple didn’t think it was in the blood sup­ply, but then three cases sur­faced of he­mo­phil­iacs who were not gay and not drug users. That was re­peated by peo­ple with a sin­gle trans­fu­sion. It be­came quite clear this was due to a new virus trans­mit­ted through sex­ual ac­tiv­ity, or through the blood, and not re­stricted to gay men,” Cur­ran said.

The CDC in 1983 is­sued preven­tion rec­om­men­da­tions, even be­fore there was a known cause, Cur­ran said. That year, re­searchers at the Pas­teur In­sti­tute in Paris pub­lished find­ings that iden­ti­fied a virus as­so­ci­ated with AIDS risk. In 1984, a team headed by Robert Gallo at the Na­tional Can­cer In­sti­tute pub­lished its work, es­tab­lish­ing the link be­tween the hu­man im­mod­e­fi­ciency virus and AIDS.

Since then, an es­ti­mated 35 mil­lion peo­ple have died of AIDS, said Cur­ran, co-di­rec­tor and prin­ci­pal in­ves­ti­ga­tor at the Cen­ter for AIDS Re­search and dean of the Rollins School of Pub­lic Health at Emory Univer­sity in At­lanta. An­other 10 mil­lion peo­ple are re­ceiv­ing life­ex­tend­ing drug ther­apy, “but there are 20 mil­lion peo­ple who don’t have (the drugs) and 2 mil­lion peo­ple are get­ting in­fected” each year.

“The high­est pri­or­i­ties now are cu­ra­tive ther­a­pies and (find­ing) a vac­cine,” Cur­ran said.

Craig Ven­ter, left, pres­i­dent of Cel­era Ge­nomics, Pres­i­dent Bill Clin­ton and Dr. Fran­cis Collins, who led the Hu­man Genome Project, gather for a tele­con­fer­ence on June 26,2000, to an­nounce that the In­ter­na­tional Hu­man Genome Project and C el era Ge no mic shave both com­pleted an ini­tial se­quenc­ing of the hu­man genome.

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