Precision Ecologic Medicine: Tailoring Care to Mitigate Impacts of Climate Change

Abstract

As recent extreme weather events demonstrate, climate change presents unprecedented and increasing health risks, disproportionately so for disadvantaged communities in the U.S. already experiencing health disparities. As patients in these frontline communities live through extreme weather events, socioeconomic and health stressors are compounded; thus, their healthcare teams will need tools to provide precision ecologic medicine approaches to their care. Many primary care teams are taking actionable steps to bring community-level socioeconomic data (“community vital signs”) into electronic medical records, to facilitate tailoring care based on a given patient’s circumstances. This work can be extended to include environmental risk data, thus equipping healthcare teams with an awareness of clinical and community vital signs and making them better positioned to mitigate climate impacts on health. For example, if healthcare teams can easily identify patients who have multiple chronic conditions and live in an urban heat island, they can proactively arrange to “prescribe” an air conditioner, heat pump, and/or air purifier. Or, when a severe storm/heat event/poor air quality event is predicted, they can take preemptive steps to get help to patients at high medical and socioeconomic risk, rather than waiting for them to arrive in the emergency department. Advances in health information technologies now make it technically feasible to integrate a wealth of publicly-available community-level data into EMRs. Efforts to bring this contextual data into clinical settings must be accelerated to equip healthcare teams to provide precision ecologic medicine interventions to their patients.

Introduction

Climate change-induced extreme weather events are a profound threat to human health. Communities on the frontlines of climate change are disproportionately experiencing adverse health outcomes and economic setbacks. ¹ These disadvantages are caused by historical and current structural inequities that drive disparities in the preventable morbidity and mortality between those living on the frontlines of climate change and other communities less directly affected.^2-4 This disparate risk occurs because “Different social groups . . . differ in their empowerment to take up health interventions, due to . . . disadvantage across . . . the life course.” ¹ There is clear and growing evidence that where a person lives predicts their health at least as powerfully as their genetics,^5,6 and “the conditions in which people are born, grow, work, live and age and . . . the conditions of daily life” ⁷ influence health outcomes more than medical care does.^8,9 The upshot of these circumstances is that patients in communities hit the hardest by climate change are also those least able to mitigate its health consequences.^10,11

The health risks faced by disadvantaged groups in the United States (U.S.) are exacerbated by the healthcare system’s present inability to tailor care based on patients’ environmental exposures.^12,13 Many healthcare institutions have lacked both the resources and the motivation to change course, understandably finding it easier to focus on mitigating the health effects of atomistic genetic codes (precision medicine) rather than their macro-environmental milieu. ¹⁴ As traditional biomedical research and care institutions begin to recognize that mitigating the health effects of climate change is within their scope, ¹⁵ lessons learned from genetics-focused precision medicine are relevant. The emerging field of “precision environmental health,” ¹⁶ which focuses on the interaction of genes and environment to understand an individual’s tailored risk, is one important step in this direction.

We propose a bold, actionable path forward for climate-related health. We describe our vision for precision ecologic medicine, which would embed geocoded community, ecologic and environmental data (“community vital signs”) into the electronic medical record (EMR) at the point of care. This will allow healthcare teams to know more information about a patient’s individual risks; guiding tailored care and referral to services as well as responses to extreme climate-related events.

Early lessons learned by primary care teams who are taking actionable steps to bring “community vital signs” into EMRs can inform the implementation of precision ecologic medicine approaches.^17,18 Our team’s experience shows that when we bring community vital signs data together with EMR data, we can highlight areas of high social risk within a clinic’s catchment area. In one study, we mapped health insurance status and co-developed workflows, in partnership with clinics, to conduct proactive outreach to patients to offer health insurance information and assistance.^19,20 Many resources have been spent on genetics-focused “precision medicine” and “precision environmental health” approaches. ²¹ We argue that it is necessary to expand the research and healthcare resources devoted to addressing social, economic, and environmental risk factors. Doing so will accelerate the promising new initiatives seeking to improve how healthcare systems identify and address patients’ social risks (also called adverse social determinants of health)^17,18,22 by including actionable environmental risk data and using these data to mitigate the impact of climate events on patients’ health.^23,24 This information will save lives.

Precision Ecologic Medicine

A precision ecologic medicine approach would ensure that frontline care teams have the information and resources needed to tailor healthcare decisions, recommendations, resources, treatments, and services based on data about a patient’s socioeconomic status and their environmental exposures. ¹⁸ Embedding these types of community vital signs can inform healthcare professionals about the socio-environmental factors impacting an individual’s health. A few examples of data elements that could be included: tree canopy and average temperature variations during seasons as compared to the mean; particulate matter exposure during seasons as compared to the mean; building structure; access to heat and cooling equipment, or safe water; violent crime statistics; age and disability demographics; walkability; proximity to community centers, churches, public schools, fire departments, healthcare clinics, hospitals, grocery stores, public transportation. The inclusion of this information could suggest the need for personalization of the care team (eg, add community health workers, health navigators, behavioral health specialists, case managers). It could inform providing “prescriptions” for air conditioners/purifiers, heat pumps, or indoor exercise facilities, as well as referrals to “enabling” services (eg, interpretation, transportation, cooling center locations). ²² And, it could facilitate care teams’ efforts to assist vulnerable patients with coordinated community service referrals and other tailored actions to prevent against and respond to climate-related events that worsen health.^18,22

Health policy changes and technological advances now make it possible to bring such data to the care team, and to do so in a way that requires far less investment than that needed to make precision genomics information similarly available. Most notably, advances in health information technology such as EMRs provide a platform for integrating publicly-available community data into the health record. Yet, while EMRs currently provide broad clinical information to healthcare teams, often including genetic information, few (if any) currently present climate-related health risk information (eg, urban heat islands, occupational extreme heat exposures, air quality, etc.).

Federal requirements for the “meaningful use” of EMRs already involve integrating some information about patients’ social and economic risks (eg, financial strain, exposure to violence) and more is recommended by the National Academies of Science, Engineering, and Medicine (NASEM) and others. ²⁵ One NASEM report noted that “capturing social determinants of health in EMR data will allow healthcare providers to better characterize, understand the causes of, and identify appropriate interventions that health systems (and non-healthcare systems) can make to reduce health disparities, which will allow critical social problems and also costly problems for the health system and society as a whole to be addressed.” ²⁵ Taking this recommendation one step further, we assert that healthcare leaders should invest in precision ecologic medicine by integrating contextual factors into patient charts to facilitate the use of this information in care decisions. And, for such approaches to care to be effective, insurance payers should consider covering climate-related precision care elements, including treatments to mitigate the impact of climate change on health (eg, heat pumps, water filters, air purifiers).

Community Vital Signs Data at the Point of Care

A community vital signs “data portal” is envisioned to bring information from diverse public sources into EMRs. Advances in geospatial technology and public access to such contextual information now enable automating embedded data in the medical chart. With this geo-referenced/geo-codable information in the EMR, healthcare teams could consider both clinical and climate-related community vital signs data. The most significant investments are needed in the primary care sector. Primary care is the nation’s largest platform for healthcare delivery ²⁶ and the central point of connection for mitigating local challenges to health.^27,28 Primary care is the (historically underfunded) “tip of the spear” in attempts to address climate threats to health.

In a clinic, use of the data portal could look like: a patient with multiple chronic conditions living in an urban heat island would benefit from durable medical equipment prescriptions for a heat pump, air conditioner, and/or air purifier. This patient is connected to a social worker at the clinic who helps them complete the forms needed for state/county provision of this equipment. A family is provided educational resources on finding alternatives to outdoor activities for children during extreme heat events or poor air quality. A patient is provided information from their primary care doctor about how to care for themselves and loved ones during predicted extreme heat, wildfire, or flooding events. The primary care team gets this information through automated clinical decision support, based on best practice guidelines.

Access to these data could support care teams’ understanding of the factors impacting patients’ health. If the right data are provided at the right time, it could revolutionize how healthcare teams improve patient health both at a population and individual level, during and outside of healthcare visits, as it would inform clinical decision-making, panel management, referrals to community resources, and immediate responses to adverse climate-related events. This will require working with patients, healthcare professionals, local organizations, policy makers, and other stakeholders to prioritize community data based on their potential health impacts in specific areas. It will require determining how these data should be presented in EMRs, with accompanying best practice guidelines on individualized care, to ensure that clinical decisions and referrals reflect an individual’s context-driven needs. Enhancing healthcare teams’ access to these tools for precision ecologic medicine will require substantial resources but is necessary to managing climate impacts on health.

We must also prioritize equipping and training the next generation of healthcare teams to be prepared for these challenges. ²⁹ Training the next generation of primary care providers in understanding the impact of climate changes on disease risk, health care delivery adaptation, and disaster preparedness. Curricula and programs to build these skills are becoming more common across healthcare training settings (eg, medical schools, nursing schools, and residencies).^30-32

Beyond Precision Ecologic Medicine—Community Surveillance Systems

This commentary focuses primarily on the urgent need for healthcare systems to adopt precision ecologic medicine approaches by incorporating community vital signs data into care plans as a step toward mitigating the impact of climate change on health. Beyond individualizing care based on ecologic context, we propose that such data could be used to enhance population-level health efforts and community resilience plans for climate adaptation. For example, healthcare systems can contribute EMR data to surveillance systems that need granular data on both individual- and neighborhood-level health outcomes. Geospatial mapping platforms enable combining and displaying various data on medical conditions and health outcomes, socio-economic factors, and environmental exposures; these data can be used to understand health risks in a community.^19,33,34 This understanding would inform community leaders and policy makers looking to make strategic investments to mitigate and prevent climate impacts on frontline communities. ³⁵ For example, as wildfire seasons grow longer, population rates of respiratory illness, cardiovascular disease, mental illness, and related conditions will increase in exposed communities.^36,37 If we know which communities are at highest socio-environmental and medical risk, we can support them proactively rather than waiting for them to suffer during a severe storm/heat event/poor air quality week.

An example of how such surveillance systems could be developed and used is the Oregon ESSENCE program, which is a collaboration between the Oregon Health Authority (OHA) and The Johns Hopkins University Applied Physics Laboratory. ³⁸ This system is designed to monitor what is happening across emergency departments and hospitals within Oregon during public health emergencies, gathering the necessary information that can be used to create policies to mitigate disease and death in anticipation of future public health emergencies.

Although our vision for precision ecologic medicine is focused on helping healthcare teams provide tailored care, we also recognize the need for healthcare systems to be actively involved in efforts to reverse the devastating climate degradation that is happening, including reducing their direct role in contributing to the problem. For instance, the healthcare system (hospital, clinics, medication fabrication, ³⁹ use, and waste) contributes to 7% to the total U.S. greenhouse gas emissions.^40,41 Several U.S. and global initiatives to promote green hospitals and reduce waste and pollution are important steps forward.^40,41

Conclusion

Socioeconomic and environmental risks greatly impact morbidity and mortality, and can influence health outcomes more powerfully than medical care does. Patients with fewer economic options, and already experiencing a high chronic disease burden, often must live and work in areas most impacted by climate change. As they experience extreme weather events on top of other stressors, their healthcare teams need the tools to use precision ecologic medicine approaches to help inure them against climate-driven health impacts. As calls to individualize clinical decision-making based on precise genetic data increase, it is imperative to also develop and test precision ecologic medicine approaches which must involve incorporating relevant community-level data into health care provision.

Climate change-induced extreme weather events will become more severe and frequent as temperatures continue to rise in the thermal inertia that is unavoidable for the next few decades. As adverse health effects will intensify during this time, the proposed precision ecologic medicine interventions will be critically important to population health. Precision ecologic medicine approaches could both mitigate climate change impacts on human health and potentially reduce economic drivers of increasing U.S. healthcare costs by reducing the burden of disease affecting frontline communities. ⁴² The ideas outlined here highlight the need for innovative methods that go beyond traditional reactive hospital-centered medical care to patient-centered holistic approaches that account for patient context. We need a clear vision, technological infrastructure, healthcare transformation, educational interventions, and support for frontline primary care teams to partner with local community organizations to address and mitigate the impacts of climate change on health. Lacking these, our healthcare system will fail to meet the needs of patients and communities in the face of climate change.