Looking to the Future on Nashville Medical News

Looking to the Future

By: CINDY SANDERS

William W. Stead, MD, associate vice chancellor for Strategy/Transformation and chief information officer at VUMC

Vanderbilt Vision 2020

Measure... innovate...engage... impact – these four simple words hold the key to Vanderbilt's vision for the future of healthcare and serve as a directive for the academic medical center to affect change on a local, regional, national and international level.

Despite past successes, the leadership at Vanderbilt University Medical Center finds the current national model of care, research and teaching is unsustainable. Mounting economic pressures have reduced available federal funds for both delivery and discovery. The cost of delivering healthcare has risen at a pace that outstrips inflation. Uncompensated care has climbed dramatically over the past several years. In the face of increasing costs, employers and government entities are seeking ways to reduce their healthcare expenditures and thereby improve their international competitiveness. And there is a growing dissatisfaction across the public and private sectors with the nation's current healthcare system. Add to this an aging population that faces increased risk for chronic ailments through poor behavioral choices, and it's easy to see why clinicians, researchers and policy experts have all set their sights on creating disruptive change to turn the tide on these negative trends.

Even with enormous investment in care, the United States lags behind most industrialized nations in terms of health status and mortality. As a nation, we're spending more and receiving less. To shift this paradigm, William W. Stead, MD, associate vice chancellor for Strategy/Transformation and chief information officer at VUMC, has worked with colleagues across multiple disciplines to craft Vision 2020... a plan to "aggressively address the unprecedented challenges we face in science and healthcare."

Stead explained, "We fairly quickly decided the medical center had reached a point where we needed to consider a major change in trajectory.

"Our historic role was to educate people, discover knowledge, and take care of people we could touch directly," he continued, noting the emphasis has always been on "inputs." Stead added, "Our focus was not on the collective outputs, which is how do we change health status locally and globally."

Now, he said, that emphasis is shifting. "We think it's time for us to take a much more active role in trying to achieve the change in health status that we think is both needed and possible."

Citing McGinnis & Foege, "Actual causes of death in the United States" (JAMA 1993: 270(18): 2207-12) and the more recent McGinnis, Williams-Russo, and Knickman, "The case for more active policy attention to health promotion" (Health Affairs 2002; 21(2): 78-93), Stead said shortfalls in medical care as we know it today only account for about 10 percent of early mortality. Other causes include:

Behaviors: 40 percent;

Genetics: 30 percent;

Social Interaction: 15 percent; and

Environmental toxins: 5 percent.

"So if we want to make a significant improvement in health status, we've got to go after those other factors... not just continue to focus on healthcare as we know it," he said.

The reason Stead and his colleagues believe Vanderbilt is in a position to make a difference is three-fold. First, the center does have strong roots in clinical care and research. Second, through the informatics department, the staff has broad access to scientific tools that create a decision-making environment founded on evidence-based medicine. Finally, Stead said, Vanderbilt is situated in a community in which many leaders of the healthcare industry are headquartered and in a state run by a governor with a unique and intimate understanding of the industry.

"We think the whole approach to healthcare is going to have to happen from the inside -— not the outside. We think it's going to take a completely different approach," he noted.

Stead believes the answer lies in shifting to individualized medicine but away from individual experts.

"On one hand, we need a personalized or individualized approach to health or healthcare where we take advantage of knowledge about the individual ranging from their molecular makeup based on their genetics to their values and resources to do the things that are effective for them that might not be effective for others," he explained.

At the same time, he continued, "We believe that we've got to shift away from an approach to care that is centered around an individual expert – that's the way I was trained – to a systems approach where we systematically take the scientific evidence and develop individualized... but standard... systems of care."

At the heart of Vision 2020, Stead said, is the determination to figure out how to measure results and then find innovative ways to fill the gap between current performance levels and what is possible, taking into account human nature. Innovation, however, is useless without collaboratively engaging those who can make implementation a reality.

"When we're talking about engaging, we're really talking about crossing boundaries to get the uptake," he said, adding that Vanderbilt is ready and willing to work with other facilities and private entities in the community and beyond to achieve desired outcomes.

Already, the Center for Better Health, which was formed in 2002 as VUMC's transformational arm, has served as a neutral zone to bring together stakeholders from across different organizations to incubate ideas and debate various solutions to looming problems.

"We don't think Vanderbilt itself can do all these things," Stead stressed. "What we think Vanderbilt can do is work out the methods."

The Memphis Project is an example of using Vanderbilt's informatics expertise to come up with a viable approach to the electronic health record. For $2 per citizen per year, the six competing hospitals in Memphis plus clinics and practices throughout the city have secure access to an individual patient's full health record, thereby improving quality of care. By using an informatics approach rather than a database approach, participating facilities didn't have to automate in order to have access... turning an unwieldy, expensive nightmare into a cost effective, highly manageable solution.

It's this type of change in approach, which is quite different from the way business is usually conducted, that Stead and his colleagues believe will ultimately transform the American healthcare system. Although ambitious, Stead said it wouldn't be the first time medicine had gone through a dramatic transformation in this country. Almost 100 years ago, the healthcare industry faced a similar sea change when science was injected into the "art" of medicine. Stead expects a similar revolution will be needed to change the current path.

"We're not going to be able to do it by a little tweak to what we do today," he warned. "We're talking about a shift in the approach to health and healthcare over the next 15 years that is as drastic as the shift that occurred in this country at the beginning of the last century."

Measure... innovate... engage... impact – with the clock ticking, VUMC officials have begun to share their vision with other key stakeholders in the hope of leading the transformation in how we view health and healthcare in this country.