I have written quite a few articles about the concept of a learning health system. I was inspired by a recent talk by Clay Johnston, M.D., Ph.D., M.P.H., dean and vice president for medical affairs at the brand-new Dell Medical School at the University of Texas at Austin. He made the case for rethinking how academic medical centers define research and care.
Johnston gave a barn burner of a talk on June 1 in an NIH Collaboratory Grand Rounds session. His title was: “How Would You Build an Academic Medical System to Bridge Research and Care if You Could Start from Scratch?”
Later in his talk Johnston provided a few examples from the Dell Medical School of how they are re-inventing clinical pathways and embedding research into clinical improvement activities. But he started with something of an indictment of the current setup of academic medicine.
He pointed out some uncomfortable truths about how medical centers improve (or don’t). He argued that there is a disconnect between care and research because provider organizations are not investing much in studying care.
“When we think about prestige, it is more connected to basic discoveries. Often we don’t appreciate and value the discoveries that are made toward transforming practice,” Johnston said.
How much research and development does the provider industry actually support? “It is actually pitifully low either as an absolute number or as a percentage of total spending on research and development,” he said. “Medical device and pharmaceutical/biotech organizations spend a fair amount of what they generate to move the ball down the field. But provider organizations are really not investing in research and development that would move us forward.”
What about government research spending? Johnston notes that PCORI is spending $200 million and NIH approximately 1.4 billion for health services research, or 4 percent of the NIH budget. But he noted that that is less than what is spent on stem cell research. “So, if you look at our funding priorities, one could say we value stem cell research more than we value health services research,” he said.
In making the case for more investment in health services research, Johnson argues that our healthcare system is broken. In spite of the United States being such great innovators in healthcare, that fact hasn’t translated into improvements in health outcomes, at least in terms of life expectancy. The United States is 34th in world rankings — between Costa Rica and Cuba. “It is even worse when you graph that against how much we spend per capita,” he added. “We are not getting the bang for the buck from whatever innovations we are doing in the healthcare system. They are not leading to changes in life expectancy. That is getting worse and not better. There are many contributing factors to this. I am not saying it is all due to healthcare. But it does show a disconnect. One would expect with huge investments that we would be getting it more right over time, and we are not.”
Contributing to the disconnect between care and research is that we are not studying care, he claims. “We are comfortable and have come to accept that 80 percent of what we do is not based on evidence. We are comfortable with the fact that health is eroding despite increased expenditure,” Johnston added. “We are comfortable with the fact that our provider entities are not investing in moving care forward and that the government is investing, but not very much.”
He argued that although there is a lot of prestige associated with basic research, and discovery is in fact very important, it is not linked to the outcomes we are trying to achieve on the care side. Exacerbating that is the way we get our research ideas funded, he added. A lot of grant proposals don’t get funded and many that do won’t produce results that really matter. A lot don’t get translated into subsequent improvements in health and the lifecycle is too long. “I just finished a clinical trial I proposed 19 years ago,” he said. “That is not typical, but it isn’t that atypical. These cycles are in the 5- to 10-year range.”
Johnston argues that our research efforts are not well aligned to solving problems in the healthcare system. “We have come to accept this system and just nod and move forward,” he said. “It is like a rock that we just accept that it is too hard to move. And that is the nice thing about starting from scratch,” he added. Dell is a brand-new medical school. Its third class of students is just arriving. The University of Texas-Austin didn’t have one, so the community voted to increase their property taxes to fund it. “That allowed us to be nicely linked to the community and think about how to stay better aligned with society’s interests in health,” he said. “What is the role that research plays in that?”
Dell is looking at how it can accelerate research and improve care by bringing those two together. Johnston said it wants to accelerate a many-year cycle of innovation by embracing the need to “constantly propose ideas, build programs, create products, measure the outcomes, and iterate much more rapidly and much less expensively, as part of what we do as a caring organization.”
Johnston gave an example from Dell of designing care around the needs of the individual. In a joint pain clinical program, Dell is focused on improving outcomes and reducing inefficiencies, meaning things that don’t contribute to outcomes. “We understand that how someone works their way through our system is important to whether and how quickly they will achieve a good outcome.”
Joint pain was a priority for the community. There was a waiting list of 14 months to be seen by an orthopedic surgeon by people with joint pain among over 1,500 patients in the safety net population. They did a complete redesign of care plans for joint pain starting from scratch. It used human-centered design and created a system that included:
• Appropriate triage
• Physical Therapy/Training
• Risk Factor Management
• Constant Measurement and Adaptation
There are a number of patient-reported outcomes, including ones related to emotional state and depression. There are a lot of outcome measures related to pain and function. Those are constantly measured and the system adapted over time. “That has been running for 18 months and the results are excellent,” Johnston said. “There is no more waiting list. It took two months to get through the waiting list. The outcomes are substantially better than what happened before, and the costs are substantially less.”
Is this a research project or is it clinical care? “It is the best clinical care we can deliver focusing on innovation in the areas in which there are opportunities to improve,” Johnston said. “We are collecting such data that we can make course corrections. Will we write papers based on it? I am sure we will, but those will be retrospective. It is not the primary purpose,” he said. “The primary purpose is to provide great care. Once you are disciplined around providing great outcomes, then you are collecting data, and the environment is nicely set up to do research.”
Part of what Dell is trying to do is think differently about what “true north” is, Johnston said. He argues that for many academic medical centers, true north is prestige. “What if we were just about improving health? What if our goals were aligned better with society and what if improving health in the best way possible would be aligned with our financial incentives?”
He noted that this would require a change to value-based care and population health modes — and there are a lot of external forces pushing in that direction. “We are just pushing back because we don’t know how to do it, it sounds scary and it is not the way we have done things.” But the financials could align with improving health in the community and then at least part of the research portfolio could then be around what is needed practically to provide the best care possible and keep people healthy. “That would keep us beautifully aligned and very directly allow us to advance a research agenda that really matters,” he said. “Research could then become a differentiator and a competitive advantage like it is for every other industry.”
He admitted all this may seem like a fantasy, but he doesn’t believe it is that far off. “We have seen other industries make these kinds of transitions. This is a great time to think about how we can do things differently.”