My Involvement in APM/AAIM

Transcription

1 My Involvement in APM/AAIM 2001 Led the APM Long Range Planning process 2002 APM Board Member 2004 Released Long Range Planning report, which proposed that AAIM organizations (APM, APDIM, AIM, ASP, CDIM) be more fully integrated. Staffs were combined, President Craig Brater was appointed, and Board of Directors representing the 5 entities was formed 2006 Received the APM s Robert H. Williams award Redefining Academic Medicine for the Future Victor J Dzau, MD President, National Academy of Medicine February 26, 2016 Association of Professors of Medicine

2 History of Academic Medicine William Osler often considered as the father modern academic medicine and revolutionizing medical education, bedside teaching and residency training Along with others, Osler created the academic medicine model at Johns Hopkins. Flexner Report of 1910 The Classic: The Principles and Practice of Medicine Emergence of the clinician-scientist Source: US National Library of Medicine

3 Academic Medicine Breakthroughs Braunwald Brown Goldstein Cushing Thomas Osler Salk Blumberg Varmus Seldin Starzl Murray, Merrill, Harrison Harrison Lefkowitz Historic success of Academic Medicine & model of Physician Scientist Triple threat model Strong department chairs/leaders & role models Resources to support academics Important events influencing AM: o 1948 NIH federal funding of research. o 1950s Private employment insurance o 1965 CMS federal funding of healthcare o 1984 CMS Prospective Payment System Based on diagnosis related groups. Supports teaching hospitals with ~ $ 10 billion dollars per year.

4 Evolution of AMC In 1945, 3500 full time faculty members at US medical schools; Johns Hopkins had budgets of ~$2m. By 1965, the golden era of NIH, full time faculty in the country had grown to 17,000, and the most prominent schools had budgets of ~ $20 m. Approximately 60% of a typical medical school s budget is from federal research spending. By 1980, clinical income from faculty practice accounted for 50% of the revenue of the country s medical schools. In 1990, there were ~ 85,000 full time faculty members at US medical schools, with almost all the growth in the clinical departments. The most prominent schools budgets of ~$400 m. Since then, hospitals are the major generator of revenues, with budgets greater than schools by several fold. Challenges confronting AHCs Complex organizations Balance between academic and clinical missions Research & clinical funding NIH budget Academic subsidy US health care reform impact Future of physician scientists

5 Changing Biomedical Research Landscape Decline in NIH funding NIH s purchasing power has been cut by about 30% compared to a decade ago [[Finally some relief 2016]] Decline in pay-line & number of research project grants and R01 awards Age of principal investigators is increasing Proportion of NIH R01 principal investigators age 66 and over is increasing while the proportion of those age 36 and younger is decreasing cents subsidy required for every $1 of NIH direct cost Depends on annual subsidy from clinical enterprise, endowments & philanthropy Change in Healthcare: ACA (2010- ) Current State Future State Producer-Centered Volume Driven Unsustainable Fragmented Care FFS Payment Systems Increases coverage-17.6 million previously uninsured people are now insured Reduces Medicare spending by $600B+ over 10 years People-Centered Outcomes Driven Sustainable Coordinated Care New Payment Systems and Policies Value-based purchasing ACOs, Shared Savings Episode-based payments Medical Homes and care management. Data Transparency

6 NEJM (2013) (2009) (2013)

7 AHCs should aspire to lead the transformation of healthcare Reorganizing biomedical research and health delivery systems into a seamless continuum from discovery to clinical delivery to community health. Moving from Academic Health Center (AHC) to Academic Health Sciences System (AHSS). Bench to Bedside to Population Integration of care delivery with population health Seamless translational model of discovery-care continuum Effective use of information for care & research : Learning Health System Emphasize & accelerate Innovation Community & Population Health Globalization Dzau VJ et al, Lancet 2009 Dzau VJ et al NEJM 2013 Innovation to transform health & healthcare Traditional perspective of innovation in medicine Driven by research Funded primarily by NIH, other federal sources and industry Conducted mainly in academic medical centers Emphasizes bench to bedside Transformative innovation is needed to drive fundamental changes New models of care Disruptive technologies Patient centered, community based Multiple disciplines

8 The health innovation spectrum New Programs and Procedures (Clinical Innovation Firsts) New Devices, Diagnostics, and Technology Platforms (Product Innovation) New Care Delivery Models (Process Innovation) Examples Walk Again hand transplant Patient facing apps Clinician facing apps Devices Care Redesign Systems Engineering New Models of Business (Business Model Innovation) New Approaches to Supporting Transformation (Organizational Innovation) Research Funding Sources NIH Industry Foundations and non-profits Philanthropy Other sources PCORI CMMI AHRQ

9 Learning Healthcare Systems Healthcare research & innovations are slow to disseminate into clinical practice. Research is generally seen as a separate activity instead of being integrated with clinical practice. A learning health care system is one in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation, with best practices seamlessly embedded in the care process, patients and families active participants in all elements, and new knowledge captured as an integral by-product of the care experience. IOM (2007) AHC as a living laboratory Use of integrated clinical & research data to develop care redesign and novel care model Use of large datasets and informatics to improve health Use innovation to transform health Developing the innovation culture, ecosystem & infrastructure Source: IOM Roundtable on Value & Science-Driven Health Care, The Learning Health System Health IT Ecosystem

10 Areas of Opportunity Data & quantitative sciences Public & population health Global health Precision medicine Regulatory & implementation sciences Behavioral & social sciences Science & Technology Omics & biomarkers Regenerative biology & medicine Bio & tissue engineering Synthetic biology Combinatorial chemistry Sensing technologies Computation, big data and analytics

11 Future in Science & Innovation Strained traditional research funding Enhanced research in clinical care and health care delivery Expanded the definition of innovation Novel relationships & financing Imperative to maintain the proper balance between curiosity-driven, basic research and applied research Education: Prepared for Changing Paradigms Current HPE: Teaches disease-centered care Emphasizes acute care Is fragmented and poor teamwork Episodic encounters rather than continuous care Provides insufficient understanding of community health Provides little training on use of information systems Mismatch of competencies to patient and population needs Needed skills and competencies Social and economic health determinants Primary care + public health New technologies Data collection and analysis Policies, systems, regulations Leadership & management Interprofessional & collaborative skills

12 Multiple levels of learning Level Objectives Outcome Informative Information Skills Experts Formative Socialization Values Professionals Transformative Leadership attributes Change agents Frenk et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet Develop a right-skilled and efficient workforce The evidence instead suggests that, although the capacity of the GME system has grown in recent years, it is not producing an increasing proportion of physicians who choose to practice primary care, to provide care to underserved populations, or to locate in rural or other underserved areas. The key themes: 1) GME has an obligation to train the providers that the country needs 2) GME programs should focus on trainee outcomes as a measure of accountability 3) GME funding structures should support accountability & innovation

13 Develop a right-skilled and efficient workforce Educate to the highest level possible Learning Health System Curriculum The Institute of Medicine (IOM) has set a goal that, by the year 2020, at least 90% of clinical decisions will be supported by accurate, timely, and up to date information that reflects the best available evidence (i.e. becoming a learning healthcare system) Preparing clinical leaders to meet the expectations of the Learning Health System requires a bold and innovative curriculum that teaches the skills needed to acquire and manage clinical data, and incorporate the aggregating knowledge to inform and transform clinical practice. In January 2014, Duke launched the Learning Health System Training Program to develop the physician leaders for 21st century Learning Health Systems. Output: Comprehensive strategy for TEACHING and INTEGRATING evidence (local and clinical trial) into practice, allowing Duke to LEAD the transformation of training and future practice towards the needs of a 21 st century health system

14 Duke Learning Health System Training Program Program Director: Aimee Zaas, MD, MHS Implementation of Curricular Goals Acquisition of analytic skills Boot camp Introduction to core LHS concepts Sessions on research and statistical methods Understanding of regulatory boundaries for QI work Familiarity with DUHS Data DEDUCE Training Introduction to Performance Services Connections with key informants in DUHS who can further access systems based data Project Development/Delivery Working with DUHS operational leaders to determine systemwide priorities for projects Using analytic skills and data to understand problems and possible solutions Applying project results to drive iterative improvement and outcomes assessments Health Leadership Development: Vision There is a growing demand for trained leaders with real-world experience and innovative approaches to healthcare leadership Initial goal to train current and future leaders across health care in four themes Leadership, Management, Innovation, Quantitative health sciences Longer term goal to contribute to developing the workforce of the future New roles across clinical and non-clinical care to enable task shifting, care teams, and coordination Dzau VJ 2014

15 Creation of Leadership and Management Programs Management and Leadership Pathway for Residents (MLPR) months of project driven management rotations/modules combined with clinical training. Rotations aligned with clinical requirements, trainee interests, and institutional priorities where trainees are teamed with DUHS senior leadership Chancellor s Clinical Leadership in Academic Medicine Program (C-CHAMP) Provides a management toolkit for mid-career clinicians, that allows them to lead and grow their departments and divisions with increased efficacy. The Master of Management in Clinical Informatics (MMCi) MMCi represents an innovative curriculum that develops the workforce of the future to address the needs of people who are fluent in the use of data to drive strategic decision making. Health Leadership Development Duke Medicine is defining a Health Leadership Development core curriculum, from which we can create multiple learning experiences from customized training to degree programs with an initial focus on clinician leaders The Training Continuum Competencies Executives MBA, MHSA (future) Faculty CCHAMP, MMCi, LEADER Residents & Fellows MLPR, Master in Clinical Leadership Medical Students PCLT, Feagin, LEAD, MD/MBA Undergraduates High School Students (City of Medicine Academy) Strategy Healthcare Ethics Negotiation Healthcare System Overview Leadership Customer Relationship Management Managing Human Resources Innovation Financial Decision Making Marketing Effective Decision Making Quality and Safety Management Finance Service Operations Healthcare Law IT for Healthcare

16 Importance of the Physician Investigator The Nobel Prize in Chemistry 2012 Importance of the physician scientist Vital in transforming clinical observations into testable research hypotheses and translating research findings into medical advances bedside-to-bench and the bench to bedside approach Valuable teachers to medical students Over the last 25 years, 37 percent of Nobel Laureates in Physiology or Medicine had an MD Over the Lasker Awards last 30 years, 41 percent of the Basic Awards and 65 percent of the Clinical Awards have gone to MDs

17 Challenges Facing Physician Scientists Personal Debt-burden Work-life balance Compensation Training Environmental- funding Institutional- mission tension Societal Future Needs Increase and stabilize research funding Align the number of scientific training positions and careers Align and incentive careers with how research is now conducted - Team science Broaden career paths for physician scientists Creating an a culture that fosters scientific discovery Rethink and expand the definition of physician scientist consistent with trends in health & medicine

18 Opportunities for physician scientists Discovery Science Translational Science Interdisciplinary research Data & quantitative sciences Public & population Health Behavioral & social sciences Regulatory & implementation sciences Some thoughts Listen to the young people? Not just talking to ourselves? Concentrate on what works: evidence? Define resources & scale Bold curricular & pathway reform Be Adaptive & Resilient Be clear on our goal

19 AHS will require a Global Perspective Addressing global needs o Health Inequalities, Emerging Infections, Global Burden of Chronic Diseases o Service with Learning & Research, Healthcare Management Globalization of missions o Clinical Care o Research o Education o Policy Redefining Academic Medicine From Reductionist to Systems Approach Multidisciplinary Sciences (medical & non-medical) From Individual to Team Science Molecules to Population Health Big Data & Information Science From Discovery Science to Translational Science, to Healthcare Delivery Science, Improvement Science & Regulatory Science. Bench to Bedside to Population Discovery to Care Continuum Regional to National to Global

20 Redefining and Redesigning Ourselves Academic Health Centers have led in training the clinicianscientists that innovate in the area of discovery science. However, society expects more from us today. In the future, we will have to redefine ourselves to focus not only on discovery science but implementation science in the transformation to how we best care for patients, addressing their health needs through population health management. The AHC of the future will form closer partnerships with the community, our patients, and the faculty who represent the broader University. We have certainly evolved since the days of proprietary trade schools, but the evolution will only continue as we find new ways to educate the provider of the future that is needed to accomplish the goals of cost, quality, and access Thank You

21 Appendix Innovation presents a promising avenue to transform health & healthcare Status quo or incremental changes will not be adequate to meet growing challenges of access, cost & quality locally or globally Transformative innovation is needed to drive fundamental changes New models of care Disruptive technologies Novel training and workforce development programs Organizations that embrace and support innovation will be best positioned to lead

22 Innovation to transform health & healthcare Traditional perspective of innovation in medicine Driven by research Funded primarily by NIH, other federal sources and industry Conducted mainly in academic medical centers By researchers often away from practice Transformative innovation is needed to drive fundamental changes New models of care Disruptive technologies Novel training and workforce development programs Foundational elements: Digital Infrastructure Public Health Research Clinical Systems Clinical Research Patient / Family Data Warehouse Scientific Discovery / Omics Infrastructure / HIE / Security

23 How we have gone from research-intensive institutions to clinical-intensive Focus on specialized procedures and patients as opposed to routine clinical care (1900-WWII) Increase in Employer-based coverage (post WWII) Increased the focus on clinical care as more people had the financial means to be seen for routine care Creation of Medicare and Medicaid (1965) After the passage of Medicare and Medicaid, the clinical responsibilities to care for patients covered under these plans became a lot more demanding. Increasing the clinical focus on education Creation of HMOs (1990s) Margins at teaching hospitals suffered at AHCs as insurers became less willing to pay additional costs to academic centers Affordable Care Act (2010) and the Future? Source: Ludmerer, K. The Development of American Medical Education from the Turn of the Century to the Era of Managed Care. Clinical Orthopaedics and Related Research Research Funding Sources NIH Industry Foundations and non-profits Philanthropy Other sources PCORI CMMI AHRQ

24 Need a 21 st century education reform Frenk et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. The Lancet Projects Using Available Data Sets to Define a Clinical Problem: Quantifying Observation Admissions to DUHS Large Scale Quality Improvement for Multi disciplinary Problem: Maternal Mg Protocol and Neonatal Bowel Perforations Improving Care at Duke Using Duke Data and an External Data Platform (ERAS) and Cost Saving Using an Expensive Medication Using Available Data Sets to Define a Clinical Problem: Quantifying Observation Admissions to DUHS Trailblazers & Year Incoming Cohort Neonatology Internal Medicine Resident Neonatal Perinatal Fellow Adult /Peds Rheumatology Nephrology Surgery Resident Pulmonary/Criti cal Care Rheumatology Hematology/On cology Maternal Fetal Medicine Internal Medicine Resident Infectious Diseases 48

25 Global Collaborations Across the Discovery to Care Spectrum Discovery Science Experimental Medicine Clinical Trials Implementation Science Global and Population Health Duke NUS Graduate Medical School (Singapore) DGHI initiatives; IPIHD (Worldwide) Medanta Duke Research Institute Jubilant (India), collaborations SingHealth (India) IMU (Singapore) Medanta SCRI (Singapore), Duke Research Institute BCRI (Brazil) (MDRI) Tata Medical Center (India) National Medical Holding, Nazarbayev University (Kazakhstan) Clinical Research Education and Training (CREATe) China International COE for Chronic Disease Prevention(China) Clinical Research PUHSC Duke Cardiology Education and Training Training Center (China US) (India) Dzau et al, Lancet Enhance inter- and trans- professional practice Transdisciplinary professionalism: an approach to creating and carrying out a shared social contract that ensures multiple health disciplines, working in concert, are worthy of the trust of patients and the public. Cruess, R., and S. Cruess Professionalism and medicine s social contract with society. Presented at the IOM workshop Establishing Transdisciplinary Professionalism for Health. Washington, DC, May 14.

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27 Academic Medicine Breakthroughs Baruch Samuel Blumberg co recipient of 1976 Nobel Prize for his work on the hepatitis B virus Michael Stuart Brown, Joseph Leonard Goldstein co recipient of 1985 Nobel Prize for describing the regulation of cholesterol metabolism Harvey Cushing father of modern day brain surgery E. Donnall Thomas co recipient of 1990 Nobel Prize for their discoveries concerning "organ and cell transplantation in the treatment of human disease William Osler father of modern medicine Jonas Salk developed a vaccine for polio Thomas Starzl performed the first liver transplant Joseph Murray, John Merrill, Hartwell Harrison performed the 1 st Kidney Transplant (Nobel Prize) Eugene Braunwald groundbreaking work in defining therapies for ACS & HF Nobel Prizes: Harold Varmus, Robert Lefkowitz Tinsley Harrison: editor of the first five editions of Harrison's Principles of Internal Medicine Donald Seldin: Dr. Seldin is widely revered as one of the greatest chairs of Internal Medicine in American medical history. He has trained literally thousands of medical students and residents, and many of his students occupy high academic positions. He is considered the intellectual father of UT Southwestern Medical School. Evolution of Academic Medicine Medical Schools & teaching hospitals Emphasis & approaches Financing of the Academic Medical Center 1900 Proprietary Trade Schools Non scientific, empirical approach to diagnoses and treatment of medical conditions No systematic financing for research. Most support of medical schools coming from tuition dollars Medical schools based in universities with affiliated teaching hospitals Today Medical schools with aligned/ integrated with hospitals and health systems = Academic Health Centers/systems Emphasis on acute hospital care and bedside teaching. Research on pathophysiology. Emphasis on vaccinations and new surgeries (transplant) through increasing understanding of disease and human body Integrated care: acute to chronic & community care NIH 1948 federal funding of research. CMS established 1965 Employer funding of health insurance Today, very dependent on NIH, subsidized by health system & faculty practice

28 CMMI: Innovations Portfolio o Accountable Care Organizations (ACOs) o State Innovation Models Initiative o Primary Care Transformation o Bundled Payment for Care Improvement o Capacity to Spread Innovation o o Initiatives Focused on the Medicaid Population Medicare-Medicaid Enrollees o Health Care Innovation Awards Modified from Patrick Conway, Deputy Administrator for Innovation and Quality & CMS Chief Medical Officer Agenda History of Academic Medicine Current Challenges facing Academic Medicine Academic Medicine and the transformation of health and medicine Discovery-Care Continuum to Population Health Leading innovation Educating for the future Global impact Preparing for the Future

29 Evolution of Academic Medicine Medical Schools & teaching hospitals Financing of the Academic Medical Center 1900 Proprietary Trade Schools No systematic financing for research. Most support of medical schools coming from tuition dollars Medical schools based in universities with affiliated teaching hospitals NIH 1948 federal funding of research. CMS established 1965 Today Medical schools with aligned/ integrated with hospitals and health systems = Academic Health Centers/systems Employer funding of health insurance Today, very dependent on NIH, subsidized by health system & faculty practice