David Posch
David Posch, M.S.
CEO of Vanderbilt University Hospital and Clinics
What are the major changes that you think will come to Vanderbilt and the Medical Center over the next10 years?
When I think about a 10-year horizon, a top consideration is that the advance of science is accelerating, and with it our ability to quickly translate new discovery into clinical practice. There is the science of health and there is also a science of work design, and we’re trying to create a confluence between the two, so that as scientific discovery occurs we have a capacity to express it in highly reliable, efficient systems of care delivery.
I’d also say that we are moving away from the idea of episodic, problem-focused care of patients, to thinking more about populations and about each patient’s health over a longer period of time. Ten years from now, I imagine an extraordinarily well-connected system of care that ties together the various disciplines and the various elements of the care process in the home, in ambulatory care settings, in emergent care settings, in the hospital and in post-acute care settings. We truly will have connected those environments together extraordinarily well, environments which historically have not been well- connected.
Where do you see the seeds of those changes now?
Regarding the translation of new discovery into health care, an example can be seen now in our efforts to deliver pharmacogenomic knowledge to the clinician, in real time, for appropriate decision-making based on the patient’s genotype.
In terms of a more well-connected systems of care, there’s our work on care transitions between patient care settings, and our efforts to leverage our electronic records systems to continually predict and anticipate patient needs. Examples include the Anticoagulation Clinic, My Health Team at Vanderbilt, what we’ve done in ventilator-acquired pneumonia and what we’ve done more generally in the ICUs in terms of designing work that is evidence-based and extraordinarily reliable.
We’ll be applying principles of work design on bigger problems and bigger populations of patients across the whole continuum—cueing teams about what exactly needs to be done based upon what’s going on with the patient; deploying evidence to support decision-making processes; and ensuring that we don’t have gaps in care and that everything that evidence would suggest needs to be done has in fact been done on those patients
Does eliminating gaps in care presuppose a different payment model than what we have today?
Part of what we’ve got to deal with in the next 10 years is that the amount of money we’re paid per unit of service will go down—no question about it. Secondly, economic risk will be moved, in part at least, from the payer to the provider. For example, if somebody has coronary heart disease, we’ll be responsible for all the care for that individual for a defined period of time, to include hospitalization, angioplasty, open-heart surgery and other procedures, physician services, post-discharge care—all for one price.
While changes like this are likely to occur with reimbursement, we will still have a period of time during which we will have mixed payment models and potentially conflicting rewards. However, even in the current fee-for-service model, by applying proper evidence and eliminating gaps and anticipating needs, while you may avoid things that pay a lot of money (like hospitalizations and surgical interventions), you will have also liberated capacity, and that means you now have the space and the machine technology and the human resources to see another patient who needs you.
So I think the answer is that you don’t use the reimbursement system and the current rewards structure as an excuse to not do the right thing; instead, we focus our efforts on achieving care coordination, achieving the rigorous and reliable application of evidence, and achieving the engagement of our patients and families in their care process, all to get to higher levels of quality and value. Doing this work has the potential to be less resource intensive and to eliminate countless examples of re-work on patients that occur today. Success in these efforts can create the opportunity to liberate capacity and use it to take care of an even larger portion of the population than we serve today.
What is happening now at Vanderbilt that has a chance to have impact all over the world?
I think our work in genomics and proteomics, and the relationship of those to drug therapy, has an enormous opportunity to have impact on a very broad scale. I would also say that our efforts to more broadly integrate best evidence directly into the care process in real time to assist decisions and/or cue action also has very significant potential impact.
The work methods by which we do this can be informative to others. Dr. Stead [VUMC chief strategy and information officer] and others in cognitive theory talk about an exploding volume of biomedical knowledge having overwhelmed the cognitive abilities of individual clinical decision-makers. Thus the need now to bring informatics capabilities to that decision-making matrix. We’re doing that. And now we’re getting into personalized medicine, where we’ve begun to tailor therapies based on patients’ genetic and proteomic data. We are really pushing that front right now and that is without a doubt where we’re really going to make an impact.
What are the biggest obstacles or challenges Vanderbilt and the Medical Center will face in the next 10 years?
I think the money will be a challenge. The rapidity of changing reimbursement models, and the rules and regulations that will come from outside that we have to adapt to, creates a lot of internal challenge. It means having to change quickly, simply to keep in balance the overall financing of the enterprise. I think that we have an extraordinarily strong culture as an organization that is engaged in trying to make a real difference for our patients and to the health system in general. As we get challenged with changing financial models, it pushes and challenges that culture. I think we’re going to have to manage it very carefully, to not have people get cynical, but to keep focused on our aspirational goals and what we can achieve
What are your hopes for Vanderbilt and the Medical Center in the next 10 years?
What we’re learning is that health care today really requires teams. And those teams are not necessarily stable. By that I mean that teams of different people form on various problems we face very quickly. I believe the need to do this will accelerate. So our success as an organization is one where individuals bring expertise and a capability of moving into different kinds of teams very quickly to solve problems and then move on. This allows for a very innovative, flexible organization. As you create that innovation, you have to have an operating platform—the combination of people, process and technology—that allows that innovation to get embedded into your normal operation and scaled very quickly for large populations
I think the organization that can master accelerated innovation and change its fundamental operating platform to accept innovation quickly is going to be the superior performing organization in health care in the future. I think this next decade is one during which there will be a fundamental shake-out of health care organizations. The organizations that are capable of innovation and change are going to be those organizations that excel. I think Vanderbilt is capable of doing that. That’s really my hope. I think that not only do we push what medical science discovers, but we also push the whole idea of creating a health care organization that can express that science reliably, quickly and at scale for a broad population of individuals.
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