The age of computer-driven health information has arrived, and entrepreneurs are rapidly developing the products that eventually will wire the clinical enterprise and may well transform the world of academic medicine. While this veritable information revolution holds great promise for improving medical care, educating students, and informing consumers, it also poses threats to the professional traditions of medicine at a time when practitioners are already reeling from other powerful forces of change. The Association of American Medical Colleges (AAMC) attaches such importance to the role that advanced information and communication technologies will play in the health care system that on December 4, 1998, it devoted the final meeting of the Forum on the Future of Academic Medicine to that subject. Highlights of that meeting are reported below. The forum's influential members arrived at no consensus regarding how the greater use of organized information will evolve, but their prolonged discussion identified issues of concern and certainly raised their consciousness.
During its existence, the forum, created by the AAMC and supported by The Robert Wood Johnson Foundation, brought together private-sector and academic leaders seven times during 1997–1999 to discuss the future of academic medicine beyond the immediately predictable. The ground rules for the discussions were that none of the comments would be attributed to individual forum members, but that the formal presentations of individual speakers and the dialog of the AAMC executives who attended were fair game. Steven A. Schroeder, MD, chief executive officer of The Robert Wood Johnson Foundation, set the course of the forum when he said at its first meeting that its gatherings were “a place to explore alternative pathways and visions of what academic medical centers might look like in 20 years.” At this last meeting, Dr. Jordan J. Cohen, president of the AAMC, expressed hope that academic health centers could serve as “prototype systems” upon which to build the future health care system.
ENVISIONING THE INFORMATICS FUTURE: DR. WILLIAM W. STEAD'S REMARKS
Discussions at the final meeting were stimulated by the opening comments of William W. Stead, MD, associate vice chancellor for health affairs at Vanderbilt University Medical Center and director of its informatics center. Dr. Stead envisions a future—as he outlined in the Journal of the American Medical Informatics Association1 —in which, through the heavy use of informatics and information technology, the consumer would be placed squarely in the center of the system and empowered with greater knowledge of health care. Dr. Stead asserted that such a system could provide high-quality care at an affordable cost, although he conceded that it also would threaten the traditional role of physicians and the mechanisms through which academic centers now derive much of their financial support.
He also foresaw a system in which children learn about health issues during the kindergarten through 12th-grade years and in which the primary health care provider plays the role of mentor and coach. He wrote: “Health is viewed holistically, recognizing the interplay among family, education, finances, the brain, and pathophysiology. Simple questions are answered electronically…. I see a world in which diagnostic problems are researched by patients and their primary health providers with the help of a digital consultant…. Each health-related invasive procedure is managed through remote robotics by a small cadre of experts who are dedicated to that activity.” Dr. Stead asserted that a health care system built on “this type of revolutionary change would be much more effective and efficient than the health enterprise of 1998. Individual consumers would be in charge, engaged in their own health maintenance, and informed.”
Three Visions of the Future
Through the use of three scenarios, Dr. Stead demonstrated to forum participants how he envisioned people would interact with the futuristic health care system that he believes lies ahead. He emphasized that “there is no new technology required to make these scenarios happen that is not available today off the shelf.” But the challenge of employing these approaches, Stead added, is “learning how to work in a fundamentally different way.”
Voice of the system (VOS): Good morning, Susan, are you there?
Susan: Yes, Amy and I are here.
VOS: There is a high level of pollen in the atmosphere this morning. Dr. Smith's guidelines suggest that you temporarily adjust Amy's asthma medication from one puff four times a day to two puffs four times a day. This recommendation is based on the heightened pollen count and Amy's morning flowmeter reading. Are you comfortable with the change, or would you like me to send a question to Dr. Smith?
Susan: No, I am comfortable with it.
VOS: There is also an elevated amount of interior dust detected in your home. Please replace the air conditioning filter. Make sure Amy is not nearby when you replace the filter.
Susan: I will.
VOS: The family stock holdings are doing well. With oil prices heading downward, you financial advisor suggested that you check your energy stocks.
VOS (speaking to Susan's husband John): Good morning, John. The home sensors indicated that you have had a good aerobic workout and your weight is 187 pounds. Your pulse, blood pressure, and respiratory rate are within normal range. To maintain your weight-loss program you will need 1,200 calories of food intake today. Your weight is still 9% over the weight-loss goal that you and your dietitian, Ms. Jones, set. Ms. Jones has an appointment opening on Thursday at 2 P.M. Your schedule indicated that you are free at that time. Would you like me to schedule an appointment for you?
John: Yes, I would.
Stead urged participants to take note of three features of the scenario. “First, that technology has receded into the background. Second, the family unit is the primary health provider empowered by access to information and support from health coaches, as needed. And third, the scenario's vision recognizes that health results from the complex interplay between brain, genetics, environment, and habits, and it seeks to deal with that interplay.”
Voice of the system (VOS) (addressing an EMT technician who is driving to the scene of an accident): An accident has just occurred at Broadway and West End involving a truck and a passenger car. The registered owner—driver of the truck is a 55-year-old man with emphysema. The passenger car is owned by a family that includes a 35-year-old member with insulin-dependent diabetes.
Technican: Can you give me a quick review of any predictable medical issues that might result from this motor vehicle accident?
VOS: A person with insulin-dependent diabetes might experience hypoglycemia, resulting in an altered state of awareness. This might have caused the accident. Emphysema can predispose an accident victim to pneumothorax.
Technician: May I please have a scan on this possible issue?
VOS: You have completed all relative modules of hypoglycemia. Your previous ten interventions were successful. You have not fully completed the modules necessary to manage pneumothorax. You should call for telepresent supervision if you suspect pneumothorax. You will be at the accident site in 90 seconds. Good luck!
Dr. Stead emphasized three features of this scenario as noteworthy. “The environment is information-rich, but overload is avoided by filtering what is presented to apply only to the current context. The credentials are based on an individual's learning records and documented outcomes, and on-demand access to support is available for subjects outside the documented competency of the technician.”
EMT technician: May I have my continuing education curriculum please? I'd like to begin the training module on relevant cases.
Voice of the system (VOS): Your recent experience with decompressing a tension pneumothorax at an accident site under supervision through telepresence indicates an opportunity for further education. With completion of the education modules and successful management of two more cases under supervision, you will be credentialed to handle this situation without telepresence supervision. Would you like to begin the education modules relevant to pneumothorax?
Technician: Yes, I would. Please give me a listing of modules.
VOS: The modules are anatomy of the neck and thorax, normal lung physiology, normal cardiac physiology, pathophysiology of tension pneumothorax, and decompression procedures. You successfully completed the module on the neck and thorax in December.
Technician: Well, let me begin with normal lung physiology.
Implications for Academic Medicine
Dr. Stead discussed the implications of these scenarios for academic medicine by placing them in a context that recognized recommendations issued last year by the AAMC's Advisory Panel on the Mission and Organization of Medical Schools. Stead cited a recommendation that characterized medical education as a lifelong process that begins in medical school and continues through residency training into actual practice. Wherever the locus, “students must learn how to filter, evaluate, and reconcile information.” Stead said the techniques applied in lifelong learning should be adapted and used in medical school. For example, he said that in medical schools, students should be taught concepts—such as the various models of drug-to-drug interactions—rather than be required to memorize the particular characteristics of an individual drug. Also, medical schools should make more frequent use of electronic conferencing to support groups of people that are trying to learn about the same problem. “That technology, which takes no content development, has been shown outside of the medical world to be capable of turning half of the grade C's into A's.”
Dr. Stead said that he saw no reason why medical schools should not also consider teaching younger students as well. “Why not begin to move health education back into kindergarten through 12?” Also, he suggested that through other outreach efforts, medical schools could attract interested non-professional adults to engage in lifelong learning. “Why not support the individual or the family as their health care provider, giving them the information to model their choices, and coaching them, or intervening when need be, instead of having a required middle person [a professional], if you will?”
Dr. Stead envisioned other roles for medical schools as well, given their missions as producers of information and distributors of that information through publication, education, and service. “Why don't we look at a potential role in which we could become the information providers and the quality assurance hubs of our regions?” He urged participants to consider replicating the model Duke University developed as an integral part of its medical center decades ago. “Duke linked up with community hospitals around the state, but with a requirement that all pathology specimens had to come back to Duke, where there would be a central point of observation, and therefore a quality control hub. I think that was a 1930s' vision of what we might consider today.”
Vanderbilt University, he said, is considering whether it should vie to become the information and quality assurance hub of Columbia—HCA “rather than compete against it. If we could do that, then we would have a much larger market for our information resource, and we would be able to limit our patient-care services to those 50 things that right now we do that no other provider in middle Tennessee and the surrounding region does.”
Summary and Discussion with Dr. Stead
Summing up, Dr. Stead asked: “What do we need to do? First, we've got to frame the message. We've got to help people understand the opportunity that academic medicine and the health system at large have because of what I think of as the disintermediation of the network economy. I think we've got a major challenge in developing informatics-literate business leadership for the health care industry. We need people who understand the business need and the art of the possible.”
He cited important tasks ahead to be investing more heavily in health informatics research and the development of new partnerships. “Look what has happened to General Motors. It used to build cars, but now they're in the business of doing market analysis and design. That's all they do. Everything else is out-sourced. And if you look at the information production hub of an academic medical center, we're going to have a fundamentally different partnership—not just with the other pieces of our current integrated delivery system, but with payers, the pharmaceutical industry, everybody. We have got to develop some regional or global infrastructure that allows, if you will, a virtual medical center to work.”
In response, one participant asked Dr. Stead to clarify his vision of the future academic medical center. He explained: “You have depicted an academic medical center that places heavy emphasis on the creation of new knowledge, its archiving, and its distribution. In short, information and its distribution are the products of the enterprise. I'm having a little trouble making the transition between that view and the configuration of today's academic medical center, the product of which is the education of students. I can't see the advantage of much of what you are articulating to the development of people and their potential. Where is the right balance between the continuing emphasis on people, human interactions, the informal curriculum, and technology-dependent, distant learning?”
Dr. Stead conceded that identifying the appropriate balance is “one of the items I have the most trouble with when I am on the Vanderbilt campus… because Vanderbilt is a place known for its warm and fuzzy interpersonal skills.” Stead went on to explain that his interest is not in promoting distance learning but rather in developing “education distributed across a lifetime. It's a continuum. People who have the time, money, and ability to be with us at home base should be supported by faculty, but also equipped to engage in lifetime learning after they graduate. We can educate relatively few people at our home base, but we also should strive to broaden our intellectual reach beyond the campus by taking advantage of the new technology that sorts and distributes information.”
The questioner was still skeptical. He conceded that information is a very powerful tool and that its creation is a major priority of an academic medical center. But he thought serious complications could arise if clinical information were made available to patients who did not fully understand its implications. Moreover, he said a major challenge facing the medical profession is persuading people to change personal behaviors that they recognize intellectually are harmful—smoking, substance abuse, and overeating—but that they persist in doing, regardless of what their physicians may counsel.
In a related comment, Dr. Cohen of the AAMC conceded that a growing number of patients are becoming more sophisticated users of the Internet and of information gleaned from medical journals, but he asserted that Dr. Stead's framework is “pretty remote from the way in which most people live and will continue to live and make decisions.” Dr. Stead agreed, but said that the world is changing rapidly, particularly among members of the younger generation, who are growing up relying on computer-based information. And what may seem far-fetched today will become reality tomorrow, particularly if children begin learning about health issues in kindergarten and some emphasis is placed on these subjects through high school.
Another participant asked Dr. Stead what steps Vanderbilt was prepared to take to preserve its intellectual capital if its program evolved as he envisioned. In response, Dr. Stead was generally critical of academic medical centers for their failure to protect this component of their enterprise. “Right now, academics in general give away their intellectual property. It's crazy. We actually sign it away with every copyright…. We could be getting an economic edge out of our intellectual property we do not now get.”
ASSESSING THE INFORMATION ENVIRONMENT: REMARKS OF DR. VALERIE FLORANCE
Next, the forum heard from Valerie Florance, PhD, director of the AAMC's email@example.com project. The over-riding goal of the two-year project is to explore the ways that medical schools and teaching hospitals can best use information technology and the Internet in the coming decade. In her opening remarks, Dr. Florance agreed with Dr. Stead that the information technology infrastructure is already in place or soon will be. “That's a framework… we can count on… to provide a foundation for a national health information network. It's really a global health information network, because, of course, with the Internet, there is hardly such a thing as a national information network.”
GENERAL DISCUSSION: INFORMATION TECHNOLOGY AND AMCS
Following the two presentations, the participants engaged in a general discussion of information technology and the academic medical center. Participants expressed concern that centers were investing too little in information technology; that centers would have a difficult time profiting from such investments because they are expected to make their new knowledge widely available without necessarily reaping a financial return; and that because centers are so fragmented organizationally, implementing system-wide information systems would be a major challenge. One participant said: “My institution hasn't come to grips with the fact that change is absolutely necessary. Indeed, I might argue that the incremental changes we have instituted are making things far worse by depleting our capital, whether it's money, intellect, or time, and not addressing fundamental change. Radical change needs to be accomplished. Let's not spend one more dollar keeping the old order in place.”
The AAMC's Dr. Cohen conceded that stimulating major change is difficult but said that all of the stakeholders must face this reality because the public is losing confidence in the current system. “Market-oriented managed care is clearly not the final solution. The backlash reflects the unease that not only providers but also the public increasingly are expressing about the ways care is financed and structured. Putting this recent history together with other insights, I think we can tic off some of the desirable features of the system that hopefully academic medical centers will have a role in molding. We would all agree that the system must be cost-contained…. It will be more patient-centered, evidence-based, and quality-driven.
Performance needs to be measured at all levels… as the driver of continuous quality improvement…. Teamwork must be inculcated into all health-care professionals and the patients themselves…. Top-down command is an out-moded concept, we're really talking about utilizing the skills of all kinds of health care professionals who have roles to play in improving the health of the public, and placing a greater emphasis on health promotion, disease prevention, and patient education…. And, finally, there must be a culture of beneficence and caring, rather than the perception of many today that the system is committed to bottom-line profits instead of to its fundamental social purpose.”
Cohen continued: “Having identified these desirable features… the question is how in the world can we think about going from where we are now to something that would embody this vision of the future? In my mind, there is no alternative but to have a coherent system in place to do this. No such system is in the offing, but I think the logical place to begin is with academic health systems. These protosystems—integrated delivery systems that have grown up in many parts of the country—are, to my biased way of thinking, the best place to begin. Other possibilities? The medical care system of the Veterans Administration—but I don't see that as sufficiently engaged with the rest of the country. I don't see insurance companies. I don't see the pharmaceutical industry doing this…. There is an awful lot to recommend that academic medicine take this on as a responsibility because there is no other logical place to look for leadership. This task would be very much in keeping with the tradition of thinking of ourselves as the wellspring of innovation for medicine…. We do have a reputation for quality and for commitment to community service that provides credibility as a place to begin. Moreover, there is more alignment within these integrated, academically oriented delivery systems among the practitioners, the hospitals, and other community resources than one would find in the distributed community setting at large.”
Cohen concluded his thoughts by calling for “the creation of some kind of nationwide network of collaborating academic health systems in order to begin to develop this more tightly coupled—rather than such a loosely coupled—system. This network can begin to collaborate in very significant ways to monitor the outcomes of care across the whole system of academically-oriented health systems. Richard M. Knapp, PhD (the AAMC's executive vice president), has called it the National Football League of medical centers. I think that is a useful way to think of what I have in mind; some kind of an allegiance to a common set of goals, principles, and practices that can move us towards a more organized way of operating…. What the Forum on the Future of Academic Medicine has taught me is that, in the absence of a more coordinated, systematic, collaborative set of arrangements among academic medical centers, we are not likely to continue to be the pacesetter for high-quality health care and improvement of health in the country.”
In response, several participants underscored the difficulty of institutions' moving in a coordinated fashion toward a broader organizational goal. Moreover, such an amalgam of institutions would, in all likelihood, so greatly favor the more elite, research-intensive enterprises, at the expense of community-oriented academic centers, that efforts to coordinate across disparate organizations, not to mention boundaries of geography, departments, and disciplines, would greatly inhibit progress.
Nevertheless, as the forum wound down, all participants, in a variety of ways, agreed that maintaining the status quo was not a viable option for academic medicine because strong pressures were already roiling the existing structures. That left two alternatives, participants suggested. The stewards of academic medical centers could assume greater responsibility in re-engineering their institutions to make them more compatible with new societal goals (more effective approaches to cost containment, identifying the outcomes of medical care, and attending more closely to the health of the public). Or they could cling to the existing structures and have change thrust upon their institutions by outside forces with far less knowledge of and sympathy with the imperatives of academic medicine. At one point in the discussion, Dr. Cohen reminded participants of a comment that one of them had made at an earlier session. “We were told,” he said, “that fundamental change had not occurred in any industry without a change in personnel, without a middle management, in particular, being an impediment to change. That's a scary prospect, but it is at least a lesson that apparently has been repeated in other sectors of the economy.”
That judgment, which resonated with other participants, suggested that conflict and discord are always byproducts of major change. Moreover, nothing in the dialog indicated that the participants believed academic medical centers would be spared painful dislocations if they embarked on a road of institutional reform in response to the pressures of the new and more competitive global economy. Greater awareness of that message, not necessarily welcomed, may become one of the lasting legacies of the Forum on the Future of Academic Medicine.
1. Stead WW. The challenge to health informatics for 1999–2000. J Am Med Informatics Assoc. 1999;6:88–9.
MEMBERS OF THE FORUM ON THE FUTURE OF ACADEMIC MEDICINE
Ron J. Anderson, MD, president and CEO, Parkland Memorial Hospital, Dallas, Texas
Carol A. Aschenbrener, MD,* senior scholar in residence, Association of Academic Health Plans, Washington, D.C.
Lonnie R. Bristow, MD, immediate past president, American Medical Association, Chicago, Illinois
Christine Cassel, MD,* chairman, Department of Geriatrics and Adult Development, Mount Sinai Medical Center, New York City
Jordan J. Cohen, MD, president, Association of American Medical Colleges, Washington, D.C.
The Honorable James H. S. Cooper,* managing director, Equitable Securities Corporation, Nashville, Tennessee
K. James Ehlen, MD,* president, Allina Health System, Minneapolis, Minnesota
Stephen Friedman,* senior chairman, Goldman, Sachs & Co., New York City
Jay M. Gellert,* president and chief operating officer, Health Systems International, Inc., Woodlands Hills, California
Bruce L. Gewertz, MD, chairman, Department of Surgery, University of Chicago, Chicago, Illinois
Lee Goldman, MD,* chairman, Department of Medicine, University of California, San Francisco
The Honorable Bill Gradison, president, Health Insurance Association of America, Washington, D.C.
Paul F. Griner, MD, vice president and director, Center for the Assessment and Management of Change in Academic Medicine, Association of American Medical Colleges, Washington, D.C.
Robert Z. Gussin, PhD, vice president, Johnson & Johnson, New Brunswick, New Jersey
Margaret A. Hamburg, MD, commissioner of health, New York City
Jeffrey L. Houpt, MD,* dean-designate, University of North Carolina School of Medicine, Chapel Hill
Mi Ja Kim, PhD, vice chancellor and dean, Graduate College, University of Illinois at Chicago College of Medicine, Chicago, Illinois
Philip Leder, MD,* chairman, Department of Genetics, Harvard Medical School, Cambridge, Massachusetts
Mark V. Pauly, PhD, vice dean and director, The Wharton School, University of Pennsylvania, Philadelphia
Hunter R. Rawlings, III, PhD,* president, Cornell University, Ithaca, New York
David B. Skinner, MD, president and professor of surgery, New York Hospital, New York City
Andrew G. Wallace, MD, vice president of health affairs and dean, Dartmouth Medical School, Hanover, New Hampshire
Donald E. Wilson, MD, dean, University of Maryland School of Medicine, Baltimore, Maryland
Guest speakers: William Stead, MD, Janet Florance, PhD
Observers: Herbert Swick, MD, Thomas Moberg, PhD, David Witter
Consultants to the Forum: John Iglehart, Thomas Gilmore, Stephen Lorch
Invited staff attending: Michael Whitcomb, MD, Richard Knapp, PhD, Robert Dickler, Joseph Keyes, JD
*Absent from the December 4, 1998 meeting. Cited Here...