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Creating 21st-Century Laboratories and Classrooms for Improving Population Health: A Call to Action for Academic Medical Centers

DeVoe, Jennifer E. MD, DPhil; Likumahuwa-Ackman, Sonja MID, MPH; Shannon, Jackilen PhD, MPH; Steiner Hayward, Elizabeth MD

doi: 10.1097/ACM.0000000000001385
Perspectives
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Academic medical centers (AMCs) in the United States built world-class infrastructure to successfully combat disease in the 20th century, which is inadequate for the complexity of sustaining and improving population health. AMCs must now build first-rate 21st-century infrastructure to connect combating disease and promoting health. This infrastructure must acknowledge the bio-psycho-social-environmental factors impacting health and will need to reach far beyond the AMC walls to foster community “laboratories” that support the “science of health,” complementary to those supporting the “science of medicine”; cultivate community “classrooms” to stimulate learning and discovery in the places where people live, work, and play; and strengthen bridges between academic centers and these community laboratories and classrooms to facilitate bidirectional teaching, learning, innovation, and discovery.

Private and public entities made deep financial investments that contributed to the AMC disease-centered approach to clinical care, education, and research in the 20th century. Many of these same funders now recognize the need to transform U.S. health care into a system that is accountable for population health and the need for a medical workforce equipped with the skills to measure and improve health. Innovative ideas about communities as centers of learning, the importance of social factors as major determinants of health, and the need for multidisciplinary perspectives to solve complex problems are not new; many are 20th-century ideas still waiting to be fully implemented. The window of opportunity is now. The authors articulate how AMCs must take bigger and bolder steps to become leaders in population health.

J.E. DeVoe is professor and chair, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, and senior research advisor, OCHIN, Inc., Portland, Oregon.

S. Likumahuwa-Ackman is research program manager, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon.

J. Shannon is associate professor, School of Public Health, director, Knight Community Engaged Research Program, Knight Cancer Institute, and associate director, Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland, Oregon.

E. Steiner Hayward is adjunct associate professor, Department of Family Medicine, Oregon Health & Science University, Portland, Oregon, and senator, Oregon State Legislature, Salem, Oregon.

Funding/Support: None reported.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Jennifer E. DeVoe, Department of Family Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd., Mailcode: FM, Portland, OR 97239; telephone: (503) 494-8936; e-mail: devoej@ohsu.edu.

Despite 20th-century advances in treating disease, people in the United States have poorer health and shorter lives than populations in other developed countries around the world.1,2 U.S. academic medical centers (AMCs) have built world-class biomedical laboratories, research campuses, and medical school classrooms largely focused on combating disease. Many diseases are now treatable, and some are curable. Yet, this biomedical progress has also led to skyrocketing health care costs with minimal gains in population health.1,3 For the United States to maintain a healthy, productive population in the future without bankrupting its economy, AMCs must now promote and improve health in addition to combating disease.4–6 Many AMCs have adopted vision statements describing aspirations to improve population health.7–9 Now is the time to take big, bold steps toward realizing these visions. In this article, we explore ways in which AMCs can enhance existing clinical infrastructure and community–academic partnerships to connect the dots between combating disease and promoting health.

We suggest three overarching intermediate goals: Foster community “laboratories” that support the “science of health,” complementary to those supporting the “science of medicine”; cultivate community “classrooms” to stimulate learning and discovery in the places where people live, work, and play; and strengthen bridges between AMCs and these community laboratories and classrooms to facilitate bidirectional teaching, learning, innovation, and discovery. For AMCs serious about achieving these goals, we offer several synergistic strategies that build on current infrastructure. Table 1 summarizes these strategies.

Table 1

Table 1

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Key Short-Term Strategies That Build on Current AMC Infrastructure

Strategy 1: Strengthen academic primary care

Clinical services account for only 20% of health for a typical American, with health behaviors (30%), social and economic factors (40%), and the physical environment (10%) making up the other 80%.10,11 In addition to the limited impact of clinical services on population health, health care is increasingly managed in home- and community-based outpatient settings and not in hospitals.12–15 Although financial incentives have traditionally rewarded AMCs for a hospital-based, disease-centric approach to clinical care and research, AMCs are now facing the need to realign resources and priorities to better promote health. The primary care disciplines are positioned to play a bridging role between traditional systems and new models. Primary care spans across medicine and population health, academic hospitals, and community clinics. Trained in both inpatient and outpatient settings, and treating adults and children for both physical and mental health needs, primary care professionals already play leading roles in building the bridges needed for community–academic partnerships.16–19 With this unique “boundary spanning” expertise, primary care professionals have great potential to lead and support 21st-century learning and discovery efforts to promote and improve health. Yet, inadequate investment in U.S. academic primary care programs over the last few decades has led to chronic workforce shortages,20,21 poor geographic distribution of primary care physicians,22 and their increased workload.23 Some AMCs do not even have departments in all of the primary care specialties (including Harvard, Johns Hopkins, Stanford, Yale, Cornell, and Vanderbilt, which lack departments of family medicine); others are threatening to close primary care departments despite strong support for primary care from students and local communities.24–26 There is an inherent tension between AMCs that have a financial model based on tertiary care, where primary care specialties are undervalued, and the future financial model which will be based on population health and affordable, accountable care.27

To effectively mobilize and fully capitalize on primary care’s vital bridging role, all AMCs must make strengthening the primary care workforce a top priority. Increased and sustained AMC investment in primary care departments would enable the creation of academic “discovery clinics” to serve as incubators for innovation and new scientific methods for conducting primary care research. These clinics would focus broadly on developing and testing the effectiveness of novel primary care interventions, delivery models, and workforce training methods with a primary focus on improving health (which may or may not require adding more technologies and high-cost therapies). As new primary care approaches for preventing disease and improving population health are discovered, strong departments can facilitate rapid implementation and the spread of new knowledge into practice. Primary care discovery clinics will also be an inspirational training ground for future generations, equipping them with the skills to continually improve and effectively measure their contributions to promoting health. Some AMCs cite Medicare’s 20th-century restrictions on graduate medical education (GME) funding as a hindrance to increased investments in primary care; however, new state-based Medicaid programs to increase primary care training opportunities will enable AMCs to increase their GME funding and explore new partnerships with community health centers to develop primary care discovery clinics in underserved neighborhoods.28–33 The business case for investing in academic primary care will be further strengthened when having strong primary care clinics will no longer threaten the bottom line of an AMC hospital needing to fill beds but instead support an AMC to become a successful accountable care organization rewarded for improving population health.5,27,34

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Strategy 2: Build primary care extension programs

Traditionally, bricks and mortar have symbolized AMC success: To effectively combat disease, laboratories were built on campus and equipped with state-of-the-art technologies. To improve population health, 21st-century bricks and mortar should be strategically placed where populations “are born, grow up, live, work, and age.”35 Primary care extension programs (PCEPs) can be one of these investments to speed health care transformation in the communities surrounding an AMC, analogous to the cooperative extension programs of the Department of Agriculture that sped the modernization of farming a century ago.36 The PCEP model is outlined, though not funded, in the Affordable Care Act legislation (Section 5405). AMCs can begin building PCEPs by making sustainable investments37 in the work of existing organizations (e.g., public health agencies, practice-based research networks, Area Health Education Centers [AHECs]), taking on different forms to meet the needs of diverse rural, urban, and suburban communities.38–43 For example, the University of New Mexico Health Sciences Center built on an AHEC to create health extension rural offices (HEROs) with health extension agents who work side-by-side with community practices, connecting them with AMC resources on the basis of community health priorities.44 In collaboration with the New Mexico Department of Health, HEROs coordinate county health report cards to monitor effectiveness of university programs in meeting the communities’ needs. These measurements hold the university accountable for doing community-based work that leads to measureable improvements in health.

AMCs sponsor consult lines or telemedicine programs to efficiently connect community physicians with academic subspecialists.45,46 But who can a community-based primary care physician call for consultations regarding practice transformation, engaging patients via the personal health record, integrating mental health care, or managing population health? Community primary care teams should be able to call a PCEP supported by a nearby AMC.47 In partnership with local public health agencies and other community organizations, AMCs can continuously assess community needs and conduct rapid testing to determine how to build and sustain PCEPs that support improved community health.

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Strategy 3: Support patient-centered medical villages

Another way for AMCs to support primary care modernization is through investments in community-based shared resources, or collaboratives, where primary care clinics can work together to learn and adopt best practices. Many clinics have officially been certified as patient-centered medical homes (PCMHs). The National Committee for Quality Assurance has certified 11,287 official PCMH sites as of November 2015 across three tiers (229 Level 1; 2,533 Level 2; and 8,535 Level 3).48 Some of the most pioneering PCMHs already serve as discovery clinics and primary care laboratories for testing new innovations and studying best practices that can be widely implemented.49–52 However, each PCMH does not have to reinvent the same innovation wheel. AMCs can support PCMHs in their communities to join together and form collaborative “patient-centered medical villages” (PCMVs), where they can share experiences, have champions spreading innovations, and strive to improve patient and population health outcomes.53,54 AMC hospitals participate in patient-centered medical neighborhoods, which represent vertical linkages between subspecialty facilities and PCMHs,54,55 but vertically integrated neighborhoods do not allow for the sharing of innovations across primary care settings. A PCMV creates horizontal linkages to accelerate discovery and learning in primary care, to share resources across many settings (including primary care and public health entities), to understand variation in outcomes, and to disseminate best practices through learning collaboratives and practice facilitation (Figure 1).53

Figure 1

Figure 1

On the basis of international evidence that countries with strong primary care systems have healthier populations, it is likely that primary care transformation will improve population health in the United States.18 AMCs, in collaboration with state and federal organizations, should be actively launching, convening, and supporting PCEPs, PCMVs, or similar structures such as community-centered health homes,56 Health Commons,57 or health outcome trusts.58 AMCs should also be building the infrastructure to evaluate these efforts.

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Strategy 4: Support communities as learning systems for health

Many AMCs now use “big data” to inform “learning health systems”59–61; however, these data are not commonly shared with the communities they serve. AMCs should be supporting the “community as a learning system for health,” as described by the National Committee on Vital Health Statistics (NCVHS). The NCVHS outlined a model in which AMCs work alongside other entities and institutions in the community (i.e., public health, federal agencies, nonprofits), providing data and analytical resources to help identify and address important health concerns.62,63 Together, communities of solution are created.64,65

In forming these partnerships, a major consideration for AMCs must be whether community priorities match with academic priorities.66 If not, why not? How can they be better aligned? Are academic researchers studying the problems of most concern to their local communities and discovering solutions most likely to improve health?

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Strategy 5: Build on early efforts to invest in communities as a resource for sustained research

Historically, AMC-based researchers have designed and conducted clinical trials and other types of studies solely within AMC facilities; occasionally, they have engaged communities to recruit patients. Increasingly, there is recognition that communities should be involved in all aspects of a study, from the development of research ideas and study designs to the interpretation of findings.67–69 This emphasis on the vital role of the community is illustrated by the increasing emphasis the National Center for Advancing Translational Sciences (NCATS) is placing on the role of community engagement in the NCATS-funded Clinical and Translational Science Award (CTSA) programs. Successful CTSAs must demonstrate capacity to meet the Institute of Medicine recommendation that community be engaged in all phases of research.70 In learning how to build resources for this type of sustained community-engaged research, we can draw lessons from the models of dissemination and implementation that have been developed and used primarily to guide clinical practice change.71–73

To meaningfully invest in a vision to engage communities as resources for sustained research, AMCs must partner with communities and collectively establish community-based research collaboratives74 that facilitate a bidirectional exchange of information and strengthen capacity, relevance, and receptivity. Capacity incorporates training, technical assistance, and resource development. Relevance focuses on opening channels of communication to ensure that the questions of importance to the community are heard and given priority in research decisions. Receptivity addresses a need to ensure that when a meaningful question is identified and the capacity is present to address the question, the community members and leaders are receptive and trusting in the research and the researcher. Receptivity also pertains to ensuring that the community understands what it means to conduct and to participate in research.66,75 Beyond NCATS, other organizations across the National Institutes of Health are focusing more attention on conducting pragmatic, community-based trials, and the Patient-Centered Outcomes Research Institute has increased attention to the need for increased stakeholder engagement in research. These changes represent paradigm shifts that will require AMCs to have robust community laboratories in motivated and engaged communities.

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Strategy 6: Cultivate and strengthen community classrooms

Learners must be equipped to provide care effectively in many different environments and settings. Are learners, trained primarily in AMC hospitals, ready to practice in community settings? Although the idea of moving training out into the community is not new,76 “community classrooms” have been difficult to implement widely without sustainable community-based infrastructure for innovation and discovery—“community laboratories” (also not a new concept but one ready for prime time!).77 As PCEPs, PCMVs, community-based research collaboratives, and other community systems of learning are developed, we will have naturally occurring community laboratories and classrooms, which will help to turn this nascent idea into a mature reality. This transformation will require bold leadership from AMCs and especially from robust, strong primary care disciplines, such as family medicine. Dr. John Saultz, past president of the Society of Teachers of Family Medicine, recently issued a call to action for the discipline:

Our old mission was to train family physicians. Our new mission is to invent and study new models of primary care and teach learners from multiple disciplines to care for populations of people in community settings as teams. Patient-centered care is not about what physicians do; it is about how individuals and communities receive the care they need. We are fond of saying that family physicians should be leaders in the new health care system. This is the path to take if we are serious.78(p740)

This bold action requires significant investments in community-based infrastructure and community–academic partnerships supporting innovation, discovery, and training. The majority of U.S. health care visits occur in community-based primary care settings79,80; yet, nearly all medical classrooms and laboratories are in hospital-based academic settings. Thus, it is imperative that we expand and accelerate the development of community-based research and training sites to better understand how to improve care in the most commonly used health care settings. There are already many examples of great progress in this area.60,69 AMCs need to support and encourage their local and regional communities to build on these foundations.

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AMCs Must Make Longer-Term Investments to Strengthen Community–Academic Partnerships

To complement facilities built in the 20th century for combating diseases, AMCs must make major investments, launch philanthropic campaigns, and partner with communities in building 21st-century infrastructure for multidisciplinary investigation, collaboration, and learning that promotes healthier populations. One strategy to bring multidisciplinary teams together (to teach students, conduct research, and improve health) is to create an Institute for Healthy People (IHP), connecting academic siloes and partnering effectively with community organizations. As shown in Figure 2, pillars of the IHP would include academic centers of excellence, community laboratories, and community classrooms, with foundational cores to support improvement, research, shared partnerships, data infrastructure, analytics, and engagement.

Figure 2

Figure 2

In the IHP model, community leaders work together with academic faculty to develop and govern a shared institute that serves as a hub for promoting and measuring improvements in population health. Within the institute, centers of excellence convene academic and community researchers to work across departments to do cutting-edge, cross-disciplinary research in scientific fields such as dissemination and implementation science, health services research, and improvement science. In addition to conducting traditional controlled studies, these teams are equipped to study natural experiments. These multidisciplinary centers also provide innovative opportunities for teaching and learning in new ways with dedicated resources for career development and coordinating opportunities for learners. This important infrastructure helps recruit, train, place, and assess learners, as well as ensuring that learners are able to take full advantage of institute resources and opportunities. Featured prominently in this model (and underdeveloped or nonexistent in most AMCs) are community laboratories and classrooms. These 21st-century labs and classrooms make all of this exciting work come alive.

AMCs and government agencies play vital roles in supporting the institute and ensuring coordination of core resources shared across all programs, such as data infrastructure, measurement and analytics expertise, institutional review boards and other regulatory bodies familiar with community settings, quality improvement coaching, practice facilitation, engagement, and communication experts. This model ensures that specialized expertise is always available for limited-duration projects, shared across all centers and labs. To address a broad spectrum of community health needs, community infrastructure and IHP collaborators extend outside of traditional health care settings. For example, community laboratories include not just primary care clinics but also schools, prisons, public park systems, and so forth. Faculty are from the AMC but also from schools of public health, education, law, engineering, social work, and related fields. Local and state organizations help to identify resources across multiple institutions, connecting communities with similar interests and supporting shared resources in a range of ways. As a collaborative partnership between a broad and diverse group of organizations, the institute is also well positioned to increase public awareness about how efforts to promote population health differ from efforts to combat disease. Academic public health leaders have described similar models in the past, and many are in the process of being built, but traditional disease-based funding paradigms in medicine have hindered the growth and sustainability of such models on AMC campuses. As AMCs see dwindling funds to combat diseases and more incentives to improve population health, the IHP is a model for building stronger bridges between communities, public health, and medicine on the pathway toward better health.

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Concluding Remarks

Innovative ideas about communities as centers of learning, the social determinants of health, and the need for multidisciplinary perspectives to solve complex problems are not new; many are 20th-century ideas ready for implementation in the 21st century. AMCs have a responsibility to be leaders in promoting health, especially if they want to realize visions about improving population health.5 There are multiple ways in which AMCs can serve and empower communities to promote and improve health. These are daunting, but rewarding, opportunities. Barriers from the past still exist (e.g., volume-based clinical payment, disease-based research funding streams); however, greater emphasis is being placed on improving value, population health, and patient-centered outcomes. To build world-class 21st-century infrastructure for improving health, AMCs can renew investments in primary care, strengthen ties with public health, create sustainable community laboratories and classrooms, envision multidisciplinary research centers, and build strong community–academic partnerships for facilitating bidirectional teaching, learning, innovation, and discovery. Realizing these visions will require constructing more bridges and fewer tall buildings. Ultimately, these changes will result in healthier, better-educated, more productive populations.

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