- One of the proudest moments in a physician’s life is when he or she crosses the stage to shake hands with faculty and receive the coveted MD degree.
The embossed leatherette folio represents the culmination of years of hard work and academic achievement, and launches the newly-minted doctor into a life-long career of service to the community and the science of clinical care.
But as the healthcare industry struggles with questions of financial sustainability, EHR burnout, and how to manage populations at scale, some medical school educators are taking a harder look at what goes into getting a degree – and what comes out the other side.
Dr. David B. Nash, Dean of the Jefferson College of Population Health, is a leading voice in the conversation about how to train providers to practice in a data-driven world while moving the industry further down the road of value-based care.
With an emphasis on analytics and thinking holistically about population health, Nash sees a number of opportunities to use education to realign a bloated financial system staggering towards the cliffs of unsustainability – and threatening to take patients and clinicians over the edge.
“Our medical education system is upside down, inside out, and backwards,” Nash told HealthITAnalytics.com.
“Now that we are starting to deploy value-based care strategies and develop the health IT tools we need to make them work, we are starting to see changes – but we still need to reevaluate the way we’re training people before they leave academia and get into the real world.”
Education is the linchpin to a less wasteful, more standardized, and more effective healthcare system, Nash stressed.
Training providers from the very beginning to embrace population health management will be critical for accelerating the industry’s transformation into a truly value-based care delivery system.
Training a new generation of data-driven leaders
The Jefferson College of Population Health is at the forefront of training a new type of population health professional.
As the first school of its kind, the College offers graduate certificates and degrees in a variety of areas, including health policy, quality and safety, public health, and operational excellence.
“For the past ten years, the Jefferson College of Population Health has helped to sculpt the field by creating unique online, graduate-level curriculum, editing the only peer-reviewed journal in the field, and offering the best-selling textbook in the field, called Population Health: Creating a Culture of Wellness,” said Nash.
“These three pillars support the mission of the College, which is to train leaders who can make sense of this crazy system by turning data into information.”
The school’s newest online degree program is focused squarely on helping healthcare professionals develop analytical skills.
Graduates of the Population Health Intelligence programs – trademark – will be well equipped to identify health IT needs, respond to trends in socioeconomic data, and take advantage of opportunities to integrate data-driven decision-making into the care environment.
“We don’t teach students to code or develop software,” said Nash. “Instead, the program is focused on how to become an interpreter of data. We recruited a leader from Optum to head the program, so you can tell that we’re serious about promoting the role of data analytics are a core part of population health.”
Nash wants to help create as many data-savvy population health leaders as he possibly can.
“Nearly a third of our spending – that’s more than a trillion dollars a year – has no value,” he explained. “We need this new generation to put us squarely on the road to redemption,” he said. “That is the road to value-based care.”
“If we could use better data and better population health management to reverse even a tiny part of that trend, and turn waste into revenue, we could see significant, significant change.”
Nash is currently in the process of recruiting some additional support for this challenging endeavor.
The new Navvis Professorship of Population Health, funded by a $2 million endowment from the population health solutions company, will be the first nationally-focused professorship based entirely around identifying new approaches to delivering high-quality, patient-centered care at the population level.
“The professorship will enable us to recruit another national expert and thought leader to help us continue to grow and share our knowledge, which is much-needed and very exciting,” Nash said.
The endowed position is also one of the few opportunities in healthcare academia that is supported by a private sector contribution, he added.
“Private sector companies can see the writing on the wall. They know that we are on an unsustainable trajectory,” he said.
“Thinking long-term about population health – especially about data and technology – is in their interests, too. So it’s not really that surprising that we’ve seen more private sector money coming into healthcare in the last decade than we have in the previous 30 years.”
Zen and the Art of Population Health Management
The influx of private sector money is producing rapid changes in the way healthcare professionals rely upon and interact with health IT tools, and the rush to become the name-brand leader in enabling technologies is entering a revival phase as new players gravitate towards a highly lucrative marketplace.
But technology is only one part of the problem – and only a fraction of the solution, Nash believes. The healthcare industry must undergo a fundamental shift at a much deeper level.
“Private practice fee-for-service reimbursement is the most pernicious thing in the known universe,” he stated. “Why should I measure and improve if I’m going to get paid no matter what happens? Fee-for-service is the biggest roadblock to population health.”
Ridding the industry of fee-for-service isn’t just a matter for policy experts, regulators, and lawmakers.
Physicians, and the people responsible for educating them, must radically alter their mindsets starting at the moment they set foot in their first lecture hall.
“The seeming inability to change provider behavior is a direct result of educational system,” Nash said. “Right now, we teach physicians that autonomy is the essence of who they are and what they do.”
“As a result, we’re still functioning in a $3 trillion industry like a guild in the Middle Ages. Everyone learns from their mentor the secret of how to manufacture this beautiful, unique thing, and those secrets naturally represent the only correct way to practice medicine.”
“One of our favorite sayings at the College is ‘no outcome, no income,’” said Nash. “We want to achieve a future state where you can no longer hide the fact that an MRI varies in price by a factor of five or more depending on the market.”
“Imagine trying to buy a car like that,” he continued. “In Cleveland, the car costs $20,000. In New York, the same exact model of vehicle costs $40,000. And because the car in New York was built in a different factory, the people there were taught to put the exhaust pipe on the left instead of the right.”
“But half of the repair shops don’t stock left-side brackets, because they were always told that exhaust pipes should only exist on the right. How do you get your car fixed? How can you predict how much it will cost? That’s exactly what healthcare is right now.”
Standardization should be the goal, and data analytics that illuminate variations in care, encourage price transparency, and monitor physician performance are critical to achieving that aim.
“When I trained, 40 years ago, there was no way to close that feedback loop,” Nash recalled. “We assumed we were doing great, and there was no evidence to the contrary.”
“Analytics has helped us see that there is a correlation between the distribution of physician behavior and patient outcomes. And data will help us change the way people make decisions so that they’re more consistent and more valuable to the patient.”
Bridging the gap between the current state and the ideals of the future will require physicians to engage in some potentially uncomfortable self-examination.
“We can take some cues from Robert Pirsig,” Nash said, referencing the author of Zen and the Art of Motorcycle Maintenance. “Here’s where the Zen comes in for doctors. In order to move forward, you have to give up what you value most, right? If you want to be loved, you have to give love. If you want to be understood, you have to be understanding.”
“In the clinical world, if you want to be completely autonomous, then you have to be completely responsible. That means being accountable for everything you do. You must be completely transparent about everything: outcomes, errors, income – everything.”
Complete transparency will create a truly consumer-centered marketplace for healthcare, lowering prices and creating a strong incentive for providers to compete on quality, patient experiences, and outcomes.
“Then we can achieve the goal of ‘no outcome, no income,’” he said. “Analytics will be the fuel for that. We couldn’t have done it 40 years ago – we couldn’t even have done it 10 years ago. Now we have the tools, and I find that incredibly exciting.”
Treating the disease, not the symptoms, behind EHR fatigue
Suggesting a heavier reliance on data immediately raises questions of EHR burnout and health IT fatigue, which may be equally common and nearly as pernicious as fee-for-service reimbursement.
EHR technology is accelerating an epidemic of clinical burnout, the AMA and other leading organizations repeatedly warn, resulting in early retirements, withdrawn clinicians, and potentially patient safety errors.
“Human factors engineering has not been central to the healthcare conversation,” Nash agreed. “Burnout is a product of poor design and inattention to the way people work.”
“We need experts to come in and look at the workflow to find a better way. Everyone agrees that EHRs have to be more streamlined and data has to be more portable.”
Six clicks to sign a chart is five clicks too many, he added. “Why would I want to use a system like that? When we used paper, all we had to do was scribble our initials and we were done. It can be very difficult for doctors to make that transition.”
Nash sees promise in the fact that younger physicians, including his own daughter, have simply grown up with the technology skills that allow them to navigate complex menus and zig-zag through workflows without all that much thought.
“My daughter just finished her chief residency, and she has never used a paper chart,” he said. “EHRs have become the default way to practice medicine, and she has the benefit of having been taught that from day one. As we train the next generation – and as the developers keep improving the products they offer – it’s going to get easier. I do believe that.”
In the meantime, the health system as a whole needs to put in a concerted effort to treat what is truly ailing clinicians and patients: misaligned incentives, a lack of data to monitor performance, and a deep divide between how physicians ought to make decisions and how they actually practice.
“The root of the problem is that physicians don’t really understand how to work efficiently within complex systems. That all goes back to training for autonomy instead of training for outcomes,” Nash pointed out.
“If I teach you that you’re the center of the known universe, how likely are you to engage correctly with complex systems that don’t actually revolve around the opinions and desires of a single physician? If I reward you financially for acting autonomously regardless of the outcome, how likely are you to change behaviors that aren’t working?”
Breaking away from the complicated cycle of conflicting motivations, unnecessary variation, opaque pricing, and provider burnout will require large-scale collaboration across all the moving parts of the healthcare industry.
Medical schools will be at the center of these efforts, Nash believes, as the old guard of guild-trained physicians slowly gives way to a new generation of clinicians who will practice in a world where data-driven, value-based population health management is the default position.
“That’s why we’re doing what we’re doing at Thomas Jefferson University, and that’s why having a full-time professorship to help develop these new approaches is such an important step forward,” Nash said.
“There will definitely be plenty of work for whoever steps into that position, and plenty of other positions throughout the industry. I am very eager to find the right person to fill the professorship, and I feel very fortunate to be in a position to keep pushing the industry in the right direction.”