Jeffrey Balser, MD, PhD, serves as Dean of Vanderbilt University School of Medicine; President and Chief Executive Officer of Vanderbilt University Medical Center.
On May 24th, Dr. Balser will serve on the keynote panel “Change Management in the Era of Disruption: Strategies for Executives” at Becker’s Hospital Review 11th Annual Meeting. As part of an ongoing series, Becker’s is talking to healthcare leaders who plan to speak at the conference, which will take place on May 24-26, 2021 in Chicago.
To learn more about the conference and Dr. Balser’s session, click here.
Question: What, from your perspective, is the biggest challenge about the future of work for hospitals, and what can they do about it? (i.e. automation, desire for more flexibility, clinician shortages, etc.)
Jeffrey Balser: Simply put – it’s waste in health care. The build-up of waste is never-ending and it’s all around us. Taming it requires perpetual action. It was interesting to read the recent review of the literature published in JAMA that pegged the annual cost of waste in the U.S. health care system between $760 billion to $935 billion — or a quarter of total health spending. This astonishing statistic, in view of the growing imperative to control cost, makes it plain that we can no longer afford to ignore this issue.
Waste results from many things. But a big culprit is the variability we tolerate across dozens, hundreds, or even thousands of repetitive tasks. We can reduce unconscious decisions that can lead to waste by using just-in-time decision support.
Waste and the elimination of unconscious variability is a big priority at VUMC. Our robust and active Pharmacy & Therapeutics Committee is staffed by a broad range of pharmacy and clinical specialists who continually review the literature on efficacy, cost, side effects and other information impacting drug selection. Then we push that information to clinicians as they electronically order treatments at the point of care. We make the least costly, most effective choice the “default” option, and thereby largely eliminate unconscious variability.
Clinicians can opt, of course, for an action other than the recommendation because the system can’t anticipate every circumstance. Yet, the cost savings from providing well-timed recommendations that are followed in the vast majority of cases is staggering. VUMC saves more than $35 million annually on inpatient drugs alone, compared to the average medical center with comparable acuity and volume of patients. Now we have a Lab Formulary Committee – and these are just the tip of the iceberg.
Q: How can hospitals reconcile the need to maintain inpatient volumes with the mission to keep people healthier and out of the hospital?
JB: We want patients to be where they can receive the care they need, and so often that’s close to home. VUMC is focused on “tuning acuity,” rationalizing care across a growing web of clinics and outpatient centers as well as partner hospitals with the goal of keeping lower acuity patients closer to home while ensuring those requiring the most complex care are brought to our quaternary facilities. As an academic medical center, we recognize the rising demand for specialized care close to home, and we focus on establishing low-acuity specialty care services for patients with our partners in the regional setting.
Another way we’re keeping people close to home is through telehealth. We’ve had success in many of our telehealth programs including tele-neurology, and these programs help ensure people across the Mid-Southern region can access primary care as well as a growing array of specialty care services close to home, while also facilitating linkage to our tertiary services when needed. I think the capabilities and success of telehealth programs will continue to expand as health care providers look for effective ways to keep people healthier and out of the hospital.
Q: What do you see as the most exciting opportunity in healthcare right now?
JB: As incongruous as it sounds, I’m excited about the opportunities to reduce waste through decision support and standardization, because the same processes that will reduce noise in healthcare decision-making will also allow us to deliver more personalized care when it matters most. We make unconscious choices all the time – while driving, at the grocery store and certainly when caring for patients. These routine decisions are often based on our biases, traditions and even on recently acquired anecdotal information. Our goal at VUMC is to reduce the wide variability in these unconscious choices and at the same time encourage personalized care by giving conscious choice greater visibility and impact.
By redesigning our decision support to consistently provide the most cost-effective and evidence-based recommendations at the point-of-care, we can largely eliminate unconscious and costly variability. At the same time, by incorporating the special characteristics and preferences of each person — from their DNA sequence to their social, behavioral and environmental context – into our electronic decision support, we are building personalization into the system. To have impact, the advice to clinicians must be provided “just-in-time,” in a manner that anneals to clinical workflow at the moment of choice for a treatment or test. The key is to build in personalization only where and when it matters.
Experience and training always come first, yet with the explosion of healthcare evidence and economic factors to consider, we increasingly need to support clinician expertise – and respect people’s time – by building systems that provide standard, evidence-based default options while supporting a change of course when special circumstances arise. For instance, when a VUMC clinician selects a different drug than the “standard” because just-in-time genomic information provided by our electronic drug order entry system prompts the ordering clinician and suggests a high risk of side effects — that’s a conscious choice. We want our medical teams to apply their cognitive skills and energy on deliberate, conscious choices about what care to provide, and how to provide it.
Waste, standardization and the promise of personalized care are inextricably linked. We can make more room for the things that really do matter — the qualities of care and expertise that change lives — by eliminating noise and clutter in healthcare decision making.
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