BUILDING AN ACADEMIC PEDIATRIC HEALTH SYSTEM AS THE WORLD CONTINUES TO TURN: A CASE STUDY

Abstract

In 2011, All Children’s Hospital (ACH) joined the Johns Hopkins Health System (JHHS) and in so doing became a member of Johns Hopkins Medicine (JHM). The value proposition for the joining of ACH and JHHS/JHM was to transform ACH into an academic pediatric health system. This case study of the transformation provides evidence for the usefulness of a precision medicine framework to organize investments in programs and practices that further the tripartite mission of academic medical centers and may increase the value of the care they deliver.

INTRODUCTION

In 2011, All Children’s Hospital (ACH) joined the Johns Hopkins Health System (JHHS) and in so doing became a member of Johns Hopkins Medicine (JHM). ACH is a 259-bed free-standing acute care children’s hospital located in St. Petersburg, Florida, and is one of only three such hospitals in Florida. JHM is headquartered in Baltimore, Maryland, and unites physicians and scientists of the Johns Hopkins University School of Medicine with the organizations, health professionals, and facilities of the JHHS.

The value proposition for the joining of ACH and JHHS/JHM was to transform ACH into an academic pediatric health system. At the time of the integration the primary focus of ACH was the clinical care of children. The board of trustees of ACH recognized that to become a leader in the care of children for the state and the nation, ACH needed to transform into a true academic health system and invest and develop the teaching and research legs of their mission. JHHS/JHM saw the integration as an opportunity to expand the scope and reach of the tripartite mission of JHHS/JHM pediatrics beyond the Johns Hopkins Children’s Center in Baltimore, Maryland. This article represents a case study of the initial phase of the transformation of ACH into an academic pediatric health system at a time when the health care world continues to turn fast.

VALUE-BASED CARE

It was recognized early on in the integration of ACH into JHHS/JHM that the landscape of health care was shifting. Insurance companies, consumers, and government agencies were (and continue to be) pressuring health care systems and health care providers to change their primary focus from volume-related metrics such as average daily census and work relative-value units to metrics that were focused on value. Value in the context of health care has been defined as the optimal combination of quality and cost. The Institute for Healthcare Improvement’s Triple Aim for Populations provides a useful articulation of the dimensions of value: great patient experience of care (including quality and satisfaction); excellent health of populations; and low per capita cost of health care (1).

PRECISION MEDICINE

One approach to creating value can be found through a precision medicine framework. Precision medicine looks for and provides tailored treatments for distinct subsets of individuals with a particular disease (2,3). These subsets or segments of individuals with a disease are created in such a way that they demonstrate less variation in manifestation of the disease and/or response to treatment within each segment of individuals with the disease compared to the variation seen among all individuals with the disease. By segmenting the population into more homogeneous subsets, providers can deliver more precise care to the population. The actualization of this framework requires changes in clinical practice, support for specific types of research and research infrastructure, and new approaches to residency training. ACH’s newly completed strategic plan is using the precision medicine framework to drive all aspects of the mission.

PRECISION MEDICINE IN CLINICAL PRACTICE

While most individuals think of precision medicine as the use of genetics to guide therapy for cancer, precision medicine principles can be applied for other conditions and organize care around segments of the target population defined by more than genetics (4,5). Furthermore, precision medicine can include treatments that go beyond pharmacologic therapies. In the transformation of ACH we have used of care pathways and strategic bed placement to offer more precise care and create value.

Care pathways are structured care plans which detail essential steps in the care of patients with a specific clinical problem based on best practice guidelines. To the extent that physicians and other providers adhere to the care pathways for the specific clinical problem, patients receive less unintended variance from best practices and more precise care. One example of the successful use of care pathways is with acute pediatric asthma presenting to the emergency center at ACH. ACH implemented care pathways in the emergency department almost 2 years ago and have significantly reduced the hospital admission for low and moderate acuity asthma.

Another precision medicine practice currently being used at ACH is strategic bed placement. Strategic bed placement is practice of cohorting segments of the target population into clinical care units specifically designed for their care needs. The cohorting of similar segments of the population into the same clinical unit allows for a culture of care that is more closely aligned with the needs of the patients and thus more precise. A recent example at ACH is the creation of extended post-surgical care unit. Many children who come into ACH for a procedure that can be considered day-surgery take longer than a few hours to recover, and in those instances or when the post-surgical care unit closes a few hours after the last case of the day, patients are admitted to the hospital. In most cases, these children and their families experience a break in care during the transition to the floor and many times stay in the hospital longer than is necessary before the surgical team has time to discharge them. The extended post-surgical care unit addresses both of these shortcomings of traditional care. Children who have taken more than a few hours to recover but who are characterized as patients who will go home within 12 hours are allowed to stay in the post-surgical unit that whole time and are discharged as soon as they are ready.

PRECISION MEDICINE IN RESEARCH

In the winter of 2015, President Obama announced the National Institutes of Health’s (NIH’s) Precision Medicine Initiative (PMI) during his State of the Union address to congress (4−6). In September of that same year, the NIH released the report from the advisory council for their PMI. In that report, the advisory group pointed out that PMI would focus predominately on cancer in the near term but in the longer term would focus on health and other diseases. The report highlighted the key building blocks for such a research initiative: cohort assembly and participant engagement, data storage and bio-banking, and research policy.

ACH, anticipating the need for institutional investment in research cores and services that parallel those subsequently detailed by the PMI report, made the investments outlined in Figure 1. The most significant of the investments was the Institution-wide Prospective, Inception Cohort Study of Individuals with Childhood-onset Acute and Chronic Health Conditions (iPICS). iPICSs is a prospective inception cohort of children seeking care at ACH who have acute and chronic diseases such as asthma, prematurity, pulmonary hypertension, and obesity. It also includes a cohort of pregnant women and newborns. What makes the value of this cohort relatively unique is the institution-wide investment in the cohort, the availability of the cores to support the work including a bio-repository, and its inclusion of determinants of illness beyond biological and clinical factors that include behavioral and social factors.

Fig. 1.

Investments made by All Children’s Hospital Johns Hopkins Medical toward following the National Institutes of Health Precision Medicine Initiative.

PRECISION MEDICINE IN RESIDENCY TRAINING

Johns Hopkins University School of Medicine launched a new medical student curriculum called “Genes to Society” in 2009 (7). The goal of the curriculum is “to encourage students to explore the biologic properties of a patient’s health within a larger, integrated system including social, cultural, psychological, and environmental variables.” At its center, the curriculum is about understanding factors that predispose and cause illness and hospitalization or maintain wellness.

As part of the integration agreement between ACH and JHHS/JHM, the board of trustees of ACH stipulated the creation of a new general pediatric residency program based on the principles of Genes to Society. The first class of residents started in the summer of 2014. Keeping with the goals of Genes to Society, ACH augmented the core competencies outlined by the Accreditation Council for Graduate Medical Education, with three additional competencies that may lead to a precision medicine orientation to care: 1) Address factors that pre-dispose and cause illness and hospitalization; 2) Lead integrated care teams in the delivery of longitudinal care in and out of hospitals; and 3) Deliver efficient, less costly, and higher quality care.

To achieve these competencies, the leaders of the ACH pediatric residency implemented three innovative activities. The Precision In-Patient Medicine Rotation is the general in-patient clinical care service. It is based on the Johns Hopkins Bayview Aliki Initiative (8). The rotation lasts 6 weeks instead of the usual 4 weeks or 1 month to build greater team cohesion in the context of shorter resident work hours. In addition, each of the three interns on the team are only responsible for four patients so that when one of them is covering the whole service (which happens often) they still have time to delve into the clinical, behavioral, and social aspects of the patients’ illnesses.

A second activity is monthly peer-mentoring groups where there is in-depth exploration of value-based care and precision medicine. And the third innovative activity is the Leadership Executive Academic Development (LEAD) Program, a 2-week intensive experience outside of the hospital with a focus on team-based immersion learning facilitated by experts from interdisciplinary fields in ethics, business, education, and leadership.

CONCLUSION

The case study of ACH demonstrates how precision medicine can act as a framework for organizing and investing in all legs of the mission of an academic pediatric health system. The adoption of a comprehensive precision medicine framework can help differentiate academic health systems from other systems and may justify the continued investment in academic health systems as they create value for the system as well as the broader public.

DISCUSSION

Lee, Boston: What is different about training the young house staff to be team-members versus the way we were all trained?

Ellen, St. Petersburg, FL: You probably were training exactly right; I think what has happened is that the 80-hour work rule or the change in how many straight hours you can work, have been disruptive to the residents’ experience building and leading care teams. They have shorter shifts, have to leave to go to clinic, having to do all of these things, and you have to be intentional about creating that kind of teamwork or you won’t get it. And that was the perspective that drove us in this.

Southwick, Gainesville: Have you experienced much pushback from the physicians who were there originally?

Ellen, St. Petersburg, FL: I think what has been very helpful is that no one has questioned our motivation; it’s about improving the quality of care, and that is the mantra that we have to keep talking about and it’s not about some type of control or “Hopkins knows better than anybody.” We are very careful not to portray it that way.

Zeidel, Boston: Very interesting development in education and I think a lot of important trends. But let me ask as a bit of a stick in the mud, is there a process? Also, as you built this, are you able to retain the ability of residents to think mechanistically about the patients problems understand step by step what is wrong with them, think pathophysiologically and maybe also think about maybe advancing the basic understanding of the mechanisms of the disease as well as the processes of care. Obviously I am pretty passionate about processes of care as well.

Ellen, St. Petersburg, FL: And I would tell you that it is exactly what we are trying to do. And I think that the reason we are trying to limit the number of patients is because rather than walking around with the clipboard which residents have a tendency to do, and start checking boxes and never really reflecting on pathophysiology, is getting them to actually understand the mechanisms of illness and understand the pathways that cause them to get sick, why they are sick now, and what their recovery looks like, and why that may be different. And I think that is exactly what we are trying to get residents to think about.

LeBlond, Billings: We are doing very much the same thing; we just started in medicine residency. The first internal medicine residency between Spokane and Minneapolis. We introduced our first class in July of 2014 and a second class this summer and it’s been a very interesting journey; introducing academics into an institution of a very high quality care, by very busy doctors, and for those of us who spend most of our career in academic medical centers, it’s a very disruptive technology to introduce a residency program into that environment. I echo your concern about teams; we just eliminated Friday days off for any of our residents because Friday is the only day, full day, in our training program when our team is together the whole day with each of the interns having two half-day afternoon clinics. They are two in a half-day clinic; everybody needs a day off, they get a golden weekend. You basically are working with a partial team cross covering everybody; it is a completely disruptive way to take care of patients that sort of is foisted upon us and our ability to change that paradigm is very difficult. On the weekends, the only continuity of care is by the attending so it’s a big challenge and I think we are all going to have to figure out ways to deal with this.

Forrest, New Haven: I agree with all that Mark Zeidel and you have said. What measurements, if any, do you have of that you are increasing the house staffs understanding of the process pathophysiology of the disease?

Ellen, St. Petersburg, FL: It’s what we are working on right now.

Ludmerer, St. Louis: Tying together some of the comments that have been made, the issue of work hours is different from the issue of working conditions. So a lot of the disruption we have has to do with specific regimentation of shifts and you have to be out of this time and loss of continuity. I will just say that for the moment the work rules are under consideration for revision and I don’t think that is going to be a lasting circumstance. On the conditions of work, which is what I think is the great contribution of the Aliki Initiative and what you are following, the single important intervention is allowing residents to have a manageable number of patients. And from that, everything could occur: The opportunity to reflect, the opportunity to think, not only what is there to do or what is the justification for doing it and how were the rules developed in the first place, so that gets into inquiry into research into thinking of what is to make medicine better in the future. As you point out, you have, a more manageable workload that allows cooperation and collaboration with nurses and social workers and better teamwork. Then, that is the critical intervention. You are able to do it in your institution because you already have hospitals in place, faculty in place. You didn’t need residents to be the labor to keep the hospital going and that is why it is succeeding. I would point out an answer to the issue of measurement and data, we do have to measure what we do…David Hellmann and, as I am sure you know, at Johns Hopkins and Roy Ziegelstein have data from the Center showing that the Aliki Initiative allowing manageable number of patients, does work in terms of information learned by residents in terms of reducing cost of care and improving quality of care and improving morale in a sense of good work. And in terms of just cost of care, the 30-day readmission rated from congestive failure and pneumonia on the standard service is about 13% on the Aliki service is about 4%. So the data are coming in…..we need more data to document what too many of us is intuitively obvious and in concert with our experience, but data are there and is continuing to grow.