Stanford physicians and leaders visited the Utah-based health-care system to share ideas for a wide-ranging partnership in clinical research, patient care and education.
April 22, 2016 - By Ruthann Richter
For many medical problems, there is more than one solution and often wide variations among physicians as to which tool or treatment they use. For instance, for a child with enlarged tonsils, a surgeon may choose among many different surgical instruments to effectively remove them. But is one method better than the others, both in terms of the child’s welfare and overall health-care costs?
For the last few decades, Intermountain Healthcare, a not-for-profit health-care system based in Utah, has made an art of dissecting these issues by analyzing data to develop standards of care that reflect what works best for patients and is most affordable. Now physicians at Stanford Medicine are hoping to learn from that experience.
“Intermountain has become a world leader in terms of managing clinical care in a way that reduces the variability of care and improves quality while reducing costs,” said Bryan Bohman, MD, clinical associate professor of anesthesia at the School of Medicine and associate chief medical officer at Stanford Health Care. “They’re thought of as one of the very top organizations in learning to manage clinical care. That’s one reason we are partnering with them.”
On April 14, Bohman was among 17 Stanford Medicine clinicians and administrators — including Lloyd Minor, MD, dean of the Stanford School of Medicine, who led the group — who went to Utah to hear from Intermountain specialists how they have used evidence from large, published studies and detailed data from their approximately 850,000 patients to improve care while saving money both for patients and insurers.
The visit was part of a major new collaboration between the two institutions, which will spend $3.75 million to enable joint clinical, research and education projects that are expected to benefit both — and possibly the U.S. health-care system at large. Intermountain is contributing $2.5 million to the partnership, while Stanford will provide $1.25 million.
“Stanford Medicine is honored to be collaborating with such an innovative and integrated health delivery system,” said Lloyd Minor, MD, dean of the Stanford School of Medicine. “Our partnership will result in higher quality care for both Stanford and Intermountain patients while establishing models that can be adopted by health-care organizations around the world.”
The partnership will span a range of projects in cancer, heart disease, pediatrics and other specialties, as well as improvements in clinical care and an exchange of trainees who will do rotations at the two institutions.
“There is such great potential to work together,” Charles Sorenson, MD, president and CEO of Intermountain, said during the April 14 meeting. “Investment in these collaborative projects will be beneficial to you at Stanford, as well as us.”
About two years ago, Sorenson said, Intermountain began looking for a “nationally recognized, admired partner” in academia. Intermountain already had a connection to Stanford through Arnold Milstein, MD, a professor of medicine and director of Stanford’s Clinical Excellence Research Center, who used the health-care system as a pilot site for his “ambulatory care ICU” project, a new form of outpatient care to prevent costly and dangerous health crises in patients with chronic disease. Milstein is now on the board of Intermountain.
Other physicians, including Bohman, have attended Intermountain’s Advanced Training Program, led by Brent James, MD, executive director of the Intermountain Institute for Health Care Delivery Research and the guru of standardized clinical care.
‘A really good fit’
After a preliminary meeting between leaders at Stanford and Intermountain, “it became obvious there was a really good fit in terms of mutual benefit,” Bohman said. “They wanted an academic partner with a deep reserve of outstanding scientists, including innovative analytics and informatics. We were looking to their very large clinical population that would help us in terms of clinical trials, in the training of house officers and in doing collaborative research.”
If we can pool our data, we can learn a lot more about these relatively rare mutations.
Among the joint research projects in the offing is a cancer genomics study. The institutions will form a consortium to share molecular tumor data on a range of tumor types including breast, colon and esophageal tumors. Genetic data will be linked with outcomes data from targeted therapies with an eye to developing better treatments, said Eben Rosenthal, MD, a professor of otolaryngology and medical director of the Stanford Cancer Center.
“When you do genetic testing on a tumor, there are dozens of mutations of unknown certainty,” Rosenthal said. “Are they driving the tumor or are they incidental? Can they be targeted with a drug? And what is the outcome of a drug?
“If we can pool our data, we can learn a lot more about these relatively rare mutations,” he added. “The power of that, from the standpoint of Intermountain, is that we have really smart people to do the data analysis and cutting-edge science, while they have a huge population for which they have rigorously maintained records. To me, that just has massive potential to make an impact.”
Intermountain has the nation’s largest biorepository, started in 1975, which stores more than 3 million tissue samples used for the advancement of cancer treatment and other research. Stanford oncologist James Ford, MD, associate professor of medicine, is leading the project in collaboration with Lincoln Nadauld, MD, PhD, at Intermountain.
Antibiotics in newborns
In another project, Jochen Profit, MD, assistant professor of pediatrics, is working with Intermountain neonatologists on an issue of national concern in the field: the overuse of antibiotics in newborns.
A recent, landmark study by the California Perinatal Quality Care collaborative, housed at Lucile Packard Children’s Hospital Stanford, showed wide variations in use of antibiotics among sick newborns in intensive care units. That has led to a major effort among California NICUs, including Packard’s, to reduce use of these drugs, particularly for sepsis, Profit said.
Sepsis is a rare infection, but it can be life-threatening and there is no easy way to detect who is at risk for the disease, he said. So the tendency is for doctors to overtreat with antibiotics, which can lead to serious complications.
Profit is working with neonatal intensive care units across the state to integrate an Intermountain training program to minimize unnecessary antibiotic use and generally improve quality of care for these infants.
“They [Intermountain] have this culture of quality, where they constantly think about how to improve, even in many areas where they are already national leaders,” Profit said. “It’s a different attitude than you see at a lot of hospitals.”
Stanford Medicine physicians also hope to benefit from adopting some of the “care pathway” models for which Intermountain is well-known. These are care guidelines that specify use of certain drugs and treatments for a given condition, based on scientific evidence. These guidelines help reduce variations in practice among physicians and improve patient outcomes.
There may be a real opportunity to work with a system that is more representative of the population as a whole.
As Intermountain cardiologist Donald Lappé, MD, said, “We’re reducing variability of care because you can’t manage chaos. You can’t improve quality if you can’t manage the care process.”
Cardiologist Paul Heidenreich, MD, professor of medicine and of health research and policy at Stanford, said Stanford Health Care plans to adopt an Intermountain care pathway for patients who come into the emergency room in the throes of a heart attack. Among other things, these patients will receive one of a few specific antiplatelet medications, which help treat and prevent blood clots that are often the cause of the heart attack. Standardizing drug choices helps reduce errors and improve patient safety because trainees, nurses and other clinicians can use standard order sets and don’t have to wait to determine the preferences of attending physicians, which can vary widely, Heidenreich said.
This approach also enables physicians to focus on what may be uniquely different about the patient, Bohman said. “Care pathways align the entire health-care team to ensure that the basic blocking and tackling are reliably performed, allowing the physician to focus on humanistic aspects of care as well as any unusual aspects that may actually require a different treatment,” he said.
From Intermountain’s perspective, Stanford can help by taking a critical look at its data and validating its care pathways in Stanford’s more diverse patient population, said David Skarda, MD, medical director of the Surgical Services Clinical Program.
“There may be a real opportunity to work with a system that is more representative of the population as a whole,” he said.
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