Mark: Hi, I'm Mark Briesacher, Chief Physician Executive at Intermountain Healthcare and I'm here today with Dr. Scott Stevens who is our Medical Director for the Medical Specialties Clinical Program. Scott, welcome.
Scott: Thank you Mark.
Mark: I've been thinking about when we first met and we actually met because I have a lot in common with your wife, Dr. Lisa Palmieri in that we're both pediatricians and I'm pretty sure it was within that context that our paths first crossed.
Scott: I think you're absolutely correct and I definitely understand being married to a pediatrician what the importance of children versus adult healthcare is but I'm going to try to make a contribution in the adult arena anyway.
That's right. Children are not small adults. That's the basic rule. Well thanks for being here. This is really exciting because the Medical Specialties Clinical Program is a new clinical program at Intermountain Healthcare. And you know I think maybe if you could just start with telling us a little bit about it.
I'd be pleased to, thank you. Performing this new clinical program out of the realization that a number of the subspecialties in medicine and related fields have not previously had a clear home within the clinical programs and that's resulted in some degree of fragmentation of the way care is delivered as well as the approach to care in these disciplines. As the new clinical program was being put together we realized that if we could gather each of these specialties together across the system we could realize economies of scale, we could learn best practices from various specialists within the system, share wisdom, collaborate and really create a collegial environment with the most important goal of improving the care of our patients to help them live the healthiest lives possible. But with the secondary goal of collegial interaction between all of our specialists be they employed or affiliated with the underlying goal of ensuring we help them get the highest possible professional satisfaction from the care that they deliver to their patients.
I love the way you framed that because I think this idea is really important that as we talk about making care better, you know more safe, higher quality, better experience. We also know that how physicians and nurses, the staff, all the caregivers that are part of delivering that care how they are doing, how they are feeling, how connected they are to our mission. How much trust there is is directly related to making that care better, safer, higher quality.
Absolutely. I think there's very clear evidence in the medical literature that happier and more satisfied caregivers give better care. So when we're taking care of our caregivers we're taking care of our patients as well. And those two goals work hand in hand, they're not in competition with each other. And that's one of the most exciting parts of this job for me is I get to visit all of our specialty providers, meet with team members and I become a storehouse for great ideas that people have in their individual locations and I hope that the team that I work with then becomes a conduit to disseminate the best ideas across the system. When one area has found something that's working like gangbusters we got to very quickly be able to spread that to the rest of the specialists throughout the system. And when an idea can cross between different specialties we want to make sure we're in a place to disseminate that as well. So for my approach the biggest wins are when we find a way to make care better for our patients which at the same time makes professional satisfaction for our caregivers get better.
So the clinical program's been in place really just a couple of months. I know you've been out and about talking with doctors and advance practice clinicians and providers and the teams. What have you been hearing? What's been on their minds?
So I think we visited approximately 40 percent of the specialists in the system and we have a wonderful team making these visits. I'm able to attend many of them. Kelly Donohue, our Improvement Specialist has been the workhorse of this endeavor and has actually done nearly every visit and is doing an amazing job. And Marnie Chandler our Executive Director has been involved in many of those. When we meet with caregivers in the specialty clinic we try to make connection with as many people in the care team as we can to get a real feel for how the practice is running, what are the pebbles in the shoes, what are the things that are working well and we're creating a database of both challenges and best ideas to help us move forward as we organize each specialty.
The two biggest things I'm hearing are an incredible eagerness to collaborate. Many of our specialists feel like they've been so to speak living on an island in their individual clinic. Most of our specialists are in groups of a very small number of people and sometimes just one in a clinic. And so these people will tend to feel isolated and there's an incredible eagerness to connect with their colleagues and find a venue by which they can share ideas and make things better.
The frustration that I hear the most is undoubtedly access. I have not met a specialist who is incredibly frustrated that there are so many patients to care for so many people who need their expertise and it takes a long time to book a visit for a new consult. And so we're looking at creative ways to try to ease the access challenges that we have in our system in part by enhancing telemedicine when that's appropriate, by working smarter across the system so we can distribute patients who need care to venues where that care is most readily available. And we're working very hard in making our referral process more intelligent and streamlined. So we identify the patients who need to be seen the soonest effectively and get them in quickly. We are able to see patients in the primary care setting with co-management who may be able to defer or avoid an in-person referral altogether. And from the perspective of the busy specialists we're also able to identify those patients that may be best referred somewhere else.
I'm not surprised to hear knowing the physicians that are part of Intermountain Healthcare that they feel the challenge and the responsibility to provide great access to care and it's a really impressive list of things that they already are thinking about and talking about. You know I bet a lot of people don't know about your work at Intermountain Medical Center and across Intermountain Healthcare when it comes to thrombosis pulmonary embolism, managing chronic anticoagulation. I wonder if you could talk a little bit about maybe the recent past, your body of work that in my mind makes you the ideal leader for this clinical program.
Well it's kind of you to put it that way. I have reflected that I'm actually a general internist by training and not a board certified specialist which maybe is a little bit ironic given the role that's been offered to me. However over the years with Intermountain Healthcare and counting my original residency at LDS Hospital I've been with Intermountain 22 years coming up on 23 now. Very shortly after residency I took an interest in thrombosis and anticoagulation and started some research under the mentorship of Dr. Greg Elliott who as you know is a re
Markably accomplished physician and a master in the field.
Mark: And just a really nice generous person.
And a wonderful human being. I'm not sure if his mentorship has been more important to me as a medical scientist or more important as a human being but I think it's probably the latter. As I published a little research and developed some expertise in thrombosis I started getting informal consultation for more difficult cases. That eventually grew in to a somewhat informal clinical service at LDS Hospital and then at about the time of the move to Intermountain Medical Center we formalized that into the Thrombosis Clinic and Thrombosis Consultation Service and it was at that time that Dr. Scott Waller who is another fabulous physician joined me in those endeavors.
Anticoagulation internationally is an extraordinarily multidisciplinary field because to some degree it's never been fully owned by any single boarded medical specialty. So of course hematologists often work in the field. Pulmonologists work in the field. Vascular surgeons work in the field. Cardiologists work in the field. It's been a field rich with input from pharmacy so it's very collaborative by its nature. And we quickly made our way into joining others who are doing a fabulous job in those collaborative arenas in Intermountain Healthcare particularly the Chronic Anticoagulation Clinic run by Page Christiansen and Steve Towner which started at the Salt Lake Clinic and has now spread its best practices to 18 sites within Intermountain Healthcare. And we've been proud to be able to be part of the team that's helped that process develop.
So it's been really fun to see the growth of thrombosis and anticoagulation in Intermountain Healthcare in general. I've been honored to be a small part of great teams that have accomplished wonderful things. And in addition to what I hope is making for the best possible care of our anticoagulation patients within Intermountain Healthcare we've also been fortunate to have a strong academic presence. And the last I checked the Thrombosis Research Group which is a collaboration of researchers in the arena at Intermountain Healthcare their published work has been cited over 8000 times in the medical literature and members of our research group have been authors on several international guidelines. So we've been fortunate to have the opportunity to improve our care with an Intermountain and also to have an influence upon the standard of care both in the United States and across the world.
I think it's really impressive the work that you've accomplished. And actually mentioning Steve Towner who's a good friend of mine and an old basketball buddy going way back it is amazing to me how really a small group of committed caregivers realized that we could be better, our patients could get better care, safer care and had the courage, the persistence, the curiosity to really develop something that is now a nationally and internationally respected program right here at Intermountain Healthcare. So none of that happens without great leadership and I'm very thankful for that Scott. And now I'm looking forward to the same thing happening in all 10 specialties that are now part of the Medical Specialties Clinical Program. So it is quite an endeavor that you're undertaking here.
I'm wondering if we could maybe switch to why this is so important at this time. And I'm interested in your thoughts around the transition from a viewing healthcare through a fee for service lens. You see me in clinic, we develop a plan and here are the charges and then I see you three months from now to the new world of where we're doing both fee for service and almost an equal amount of taking risk and almost an equal amount of taking care of whole populations where we're responsible for the safety and quality and experience of care, we're responsible for having great access. We're responsible from a stewardship perspective, from an affordability perspective in that these are populations for which we are prepaid for their health and well-being and for their medical care. And it strikes me that in this new mixed model of fee for service and fee for value that the role of a medical specialist who oftentimes is managing chronic conditions, not uncommonly conditions that require expensive laboratory and imaging tests and even more importantly expensive medication interventions. It strikes me that these specialties are of extraordinary importance to our work in caring for people in our communities.
I couldn't agree more. And I have to say that from my perspective as the director of this clinical program I'm very excited about the shift in emphasis from fee for service to fee for value or pre-paid care as you've so nicely described. I view that paradigm as a much better fit with what the medical specialties by and large do than the fee for service paradigm. I say that because many of our specialties tend to perform relatively few interventional procedures and tend to be pretty heavy on what has sometimes been called the cognitive aspects of medicine which is to say thinking through a complex medical decision but not necessarily performing any interventions. And the fee for service paradigm has not always recognized the cognitive aspect of healthcare as fully as it might in an ideal world.
Mark: Very well stated.
Thank you. So I believe medical specialties are ideally poised to take advantage of the opportunities that a fee for value environment affords us and really get creative with how we deliver care. So for a cognitive task it's very often possible for that cognitive decision making to take place in a location remote from where the patient is. So telehealth I think will be a powerful tool for many of our medical specialties. Provider to provider guidance where a specialist may co-manage care with the primary physician or frontline provider to help provide excellent care in the location where the patient, as the saying goes "works, plays, lives and prays", rather than moving the patients always to the location of the specialist which are often clustered in our more large urban areas.
Additionally we can realize better care and less expensive care by coordinating our care better. So one of the major outputs of clinical programs historically in Intermountain Healthcare has been care process models which are tools for which we've become internationally famous. However my observation has been that care process models are very often targeted in only one arena of healthcare. So a care process model targeted to primary care physicians is limited to the primary care component of care. If a specialist must become involved in the care of the care process model usually doesn't have information guiding that aspect of care. Similarly care process models that live within the specialties tend not to be relevant to primary or frontline care. So I envision the medical specialties collaborating in a way where we create care process models and best care that spans the entire continuum, that helps primary care physician or provider manage care, assists in determining when specialist input is needed, moves through the specialty aspects of care to make our care standardized and as affordable as possible. But then has important innovations such as a period of code management between the primary or frontline care provider and the specialist so that that interaction is performed at maximum efficiency and maximum benefit to the patient.
And also components at the far end of care when disease becomes very advanced. Our care process models don't at the present time tend to add palliative care components. And yet for many diseases best care will at some point along the way involve palliative care and bringing a palliative component into the best care standards for each of the areas in which we create protocols will be crucially important. And I think this seamless continuum, this mutually agreed upon set of best standards is one of the situations where better care can also be less expensive care which can often although not always be the case. But when we can achieve that goal I think that's wonderful.
I'm really struck by the co-management idea and actually super excited about it. As a general pediatrician you're always learning right and you're re-learning and I'm thinking that if I could have a pediatric endocrinologist join a visit in my clinic working through some unusual thyroid laboratory studies helping me with the subtleties of a physical exam and educating me during the encounter and of course having the patient and family right there in my office as opposed to us trying to figure out how we're going to get into or on someone's schedule and that's going to be on another day and it's going to be another drive and all of that time being saved for the patient. It just strikes me that everybody is kind of learning and growing and having an amazing experience, both the family and the patient as well as me as the primary care physician and the specialist who is able to care for even more people in the population and play that very rewarding role as a teacher to both my patient and to me.
Absolutely. And I really believe as something of a specialist myself that the education goes both ways. Hopefully I will generally know more about the isolated area of medicine in which I live than the frontline provider who's referring the patient. But we have some really smart people out there and it's not unusual that I get taught something. But outside the particular question being asked, the deep and abiding relationship between the primary care provider and the patient is profound and incredibly meaningful and the primary care provider can most certainly educate me about that patient in a way that is much much deeper than I can ever manage from the isolated specialty encounters I might have with that patient.
And also it's not as if most patients I see have thrombosis as their only problem right. The primary care physician or provider is the one that knows the other issues going on and helps balance my work in concert with the work of perhaps other specialists that that patient may be interacting with or other disease processes under management that would influence what I do. And so that education goes both ways and I think it's tremendously valuable.
Mark: And they would be able to provide you with important things like this patient's daughter's getting married in three months and they really want to be able to fly to that event.
Because in the end it's so personal right. Our patients think of things in terms of how does this help me with my goals in life, how does this affect my goals in life. And having someone who already knows that actually not only makes the care better but it's also a time saver for everybody in that instance.
I couldn't agree more. And to me that's the beauty of the medical profession. We traditionally wear white coats to reflect our scientific background implying that perhaps we were just in the lab a few minutes before and now we're coming to see the patient which is true for some but not all. But though being a great physician requires being a good scientist or conversant with good science our job is to take the science we know and apply it to the individual human being before us. And that's a scale that doesn't come from being a great scientist. That's a skill that comes from being a great human being. And one way in which we yet to become better human beings is existing in communities of professionals where we enrich one another's relationships and appreciation for our patients. And that's something that I would really be honored to help facilitate as our clinical program moves forward.
Scott thank you so much. We started talking about people and we've ended talking about people and I'm just so glad that you're in this position. I'm going to watch with much much anticipation because I know you and all the people on the team and all of our medical specialists out there are going to do amazing things. So thank you.
Thank you. And I'm honored to have this opportunity and I want to acknowledge the amazing care that our medical specialists deliver. And I'm humbled to be able to work with them to see if we can't organize that and have the entire system function more smoothly to make things as good as possible for our patients who really need us.
Mark: The best days are ahead, that's for sure. Thanks Scott.
Scott: Thank you.