REthink: Spring 2019 by DellMedSchool

featuring JOYCELYN ELDERS, DAVID FEINBERG & MARK Mc CLELLAN

From the start, one of Dell Med’s major advantages has been the foundation it’s built on: The University of Texas at Austin. And the medical school’s connectedness spans the Forty Acres, from alignment with President Gregory L. Fenves’ goal to revolutionize personal and public health to education, research and innovation collaborations across all 18 schools and colleges.

College of Fine Arts Design Institute for Health

College of Pharmacy + School of Nursing + Steve Hicks School of Social Work Center for Health Interprofessional Practice & Education

› dellmed.utexas.edu

“a leading, pioneering, edgy medical school” adm. brett giroir

McCombs School of Business Value Institute for Health & Care

u.s. assistant secretary for health

REthink | POW E RE D BY DE LL ME DI CA L SC H OOL | 2019

CONNECTED ACROSS CAMPUS

Moody College of Communication Center for Health Communication

“the right team, in the right place, at the right time” president gregory l. fenves

the university of texas at austin

issue no. 9 • spring 2019

ONEEVERYONE

Ann Hamilton (2017)

Photographic portraits selected from more than 21,000 taken of individuals in the Austin community are on display at the Dell Medical School campus as part of ONEEVERYONE.

SPIRAL OF THE GALAXY

Commissioned by the public art program of The University of Texas at Austin, Landmarks, the project welcomed any person who had ever received or provided care — everyone. To create it, participants stood behind a semi-transparent membrane that focused only on the points of the body touching the material.

ma rc qu in n ( 2013)

Landmarks’ Spiral of the Galaxy occupies the courtyard of Dell Med’s Health Learning Building — described by Texas Architect as “a place of collaboration and openness, a hive of learning.” Modeled after a conch in the British Natural History Museum, the sculpture evokes a sense of reality but on an impossibly large scale. Its form, the shell, is a model of biologic engineering. Beginning in a small spiral, the mollusk adapts to its surroundings. Nourished by the environment, it builds upon previous foundations. Each iteration is necessary to protect future growth. Prior layers may lose their luster, but the leading edge gleams with potential. Ironically, this is where it is most inventive as well as most vulnerable.

As an educator, my goal is to help future physicians understand the importance of that which makes us human. ONEEVERYONE encourages us to do this by showing a hand, a shoulder, a gaze. It is tempting to focus on the collection of parts, imagining a composite who represents the community outside the frames. To concentrate on what we see clearly, however, may neglect the individuals obscured in the background. To appreciate both in equal measure is the great challenge of health care.

Remembering that what this tiny architect leaves behind is what’s treasured most, our job as physician-educators is to inspire ingenuity, adaptability, resourcefulness and perseverance. Just as important is the capacity for joy, empathy and humility.

— Steve Steffensen, M.D.

“

Some doctors are so inundated with the business of medicine that good bedside manner has become a lost art. As a preventive measure, the new Dell Medical School … is challenging students … to embrace their feelings by examining the fine arts.

— Steve Steffensen, M.D.

march 2017 43

LEADERSHIP

S. Claiborne “Clay” Johnston Dean, Dell Medical School

Contents

John Daigre Executive Director of Communications & External Affairs, Dell Medical School EDITOR

issue no. 09 · spring 2019

Mary Kincy Cope

06 Med Ed for the Next Century

A S S O C I AT E E D I T O R

How do you create the medical school of the future?

10 Practicing What We Teach At UT Health Austin, don’t expect business as usual

Hannah Jane Collins COPYEDITOR

Ali Killian

14 Value-Based Health Care: A Definition Elizabeth Teisberg on restoring health care to its purpose

16 Seeing the System A design application for academic medicine

18 The (Real) Future of Health Care Google’s David Feinberg talks with Clay Johnston

20 Redesigning Austin’s Mental Health System The transformation of an outdated facility to a continuum of care

22 The Fourth Pillar Research, education and care — plus

24 Trending: Population Health The movement’s leaders define opportunities for medical schools

26 The ‘Team of Teams’ Approach Establishing a model for collaborative leadership

28 Building a World-Class Center for Brain Health A spotlight shines on the Mulva Clinic for the Neurosciences

30 The Business of Improving Health About the Texas hub marrying academia and industry

32 Joycelyn Elders on ‘Fighting Well’ Jewel Mullen talks health equity with the ex-surgeon general

34 Beyond Medical History A partnership that treats childhood asthma with data

WRITERS

Shahreen Abedin Kimberly Berger Hannah Jane Collins Mary Kincy Cope John Daigre CONTRIBUTORS

José Colucci Jr. Katherine Corley Angela Curtis Steve Steffensen Kristin Tommey ART DIRECTION & DESIGN

Hoyt Haffelder Josh Korwin, Three Steps Ahead PHOTOGRAPHY

Thomas Meredith Charles Quinn O N T H E COV E R

Madi McGuire, a member of Dell Med’s Health Leadership Apprentice Program, tries on a white coat — and tries her hand at manipulating an image of a heart. It is displayed on a 65-inch interactive screen that students use to explore (and virtually dissect) 3� renderings of radiographic anatomy images.

36 36 Hours as a Surgical Resident Starting at 5 a.m. with co-chief Brittany Bankhead-Kendall

38 5 Things Every Med Student Should Know A lesson in reform from Mark McClellan and Karen DeSalvo

Email us at communications@dellmed.utexas.edu.

FROM THE DEAN

he creation of a new medical school isn’t particularly unusual. But an opportunity like the one here in Austin — to

build an academic health system from the ground up on the campus of one of the country’s great public universities, in one of America’s most vibrant and forward-thinking cities and with that community’s financial support — is remarkable. Five years in, we’re seeing early indications of the promise of our groundbreaking “Leading EDGE” curriculum and our signature, team-based model of care. We remain focused on our commitment to measurably improving health in our local community. We’re attracting talent like Karen DeSalvo, a nationally recognized leader in public health and IT, and Charles Fraser, who brought one of the best pediatric cardiac surgical teams in the country to Dell Medical School and its clinical practice, UT Health Austin. And we’ve built a reputation from our mission to revolutionize how people get and stay healthy. It’s an ambitious claim that’s attracted a lot of attention — maybe

more than we expected. Fast Company wrote about our plan to, in its words, “start a mini revolution” in health. Health Affairs dedicated 3,000 words to our commitment to making Austin a model healthy city and evolving new models of care that reward value. Is it hype? It’s fair to ask. I’ve pondered it myself. My conclusion: The interest has as much to do with the resonance of our mission as it does the school itself. America’s health care system is broken and backward. Nothing short of radical change will do — and people know it. Together with medical educators, researchers, clinicians and community partners in Austin and beyond, we’re here for the challenge.

S. Claiborne “Clay” Johnston, Ph.D., M.D. Dean, Dell Medical School Vice President for Medical Affairs, The University of Texas at Austin Frank & Charmaine Denius Distinguished Dean’s Chair in Medical Leadership

Dell Med has three advantages that support our ability to help shape the medical school (and the academic health system) of the future. The opportunity to start from scratch Free of legacy obligations, we align our approach to med ed with efficacy, not history. The same is true for our ability to rethink how to care for patients and their families, accelerate research, and leverage innovation and partnerships.

Unprecedented partnership with our community In 2012, local voters approved a measure to invest in the creation of a medical school focused on improving health in our community — particularly for those who have historically faced the greatest challenges to health. The result was Dell Med, with a unique mandate from — and responsibility to — Austin and Travis County.

A foundation for collaboration The University of Texas System is made up of 14 educational institutions throughout the state, including eight universities and six health institutions — one of which is MD Anderson, the No. 1 cancer care center in the country. The University of Texas at Austin, led by President Gregory L. Fenves and home to Dell Med, ranks among the top research universities in the U.S. Cross-campus collaborations bring business expertise, engineering capability, communication talent, nursing know-how and other vital perspectives to every aspect of Dell Med’s work.

Med Ed for the Next Century In an age of surgical robots and artificial intelligence, how do you create the medical school of the future? by mary kincy cope

students use dell medâ&#x20AC;&#x2122;s sectra to explore 3d Âť anatomical renderings

spring 2019

more on innovation, leadership & discovery:

dellmed.utexas.edu/growth-year

ne of the newest medical schools in the country, Dell Medical School at The University of Texas at Austin, has a laboratory with a wall of windows overlooking the busy street that borders the Capitol just a few blocks away. At 7:18 on a Friday night, it’s dark enough inside that the metal tables where cadavers sometimes lie fade from view. There’s a screen visible. A student approaches it, and a camera shutter clicks. The image that’s captured is moody and dramatic: a lone woman manipulating a cold, blue heart on a massive, glowing monitor. It’s a scene from the medical school of the future, but — as it turns out — it’s not very emblematic of Dell Med, with its focus on team-based learning, self-discovery and engagement with community partners. “From Day 1, our students are working in teams to solve problems, whether in the classroom through case studies or in the hospital during clerkships,” says Beth Nelson, associate dean of undergraduate medical education. “We’re focused on building skills in communication, collaboration and leadership, so that when students graduate they are prepared not only to care for individual patients but to take on systemic challenges to health.”

‘Envisioning What the Future Should Be’ The curricular model at Dell Med is called the Leading EDGE, highlighting the focus of each year of study: essentials, delivery, growth and exploration. Grounded in value-based care and health systems science, it begins by accelerating the preclinical curriculum so that by the second year, students are prepared to enter

clerkships and apply clinical skills in hospitals and clinics. Then comes an Innovation, Leadership and Discovery block in which students plan and lead collaborative efforts to tackle community health challenges. They have the option to pursue a research, population health, health care design or entrepreneurship interest. Alternately, they can pursue a dual degree — an MBA, MPH, MEd or a master’s in Biomedical Engineering, Health Care Transformation or Design in Health.

“The idea is that as Dell Med and other schools demonstrate the effectiveness of new practices and procedures, other schools will start to embrace changes, if only to remain competitive.” october 2015

“We carve out this nine-month block to give students a chance to take a deep dive into different aspects of the health ecosystem,” Nelson says. “We’re preparing them to understand the challenges to health so they can begin envisioning what the future should be — and how they can make it happen.” The fourth year gives students the opportunity to explore residency disciplines and hone medical skills through senior electives, acting internships and critical care experiences. The approach, while unique, puts Dell Med in a class with a handful of other medical schools across the country shifting curricula to align with contemporary learning theories — and contemporary challenges to health. 7

rethink: new perspectives on health

ADMISSION TO MISSION

“As our understanding of health and human flourishing has evolved, the need for physicians to be trained across multiple dimensions has become critically apparent,” says Bonnie Miller, an associate dean at Vanderbilt University School of Medicine. “All physicians must have a better appreciation of the system-level issues that promote or impede high-quality health care delivery and healthy communities, and cadres of physician leaders must be trained in areas ranging from basic science research to population and community health to engineering and device development. All must possess a creative and entrepreneurial spirit while also modeling the core values and attributes of the medical profession. “Over a very short period of time, Dell Med has become an exemplar of the forward-facing medical school that embraces this vision and the attendant educational responsibilities, and demonstrates to other schools how it should be done.”

Dell Med’s focused admission process looks for skilled collaborators ready to conduct intense, mutually supportive work in a pass-fail structure. Aside from evidence of the aptitude and stamina required by an accelerated curriculum, a series of encounters with diverse interviewers and a preliminary video interview identify personal attributes like resilience and adaptability, life experience, and capacity for mission contribution. Sharmila Paul, a first-year student, recognized the connection between her experiences as an applicant and as a student almost immediately. “Dell Med’s faculty understand that clinicians need to work within — and, ultimately, lead — highly functional teams,” she says. “That dynamic constitutes the connective tissue of the entire Dell Med experience, and it started in those initial interviews.”

‘We See It as Our Responsibility’ Modern medical education has its beginnings in the Flexner Report, a study published in 1910 that called for more stringent admission and graduation requirements and set standards for curricular adherence to mainstream science. More than 100 years later, what would later be called Dell Med found itself with an unusual opportunity in 2011, when a team led by Sue Cox began building a vision for undergraduate medical education in Austin. “It was the kind of thing you think about but never expect to be able to do,” says Cox, who headed the UT Southwestern Medical School residency programs based in Austin before becoming Dell Med’s executive vice dean of academics. “Free from the restraints of an established curriculum, we could design an educational model aligned with efficacy rather than history. It was a chance for change across the board, from the way we teach to the competencies we prioritize.”

spring 2019

By 2016, when the first class of 50 students arrived — chosen from 4,500-plus applicants — the vision had matured to an innovative approach that consciously deviates from traditional curricula focused on medical knowledge and memorization. Instead, students engage in collaborative, experiential learning that builds skill in critical thinking and prioritizes thoughtful engagement with health challenges. Clay Johnston, dean of the school, explains why: “It’s our responsibility to prepare students to meet the challenges of a rapidly changing health care system, shifting away from a dysfunctional status quo and toward society’s interest in health.”

Proof of Concept in Step 1 Results An early indicator of success for Dell Med is the performance of the first cohort of students taking Step 1 of the U.S. Medical Licensing Examination. In 2018, the mean national average score was 230. In that same round of testing, Dell Med students earned a mean average of 244 — results on par with those of the top-performing schools in the country, including Harvard Medical School, Baylor College of Medicine and the UCSF School of Medicine. “A lot of people predicted that our students’ board scores would decline because we were reducing ‘testing to the test’ and time focused on memorization,” Johnston says. “I told them we didn’t really care because our students were learning more important things. As it turns out, we saw no sacrifice in test scores — just the opposite.” Overall, Dell Med students exceeded the national mean in every subject area tested, and all of them earned a passing score on their first attempt. “This is evidence that our curriculum is giving them a strong foundation in the science of medicine,” Nelson says. “It’s the beginning of proof of concept for us.”

STUDENT VOICES Amber Dunbar wants doctors to think about the mind, not just the body. “Mental health is one of the more forgotten aspects of physical health,” explains Dunbar, a third-year student who has made it her mission to see emotional and psychological science incorporated into standard medical care. “I am incredibly impressed with Dell Medical School’s commitment to rethinking medical education. I love that my peers are not only excellent academics, but also community leaders,” she says. Bonnie Du, a first-year student, is entering Dell Med with the goal of working to influence health care policy and enact systemic change. “I think that when you empower those without a voice and those who are disenfranchised,” she says, “society as a whole improves in so many different ways.” Dekoiya Burton was drawn to Dell Med’s mission to educate physician leaders who are as comfortable taking on transformational health challenges as they are caring for patients. “This school is committed to more than just educating the best clinicians — it’s also training the best health care advocates and community-oriented doctors,” says the second-year student. “That’s exactly what I was looking for, and it represents the change I want to help make in the health care system.”

Because of the generosity of University of Texas alumni and community members, the majority of Dell Med students receive tuition support. “My scholarship made it possible for me to take this incredible risk and pursue my dream of becoming a physician leader,” says Morgan Gaither, scientist, veteran, mother and first-year student. She received the Michael & Susan Dell Foundation Scholarship. 9

rethink: new perspectives on health

health & care

Practicing What We Teach Built on the foundation of value in health care, Dell Med’s clinical practice, UT Health Austin, is open for business. But don’t expect business as usual. by mary kincy cope

The formula for writing about health care innovation goes like this: Start with a patient. Tell her story. Make it inspirational. We can begin here in just that way, with Eduardo, who’s managing his knee pain so well that he walks seven or eight miles a day, or Chris, the golfer who’s back on the green after a joint replacement. But spotlighting those achievements, however significant, feels unnecessary, because what’s happening at UT Health Austin in its namesake city is remarkable in its own right.

‘Redefining Health Care’ in Practice The approach there, at the clinical practice of Dell Medical School, is exemplified by its Musculoskeletal Institute. It began accepting patients in a pilot phase in 2016 and is modeled as an integrated practice unit, 10

offering comprehensive, interdisciplinary and condition-focused care. The design is a working example of “the significant, positive impact that focusing on delivering value for patients can have on a clinical practice,” says C. Martin Harris, UT Health Austin’s chief business officer and a Dell Med professor of medicine. Leaders began by deciding what hip, knee and upper extremity outcomes the practice should target, then built a team-based approach that leverages shared-decision-making tools and phone, email and video communication to share information between clinicians — and with the patient — quickly and efficiently.

read about the impact:

catalyst.nejm.org/specialty-musculoskeletal-care-underserved

spring 2019

Clinical data are still limited, but early measures show that 62% of those treated for lower extremity conditions demonstrate global improvement at six months. In the same population, the elective surgery rate was lowered by more than 25% (compared to patients treated in the previously existing clinic that served those with low incomes or without insurance). Simultaneously, the creation of a perioperative surgical home in collaboration with Dell Seton Medical Center of The University of Texas in one comparison resulted in 66% fewer hospital readmissions after joint-replacement surgery, and an average length of stay reduced from 3.1 days to 1.2.

“Traditionally, objective measures of pain and function haven’t informed the course of treatment, much less the care provider’s incentive structure,” says Karl Koenig, the medical director of the institute. “We’ve built a system that not only measures and reacts, but evaluates options based on their value to the person. The question isn’t whether something is ‘safe’ to use regardless of its effectiveness. Safety is a minimum standard. The question is whether it works from that individual’s perspective and in pursuit of their goals.” The blueprint dates to 2006, when Michael Porter and Elizabeth Teisberg famously introduced health care delivery to the concept of value in “Redefining Health Care.” Recruited to Dell Med in 2016, Teisberg and Scott Wallace co-founded its Val-

ue Institute for Health and Care, a joint venture with Texas’ McCombs School of Business. They work closely with faculty developing new clinics like the one at the LIVESTRONG Cancer Institutes, where the model is designed to support individuals living with cancer in thriving. “Value-based health care delivery is about improving health results for everyone, one person at a time, through relationship-centered care,” Teisberg says. “That requires transformation of the system to organize around the health needs individuals face, starting early — before needs are acute and severe. I moved to Austin for the opportunity to pursue this aspiration at scale and thus improve health for people throughout Travis County.” Other clinics also show promising early numbers. Typically, only half of those receiving first-line treatment 11

rethink: new perspectives on health

for bipolar disorder achieve a 50% reduction in symptoms within the desired time frames of no more than six weeks for mania and eight weeks for depression. By comparison, at the Bipolar Disorder Center at the Mulva Clinic for the Neurosciences, data collected alongside local mental health authority Integral Care shows that everyone experiencing mania during the period from late November 2017 to December 2018 achieved this level of recovery by the six-week mark, and 100% of those experiencing depression met the response rate within 11 weeks of treatment.

In Pursuit of Payers The next step for UT Health Austin is finding employers and insurers ready to pay in bundle and by condition. Despite data showing an estimated overall cost reduction of 10% — and

a 46% decline in the cost of condition-based care (excluding facility fees) — resulting from the musculoskeletal case-rate agreement with the collaborative that provides safety-net care in and around Austin, many payers remain cautious about tackling the changes required for nontraditional billing and payment. At UT Health Austin, Shonu Gandhi leads the team responsible for convincing them. Her strategy focuses on courting large, local employers and on pursuing agreements poised to demonstrate cost reduction relative to historical claims alongside superior patient outcomes, which typically have not been reported to payers. “When we can interest a company in coming to UT Health Austin for the care experience and outcomes we provide, that captures the attention of insurers concerned with keeping their customers — the employers — happy,” she says.

Kevin Bozic is executive director of the Musculoskeletal Institute. In a February article published in NEJM Catalyst, he and Mark McClellan, former head of the Centers for Medicare and Medicaid Services and a senior health policy adviser at Dell Med, explain that in some ways, it’s as simple as this: If you build it, they will come. “With further experience demonstrating improved outcomes at a lower cost … we expect that condition-based bundled payment models will become a more integral complement to primary care payment reforms,” they write. Harris, with his leadership perspective, expects value to become a transformative agent — a remedy to the ills of other payment models. “We know that fee-for-service can create inefficiencies and often rewards more care rather than better care,” he says. “At the other extreme, unchecked capitation can create an economic incentive to do less. In either model, the underlying driver for decision-making may drift from what should be the only consideration, which is achieving the best outcome for the patient. “Our model sets a price, yes. But it also promises to work for the best outcome. Not only is that an equitable contractual obligation, it’s the right thing to do.”

spring 2019

“

The convergence of resources and creative opportunity [in Austin] may be very close to unparalleled … charles d. fraser jr., m.d. director, texas center for pediatric & congenital heart disease

EXCELLENCE IN TALENT & RESOURCES The academic health system in Austin — including Dell Med, the teaching hospitals of Ascension Texas, and the school’s clinical practice, UT Health Austin — is home to: • A freestanding children’s hospital: Dell Children’s Medical Center • Since 2018, a pediatric heart team led by Charles Fraser, architect of U.S. News & World Report’s No. 1 children’s cardiology and heart surgery program in America

rethink: new perspectives on health

health & care

value-based health care

[ˈvalyo͞o bāsd helTH ker], noun 1. health care that improves the outcomes that matter most to individuals and their families at an appropriate cost 2. the change required by a burning platform*

* This is what some thought leaders call the current health care system, which organizes services around physician specialties and payment models rather than patient needs — rewarding more treatment instead of better health. Evidence of the flames: Per capita, the U.S. spends more than any other country on health care, but the investment doesn’t translate to superior health and is economically unsustainable. Dell Med is part of a movement to change this by equipping current and rising leaders to abandon the burning platform for relationship-centered models of care that reward value. It is home, with the McCombs School of Business, to a dedicated Value Institute for Health and Care led by Elizabeth Teisberg, executive director, and Scott Wallace, managing director. (In 2006, Teisberg and Michael Porter co-wrote the foundational book on value-based health care, “Redefining Health Care.”) 14

“

The well-proven reality is that value-based health care improves outcomes that matter to the individuals and families we serve. The Value Institute for Health and Care is enabling high-value care delivery to scale and to spread geographically. The transformation going on now is from value to volume — making high-value results available for all. scott wallace, j.d., mba managing director, value institute for health & care

spring 2019

elizabeth teisberg, ph.d. executive director, value institute for health & care

SPREADING THE MOVEMENT

“

Improving health is the reason for health care, but the antiquated U.S. payment system stands in the way. Dell Med and the McCombs School of Business are uniquely qualified to initiate a care delivery and payment system centered on outcomes. corbin robertson jr.

chair, cullen trust for higher education ut austin distinguished alumnus, bba ’69

With the 2017 launch of UT Health Austin, the school’s clinical practice and its next step toward building a comprehensive academic health system, interdisciplinary care teams began putting a value-based approach to work for the benefit of the Central Texas community. “While the challenge of transforming health care is huge, the goal is simple: We need to restore health care to its purpose of improving health — enabling capability, comfort and calm in the lives of individuals and families,” Teisberg says. Recognizing the Value Institute to be a game changer, the Cullen Trust for Higher Education pledged $5 million to create the Cullen Trust for Higher Education Distinguished University Chair in Value-Based Care. It is held by Teisberg.

Bringing a value-based approach to the proving ground of UT Health Austin is only the start. For practicing physicians and other leaders in the health sector, the Value Institute for Health and Care offers workshops, practical support for transformation of care delivery, and a new Master of Science in Health Care Transformation degree. Workshops bring together leaders from around the world to learn and share insights on how to implement transformation to high-value care delivery through changes in culture, strategy and measurement. The M.S. degree in Health Care Transformation is a nonresidential, highly interactive program for midcareer, up-and-coming leaders in clinical enterprises and throughout the health sector. Dell Med is also training a new generation of physician leaders to focus on improving the outcomes that matter to patients and families. Beyond its own “Leading EDGE” undergraduate curriculum, “Discovering Value-Based Health Care” is freely available through OnlineMedEd.org. Created by a team of experts led by Assistant Dean for Health Care Value Christopher Moriates, the collection is used by a growing roster of undergraduate medical programs across the country — including at NYU and the University of Virginia. “No other medical school in the U.S. has a title like mine in the dean’s office — not yet, anyway,” Moriates notes. “By building it into the leadership structure, Dell Med demonstrates its commitment to ensuring future health care professionals understand the principles of value-based care and practice it naturally.” discovering value-based health care:

vbhc.dellmed.utexas.edu

rethink: new perspectives on health

josé colucci jr., ph.d. design institute for health

Seeing the System Mapping the Ecosystem of Care in Travis County, Texas: A Case Study in Design in Health by josé colucci jr.

Maps help us find our way, showing us the terrain from a perspective that makes it possible for us to see beyond our limited vantage point — and to get from here to there. Three years ago, a map of mine brought me from IDEO in Boston to The University of Texas at Austin to join the Design Institute for Health, the only design firm in the U.S. embedded in a medical school from the start. Excited by Dell Medical School’s mission of revolutionizing how people get and stay healthy (in part by taking a health ecosystem approach to making Austin a model healthy city), one of the early interests of our team of designers was finding a diagram of how health care works in Travis County. This was important. To reimagine a system, we start by deeply understanding the current state: identifying all the components, including the connections and dependencies between them. The tool we as designers use to do this is called systems mapping, and it allows us to see what is otherwise unseeable.

There Is No Map? The response to our inquiries was uniform: “There is no map. We all just know how it works.” This galvanized the design team and led to meetings with people and organizations throughout the community. What we learned was fascinating: •

Every regional health care professional interviewed had a slightly different and partial view of the system.

•

The people experiencing the health care system but working outside it knew even less about how it worked or who the entities are and how they provide services.

Today, the Design Institute is actively and collaboratively iterating on an ecosystem of care map for Travis County. We intentionally describe it as “necessarily incomplete and possibly inaccurate, but urgently needed.” It shows the functioning of the machine of public health see the work: ecosystemofcare.org care represented by the flow

of money going into the public system and the care delivered by the public system to the safety net population. It hasn’t described the commercial system at the same level of detail, but that is in future plans.

Embracing Uncomfortable Truths, Finding Meaningful Solutions Releasing the map at this stage is unconventional. As designers, we are comfortable with putting something out in the world that is not quite right to elicit the feedback that will make it better. The map is a work in progress — and it shows an imperfect system. At the Design Institute, we are excited by this state, because embracing the uncomfortable truths of where a system falls short is what enables us to see the opportunities to imagine a new way forward. With a common view of the system, we can focus on finding meaningful solutions to key questions. How might we make an individual journey through this complex system feel more approachable and connected? How might we simplify and streamline the complexity of this system? And how might we move the focus of the ecosystem beyond health care, to health itself? José Colucci Jr., Ph.D., is the director for research and development at the Design Institute for Health, a collaboration of Dell Med and the College of Fine Arts at The University of Texas at Austin.

WHAT IS SYSTEMS MAPPING? Systems mapping allows us to see what is otherwise unseeable. We start by understanding current states: identifying components, connections and dependencies. Systems maps take on many forms. They may focus on a process flow, decision trees, exchanges of value, funding sources, services and relationships. They can highlight places where collisions are occurring or where intentions, goals and exchanges are not aligned. Discovering these collision points helps identify opportunities for change. The creation of systems maps involves many principles of design: • Understanding: Start with people experiencing the system and their needs. • Iteration: Create low-cost prototypes, rapidly test, correct mistakes and iterate. • Transparency: By seeing it together, invite other perspectives to solve challenges collectively.

recap

The (Real) Future of Health Care Google’s David Feinberg & Dell Med’s Clay Johnston in Conversation @ SXSW 2019 by john daigre

While diverse industries are innovating — often with the help of technology — to improve consumer experiences, increase efficiency and lower costs, health care has hit a wall. Rising costs are not translating to improvements in outcomes. ¶ In fact, life expectancy has declined in the U.S. in the last three years. At South by Southwest in March, two health innovators — David Feinberg, head of Google’s health efforts, and Clay Johnston, dean of the Dell Medical School — sat down to talk about what it will take for health care to finally embrace technology and catch up with society’s interest in health. That conversation, edited and condensed for clarity, follows. 18

spring 2019

watch the video:

bit.ly/the-future-of-health-care

On Our Dysfunctional System David Feinberg: I would say that our health care system is perfect for what it’s designed to do, and that’s to be provider-centered. We build hospitals because that’s where you go see the doctor, and we build waiting rooms because we want doctors to have inventory. The problem is, we didn’t design the system around patients or communities. It’s broken because we designed it around the wrong people. Clay Johnston: For me, the really exciting thing is the opportunity to design an academic health system that’s organized around society’s interest in health. And that’s not health care; very few people want more health care. They might need health care, and they’re glad that they have it. But people really want health. The question is: How can we have a disciplined approach to achieving better health outcomes? DF: I actually think people don’t even just want health. People want to spend time with their grandkids, to not have to worry when their elderly parent has a bunch of appointments. And if you really want people to live long and live well while living long, only 20% of that has to do with doctors and hospitals. You can be born just a few miles apart and have a life expectancy difference of 25 years. When I was born in California, the chance of me getting Type 2 diabetes was 1 in 100. If I was born in that same hospital today, it’s 1 in 3. That’s an example of a food-borne illness that we’ve now created health care

“

I would say that our health care system is perfect for what it’s designed to do, and that’s to be provider-centered. … we designed it around the wrong people. david feinberg, m.d. google health head

systems to try to fix, as opposed to going upstream and trying to fix the problem. Even the rats in New York City have Type 2 diabetes. That’s because our bad food choices are spilling into the sewers. If we really want to change health care, we have to shift our focus to what matters. We not only have to sequence everyone’s DNA, we have to sequence your ZIP code. We have to understand things like socioeconomic factors, health literacy, cultural issues, loneliness. That’s the stuff that matters. I feel like we keep focusing on making the line go faster at Blockbuster instead of creating Netflix.

the single mom who has two jobs, who has a kid with a bad ear infection, who’s also taking care of her parents and struggling. That’s the person’s voice that I think has been missing and is absolutely crucial. I need those people on my team. Because often, I think a lot of technology companies are solving problems for people that live in Silicon Valley and not people who live in other parts of the country. CJ: That’s been a voice missing from academia as well. At Dell Med, we’ve been very purposeful about how we get into communities, really learn from those communities, and how we use human-centered design. But

On Google’s Efforts to Improve Health

then also, how do we enable people

DF: People are coming to Google asking about conditions, medications, symptoms, directions, insurance questions. We really do our best to try to organize the world’s information and make it accessible to everybody. But what if we could take that further? What if we could take that information and customize it so you can then take that in a more meaningful way to your physician? That’s one of the things we’re working on.

unfairly affected by our current health

from the communities that are most system to become the innovators and to lead the charge in finding those changes? So, harder work, but I think it’s really important to keep going.

On the Skills Future Physicians Will Need CJ: Some of it is communication skills. Some of it relates to a different kind of analytical ability. The other thing is that we need physicians who

On Hiring Talent

understand the whole health system,

DF: Here’s what I’m looking for. I want to be at the kitchen table with

including what happens outside the hospital and clinic. 19

work in progress

Redesigning Austin’s Mental Health System The state psychiatric hospital, established in 1856, was designed for “a different era of health care,” says one of the leaders of a $15.5 million redesign that will transform the outdated and deteriorating facility to a cornerstone for a system of collaborative, community-focused care. by katherine corley

hen you arrive at Austin State Hospital, one of nine inpatient state-run adult psychiatric facilities in Texas, you’re likely having one of the worst days of your life. Perhaps you’re suicidal, disoriented and frightened, or unable to care for yourself. Yet the campus does not match the complex needs of people in crisis who have arrived for inpatient psychiatric care or competency restoration — a process that assesses the ability of a person charged with a crime and with a mental health condition to understand and participate in the legal process. The facility was designed for a “different era,” says Stephen Strakowski, chair of the Department of Psychiatry at Dell Medical School. He’s leading the redesign. “Some buildings are as many as 150 years old; the hospital buildings that house adults

were built in 1958. There’s inadequate space to optimally deliver modern mental health care.” But the project is about far more than a bigger, newer facility. The Texas Health and Human Services Commission and stakeholders including local mental health authorities, people receiving care, law enforcement and more have contributed to a plan to transform the campus into an integrated system of comprehensive brain health. The approach will be anchored by innovative, person-centered facilities and programs that better serve the continuum of needs across Austin State Hospital’s broad service areas, covering 38 counties for adults and 75 counties for youth. “The No. 1 priority for the redesign is to improve the lives of people with mental illness,” says Mike Maples, deputy executive commissioner for

the Health and Specialty Care System at the Texas Health and Human Services Commission.

Planning for a Continuum of Care The Design Institute for Health — a collaboration of Dell Med and The University of Texas at Austin’s College of Fine Arts — spent much of 2018 doing fieldwork for the redesign, interviewing 65 people with mental health system experience, including people receiving care, family members, care providers, administrators, judges and law enforcement. “The foundational insight was that brain health conditions are lived through the process of recovery, not quick fixes,” explains Director of Strategy and Mission/s Katherine Jones. “The team learned that a key design challenge is for a psychiatric more support for brain health › 28

spring 2019

hospital to simultaneously keep people safe and provide a healing environment. It must accommodate a wide range of needs while also enabling excellent care. And it must be embedded in a robust system offering care across the brain health continuum: understanding and preventing mental illness; identifying problems through early detection; healing and treating mental health conditions via outpatient therapies; and sustaining mental health recovery through supportive services.” Also necessary is care across the “crisis loop,” when a mental health condition becomes severe enough that emergency intervention and inpatient care is needed. This vision, detailed in a 116-page report to Health and Human Services delivered early this year, will take years to realize; leaders see the construction of a new hospital facility as the first of many steps. read the report:

ashredesign.org

Their recommendation includes construction of a new hospital with space for 240 adult inpatient beds at a cost of $283 million. Additionopposite page: Concept rendering from the master plan of a future vision for the Austin State Hospital campus, reimagined as more than a hospital, but a platform for the entire continuum of care for a brain health system. Image created by Page/Dyal for Dell Medical School.

TRANSITION-AGE SUPPORT Fifty percent of adults with a mental illness report their symptoms began in their early teens. But older adolescents and young adults seek treatment at lower rates than any other age group. The Center for Youth Mental Health, a program of the Dell Med Department of Psychiatry established through a grant from the Michael & Susan Dell Foundation, encourages and invests in ideas that can support transition-age youth with mental illness. For example, it is partnering with other university researchers and community organizations to develop a mobile-sensing platform that can help detect changes in symptoms and provide timely intervention for adolescents at high risk of developing depression.

al proposals would add as many as 72 beds in a long-term residential building extension. If the Texas Legislature approves funding this session, construction could start later this year and finish by summer 2023. Because a new building alone will not address all challenges, the report also champions systemic changes to ensure people receive the right care at the right time and in the right place, so that beds at the new hospital will be available to those who need them. It includes recommendations to improve operations; change the reporting structure; optimize the

use of community psychiatric beds in the region; redesign competency restoration programs and processes; and increase residential care and supported housing capacity. It also advocates for the eventual transformation of the campus into one that provides brain health and social services for every recovery stage. Strakowski is enthusiastic about the redesign’s potential. “Planning for a brain health continuum of care while we’re replacing the hospital is critical,” he says. “When we actualize it, it will be revolutionary.”

brain health continuum Brain health conditions are lived through the process of recovery, not quick fixes.

rethink: new perspectives on health

spotlight

The Fourth Pillar Amid a movement toward health, not just health care, a new area of interest is joining academic medicine’s traditional concentrations — and it’s putting people’s lives in focus. by mary kincy cope

spring 2019

or more than a century, the mission has been this: teach students, do research, give care. But we know now that health care as usual drives only about 20% of health outcomes. The current state no longer makes sense, some experts are beginning to agree.

Elena Marks, president and CEO of Episcopal Health Foundation, explains why: “We’re spending our health resources almost exclusively on medical care, but we’re not getting better health.” In a February opinion published in Academic Medicine, M. Roy Wilson, president of Wayne State University and immediate past chair of the Association of American Medical Colleges board of directors, called for academic health centers (AHCs) to become “socially accountable.” The op-ed was co-signed by Herbert C. Smitherman and Richard S. Baker, leads for diversity and medical education at Wayne State. “AHCs must partner with communities to engage in collaborative solutions that address underlying causes of disease, rather than getting caught in the fragmented loop of addressing symptoms alone,” they wrote.

Charge to Practice Dell Medical School, established in 2014, is among a new wave of schools including in their missions a fourth area of focus that goes beyond community engagement to prioritize innovations targeting health — not just health care — and local impact. In Austin, Maninder “Mini” Kahlon is the vice dean for the health ecosystem and champions work to address what

she and others at the school refer to as the “broader drivers of health.” Her portfolio includes initiatives driven by Dell Med’s Department of Population Health focused on neighborhood-level assessments; community cancer screening efforts co-led by the school’s LIVESTRONG Cancer Institutes; and Factor Health, designed to shape, focus and scale innovations likely to make sustainable impact around one or more of the nonmedical drivers of health. Founding partner Episcopal Health’s $2.6 million gift launched the program. “We’re actively building a new business of health by working with payers to translate value propositions to a language that is familiar,” Kahlon says. “In turn, the payers become the innovators, as they’re empowered to support new interventions in new ways.” The choice to offer medical school resources and expertise to support partners already working in the community is deliberate. “Our role is not to replicate or replace the work others are doing in food, housing, transportation and such,” Kahlon says. “We’re most effective when we lend someone with a great idea and the ability to deliver on it our understanding of how to maximize and measure impact, or when we help translate value so payers are empowered to invest in what isn’t delivered by traditional care providers.”

THE POWER OF PARTNERSHIP Dell Med believes in the power of collaborating broadly, learning and innovating alongside any partner with an informed perspective and a good idea. Just as important is our dedication to measuring the health outcomes experienced by real people in every new model and partnership we explore, helping us to tie innovation to improvement. Then, when a success has the potential to add value to the vital, inclusive health ecosystem we envision, we can share it with the world.

It’s critical that academic medicine, with its “disproportionate and significant” impact on America’s health care system, makes such investments in health, write Wilson, Smitherman and Baker.

rethink: new perspectives on health

Bill Tierney

Belinda Reininger

Judith Wylie-Rosett

Carol R. Horowitz

Lesley H. Curtis

Dell Medical School at The University of Texas at Austin

University of Texas Rio Grande Valley School of Medicine

Albert Einstein College of Medicine

Icahn School of Medicine at Mount Sinai

Duke University School of Medicine

Maureen Durkin

Angela Fagerlin

Marc N. Gourevitch

University of Wisconsin School of Medicine & Public Health

University of Utah School of Medicine

New York University School of Medicine

Trending: Population Health Via JAMA Network Open, leaders from department-level initiatives across the U.S. weigh in on how academic medicine is embracing population health — and the opportunities med schools have to make an impact. In 2017, representatives of nine population healthfocused departments of U.S. medical schools arrived in Austin to meet with William “Bill” Tierney, who was at the time organizing the newest of them. Tierney, chair of the emergent Department of Population Health at Dell Medical School at The University of Texas at Austin, wanted their ideas. 24

A year later, by November 2018, there were 15 departments with “population” in their names at accredited, Association of American Medical Colleges schools, and leaders of the 2017 convening were preparing to publish an analysis of the trend. read the complete report: bit.ly/emergence-of-population-health

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Opportunities for Medical Schools Titled “The Emergence of Population Health in U.S. Academic Medicine” and published in April in JAMA Network Open, the analysis identifies five opportunities for U.S. medical schools to advance population health. In the authors’ words, they are: 1

POPULATION HEALTH, DEFINED

Promoting a holistic view of health that includes both clinical and social determinants of health, well-being, disease and disability and the multidisciplinary and cross-sector interventions and policies required to address them, such as early childhood education, economic development and environmental protection. This would help extend the engagement of health care beyond its principal focus on sick care — diagnosis and treatment — to encompass both traditional and upstream approaches to prevention.

2 Engaging community residents and leaders as equal partners in health improvement, including generating ideas to overcome local barriers to progress. This requires information-sharing, mutual trust and respect, intensive listening and understanding the history of experiences each party brings to the conversation. 3 Supporting health care delivery systems in addressing high levels of social need, including those of high-cost patients, in part by facilitating engagement with community resources. 4 Reinvigorating institutional acceptance of a social justice mission as integral to health care delivery. 5 Training the next generation of scholars to solve the pressing challenges of improving population health advancing health equity.

Why It Matters “Firmly establishing academic medicine’s commitment to the principles of population health — especially promoting health, preventing disease and eliminating health inequities — and to building and advancing related research, training and community-level applications represents a major step forward in bridging medicine and public health …” — Marc N. Gourevitch

The term “population health” has two common, complementary, but not interchangeable uses. Often, it refers to the health and determinants of health among a group of patients receiving health care from a particular health care institution or system … Yet population health also refers to the health and determinants of health of persons residing in a particular region or community, irrespective of whether or where they receive health care. This comprehensive view of population health considers health care one among many core drivers of population health status, maintains a focus on health equity, and is a principal focus of new departments, centers and institutes emerging at schools of medicine across the country. —“ The Emergence of Population Health in U.S. Academic Medicine,” JAMA Network Open

rethink: new perspectives on health

professional development

The ‘Team of Teams’ Approach U.S. Army Gen. Stanley McChrystal’s ‘Team of Teams,’ a New York Times bestseller, famously suggested that it’s possible to ‘combine the adaptability, agility and cohesion of a small team with the power and resources of a giant organization.’ For the world of academic medicine, it may be just what the doctor ordered. by hannah jane collins

t Dell Medical School, creating an effective team of teams culture is not just about learning to play nicely. It’s about establishing a model for collaborative leadership, actively seeking out partners across organizational boundaries and tearing down the walls that prevent those dynamic partnerships from happening. That means each person has the agency to bring passion and expertise to teams outside the traditional

reporting structure, and new initiatives are being created every day to tackle specific health issues across Austin and Travis County. “A culture that is committed to the behaviors of effective communication is essential to moving toward our goals of transformational leadership and leadership development in health care,” says Eddie Erlandson, a surgeon-turned-executive-leadership-coach who’s worked with Microsoft, Coca-Cola and Disney,

expanding the team

Dell Med is home to the first Department of Health Social Work embedded in a medical school in the country.

in addition to helping plan leadership curricula at Dell Med. “A team of teams concept can be brought to life in the day-to-day behaviors of each individual team and the teams within the organization that are committed to a mutual goal: collaborative problem-solving and continuous learning without issues around control and identities.”

spring 2019

The Street Team Most people experiencing homelessness receive care through the ER (or not at all), so when the interdisciplinary team meets patients where they are to provide holistic care, health outcomes improve. the uniquely equipped team:

Drug counselors and peer navigators join traditional primary and mental health care providers from Dell Med, CommUnityCare Health Centers and Integral Care in a “street medicine” team supporting the 7,000-plus individuals experiencing homelessness in Travis County. “Homeless Austinites living with multiple complex medical problems are among the most vulnerable and difficult-to-reach members of our community, says project director Tim Mercer, assistant professor in the departments of Population Health and Internal Medicine. “We believe this approach is a key way to address the broader needs of this population.”

The ‘B-Team’ You Want To Be On

The Team Turning Chaos Into ‘CaLM’

The majority of people in the U.S. with opioid use disorder will stay in the hospital at some point in the course of their disease. Buprenorphine saves lives of those living with addiction and decreases hospital readmission rates, and when partners across the hospital collaborate to identify individuals needing help, more lives can be saved.

Those undergoing cancer treatment have their lives upended, and most patients need more than just an oncologist: Seeking adequate care requires hours of coordinating with specialists, all while still contending with everyday stressors. When patients and families are surrounded by a customized team to guide them through every aspect of the cancer journey, quality of life greatly increases.

the uniquely equipped team:

Chaplains and pharmacists who might otherwise never cross paths in the hospital join nurses, social workers, physician assistants, physicians and trainees to form a cross-functional “B-team” of providers at Dell Seton Medical Center at The University of Texas. The team works to screen patients for opioid use disorder, initiate buprenorphine therapy, provide outpatient referrals and work to reduce stigma of opioid addiction throughout the institution. “A great part of our work has been around stigma reduction, even from those who have been working in health care for many years,” says team lead Richard Bottner, clinical assistant professor in the Department of Internal Medicine. “Opioid use disorder should be treated just like any other chronic lapsing-remitting medical condition, and there is more work to be done to prove to others that this model works.”

the uniquely equipped team:

Dietitians, fertility experts, genetic counselors, navigators and social workers share appointments and space with oncologists, specialists and nurses to provide holistic care for patients at the LIVESTRONG Cancer Institutes. This is the basis for the CaLM (Cancer Life reiMagined) model, which aims to flip the way cancer patients, survivors and their families experience life during treatment and while living with cancer. “The CaLM model is a continuation of the concept of truly patient-centered care,” says S. Gail Eckhardt, director of the LIVESTRONG Cancer Institutes. “With advances in cancer research transforming cancer into a chronic disease, the health care system as a whole is calling for a greater focus on patients and coordination of care; we are deploying a model of cancer care delivery to do that.” 27

rethink: new perspectives on health

mulva clinic for the neurosciences

Building a WorldClass Center for Brain Health James and Miriam Mulva, two of The University of Texas at Austin’s most generous supporters, saw an opportunity with the rise of Dell Medical School to improve the lives of people affected by brain diseases. The Mulva Family Foundation’s $50 million gift launched the Mulva Clinic for the Neurosciences, a brain health clinical enterprise that harnesses the university’s research expertise and embodies Dell Med’s commitment to delivering care centered on patient goals. The clinic, part of UT Health Austin, opened its doors in fall 2017 and provides care for people with Alzheimer’s disease and dementia, depression, bipolar disorder, multiple sclerosis, neck and back pain and treatment-resistant depression. Three thought leaders are working together to advance the Mulvas’ vision. David Paydarfar, John Kuo and Stephen Strakowski — chairs of Dell Med’s departments of neurology, neurosurgery and psychiatry, respectively — comprise the clinic’s leadership team. “We have the rare opportunity to build something from scratch,” Kuo says. “We can learn from the many places around the country delivering excellent care, in order to innovate, develop and implement new models for Austin.”

Delivering Team-Based Care That Treats the Whole Patient “This is more than a ‘come-in-and-see-your-doctor’ experience,” Paydarfar says. “Our interdisciplinary care teams create a cohesive plan to improve the lives of patients — and their families.” Each patient’s condition, values and goals inform the assembly of an appropriate care team, which may include a neurologist, a psychiatrist, a speech and language therapist, a social worker and a nutritionist, among others. The team then develops an individualized care plan and gets to work.

Measuring What Matters Across UT Health Austin, clinics measure health outcomes that matter to patients to determine the success of treatment. At the Mulva Clinic, that may mean helping patients age safely at home, miss fewer work days due to depressive episodes, or improve short-term memory.

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Diagnosing Faster

Leveraging a Research Powerhouse

It can take 18 months from the first complaint of symptoms of cognitive impairment to receive an accurate diagnosis of Alzheimer’s disease or dementia, delaying interventions that could slow progression. The Mulva Clinic is hard at work building an approach that allows for an accurate diagnosis as rapidly and efficiently as possible.

The University of Texas at Austin is a Tier 1 research institution with brain experts across disciplines. Previously, these scientists had to collaborate with outside clinicians to test new solutions. Today, researchers share a campus with those providing care for the conditions they’re trying to treat or eradicate. The Mulva Clinic even has research teams on-site that share resources with clinical teams.

Replicating What Works Less than a year after its opening, the Mulva Clinic’s Bipolar Disorders Center team-based approach showed a dramatic improvement in patient health compared with traditional treatment models. Now, the clinic is working with Integral Care, the local mental health authority, to replicate this model and make it available to people across the community.

“

Integrating leaders and teams across disciplines — and across UT Austin — is critical to the model we’re working to build.

Shaping the Future of Brain Health Building on the research and educational excellence of The University of Texas at Austin, the Mulva Clinic is continuing its work to build Austin’s brain health center — learning what works and what doesn’t, what matters to patients and the community, and what must come next. But the charge is clear: to become a world-renowned destination for brain health care, research and education that measurably improves the lives of patients and their families.

stephen strakowski, m.d. chair, department of psychiatry

r&d for impact

The Business of Improving Health The brain — and the body. In health innovation, academia’s ideation is often made real by industry’s execution. An unusual hub embedded at The University of Texas at Austin enables these vital partnerships, in addition to providing support for commercialization and entrepreneurship. by hannah jane collins & mary kincy cope 30

spring 2019

The Texas Health CoLab at Dell Medical School provides resources for commercializing an invention, launching a company or collaborating with industry. The results so far: award-winning technologies, local and international partnerships, and a renewed level of interest around the health tech industry in Austin. “To create economically sustainable models of care that work for everyone, you have to get the right minds in the room. Texas Health CoLab is a clear solution matching academic medicine with product development and business expertise,” says Chris Laing, executive director of Capital City Innovation, the nonprofit shaping a new Innovation District in downtown Austin anchored by Dell Med.

Accelerating Innovation of Health Products & Services The foundation of the Texas Health CoLab is in the programs it oversees to support researchers and entrepreneurs in accelerating innovation of health products and services. One is Texas Health Catalyst, hosted in collaboration with the Cockrell School of Engineering, College of Natural Sciences, College of Pharmacy and Office of Technology Commercialization. An annual cycle seeks promising innovations with the potential to improve the value of care. Awards range from seed funding to customized guidance from industry and clinical experts. Texas Health Catalyst played a key role in the early development of the MasSpec Pen, a cancer-detecting mass spectrometer “pen” that allows surgeons to identify cancerous tissue

“

Commercialization is another way we’re rethinking health. It provides an alternative funding source for the long-term sustainability of the med school while enabling health transformation through innovative new products and services. mellie price

executive director of commercialization managing director, texas health colab

in 10 seconds — 150 times faster than previous technology. Further down the funnel, Dell Med’s commercialization team works with clinicians, entrepreneurs and business experts to identify pain points impeding health transformation and provide the skills needed to evaluate proposed solutions. It’s a critical function, though one that’s unusual to academic medicine, which traditionally has been far more effective at coming up with good ideas than validating a market, writing a business plan or launching a product. Mellie Price, a veteran Central Texas entrepreneur and the Texas Health CoLab’s managing director, sees the hub’s role as “connecting the dots.” “We’re embedded in a top-tier research university, at a medical school with the capacity to offer deep clinical, research and subject-matter expertise in value-based care, population health and the future of health,” she says. “It’s a rich opportunity for investors, entrepreneurs and industry. At the same time, we’re able to provide our innovators with expertise in go-to-market strategy that puts their ideas into the health ecosystem efficiently and effectively.” That speed and direction matters in health care. Last year, it helped a real-time, shared decision-making

software make its way to the Musculoskeletal Institute at UT Health Austin, where executive director Kevin Bozic uses it to help patients decide what treatments will best meet their individual goals. The idea for the tool was Bozic’s. “As a practicing surgeon and a health services researcher, I frequently encounter clinical scenarios that are ripe for disruption in terms of opportunities to improve patient outcomes and/or reduce the overall cost of care,” he says. “Our partnership with Texas Health CoLab gives us access to the expertise and infrastructure necessary to explore opportunities for commercialization of these ideas, and potentially bring these new innovations to market.” In cases where there’s no match between a validated idea and an established company, the Texas Health CoLab may partner an innovator with an experienced entrepreneur, or co-founder in residence, interested in taking a start-up to the next level. In addition, Austin Community Foundation manages a commercialization fund that provides philanthropic seed money to the most promising fledgling companies in the Texas Health CoLab portfolio. story continues › 42

rethink: new perspectives on health

health & equity

Joycelyn Elders On ‘Fighting Well’ Paying public health physicians like cardiovascular surgeons. Weathering criticism. Pursuing revolution. Jewel Mullen teams up with REthink to interview a former surgeon general. by mary kincy cope

Twenty-five years after her resignation, former U.S. Surgeon Gen. Joycelyn Elders is as outspoken as ever. As an advocate for public health, she talked freely about masturbation, condoms and marijuana during the 16 months she spent in office during the Clinton Administration — and took her lumps for it. ¶ Now, the 85-year-old Elders, speaking from her home in Little Rock, is challenging the status quo in medical education alongside Jewel Mullen, a former principal deputy assistant secretary at the U.S. Department of Health and Human Services who’s championing health equity at Dell Medical School at The University of Texas at Austin. 32

spring 2019

Jewel Mullen: You’ve been a source of truth in medicine and public health — but 25 years later, we’re still dealing with many of the same things you were talking about in the 1990s, from gun violence to access to contraception. Why do you think it’s so hard to make sustained progress? Joycelyn Elders: As a people, we are resistant to change. But we have changed. Lots of changes have been incremental. Sometimes we may need monumental change, but incremental change is all we can make. It takes time. We just have to keep going.

Jewel Mullen

JM: How can medical educators help? Is there something we should change about the way we’re training our students and residents?

JE: We need to teach them the importance of involving their communities. And they need to learn how to influence what’s happening around them. JM: A colleague who was here to speak a few weeks ago said all medical students need to learn advocacy. JE: I agree. Mary Cope: What other skills or competencies would be on your short list? JE: I go back to leadership. Medical students are going to be leaders in their community, and they should have some skill. I don’t think we, as doctors, tend to lead very well. JM: Why aren’t medical schools more proficient at producing the doctors that the system needs?

“

You don’t have to hit them over the head with a hammer. But make sure they always have a little headache. joycelyn elders, m.d. u.s. surgeon general, 1993-94

JE: Most students are very conscious of economics, and it really drives their choices. We need to change how people are paid. If the students specializing in public health, pediatrics or mental health could earn as much as the cardiovascular surgeons, we’d be much better off. MC: Dr. Elders, what could enable some of the things that you’re calling for? Is it just a matter of will, or are there other factors that could influence toward that change? JE: You have to get at the attitudes of the community, and you’ve got to change the attitudes of politicians. Nothing’s really going to happen until you address public policy. MC: You have to speak, and forthrightly? JE: You have to have gumption. You know, we in public health and we in medicine have not fought nearly so well as we could have. JM: Is part of “fighting well” being willing to weather a short-term impact in pursuit of a long-term outcome? You went from being someone who was ostracized for talking about sex ed to having a University of Minnesota chair in sexual health education and a University of Arkansas chair in prevention and health promotion named for you. JE: You have to know what it is you’d like to achieve. I wanted all

children to have an opportunity to grow up healthy, educated and motivated, and to have hope for the future. That was my prize. I didn’t worry about the power structure that I had to fight to get there. If they never say anything about you, that means you aren’t doing anything. JM: Speaking of doing things: A few years ago, I said to you, “I don’t know what to do with myself next.” And you told me I needed to figure it out. So I did, and I came to Dell Medical School, where the mission is to revolutionize how people get and stay healthy. That has armed me with a word, “revolution,” that can be a call to action. What do you have to say to me and others who really want a revolution for health and for equity? JE: When you revolutionize something, you’re changing it, and the most difficult “C-word” in the English language is “change.” Realize that it’s not going to happen overnight. It’s going to be gradual. And the things you feel strongly about — just keep pushing forward with those. You know, you don’t have to hit them over the head with a hammer. But make sure they always have a little headache. This conversation was edited and condensed for clarity. 33

research

Beyond Medical History What’s Being Tested at a Community Clinic in Austin Isn’t Your Typical EHR by shahreen abedin

For a condition like childhood asthma, clinicians at Austin-based People’s Community Clinic knew their patients’ health was affected by more than just the medications prescribed, but they had no way to track how.

these issues,” says Anjum Khurshid, director of data

Data researchers at Dell Medical School answered the call and are collaborating with People’s to combat pediatric asthma with a data-driven approach — giving care teams a fuller picture of a child’s health than what a typical electronic health record affords.

learning how to extract information from outside data

The researchers, affiliated with Dell Med’s Department of Population Health, built a secure, cloud-based environment that integrates nonmedical information into patients’ electronic medical records. At a glance, clinicians can see a patient’s medical details as usual, plus other factors affecting their health: exposure to smoke and pollen, housing conditions and transportation accessibility. Research shows these nonmedical drivers, or social determinants of health, influence more than 80% of a person’s overall well-being.

The technical platform is based on research to manage

“Information about these factors — which are often the underlying, nonmedical causes of poor health — was not readily available to those who could help address 34

integration at Dell Med. Building the tool presented Khurshid’s team with multiple challenges. The first was a technical one: sources such as the Environmental Protection Agency, the Texas Commission on Environmental Quality, Pollen.com and Google Maps and then integrate the data securely into the patient’s electronic health record. personal health information securely, to use interoperability standards to link data, and to have capabilities to add new sources of data easily, including patient reported data. The second challenge was less straightforward. The research team had to incorporate the tool into the workflow of a bustling community clinic with minimal disruption, and there was a lot to consider. Examples: At what stage of a patient’s care should teams engage the tool? Which team member would be responsible for accessing the data? And how would the data be incorporated into a treatment plan?

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Expertise from the care teams at People’s drove the decision making process. Researchers spent time with provider focus groups and discussed the best ways to display that information to make it useful and easy to access. And as the tool begins to be used in the clinics with real patient data, the research team is prepared to measure its impact on the clinicians’ behavior and patient outcomes. “It’s yet to be seen if making this information available to providers will alter how they treat and educate patients,” Khurshid says. “If they see a predicted spike in a particular allergen, are they going to contact their patients and adjust their meds? And in the end, will the tool help to improve patients’ health?”

A Model for Collaboration Bringing together the expertise of academic researchers and community health care providers to solve a problem is an example of what Dell Med’s associate dean for research, Chris Webb, calls “radical collaboration.” “At a time when a majority of scientific breakthroughs take decades — literally — to impact health in the real world, it’s going to take these types of cross-disciplinary partnerships to shorten that time frame from discovery to impact,” Webb says. And scalability is crucial: Although the tool Khurshid’s team developed was built for kids with asthma, it’s also serving as a proof of concept for comprehensive health records around other conditions such as high blood pressure, diabetes and more. “Our vision is to expand its scope to clinics and practices across Central Texas, and then hopefully it can serve as a model globally,” says Elizabeth Matsui, professor in the departments of Population Health and Pediatrics. A pediatric allergist-immunologist and epidemiologist, Matsui serves as an adviser for this project. “Many traditional medical schools and health systems are stymied by the constraints of health care. This sort of innovation is more difficult to do in environments that don’t wholly embrace redefining how we think about helping communities become more healthy the way we do, every day, at Dell Med.”

SPANNING THE SPECTRUM OF TRANSLATIONAL RESEARCH Dell Med researchers work with an eye toward accelerated, real-world impact on health. Their work, whether at the bench or the bedside, is in pursuit of improving patient outcomes and quality of life. Thomas Yankeelov is improving patient care by helping identify, assess and predict how tumors will respond to therapies. Kelly Gaither and Radek Bukowski are investigating the causes and factors of maternal mortality using a smartphone app. Ning Jenny Jiang is researching molecular biomarkers to help diagnose and develop therapies for immune disorders and is advancing scientists’ understanding of the function of infiltrating immune cells in neurodegenerative diseases.

impact summary “When we better understand our patients’ environment outside of the clinic walls, we have a greater ability to provide effective recommendations and treatment — potentially preventing their symptoms instead of reacting to them.” aliya hussaini

portfolio director for health, michael & susan dell foundation

The Michael & Susan Dell Foundation provided grant funding for the pediatric asthma pilot. 35

36 HOURS

AS A SURGICAL RESIDENT

Only about one-third of surgeons are women. But three sit at the top of Dell Med’s residency program, following a trend toward greater representation in the field. REthink follows a day — and then some — with one of them. 7:30 a.m.

There’s really no such thing as an average day for Brittany Bankhead-Kendall. As one of Dell Medical School’s chief surgical residents, she’s become adept at managing a demanding, unpredictable schedule. An “average” 36 hours? 5:00 a.m

88:88 05:00

If I’m not already awake with my baby, this is when I start my day. Around 6 a.m., I begin my shift (at Dell Seton Medical Center at The University of Texas) by checking the O.R. board, reviewing the patient census and meeting with junior residents to review cases before another meeting with attending physicians.

am pm

88:88 07:30

Operative cases begin. Once this part starts, there’s no telling how the rest of the day will go. We take whatever comes through the door, be it an appendectomy, gallbladder removal or traumatic injuries from a car Brittany Bankheadaccident; I’ve operated on 13 people in Kendall a single shift. am pm

Around lunchtime, I’m already in the O.R. repairing a hernia when a “trauma stat” call comes in. A trauma stat means a patient’s vital signs are extreme or their injury type is especially severe, and we are expected to run — not walk — to help. In this case, someone has been in a car accident and their abdomen has been punctured.

spring 2019

11:05 p.m.

88:88 1 1:05

When I’m on call overnight, things continue pretty much like they do during the day. After patients are out of surgery, we keep a close eye on them wherever they go, whether that’s the ICU or elsewhere in the hospital. We’re constantly on the move. am pm

Tonight, there are about 30 patients in various corners my team is monitoring. 5:15 a.m.

05: 15 88:88

Finishing up with surgeries, the team and I conduct morning rounds, followed by morning report to hand off relevant information to the incoming team. I usually head home around 8. am pm

12:00 p.m.

12:00 88:88

My work doesn’t end when I leave the hospital! Today, I’m attending a meeting with other researchers in the Department of Surgery and Perioperative Care. am pm

I’m conducting a study on gender bias in medicine, which is both clinically interesting and also hits home for me personally. During the meeting, I share some early findings from an implicit bias test I’m giving to trauma patients, showing a pretty common thread of bias toward woman surgeons, and receive a lot of good feedback from faculty and fellow residents on how to move forward with publication once the rest of the results are in. 3:00 p.m.

03:00 88:88

Keen to support new doctors who envision a better health care delivery system, medical educators at Dell Med designed the Distinction Program for Care Transformation, launched in 2018. The multi-year, interdisciplinary program embedded within Dell Med’s Graduate Medical Education curriculum provides resident physicians with resources to explore and implement innovative solutions during training to improve health care in Austin and Central Texas. Participants pursue solutions to problems they see on the front lines of care — from creating a robust program for treating patients with opioid use disorder to optimizing postpartum discharge from the Mother/Baby Unit at Ascension Seton Medical Center Austin.

30%

more residents

My daughter is turning 1 soon, so I spend some time planning her birthday party, then head to the gym for a quick workout. Even though my job is physically strenuous and draining at times, I’ve found that cardio helps burn off steam, while yoga is great way to unwind and process everything going on. am pm

5:15 p.m.

88:88 05: 15

BRINGING FRESH PERSPECTIVES TO HEALTH CARE REDESIGN

am pm

590,000 hours

clinics & hospitals

Programs co-sponsored by Dell Med and Ascension Texas have increased the number of new residents providing care in Central Texas by more than 30% since 2012. In the 2018-19 academic year, these doctors will work about 590,000 hours at nearly 60 clinics and hospitals.

At last! I get time to relax with my family — and get some much-needed sleep. 37

rethink: new perspectives on health

thought leadership

Health Policy & Reform:

5 Things Every Med Student Should Know Ex-FDA head Mark McClellan and HHS veteran Karen DeSalvo — both now members of the faculty at Dell Medical School — delivered an intersession in January to second-year students. The topic: health policy and reform (part of the health systems science focus of the curriculum). recapped here are five key learnings from two top experts.

Combined, Medicaid and Medicare provide health coverage for 34% of Americans. National spending will soon exceed one-fifth of GDP, and Medicaid accounts for a rising share of most state budgets.

Health care system performance does not match investment: Despite spending twice as much as its international peers, the United States’ mortality rate is rising, driven by population groups like middle-aged white Americans living in rural areas.

The way care is financed drives how it is delivered, because it determines what can be compensated and rewarded.

inefficiencies — may be as much as $750 billion each year. Many opportunities for higher-value health care — including telemedicine, care coordination, targeted use of medical technologies and investment in nonmedical health interventions — are potentially cost-decreasing.

To get to high-value care , we must do four things: support data-sharing and analytics,

which will improve the quality of care; link payment to effective processes and outcomes; provide risk adjustment — compensation to make up for extra costs associated with high-risk individuals — to insurers to encourage competition on value; and evaluate and, as necessary, modify payment and care reforms, then scale

4 38

Excess costs — caused by unnecessary services, missed prevention opportunities, fraud and other

the ones that work best — including those that address the nonmedical drivers of health.

spring 2019

BUILDING THE PIPELINE In 2015, only 6% of medical school graduates were black; only 5% were Latinx. As a champion for giving all students equitable opportunities in the health professions — and understanding the importance of diverse cultural competencies in health care — Dell Med is working with Austin Independent School District and Austin Community College to bring health professions programs to area high schools. Meanwhile, Dell Med’s Health Sciences Summer Camps and related yearlong programs offer opportunities to high school and middle school students alike. Seventyfour percent of participants are from Title I schools, 80% report that they are more likely to pursue a health science career as a result of the experience, and 47% expect to be the first in their family to attend college. As students at The University of Texas at Austin or Huston-Tillotson University, they can join Dell Med’s Health Leadership Apprentice Program and collaborate with faculty and staff on efforts tied to the school’s work in health care transformation.

philanthropy spotlight

FUELING BIG CHANGES IN HEALTH In 2012, the people of Travis County voted to create a community-focused medical school dedicated to improving health for all. This unprecedented commitment launched Dell Medical School and cemented its focus on improving health locally as a model for the nation. The community’s vision also brought thought leaders from across the country to Austin to be a part of building something from scratch: the academic health system

of the future. With the mission of revolutionizing how people get and stay healthy, Dell Med is working with clinical and community partners to transform medical education, research and care — and to redefine the role of academic medicine to help make Austin a model healthy city. In its first five years, Dell Med has grown from an idea into a reality:

[CLINICAL ICON]

Care teams at UT Health Austin are improving the lives of people with conditions including Alzheimer’s disease, bipolar disorder, cancer, heartburn and pediatric heart disease. PAGE 10

[MED ED ICO]

Nearly 200 med students are developing as future physician leaders across the school’s innovative curriculum, while hundreds of residents and fellows join faculty in caring for patients in local clinics and hospitals. PAGE 6

[RESEARCH ICON]

Dell Med faculty are collaborating with campus researchers to advance discoveries and develop technologies and systems to improve care. PAGE 34

[COMMUNITY ICON]

Through diverse partnerships across the community, Dell Med is working to improve health outside the clinic. PAGE 20

a c o m m u n i t y ’s

vision inspired

“

$220 MILLION i n p h i l a n t h r o p i c s u p p o rt f r o m 2 ,20 0 d o n o r s

I came to Dell Med from Johns Hopkins because of the wealth of world-class research at UT Austin. My goal is to bring new ideas to better diagnose and treat cancers from the laboratory to the clinic. william matsui, m.d. deputy director, livestrong cancer institutes associate chair of oncology research

Building Momentum Investments in Dell Med — including support from local taxpayers — are essential to building teams and programs that measurably improve health, particularly for those facing the greatest challenges to it. The creation of Dell Med also inspired philanthropic support — including the Michael & Susan Dell Foundation’s foundational gift and gifts for new clinical, research and educational programs such as the Mulva Clinic for the Neurosciences, the LIVESTRONG Cancer Institutes and the Mitchel and Shannon Wong Eye Institute.

“

What’s Next? The Central Texas community charged Dell Med with creating something better for all. And we’re just getting started. America’s finest medical schools and teaching hospitals — academic medical centers — train the next generation of health care professionals, foster discoveries and provide patients with the highest quality of care. Dell Med is positioned to achieve that level of excellence and more, all while building a new academic health system that: •

Addresses health where it starts — in the places we live, learn, work and play.

•

Puts breakthroughs into practice in a fraction of the time.

•

Assembles teams to meet the needs of the whole patient.

•

Ensures all people receive the best care at the right time.

But we can’t do it without you. Learn what’s next for Dell Med and how you can invest in the future of health: email dellmedgiving@austin.utexas.edu or call 512-495-5027.

I came here because I believe in building a transformative system for patient care, research and teaching. It’s clear to me that the school is uniquely positioned to make groundbreaking contributions to health. david paydarfar, m.d.

interim director, mulva clinic for the neurosciences chair, department of neurology

“

Joining the Dell Med community gave me the opportunity to create something new and innovative. Not many people get that chance. sue cox, m.d.

executive vice dean of academics chair, department of medical education

rethink: new perspectives on health

continued from › 31

spaces in Dell Med’s Health Discovery Building that bring together worldclass companies and people passionate about improving health through multi-disciplinary collaboration:

Jonathan Levy, a partner at a private investment firm in Austin, is one of the fund’s donors. He and his wife, Leigh, view their gift as a long-term investment — just with an • In 2017, Merck & Co. Inc. located its newest information technology atypical return profile. hub in the WorkSpaces. Others are “In addition to creating jobs and in Prague, Singapore, and Brancheconomic opportunity, Dell Med can burg, New Jersey. generate widespread social impact through the incubation of innova- • Similarly, the Association of British Healthcare Industries chose tive health care solutions,” he says. the Texas Health CoLab as the “It was important for us to support home for its “ABHI Innovation those new discoveries that could Hub” — a venture that offers U.K. positively change our world.” companies the opportunity to develop their U.S. business. Attracting Collaborators

With International Scope Another track, WorkSpaces @ Texas Health CoLab, is a set of co-location

These early ventures encapsulate the growing interest in Austin as a hotbed of health tech. In 2018, the

Greater Austin Chamber of Commerce reported that more than 40 life science companies started operations in Austin in just two years, and the number of companies expressing interest to the chamber had doubled — an increase that leadership attribute to Dell Med’s opening in 2014. “Having partners who are doing dedicated work to bring devices and services to market allows for the kind of partnerships that can be difficult to come by in an academic setting,” says Ruben Rathnasingham, assistant dean of health product innovation. “Having greater options for collaboration across the city means exponentially more opportunities to improve health outcomes locally.”

BUILDING A NEW BUSINESS OF HEALTH In the U.S., we spend 80% of health care dollars on care and clinical systems, while as much as 80% of our health is determined by factors — nonmedical health drivers — that are not effectively controlled in those settings. 42

Dell Med’s Factor Health is a hub for health services research that’s designed to test and sustain interventions that address what happens outside the walls of a clinic. The platform launched in Austin in January 2019 and will soon expand to Houston. It partners with organizations like Meals on Wheels, the Boys and Girls Clubs of America and Austin Clubhouse in pursuit of a new business of health.

ONEEVERYONE

Ann Hamilton (2017)

Photographic portraits selected from more than 21,000 taken of individuals in the Austin community are on display at the Dell Medical School campus as part of ONEEVERYONE.

SPIRAL OF THE GALAXY

ma rc qu in n ( 2013)

— Steve Steffensen, M.D.

“

— Steve Steffensen, M.D.

march 2017 43

featuring JOYCELYN ELDERS, DAVID FEINBERG & MARK Mc CLELLAN

College of Fine Arts Design Institute for Health

College of Pharmacy + School of Nursing + Steve Hicks School of Social Work Center for Health Interprofessional Practice & Education

› dellmed.utexas.edu

“a leading, pioneering, edgy medical school” adm. brett giroir

McCombs School of Business Value Institute for Health & Care

u.s. assistant secretary for health

REthink | POW E RE D BY DE LL ME DI CA L SC H OOL | 2019

CONNECTED ACROSS CAMPUS

Moody College of Communication Center for Health Communication

“the right team, in the right place, at the right time” president gregory l. fenves

the university of texas at austin

issue no. 9 • spring 2019