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Vanderbilt: Laboratory for health care reform

Apr. 15, 2011, 8:48 AM

Vanderbilt University Medical Center is a laboratory for health care reform. Increasingly, Vanderbilt researchers are applying their expertise in informatics, genomics, drug discovery, basic science and clinical medicine to the solution of critical problems in patient care.

Bedside checklists and electronic “dashboards” developed at Vanderbilt, for example, enable doctors and nurses to chart in exquisite detail the care given to hospitalized patients. These measures have led to a dramatic reduction in the incidence of ventilator-associated pneumonias in the ICU., launched in 2005, enables 130,000 Vanderbilt patients to view their medical records and talk with their physicians online, thereby reducing the number of clinic visits. A more recent innovation, MyHealthTeam at Vanderbilt, uses intensive case management and telecommunications (including cell phones) to help patients bring under control challenging chronic health conditions such as severe high blood pressure and diabetes.

Patients could double

Better control translates into fewer serious complications, including heart attack and stroke, and fewer trips to the clinic, hospital and emergency room. That, in turn, opens up more slots for new patients. Last year, Jim Jirjis, chief medical information officer and medical director of Adult Primary Care, and Bill Stead, the medical center’s chief strategy and information officer, predicted the program could double the number of patients seen in the Vanderbilt clinics.

Achieving better outcomes for patients is only part of the story. According to Vice Chancellor for Health Affairs Jeff Balser, early results from a pilot study of high blood pressure patients enrolled in the MyHealthTeam suggest the program could save Vanderbilt as much as $15 million over five years.

The same goes for the efforts to prevent ventilator-associated pneumonia (VAP). Vanderbilt’s systems-based approach has cut the incidence of this life-threatening complication by more than half, preventing an estimated 16 VAP-associated deaths a year, and saving Vanderbilt more than $3 million annually. “Just imagine the impact we could have if we applied this kind of thinking to all the different problems we have in health care delivery,” Balser said.

Promise of the genome

Last year Vanderbilt began rolling out elements of a new “personalized medicine” initiative that combines the power of informatics and genomics.

Minimally invasive procedure in the Cardiology Cath Lab at Vanderbilt. (Anne Rayner / Vanderbilt)
Minimally invasive procedure in the Cardiology Cath Lab at Vanderbilt. (Anne Rayner / Vanderbilt)

In August 2010, the Vanderbilt-Ingram Cancer Center became the first cancer center in the Southeast and one of the first in the nation to offer cancer patients routine “genotyping” of their tumors at the DNA level. This information is used to personalize treatment by matching the appropriate therapy to the genetic changes, or mutations, that are driving the cancer’s growth.

The first tumor types to be tested are forms of lung cancer and melanoma, a malignant skin cancer. Both diseases have been notoriously difficult to treat, but new therapies that target specific genetic alterations in the tumors have shown promising results, said William Pao, who directs Vanderbilt’s Personalized Cancer Medicine Program. “Through a unique and cohesive set of advances that combine innovations in healthcare informatics, genomics, and drug discovery, we are beginning to deliver on the promise of the Human Genome Project with highly personalized therapy for our patients,” Balser said.

Advance notice of possible complications

Last September, Vanderbilt became the first academic medical center in the country to test patients scheduled for cardiac catheterization for a genetic variation that can affect their response to a clot-preventing drug. The information, placed in the electronic medical record, helps physicians choose the drug and dose that is best for their patients. The goal is to reduce the risk of future complications, including strokes, heart attacks and sudden cardiac death.

Every year, 4,000 patients at Vanderbilt undergo cardiac catheterization because of suspected heart disease. The X-ray test can detect “narrowings” in the coronary arteries that threaten to cut off the heart’s blood supply. In about 2,500 of these patients, tiny tubes called stents are placed in the narrowed arteries to keep them open. The patients also take the anti-coagulant drug clopidogrel to prevent clots from forming around the stent.

Problem is, a significant number of patients carry a genetic variation that prevents clopidogrel from being efficiently converted in the liver into its active form. That variation will be especially severe in about 75 of the patients, and the drug won’t work for them. The new program, called PREDICT, notifies doctors in advance if their patient has the variation so they can prescribe another, more effective drug.

Power of pathology

That’s just the beginning. Patients’ DNA will be tested for more than 200 other variations known to affect response to a wide array of medications. In the near future, for example, doctors may be able to check the “genetic records” of patients diagnosed with breast cancer to see if they are likely to respond to tamoxifen – before prescribing the drug. “Imagine a world where you’re tested once for scores of (variations) and . . . when you need it, it’s there for you,” Jirjis said. “That’s the care of the future.”

The latest Vanderbilt innovation – the diagnostic management team or DMT — harnesses the power of pathology to improve diagnostic accuracy. Testing has become increasingly complex. By correlating and integrating test results in an easily accessible way, pathologists can help clinicians improve the accuracy of their diagnoses, determine the most appropriate treatment and avoid unnecessary and costly tests.

Vanderbilt’s first DMT, established last summer to improve coagulation management, already has demonstrated impressive results. Led by Michael Laposata, executive vice chair of Pathology, the team of coagulation experts reviews the electronic medical records of every patient admitted to Vanderbilt with a clotting or bleeding problem. They use efficient testing algorithms to correlate diagnostic findings and prepare interpretive reports for the treating physician.

In the past few months, the DMT has reduced the length of stay for patients with stroke or deep vein thrombosis by as much as a third. Annual savings could exceed $250,000, said C. Wright Pinson, deputy vice chancellor for Health Affairs and CEO of Vanderbilt Health System.

If the initiative was implemented nationwide and reduced the average length of stay for just these two diagnoses by a day or two, “the amount of money that would save nationally would be in the ballpark of a billion dollars a year,” Pinson said at the medical center’s Leadership Assembly on March 3.

“Ladies and gentlemen, that’s health care reform,” Pinson said.

Fundamental shift

In February, a second DMT was established to guide clinical decision-making in diagnosing and treating blood cancers — leukemias and lymphomas. With the help of Stead and Mia Levy, assistant professor of Biomedical Informatics, Mary Zutter and her hepatopathology team developed a computerized “dashboard” and patient “flow chart” to keep track of the tests used in diagnosis and monitoring treatment and to generate comprehensive reports for the treating physician.

Members of the new Hematology/Oncology diagnostic management team include (foreground, from left) Adam Seegmiller, assistant professor of Pathology, and Megan Smith, resident in Pathology, and (background, from left) David Head, professor of Pathology, and Eric Gehrie, resident in Pathology. They are viewing blood samples under the microscope and recording their findings on the whiteboards above them. (Susan Urmy / Vanderbilt)
Members of the new Hematology/Oncology diagnostic management team include (foreground, from left) Adam Seegmiller, assistant professor of Pathology, and Megan Smith, resident in Pathology, and (background, from left) David Head, professor of Pathology, and Eric Gehrie, resident in Pathology. They are viewing blood samples under the microscope and recording their findings on the whiteboards above them. (Susan Urmy / Vanderbilt)

“When a patient comes into the clinic, all the data are there to understand patient history and laboratory tests and to direct ordering of additional ancillary tests,” said Zutter, assistant vice chancellor for Integrative Diagnostics. The comprehensive, electronic patient reports generated by the DMT link to up-to-date references and appropriate clinical trials. “We’re trying to make this easy to do. I hope and think this will dramatically improve patient care,” she said.

“We really think we can transform medicine and pathology,” said Zutter, who recently was named to the newly endowed Louise B. McGavock Chair in Pathology, Cancer Biology and Microbiology & Immunology.

Transforming the nation’s health care system won’t be easy. Only about 5 percent of U.S. hospitals, for example, have the kind of decision-support infrastructure that Vanderbilt is pioneering.

American health care is also hindered by a glaring lack of coordination across the continuum of care, treatments and services that are not regularly provided according to the latest science in an evidence-based way, and failure to engage patients in their own care. “The resolution of health care costs is truly embedded in solving these problems,” said David Posch, CEO of The Vanderbilt Clinic and executive director of the Vanderbilt Medical Group.

“The real value in health care is changing the way we deliver care,” Balser said. “It’s not arguing about how we pay for care. It’s basic, fundamental science — key discoveries that make it possible to think about directing chemotherapy to the individual tumor, but then also having systems that let you do that in large populations. If you don’t have both, you get nowhere.”

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