Better Living Through Our Shared COVID Experience

Habits.

In general, it takes about three months of regular performance of a new behavior to develop a habit – to incorporate actions into your life that becomes largely unconscious and effortless, like brushing your teeth. In my mind, the crisis in Houston became real with the closure of the Houston Rodeo on March 11. Since that date, we have all been dealing with change on an unprecedented scale. Work changed, the economy slowed, schools closed, we experienced two disease surges (or as some would contend, one long continual surge). Using the Rodeo as a marker, we are now in our 5th month of the crisis – plenty of time to have developed new habits. Today I would like to briefly review the improving data from the past week, while pausing to contemplate what positive lessons we have learned so far. How are we going to be better for having lived through this historic crisis?

We are clearly in a transitional period. The numbers this week are encouraging. For the past two weeks, the R(t) – the measure of community viral infectivity – has been at or below 1.0 due to community masking and distancing efforts. It now appears we achieved our peak of new viral infections during the 2nd week of July. New community cases in Harris and eight surrounding counties, on a rolling average basis, have decreased from about 2,400 daily at peak to around 1,800 (but keep in mind, for most of April and May we were seeing fewer than 400 cases per day, so we are still seeing a lot of new disease). New community cases reflect all positive tests, including people who are asymptomatic or minimally symptomatic.

The decrease in community disease burden in showing up in slackening hospital demand. Across TMC institutions at peak, daily admissions were above 350; we are now below 250. The daily census of patients in non-critical medical/surgical beds is dropping, and ICU patient census – which is expected to lag these other indicators – is starting to drop. In short, all the metrics are headed in the right direction.

To be clear, this does not mean things are easy. Providers in hospitals are still managing high numbers of very sick patients. Faculty, providers and residents in ICUs are fatigued. All tertiary/quaternary hospitals are providing extracorporeal membrane oxygenation (ECMO) to record numbers of patients. There are parts of Texas, particularly in the Rio Grande Valley, that are still squarely in crisis mode. So again, this is not over – just better. Vigilance around masking and physical distancing must continue. When the time is right, we must continue to encourage thoughtful, data-driven reopening decisions.

So, as we ride the backside of the current wave, I would like to reflect briefly on lessons learned – societal, organizational and personal. What new habits, skills and strengths have we developed during this crisis?
On the broadest societal level, I think this is a difficult question to answer. This will no doubt be the subject of many books to come. One lesson learned should be that the U.S. deserves a less fragmented, better-coordinated public health system. I hope this is my only global pandemic, but if we are ever unfortunate enough to experience something like this again, as a nation we must be better prepared.

In terms of institutional lessons, we have had a glimpse of what it means to be a learning health system. The AHRQ describes an learning health system as a system where “internal data and experience are systematically integrated with external evidence, and that knowledge is put into practice. As a result, patients get higher quality, safer, more efficient care, and health care delivery organizations become better places to work.”

I think that summarizes our last five months remarkably well. We have proven that if we have focus and organizational commitment, we can do big things quickly and do them well to improve the health and well-being of our community. The Baylor collection site just “swabbed” patient 10,000 this week. While other labs are challenged to provide timely results, Baylor labs continue to provide region-leading turnaround time for high reliability testing. Our researchers continue to manage productive labs and submit COVID and non-COVID related grants. Telehealth services enable us to provide necessary services to patients, and in a challenging environment, we are ahead of pace to recover all of our pre-COVID patient volume. Psychiatry in particular is performing the majority of their services virtually – including direct services in support of many in the Baylor community – and are on pace to exceed their pre-COVID levels of patient care. Curricula have been redesigned, and new students, residents and fellows smoothly onboarded. I hope a residual Baylor habit is recognizing we can accomplish important things quickly and well.

On a personal level, all of our lives are different than they were. We have faced a ton of disruption and much negative and difficult change. I think it is useful to stop and reflect for a moment on what is better, however small those things might be. What new routines have we established that we find meaningful and valuable? How would you finish this sentence?  “In the post-pandemic world, I will continue to…” These habits can be small or large, but pause to think about what they might be. For me personally, two come to mind. In the post-pandemic world, I will continue to…

• Limit my professional travel. Like most of you, I have not been on a plane since February, and have discovered I really do not miss it. I have more time at home, and seem to have been able to fulfill professional obligations fairly well remotely. To be sure, when travel becomes routine again, some face-to-face interactions will and should resume. However, I like being at home with my family and will be more selective about future trips.
• Have Sunday lunch with family. We have a new tradition of sitting down to mid-day Sunday for a family meal (within our household). Although we typically do take-out rather than cook, this feels like a throwback to a less hurried era. Pre-COVID-19, we had limited opportunity for unstructured, leisurely conversation; somehow now it seems to be more important.

In the post-COVID world, what positive thing will you continue to do? Take time to reflect. If you are inclined to share, email me your (brief) sentence, or if you are on Twitter, post using the hashtag #COVIDHabitsBCM.

Stay well.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

A Cautionary Tale

My message today is a little different.  Generally, my comments are directed to the Baylor Community, and I hope they may have broader applicability.  Today’s message is squarely directed outside of Baylor.  Please share it widely, and share it today.

You do not need me to tell you the SARS-CoV-2 situation has substantially worsened over the past week – every media outlet in the nation is covering that story.  We are in the midst of a major surge.  Our affiliate hospitals are working hard to make sure there will be beds available to meet the demand, staffed by qualified healthcare providers.  We are prepared, but clearly are in for a challenging couple of weeks.  As we manage increasing volumes of patients, and especially as we enter the holiday weekend, the most important thing we can do is work to slow the spread of COVID-19.  That is why I think the story of Frank and his family is so important.

Note: I changed the name of the main person in this story to Frank Wilson and left out some details, not at his request, but to allow this story to be told without intruding on the privacy of anyone involved in this story. The story is real, the people are real, the impact on their lives is real.

Frank Wilson and his extended family have lived in the same town for more than 40 years – three generations.  They are a close-knit family in a close-knit community.  They enjoy a pace of life that is at least a half step slower than a city like Houston.  This is the story of SARS-CoV-2 in a place far removed from the intensity and complexity of the Texas Medical Center.  It is a story of good people in a safe place.

The Wilsons planned to spend their Memorial Day the way they spend most holidays and many weekends – enjoying a family gathering at their favorite picnic spot.  This celebration took on a little more significance, as they were coming out of the coronavirus induced lock-down.  As regional leaders mandated a partial shutdown of the economy, they suffered along with the rest of the state and the country – lost shifts at work, cancelled family events.  Now public officials were reopening the economy, and life was trying to regain its normal rhythm.  There was nothing more normal for Frank than a family picnic.

What did he think of all the coronavirus warnings?  “I thought it was all a big hoax – the government trying to take control of things”.  He knew people in other parts of the country had the virus, but he did not personally know anyone who had it.  He didn’t even know anyone who knew anyone who had it.  The response of media and civic leaders seemed overblown.  “It was a big nothing.”  Thankfully, it seemed now it was behind us.  We were opening back up.  We had beaten the virus.

This Memorial Day was like countless other similar holidays – an opportunity to unwind and relax with family.  It would become a day – that would lead to a week – that would change their lives forever.

The first warning sign.  Frank’s mother became short of breath.  Her symptoms were severe enough they felt compelled to get her checked at a local emergency room.  She was evaluated and told that she was suffering from a “broken heart.”  She was still mourning the recent death of her husband – Frank’s father – and it seemed reasonable that her symptoms were anxiety related.  All were relieved it was not the virus.

Memorial Day was Monday, May 25.  Tuesday passed and was uneventful.  

Wednesday, Frank went to help a friend tune up the engine of his car.  Towards the end of the day he didn’t feel well.  That night his temperature went up and he called his boss to say he would not be at work.  He went to the hospital and got the COVID-19 test.  Results the next day – positive.  He had the virus.

Thursday, Frank’s wife developed similar symptoms.  She went to the hospital, and was sick enough to be admitted.

Also on Thursday, Frank’s mother-in-law became ill.  In retrospect, she had not felt right since mid-May, but had already had a negative test for COVID-19.  She went to the hospital, and was admitted.

Friday, Frank’s sister became ill. Like his wife, she went to the hospital and was admitted.

By Friday evening, his mother’s condition had worsened to the point he sat at her bedside all night.  He did not realize it at the time, but this would prove to be the last night she would spend in her home.  On Saturday, he took her to the hospital, and she was admitted.

Thus ended a week from which the family is still struggling to recover.

Frank was lucky.  He did not need to spend time in the hospital.  However, he tells me it was the worst thing he has ever had.  “It was ten times worse than the worst flu.  I had terrible stomach pain, and couldn’t get my breath.  It felt like a bomb was going off in my chest.”

His wife’s condition was severe enough that it looked like she would need to go on a ventilator.  Fortunately, with a combination of regular proning (face-down positioning that improves air exchange in COVID-19 patients) and high levels of supplemental oxygen, she avoided the ventilator and was discharged after about a week.

His mother-in-law’s condition deteriorated, resulting in a prolonged ICU stay.  She is profoundly weak and continues to undergo intensive rehabilitation.

Frank’s sister also wound up in the ICU, and required extracorporeal membrane oxygenation (ECMO).  This is used in patients whose lungs are so badly involved that they cannot effectively exchange oxygen between the airways of the lungs and blood, which is much like slowly drowning.  The patient’s blood is drained out of the body, infused with oxygen and replaced.  Thankfully, she recently improved to the point that she is off ECMO, although she remains hospitalized.

Frank’s mother was the most critical of all.  She was admitted to the ICU and received the best and most aggressive treatment possible, at the finest medical center in the world.  She participated in the convalescent serum trial, receiving antibodies from another patient who had recovered from COVID-19.  Despite heroic efforts, she passed away. 

This is a true story, as told to me by Frank – real people, real events. After seeing the devastation the virus brought to people he loves, his instinct is to do all he can to help others.  He wants to donate his plasma so someone might benefit from his antibodies.  Most importantly, he wants people to know the threat is real, and that everyone must act responsibly to protect each other – to protect people like his wife and sister and mother.

Our most important weapon to control the viral invader is our own safe behavior.  Mask when in public places and when exposed to others.  Practice physical distancing all of the time.  If you have any symptoms, do not go to work or places where you could infect others.  Assume everyone you meet has the virus and is infectious, even if they had a negative test.  

Importantly, for the upcoming July 4th holiday, celebrate with your immediate household – not with your extended family, and certainly not as part of a public crowd.  Celebrate at home if at all possible.

Please share this message broadly.  The following link can be used in any social media posting: https://bit.ly/2Zoadec.  The Wilson story is tragic, but will at least have some meaning if others learn from it.

I wish you all a safe, happy and healthy July 4th holiday.

Thank you all.

Hurricane

 

What follows is a very long caveat, followed by very short message; it seems to me the caveat is actually more important.

Two weeks ago, I talked about where we were. As difficult as things are now, some things are better than in April (e.g. patients seem to be somewhat younger and less critically ill, we have some emerging treatments). There is a little glimmer of hope.

Last week, I talked about where we are: the fact that our only real weapons against the viral invader are scrupulous attention to physical distancing, masking and staying away from others if you develop symptoms. Please re-read that message and broadly share with others. I still see the occasional mask-less person in the hallway and hear of someone who “didn’t feel well” for a few days at work, and turned out to test positive. I think these exceptions are few, but we need to all push for universal compliance. Mask, distance, don’t come to work sick.

As we are now in an environment where the community presence of the disease is on the rise, the natural question for this week is, “Where are we going?” What’s next?

The most honest answer – and the one that makes this whole situation so difficult – is no one knows.

It is about 6:30 Wednesday morning, and pouring down rain. I look at my weather app and see a large cloud settled over Houston. I am very confident it will be raining in half an hour. It is less clear what will happen this afternoon. I would like to spend some time outdoors on Saturday, and don’t have a clue as to whether it will rain or not.

To me, that is what the COVID-19 pandemic feels like. We can only see what is just around the corner. Everything else is opaque. Will it spontaneously fade like SARS? Become an endemic pathogen, waxing and waning for months or years to come? Mount a major recurrence during flu season? Will a safe and effective vaccine be available this year? Next?

No one knows. Dr. Fauci doesn’t know, nor do the politicians, nor do the media pundits. We have guesses – often well-educated ones – but still guesses.

We use the hurricane analogy a lot, but increasingly it is a poor fit to this situation. In Houston, we are really good at hurricane response. We know when one has the potential to hit. We have context and experience from prior storms to know how bad it might be. It makes landfall, does its damage and passes. Houston can then do what it does best – pick itself up and recover.

This is not a hurricane, though I struggle to find an accurate comparison. Comparisons all seem either trite or overblown. It is like an innocent civilian population caught between warring powers. It is like dealing with the complex physical, emotional and cognitive needs of an aging relative with dementia. It is like losing a job in a down economy and struggling to care for your family. You know it will end, but you do not know when. Part of you knows you have the resilience to get through it, and that you will find strength in a difficult situation. However, in the moment, the uncertainty is the hardest part.

So, with that caveat (nobody knows), here is my view of what to expect in the next couple of weeks:

• The viral numbers in Houston (total new cases, TMC hospital admissions, ICU census) will continue to rise.
• TMC hospitals capacity will begin to be stressed, and hospitals will activate plans for sustainable surge capacity. This will involve adjusting staffing patterns for physicians, nurses and other providers and opening additional ICU beds. The hospitals can function at this level for an extended period of time. As viral numbers continue to climb, there will be increasing planning around emergency surge capacity. It is hoped the more disruptive emergency changes in the delivery system will not be needed, and even in worse case projections right now are at least three weeks off.
• We will all know someone who develops the COVID-19 illness – a family member, friends, neighbors, co-workers. It is inevitable as the virus spreads in the community. Most of the disease in our Baylor community will be imported from the outside. Our internal testing and contact tracing processes will effectively limit the spread of the virus at work.
• The increased viral numbers and associated media focus will get the attention of the citizens of Houston and surrounding communities. For those who have not taken this seriously up to now, we will see virus avoidance behaviors start to improve. More masks, less congregation in crowded bars and beaches. The July 4th holiday weekend will still present challenges, but will be materially better managed by the public at large than Memorial Day.
• State and local officials have already started to stake out a more aggressive posture on virus control. In Harris County, masking is now required in all businesses. Officials will continue to explore effective means of limiting viral spread (through education, regulation and enforcement), while attempting to avoid the economic impact of a broader business “lockdown.”
• Improvements in masking and heightened public awareness will slow the viral spread to a degree. The success of these efforts is a major variable in predicting our peak. My current guess is that our peak will occur in late July. Remember the caveat – I don’t know if it will rain on Saturday.

My most important prediction: Our Baylor community will be stressed by the disease burden in our community, but will continue to work together effectively to meet our organizational mission. We will continue in challenging circumstances to take care of a population that needs quality healthcare more than ever, pursue new discoveries and educate future providers and scientists. Most importantly, we will keep each other safe. Thank you all.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

Control

 

Today I want to talk about control – specifically, frustration over those things we cannot control, and the importance of recognizing and maximizing those things we can.

For a phenomenon that has been with us for a relatively short period of time, it may seem strange to speak in terms of “epochs,” but it does feel like we have lived through some very distinct phases in this pandemic. April was categorized by a long list of unknowns, rapid community viral spread and an overall mood of fear and anxiety.

May seemed different. We regained a little more of a sense of routine. The virus, though not in retreat, seemed to have reached a point of community equilibrium. We breathed a small but tentative sigh of relief, and even had some optimism that we could simultaneously re-engage our regional economy and hold the infectious invader at the gate.

By June, we started to see the impact of the loosening of distancing in the community. If you have followed the recent numbers, community cases are sharply increasing, and hospital capacity is feeling the strain. Political polarization has accelerated and become personalized – “you can’t make me wear a mask” vs “I am offended by your reckless behavior.” Some of April’s anxiety has returned, but this time tinged with fatigue. When will this all end?

One of the hardest parts of dealing with the impact of the pandemic is that so much is out of our control. City, county and state officials will make decisions regarding how our community will respond. Leadership of Baylor and other TMC facilities are engaged on a daily basis in encouraging appropriate action. We can recommend, promote, cajole, provide data, and we have substantial influence. But at the end of the day, these decisions are out of our control.

The reality of the situation is obvious, but bears stating. We will be working and living our lives outside of work in the midst of a significant – and at this point, growing – viral presence in our community. Given this reality, let’s focus on those things we can control:

• Mask/maintain distancing/don’t come to work sick. This is our armor, unequivocally the best things we can do to keep the virus out of our Baylor work environment.
• Adopt a “universal precautions” mindset. In the hospital environment, providers are at risk for exposure to blood-borne pathogens (e.g. HIV, Hepatitis B & C). As a consequence, if a provider is at risk of coming into contact with any bodily fluid, it is universally assumed that the patient has a blood-borne disease, and appropriate protocols followed. We need to adopt this same mind-set around COVID-19. You should assume everyone with whom you come into contact is infected and actively shedding virus – even if you know they had a negative test yesterday. If you mask and maintain distancing, you are relatively safe.
• Hold each other accountable. Masking is required at Baylor. To keep our environment as safe as possible, we need to point out to each other when we are falling short. If I am not wearing a mask, or if I am not maintaining appropriate physical distancing, I want you to point this out to me. This needs to be not in the spirit of “tattling,” but as a collective act of compassion to our work community.
• Carry your armor outside of Baylor. Most of our time is not spent at work. I strongly encourage you to maintain scrupulous attention to masking and distancing outside of work. Frankly, your risk of exposure from a store clerk, waiter or the person on the next treadmill is probably greater than anything you will encounter at work. Wearing your armor and maintaining universal precautions outside of the walls of Baylor helps to protect you and your family. It also provides positive role models in our community. We will win converts not by preaching or scaring people into compliance, but by serving as an example.

A word of warning. We will see more infections of members of the Baylor community. This is not a failure, but an expected consequence of living in the middle of a pandemic. Baylor leadership and the ICC will also continue to do whatever is necessary to keep our community as safe possible. We have a rational approach to workplace testing (symptomatic employees and learners, surveillance testing of high exposure areas, random voluntary sentinel testing, internal contact tracing).

I have asked our Testing Advisory Committee to reconvene to review our internal testing guidelines in light of the increase in community spread. We are refreshing our surge planning efforts from earlier in the outbreak. We have passed all our internal social distancing audits with flying colors, and are making good progress in an a appropriately paced recovery across all mission areas.

We seem to say this a lot – this is far from over. I share in your concern, anxiety and fatigue in dealing with the situation thrust upon us. However, I remain extremely confident that our community will work together to see us through this ongoing crisis.

Stay safe.

(Note:  Between June 2020 through November 2021, I wrote weekly COVID-19 pandemic updates seen through the lens of a health sciences university.  My intent was to provide reliable information, acknowledge legitimate concerns, console, and encourage.  Each posting reflects issues our community was experiencing at that moment in time.  I have reproduced selected examples on this site).

Electronic Apostasy: Why I Have Re-embraced the Paper Book

As I write this, I am on an airplane at 30,000 feet, and it strikes me as an ideal time to confess a digital heresy: I have entirely abandoned electronic books.

When the first e-readers burst onto the scene, I was an early adopter; initially on a single function reader, later on a tablet.  The appeal of the technology was immediately obvious.  My entire library was at my fingertips.  I could carry hundreds of books with me everywhere (even at 30,000 feet).  It was quick and easy – virtually instantaneous – to buy a book on line.  Clearly, this was a life-enhancing technological innovation.

After several years, you can now place me firmly in the anti-e-reader camp.  Here are my top nine reasons I have sworn off e-books:

1. I miss the tactile experience.  This is probably the most obvious reason on everyone’s list of a certain generation.  Anyone who was raised (and likely, developed neurologically) reading physical books, probably misses the sensation of turning pages – the weight of the paper, the new-book and old-book aroma, the palpable crack of the spine upon completing the ritual of properly opening a new book for the first time. That ritual, incidentally, came to me courtesy of my outstanding third grade English teacher, Mrs. Walton.  I never think of Mrs. Walton when I fire up my iPad.
2. Thickness of the remaining pages is part of the experience.  E-readers all have some sort of “percent completion” feature to let you know how much of the book you have plowed through.  I need the feel of the remaining pages.  Beyond the purely tactile experience, a thick book, with lots of unread pages, motivates me (“you have a lot to read…better get to it”).  For a cliffhanger, it gives me a sense of how much time the author has to wrap things up. It helps to manage my expectations.
3. My nightstand is a major motivator.  I always have a half-dozen or so books on my nightstand in various stages of completion.  They are a constant reminder of commitments I have made, but have not yet met.  My “stack” in my e-reader probably has dozens of waiting commitments.  I have no memory of many of the books I downloaded on a whim.  I never look at my queue.  My lost books float in cyberspace, like a sailor cast adrift on a life raft hoping to be discovered.
4. The thrill is the hunt.  I love to go to the bookstore, wander around and stumble upon an unexpected treasure.  As I carry my latest acquisition around the store, I have a sense of anticipatory excitement I never experience with an electronic download.
5. Written margin notes help me learn.  As I read, I make occasional notes in the margin.  Frequently, particularly when reading non-fiction, I will flip back to my earlier notes.  Years later, when I pick up a book I previously enjoyed, I review my old notes to jog my memory of the book.  Electronic highlighting does not have the same impact.
6. I like maps.  When I read history, I love books with maps.  I like to dog-ear the pages with interesting maps, and flip back frequently as I am reading.  The ability to casually flip back to a certain page does not work well with an e-reader.
7. I enjoy looking at my bookshelf.  At home, my desk is surrounded by bookshelves.  I enjoy glancing at the spines, reminded of great books I have read.  I feel pangs of guilt for the few volumes I was never able to make it through (but will someday).  I am surrounded by friends.  I never spontaneously flip through my electronic queue, nor does it evoke any real affection.
8. My memory is flawed.  When I read a physical book, every time I pick it up, I see the title…the author’s name…the cover art.  Subsequently, I remember the details, in part due to repetition. When I read an electronic book, I am frequently in the position of enthusiastically attempting to recommend it to a friend, while struggling to remember the author’s name, and sometimes even the title.
9. I am distractible.   Reading is sometimes an effortless pleasure.  Reading is sometimes a painful slog.  Part of the benefit that comes from reading a great book is the investment you have to make of yourself in the experience.  I love to read John le Carré. The early chapters of his books are always challenging.  He drops you into the middle of a confusing story, with incomplete information. The motivation of his characters and the complexity of their situations are revealed very slowly.  It requires patience and commitment.  If the first few chapters of The Spy Who Came In From the Cold had to compete with my email, text messages, Facebook, Instagram, LinkedIn, Solitaire, Pandora, etc., I might not have ever made it through one of my favorite books.

For these reasons, and others, I am declaring my liberation from e-books.  Now, back to my reading, as soon as I finish labeling the Kodachromes in my photo albums.

Accountable Care Organizations, Explained (link to Kaiser Health News article)

Nice, brief review of Accountable Care Organizations, From Kaiser Health News:

Accountable Care Organizations, Explained

What Academic Medical Centers Can Learn From Lippi

Fra Filippo Lippi - Madonna with the Child and two Angels

What does this 15^th century Renaissance painting have to do with a 21^st century academic medical center?  Painted by Fra. Lippi (a monk of some questionable repute) in about 1465, I selected this image as an analogy for our two broad challenges in building a successful academic medical enterprise in the rapidly changing healthcare environment.

The first challenge is the need to innovate.  At first blush, Lippi’s Madonna With Child and Two Angels may not scream innovation.  However, in its time it included a number of groundbreaking techniques.  For a moment, focus on the landscape in the background of the painting.   The use of realistic perspective was an innovation of the period, and separated it from flat two-dimensionality of medieval art.  Note also the painted frame surrounding the scene; the placement of the characters in front of the frame brings them into the world of the viewer.  Coupled with the cherub in the lower right – who makes direct eye contact with the viewer, and looks like he knows a secret he wishes to share – the effect is to draw you into the painting.  This is a degree of interactivity that would have been startling at the time; something akin to watching a 3D movie when all you have known is black-and-white television.

The need for innovation in today’s academic medical center is driven by the pace of economic, demographic and scientific change.  This topic could consume (and probably deserves) many pages of discussion.  However, at least some of the challenge is represented in the Institute of Medicine’s call to create the Learning Health System (LHS) of the future from the Academic Medical Center (AMC) of the past.  A Learning Health System uses data to drive continual improvement in the care of patients.   All three words – Learning Health System – have meaning.

Academic could be interpreted by some as detached and separate from the care delivery system.  Note, that one secondary definition of the word “academic” is “theoretical, speculative; having no practical or useful significance.” Learning implies a continuous and ongoing feedback loop.  The process of discovery and acquisition of new knowledge, while still invaluable in their own right, must be actively applied to improve care.  Care that is suboptimal or inconsistent across populations must be a major catalyst for the process of discovery.

Medical strongly suggests we are focused on the diagnosis and treatment of disease –still a priority in the new world order.  However, the concept of health broadens the mission.  Not only will our emerging LHS develop startling new treatments, we will also take responsibility for maximizing the health of populations.  Prevention of disease and improvement of environmental and behavioral determinants of health will become much more critical components of an institution’s academic portfolio.

Center strongly invokes a specific place (perhaps an ivory tower).  The concept of system conveys a heightened priority on connectivity.  In the traditional model, the care delivery system is where learners go to practice when they finish training.   In the emerging model, learners and the educational process will be integrated into the delivery system.  In the Academic Medical Center, research produces knowledge that is pushed out to providers of care.  Frequently, it takes many years for this knowledge to be integrated into practice for the benefit of patients.  In the Learning Health System, the acquisition of new knowledge remains critical.  However, in addition, the science of care delivery – the implementation of new knowledge – takes on added importance.  The care delivery system becomes an important laboratory.

The second challenge represented by Lippi’s painting is the changing nature of the “halo effect” in academics.  The Madonna’s halo is faint and ethereal.  It does not jump off the canvas at the viewer, and could even be missed by the casual observer.  This reflects the diminishing value the patina of academia has for health care systems.  Over the past half a century, in a system relatively flush with revenue, a hospital could reasonably be expected to contribute resources to education and research almost purely for the associated reputational benefit.  In the emerging health care economy, hospital margins are small against historical standards, and economic success is driven by managing cost and improving outcomes.  The economic value of reputation is waning.

The challenge for the LHS of the future will be to repaint Lippi’s halo with heavy, bold, thick brushstrokes.  Successful Learning Health Systems must foster partnerships with successful care delivery systems (like Catholic Health Initiatives).  Ideal partnerships will be mutually symbiotic:  the care delivery system will provide new academic opportunities for educators and researchers.   In return, the engine of academia must drive concrete strategic advantage back to the health system partner.  I will develop this concept more fully in a future posting.

Lippi’s Madonna and Child frames the questions we all need to be asking of ourselves.  How does my work help the Baylor College of Medicine drive the culture of innovation necessary to be the national model of a Learning Health System?  How do our great strengths in education and research drive measurable strategic benefit to our health system affiliates and partners?  Finding the right answers to these questions will drive our success for decades to come.

This has been cross-posted from the Baylor College of Medicine blog Momentum