Teaching high-value care

An assistant dean for health care value discusses a new track in care transformation for residents.

After practicing for several years as a hospitalist, Christopher Moriates, MD, ACP Member, recently started a new job—a first for not only him, but for any U.S. medical school.

Dr Moriates
Dr. Moriates

Dr. Moriates is now assistant dean for health care value and an associate professor of internal medicine at Dell Medical School at The University of Texas at Austin. The new medical school is introducing a number of programs—such as a new “Distinction Track in Care Transformation” for selected residents—that will focus on high-value care, a concept which is engrained in the school's culture, he said.

“I am the first assistant dean for health care value in the country, but I really hope not to be the only,” said Dr. Moriates, adding that the school welcomed its first class of 50 medical students last July. “This is the first new med school at a major, Tier 1 research university in about 50 years, so it's a really unique opportunity,” he said.

High-value care has been a focus for Dr. Moriates, who previously published a textbook on the subject and worked with ACP on its national High Value Care curriculum. He recently spoke with ACP Hospitalist about his new position, how he teaches high-value care, and what he expects for the future.

Q: What do you do in this new role?

A: I work on educating and engaging frontline clinicians—that's medical students, residents, and physicians—in value. What I've been doing is creating new curricula and working on interactive modules that will teach the basics of value-based health care, as well supporting projects in quality improvement (QI), safety, and value for learners of all levels here.

I also work with the residents a lot in the internal medicine residency program, and we're creating some new innovative programs there. We're creating a distinction track in care transformation [for] residents. . . and we're launching a chief resident in quality and safety here, so I've been working on that, as well. Of course, I'm also still a hospitalist, and I see patients.

Q: Do others on the faculty work with value, as well?

A: Almost everybody who's coming in here has some sort of experience and perspective on value, which is really cool because it means that instead of being one of the only people locally pushing for this idea, I'm actually one of many.

Q: Why did you decide to stay in a clinical role as a hospitalist?

A: That is certainly what I went to med school to do—take care of patients and teach—and I know it definitely keeps what I'm doing grounded. I don't know how I would have credibility trying to teach and talk about the things I do if I didn't actually know what it's like to try to practice that. I can sit here and talk to a room about how obvious it is that we shouldn't get these CTs in these settings, and then I have to actually face what it's like to make those decisions, and I think that's important. I also get to work with the residents, helping drive culture change and helping set those motivations.

Q: What are some of the biggest challenges in the value world right now?

A: No matter where I go, usually I hear that getting the data we need is a bottleneck. There's tons of data. It's being collected somewhere. But to really get access to it and clean it and make meaning out of it has been incredibly challenging, and that's even more challenging when you look at value because then we want to also know something about cost data, and cost data is extremely difficult to get to in most hospitals. It's really hard to change things when you can't measure them and understand them.

In addition, with value, there are very few things that are clear, that are black and white: no value or high value. So most of the things we do require really digging in to understand the context and defining what a low-value practice is on an individual basis. We can look in aggregate—we can look at certain things that are clearly overdone—but on a one-on-one decision making process, to be able to look in and say, “Yes, that was clearly unnecessary or low-value,” requires a lot of insight that we don't always have.

Q: How can hospitalists do better in this area?

A: I think the first thing is really about embracing that motivation, so understanding some of the basics around value: why it is that we should care, measuring what matters to patients, and educating yourself a bit on costs. There are a number of resources out there that hospitalists can currently turn to. The Choosing Wisely lists are a great place to start to look and find areas where consensus says that there are areas that we overuse. Even if we can't necessarily get the data, there's nothing stopping us from measuring our own practices in informal ways and thinking twice about some of the things we're doing that show up on those lists. And I think we need to start the conversation with our colleagues, with the head of our hospitalist groups, with the administration of the hospital. I find that I've learned so much more by just asking questions and trying to understand what's going on locally by talking to those types of folks than anything else.

Q: Looking forward, how do you see the concept of value evolving in medical schools?

A: I think it's clear that med schools and especially residency programs in internal medicine across the country are introducing value into their curricula. The question is just how much it's being added. I think it really is a component of pretty much everything we do, so therefore, if you have an hour-long session on value that's given at some point in the curriculum, to me that doesn't mean you've really addressed this.

Here, we purposefully don't have a “Value-Based Health Care 101” course. We're trying to weave it throughout all four years of the medical school curriculum. So what that means is when the students in their first year are doing their case-based learning, we're starting to go through and try to find opportunities where we can embed some of these principles into the cases. For example, if they're learning about a patient with chest pain and they're thinking about stress testing, we can embed [information] about different costs of different stress tests and the benefits and the risks of those different stress tests.

Or we have a case of a patient with ARDS [acute respiratory distress syndrome] who gets intubated, and we were able to embed in there making sure that the students learn that a patient who's intubated in the ICU doesn't necessarily need routine daily chest X-rays unless they have a change in their clinical status. We are also teaching the foundational components of value-based health care early on in medical school and then getting them engaged in doing some value-improvement type work during their third year.

I'm hoping that other med schools will take similar approaches and really think about how you get it baked in to the curriculum. One way I hope that we contribute to helping do that is we are creating these online modules that are going to be interactive and adaptive and will introduce the basic concepts of value. My plan is to have those be freely available, and we'll start with the three introductory ones in 2017 so that students can go in and take those. It will provide the information they need and create a community of learners taking the curriculum.

Q: On a broader scale, would you say hospital medicine has a greater focus on value than other disciplines?

A: I think it is a trend for medicine in general, and it's spreading, but I feel like when you really look at who's embraced this, it's not surprising to see that it's the hospitalists. Hospital medicine was created on this idea that we would improve quality and safety and value. I talked to Bob Wachter, MD, FACP—who was my old boss and was there from the beginning and helped define the field—and improving value was always the mission of the field, even if they did not necessarily use that term. However, the cost side of the value equation got left behind a little bit while everybody sort of focused on QI and safety, and now it's come back to the forefront. Hospitalists, by virtue of being somewhat specialists of how to improve the system in which we work, I think have been quick to embrace this and lead projects. When you look, there are value-improvement projects across the country: decreasing inappropriate lab draws, decreasing transfusions, thinking about things like appropriate syncope workups, and getting rid of things like carotid ultrasounds. Hospital medicine, I believe, has really helped lead the charge in this.