Re-making health care:
Karolinska Institutet’s Christer Rolf advises new College of Biomedical Engineering
Here’s a riddle: How can a famed hospital with very few beds and no departments lead its nation in high-tech, low-cost medicine?
Prof. Christer Rolf’s and Karolinska University Hospital’s vision of changing health care to better serve patients and streamline Sweden’s competing public hospital systems was shared in four recent lectures hosted by TMU’s new College of Biomedical Engineering (CBE). During this first visit to the campus, Prof. Rolf praised Taipei Medical University by saying he feels at ease here because the two universities have a lot in common: an elite medical focus and many of the same institutional priorities.
In fact, in July TMU sent a team to the Karolinska Institutet – and hopes are high that student and staff exchanges may soon follow.
CBE Dean Chih-Hwa Chen joined Prof. Rolf for an interview at the end of his intensive visit, which also focused on the Swede’s specialty of orthopedic medicine. Prof. Rolf has supported the creation of a sports medicine program at Chinese University of Hong Kong.
Clearly he’s not afraid of considering radical alternatives to traditional medical organizations. “My job is to lead in transitioning toward more ambulatory care programs. The traditional organization in Divisions and Departments like Orthopedics disappears. “Instead we are moving into themes and functions: the new focus where orthopedics together with other appropriate former departments will join is called ‘trauma and reparative medicine,’ but it is multidisciplinary.”
Citing Prof. Michael Porter’s value-based health care model (which he said is also being employed by the famed Cleveland Clinic in the United States), Prof. Rolf said, “We are reshaping the whole university hospital system. Former heads of departments and divisions must re-apply for the new jobs under one of seven themes or three functions. … Because of the huge interest in these new posts, sometimes people who have worked there for 30 years and lead their departments may not even qualify for an interview.”
And even if you get chosen, you are not guaranteed continued employment, he said: “Some officers [administrators] for each theme and functions come from business backgrounds to assist the medical staff. But they must re-apply for their jobs after one year – and face the best international competition for those jobs, it’s not at all guaranteed that they can continue. So they must be bold…”
But this patient orientated approach has advantages for patients, Prof. Rolf said. For example, instead of cancer patients having to visit a range of Departments for example first visiting radiology after seeing their GP, then going and waiting for attention in an oncology department elsewhere, then waiting for the lab results taken elsewhere before coming to the surgical department, “the doctors come to the patient. These functions must combine in an efficient and well organized flow from suspected diagnosis to completed and finalized treatment.”
A range of advanced surgical and medical treatments can now be applied as ambulatory care in highly profiled day cases surgical and medical centers within the hospital. Laparoscopic surgery is an example of one area that has transitioned to mostly outpatient now. After their surgical procedures, patients may, if not being able to go directly home as a majority will do, settle into a nearby “hotel” – either a real one, or a converted ward space with a nurse manager and a bell in case of trouble.
Prof. Rolf said that this requires better-informed patients throughout the convalescence as well as families who need to be able to recognize signs of trouble. But it’s worth the extra patient education, as this system also keeps the remaining hospital resources available for patients who really need them.
The goal to be achieved by turning half of the Health Care into Ambulatory care is clearly to be able to offer fewer high-cost, full-service hospital beds which require the multidisciplinary care of a University Hospital. “We are trying to see the basic steps in each procedure in an efficient way as when you would repair a car, even though this cannot be streamlined in the exact same way because each patient has individual and often multiple needs. You don’t want patients waiting around the hospital for follow-up exams to tell what they can detect themselves: is the incision red, do you have a fever to indicate infection? Patients must learn more about their own care by being more involved and informed by their physician or surgeon.” This will also increase the demands of doctors to be very transparent and open with what they offer, providing evidence based alternatives to their patients.
And when, for example, a child with cancer needs acute care, they don’t go to the ER to sit with everyone with every other problem. Instead, they go right to the ward that knows them from other treatments before this crisis – because under this new system of “themes,” the cancer area can better deliver acute care formerly done by ER generalists.
Prof. Rolf said this reorganization is responsive to patients, but also to politicians and health economists. Since Sweden’s hospitals are overwhelmingly public and supervised by different governmental agencies, the new value-based care theory looks at per-cost services as well as quality.
He said current approaches and outcome measurements can be as impractical as “when you have a broken bone and say you did a good surgery … but the patient still has a bad outcome.
“The screws might be in the right place, but this might not give the level of function appropriate for that patient. If it’s an older person, being able to walk is the goal; if a young athlete, different procedures are needed. One size does not fit all.”
Sweden’s medical system used to welcome everyone to every hospital, but this has proven impractical. In fact, Prof. Rolf says the only clients besides cancer patients who will enter one of the campuses of Karolinska University Hospital will come by ambulance or helicopter! The hospital’s other half will be more open, but the goal is to send most patients needing routine care to the six hospitals operated by the city of Stockholm. The remaining “highly profiled” units will increase both the volume of clients they help, and the quality of care given.
This specialization extends to doctors as well. Physicians will have to adapt to more specialized roles and jobs in their practice: they will see more patients with a narrower range of conditions. Prof. Rolf spoke of inclusion criteria according to “best praxis” from evidence-based medicine using international benchmarking. The outcome measures will be clear from the start: “We have transformed surgery, and can operate at almost double the volume with more effective results.”
This involves challenging existing medical hierarchies and divisions of labor – with more teaching and clinical research in general hospitals.
Prof. Rolf criticized the narrow use of current measures of academic clinical medicine to be restricted asnumbers of papers, journal rankings and citations. He said this has lead to a system where “the most common clinical problems are the least researched. Many papers are irrelevant to patient care, because they look for limited areas that may not be clinically relevant.
In the new organization Karolinska University Hospital aims to integrate clinical practice, research and education much more within and between Themes and Functions, in order to make it truly relevant for the patients we treat.
“For example, stem cells have been a hot topic for 20 years — but how many patients have been helped by this research?” Referring to Mc Masters University and Professor Mohit Bhandari et al who has shown that “simple questions that are globally important” and “very high volumes of patients” often provides a better evidence base for best praxis than smaller clinical trials even though perfectly executed. So this means we have to organize us in a way where we can match those quality measures when we conduct an international bench marking on the care quality we provide in the future.
Karolinska University Hospital will publish its outcome measures online, with “quality outcome measures per patient flow” as the overarching goal. Other relative outcome measures will address specific patient groups, he said.
“Every patient wants 100% return to function, but if you tell someone this will take two years, it may not be very helpful. Two years is not a long time for a young patient, but for a fragile elder it’s a very long time to live with recovery.”
The new technologies of M-health (health applications using mobile phones) can help patients take more responsibility for their care as well by staying in touch with Health care providers from home.
“Quality assurance hasn’t worked, because it simply hasn’t been done,” he said. “We currently as most other Health Care providers around the world have many different databases in the hospital – and they don’t always interconnect.” Instead, a longer-term perspective can encourage patients to check in from home, and send tests or readings for follow-up by specialists at a distance.
The solution is “to have IT people and economists closer to each care unit. Then they will see what is needed, and medical staff and IT responsible can learn to communicate in a way that we get better transparency and more comprehensive baseline data.”
“It helps that we have national identity numbers so we can track patients between institutions,” Prof. Rolf said. It also helps that the technical counterpart of medical doctors are “civil engineers” who study for six years, including three years of a specific practical specialty. This means they are ready to work in industry or public-sector institutions from day one. His own son is pursuing this degree, while his daughter is pursuing medical school, a profession that enjoys a healthy female majority in Sweden.
Prof. Rolf said the Karolinska University Hospital in close relationship with Karolinska Institutet, his country’s largest medical university, has set a deadline to make this transformation by 2018 for the more specialized half of its teaching hospital. Then possibly successful parts of these ideas may be imported by five other teaching hospital campuses by 2020.
By that time, “We will have single rooms only in the wards — because these patients must be unwell enough to really need a room with full hospital care and the remaining patients will only go through their care at one of Karolinska University Hospitals Ambulatory Units.
Prof. Rolf’s other ideas also encompass biomedical engineering: “Why not put smart sensors in more surgical sites to monitor healing? We may be able do this now by closer communication and research between engineers and medical experts.” To advise the new College of Biomedical Engineering is a vote of confidence – and perhaps the beginning of some exciting changes for TMU’s affiliated hospitals.
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