Dr. William Stead is Associate Vice Chancellor for Health Affairs and Chief Strategy Officer at Vanderbilt University Medical Center (VUMC). He received his B.A., M.D., and residency training in Internal Medicine and Nephrology from Duke University. He went on to help develop The Medical Record (TMR), one of the first practical electronic medical record systems and also helped Duke build one of the first patient-centered hospital information systems (IBM’s PCS/ADS). He moved to VUMC in 1991 and has since guided the development of the Department of Biomedical Informatics, Eskind Biomedical Library, Center for Better Health, and operational units, providing information technology infrastructure to support education, research and health care programs throughout the Medical Center. Dr. Stead is a Founding Fellow of both the American College of Medical Informatics and the American Institute for Engineering in Biology and Medicine, amongst serving many other roles. Lastly, in addition to his academic and advisory responsibilities, Dr. Stead is a Director of HealthStream.
Can you shed some light onto your background as well as how you got interested in medicine/Nephrology in the first place?
My father was chairman of medicine at Duke University, and I grew up on the Duke campus surrounded by an academic medical environment. As an undergraduate at Duke, I became interested in computers, and had the chance to work on a project looking at whether you could do things with a digital computer in an ICU or an operating room that you couldn’t do with an analog computer. That project ultimately turned into a cardiovascular databank where the computer was used to tie processes and outcomes together.
I then went to Duke Medical School, and started there in 1970, in what was then the Duke new curriculum. What Duke did was compress the two basic science years into the first year, compress the required clinical clerkships into the second year, freeing up the full third year for research, and leaving the fourth year for clinical electives. During my 3rd year, I worked in what you would now call a medical informatics lab. I took part of that 3rd year before my first year and arranged to continue the work through breaks to graduate in 3 years instead of four. I then completed internship and one year of residency in Internal Medicine, followed by two years of nephrology fellowship, one of which was back in the medical informatics lab. It was seven years between entry to medical school and appointment to the Duke Nephrology faculty.
I picked Nephrology because of Ike Robinson who was interested in how computing could affect nephrology. Dr. Robinson was division chief and he let me do the research year of my fellowship in my first year. At that time, I built one of the first computer-based patient record systems. I used that system when I went onto my clinical nephrology rotations.
When I joined Duke’s faculty I was given responsibility over one of their Dialysis units, using it as a test bed for the EHR. Ike Robinson came to Vanderbilt in 1981 as Vice Chancellor for Health Affairs. In 1990, he reconnected with me over a Duke Alumni Breakfast event and asked me to come over to Vanderbilt where I could set up the informatics work how I wanted it set up.
What are some changes would you like to see in medical education today?
I think what Vanderbilt is now doing with Curriculum 2.0 is a great model for the future of medical education. Curriculum 2.0 begins a shift from a four year sequence of courses where you learn a lot of facts “just-in case” to a system of learning built around individualized learning plans. Our goal is to ultimately build a competency gated curriculum instead of a time in place gated one.
Curriculum 2.0 is the closest example of that at this juncture, but it is only part of the way there. It begins with a first year that shows the entering student what the knowledge space looks like – both breadth, the many biomedical science, social science, engineering, etc disciplines related to health and healthcare – and depth, examples of the detail of a discipline. The second year provides a foundation of care though disciplinary clerkships with basic science taught in the clinical context to allow students to really see how science and care work together. The individual learning plans and the immersion courses of the last two years are great steps in the right direction.
Dr. Bonnie Miller and I are working very hard on the next step. We need to figure out how to convert the clinical training environment into one that, at least for non-procedural areas, involves inter-professional and multi-generational learning working teams. This will allow our students and our faculty to better understand how a team brings the necessary expertise to bear, to directly connect learning and health system outcomes, and to allow more personalized treatment and care of patients.
Going forward, what role do you believe informatics will have in transforming healthcare and education?
At their heart, the current education and care models are built around the individual brain of the clinician, and most of what we have done with technology is to decrease the barriers to an individual locating information and communicating with other people. Cognitive processing continues to be largely isolated to individual brains. Instead we need to use technology to allow us to think as a system of brains by augmenting person to person (low bandwidth) communication with each person having their own lens providing a personalized view into a common fact base (high bandwidth).
We need a systems approach to care, where standard processes and technology make it easy to do the right thing. We need humans to focus on our unique skills of sensing, understanding patient’s values, recognizing patterns, and applying judgments while being supported by standard processes and just-in-time access to facts as they are needed.
Also, we know that only 10% of premature mortality in the US is the result of shortfalls in healthcare. This includes everything from lack of access and to medical errors. The rest relates to social and behavioral determinants, environmental factors, and genetics, all of which are largely outside of the domain of healthcare. We are on the cusp of informatics and consumer technology to allow development of individual life management aids to help people deal with the problems they are facing from financial management to stress to health. They will own the data and it will provide a way for context sensitive trends to be detected, and for advice to be given directly to people, while allowing them to connect to healthcare as needed.
What do you believe is necessary to promote adoption of new technologies in the healthcare system?
The first stage of meaningful use and the related Medicare and Medicaid incentives were useful because they got people to use EHR technology. Unfortunately, the country pressed on to stages 2 and 3 without pausing to do the work re-design to get an optimal interaction among the people, processes and technologies. We need to work on getting proper alignment between them now.
The second thing that needs to be done is to build interoperability into the technology. Today, people build systems to automate one healthcare facility or another. Each system has its own standards and interfaces, but unfortunately they don’t often speak the same language. It is like taking an envelope from the US to China and standardizing the address but not interpreting the language.
There needs to be work in adding social and behavioral determinants to health records. The IOM has recommended including the answers to 25 standard questions in every EHR as a psycho-social vital sign. Standardizing on a set of scientifically validated questions is an example of building-in interoperability. You will not get consistent information if you allow people to ask various questions and then try to convert it to a standard code set afterwards.
Do you have any final thoughts regarding the Medical profession as a whole?
I think as a profession, we have to get back to our roots. I went to medical school from 1970-1973 and I was told to care for and about the patient and not their disease back then. Since then, we have totally lost sight of that. There are exceptions of course, but most of the superb physicians we have care for just their part of the person, and don’t often think about the best care for the patient as a whole.
Physicians also need to learn to become part of the team. There are times of course that the physician will be leading the team, but they should be equally comfortable in leading and serving as part of the greater team.