WHILE A GRADUATE STUDENT STUDYING IN CHINA, Molly J. Coye was riveted by the stories she heard of the public-health campaigns at the end of World War II to eradicate infectious illnesses that were tormenting the lives of rural people. Those lessons were so stirring for the young scholar that, after receiving her master’s degree in Asian studies at Stanford University, she went on to earn her M.D. and M.P.H. degrees from Johns Hopkins University. “I was inspired to study medicine in order to improve community health,” she says.
Her career since then has taken her around the country, giving her a breadth of experience that overlaps academia, government and the private sector. She served as commissioner of public health for the State of New Jersey and director of health services of the California Department of Health Services, head of the Division of Public Health Practice at Johns Hopkins School of Hygiene and Public Health, and has founded and served on the boards of several prominent healthcare-related companies.
Now she is at UCLA, where she is chief innovation officer for UCLA Health System and heads the new UCLA Innovates Healthcare initiative. UCLA Medicine spoke with Dr. Coye about innovation and her goals for UCLA.
Your role as chief innovative officer for UCLA Health System is an unusual position in academic medicine. There aren’t many of you in the country.
Molly J. Coye: We’re still a rare breed, but I am very excited about it. Dr. Washington (A. Eugene Washington, M.D., M.Sc., vice chancellor for UCLA Health Sciences and dean of the David Geffen School of Medicine at UCLA) and the leadership of UCLA Health System invited me to come to UCLA to work with them on the transformations of the healthcare-delivery system that we will need for the future. UCLA has a tremendous history of accomplishment in research and clinical excellence in individual specialties and primary care, but the health system itself has only begun to make major improvements in patient experience, care coordination and costs in the last few years. The experience for patients and families has reached record levels of satisfaction in our hospitals, and now we are tackling the challenges of the outpatient settings. We know there are improvements to be made in wait times for appointments, coordinating referrals more smoothly, and other processes that often frustrate patients and referring physicians. We will continue to support clinical excellence in the care we deliver, but reinforce this approach with a better experience.
What will you be focusing on?
MJC: We will be looking for ways to improve care delivery that will make a significant difference, really move the needle, in the next three-to-five years. Any significant change takes that long to spread within an organization. So our focus will be primarily on innovations that are already proven to have great benefit but have not yet been widely adopted. The success of innovation has less to do with dreaming up new ideas than with our seriousness of intent and our ability to actually implement innovations broadly, to take them to scale. Many powerful innovations have been generated by researchers or clinicians at UCLA or other health systems and shown to be effective, but they languished after their initial proof. We want to turn this around. We know from quality and performance-excellence programs here at UCLA that we’re capable of realizing tremendous change in a relatively short period of time; we just have to use those change-management skills to drive major transformations.
Another area of focus will be health reform. The recent federal health-reform legislation established Accountable Care Organizations (ACO). ACOs are a little like unicorns: Everybody can describe one, yet nobody’s seen one. But we believe that these ACOs will present a great opportunity for UCLA to parlay its established expertise in population-health management into a rapidly growing service for a larger share of L.A.’s population. Our experience over the past two decades of managing populations through HMOs gives us skills that most academic medical centers don’t have. We know how to coordinate care. We know how to figure out what the costs are and try to manage them appropriately. We’ve been doing it for quite a while, and we’ve been doing it very well.
When we speak of innovation and a culture of innovation, what are we talking about in the context of an academic medical center?
MJC: Traditionally, people think of innovation as simply inventing something new, and there is no place on Earth better for that than a large academic center. But today we understand that true innovation involves being able to actually deploy that new service or technology broadly across the entire set of clinical services or populations that could benefit from this change. At UCLA, we will start with the need for transformation – what do patients, care providers, government and employers, all the different stakeholders, want in a transformed healthcare system – and then look for the innovations that could actually realize those hopes. So it’s a different approach – sort of a question of the cart and the horse – that is generally now referred to as “design-driven” innovation. We start with the design of the system that we need, and then we look for the tools to get there. Part of what will distinguish us in the future is our ability to discern which innovations will most effectively move us forward, and then to effectively implement them.
You have worked on healthcare issues in government, the private sector and academia. Why is now the right time for you to be here, at UCLA, and why is UCLA the right place for you to be at this time?
MJC: Sometimes you are offered an opportunity to use all the skills you have acquired over your career to help realize the deepest aspirations we have for healthcare. UCLA is extraordinary in the excellence and breadth and depth of its clinical care and its influence across the country. I believe that we have a real opportunity to distinguish ourselves now for the innovations we bring to care delivery and to set patterns that many other centers will want to follow. More specifically, for the last 10 years, I led a technology-forecasting organization that researched the impact of emerging medical and information technologies to identify technologies that could support the changes in healthcare that we need. Now I have the opportunity to draw on that knowledge and to work with an organization that is well along the path to transformation.
The focus throughout your career has been on addressing the ills of healthcare. What is ailing healthcare?
MJC: I think the fundamental flaw is that we have not listened enough to patients. When we listen to patients and to patients’ families, as we have learned to do at UCLA, and we have respect for their concerns and needs, we can make the care we deliver so much more effective. We also are beginning to recognize that our clinical expertise – our ability to invent new diagnostic and therapeutic modalities – often exceeds our ability to deliver them appropriately to the patients who need them and to support the patients in doing their share of work toward recovery. Consider, for example, a patient who has had a very successful operation, but in the following weeks doesn’t care for herself appropriately and winds up back in the hospital. Or the kind of case we are focused on now – patients with congestive heart failure (CHF) who are admitted, treated and discharged, only to bounce back three months later because there was no support to make sure that the patient understood his or her meds or had a follow-up appointment with a physician. Roughly half of all the CHF patients who are readmitted have not seen a physician at all since their discharge. In such situations, we have to acknowledge that our care is not as effective as it ought to be.
What could we be doing better in that regard?
MJC: We are developing coordinated-care systems that allow us to track patients and support them throughout their care and at home. Just a few blocks away from the Westwood campus, the Veterans Administration does this tracking with a basic in-home monitoring system. When their patients with diabetes or CHF or COPD leave the hospital, they are followed into the home with a very simple device that monitors their blood pressure, weight or other parameters. Not only does this device monitor their health, it also gives the patient a way to communicate back to his or her healthcare provider if he or she has a concern. And it delivers health education to the patient about his or her diagnosis, allowing educators and nurses and social workers to provide coaching and oversight. Using this device, the VA has cut emergency visits and readmissions to the hospital by one-third to one-half for more than 30 chronic conditions. UCLA is piloting this approach. It’s very exciting, and UCLA is leading a multi-campus trial to see how this could be deployed for our patients with CHF. We are hoping that we’ll be able to use it quite broadly to support seniors in living independently in the community as well. So here is an example of a service, combined with a technology, that doesn’t interfere with the medical management of a patient, but meets the patient’s needs and drives down the cost and the morbidity associated with the condition.
Healthcare is an enormous ship, and big ships don’t change course quickly. What is required to help nudge this huge ship in the right direction?
MJC: We need to act as a system, which is true locally – at UCLA – and nationally. As long as every individual clinician makes unilateral decisions about his or her approach to care delivery, some of those decisions will be excellent, and some will present problems for patient access and effective care. And when a new idea comes along that’s very effective, it might be adopted by one or two departments and not by the rest. Nationally, the Institute of Medicine estimates that the time lag between proof and adoption of effective new modes of care is approximately 17 years. We’re seeing this timeframe start to change around the country at different speeds. Some places have very rapidly moved to function as an integrated system, and they have been very effective in making their clinical care consistent and their patients more satisfied and healthier. Other places are much slower. Organizational change is very, very tough. And it is only with the collaborative leadership of all the parts of a complex institution like UCLA Health System that we will be able to move steadily forward, make the changes that our patients and our clinicians need and put UCLA at the forefront of healthcare transformation.
What is a key area that is ripe for the kind of changes you envision?
MJC: At UCLA, the most exciting event over the next few years will be implementing the electronic medical record – UCLA’s CareConnect. It will be, of course, frustrating in the first couple of weeks when we actually roll it out, and there are always glitches, but it is a real transformation. It doesn’t sound exciting, but the changes that this system will bring are absolutely profound. It will allow care coordination among the physicians, nurses, and everyone involved in the care of a patient – from primary care all the way through the most advanced procedures he or she undergo here, and then back into the community – all of it will be tracked and coordinated.
Another thing we can do with this system is to integrate clinical decision support into the medical record. For example, what laboratory science and pathology and radiology together know about appropriate diagnostic approaches can be integrated into the electronic record, so that a primary-care provider will receive a suggestion for a test or an imaging study at just the right moment. Research shows that that this capability can create a substantial improvement.
And we will also be able to track the results of what we’re doing. Right now, that process is done infrequently and principally through individual outcome studies, which may take years and can cost hundreds of thousands of dollars. With a clinical-data repository, which is essentially the sum of all the information on all the patients whom we see, we will be able to vastly expand our research at far less expense and with much larger numbers. We will truly be a “learning system of care.”