Best Practices: Intermountain Healthcare has become a player in healthcare research
Intermountain Healthcare has figured prominently in the Utah healthcare field for decades. While operating as the Intermountain West’s largest provider of health services, Intermountain has, less publicly, become something of an R&D powerhouse.
“Intermountain is focused on delivering the best care to folks here in Utah,” says Dr. Mike Phillips, Intermountain’s chief of clinical and outreach services. “To do that, we need to innovate.”
In other words, Intermountain Healthcare isn’t content to merely adopt medical advances created by others. “The research footprint has always been there but it’s always been small,” says Dr. Raj Srivastava, assistant vice president of research at Intermountain. Over the past decade, that footprint has expanded considerably.
Fighting cancer with genomics
Phillips says the genomics program developed by Intermountain Healthcare is “best in class.” Unlike, say, the genomics research done at the University of Utah, Intermountain’s research is less about scientific breakthrough and more about “delivering precision healthcare.” While its research may result in the advancement of scientific understanding of genomics, Intermountain ultimately wants to “study best evidence-based care and generate a care process model to track outcomes,” says Phillips.
Intermountain Healthcare spun off Navican Precision Cancer Care in response to a care-based problem. Dr. Lincoln Nadauld—at the time a researcher at Stanford, now an Intermountain employee and advisor at Navican—was concerned over patients’ lack of response to their cancer treatments. Srivastava recounts how many patients were getting “course after course of changing treatments” to little or no effect. Or to negative effect, considering the side effects of many oncological therapies.
Intermountain Healthcare partnered with Nadauld and a team of researchers in a 2013 study that ran for two years. After assembling a board of international tumor experts, Nadauld et al looked at patients who had failed advanced therapies, says Srivastava. The study’s outcome “revealed that precision medicine treatment can lengthen survival in advanced cancer patients—and do so without increasing costs,” according to an Intermountain press statement about the study.
At the core of the study was an extensive genomics mapping project. Half of the study’s participants received genomic testing and targeted therapy, while the other half—the control group— received “standard chemotherapy … or best supportive care” (study abstract). Of the former group, Phillips says, “the point that cannot be overemphasized” is that by “developing a precision genomic footprint” of each of these patients, the researchers were able to identify “the specific therapy that will work for them.”
Outcomes were remarkable. “Patients tended to live twice as long,” in the precision care group, says Srivastava, while therapies “cost the same or in some cases even less.” According to the study abstract, “per patient charges per week were $4,665 in the precision treatment group and $5,000 in the control group.” Meanwhile, “the average progression-free survival was 22.9 weeks for the precision medicine group and 12.0 weeks for the control group.”
Thus was born Navican. “We looked at the results,” Phillips recalls, “and said to ourselves, ‘if we can do this for the patients in our system, should we not develop this for others as well?’.”
Navican’s TheraMap solution uses genomics and clinical testing to offer therapy matching for oncologists and their patients. And fast. Normally, the therapies used in the study would require lengthy “special use permissions.” Unacceptable, says Phillips. “Expert care should happen in days, not months.” Armed with the results of a patient’s genetic footprint, oncologists “are able to fast-track the indicated therapy.”
And many targeted treatments are kinder that traditional chemo. “Often, these therapies are not intravenous,” says Srivastava. “Patients experience a higher quality of life.”
Efficiencies and outcomes
In partnership with healthcare services firm Oxeon, Intermountain Healthcare launched Empiric Health “to understand how supplies are used in the OR, and to train physicians and nurses on using supplies in the OR,” says Phillips. Empiric’s model was based on a previous Intermountain program called ProComp. The program has saved Intermountain more than $90 million so far as a result of supply savings, length-of-stay reductions and other operational efficiencies.
With its proprietary analytics and workflow-optimization tools, Empiric offers a “data-driven dialogue with providers” with the goal to “uncover variation in cost, quality and outcomes.” By using Empiric’s proprietary analytics framework, clinicians can make evidence-based care decisions that cut expenses “while improving clinical quality and patient outcomes,” per Empiric’s website.
Given the program’s success at Intermountain Healthcare, says Phillips, “We wanted to make this available to other institutions.”
But wait—there’s more! Intermountain has also made advances in antibiotics research. Or, more precisely, the overuse of antibiotics. Responding to the threat of so-called superbugs—bacteria that evolve a resistance to antibiotics due to prolonged exposure—Intermountain has been researching antibiotics for years. In 2013, Dr. Eddie Stenehjem, the medical director of antimicrobial stewardship, and a team of researchers launched “the largest study of its kind” to examine antibiotic use and pinpoint strategies to optimize antibiotic prescribing.
Antibiotic stewardship is a hot topic in the medical community. According to The Society for Healthcare Epidemiology of America (SHEA), the term “refers to a set of coordinated strategies to improve the use of antimicrobial medications.” Awareness reached a critical point in 2014 when the Obama administration announced “a comprehensive set of new federal actions to combat the rise of antibiotic-resistant bacteria,” according to an Intermountain statement. In 2015, the White House hosted a one-day antibiotic stewardship forum to bring together government and healthcare stakeholders. Intermountain Healthcare was present, represented by Dr. Eddie Stenehjem.
Statistically-speaking, the more remote a health clinic, the higher the occurrence of antibiotic over-prescription. Large urban hospitals “generally have the resources to implement antibiotic stewardship programs,” while smaller, rural hospitals “lack adequate infectious disease providers,” and consequently “have varying rates of antibiotic utilization.” Translation: understaffed and under-funded clinics have trouble tracking and regulating the amount of antibiotics prescribed.
In the absence of data-driven policies, an overworked provider is likely to default to the path of least resistance: prescribe the antibiotic and move on to the next patient. The alternative would require the doc to explain to a patient why an antibiotic may not be advisable. Usually, the patient just wants to get the prescription and go home. Denying the patient’s wish takes considerably more mental and emotional effort than obliging.
Stenehjem headed a study that found similar antibiotics use rates in small and large hospitals, and that small community hospitals weren’t using antibiotic stewardship programs. The study, published in PubMed in August 2017, describes the barriers the small hospitals encounter when implementing an antibiotic stewardship team. In the report, Stenehjem, et al “propose potential solutions that tailor stewardship activities to the needs of the facility and the resources typically available.”
From one doc to another
Dr. Raj Srivastava tells how Stenehjam’s solutions included a telemedicine initiative that paired rural providers with urban programs. Via teleconference technologies, small hospitals could participate in antibiotic stewardship awareness and protocols offered by large facilities.
The program subsequently expanded beyond antibiotics. “Dr. Stenehjam started with antibiotics, Srivastava says, “and then his findings helped Intermountain just as they were starting to invest in telemedicine.”
“We’re running a virtual hospital,” adds Phillips. “We have ICU docs here [in urban centers] that provide expert care to remote clinics.” Often, for fairly severe cases that would previously have required transport to a major facility, “the patient is able to stay locally and get the same level of treatment” because the big-city specialist is only a screen away. “Small hospitals see a decrease in mortality, and cost of care is dropped.”
In expanding its research and development, Intermountain Healthcare isn’t trying to compete with other research facilities. Whereas, Srivastava says, other organizations might be “doing research for research’s sake,” Intermountain performs research with “a mandate to be a model healthcare system.”
To that end, “we focus on point-of-care delivery,” says Phillips. “It’s later in the research process than other research institutions.” In other words, find a problem with the way healthcare is delivered, then find the solution. “We’re all about providing better care,” he concludes, “because that’s what matters most to the patient.”