Dzau looks back on tenure at Duke

Jun. 09, 2014 @ 07:05 PM

Dr. Victor Dzau is stepping down June 30 as president and CEO of the Duke University Health System and as Duke University’s chancellor for health affairs.
After nearly a decade at Duke, Dzau will begin July 1 in his new role as president of the Institute of Medicine. The nonprofit, which is part of the National Academies, provides recommendations and analysis on health issues.
Under his leadership, Duke Medicine added the new Duke Cancer Center facility, the Duke Medicine Pavilion, the Trent Semans Center for Health Education, a new Duke University School of Nursing facility, and it has also launched construction on a new Duke Eye Center building.
In addition, the system also launched a new electronic health record system and started an Accountable Care Organization.
Dzau plans to make Durham his permanent home although he’s taking a job at the Washington D.C.-based nonprofit institute.
Dzau recently sat down with The Herald-Sun to talk about the physical transformation of the health system, the Affordable Care Act and other topics.

Q: In your 10 years as president and CEO of the Durham University Health System, did you accomplish all that you set out to do?
A: I think it’s hard for one to say that one set out to a do a set of things, and were they accomplished? I think it’s probably more important to say: Where is the institution today, compared to 10 years ago? And my feeling is that if I were to think about this institution, first I want to give credit for everyone who’s worked with me. And the success and achievement of this institution is a reflection of the people at Duke Medicine, rather than myself.
That being said, I would say that patient-centered care is one thing that we are very proud of. You know, this is a central focus for us for the last several years. As you recall  ... we had a series of medical errors before I came, and since I was here. And so it was very important for our organization to be totally fixed on making sure that the care for our patients has quality and it’s all about the patients and not about doctors and nurses. So I think that’s one. And if you look at today, I would say by all measures, the quality of care, the quality of patient experience, the outcomes in terms of safety, I think we are really a terrific organization from that viewpoint.
What’s really important for us is making sure that we are a contributor to the health of Durham and the health of the Triangle. When you talk about patient-centered care, you obviously talk about care, but I think at the end of the day it’s about how healthy is your community and how do we play a vital role in enhancing the health of the community? So over the year we’ve not only reached well out to the community, deeply in the community, in terms of developing programs, hospital-based clinics, community clinics and many other patient programs, home programs etc., we’ve been even more engaged I believe in looking at what are the socio-economic issues in the Durham community and the Triangle and how can we as Duke Medicine play a role to improve those socio-economic conditions which we call “social determinants of health” that improves the health of the community. So I would say those are really important issues for us: Community, commitment, and improvement of health, and of course improving health care by putting patients at the center.

Q: To switch gears slightly, the physical landscape of the health system has changed on your watch and it continues to change with the Duke Eye Center construction. Can you talk about the impact of the building projects that have been completed and also started during your tenure, and what impact those have on patient care and on the system’s finances?
A: First of all I think, whatever we do, we always think about putting the patient first. So in many of these facilities we really think about how we can serve our patients better. One example: the Cancer Center. Have you visited the Cancer Center? Oh you have to. You will see that it’s built all for the patients. The dollars we have gathered from patient care, we invest right into our facilities, our people, our technology to improve patient care. So if you look at the Cancer Center, you walk in, you find it’s a most welcoming place. On the first floor, there are no clinics. There is a meditation room, there is a patient library, there’s all these amenities for a patient to feel at home. And if you look at the Cancer Center, the way it’s structured, it’s all around the patient. It’s multidisciplinary around the disease, and for example, on the fourth floor we have an infusion center that has a roof garden to let patients (go there) on a beautiful day like this (rather than) being cooped up in a little room getting an infusion. It really gets the kind of sense of the greater value.

Q: And what about the impact of these building projects on the system’s finances?
A: I was going to say that we have built the Duke Medical Pavilion because we recognized that we were running out of capacity and our operating rooms needed to be better, we needed a better ICU for our patients, and we’ve done, you know, as you said, the Eye Center and others. All to improve patient care. When we embarked on these projects, we were very careful to look at the finances, how to finance these projects. This was back in 2007, a year even earlier than that, we were planning. And then of course throughout the years with changing economic situations, etc, we’ve always gone back to revisit this deeply to be sure that we are not putting constraints on the organization’s finances and ultimately realize the vision of caring for the patient. And I will say very proudly today to you that actually we’ve met all those goals. The way we approached it was a combination of, you know, cash flow, philanthropy and also borrowing, through issue of bonds. And today, I think we’re meeting a lot of our targets and, you know, Duke Medicine is pretty healthy financially despite all the changing environment. But in large part, it’s because our people are performing so well that even as we open up these news beds, we’re getting full because … there’s a lot of care that’s needed and people are coming to Duke for care.

Q: The system has also implemented a new electronic record system – Epic -- and launched an Accountable Care Organization. Can you talk about the impact of those changes?
A: They are so important. I think we all recognize that to provide the best care for patients, you need an integrated information technology system of which the electronic health record is obviously a very important part, right? Because this way you can capture all the information of the patient made available to the providers and the patients, and make it available throughout the entire system so that, truly, we talk about patient getting the right care, at the right place at the right time. Also through Epic, we are able to connect with other systems that have Epic such has Novant and many others; now UNC just implemented (it). So I think the patients here in North Carolina are going to be well-served by having common electronic health records or at least interface between different organizations. Also it’s really a little bit more that electronic health record. It really is an entire information system that allows you to look at chart capture, laboratory testing, finances, work flow, decision-making. So when the provider logs on and looks at certain things they’re ordering, and confront certain conditions, they’re able to get the best of information from the computer to talk about what’s best care, right? … So it’s a phenomenal system that can help us really improve patient care. So I feel it’s absolutely necessary… they have meaningful use, and expect people to meet up to those expectations. Well we’ve met up to all those expectations and exceed them. We’re very proud of them.
That’s another big investment. But you know what? Investing in people, investing in facilities investing in (information technology) only makes us a better organization to serve the patients.
Now with regards to ACO – it’s really thinking about where health care is going. And there again, when you asked me the initial question, where we are? I think we’re very different than 10 years ago. Because 10 years ago, we didn’t have the Affordable Care Act, we didn’t have …the changing environment. I think we’re really well prepared by creating an ACO or the Medicare shared savings program. We begin to (look) at population health. We’ve always been very conscientious of community health, right? We’re always very conscientious of how to bring care to the community, and as I said earlier, how to improve health. This is one expression of that. Population health in terms of caring for the population by creating a program called an ACO. An ACO is an Accountable Care Organization and the way it works is, to be accountable for the health of the population it serves, and … to be accountable for the cost of the care of the population. So the idea would be to create provider-based physician, staff, providers working with the hospital, to look at a population of Medicare that we serve. So it goes beyond Duke. It actually should include community physicians and others who work with us to manage that population.

Q: To segue to the next question- What impact have you seen from the ACA on the system, what impact do you expect to see in the future and do you notice any specific changes since the launch of the health insurance exchange and the individual insurance mandate?
That’s a lot of questions.
I’m sorry.
Basically the Affordable Care Act – what impact have you seen?
A: I think a significant impact. I think we are a different organization today because we are preparing for, you know, a more affordable care. Right? Which is value-based care. We are preparing for a reduction in our costs. We are assuring the quality of the care that we give and we’re looking at a population. So when think about this, really what we’re looking about essentially is to say, how are we caring for patients the best way? And so we’ve undertaken in the last few years major initiatives called care redesign. How do we redesign the care for our patients which is better and less expensive? So we have teams of people looking at every single area to say, “Should we look at care differently around diabetes, around heart failure, around stroke, etc.?” And we are creating these things called care bundles, which puts together around the diagnosis, you know, everything that’s related to the patient care, and trying to see whether there’s a better way to care for patients by cutting down the cost. So these are very important. The Accountable Care Organization is part of that expression of what they call the care continuum -- moving from the hospital into the community or vice versa. So a patient is cared for not only in the hospital, but then they pass to physicians, and they actually follow them and make sure they’re getting the best care. The Affordable Care Act says if you readmit the patient after they’ve been discharged for heart failure … you get penalized. So obviously we’re putting a lot of effort into making sure that the care in the community is improved so they don’t come back to the hospital. That’s all good in my opinion. We’re taking down a lot of costs. We recognize of course that the future is making the care more affordable for our patients. So to do so, we have to reduce the cost of care at Duke. We recognize we are a world-class … organization, we tend to be a little more expensive, but we need to take the cost down. So we are right now, undergoing an initiative called “Transforming Our Future.” And (with) “Transforming Our Future,” we’re going to take $200 million of our fundamental cost out of our cost structure, and do that on a sustainable basis not just one time, but once we take it out, we’re going to keep it out. So we’re going through that right now. And the way we’re going through this, we’re going through the entire organization, getting everybody involved at different levels looking at what are the areas that, in fact, create expenses or cost of this organization and each area we look very thoughtfully, very carefully, how to do that. So that’s why we’re not saying we’re going to lay off so many people, we’re going to reduce work size. What we want to do is say, what’s the best way for care for our patients, how do we design care, and with that model, we do we decide how many people we need for each area.
As you know the entire country, if not (people) globally, are all looking at how do we create affordable care at great quality and provide access. So it’s access, affordability and cost of care. So part of the whole issue of what public wants is, to bend the cost curve. If you read your paper, every day, if you look at television ads, everybody is obsessed, if not, shall we say, really, really worried about whether we can afford the care that we’re going to have in the future. So we feel it’s our obligation and our responsibility to take the cost down. So I would say it’s not necessarily the word -- what did you say again? -- I think it’s really the right thing do is to look at whether there’s any waste, whether there’s any redundancy, whether there’s any efficiency, and how can we provide even better care at low cost. That’s what everybody wants. And how can we provide even better care at low cost? That’s what everybody wants, and that’s why we have a responsibility of doing that.

Q: Does the Affordable Care Act put particular cost pressure on the system?
A: Oh yes very much so. I think the Affordable Care Act starts with the value-based purchasing. I talked about readmissions. They started moving into the whole idea of how to take the cost down by reducing reimbursements in Medicare and different areas. So we’re already seeing reimbursement reducing. So if you have less reimbursement, you have the same cost, many organizations face a significant financial problem. I think we’ve been more prepared and more proactive in thinking about how to take that cost down so we can actually in parallel in reimbursement drops, we’re actually well prepared. And the Affordable Care Act also talks about eventually keeping patients out of the hospital so that you don’t have to use as much hospital cost and facilities. We’re doing the same thing. So by better internally looking at what’s the best way to make efficiencies, it’s good for everybody. Now, yes the health exchange, I think that’s playing an important role certainly in a conceptual way because to begin with the health exchange yes to the patients, you can go to a public site and buy your own insurance. And you can look at, you know, Platinum, Silver, Bronze. You can choose what you want. And so in many ways, patients are becoming consumers and are more cost-conscious and because they may buy products which in fact have a lower cost, we need to take the cost down to make the cost of the care more affordable.
But there are some consequences of the health exchange. Because if the patient is not educated, they try to buy the lowest-cost (plan) possible but they have high-deductibles that’s going to be a problem for them at some point. So I think there’s a different issue about educating the public. But our job is to not only help them, to provide the care, but to provide the most affordable care for our patients.

Q: I also had a question about changes in the structure of systems. I’ve (read about) a trend of systems buying or absorbing more private practices. Is that something that Duke has done and what is driving that trend?
A: I think we’ve been a lot more thoughtful than others. I know that many other systems are buying hospitals and practices. As you notice, we’re not in the newspaper that often in that area. … I would say that for about five, six years we’re building primary care and now we’ve grown to probably the largest primary care network -- because we think it’s important – in North Carolina. We have some 300 providers in primary care throughout the Triangle. We’ve been expanding more organically our own faculty and they are going out there to practice in Wake County and many other areas. People have joined us for sure, but we’re not waving the flag out there to say we’re buying practices. When it makes sense, we welcome them because we want to obviously have a larger network and have patients being able to access practices in the community. We’re not going out there just to buy practices, you know, as some people are doing to expand their size. We’re doing it very thoughtfully. Likewise with the hospital. We have been very cautious about that too. You’ve probably read about our Lifepoint relationship called Duke Lifepoint. We’ve created a joint venture so that this way we’re not just out there using Duke’s capital only we are in partnership with another one sensibly looking at what are those community hospitals that we can bring capital to help them improve their current financial structure and invest and Duke’s role is to bring the quality of care and the clinical education. And we’ve been very successful at doing that.

Q: Are there any specific numbers of practice that duke has absorbed?
A: I don’t know that number. I know that we have expanded our faculty, our provider size quite substantially. But I can’t tell you how many practices we absorbed. We have been expanding on the other hand, as I said, in a very cautious way.

Q: What is driving that trend and what does Duke have to benefit from it?
A: If you remember, I said this really important thing about population health. And certainly in the new environment, if you want to care for a large population, which is what the Affordable Care Act is moving toward, you need a large network of physicians, right? You know, so we’ve gone away from the idea of a medical center to a system. “Center” means people come to you, “system and network” is you reach out, you know, as a fully integrated entity toward the community. So, obviously, we recognize that we’re going to end up serving the population, we need to be bigger we need to be closer to the patients and that’s what we’ve’ done.

Q: What changes do you see coming for health care overall? You mentioned some of the changes you’ve seen specifically at Duke, but with the Affordable Care Act, with the (addition) of primary care into systems, do you see any big impact to health care going forward?
A: I think the intention of the Affordable Care Act, the intentions are good, and if we’re able to realize the Affordable Care Act totally as it’s intended, you will see a lot more people being covered. You will see costs of care going down, and you will see the quality being at least equal, not going up. That’s the intent of this. And the conversation you had I have just been having … we are moving that way. Not easily. It’s not easy to implement all these changes. Sometimes the journey is more challenging, but it’s a great journey. And so, I would say if we fully realize this, more North Carolinians are going to get more care at a lot more affordable level at good quality. Now you know not everything’s well within the control of people like myself, or Duke, or even within the federal government. The state plays a big role, like Medicaid expansion, the health exchange. Those things are still variables that need to be sorted out in this state. But I do think that given the aging population, given the expansion of health coverage, and possibly depending on the policy (for) Medicaid… we are going to see a lot more patients being taken care of. In Massachusetts, when they went to Massachusetts Care, or “Romney Care” as they call it, they found a huge surge of patients that came out that didn’t have insurance before that wanted see doctors. That’s why we’re building a primary care network.

Q: Any other big changes that you expect for health care overall…?
A: I think a very important part, which I’ve been very proud of Duke taking leadership and very important for places like Duke or UNC or Wake Forest is the whole idea of the academic organizations being able to bring innovation to health care. Because you know, as academic organizations we’ve always been thinking about research transition and innovation. We always say, what’s the next best thing? I think channeling our energy in the academic side toward health innovation. Traditionally, you think about discovery of molecules getting the Nobel Prize. That’s important, too. And Duke’s got its share of Nobel Prize …but putting our energies into think about how we can improve care is really important. … And as you know about a year ago, I launched an institute called Health Innovation to try to make the whole place think about better ways to think about patients to try to bring together this whole large amount information that we have now through electronic health records and the use the analytic capabilities to look at data, big data, to determine how we can be a learning health care system, and try to use the new technology of digital technology sensors and others to manage patients better in the community in their homes and so they don’t have to use our facilities as much. I think that’s all good stuff and I think that has a very important part of the future of health care.

Q: What’s the most exciting research going on in medicine right now, and what do you expect to be the most transformative?
A: I was just saying that what’s exciting to me is truly health innovation. Taking a look at health and health care and to say, how do we make it better? So that’s a focus. And you know, for example, at Duke, we have Durham Health Innovation which is an initiative that we will work with the Department of Health and others bringing in geographic information systems, mapping the patient, the community, where do they live, what are the economic factors, what’s the closest clinic where’s the closest grocery store, the closest barber shop to work together to improve the health. I’m also very passionate about education. As you know, I happen to think that education is the way of the future. It should be a solution for most of our societal problems, whether it’s jobs, and as you know education greatly influences health. Some people will say, well you know, when we look at the environment and people don’t have access to health, and very early they don’t have good health habits they don’t have money they don’t have jobs, well you know if you have education particularly early education, early childhood, that’s going to make a huge difference in mental health, obesity, etc. As you know, I’ve been very involved with City of Medicine Academy; we’ve been very proud of this. This year’s graduation rate was 100 percent, and as you know I’ve been leading the task force called Made in Durham and we’re still working with the city and county to get the budget. But I personally am leading the private sector side and my wife and I personally have given a donation to help (get it) going because I personally believe this community, when you can get everybody together to work for the right thing it can be transformational. So you asked me what’s transformational, it’s actually getting the right people together to think about how to do things differently and to concentrate on the good of the community which is education, health, jobs … and I think the only way to address it is if everybody works together for the same reason. And so for me, the 10 years has been a great learning experience for me to understand community. To understand what it takes. And coming in as a doctor and a provider of care, I think about it as, well we create more clinics like Lyon Park, Walltown, Holton, we’ll be delivering more care. If we think about putting clinics in the schools -- we’ll have young people accessing health care. We’ll think about providing more programs at people’s home we’ll be able to take better care of them. But I’ve learned that’s not enough. What we need to do is think about how to work with everybody, whether it’s schools, governments, faith-based organizations, employers together to address the issue. Not just about care but health, economy, and education and the good of the community. So I think that’s to me, if you asked me what I feel kind of a very proud moment I think it’s the recognition that we’re an important part of the community. We work together with them.

Q: What will be your priorities in your role as president of the Institute of Medicine?
A: Well let me say just finishing up as you know, two weeks ago I was given the Order of the Long Leaf Pine. To me, it’s a great honor to be recognized as a citizen of North Carolina because my wife and I are so passionate about the state and about Durham. As you know we’re making this our home, our permanent home. While I’m going to be in Washington, we’re living here. We’re going to continue to contribute to the community, volunteer to do what whatever we can. In that context in answer to your question, I feel I’ve learned so much from North Carolina and learned about people and communities that I can take these lessons and hopefully apply it to a more national stage. And as you think about national policies, how do we decide what do we do in terms of health care, etc., being on the ground and having worked with people at least makes me more knowledgeable when I advise the government and others in areas of policy. I have the welfare of people at heart. I think that’s very important. It’s going into not just theory, but reality. So, the IOM which you know is part of the National Academy, it is in fact an independent organization chartered by Congress to become an advisor to the government and nation in areas of health care. So I wanted to have a chance to take a step back and go on a listening tour as I’ve done here and find out what are the things that really people feel they’re so critical to the health of the nation, to the research that can help us improve health that IOM should tackle. I want to be able to put that together and come up with a strategic plan to take on these issues so that we can actually truly advise the nation and globally and government to say these are the issues we need to take care of. So that’s what I’m thinking. And when you look at the Institute of Medicine and the work it’s done for example in medical errors and other important areas that’s been very impactful. I want to be able to continue that trajectory, but perhaps take what’s really important now as we go toward the future and try to have IOM tackle those areas.