Commentary Academic Medical Center R&D: A Call for Creating an Operational Research Infrastructure within the Academic Medical Center Devin M. Mann, M.D., M.S.1,2 and Rachel Hess, M.D., M.S.3

Keywords: innovation, academic health center, research operations, translational research Scope of the Issue

Academic medical centers are complex organizations with three linked, but siloed missions: education, knowledge generation, and care delivery. This impressive array of expertise has historically delivered the most sophisticated, innovative care. These innovations in care have typically come out of the tight connections between clinical care and clinical and basic science laboratories. This allows basic science to move from clinical insight (the first phase of translational science or T1) and through clinical trials (T2).1 The path for moving these findings into usual care (T3) and to impact population health (T4) is less clear.2 While basic discovery, T1, and T2 research blossoms under tightly controlled conditions, studying health delivery sciences (T3 and T4) in conditions removed from routine clinic care creates barriers to robust implementation and dissemination. We are in a new paradigm of healthcare in the United States. The need to deliver high value care—care that is both high quality and high efficiency—cannot be accomplished in the absence of systematic research and experimentation in clinical delivery. We are not developing, evaluating, and translating new evidence into clinical care quickly enough—the result is that our patients are not getting the highest value care. While medicine has borrowed a great deal of corporate culture in its quality improvement efforts—few have adopted a similar emphasis on R&D investment in its core product—healthcare delivery. Despite a rich pool of experts to draw upon, academic medical centers typically lack the infrastructure; the financial incentives; and the teams with operations, research, and clinical representatives to support this T3 and T4 cross-disciplinary, operationally sensitive research. Misaligned Infrastructure

Many academic medical centers are amalgams of academic (medical school) and operational (medical center) entities. Research groups are typically located within the medical school and quality improvement teams within the medical center. Each body is driven by overlapping but distinct priorities, incentives, and infrastructures, and has distinct mandates and paces. The academic side operates in a currency of grants and publications, with an apparently longer timeline than the operations side that operates in a system that rewards more immediate clinical and financial outcomes. These styles and reward systems, which seem on the surface to be in conflict, mean that research and operations too often work in isolation of each other, with collaboration as the exception rather than the rule. This is a lost opportunity for enhancing the rigor or our health delivery redesign and the real world impact of our research investments.

Financial Barriers

Research and operations have both perceived and real budget separation. Researchers at academic medical centers rely heavily on extramural funding, while operations budgets are predominately supported through clinical revenue. This results in researchers being more sensitive to the priorities of granting agencies, over operational needs, and operations teams being more sensitive to programs with a clear return on investment, including special federal, state or local grant programs tied to policy reform (e.g., meaningful use). This reality creates little momentum for researchers to bend their interests to operational needs and for operational leaders to integrate research agendas into their improvement programs. Fully integrated organizations such as Kaiser Permanente or Geisinger Health System are examples of how aligned incentives provide a pathway for integrating researchers into the operational agenda. Institutions like these have demonstrated a strong ability to create innovative research that directly improves their ability to deliver care and save costs. These institutions have clear incentives, because of their financial structure, to invest in innovations that enhance their ability to deliver high-quality care; helping bridge the divide between operations and research. As we move toward prospective, risk-based payment models (e.g., Accountable Care Organization [ACOs]), more organizations will find that these incentives are aligned. Missing Players on the Team

How can organizations envision the alignment of the academic, research, and operational missions? Consider a new program in hypertension. In order to improve care and meet incentive payment targets, the operational team brings together clinicians, managers, and technical leads to create a program that follows evidence-based guidelines to improve hypertension management in clinical practice. Over the course of a year, this team develops and deploys the program and follows the key quality metrics to evaluate its success. They have not included anyone with implementation or outcomes evaluation expertise and miss opportunities to test highly innovative solutions or systematically understand why some practices respond better to the program than others. They are less likely to employ novel health IT, decision support or other technologies in their program development. The evaluation is primarily based on process measures necessary to meet the externally imposed targets and does not include more robust risk adjustment or patient-centered outcomes. The team will leverage the known evidence but will not ask new questions that extend our collective understanding of how improve healthcare.

Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA; 2Boston Medical Center, Boston, Massachusetts, USA; 3Department of Population Health Sciences and Department of Internal Medicine, University of Utah Health Sciences, Salt Lake City, Utah, USA. 1

Correspondence: Devin M Mann ([email protected]) DOI: 10.1111/cts.12329

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In parallel, a research-based team sets out to tackle the same problem. This group combines researchers from several basic and clinical academic disciplines to create a multidisciplinary hypertension research center. They plan to implement their findings via an educational campaign and decision supports to providers through the electronic health record. While highly collaborative, the group does not include anyone with operational responsibility, insight, or expertise. Its priorities, decisions and focus areas risk being misaligned with the medical center’s needs, incentives, and other initiatives. The impact of this disassociation may be not be obvious at first but will likely become clear with time. For example, the team assumes that if the clinical trial data demonstrate effectiveness then the medical center will immediately use its infrastructure to implement its findings. They do not understand the competing priorities of the many improvement projects already underway and the fixed constraints of resources. They may be unaware of new initiatives in quality, population health and decision support focused on uncontrolled hypertension across the medical center. Their inadequate exposure to operational systems, workflows and culture limits their ability to design interventions suited for clinical implementation and dissemination. The research team may or may not choose to change their goals based on these operational realities but without a more integrated approach this decision point is never even reached. If these complimentary operational perspectives were integrated, the ultimate outcome would more likely be realistic innovations that could meet both the research and operational needs, more effectively use both groups’ resources, and help drive the medical center to better healthcare delivery in the near and long term. Future State—Roadmap to a New Reality

The following are steps that can be taken to achieve a more integrated operational-research agenda at academic medical centers. 1. Create the governance and organizational infrastructure that allows a hybridization of research and operational goals, incentives, and resources. Build joint operational research bodies that bring together disparate resources and guide these integrated projects.

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2. Create incentives for researchers to embed operationally savvy clinicians in their research programs. Encourage researchers to become sensitive to operational metrics when seeking support from operational partners. 3. Embed researchers in the long-term planning of operational initiatives. Encourage the integration of research design, and possibly funding, into the operational implementation. 4. Incent and reward operational leaders who support embedding research within their improvement programs. Facilitate an appreciation among operational leadership regarding the potential for research to contribute to developing novel solutions to healthcare delivery problems. 5. Recognize the importance and ultimate benefits to margins of investing in a more robust and rigorous operational research agenda. Changes in healthcare financing (ACO’s, value-based care, etc.) are creating financial opportunities that align research and operations toward delivering more cost effective care. 6. Consider how to reward faculty and staff who promote this joint vision. Traditional reward systems will need to become more flexible so that they can reward the effort required to foster collaboration and integrating the goals of the operations and research communities at the institution. Conclusion

T3 and T4 efforts must mimic the rapid generation of knowledge achieved by T1 and T2 programs. Only by closer linkage of these researchers with health system operational teams can we fulfill the mission of redesigning our healthcare delivery system and creating a new learning health system.3 Academic medical centers have adopted many features of successful corporations but they have to date eschewed substantial operational R&D investments. The barriers preventing this investment need to be removed in order to promote clinically realistic innovation. References

1. Kon AA. The Clinical and Translational Science Award (CTSA) Consortium and the translational research model. Am J Bioeth. 2008; 8(3): 58–60. 2. Schweikhart SA, Dembe AE. The applicability of lean and six sigma techniques to clinical and translational research. J Investig Med. 2009; 57(7): 748–755. 3. Olsen L, Aisner D, McGinnis JM (eds.). The Learning Healthcare System: Workshop Summary. Washington DC: National Academy of Sciences; 2007.

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Academic Medical Center R&D: A Call for Creating an Operational Research Infrastructure within the Academic Medical Center.

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