Interview with New MIT Medical Director
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FNL: On a somewhat more mundane issue, we recently went from Crosby Benefits to WageWorks, and there was a big issue for many months about WageWorks not accepting MIT as a medical facility and individuals having to get reimbursed rather than directly using the WageWorks credit card. My understanding was that it was complicated for WageWorks because we aren’t a hospital or specifically a medical facility. Do you see any other issues, either positive or negative, because of our unique kind of structure?
CS: Well, because of our unique structure, we have issues around our technological infrastructure – our IT systems. That plays into the Crosby/WageWorks question. We have to be different with our IT in some ways because of HIPAA, the privacy rules that we have to live under, because we are a medical facility. But, when it comes down to the nuts and bolts of it, at the end of the day our Tax ID number is not that of a medical facility, it’s that of a research university, so that does complicate things to a degree. And my sense is that our structure does lead to a way things are done that you would not necessarily proceed with if you were in a free-standing medical group or medical practice somewhere else.
FNL: So maybe to tie this area up: FollowMyHealth® is a piece of software that the Institute now uses to contact your doctor and theoretically to make appointments – and I really mean theoretically – and to get everything electronically online. And is it true that we have no control over the software because it is not ours? It’s similar to downloading an app from Google, for example, if you don’t like the app, well you deal with Google. You can’t change it, and MIT can’t change FollowMyHealth. And there are significant problems with it. It’s really embarrassing compared to those used by other medical organizations.
CS: Could you give me an example?
FNL: I use a AliveCor to monitor arrhythmia. Last week, I sent my contact information from my Website to my cardiologist at MGH. Overnight, he responded with a long email. His staff contacted me while I was on the road, and this morning I got a monitor installed. I tried to set up this appointment through FollowMyHealth last fall. Over three months after I sent that in, I got an email saying can we talk about this. And there are more general issues in addition to FollowMyHealth.
CS: Will you share some of them?
FNL: We’ve gotten feedback from many faculty regarding difficulty in setting up appointments; rude and abusive behavior by the outer office staff; being bounced around from one physician to another; and things like that. And it just seems that the quality of human interaction has gone downhill over the years. And it’s also amazing to me that MIT has conferences on digital medical record technology and people come and pay big fees to attend those conferences and we have FollowMyHealth, where you can’t even do an email enclosure.
CS: Because I am new, I haven’t had a lot of direct interaction with FollowMyHealth, but if you were my patient I would want FollowMyHealth to be functional for you to interact with me clinically. But from the Medical Director side of my job, FollowMyHealth is not really designed to be part of the administrative piece of what I do. That part would have to come through email or a phone call. I do have a background in medical informatics and EMR [Electronic Medical Records] implementations, and so that is an area of focus for me. And over the next couple of years, the electronic medical record, which we call TouchWorks, and its companion piece FollowMyHealth as the patient portal side of things, is an area that we need to focus on. But as I’m sure you are aware, EMR initiatives come with a big price tag. It’s going to be a matter of understanding and analyzing the system that we have versus what’s available, and asking does it make sense to make a switch to something different or do we invest our resources in trying to optimize these two products that we already have. I don’t think we’re in a position to go into a build-our-own homegrown system. That is not our area of expertise, nor would I want to manage that. And when you look at the fact that our patients, faculty, staff, students, all get hospitalized at or get some care at non-MIT facilities, we really have to look with an eye on the interoperability, which is a challenge just in general for medicine and for EMRs in particular. Having the ability to more directly interface with some of these other organizations that we interact with is going to be one of our challenges.
FNL: It seems like you are suggesting that it could very well be a financial question, and if it is a financial question does that just go right to the VP of Finance to make that decision?
CS: I think the first question is a clinical question. The clinical question is, does our current set of systems meet the clinical needs of our patients and of our providers to do excellent medical care? If the answer is no, then we have to ask what is our next step, and with whatever the next step is there is definitely a substantial price tag that comes along with it. It can’t truly be just one or the other though. You’d need to have a compelling clinical reason to make a change in the first place, and then in the second place you’d have to figure out the financing of that change. So part of what I have to do in this next year with my team is to figure out if there are compelling clinical reasons to make a change. I have already identified what I think are quite a few reasons and part of my ability to do that is that I have the perspective of coming from a place with a completely different set of clinical records that were much more functional than what I’ve observed here. One of the issues here – and at the same time it’s a wonderful thing – is that most of the people in our group have been here a long time and they haven’t really had exposure to what’s out there now in the world of record-keeping and portals. We have to get exposure and insight into what other products are available that might actually lend themselves to providing better care here.
FNL: So could we include that as part of your answer to the major challenges question?
CS: Oh yes. I think it’s hard to move the clinical systems along without the right kind of recordkeeping and the ability to collect data that comes with a really highly functional system, and that includes patient-entered data. Patients want to be able to enter data at home and have it land in their medical record. Or as they are sitting in the waiting room, a provider may want to hand them a tablet so that they can fill out a questionnaire at the time of the visit and then it goes to their medical record automatically.
FNL: I’d like to return for a minute to the 18-bed infirmary that used to be upstairs. To many faculty the loss of that wonderful benefit seemed to be strictly a financial decision.
CS: My understanding is that it was largely a financial decision, but it could probably be supported as well on the clinical side. It’s not like we’re some college in the boondocks where there is no other hospital. We have world-class medical facilities in the area that you can literally see out of numerous windows. And there is good literature that says when you look at low-volume hospitals their outcomes aren’t as good. Now, we had good outcomes for the kinds of things that we were doing here, but we want to provide the highest level of care that the patient needs, which might have been limited by the size of our facility.
FNL: Still there are many instances of excellent care here because of the small population and thus the ability of the medical staff to offer more personalized care.
CS: I’m sure that’s true. And I would like to talk about the customer service aspects that you’ve mentioned. There is definitely work that goes on within the Medical Department to improve customer service and there are some good initiatives that are under way. I expect the highest level of customer service and caring towards patients that walk in the door, or call, or send a message, for whatever reason they are engaging us. I think outside of this environment, a medical group could never afford not to have their best foot forward, because patients vote with their feet. But MIT Medical has essentially been a closed model HMO for many years, until quite recently when other options or choice of health plan have become available through the Benefits Office. So patients didn’t really have the opportunity to vote with their feet, as they do now. Providing excellent patient service throughout MIT Medical is extremely important, and will be an area where we focus our efforts in the upcoming year.
FNL: So is there now a feedback mechanism?
CS: There is, and I’ve gotten some feedback from faculty through the Press-Ganey survey that we administer, which is one that 40% of health care facilities in America use, and it allows us to compare ourselves to other organizations. That is one mechanism. Within the survey there is a very generous comment box where you can put in any kind of level of detail or comment – and we look at those comments, both good and bad. In all honesty, we have received negative feedback about the survey itself in terms of the language and questions that are asked. But because it’s a nationally administered survey, it’s geared to patients that are at the fifth or sixth grade reading level. We have to be mindful that not every patient we care for at MIT Medical has extremely high literacy levels.
FNL: It’s also sent through the mail, through the snail mail.
CS: Now it’s electronically available. Patients get an email with a link to the survey. Of course, completing the survey is always optional. The other feedback we’ve had is around the length of the survey. So we’re working to shorten that up, trying to figure out what do we really want to get at, as well as maintaining the comment box.
FNL: What are some of the other areas that you’d like to focus on – again given that you’ve only been here half a year, roughly.
CS: Three months.
FNL: Oh! Still are there other areas, such as concerns about outsourcing, temporary physicians, etcetera?
CS: Let’s start with the concept of outsourcing. We have to always look at the services we provide within the building and decide if we can provide them at a high level of quality and good access. One place this comes into play is every time we renew contracts with whatever specialists with whom we interact. We must ask, does this make sense? One issue is that there is some difficulty finding doctors who want to practice here if we only need them, for example, for half a day, every other week. So there’s that practical consideration in the sub-specialty areas, when you’re thinking about G.I. or Cardiology or what have you. We have to understand if we want and need that service, but also can we find somebody who could fill the limited slots that we need, because we do not have the patient volume to support full-time specialists. And I’d prefer not to use the word outsourcing, but I would rather think about it in terms of finding appropriate clinical partners who we can collaborate with to provide the care that our patients need, either in our building or outside of our building. So, it’s really more of a collaborative effort to develop relationships with particular specialists that we need to provide care to our patients in a way that has great communication, great quality care, and great outcomes for patients.
FNL: Would you say that it’s unlikely that Urgent Care or the infirmary would go back to what they were before? Do you think any of what’s been cut over the last decade or more are likely to return?
CS: I would say it’s pretty unlikely. Let me talk about Urgent Care for a minute since we haven’t talked too much about that. Urgent Care is one of those things that we are looking at closely because it appears that there’s a lot of waiting going on down there that I’m not sure is the best thing for people who want to use an urgent service. So we are trying to understand what is driving those wait times. I walk down the stairs and I see people waiting there – and I don’t like seeing patients waiting.
FNL: Part of it, a good part of it, is the moving from the hand-written recordkeeping to the computer.
CS: That’s an example of where I think the way our EMR system is set up might not be the most efficient for patient care. When we look at the staffing in Urgent Care, it has increased in terms of nurses and nurse practitioners. We have the Emergency Attending, the EA, who is one of our primary care doctors who is the backup care doctor during the week. I think parts of that system work pretty well, but I also think that we have doctors and nurse practitioners doing things they needn’t be doing if you really want to provide good urgent care. They shouldn’t be calling in prescriptions themselves or doing a prior authorization themselves, because they should be spending their time in a room with a patient. Right? We want them in front of patients, attending to the needs of patients. We should expand the role of the medical assistant, who can do a lot of those intermediary tasks on behalf of the provider. I think if we staffed Urgent Care with the right team of caregivers, we could actually decrease wait times and provide a higher level of service.
FNL: And part of that will be a financial decision?
CS: Yes, any changes of these types have to be informed by clinical, operational, and financial data. We always have to make sure any changes that are made are clinically appropriate. Another issue around Urgent Care is thinking about whether we are open at the right times. When we are open do we have the right amount of people there to provide for the demand that we have? We know that we have peak demand in the afternoon. How do we staff for that? I know that students don’t want to come here when we open at seven o’clock in the morning, but I do know that a Facilities employee getting off the night shift may want to come at seven o’clock in the morning. So we have to figure out those needs. I know that somebody who works in an office on campus probably isn’t going to come to Urgent Care at ten o’clock at night here in downtown Cambridge if they live in the suburbs.
CS: So, it’s trying to figure out the patterns of demand, and staffing to meet the demand. That should elevate the level of service.
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FNL: So to broaden the question: There appears to be great trepidation among many of the faculty, especially people who have been here for quite a while and have seen the cut in medical services, that the Institute seems to be heading toward deciding that the whole thing is unaffordable and that down the road it will all be outsourced. That if you get below a certain critical size it all goes away.
CS: So, I will tell you, I just left a perfectly good job that I didn’t have to leave, at a perfectly wonderful organization where I could have continued my career. But I left that job to come here, and I certainly don’t want this place to go away either. I am committed to making MIT Medical of such great value to the community and to MIT that it couldn’t possibly be closed or outsourced.
FNL: Great. So, you took this job because you saw a future here.
CS: Yes. But I think the future is an actuality. We have what every health care organization wants. All health care organizations out there want to control as much of the delivery system as they can. The only part of the delivery system that we don’t really have is a hospital, and I’m actually quite good with that. I think the hospital is the Wild West of health care cost. What we want to do is make sure that the hospitals we use have our same aspirations towards providing high quality, low cost care; high value health care. I’m confident that the hospitals that we partner most with, which are Mt. Auburn and Mass. General, are on that path.
FNL: And Martha’s Vineyard Hospital.
CS: Right. The only critical access hospital in Massachusetts, I believe.
CS: So it’s all about finding the balance. We have this health care delivery system. We have a health plan. We have patients. We have doctors. We have enough ancillary services to do most of everything you’d need for excellent primary care. So, we actually do have the ability to provide that high value care from soup to nuts, right?
FNL: Do we still do infusions here?
CS: Yes we do, and that’s a perfect example of keeping a service in-house. We want to do that. In fact, we want to drive more business in-house. And the other thing is, in terms of sustainability of this facility, we want to grow patient volumes. If we can show that we are a high value provider, not just to MIT, but to the patients who have the opportunity to pick us for their primary care, that’s what we want to do. We want people to pick us because we’re a great place to get care, and that’s going to become more evident as time goes on. For example, I believe that MIT is considering adding a high deductible health plan.
FNL: So that would bring in non-MIT people?
CS: No. It would be offered as a third option, along with the Traditional and Choice plans. It’s great for healthy people, younger people, people who don’t use a lot of health care services. But when they do use it, it’s coming out of their pocket, until they meet the high deductible. And the Choice plan has given people the opportunity to go to some place maybe closer to home, but it has pulled them out of our facility. If we are a high quality, low cost provider, my hope is that more MIT employees will choose MIT Medical for their primary care.
FNL: As opposed to choosing doctors in Boston. If they live in Cambridge, they’d rather be with a doctor in Boston than somebody here.
CS: Perhaps. But at the end of the day we want to be the primary care provider of choice. I do not want to have a building full of primary care doctors who don’t have patients to see.
FNL: Access to primary care doctors is an issue. Long wait times and other things we’ve discussed.
CS: Yes. So the direction I’d like to go here I experienced when I practiced at Dartmouth-Hitchcock. They have a long history of many physician assistants and nurse practitioners as part of the team. I think this is one area where we have to start evolving the model of care to more of a team approach, because we have a looming physician shortage, and in particular it shows up in primary care.
FNL: I can see that.
CS: It’s becoming increasingly hard to replace them. I spoke with our HR professional here in the department and it took over a year to fill our last two primary care openings. It’s very difficult to find primary care physicians and it’s even hard to fill on the nurse practitioner side, and I think at the end of the day we are going to have access to fewer primary care physicians than we have had previously.
FNL: So back to the question of wait times to see primary care physicians. It’s hard to cut into that unless you cut the amount of time the primary care physician sees the patient, which you don’t want to do.
CS: Correct. There are ways you can decrease wait times. One is to make sure that people are seeking primary care services for things they need. I think you mentioned regular checkups. A lot of the medical literature says that for most people the regular checkup is not really useful. So, for instance, a healthy 30-year-old does not necessarily need to have an annual primary care checkup or a physical, because they’re healthy. They may however need pregnancy care, or care for things like strep throat. We want to use evidence-based practices, so that we’re providing services for people who need those services, but not providing unneeded services to healthy people who don’t need them. That’s part of it. What that does is align your resources with where your needs are.
FNL: That’s it. My experience has become that you get what you ask for after a while, but there’s no proactive part of the MIT Medical system that helps take care of you, and it used to be more proactive.
CS: So again, this gets back to the team concept. Nationwide there’s something called the patient-centered medical home concept that’s been put into place. That is using the team, which is made up of doctors and nurse practitioners or physician assistants, so you have several providers. You also have RNs and medical assistants on the team. You might have a non-clinical person whose entire job is to just look at the panel of patients that are assigned to that team and figure out who needs what and facilitate getting that done.
FNL: There’s also the issue of a negative experience inhibiting someone from seeking care when they need it.
CS: There is so much literature on that particular issue. We know that if we don’t communicate well, if we don’t provide adequate access, if we make you feel uncomfortable or unwelcome, that it can lead to poorer health outcomes.
FNL: That you know that is helpful. Whether you can do something about it is another issue.
CS: We can and will do something about it, but it’s going to be hard and it will take time. We have to do a full assessment of the situation. Then we have to decide what are our customer service standards. We have to make sure everyone who works at MIT Medical knows what the standards are, and that they are acting professionally. This is your job. Your job is to be kind to patients, and to make them feel welcome and cared for. That’s the job of everyone here. It’s not just the job of the secretary or the physician or nurse practitioner. It could be the lab tech, it could be the X-ray technician, it could be the billing office. Our job is to care for patients in a caring manner.
FNL: Have you addressed the entire medical community yourself along these lines?
CS: Not yet. I’ve been doing a lot of observation and listening. We’re going to have a group meeting of all the provider staff sometime probably in early June, and ongoing meetings with the rest of the staff thereafter. It’s a busy time right now to do that, to pull everyone out and to sit down and talk about that. Our demand decreases in the summer, and I think that will be a great time for us to start laying this groundwork.
FNL: It’s nothing but the sum of the individual operations that happen every day by individuals. So, making that happen, getting people to follow true north, at least for a significant part of the day, is the big challenge for you. It has almost nothing to do with medicine.
CS: But it does. It has everything to do with medicine. One of the wonderful things that I am very fortunate to have in my new role here is that I have good doctors and nurse practitioners. They are doing the right thing for the patients when the patient is in front of them. Some places have doctors who are getting malpractice suits all the time and they’re not practicing evidence-based high quality medicine. That’s another whole set of issues that thankfully we do not have to worry about here. But what I do have to worry about is getting everyone to understand the expectations of our three core values: Patients First; Working Together; and Striving to Be Our Best.
FNL: So all this stuff we’ve talked about in terms of the electronics and the kinds of doctors or quality of the personnel – all of this is going to cost money.
FNL: So you anticipate, I hope and assume, that that money will be available, given that you will make cogent arguments for the need.
CS: What we have to do is assess our situation and come up with a plan for how we want to get to where we want to get on a road map and then start figuring out how and when we can ask for needed resources. But, you know, it’s going to be a process. It’s not going to be any kind of an overnight thing. And the priorities for the Medical Department are going to be in a list of other priorities for the Institute – maintaining the Institute’s educational mission and research, and there are infrastructure issues.
FNL: How about fundraising. Do you have a fundraising arm?
CS: I’d love to have a fundraising arm.
FNL: One of the reasons medical schools are independent of the universities that they typically associate with is because of the fundraising. Have you been part of the next campaign discussion?
CS: Not as of yet, but I’m talking to somebody from the Development Office.
FNL: Any other changes you’re anticipating?
CS: I think we need some infrastructure changes to our building. It’s not set up to do team-based care. There’s no place for a team to sit. Another resource we have is the Community Wellness Department, and they’re doing a lot of great work. We’d like to expand the scope of services they provide, to a broader range of community members.
FNL: Any other things?
CS: Well this Saturday, for instance, is National Advanced Care Planning Day. Have you had any education around Advanced Directives and planning for your future health care needs if you are unable to speak for yourself? That is a service that we, as the Medical Department, should be working on together with all the members of our community, be they old or be they young. It’s not just an issue for geriatric folks. It’s an issue for 50-year-olds who have a brain aneurysm or a bike accident, to have their wishes for their healthcare choices documented so that if they are not able to speak for themselves, they can have their wishes followed. That’s a huge one on my mind. There are people that have worked at MIT their entire career and maybe their wife has passed away, or their husband. Maybe they never married at all. Maybe they were an only child. They don’t have a brother or a sister or nieces or nephews. How do we make sure that those members of our community, if something happens, have somebody or something (like an Advanced Directive) that can speak for them? End of life decisions are very personal and sensitive, and I think we can do a much better job of helping our patients have these conversations with their loved ones and getting their wishes documented.
FNL: And even if they retire, they often remain with the medical program.
CS: And they’re at the polar end opposite of the spectrum from students. We need to have some core capabilities of how to care for elderly folks who maybe are having more medical problems than they had when they were younger and are going in and out of the hospital, or a nursing home, or a rehab facility.
FNL: So, this is another area you’ve got to expand and develop resources within MIT Medical.
CS: Yes, and we’re actively working on it right now.
FNL: Let’s address the whole mental health issue. MIT Medical has expanded those resources over the last few years. Are there plans to continue that?
CS: I think we have a very strong Mental Health and Counseling Service here and they do an excellent job with the patients that they see. But we have increased demand and the increased demand is coming through, I think, because of MIT’s excellent efforts to publicize the availability of Mental Health and Counseling, and to de-stigmatize those issues that members of our community face. So our students are seeking the services. Then we have the behavioral health needs of the rest of our community, our faculty, staff, dependents, and retirees. How do we address those needs? The Mental Health and Counseling Service is really oriented towards caring for all of our students. We have to understand what is the best way to care for the rest of the group, and to provide opportunity for some care within our facility. It may not happen in a freestanding mental health center. Again, in the medical home team concept that most organizations have put into place, many have put behavioral health clinicians right there in the primary care team, to work together with the primary care doctor. A lot of depression, a lot of anxiety – a lot of it is a primary care problem, but those primary care doctors need support and assistance with managing that, and how can we best do that? We’re not talking about complicated schizophrenia or complicated bipolar disorder. Those patients clearly are best served at other places where that’s their specialty. Just as your primary care doctor would send you to a specialist if you needed one for a complex cardiology problem, the same thing goes for behavioral health. Part of it is connecting the head to the body. You can’t look at just the head, and you can’t look at just the body. You have to look at the whole person, and I think we have to move towards a more integrated model that way.
FNL: Speaking about integrating the whole body, what about dental care?
CS: We have a dental clinic here, and we just did some major renovations. But it’s kind of a little known fact. I got here and I didn’t even know there were dentists that were in the Department. But it’s just what we were talking about earlier. We have this service that we provide. We want people to use it because it’s a fixed cost. We want people to use the things that we have here. That’s one of the things that I would say - if you have a choice, we’d like you to choose us. I want you to choose us because you want to, not because you have to! But also, when you get here, I want you to have an excellent experience, like you would have at any other place that you might choose. I want you to choose us for our quality, our caring, our convenience.
FNL: When you start recruiting for positions to join this group, does the fact that they could potentially get involved with the rest of MIT and the MIT faculty, and genetics research, etcetera, attract people or do they not have time to do that?
CS: My understanding from my group is that they just did a new brochure for recruiting physicians before I came and one of the things they highlight is the connection with MIT and the things that happen on campus. I think one of the things I’d like to see is for MIT Medical to be more engaged in the educational and research enterprise of the Institute, in whatever ways we can be helpful, without being disruptive to patients.
FNL: Dr. Stuopis, thank you very much for meeting with us. You have shared many important ideas with the MIT community.
CS: Thank you very much. It was really my pleasure.
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