4. VISION FOR THE FUTURE

1. Domain Characteristics
   • Patient Care
   • Research
   • Education
   • Administrative
2. Scenarios
   • A "Day-in-the-life" of a Clinical Instructor

IPAC and the domain committees identified expected key characteristics of each domain five to ten years from now. These qualities include those that are considered likely given current environmental trends and those that are considered desirable or necessary to improve our operations and our ability to collaborate internally and externally:

• We expect to develop and utilize internal and national guidelines for care.
• Patient care will be given increasingly in the community, in outpatient settings, and at home, and less in acute care settings. We will manage patient education and care across geographical settings and organizational boundaries.
• We will be able to access and share patients' health and "insurance" records across geographical settings and organizational boundaries, with appropriate authorization.
• We will increase our use of objective data, including outcomes (patient, student, etc.), to evaluate programs and processes and to compete for resources.
• Generalists will be increasingly important providers of professional service. They will be expected to handle a wide spectrum of symptoms, diseases, and conditions without use of a specialist.
• We will be able to monitor patient flow dynamics within our facilities and within the larger health care system.
• The level of acuity of hospitalized patients will continue to increase.
• New, less invasive ways of handling medical and nursing procedures will continue to appear.
• More patient care will be managed by providers other than physicians.
• We will have greatly increased levels of communication with referring physicians, other providers, and patients, including increasing use of remote consults.
• Our health care providers will engage in increased personal communications with patients and patient education.

• Investigators will have easy access to current information about other investigators' research interests and activities.
• We will share technology and research data within and among institutions.
• We will emphasize faculty development and re-development.
• We will use improved and streamlined processes for identifying funding sources and submitting grants.
• We will use efficient mechanisms to identify and recruit candidates for faculty, post doc, and support staff positions

• Our curricula will increasingly emphasize self-paced, problem-based, and team learning.
• Our curricula will increasingly emphasize access to and application of changing information rather than recall and use of memorized facts and procedures.
• We will rely on distance learning and clinical learning at remote sites.
• Integration and collaboration among our academic and professional disciplines will increase.
• We will emphasize life-long education.
• Information technology will support the entire teaching and learning process; VUMC will be a leader in the use of information technology in education.

• Our decision making processes (policy, operational, therapeutic, evaluative, etc.) will be improved at all levels.
• We will flatten our organization structure.
• We will rely increasingly on digital communication: e-mail, scheduling, meetings, etc.
• We will replace our common paper-based systems (payroll, time and attendance, medical record, telephone directory, etc.) with streamlined, automated processes.
• Operations and decision making will be supported by accessible, shareable, non-redundant information.
• We will increasingly base compensation decisions on individual skills and performance of the organization as a whole.

Each domain committee wrote one or more scenarios to illustrate how they might work in the future. After reviewing the scenarios across the four domains, these features stand out:

• Faculty, staff, students, and patients are skilled in the use of available information technologies. Multi-media communications and computing are ubiquitous and their use is fully incorporated in routine processes of faculty, staff, students, and patients.
• Faculty, staff, and students are able to access readily, integrate, and manipulate a wide variety of information types and sources, when and where needed.
• We use many types of models, simulations, and experiential data banks to support decision making and process improvement. Organizational structures are flattened and timely operational decisions are made by front-line staff.
• We have high levels of collaboration and facilitated communication: among health care providers, researchers, learners, teachers, managers, patients, and other organizations. E-mail; interactive, multi-media, distributed conferencing; and scheduling and tracking systems are used to assist individual and group communications, meetings, and performance.
• We use streamlined processes and support systems for the entire grant life-cycle and other educational and research activities.
• We manage patient care across geographical locations using well-integrated systems for health records, cost control, care pathways, scheduling, decision support, monitoring, patient education, coordination of social services, and follow-up.
• We have shifted to a pattern of life-long, just-in-time, individualized learning, with support and incentives for faculty and staff development and redevelopment.

On the next pages is an example of a scenario written for the Education Domain Committee (in what follows, "Galileo" refers to the IAIMS). Aspects of this scenario have been prototyped and dramatized in a 10-minute video to be used with groups of faculty and staff to obtain additional input in our planning process.

0730

arrive in my office and ask Galileo "Messages". A digitized sound announces messages by time, caller, and priority, and displays message on screen. Galileo asks "Call back high priority?" I answer "Yes" so Galileo dials the callback.

0745

Galileo displays key appointments, patients in hospital (ward, day of admission, problem list, and things to do), and clinic appointments. I press a key to print out this list on 3x5 pocket card.

0750

Galileo sounds "Student rounds reminder." Today we will be discussing thrombocytopenia, so I query the hospital database for patients with petechia and other physical findings useful for presentation to the students. I also ask Galileo to print thrombocytopenia "Review and References" from the appropriate learning module.

0754

As it is Monday, I scan the contents of my weekly custom magazine with recent updates, new reviews, health science news update, and customized literature search on the 10 most common fields that I have preselected.

0800

To rounds on in-patient units. Before seeing each patient, I query Galileo using the unit workstation for patient condition, diagnosis, vital signs, and other relevant clinical data in graphical format along with a problem list and things to do. I visit with and examine patients. I then enter my notes and orders on the workstation, examine a recent radiographic image, and review lab data. I finish rounds and review my notes and orders to ensure accuracy.

1000

With my list of patients hospitalized with thrombocytopenia, I select patients to examine and locate their room numbers. Students and I make rounds on these patients, reviewing charts using Galileo first before seeing each patient. We then meet at the computer lab and use Galileo to review peripheral blood smears of various diseases that cause or are associated with a low platelet count. We then call up a problem-based learning module to work through a differential diagnosis of thrombocytopenia in healthy and ill adults and children. Several students ask about leukemia, so we review bone marrow histology on screen. A nursing student inquires about treatment results, so we use Galileo to display Kaplan-Meier plots of survival of patients followed at Vanderbilt Medical Center with acute leukemia. Another student volunteers to do a literature search on risks of central nervous system hemorrhage while we get a refill of coffee.

1100

I return to the office where I access selected digitized images of photomicrographs and choose images for an electronic folder for my 2:15 pm problem-based learning session on anemia. I send the Media Center a network message asking them to queue up the 15 minute video on the "Laboratory Workup of Anemia" for the students to view before I start my problem cases.

1115

I read portions of my weekly magazine and catch up on letters and projects.

1200

I select remote teleconferencing from my computer screen to view a lecture being given by Dr. Jones at Duke. It's pretty boring so I go back to the teleconferences menu to look for on-line alternatives while I eat lunch in my office.

1300

Its now midway through the current pediatric clerkship rotation so I use Galileo to access the "Pediatric Clerkship Administrators" menu. Selecting "Module Use," I determine how many students have studied each module and note which cases have given them the most trouble. Seeing that questions on fetal circulation are often missed, I send a note to Dr. Smith in Neonatology asking her to add more emphasis on this topic and consider revising the fetal care module.

1330

Galileo alerts me that I have a priority telemedicine call from a pediatrician in Dixon who wants advice about transferring a child with unexplained adenopathy. I ask to see the child on screen and watch the referring pediatrician point out the size of the nodes and the liver. I ask him to show me the peripheral smear on screen. There are some worrisome cells there, so I capture the images and transfer the files to the "Clinical Admit Database." This will schedule the child for an appointment with my partner in the morning, allow me to choose preliminary lab tests, verify demographic data, and alert my partner's patient list and appointment schedule.

Two other low priority teleconsults are answered as I type recommendations for differential diagnosis, evaluation, and therapy. I use the "Callback" menu to make an automatic call back in 2 days for follow-up.

1400

Off to my problem-based learning session where I display the images in my electronic slide folder through the network. At the discussion session, I am asked what base pair mutation causes the most common forms of thalassemia. Not recalling this fact, we use Galileo to search for thalassemia in currently available Vanderbilt learning modules. The mutations are not listed in any of these modules, but a reference is indicated, so we double-click the mouse button and the "Medline Televideo Database" displays the reference and asks if we want to see the sequencing gels. We view the gels, talk about polymerase chain reaction techniques used to identify genotype, and highlight the "take-home" information which is printed out in bullet summary form for each student to take with them.

1500

I start afternoon rounds. An old patient with whom I am not familiar was admitted to my service with fever and neutropenia. I call up her history and therapy schedule from Galileo using the workstation on the patient care unit. I ask to queue up the "Patient and Family Information" module which covers the management of febrile, neutropenic children. I talk with the family, examine the child, and show them how to view the module on their video screen. I will come back after rounds to answer their questions.

1530

At the workstation, I review all the new lab data obtained on my patients today. I review a single chest x-ray and place the cursor on a suspected nodule, asking the attending on-line radiologist to comment on that abnormality. She says that its an old granuloma, so I'm reassured. I note that an echocardiogram obtained on one of my patients has shown significant deterioration, so I highlight "Cardiology Consult," type in or record my clinical question, and request 24-hour service.

1630

Finishing afternoon rounds, I head back to the office, ask Galileo "Messages," and listen to the audio messages while I call up the typed messages for viewing on-screen. I ask Galileo to call back the people who wanted to talk with me by priority. Fortunately, the microphone/speaker in the computerphone allows me to talk with my hands free so I can look up a patient chart or a recent article as I talk. The conversation is digitized for storage at my request for medicolegal reasons.

1700

At last a break so I can work on a review for the Online Journal of Clinical Medicine covering the subject of aplastic crisis and sickle cell disease. Making sure that the smears and bone marrow images are linked to the review, I submit the review by modem. It will automatically enter Galileo as well.

1800

Time to head home so I unplug my palmtop computer/telecom device from my personal computer to take with me in the car. On the way home, I get a call from a resident about a patient so I discuss the problem with him. I also get a digitized text query that I will answer when I get home.

2030

Noting that there is no hockey on the holographic sports network, I reluctantly fire up the palmtop and write some notes for tomorrow. Seeing that I am asked to meet with a student discussion group about acute leukemia, I access my personal computer at work to queue up a printing of the latest review covering this subject, select 5 images to display for case discussion, and list all patients hospitalized with acute leukemia. I will pick this up in the morning.

2200

Getting sleepy I plug in a CD-ROM to watch my favorite flying video while I listen to some Mozart. The palmtop watches over my calls and will alert me if any requires a real time response.

2230

Asleep now, I needn't worry as the timer will shut off the CD, lock the doors, activate the alarm, and dump some food for the dog in a dish.