Report 3 The Blue Ridge A C A D E M I C H E A LT H G R O U P Into the 21st Century: Academic Health Centers as Knowledge Leaders Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 The Forces Shaping Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Knowledge as Capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6 AHCs and Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 A Knowledge Infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 A Knowledge Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Knowledge Management Processes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Rising to the Challenge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 IT in Support of AHC Knowledge Management . . . . . . . . . . . . . . . . . . . .18 Managing an AHC Asset . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Preparing AHC Professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24 A National Health Information Infrastructure . . . . . . . . . . . . . . . . . . . . . .26 Partners in Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Appendix 1: Previous Blue Ridge Group Recommendations . . . . . . . . . . . .33 Appendix 2: External Forces Shaping Health Care . . . . . . . . . . . . . . . . . . .35 Appendix 3: Possible Approaches for Knowledge Management . . . . . . . . . .39 About the Blue Ridge Academic Health Group . . . . . . . . . . . . . . . . . . . . . .42 About the Core Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43 About the Invited Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 Reproductions of this document may be made with the written permission of the University of Virginia Health System by contacting: Elaine Steen, University of Virginia Health System Box 800413, Charlottesville, VA 22908 Fax: (804) 243-6078, Internet: ebs9g@virginia.edu Into the 21st Century: Academic Health Centers as Knowledge Leaders is the third in a series of reports produced by the Blue Ridge Academic Health Group. The recommendations and opinions expressed in this report represent those of the Blue Ridge Academic Health Group and are not official positions of the University of Virginia. It is not intended to be relied upon as a substitute for specific legal and business advice. Copies are available at no charge. To order, see the enclosed form. For questions about this report, contact: Don E. Detmer, M.D., University of Virginia, (804) 924-0198, ded2x@virginia.edu Copyright 2000 by the Rector and Visitors of the University of Virginia. The Blue Ridge Academic Health Group Mission Gabriele McLaughlin, M.I.S., principal, The Document Company – Xerox T he Blue Ridge Academic Health Group seeks to take a societal view of health and health care needs and to identify recommendations for academic Stephanie Reel, vice president, information services, The Johns Hopkins University; Johns Hopkins Medicine health centers (AHCs) to help create greater value Jay E. Toole, national director for health e-commerce, for society. The Blue Ridge Group also recommends Cap Gemini Ernst & Young U.S. LLC public policies to enable AHCs to accomplish Knowledge Management Advisors these ends. Eric Darr, Cap Gemini Ernst & Young U.S. LLC Members G.T. Hickman, Cap Gemini Ernst & Young U.S. LLC Enriqueta C. Bond, Ph.D., president, Burroughs John G. Peetz, Jr., vice president, chief knowledge officer, Wellcome Fund Cap Gemini Ernst & Young U.S. LLC Robert W. Cantrell, M.D., vice president and provost, University of Virginia Health System Staff Don E. Detmer, M.D., Dennis Gillings Cap Gemini Ernst & Young U.S. LLC professor of health management, Judge Institute of Management Studies, University of Cambridge* Mark L. Penkhus, M.H.A., former partner of Ernst & Young LLP, Health Market Consulting Unit until Michael A. Geheb, M.D., senior vice president August 1999, currently executive director and chief for clinical programs, Oregon Health Sciences University executive officer, Vanderbilt University Hospital Jeff C. Goldsmith, Ph.D., president, Health Futures, Inc. Tina Savoy, senior marketing associate Michael M.E. Johns, M.D., executive vice president University of Virginia of Health Affairs and director, The Robert W. Woodruff Health Sciences Center, Emory University Charlotte Ott, senior executive assistant Peter O. Kohler, M.D., president, Oregon Health Elaine Steen, health policy analyst** Sciences University Founders Edward D. Miller, Jr., M.D., dean and chief executive officer, Johns Hopkins Medicine, The Johns Hopkins The University of Virginia and Cap Gemini Ernst & University Young U.S. LLC are founders of the Blue Ridge John G. Nackel, Ph.D., managing director Academic Health Group. The University of Virginia for new ventures, Cap Gemini Ernst & Young LLP convenes the group and serves as its locus of operations. Cap Gemini Ernst & Young U.S. LLC provides core George F. Sheldon, M.D., chairman and professor, funding and facilitation for the group. Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill Invited Participants Gerard N. Burrow, M.D., special advisor to the president, and David Paige Smith professor of medicine, Yale University School of Medicine Mark Frisse, M.D., M.S., M.B.A., vice president of clinical information, Express Scripts, Inc. *Chair **Editor Most colleges and universities are attempting to respond to the challenges and opportunities presented by a changing world. They are evolving to serve a new age. But most are evolving within the traditional paradigms, according to time-honored processes of considered reflection and consensus that have long characterized the academy. The changes that have occurred in the university, while important, have not grappled with the extraordinary implications of an age of knowledge, a culture of learning, which will be our likely future. – A University for the 21st Century, James J. Duderstadt, 2000 Introduction student experience? As patients change their E nabled by technological developments and accompanied by an economy undergoing fundamental changes, the approaches to seeking and receiving health care services, how should AHCs knowledge age has arrived. Its impact is adjust the preparation of health profession- already evident in the nature, scope, and als? As research becomes more interdiscipli- pace of competition among businesses, nary, interinstitutional, commercialized, and work of individuals, and expectations of the is performed more often by research teams public. As this new era unfolds, organiza- outside academia, how can AHCs remain tions are assuming new roles, acquiring new attractive sites for researchers to ply their capabilities, developing new business mod- talents? As other organizations become els, and interacting with consumers in dif- more knowledge-focused and capable and ferent ways. Simultaneously, a flood of technology blurs differences among organi- advances in the ability to preserve health zations, what will preclude other organiza- and treat disease is creating exciting tions from developing innovative ways to prospects and greater challenges for health provide the services traditionally provided care organizations and professionals and by AHCs? More specifically, which knowl- their patients. edge management practices will contribute At first glance it might appear that as the most to AHC performance and to the institutions with a strong tradition of dis- goal of a value-driven health system? How covering and sharing knowledge, academic much should AHCs invest to strengthen health centers (AHCs) would automatically their knowledge capabilities? become leaders of the health domain within Each AHC must determine how to the emerging knowledge economy. In fact, respond to these challenges in line with its however, this leadership position is not own unique characteristics, in consultation assured. AHCs have been surpassed by with its peers, and in light of lessons from other industries in the practices used to other industries. Nevertheless, a common manage and leverage knowledge. They face set of elements that all AHCs consider will growing competition in the discovery of likely emerge as they grapple with their new knowledge and are being challenged future. These include assessment of leader- for the role of preferred source of health ship, capabilities of health professionals and knowledge. Moreover, they must update other AHC staff, the technical infrastruc- their educational models for effectiveness in ture, and standard practices and business the digital era. Thus, AHCs need to attend models in use. In this and two future to their organizational knowledge capabili- reports, the Blue Ridge Academic Health ties and to their role in the future health Group (the Blue Ridge Group) provides care environment. background on specific topics that cross AHC leaders face the pressing and piv- these domains – knowledge management, otal question of how to position their orga- e-commerce, and leadership. The Group’s nizations for future success. When current intent is not to offer definitive answers, but medical knowledge is ubiquitous and med- rather, to stimulate thinking, discussion, ical technology widely diffused, what added and action within AHCs. value can AHCs bring to the patient and 1 In light of experience in other indus- of our health system while preserving and tries, the Blue Ridge Group chose to explore expanding their missions of patient care, the role of knowledge within leading orga- education, research, and public service. nizations, examine current AHC knowledge The report also complements the rec- practices, and identify ways AHCs can ommendations from previous Blue Ridge realign their knowledge capabilities for Group reports (see Appendix 1). Knowledge greater benefit to those they serve. Through management supports and is supported by this report, the Blue Ridge Group seeks to: enterprise-wide management. A knowledge provide an introduction to knowledge man- management infrastructure can advance use agement; share examples of how a variety of of organizational performance measures. corporations are approaching knowledge Moreover, managing knowledge contributes management; encourage broader use of to the development of a value-driven health knowledge management within AHCs; and system by enabling the practice of medicine advance thinking about how knowledge is based on evidence, productivity enhance- tied to the leadership role within the health ments, and adoption of innovative practices. community and is increasingly linked to Aggressive use of organizational knowledge success in the market. The recommenda- and information technology can extend the tions presented in the report advocate action range of ways that health care professionals by AHCs in three areas: increased attention and organizations interact with patients, and resource allocation to managing their enable patients to assume more control in knowledge, preparation of health profes- managing their health, and support popula- sionals for the knowledge economy, and tion health management. participation in the development of a Although knowledge management national health information infrastructure. within AHCs appeared to be a simple con- A fourth recommendation encourages other cept, it proved to be more challenging than health organizations to support the diffu- originally anticipated by the Blue Ridge sion of knowledge management within Group. Unlike the topics of its previous health care (see Exhibit 1). reports, knowledge management (as This report builds naturally on three described in this report) is not widely dis- themes of the two previous Blue Ridge cussed within AHCs. Moreover, the Blue Group reports (Blue Ridge Academic Health Ridge Group is not aware of any AHCs that Group 1998 and 1999). First, change is are fully configured for optimal knowledge inevitable for AHCs and AHC leaders management as are organizations in other should seek creative responses to the chal- sectors of the economy. Although the gener- lenges confronting them. To be successful, al concepts surrounding knowledge man- the exploitation of internal resources will agement are relatively easy to agree with, the become as important as seeking increased actual implementation is filled with difficul- external resources. Second, information and ties, not least of which is the need to change information management play a critical role individual and organizational behaviors. in improving the performance and strength- Knowledge management presents challenges ening the viability of AHCs. Third, AHCs similar to – but surpassing – those associated can demonstrate leadership for the rest of with information system implementation. the health care industry by their actions It is a field that is still developing (and and, in so doing, advance the development in general is not well understood) and 2 might be viewed as a management fad by by bioinformatics. Despite the challenges some members of the AHC community. At surrounding knowledge management, the the same time, it is a field with a great deal Blue Ridge Group believes that it will prove of breadth and depth. Rather than address to be part of the evolution of sound busi- knowledge management broadly within ness practices and offers this report to AHCs, it would have been possible to focus increase attention of AHCs to the topic. exclusively on the application of knowledge management practices to a single issue, such as the emergence of and demands created Exhibit 1. Recommendations 1. AHCs should explicitly manage their knowledge as an organizational asset to improve their performance and strengthen their ability to meet both the market and social needs of their immediate community or region and the needs of the broader health care community. 2. AHCs should help current and future health professionals acquire the skills needed to use existing organizational knowledge, prepare for the new demands associated with their professions in the digital era, and contribute to the new discipline of knowledge management as it evolves. 3. AHCs should actively participate in the effort to develop and manage a sound national information infrastructure for health. 4. Federal agencies, philanthropic organizations, and professional organizations should advance understanding of the role of knowledge in the future health system and support activities that will further diffuse successful knowledge management practices in health care. 3 The Forces Shaping Health Care 4,300 medical and scientific journals and a M ajor challenges facing the health care community include providing insur- ance coverage to the entire population, mea- total of over 10 million citations. It handles over 16 million searches per month, with surably improving the health outcomes, and one-third of them being requested by non- achieving high quality services consistently health professionals (National Library of (Blue Ridge Academic Health Group, 1999; Medicine, 1999; Lindberg, 2000). Some Institute of Medicine, 1999). To accomplish physicians have begun to respond to elec- these objectives, health care organizations tronic mail from both their patients and the and professionals must manage the health of general public (Borowitz and Wyatt, 1998), populations through evidence-based medi- thereby improving ongoing communication cine, collaborative care, and chronic disease between the patient and physician, in the management. Simultaneously, they face new first case, and providing a service that may – and at times conflicting – accreditation or may not result in a referral, in the sec- requirements and greater public scrutiny in ond. (In both instances, concerns about their handling of person-specific health confidentiality, practicing medicine across information. Underlying all of these chal- state lines, and compensation arise.) lenges is the need to manage and organize The Internet consumer health market cohesively the ever-growing volume of is projected to reach $1.7 billion by 2003 health-related data and knowledge. (Nash, 1999). Web sites are a common fea- Information systems and processes for man- ture for many hospitals and health systems, aging and communicating knowledge to but they face stiff competition on the basis work teams and other key stakeholders have of both format and content from a wide become cornerstones for health care variety of independent Web sites that pro- organizations. vide updates on medical advances and infor- The health care environment is also mation on specific conditions in user friend- being shaped by a series of interwoven ly formats. The most well-known sites have external forces, including demographic been developed and are maintained by firms trends, increasing consumerism, advances in whose primary function is to serve as man- telecommunications and computers, and agers or brokers of health information and changes in the nature of economic transac- knowledge for both professionals and the tions (see Appendix 2 for discussion of these general public (e.g., WebMD, Mediconsult, forces). For example, the increased connec- Intelihealth, AmericasDoctor, drkoop) tivity of the U.S. population has begun to (Miller, 1999). These brokers bring greater change the nature of patient interactions interactivity to the use of the Internet for with health professionals and organizations health and offer more options for customiz- by offering new tools to patients as well as ing interactions. Health consumers can professionals. An estimated one-third of the obtain virtual consults 24 hours a day, over 92 million Internet users seek health- locate physicians in their area, check the related information (Conte, 1999; compatibility of drugs they are using, learn International Communications, 1999). about clinical trials, participate in special- The world’s largest medical database, ized support groups, develop personalized MEDLINE, includes references from about health records, and fill drug prescriptions – 4 all via the Internet and without interacting Far more dramatic changes are project- with a traditional health provider organiza- ed for the not-too-distant future. Ray tion (National Research Council, 2000a). Kurzweil (who worked on optical character In general, however, the health care recognition in the 1970s, voice recognition industry’s response to the transforming in the 1980s, and print-to-speech reading economy is nascent compared to other software in the 1990s) has predicted that in industries where instantaneous communica- just 10 years, a $1,000 personal computer tions and computing capabilities separate will be able to perform a trillion calculations selling and the delivery of goods, reduce per second. At that point, most text will be response time to customers, enable cus- created using continuous speech recogni- tomization, and speed the diffusion of new tion; routine business transactions (e.g., trends within and across organizations and purchases, travel reservations) will most industries. The banking, travel, and retail often take place between a human and a industries have already developed the ability virtual personality; and intelligent course- to provide services electronically and, in ware will be a standard means of learning many cases, to improve upon them. They (along with traditional classrooms). are using the capabilities offered by the According to Kurzweil, things will really Internet and other kinds of information start to get interesting around 2029, when technology to transform how they do busi- a $1,000 (in 1999 dollars) unit of computa- ness by extending their accessibility, making tion will have the computing capacity of better use of their organizational informa- approximately 1,000 brains and direct neur- tion, using encounters with customers to al pathways will have been perfected for gather new information, and using such high-bandwidth connection to the human information to develop new services. brain. By that time, automated agents will These developments are influencing be learning on their own and significant the general public’s performance expecta- knowledge will be created by machines tions for other industries, including health with little or no human intervention care. If some industries can become more (Kurzweil, 1999). accessible and flexible, provide streamlined Whether or not Kurzweil’s predictions services, integrate information, and offer are totally on target, the major thrust of his greater value, why not all industries? hypotheses is difficult to ignore. And, although the pace of development Technological advancements will not only may be mitigated somewhat by well-publi- continue, but will do so at an accelerating cized shortcomings (e.g., temporary unavail- rate of speed, with the ultimate impact ability of Web sites or inability to fill orders being unavoidable for our society and placed electronically during peak periods), economy. Organizations cannot afford to the general direction is irreversible. ignore the direction and magnitude of the Ultimately, success will gravitate to those forthcoming changes. who reliably deliver on these emerging criteria of high performance. 5 Knowledge as Capital effort to find it and make it explicit C ompetitive success has always been a function of a firm’s knowledge about how to optimize its resources. Compared to (Nonaka and Takeuchi, 1995). Once knowledge is captured in a way other assets (i.e., land, capital, and labor), that allows it to be described, shared, and the role of organizational knowledge has deployed to do something that could not be grown over time. The current information- done previously, it becomes an organization- based, global economy has transformed this al asset or intellectual capital (Stewart, intangible asset into the primary source of 1997). Unlike other assets that are easily wealth for firms and nations. Knowledge accounted for and managed, the value of and information now are both raw materials this asset resides in an organization’s people, and valuable products. Not only has the structures, and relationships. Simply spend- knowledge intensity of goods and services ing more money on experts, information increased dramatically, but knowledge and systems, or databases will not, however, information also play a critical role as orga- increase intellectual capital. These actions nizations adapt to their ever-changing envi- must occur within an environment that is ronment. The increasing speed of change in shaped by strategies that focus the allocation markets, staff attrition, growth in the scope of organizational knowledge resources on of organizations, globalization of markets clearly defined goals and that expects and and firms, growth in networked organiza- enables colleagues to share and act on infor- tions, and changing consumer expectations mation, knowledge, and expertise. all place new demands on organizations that Organizational efforts to develop such can be offset through management of infor- strategies and create such an environment are mation and knowledge (Cole, 1998; often described as knowledge management. Stewart, 1997). Knowledge management initiatives generally Organizational knowledge is typically focus on two fundamental objectives: enable tacit rather than explicit (Bock, 1998). It knowledge sharing and use knowledge to appears in unwritten rules, undocumented generate value (See Exhibit 2.) Successful experiences, and uncaptured expert talent. knowledge management initiatives underlie This important resource tends to be local; existing business processes; support specific taken for granted by those who possess it; business strategies and objectives; focus on not easily codified; and, therefore, often dif- solution of concrete problems; provide a ficult to communicate. As the value of range of tools that can be skillfully used by knowledge has grown, the transformation of workers; and, most importantly, lead to tacit to explicit knowledge has become one action as a result of the new knowledge or of the most important challenges for organi- insight gained. zations. It cannot, however, be met by tech- A growing number of business leaders nology alone. Knowledge transformation consider the ability to manage and act on and diffusion is most likely to occur in an organizational knowledge as essential to the environment of trust through dialogue and success of firms (Wah, 1999). A diverse set interactive problem solving. Knowledge of companies are strengthening and, in generally spreads when people gather and some cases, transforming themselves by share stories or if they make a systematic focusing on, capturing, organizing, commu- 6 nicating, and acting on their organizational 1998; McCune, 1999). In essence, these knowledge. These companies are succeeding companies are using knowledge to extend in reducing costs, improving quality, stream- capabilities, strengthen relationships, and lining processes, managing huge organiza- create value. Along the way, many of them tional changes, creating new products, have enhanced their company culture and improving productivity, and retaining criti- sense of identity in order to drive substan- cally important knowledge workers tial changes. (Stewart, 1997; Davenport and Prusak, I have long believed in technology, what can be done, will be done. In every other industry and endeavor, information technology is revolutionizing how work is done. It has become or is becoming the X Factor. I believe it will do so in medicine too. – The X Factor, Andrew Grove, Journal of the American Medical Association, October 21, 1998 7 AHCs and Knowledge them (North Carolina AHEC A lthough AHCs differ in many ways, knowledge is a core element of these organizations. Each of the AHC missions Program, 1999 ). A wide range of information and relies upon communication, application, knowledge needed by AHC staff or their and analysis of an ever-growing volume of customers is increasingly available online complex information and knowledge. (e.g., institutional policies, medical school Sharing of information and knowledge applications, residency opportunities, lec- among researchers, between clinicians, with tures, expertise of faculty within the institu- patients, from teachers to students, from tion) (Johns Hopkins Medicine, 1999a and mentors to residents, and sometimes even 1999b). In some cases, this material is for- across these lines is the cornerstone of daily matted for a specific target audience. For AHC operations. AHCs have been gradual- example, as part of an effort to create better ly expanding their methods of sharing, patient services, billing, and scheduling, developing, and applying knowledge as Emory Health System is developing a Web information technology evolves. To varying site for the general public that will offer degrees and in a variety of ways, AHCs information on wellness, disease manage- make information and knowledge more ment, clinical trials, and how to access ser- accessible for internal and external users, vices at Emory (COR Health LLC, 2000; target how knowledge is presented, and Emory Health System, 2000). In other insert knowledge into routine processes to instances, AHC staff are using information improve efficiency or outcomes. Some and knowledge that are readily accessible to AHCs are becoming more sophisticated in improve processes (e.g., use standard tem- their use of knowledge as a means of inter- plates in preparing grant proposals or make acting with potential or actual consumers. online image databases available to assist As primary knowledge repositories for faculty in preparing lectures) (University of AHCs, health sciences libraries have been at Virginia, 1997; Johns Hopkins Medicine, the forefront of acquiring access to and 1999c). Clinical information systems now making available the knowledge needed by include clinical alerts and reminders and AHC professionals. The shift from print to real-time access to most current medical digital media is enabling libraries to bring knowledge to ensure that complete data are knowledge closer to the actual site of work collected, to assist clinicians in making for more convenient and faster use. In addi- sound decisions, and to minimize adverse tion, health sciences libraries have used their events (Bates et al., 1998; Hunt et al., 1998; knowledge resources and staff expertise to Sackett et al., 1998). Vanderbilt University support a variety of communities important formats clinical protocols for residents to to, but not physically part of the AHC. For load into Palm Pilots, thereby providing example, medical student preceptors are immediate access to important knowledge. often provided access to online knowledge In addition to disseminating knowl- sources. The North Carolina AHEC is edge through traditional mechanisms (e.g., building upon this concept by providing classrooms, rounds, publications), AHCs preceptors access to a customized library have begun to offer online education oppor- and creating a virtual faculty lounge for tunities for students, residents, professionals, 8 and patients (Sikorski and Peters, 1998; Chicago, 1999). It is now easier to dissemi- University of Virginia Health System, nate and access information about clinical 2000a and 2000b). AHCs have also begun trials and resulting protocols. Patients from to repackage the knowledge generated with- a broader area can also participate in these in their institutions for other users to meet studies (National Library of Medicine, 2000). specific market needs and to form partner- Similarly, biomedical researchers can more ships that combine knowledge bases or easily submit their findings or access the dis- establish more effective knowledge distribu- coveries of other researchers via a govern- tion channels. For example, Johns Hopkins ment established mechanism for manage- publishes the Johns Hopkins Family Health ment of research results related to human Book and established a Web presence for its genome or use computational tools provided knowledge in the form of Intelihealth by the National Center for Biotechnology (Intelihealth, 1999; Johns Hopkins, 1999). Information (National Center for A consortium of midwest AHCs established Biotechnology Information, 2000). Several a Web site to provide specific information universities have established technology resources selected by librarians and informa- transfer offices to manage their intellectual tion professionals (Health Web, 2000). property assets (Stanford University, 2000; Another group of AHCs formed webEBM UNC-Chapel Hill, 2000). These offices to assist clinicians and patients in making assist faculty in obtaining research support informed decisions through the use of from corporate sponsors, license discoveries evidence-based clinical guidelines developed by faculty and staff, and develop (webEBM, 2000). agreements for sending university materials Centralized, longitudinal clinical data- to scientists at other institutions. bases derived from clinical records enable Although a wide knowledge of activi- AHC faculty to study patients over time or ties can be found across AHCs, knowledge across populations while maintaining management activity within and across patient privacy. Such databases enable a AHCs is uneven. Despite their wealth of clinical researcher to focus on questions of knowledge, large pools of highly educated immediate concern to a particular popula- and motivated professionals, and increasing- tion and to use the results to inform clinical ly robust information technology infrastruc- practices in a fairly short time frame or to tures, AHCs underutilize their knowledge. compete for extramural research funding Knowledge enables academic success for (Duke University Medical Center, 2000; AHC professionals, is needed for positive University of Virginia Health System,1999). clinical results, and is the basis for ongoing Through an IAIMS grant funded by the research. It is not, however, a commodity in National Library of Medicine, the and of itself. It is not considered as a form University of Chicago is promoting collabo- of capital that ought to be maximized. rative and translational research by linking The typical AHC organizational struc- basic researchers with clinicians through a ture (i.e., dominated by clinical depart- series of databases including “individual ments) has been credited with inhibiting research interests, gene sequences, genetic enterprise-wide management of revenues, maps, antibodies to the proteins encoded by facilities, and personnel. It also has limited the genes, patient data, and patient slides in evolution of knowledge management prac- the pathology service” (University of tices within AHCs, which have tended to be 9 localized and often individualized rather and leveraged to improve organizational than viewed in terms of meeting organiza- performance. There is a great deal of tacit tional strategies. Knowledge management knowledge within AHC faculty and staff within AHCs is often piecemeal and ad that could advance the strategic objectives of hoc, sometimes initiated by the interests of the organization, if it is identified and a single faculty member rather than being added to explicit knowledge bases. the result of the decision to respond to a As educators, clinicians, and specific organizational need. Typically, researchers, AHC staff share knowledge on a knowledge gained during work processes is daily basis with a variety of audiences. used for one purpose; rarely is it captured Sharing knowledge for purposes of educat- for subsequent application or transferred ing students, treating patients, or dissemi- from one organizational domain to another nating research results is, however, very dif- to improve processes or stimulate new prod- ferent from sharing knowledge to transform ucts, as is increasingly practiced in other a business. Like other successful businesses, industries. Just as AHC faculty and staff AHCs can find opportunities for innovation cross functional lines to perform their work, throughout their institutions – literally from knowledge resources must be released from the ground floor where support services rigid organizational structures and made reside, to clinics and patient care units, to available to all staff who can contribute to classrooms, to research laboratories, to or benefit from them. administrative suites. Within each of the AHCs tend to view organizational missions and the accompanying administra- knowledge narrowly. In addition to the tive and support services, there are multiple medical knowledge that is critical for patient points for gathering or applying organiza- care and basic science knowledge that sup- tional knowledge. At each stage of a work ports research, knowledge exists on a wide process there may be an opportunity to cre- range of topics related to patient prefer- ate greater value simply by making existing ences, suppliers, potential collaborators, knowledge readily available to those who work processes, and in-house experts that need it. has only begun to be captured, managed, Today, the improvement of organizations and the information systems in them is not a matter of making more information available, but of conserving scarce human attention so that it can focus on the information that is most important and most relevant to the decisions that have to be made. ........ Information isn’t the scarce resource; human time and attention is the scarce resource. — Simon, H.A. 1997 10 A Knowledge Infrastructure and assessment of credibility and O ften the most visible element of an organization’s knowledge management initiative is the creation of a knowledge reliability of data and knowledge sources. infrastructure or knowledge web. At its most basic level, the knowledge web con- • Processes to be used to capture nects staff with information and knowledge knowledge from professionals without needed for their work and connects them to adding substantially to their work, to each other. A knowledge web builds upon filter new knowledge to determine and enhances the existing organizational usefulness to others, and to classify and technological infrastructure in at least two code content so that it can be easily ways. First, the technological infrastructure accessed by future users. is used to capture and, in some cases, to • Policies needed to manage issues codify knowledge so that others can access it surrounding intellectual property and in the future. By making organizational in the case of health care, to safeguard knowledge readily available, the knowledge patient privacy when knowledge web eliminates redundant work steps and resources come from patient data. enables staff to focus on unique attributes of a task sooner. Second, it goes beyond sup- • Resources needed to support the port of transactions to support of relation- knowledge infrastructure ships (among staff, between the organiza- (e.g., dedicating staff to managing tion and staff, and between the organization organizational knowledge, expanding and its customers or suppliers) that generate existing information technology value. As an added benefit, establishment of infrastructure, and ensuring that future a strong knowledge web prepares the orga- information technology investment nization for introduction of e-commerce supports knowledge management practices into its business. objectives). In addition to a technological infra- structure and the actual content, the knowl- • Services provided by the knowledge edge web encompasses processes for gather- infrastructure (e.g., defining shared ing, filtering, and disseminating knowledge; services, offering integrated services policies to guide the organization’s develop- to staff ). ment and use of knowledge; and designated staff to manage the knowledge web and • Relationships between and support the organization’s use of knowledge responsibilities of knowledge (Bock, 1998; Davenport and Prusak, 1998). management and information To establish a knowledge infrastructure, an technology staff. organization must address: Firms may develop a knowledge infra- • Content to be included, determined in structure to support a particular kind of part by focus of the knowledge knowledge to be managed, to support a par- management effort (e.g., single unit, ticular group of workers, or to resolve a spe- multiple units, or entire organization) cific organizational need, as has been done 11 by various companies. For example, to max- ence and contributing to improved staff imize the number of problems that can be retention. It includes practice-specific solved with a single telephone call, technical knowledge bases, a catalog, a navigation tax- support representatives at Dell Computer onomy, search engines, a set of templates for Corporation use a knowledge base that use in adding new content, a database advises them on the kinds of questions to describing consultant skills, guidelines for ask callers and guides technicians through ownership of content, and a standardized problem solving (McCune, 1999). Hewlett technology platform. Packard has established an electronic net- A key element of the Cap Gemini work to manage and distribute knowledge Ernst & Young knowledge web is the avail- in response to customers’ demands for rapid ability of filtered sets of online material con- service. The system is used by 1,900 techni- taining essential knowledge a consultant cal staff members whose job is to keep cus- needs to possess to work in a given area. tomers’ systems up and running. Once a The knowledge infrastructure includes a problem is reported, a description of the chief knowledge officer, a knowledge problem and its urgency are entered into a process committee, knowledge networks database. The database is updated as for each of the key consulting domains, a employees work in it so that if the problem nd three knowledge-focused units. One unit is not resolved by the end of shift, it is sent focuses on creating new knowledge, another to the next center with full information structures knowledge into methods and (Stewart, 1997). automated tools, the third gathers and Alternatively, a knowledge web may be stores the firm’s acquired knowledge and designed to provide knowledge resources to external knowledge. the entire organization, as was done by Ernst & Young LLP (Center for Business Innovation, 1996a). The knowledge web supports 80,000 professionals and has been credited with improving their work experi- Just as with health care, the higher education enterprise is entering a period in which market forces could well lead to massive restructuring. — A University for the 21st Century, James J. Duderstadt, 2000 12 A Knowledge Culture Based on research begun in the 1980s, F or a knowledge infrastructure to be effective, the organizational culture must expect and endorse knowledge sharing Xerox has emphasized communities of prac- tice in its knowledge management (Murray, (McDermott and O’Dell, 2000; O’Dell and 1999). Xerox identified a gap between the Grayson, 1998). Enterprise-wide focus is knowledge applied in the field by service essential for organizational success, but not technicians and information found in man- easily achieved in environments where units uals. After studying how technicians interact traditionally have been autonomous. with each other to share knowledge (i.e., tell Employees may be accustomed to hoarding war stories to teach each other to diagnose knowledge in the belief that such behavior and fix machines), the Eureka system was protects their power or ensures their value developed to allow technicians to share their to the organization. Organizations must also stories in the form of electronic tips. Field overcome broader cultural influences. service representatives create and maintain Contemporary society values individuals the knowledge base by contributing tips with technical expertise and those who cre- that are validated by a formal review com- ate knowledge over those who share knowl- mittee. By using a common documentation edge. As a result, staff may be resistant to method to facilitate lateral communication, trying practices developed elsewhere. This the system enables Xerox service teams situation is exacerbated by lack of awareness around the globe to diagnose, solve, and of what and how things are done elsewhere prevent equipment problems. Equally in the organization. important, other groups within Xerox now Thus, organizations seeking to manage access and use the knowledge contained in knowledge need to attend to the nontechni- Eureka to improve their work product. cal components of the knowledge manage- Engineering, manufacturing, and documen- ment infrastructure and begin the gradual tation units use the knowledge to improve process of cultivating an organizational cli- design, production, user instructions, and mate for sharing (see Exhibit 2). Supporting technical manuals. communities of practice is one way to foster Novartis, a life sciences company cre- a knowledge-sharing culture. Informal net- ated in 1996 through the largest merger in works known as communities of practice are history to that point in time, has focused on critical building blocks of a knowledge- creating a knowledge culture since its incep- based company because they provide the tion. Novartis’ corporate objectives include: mechanism by which ideas, information, the “transmutation of accumulated knowl- and new practices spread most easily edge into a corporate asset by exploiting the throughout an organization (Senge et al., vast amount of knowledge across organiza- 1999). Communities of practice or formal tional boundaries; providing easy, rapid work units provide natural boundaries for access to a global knowledge base; eliminat- initiating projects that can then be replicat- ing time and space constraints in communi- ed for similar groups, revised for groups cations; and stimulating associates to experi- with different needs, or expanded for the ence the value of knowledge sharing” entire organization. (Probst, 1998). Accordingly, the company designated knowledge managers, established 13 advisory committees and knowledge net- scouring the work done by small innovative works, and created a series of awards for companies who cannot afford to develop innovative research both within and outside their ideas to maximum potential; and the company. Novartis’ knowledge activities developing partnerships to increase its include: using its knowledge about con- knowledge base on health, safety, and sumers to shape its research and develop- environment issues (Novartis, 1999). ment of nonprescription drugs; routinely The exponential growth of technology in the first two decades of the 20th century matched that of the entire 19th century. The exponential growth of technology in the first five years of the 21st century will inevitably, inexorably, match that of the entire 20th century. — The Age of Spiritual Machines, Ray Kurzweil, 1999 14 Knowledge Management Processes quantification of key internal measures dur- T he most tangible results from knowl- edge management activities often arise from efforts to harvest, transfer, and apply ing completion meetings. Business lessons that emerge from facilitated team sessions organizational knowledge. Hoffman- are translated into best practices and are LaRoche, a Swiss-based international phar- added to the corporate knowledge database. maceutical company, used a knowledge In addition, approximately one-quarter of management initiative to reduce both filing BP business units have knowledge guardians and Food and Drug Administration who help their teams harvest newly created approval time for new drugs. Roche success- knowledge (Wah, 1999). fully improved its performance in applica- The World Bank is using knowledge tion preparation and approval time by map- management techniques to streamline its ping its existing knowledge and prototyping work processes. It has adopted a new the application process to determine what approach for responding to technical ques- knowledge customers need to have and tions (e.g., education strategy development). how to create that knowledge. The applica- Rather than assembling a study team to visit tion for a new indication for one drug a country and write a report, which usually resulted in a reduction in filing time from a takes months, a project manager contacts a projected 18 months to three months and community of practice within the bank ask- approval time from a projected three years ing for advice. Responses come from bank to nine months, at an estimated savings of staff and partners around the world, $1 million per day (Center for Business enabling a report to be produced quickly Innovation, 1996b). and added to the bank’s knowledge base on British Petroleum (BP) seeks to “make development issues. Over 100 communities the reuse of existing knowledge a routine of practice contribute to the knowledge way of doing business and to create new base, which is envisioned to ultimately be knowledge to radically improve business available to anyone via the Internet (World performance” (Wah, 1999). BP’s Peer Assist Bank, 2000). Program has proven to be highly effective in Another class of knowledge manage- transferring knowledge within the organiza- ment activities focuses on increasing the tion (Ernst & Young LLP, 1998a). After ini- knowledge of the organization. KPMG LLP, tial research and data analysis, new project a consulting firm, is using a Web-based cur- teams identify issues needing clarification. riculum on Internet studies to ensure that They call on experts within the company to all staff in its consulting division, from form a group that meets with the project administrative assistants to senior partners, team for one to three days to identify possi- have the necessary skills to respond to the ble solutions to the issues. Invited experts emergence of the Internet as a major busi- participate willingly, even though the task is ness force. The 50-hour course is offered in addition to their regular job. They view online, includes a pretest and final exam as the invitation as an honor and an opportu- well as virtual lectures, and is updated every nity to see what is happening in another 90 days. Within three months of its avail- part of the company. ability online, 95% of KPMG’s domestic A project is not complete at BP until workforce had taken the final test. KPMG those involved have articulated lessons has also developed higher-level courses for learned, action points for the future, and interested staff (Balu, 2000). 15 Rising to the Challenge answer and the new capabilities of comput- H ow AHCs respond to the challenges of defining their role, building new capabilities, becoming more responsive, and ers to process increasingly complex prob- lems. From discovery to application dissem- developing new models for their clinical, ination and all possible combinations of educational, and research enterprises will these three activities, networking will determine their influence in the health sys- become normative behavior. tem of the 21st century – nationally and Today, all AHC personnel need to be globally. The Blue Ridge Group believes knowledge workers (Drucker, 1988). Faculty that AHCs can become leaders within the and staff need to think in terms of what the health community by establishing them- organization needs and to define the selves as premier knowledge managers for all resources (other than financial) they need health knowledge domains (such as health from the institution to be effective in their maintenance, disease management, evi- work in a post-Gutenberg world. AHCs can dence-based medicine, and population use knowledge management activities to health management). Doing so will enable promote desired behavior. Moreover, well- AHCs to evolve from their traditional roots designed knowledge management programs into organizations that are able to respond can facilitate work processes, enrich work to contemporary forces and anticipated experience, and promote career develop- needs of individual patients, regions, the ment of the workforce and thereby increas- nation, and beyond. ing satisfaction of staff. Pursuing this path will require that A variety of factors may impede knowl- AHCs allocate resources to knowledge man- edge management within AHCs. AHC agement. Actual investments in the techno- leaders and staff may underestimate the logical infrastructure will depend on the need to strengthen their knowledge man- current status of an individual AHC infra- agement capabilities and incorporate knowl- structure, but in virtually all cases, addition- edge management practices into their work al attention and investment will be needed processes in light of the myriad demands on to strengthen knowledge management and their time, attention, and financial electronic commerce capabilities. Equally resources. Revenue streams for patient care important and perhaps more difficult will services that depend on externally deter- be the preparation of staff, not only by mined reimbursement mechanisms do not building skills to use knowledge manage- create incentives for health organizations ment systems, but also for a potentially dra- and professionals to pursue nonreim- matic transformation of their roles as clini- bursable activities like knowledge manage- cians, educators, and researchers. Health ment, despite the potential positive impact professionals will increasingly serve as on patient outcome, organizational efficiency, coaches to more of their patients. and ultimately the bottom line. Further, Instructors may function more as collabora- AHCs may not recognize the crucial dis- tors in the learning process. Researchers tinction between explicitly managing their may find that some traditional research organizational knowledge and developing methodologies are too limited given the information systems (see next section). Or, new questions they will be seeking to they may possess a false sense of security 16 created by the fact that AHCs have plex as technology and business models been in the knowledge business since their have evolved. Libraries face growing chal- inception and already have numerous, lenges in keeping up with the growth in albeit disjointed, knowledge management electronic media and the technological activities underway. infrastructure needed to serve patrons on AHC leaders face substantial challenges top of rising subscription costs. Biomedical in creating an environment in which knowl- researchers require increasingly sophisticated edge and information of all kinds are shared capabilities (i.e., access to and expertise in with ease. Such an effort requires decisions biomedical computer applications) to ana- and behaviors that will likely conflict with lyze complex molecular structures and link some traditional AHC habits. Previous them to relevant clinical information. organizational structures and practices, as Current laws and policies aimed at protect- well as reimbursement mechanisms, rein- ing intellectual property are outmoded in forced a tendency to think in terms of the digital environment and a new policy departmental needs rather than the whole framework has not yet begun to take shape enterprise and to hold onto information (National Research Council, 2000a). and knowledge rather than to share it. And Managing intellectual property in the AHC even if faculty wanted to share information environment requires a fine balance with colleagues, there typically were limited between the education of professionals and means to do so easily. As a result, sharing dissemination of research results to advance information beyond a work unit was not health and the protection of intellectual standard practice. There are also knowledge property to maximize potential revenue issues that arise because the various business associated with new discoveries. Moreover, units of the AHC – the medical school, the relationships that AHCs establish to nursing school, hospital, public health leverage their intellectual capital – through school, primary care network, basic science funding or collaboration or for dissemina- departments, medical libraries, e-health tion – require new organizational models databases, etc. – have different professional and behaviors and raise new conflict of and administrative knowledge glossaries, interest issues that need to be managed grammars, and standards. (Angell, 2000; COR Health LLC, 2000; Several knowledge issues of particular Intelihealth, 1999 ). concern to AHCs have become more com- Universities are a collection of brilliant people, but not examples of collective brilliance. Because there is little information flow, the university is not intelligent as a whole. — Betty Zucker, as quoted in Intellectual Capital: The Wealth of New Organizations by Thomas A. Stewart, 1997 17 IT in Support of AHC Knowledge Management old improvement for the practice of sound A HC leaders and staff may view the presence of an information technology (IT) infrastructure as equivalent to knowl- medicine and is not easily achieved in the complex AHC practice environment, as it edge management. Certainly, mature requires overcoming historical differences knowledge management initiatives cannot in how inpatient and outpatient records succeed without a robust IT infrastructure, were maintained. but knowledge management encompasses Despite the considerable progress much more than technology because knowl- achieved, however, significant work remains edge management is ultimately about for information systems to meet the needs behaviors and actions. Moreover, not all IT of contemporary health care and for indi- is capable of supporting knowledge manage- vidual organizations to implement truly ment efforts. Ultimately, an organization’s robust systems throughout their organiza- knowledge management should inform and tions. In addition to widely known issues drive the IT infrastructure development. To surrounding health care IT (e.g., confiden- accomplish this objective, some organiza- tiality protection, ease of use, standards for tions name a chief knowledge officer to data), outstanding needs generate additional oversee knowledge management efforts and requirements for information systems in to work with the chief information officer AHCs (Goldsmith, 2000). For example, one (see Exhibit 3 for comparison of chief infor- as yet unmet requirement for information mation officer and chief knowledge officer systems is the ability to generate three dis- roles within an AHC). tinct kinds of clinical data sets. In addition Much like their organizational struc- to the patient records traditionally main- ture, the IT infrastructure of AHCs — tained by health care organizations to sup- including electronic mail, office support port institutional needs, increasingly software, clinical information systems, patients seek to maintain their own records online access to health knowledge sources, to aid in the long-term management of and a variety of administrative systems – is their health. The growing emphasis on typically large, complex, fragmented, domi- managing population health requires data- nated by the clinical operation, and gradual- bases that incorporate health information ly becoming more integrated. AHCs have for the residents of entire regions. Each of advanced their technological platform con- these kinds of health records — personal, siderably during the past decade and are organizational, and population — impacts continuing to do so by implementing more research and education, as well as patient comprehensive and integrated systems, care, and is an important element of the building institutional Web sites and health information infrastructure for the resources, and confronting issues surround- country, but to date organizational health ing the control and management of infor- records have received the most attention mation systems. For example, many AHCs and development (National Committee on are making strides toward achieving the Vital and Health Statistics, 1998). objective of having all relevant patient data Organizations seeking to manage their available to health professionals during a knowledge effectively require an even higher patient encounter. This represents a thresh- level of capabilities from their IT infrastruc- 18 ture. Current information systems within many AHCs, but just-in-time knowledge AHCs facilitate communication; collect, access is not a standard part of each health organize, and provide access to data; stream- professional’s interaction with their organi- line certain work processes (e.g., ordering zation’s information system (Chueh and tests and reporting results); and, in some Barnett, 1997). Similar opportunities exist cases, guide clinical decision-making to support research and education through through alerts or links to knowledge just-in-time knowledge strategies, as well. sources. In addition to these functions, a For example, AHCs face the ongoing chal- knowledge management infrastructure facil- lenges of sharing knowledge among itates connections within communities or researchers in real time, increasing the effi- practice or work units; provides access to all ciency of research, and quickly moving the the kinds of knowledge needed for staff to knowledge created through research into perform their work; increases organizational practice and teaching. knowledge; and promotes the use of knowl- A knowledge management system can edge in routine tasks, innovation, and inter- enable AHCs to optimize resources spent actions with customers. on obtaining access to external knowledge Thus, an information system that is sources as well as the time spent by faculty part of a knowledge management infrastruc- and staff on keeping up with the knowledge ture includes standard terminology, directo- in their field. Individual departments or ser- ries of available contents, robust search vice centers may provide staff with sum- engines, templates for easy collection of maries of seminal journals for their field. knowledge, both global and unit-specific Urgent findings can be highlighted in regu- databases and knowledge sources, and lar bulletins and linked to the records of prompts or alerts of available knowledge patients with relevant diagnoses. Costs of embedded within processes supported by subscriptions can then be consolidated and the information system (McCune, 1999). staff can be freed from reviewing every jour- Moreover, the system is supported by staff nal to focus on those of particular interest. who focus on the knowledge needs of users. Summaries of developments across multiple Ideally, such systems provide the knowledge fields can be combined to offer interdiscipli- needed by users without them having to nary perspectives on advances in clinical think about what they need and how to get it. care and research. A knowledge infrastructure makes An AHC knowledge management sys- needed information and knowledge avail- tem should intersect the clinical arena with able automatically as part of the work the research and education enterprise. If it process, or upon demand to meet specific does not, there is a great likelihood that the requests, or via periodic updates that pro- information systems for each mission will be vide a synthesis of developments with easy designed and implemented so that most of access to greater detail. Clinicians need the potential synergy across the missions immediate focused access to current and rel- will be lost. Specific knowledge resources evant knowledge when making decisions in and processes for capturing and formatting the course of regular patient care. Clinical organizational knowledge are required to alerts (e.g., to prevent adverse reactions) meet the needs of education and research have been shown to be very effective in communities of practice. Particular consid- achieving positive outcomes and are used by eration of how to facilitate knowledge trans- 19 fer across mission domains, organizational units, or specialties is needed. Although a single information system within an AHC is unlikely, consistency among various systems used by staff is desirable and knowledge management practices would be aided by a global index (accessible from each system in use) that identifies how to access various organizational knowledge resources. AHC information systems need to be evaluated in light of the new requirements posed by knowledge management. Does the system reinforce a knowledge management and learning culture? Does the system pro- vide a means of implementing knowledge strategies for patients, referring physicians, students, and staff? Does the system capture the various kinds of information that will form the basis of new organizational knowl- edge? Does the system offer the potential to create advantage in the market by allowing the institution to provide services or pro- vide them in a way other organizations cannot offer? Managing for knowledge means creating a thriving work and learning environment that fosters the continuous creation, aggregation, use and re-use of both organizational and personal knowledge in the pursuit of new business value. — Paul Allaire, Chairman, Xerox Corporation 20 Managing an AHC Asset Recommendation 1. AHCs should explicitly manage their knowledge as an organiza- tional asset to improve their performance and strengthen their ability to meet both the market and social needs of their immediate community or region and the broader health care community. • Which parts of the evolving health T he emergence of the knowledge age is opening a wide range of possibilities for the future of health care. The emergence market (including e-health) it makes sense for an AHC to compete in of the knowledge economy is creating a new set of demands for organizations to meet for • The extent to and means by which success in the market. Meanwhile, the need AHCs can advance health of for a health system that focuses on improv- populations ing the health of the population and man- aging costs presents its own set of challenges • The changing educational to AHCs. The combination of these factors environment, as well as the changing led the Blue Ridge Group to conclude that base of learners (including health knowledge management is a critical success professional students, patients, factor for AHCs in the 21st century. faculty, and staff) Fortunately, the set of characteristics that • The kind of research that will likely define AHCs – multimission, large size, be in demand complex organizational structure, sophisti- cated work, highly educated professionals, • How to build an infrastructure that and a strong tradition of seeking, discover- fosters collaboration across disciplines ing, and disseminating knowledge — pro- and across domains vide the foundation for large gains to be earned through well conceived knowledge • How to generate value in each management initiatives. AHC program Such initiatives must be based on clear- ly defined organizational strategies and sup- Once an AHC has developed focused port organizational mission. Thus, a first organizational strategies for the emerging step for AHCs seeking to expand their environment, it can develop corresponding knowledge management capacity is to knowledge strategies. An AHC may choose assess their current mission and strategies to foster productivity of a particular unit or in the context of the anticipated environ- community of practice, capture existing ment. Among the multitude of factors knowledge for reuse elsewhere in the organi- to be considered: zation, encourage collaboration among researchers, or embed knowledge in routine • The impact of the interconnected encounters with patients and other cus- economy, but not yet fully tomers as a means of solidifying market connected public position. Exhibit 4 presents a scenario of 21 how an AHC might focus its knowledge munity of practice. Both pilot projects and assets on strengthening its clinical enterprise, ongoing programs should have a clear strat- and Appendix 3 describes approaches AHCs egy and be evaluated to determine if objec- can use to strengthen their position as tives are met and to identify those factors knowledge managers in the clinical arena. that contributed to or hindered successful If AHCs follow a path similar to that knowledge management within that organi- of organizations with robust knowledge zation. Highlighting early projects can management programs, knowledge manage- introduce other staff to the concepts and ment practices and infrastructure will benefits of knowledge management, as well become a visible and integral part of daily as reinforce the organization’s commitment operations. AHCs can improve their ability to the endeavor. to share and act on knowledge within and Once pilot projects are underway, an external to the organization by building AHC can attend to the design of its knowl- facile enterprise-wide knowledge webs to edge web (i.e., goals, policies, content, support the various communities of practice processes, staff, and technological infrastruc- that exist within AHCs or in which AHCs ture). This design process should incorpo- participate (including patients, localities, rate lessons learned from the pilot or previ- and surrounding regions). Knowledge man- ous knowledge management experiences, agement initiatives, however, need not and build on work accomplished or underway probably should not begin with organiza- within information technology units and tion-wide implementation. A phased imple- the library (including information technolo- mentation is more likely to yield desired gy and resources already in place), and focus results and complement availability of on meeting the current and projected needs organizational resources. For example, an of the communities of practice. In addition, AHC can initiate limited scope, high AHCs should assign responsibility for lead- impact knowledge projects or build upon ing knowledge management efforts within existing knowledge activity in the near term the organization to “knowledge officers” to strengthen their knowledge management and introduce performance expectations skills, while concurrently developing a that address knowledge management comprehensive knowledge management behaviors by staff. Subsequent phases will infrastructure. likely involve expansion of pilot programs A variety of activities are appropriate and development of the knowledge web for the first phase of an AHC knowledge with sustainable budgets so that the AHC management program. AHCs can begin by as a learning organization can continue identifying their existing knowledge man- its progression. agement activities and assessing their value By already serving as a steward of some in serving their defined needs and potential AHC knowledge, providing integrated ser- to serve as organizational models. Units dis- vices to multiple audiences, and adapting playing clear evidence of explicit knowledge to an increasingly technology-intensive envi- management or early adopters of IT are ronment, the health sciences library is well strong candidates for participation in larger positioned to play an active role in AHC pilot projects. Pilot projects should be knowledge management development. designed to provide specific knowledge Library staff can contribute to the develop- management capabilities to a defined com- ment of the technological infrastructure and 22 consideration of how to manage organiza- tional knowledge that resides outside stan- dard knowledge bases. Aided by IAIMS funding from the National Library of Medicine, some health sciences libraries have already sought such a role (IAIMS Consortium, 2000). In the knowledge-creating company, inventing new knowledge is not a specialized activity — the province of the R&D department or marketing or strategic planning. It is a way of behaving, indeed a way of being, in which everyone is a knowledge worker — that is to say, an entrepreneur. — The Knowledge Creating Company, Ikujiro Nonaka, 1998 23 Preparing AHC Professionals Recommendation 2. AHCs should help current and future health professionals acquire the skills needed to use existing organizational knowledge, prepare for the new demands associated with their professions in the digital era, and contribute to the new disciplines of knowledge management as they emerge. Subsequently, AHCs can focus atten- A HCs face substantial education and training challenges as they increase their knowledge focus and as health profes- tion on developing more subtle but equally important skills. Data management, identi- sionals grapple with their evolving roles. fying gaps in knowledge, developing strate- These issues impact both the educational gies to fill gaps, and capturing new knowl- and operational domains of AHCs, require edge that emerges from organizational expe- both immediate and longer-term responses, rience are capabilities that all health profes- affect current and future health professionals sionals need to master. Traditional classroom alike, and can be addressed through a com- and training experiences, collaboratories (see bination of traditional and innovative below), online tutorials, new curriculum approaches. The content and methodologies content, updated incentives, individual and used in the education of health professionals work unit role models, information systems, will shift perceptibly (AAMC, 2000a). A processes, and policies can all be used to primary objective is to lessen the distance promote knowledge management learning. and discomfort between human (carbon- Defining professionalism in and based) and computer (silicon-based) knowl- preparing students and professionals for a edge so that accessing, processing, and changing environment presents a complex applying the growing knowledge base set of questions for AHCs. What are proper becomes second-nature for all professionals, roles and professional values? What profi- whether or not they are already accustomed ciencies are required? And how does one to information technology and inclined demonstrate accountability in the knowl- toward ongoing knowledge synthesis. edge-based, consumer-focused health econo- From the perspective of transitioning my? These questions are particularly ger- an AHC into a knowledge-managed organi- mane as the care system shifts from one zation, the most pressing need is to ensure designed for and oriented to the deliverer to that staff and students alike understand that one designed for and oriented to the user. A application of relevant knowledge resources critical challenge facing AHCs is to mobilize is an integral part of health care processes. human adaptability to achieve better perfor- This requires proficiency in the use of both mance while remaining connected to and information systems, in general, and the guided by the set of essential values and AHC’s information systems specifically. It virtues that have traditionally shaped health also requires that health professionals and professionals. Faculty and staff need to be students develop, expand, or reinforce a supported during these anticipated transi- consistent habit of incorporating available tions since all are at varying starting points. knowledge into their work processes. 24 The substantial shift in the balance of Learning and practice will be more power is particularly important as a cultural interdisciplinary and will engage people change. AHCs need to create an environ- working in teams (Detmer, 1997; ment where models of new behavior can be Duderstadt, 2000). One term suggested for developed and assessed in the midst of such environments is collaboratories, where change so that health professionals can all stakeholders are involved through some determine which approaches are most representatives capable of both contributing appropriate. This will likely result in new and learning so that smoother, more effec- roles being created and new kinds of inter- tive approaches to care, education, or actions emerging. Explicit boundary-span- research emerge. The goal is more effective ning roles, such as clinician-executives, clini- knowledge transfer, better management, cian-educators, and clinician-researchers, safer care, and better outcomes for the need to become more prevalent as a means resources used. For example, teams of stu- of maintaining balance among the AHC dents and faculty can be established to pur- missions of research, service, and teaching sue relevant and timely problems or issues. (Levinson and Rubenstein, 1999). Such indi- The goal of such a model is not simply mas- viduals equipped with computer-based data tery of knowledge bases through memory repositories and support programs can and study but also development of new assure that knowledge flows across bound- skills and talents on planning and manage- aries and that the databases used by learners ment of change in real-time learning so that contain sufficient common language across others available can discuss just what was domains to carry messages clearly. In time, learned. As an added benefit, the organiza- new models of professional development tion, as well as those directly involved, can may be appropriate, including knowledge capture and apply the output. It is likely managers as a specific discipline within that a number of new models for care, edu- library science or as part of the role of the cation, and research will emerge from these clinician-educator or clinician-manager. various communities of practice within such stimulating environments. The flows of knowledge are what precipitate innovation and innovation is the most prevalent means of competition. — Wellsprings of Knowledge: Building and Sustaining the Source of Innovation, Dorothy Leonard-Barton, 1998 25 A National Health Information Infrastructure Recommendation 3. AHCs should actively participate in the effort to develop and manage a sound national health information infrastructure. information, policies for protecting privacy A s health care becomes more knowl- edge-intensive and its dependence on connectivity increases, the existence of a and rights of authors, issues of ownership of data, both human and financial resources robust national health information infra- needed to develop and manage the infra- structure (NHII) specifically designed to structure, and the level of services provided. meet the needs of contemporary patient As the scale of an NHII far exceeds that of care, health professional education, and organizational systems, the complexity of medical research will grow in importance to issues is magnified. Despite the fact that individual health organizations, particularly health care telecommunications issues are AHCs. Such an infrastructure will ultimate- more complex than those associated with ly impact how well the nation’s health pro- many industries and that the potential fessionals are able to access the ever-growing impact on health is substantial, there is no tangle of knowledge on maintaining health individual or agency responsible for over- and managing disease, the ability for health sight of this valuable public resource nor has care organizations to extend their use of there been much interest among health pro- telemedicine technology, the adoption of fessionals in it. As a result, the infrastructure new education modules for professionals, is not developing to meet the full range of and the ability of researchers to collaborate health needs (National Committee on Vital over distances. In essence, a series of elec- and Health Statistics, 1998). tronic health information resources com- The NHII can impact the health of bined with the technologies that support both individual and populations of patients. the Internet and the workstations of indi- For example, the Internet as currently viduals and organizations constitute what designed may impede telehealth opportuni- now serves as the NHII in the U.S. These ties. The bandwidth allowed in the design resources (e.g., shared research databases, of the Internet is disproportionately sized so clinical repositories, and electronic journals) that a central source can send far more are aimed at health professionals and the information to people’s homes than it is public, are maintained by a variety of public capable of receiving from them. Meanwhile, and private organizations, and are growing telehealth applications require a lot of band- on a daily basis. width sending pictures from homes to help Just as with the development of an guide care in real time (National Research organizational information technology Council, 2000b). Other technological limi- infrastructure, there is a range of issues asso- tations arise for researchers seeking to access ciated with a national infrastructure that the National Library of Medicine’s Visible must be confronted. These relate to technol- Human image datasets or to use the com- ogy adopted, content made available, putational tools that accompany the processes for capturing new knowledge and Genbank database of molecular sequences 26 (Lindberg, 2000). Moreover, recent federal improving health. Second, AHCs can legislative developments could impede actively participate in the development of rather than stimulate the development and processes used to evaluate the quality of use of the NHII, as in the case of pending content included in the NHII. Third, legislation on health data privacy threaten- AHCs can develop training programs that ing use of cancer registries and similar will prepare health professionals who can research databases (Detmer, 2000). use the NHII, as well as help to develop the Several professional societies and gov- NHII. Fourth, AHCs can participate in ernment agencies are already addressing research and development surrounding the some of the issues surrounding an NHII. NHII, through collaborative projects in For example, NLM has a long history of their regions, by serving as institutional test- using the Internet to make its resources beds, and by assessing the effectiveness of available, continues to expand its offerings NHII projects and technologies. AHCs can for broader audiences, has sponsored explore how the NHII can be made most research on applications of the next-genera- useful for health care organizations, profes- tion Internet underway, and commissioned sionals, and individual patients through its a recently released report on the use of the use in their own institutions. Finally, AHCs Internet to support health (National can serve as role models on how to use the Research Council, 2000b). A coalition of resources available through a knowledge organizations has joined forces to provide management infrastructure to improve orga- public health professionals with timely, con- nizational performance within health care venient access to information resources to organizations. aid them in improving the health of the Looking even more broadly, AHCs public (Partners in Information Access for can also contribute to and benefit from the Public Health Professionals, 2000). Despite evolution of a global health information these and other efforts, substantial work infrastructure. By partnering with interna- remains to be done. tional organizations, AHCs can help to AHCs not only have a vested interest make existing knowledge more readily in seeing the NHII evolve in a timely and available to health professionals elsewhere coherent manner, they also have much to and identify new teaching and research contribute to its evolution. First, AHCs and opportunities for their faculty. Shared their professional organizations have consid- knowledge may provide the foundation for erable influence locally, regionally, and collaborative relationships and structures nationally that can be used to bring atten- that extend the influence of an AHC in its tion to the need for the NHII as a means of efforts to advance health (Michigan State enabling knowledge management and University, 1999 ). 27 Partners in Knowledge Recommendation 4. Federal agencies, philanthropic organizations, and professional organizations should advance understanding of the role of knowledge in the future health system and support activities that will further diffuse successful knowledge management practices in health care. new training program to prepare individuals F or knowledge management to become an integral part of the future health sys- tem in the U.S., a variety of public and pri- in biomedical computing applications and to fund research infrastructure needs such vate organizations must continue, expand, as database development, coordination, or initiate programs that promote both the and management (NIH, 1999). Perhaps cultural and technological requirements less obvious, as a major influence for needed for effective knowledge management health care organizations, the Health Care within health care organizations. Such pro- Financing Administration can ensure that grams should include both direct (i.e., fund- its requirements support rather than thwart ing) and indirect (i.e., policy) efforts to knowledge management and make its increase understanding, build capabilities, knowledge resources available to health and promote use of knowledge manage- care organizations. ment by organizations, professionals, and Just as guidelines on the use of com- patients. Health care organizations will ben- puters in clinical data management were efit from funding that supports research, developed in the 1970s, attributes of com- investment in technology, development of puter-based patient records were developed content, creation of new curriculum, and in the 1980s, and criteria for evaluation of training. Federal agencies, accreditation computer-based patient record system organizations, third-party payers, and the implementation were developed in the business community can also advance 1990s, basic components of and guidelines knowledge management by creating incen- for knowledge management systems for tives that reward knowledge management health care organizations are needed by organizations and individuals, as well as (Barnett, 1979; Institute of Medicine, 1997; identifying and removing barriers to knowl- Computer-Based Patient Record Institute, edge management. 1995). Other knowledge management For example, in addition to a continu- research issues include, but are ing role in the development of health not limited to: knowledge sources (e.g., NLM’s Medline Plus and Pubmed, GenBank), federal agen- • Identifying incentives such as cies can ensure that sufficient funding is reimbursement mechanisms that available to train new and retrain existing encourage investment in knowledge health professionals in knowledge manage- management resources by health ment skills. A National Institutes of Health care organizations (NIH) working group on biomedical com- • Identifying effective means of meeting puting recently called for NIH to develop a knowledge needs for health care 28 professionals who are not part of policies, guidelines, and training materials health care organizations (AAMC, 2000b). Currently, through a pro- ject called better_health@here.now, the • Identifying effective methods of AAMC is exploring how medical schools cultivating knowledge management in and teaching hospitals can best use informa- health care organizations other than tion technology in biomedical research, edu- AHCs cation, and health care to improve the health of people and communities (AAMC, • Facilitating knowledge across mission 1999). Part of this project includes a review areas within AHCs of the IAIMS grant program and develop- ment of recommendations on how NLM AHC professional associations (i.e., and other agencies can continue to shape AAMC, AHC, and UHC) already support the scope and context of information tech- knowledge management by pooling and nology applications. These organizations, making available AHC information to their along with AMIA and specialty societies, constituents, as well as by bringing AHCs can fulfill the important role of educating together to share knowledge and collaborate members on knowledge management skills on specific initiatives. For example, AAMC as well as on the need to support develop- has launched a Web site on research compli- ment of an NHII. ance with links to institutions with model The competitiveness of a firm is more than anything a function of what it knows, how it uses what it knows, and how fast it can know something new. — Blur: The Speed of Change in the Connected Economy, Stan Davis and Christopher Meyer, 1998 29 Conclusion potential threat into an unprecedented I ncreasing connectivity resulting from advances in computing and communica- tions technology, accompanied by an opportunity and solidly advance their orga- nizations. Incorporating knowledge man- increasingly consumer-driven market, are agement practices into work processes and changing the speed and nature of economic routinely acting on insights gained from interactions, as well as creating a new source organizational knowledge will benefit each of value for individuals and organizations. mission area, each organizational unit, and Organizations are changing what they do, potentially each patient and staff member. how they do it, and how quickly they do it. Sound knowledge management is essential At the same time, the health care sector to AHCs as they strive to become value- continues to face a set of challenges that driven organizations where: impact the nation’s health, such as lack of universal coverage, the need to create safer • Patients feel connected and view the care systems, and a gap between available institution as a resource not just when and applied medical knowledge (Blue Ridge they are sick, but as they manage their Academic Health Group 1999; Institute of health on a daily basis Medicine, 1999; Haynes et al., 1995). • The surrounding community can Information systems and knowledge man- visibly see how the AHC is agement are linked to the resolution of contributing to monitoring and many of the issues facing health care organi- improving the population’s health zations and will likely account for dramatic changes in health care in the next decade. • The faculty and residents are The Blue Ridge Academic Health supported in their clinical care Group is convinced that AHCs must con- decisions through comprehensive, front the forthcoming changes directly and validated, targeted information and deliberately define their role within a health knowledge — including clinical, care industry that is experiencing constant financial, and administrative data change, amidst an economy that is simulta- neously undergoing transformation. Despite • The education process is an already full agenda and, in some cases, streamlined, interactive, customized, serious financial concerns, AHCs need to multidisciplinary, reflective of the anticipate and manage their forthcoming current practice environment, and organizational metamorphosis. To do so, flexible to meet the needs of students AHCs will need to acquire the organization- al capabilities to function effectively in an • Researchers rely on institutional environment that is increasingly knowledge- knowledge systems to develop driven, connected, fluid, dependent on proposals, manage research grants, more players, and much more responsive and disseminate findings, as well as to to consumers. build communities of collaborators The Blue Ridge Group believes that where data are shared, combined in AHCs can and should expand their knowl- new ways, analyzed, and used to edge management capacity to convert a create new knowledge 30 • The influence and revenue generating opportunities extend beyond its immediate area • Collaboration and innovation are evident throughout the organization • Staff share a common understanding of the institution’s goals and each individual decision is understood as an opportunity to support those goals AHCs (individually and as a group) possess phenomenal energy and intellectual assets with which to transform their organi- zations in response to changing societal needs and expectations and emerging tech- nology. AHCs can use all their various kinds of knowledge to innovate their roles in the health system and can use the organizational processes to fulfill those roles. They can also identify new resources and form new collab- orative relationships that will enable them to increase the visibility of knowledge man- agement as a standard practice for effective health care, education, and research. Moreover, they can promote the develop- ment and use of a national information infrastructure as a means of advancing health. AHCs are well positioned to be lead- ers of the health community throughout the knowledge age. They must, however, take full advantage of their organizational knowl- edge to do so. 31 32 Appendix 1. Previous Blue Ridge Group Recommendations From Report 1. Academic Health Centers: Getting Down To Business 1. AHCs must base their management structures on the “enterprise.” Individual com- ponents of AHCs that currently perceive themselves as independent and isolated must view themselves as integral to a common enterprise and must commit to accomplish- ing common goals and objectives. 2. AHCs must use performance measures with evidence-based value to make informed decisions and to demonstrate public accountability. 3. AHCs should implement business practices based on performance metrics to improve return on investment. 4. AHCs need to develop and implement performance measures that assess AHC impact on the community and region. From Report 2. Promoting Value and Expanded Coverage: Good Health Is Good Business 1. By 2001, Congress should pass legislation that mandates health insurance coverage, whether privately or publicly funded, for all residents as a national objective. By 2005, Congress should pass legislation that creates the framework and authorizes funding for insurance to be extended to all residents. This insurance should provide access to a minimum set of effective health services, including preventive, health maintenance, and acute and chronic illness care. 2. The Department of Health and Human Services, state and local health depart- ments, health care provider organizations, schools of public health, private founda- tions, and other public and private health-related organizations should make popula- tion health management the primary objective of public health. 3. Each community or region should assume responsibility for improving the health of its residents. Each health care delivery organization (public or private) within the community or region should help to initiate (if necessary), actively participate in, and support through their clinical and service programs these efforts to advance the health of residents of the community or region. Federal and state legislators and agencies should support community and regional efforts by developing policies (including dis- tribution of resources) that create incentives for individuals, local agencies, health care organizations and professionals, and employers to adopt strategies that measurably advance health. 4. In addition to participating in community or regional efforts to advance the popu- lation’s health, each academic health center (AHC) should provide leadership–through research and education of current and future health professionals – on population health management and a value-driven health system as fundamental strategies for health care delivery in the 21st century. 34 Appendix 2. External Forces Shaping Health Care Telecommunication capabilities make it I n addition to a multitude of develop- ments within health care that are chang- ing its shape, the health care milieu is also possible to invest less in physical capital and focus more on intellectual capital. being shaped by a series of interwoven Relationships with many employees are external forces, including demographic shifting, as they are more likely to be loyal trends, increasing consumerism, advances in to their work team or profession than to telecommunications and computers, and one company. AHCs have already experi- changes in the nature of economic transac- enced this phenomenon with subspecialists tions. As the U.S. population has aged, in medicine and nursing. In the future, become more diverse, and developed new more and more of the workforce will qualify family structures, its needs and desires have as crucial knowledge workers so that their changed. The past decade of continued eco- leaving the organization will add both sub- nomic growth and the accompanying stantial training and recruiting costs. There increase in purchasing power of many citi- are few examples in AHCs today that are zens has made them more demanding con- more reflective of this trend than are IT sumers. Their overall experience, not just support personnel. Thus, there is a greater the quality or price of a product or service, need to build connections with employees is now one of the factors weighed in their through mentoring, professional develop- consumption decisions (Neuborne, 1999). ment opportunities, or flexible employment Whereas in the past health care was able to models and to maintain contact after staff force the public to deal with its disjointed leave the organization. Moreover, formal service patterns, today more care systems are relationships are giving way to evolving roles moving aggressively to smooth the patient within economic webs, where competitors experience through well-organized disease may now collaborate and businesses increas- management models. Whether through ingly depend on other businesses for their evening and weekend hours for pediatric well-being (Davis and Meyer, 1998). clinics, physician practices located in gro- Mergers between organizations present chal- cery stores, drive-up windows for filling pre- lenges in preserving valuable organizational scriptions, or at- home monitoring of chronic knowledge, as well as aligning and leverag- conditions, health care organizations are ing the combined knowledge base. Global striving to meet these new needs and transactions are now commonplace across demands of patients (Ernst & Young LLP, most industries and offer new potential 1998a). There is a reasonable likelihood markets even for typically local products, that such “user friendly” redesign for ser- but require knowledge of and sensitivity to vices will become a central health industry local cultural and infrastructure concerns. driver in the coming decade (Institute for Not only are businesses responding to the Future, 2000) and that health care will consumer demands for higher levels of ser- increasingly incorporate business practices vice, they have begun to customize their ser- that are standard in other industries as part vices and products. This customization is of its routine operation. possible in part because interactions Advances in information technology between producers and consumers are and communications have changed the increasingly supported by “pervasive con- nature of work and what is most highly val- nectivity” (Davis and Meyer, 1998). Such ued in the market (Davis and Meyer, 1998). connectivity allows greater communication 36 between the customer and producer, and producers use this as an opportunity to learn about customer preferences so that they can anticipate future needs, customize to meet unique needs, and upgrade their offerings through incremental enhance- ments. For businesses, the ideal interaction with customers involves an exchange of information and emotion (e.g., loyalty, esteem, or engagement), as well as compen- sation for the good or service received. 37 Appendix 3. Possible Approaches to Knowledge Management in the Clinical Arena AHCs can seek to harvest knowledge – T he pace of scientific discovery and the accompanying growth in knowledge about maintaining health and managing both explicit and tacit – not necessarily captured through traditional means or in diseases, along with the proliferation of traditional places. For example, in addition users of this knowledge and possible speed to the knowledge from the scientific bases, of diffusion, presents an opportunity for there is knowledge about how the culture of AHCs to reshape their role as educators or particular groups influences whether or not disseminators of knowledge. For example, they will follow treatment protocols, Iowa's Virtual Hospital has been very help- whether an insurer will reimburse for a ful to Iowans and thousands of others given treatment, or how to gain authoriza- (University of Iowa, 2000). By recognizing tion for a certain drug expeditiously. These that not all information is equal and not all aspects of providing clinical services are not users are equal, AHCs and their staff can resolved through literature searches, yet can apply their expertise to helping shape a impact the efficiency and effectiveness of knowledge base that relies upon valid infor- services provided as well as patient satisfac- mation (Cochrane Collaboration, 1999; tion with care. Medem, 2000). Achieving such an outcome Patients themselves represent an will require consideration of what consti- untapped well of information at the same- tutes reliability and development of guide- time as they may be the most important lines to ensure accuracy. Further, AHCs can students that AHCs educate. Clinicians may assist nonmedical consumers of this knowl- find that information shared by patients is edge in understanding specific considera- nonlinear when juxtaposed against their tions for its application. structured data gathering and evaluation. Some AHCs may choose to pursue Those data that are difficult to codify may, their role as knowledge managers quite however, contain valuable insights for care aggressively from the perspective of prepar- of that patient or family member, or may ing their patients and citizens to become point to the need to investigate a broader proficient in using available health knowl- problem within the population. AHCs edge to manage their personal health. could explore alternative ways to capturing Building upon existing community and patient experiences so that patients feel patient education programs (e.g., mini-med heard, encounters with clinicians are effi- schools) and using existing technological cient, and potentially useful information is resources (e.g., computer classrooms), these identified and acted upon (possibly by AHCs may develop and offer classes for the someone other than the primary clinician.) general public, selected employers, or target- Patients are unlikely to know what informa- ed patients on how to access health tion is most useful to clinicians nor know resources on the Internet and assess the what has been captured from previous visits quality of those resources. By interacting and would likely benefit from education on with patients and potential patients in new how to have effective interactions with clini- ways, AHCs may help to solidify local rela- cians. Patient encounters can shed light not tionships and encourage the emergence of a only on immediate health needs, but also new kind of community of practice that may on broader health needs and service prefer- benefit the AHC. ences if such information is captured and shared within the organization. 40 41 About the Blue Ridge Academic Health Group Ridge Group meetings to bring additional T he Blue Ridge Academic Health Group seeks to take a societal view of health and health care needs and to make expertise or perspectives on a specific topic. Blue Ridge Group members collectively recommendations to academic health cen- select the topics to be addressed at annual ters to help them create greater value for meetings. Criteria for selection of report society. The Blue Ridge Group also intends topics include relevance to the operation of to recommend public policies to enable academic health centers and to the ability of AHCs to accomplish these ends. AHCs to provide value to society, the likeli- Three basic premises underlie this mis- hood of being able to make specific recom- sion. First, health care in the United States mendations that will lead to productive is experiencing a series of transformations action by AHCs or other organizations, and that ultimately will require new approaches the ability to frame useful recommendations in health care delivery systems, education, during two-day meetings. research and knowledge management. Before each meeting, an extensive liter- Second, the recent upheavals in health care ature review is conducted. During the meet- have been largely driven by financial objec- ing, participants reflect on emerging trends, tives. Yet, the potential exists for fundamen- share experiences from AHCs, and hear pre- tal changes in health care to improve health sentations on specific issues. Most of the and manage costs. Analysis and evaluation working session is dedicated to a discussion of the ongoing evolution in health care of what AHCs can and should be doing in a delivery must address the impact on the particular area to achieve visible progress, or a health of individuals and the population, as discussion of what public and private policy well as on cost. Third, AHCs play a unique and philanthropic organizations can do to role in the U.S. health care system as they facilitate the efforts of AHCs to fulfill their develop, apply, and disseminate knowledge societal mission. The results of the group’s to improve health. In so doing, they have deliberations are presented in brief reports assumed responsibilities and face greater chal- that are disseminated to targeted audiences. lenges that other health care provider institu- tions do not bear. As a result, AHCs face greater risks and greater opportunities as the U.S. health care system continues to evolve. The Blue Ridge Group was founded in March 1997, by the Virginia Health Policy Center (VHPC) at the University of Virginia and the Health Market Unit lead- ership at Ernst & Young LLP (now Cap Gemini Ernst & Young U.S. LLC). Group members were selected to bring together seasoned, active leaders with a broad range of experience in and knowledge of academic health centers and health care in the United States. Other participants are invited to Blue 42 About the Core Members Enriqueta C. Bond, Ph.D. otolaryngological societies and has taken an President active leadership role in many, including the Burroughs Wellcome Fund American College of Surgeons, the American Society for Head and Neck Dr. Bond is the president of the Burroughs Surgery, and the American Broncho- Wellcome Fund. She formerly held a num- Esophagological Association. Dr. Cantrell ber of research and administrative positions has received the Mosher Award for clinical at the Institute of Medicine, National research, published numerous articles, and Academy of Sciences; Department of lectured nationally and internationally. Medical Sciences, Southern Illinois University School of Medicine; and the Don E. Detmer, M.D. Biology Department at Chatham College. Dennis Gillings Professor of Health Dr. Bond also serves on several advisory Management committees and boards, some of which University of Cambridge include the Council of the Institute of Director, Cambridge University Health Medicine and the National Center for Infectious Diseases, Centers for Disease Dr. Detmer heads the Health Policy and Control and Prevention. She has authored Management Center within the Judge and coauthored more than 50 publications Institute of Management Studies at and reports on science policy. Cambridge University’s Business School. He chairs the Board on Health Care Services of Robert W. Cantrell, M.D. the Institute of Medicine and is a board Vice President and Provost member of several organizations, including University of Virginia Health System the China Medical Board of New York, the Nuffield Trust in London, and the Dr. Cantrell is vice president and provost American Journal of Surgery Editorial Board. for the University of Virginia Health He has authored more than 140 articles and System. Also a surgeon-educator and med- book chapters. Dr. Detmer earned his med- ical administrator, he is the former president ical degree at the University of Kansas after of the American Academy of undergraduate studies there and at Durham Otolaryngology-Head and Neck Surgery. As University of England. He conducts his a captain in the U.S. Navy, he served as work with the Blue Ridge Group through a chair of Otolaryngology-Head and Neck professorship at the University of Virginia, Surgery at the Naval Regional Medical where in the past he served as vice president Center in San Diego, California. Dr. and provost for health sciences and as uni- Cantrell was also the Fitz Hugh professor versity professor. and chair of the Department of Otolaryngology-Head and Neck Surgery at the University of Virginia School of Medicine. He also has been a consultant to the surgeon general of the U.S. Navy and to the National Institutes of Health (NIH). Dr. Cantrell is a member or fellow of 33 43 Michael A. Geheb, M.D. School of Business at the University of Professor of Medicine and Senior Vice Chicago. He has also lectured on health ser- President for Clinical Programs vices management and policy at the Oregon Health Sciences University Harvard Business School, the Wharton School of Finance, Johns Hopkins, Dr. Geheb is professor of medicine and Washington University, and the University senior vice president for clinical programs at of California at Berkeley. Dr. Goldsmith has Oregon Health Sciences University. Dr. served as national advisor for health care for Geheb has also served as professor of medi- Cap Gemini Ernst & Young LLP, was direc- cine, and was the first director and chief tor of planning and government affairs at executive officer of the University of the University of Chicago Medical Center, Alabama at Birmingham Health System. and special assistant to the dean of the Prior to that, Dr. Geheb was associate dean Pritzker School of Medicine. Dr. Goldsmith for clinical affairs and director of clinical has written for the Harvard Business Review services at the State University of New York and has been a source for articles on med- at Stony Brook University Medical Center. ical technology and health services for the Dr. Geheb’s professional associations include Wall Street Journal, the New York Times, the American Federation for Clinical Business Week, Time, and other publications. Research, the Board of Directors of the University Hospital Consortium, and the Michael M.E. Johns, M.D. American Board of Internal Medicine’s Executive Vice President for Health Affairs Board of Directors. Dr. Geheb is coeditor of Emory University the textbook Principles and Practice of Director Medical Intensive Care and coeditor of the The Robert W. Woodruff Health Sciences Center Critical Care Clinics series. He also speaks Chairman of the Board frequently to national audiences on health and Chief Executive Officer care policy issues related to academic pro- Emory Health Care ductivity and financial models for academic clinical enterprises. Dr. Johns heads Emory’s academic and clin- ical institutions and programs in the health Jeff C. Goldsmith, Ph.D. sciences and is a professor in the President Department of Surgery. A former dean of Health Futures, Inc. the Johns Hopkins School of Medicine, he was professor and chair of the Department Dr. Goldsmith’s consulting firm assists a of Otolaryngology-Head and Neck Surgery wide range of health care organizations with at Johns Hopkins. Before that he was assis- environmental analysis and strategy devel- tant chief of the Otolaryngology Service at opment. He is a member of the board of Walter Reed Army Medical Center. Dr. directors of Cerner Corporation and of Johns is a member of the Institute of Essent Corporation. He is currently an asso- Medicine and a fellow of the American ciate professor of medical education at the Association for the Advancement of Science. University of Virginia. He is a former lec- He serves on the governing boards of the turer in the Department of Medicine of the National Research Council and the Clinical Pritzker School of Medicine at the Center of the NIH and on the Advisory University of Chicago and in the Graduate Committee of the Director of the Centers 44 for Disease Control and Prevention. He is Anesthesiology and Critical Care Medicine, president of the American Board of interim dean of the School of Medicine; Otolaryngology and editor of the Archives professor of anesthesiology and surgery and of Otolaryngology-Head and Neck Surgery. medical director of the Surgical Intensive Dr. Johns received his bachelor’s degree and Care Unit at the University of Virginia; continued with graduate studies in biology E.M. Papper Professor and chairman of the at Wayne State University. He earned his Department of Anesthesiology in the M.D. at the University of Michigan School College of Physicians and Surgeons at of Medicine. Columbia University. Dr. Miller has authored and coauthored more than 150 Peter O. Kohler, M.D. scientific abstracts and book chapters. He President received his B.A. from Ohio Wesleyan Oregon Health Sciences University University and his M.D. from the University of Rochester School of Medicine Dr. Kohler is president of Oregon Health and Dentistry. Sciences University. After holding positions at the NIH, he became professor of medi- John G. Nackel, Ph.D. cine and chief of the Endocrinology Division at the Baylor College of Medicine. Managing Director, New Ventures He later served as chairman of the Cap Gemini Ernst & Young U.S. LLC Department of Medicine at the University Dr. Nackel is the managing director, New of Arkansas, then as dean of the Medical Ventures, with Cap Gemini Ernst & Young School at the University of Texas Health U.S. LLC. Prior to this position, he served Science Center in San Antonio. Dr. Kohler as national director, Health Care has served on several boards. He has been Consulting. While with Cap Gemini Ernst chairman of the NIH Endocrinology Study & Young, he has worked in various posi- Section and chairman of the Board of tions and directed numerous projects in the Scientific Counselors for the National U.S. and internationally. He has served the Institute of Child Health and Human pharmaceutical and life sciences, managed Development. Currently, he is chairman of care, and provider segments of the health the Institute of Medicine Task Force on care industry. In his New Ventures position, Quality in Long-Term Care. He is past he oversees the firm’s spinoff companies and chair of the Board of Directors of the strategic investments. Dr. Nackel has pre- Association of Academic Health Centers. sented papers and keynote addresses at more Dr. Kohler received his B.A. from the than 200 professional society and health University of Virginia and earned his M.D. care trade association meetings. He has pub- at Duke Medical School. lished more than 30 articles on applications of cost and quality improvement, informa- Edward D. Miller, Jr., M.D. tion systems and health systems engineer- Dean and Chief Executive Officer ing; and is the co-author of the award- Johns Hopkins Medicine winning book Cost Management for Hospitals. He was co-editor of the Society Dr. Miller is chief executive officer of Johns for Health Systems’ special issue focused on Hopkins Medicine. His former posts patient care. Dr. Nackel received a B.S. include chairman of the Department of from Tufts University and master’s degrees 45 in public health and industrial engineering from the University of Missouri-Columbia. Also from the University of Missouri, he was awarded a Ph.D. in health care systems design from the Department of Industrial Engineering. George F. Sheldon, M.D. Chairman and Professor Department of Surgery University of North Carolina at Chapel Hill Dr. Sheldon’s background in graduate med- ical education spans four institutions: Kansas University, the Mayo Clinic, the University of California at San Francisco, and Harvard University. He is currently chairman and professor of the Department of Surgery at the University of North Carolina at Chapel Hill. He was formerly professor of surgery in the Department of Surgery at the University of California at San Francisco. He has held several national appointments, including president of the American Surgical Association, chairman of the American Board of Surgery, and mem- ber of the Council on Graduate Medical Education. He is currently president-elect of the American College of Surgeons and chair-elect of the Council of Academic Societies of the Association of American Medical Colleges. He has published 195 articles and book chapters and coauthored eight books. 46 About the Invited Participants Gerard N. Burrow, M.D. Mark E. Frisse, M.D., M.S., M.B.A. Special Advisor to the President of Yale for Vice President of Clinical Information Health Affairs Services Express Scripts, Inc. Yale University School of Medicine Dr. Frisse is vice president of Clinical Dr. Burrow is a special advisor to the presi- Information Services at Express Scripts, a dent of Yale for health affairs. He is also a pharmacy benefits management concern. senior advisor to the WHO program on His responsibilities there include the devel- safe motherhood. Dr. Burrow has 44 years opment of Internet-enabled consumer of medical experience and specializes in health information and clinical data analysis endocrinology and thyroid disease. He has systems. Previously, Dr. Frisse was associate held several appointments as assistant pro- dean and director of the Bernard Becker fessor, associate professor, and professor of Medical Library in the School of Medicine, medicine at Yale University and the professor of medicine, and associate profes- University of Toronto and served as dean of sor of medical informatics at Columbia the School of Medicine and vice chancellor University. He also served as a faculty and for health sciences at the University of academic director of the Health Science California at San Diego. He has served as Management Executive M.B.A. program at president of the American Thyroid the John M. Olin School of Business. Dr. Association, and is a member of the Frisse received his B.S. from the University Institute of Medicine of the National of Notre Dame and his M.D. and M.B.A. Academy of Sciences. He is a fellow of the from Washington University in St. Louis. American Association for the Advancement He earned his master’s degree in Medical of Science, and a member of the Society for Computer Science from Stanford Clinical Investigation and the Association of University. He has written frequently for the American Physicians. He serves on the journal Academic Medicine. Board of Directors of Gaylord Hospital, the Sea Research Foundation, and the National Gabriele McLaughlin, M.B.A., Principal Medical Fellowships, Inc. He is past chair- The Document Company – Xerox man of the medical schools’ section of the Xerox Professional Services American Medical Association. Dr. Burrow earned his B.A. from Brown University and Ms. McLaughlin is the subject matter expert his M.D. from Yale University. He has for knowledge management at Xerox. She is served on the editorial boards of several sci- a principal in the industry consulting and entific journals, including the Journal of systems integration organization. She is also Clinical Endocrinology, Metabolism, and a corporate knowledge management cham- Annals of Internal Medicine. He is also coed- pion, and participates in the development of itor of a major textbook, Medical the corporate business strategy for the devel- Complications During Pregnancy. He has opment of knowledge management meth- written more than 150 scientific articles. ods and practices. She is currently involved in projects focusing on strategic linkages for knowledge management and intellectual capital management systems. Ms. 47 McLaughlin holds a Diploma of English ences, and managed care organizations. He Studies from the University of Cambridge, has more than 25 years experience in health England; an undergraduate degree in care and information systems. He has served Business Economics from the Academy on as president of a major health care informa- the Rhine, in Cologne, Germany; and an tion systems vendor, director of a worldwide M.S. for Information Management from information systems health care practice for the American University, in Washington, a “Big Six” accounting firm, and directed D.C. numerous strategic information systems planning engagements for hospitals, multi- Stephanie L. Reel hospital groups, and integrated health care Vice President and Chief Information Officer providers. Mr. Toole received his B.A. from Johns Hopkins University Franklin and Marshall College and certifica- tion from the Executive Graduate Program Mrs. Reel has more than 15 years of experi- in Health Care Financial Management from ence in information systems, working with the University of South Carolina. He serves health care providers and payors. Mrs. Reel on the editorial boards of ADVANCE for is a member of the Information Technology Health Information Executives and Health Board for the State of Maryland, the Health Informatics magazines. He is a past board Care Information Systems Executive and executive committee member for the Association, the College of Health Care Computer-Based Patient Record Institute Information Systems Executives, and the (CPRI); past chairman of the Center for Health Care Information Management Health Care Information Management Systems Society. She has served as chairper- (CHIM); past board member for the son for the Maryland State Health and College of Health Care Information Medical Systems Committee and sits on the Management Executives (CHIME), and a Advisory Board for Villa Julie College, in current member of the American Hospital Baltimore. She is also a member of the Association (AHA) and Health Care Customer Advisory Board for Bell Atlantic Financial Management Association and the Client Advisory Board for (HFMA). Compuware. Mrs. Reel received a B.S. in Information Systems Management from the University of Maryland and an M.B.A. from Loyola College of Baltimore. Jay Toole National Director for Health e-Commerce Practice Cap Gemini Ernst & Young U.S. LLC Mr. Toole serves as a national director for the CGE&Y’s Health e-Commerce practice. 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Parents: http://hsc.virginia.edu/medicine/ New York: Doubleday, 2000. clinical/pediatrics/CMC/tutorial.html, • Sikorski R. and R. Peters. Tools for 2000b. change: CME on the Internet. JAMA • Wah, L. Behind the buzz. Management 280 (11): 1013-1014, 1998. Review 88 (4): 16-26. • Simon, H.A. The future of information • WebEBM. Evidence-Based Medicine: systems. Annals of Operations Research, http//www.webebm.com, 2000. 71: 3-14, 1997. • World Bank, Education Strategy: • Stanford University. Office of Examples of Knowledge Sharing: Technological Licensing: http://otl. http://www.worldbank.org/ks/hatml/ stanford.edu/about/what.html, 2000. examples_education.html, 2000. • Stewart, T. Intellectual Capital: The New Wealth of Organizations. New York: Doubleday, 1997. • University of Chicago. Welcome to UC-IAIMS! :http://www.uciaims. uchicago.edu/interface/welcome.htm, 1999. • University of Iowa. Virtual Hospital: http://www.vh.org. 52 Exhibit 2. Knowledge Management Goals, Strategies, and Actions GOALS STRATEGIES ACTIONS • Enable Create knowledge management culture • Demonstrate leadership commitment through vision statement, time on meeting agenda, and investment in knowledge management resources knowledge • Make knowledge visible and show role of information within an organization sharing • Instill responsibility for knowledge sharing • Establish organization-wide knowledge goals • Align performance incentives with sharing behaviors Build technical and staffing infrastructure • Establish ways to recognize outstanding knowledge management practices by staff • Build connections among people as part of the knowledge-management infrastructure • Appoint a chief knowledge officer (both technically and socially) • Designate knowledge stewards to maintain organizational knowledge bases • Assign explicit knowledge roles and provide assistance to staff seeking information or knowledge • Rotate staff into and out of specific knowledge management roles Harvest organizational knowledge • Establish networks with common hardware and software platforms • Share expertise and best practices • Provide electronic access to knowledge bases wherever staff • Capture past experiences and organizational learning are working • Access valuable knowledge from external sources • Establish electronic connections with customers, suppliers, and other potential partners • Build and mine customer knowledge bases • Develop databases that contain internal and external knowledge (e.g., enter project summary reports into database, document lessons learned, purchase online subscriptions or databases) • Distribute knowledge on demand and push knowledge to staff • Promote learning opportunities (e.g., mentors, multifunctional project teams, communities of practice, training, technology or best practices fair) • Seek to uncover organizational knowledge through knowledge mapping, prototyping, learning history, after-action reviews, and internal benchmarking • Act on • Apply organizational knowledge in decisions, processes, • Try new approaches to stimulate innovation and transactions • organizational Provide open access to company information knowledge and • Embed knowledge in products and services • Identify or create internal knowledge brokers • Create new knowledge through innovation insights • Use knowledge to strengthen organizational relationships • Assess value • Measure knowledge assets and impact of knowledge management Exhibit 3. Chief Information Officer Role Versus Chief Knowledge Officer Role Chief Information Officer Chief Knowledge Officer Overall responsibility Overall responsibility Setting strategy for the technical infrastructure design of infor- Identifying knowledge domains and setting strategy for their mation systems (IS) to support knowledge management strategy. development. These domains are in clinical, research, and educational knowledge areas. Key relationship is with the Chief Knowledge Officer Key relationship is with the Chief Information Officer Specific responsibilities Specific responsibilities • Fiduciary and management responsibility for the develop- ment and ongoing operation of the IS technology network • Identification, evaluation, and development of key infor- including vendor relationships mation databases to be created, acquired, and integrated to establish each domain of knowledge management • Managing IS professionals with technical expertise • Developing and maintaining IS policies and standards to • Managing knowledge management professionals who can organize and assemble content to be deployed using infor- ensure ease of use and access, regulatory compliance, and mation systems technology data integrity • Identifying the IS technical needs and maintenance of • Identifying program needs in knowledge domains and maintenance of relationships with key stakeholders relationships with key stakeholders • Evaluating new IS technology to support the evolution of • Identifying and monitoring new knowledge management approaches knowledge management • Developing and implementing business processes supported • Providing advice on directions and goals of the business processes in each knowledge management domain, by IS technology, including financial and administrative including the business processes to support the AHC systems, to support the AHC and its knowledge management domains Clinical Domain Clinical Domain Stakeholders: groups of patients (populations), individual patients, insurers, referring physicians, AHC physicians, Stakeholders: groups of patients (populations), individual nurses and other care-givers, other employees patients, insurers, referring physicians, AHC physicians, nurses and other care-givers, other employees Sample Activities: Sample Activities: • Standardizing content for medical records, including information to referring physicians and to patients, • Modifying the patient business cycle, including billing and potentially online registration, for ease of use • Developing Web-based strategies to deliver knowledge to • Developing, monitoring, and updating clinical protocols patients and referring physicians Research Domain • Providing technical support for laboratory information systems and filmless clinical imaging systems Stakeholders: researchers, trainees, and administrators Sample Activities: Research Domain Stakeholders: researchers, trainees, and administrators • Establishing standards for scientific databases • Developing knowledge domains for technology transfer Sample Activities: • Developing standard institutional forms and protocols for • Developing databases and sites for dissemination of results submitting grants (both federal and commercial) • Developing and supporting IS tools for grant management Education Domain Education Domain Stakeholders: undergraduate and graduate students, including residents, community physicians, nurses, and other practicing Stakeholders: undergraduate and graduate students, including health professionals residents, community physicians, nurses, and other practicing health professionals Sample Activities: Sample Activities: • Developing content for distance and online learning for students, residents, and practicing physicians • Developing and maintaining Web-based application processes for undergraduates, graduates, and postgraduate • Developing content for secure online testing education • Developing and applying computerized testing technology • Maintaining online tracking of registration, course billing, and continuing medical education credits Exhibit 4. Patient-Focused, Knowledge-Driven Health Care Services Imagine a patient-focused, knowledge-driven AHC • Confidence that all relevant previous health history health system where high quality care is provided effi- is available to health professionals ciently and patients experience convenience, greater • For return visits, the option of pre-registering 24 control in their interactions with AHC, continuity hours prior to a scheduled appointment via the across AHC encounters, integration of all health-related Internet from their home or work site or upon information, and assistance with their ultimate objec- arrival at a clinic terminal tives – staying healthy and achieving good results when treated for illness. In turn, patients develop • Relevant medical literature and institution or physi- stronger affiliation with the AHC insofar as they feel cian specific patient education during visits confidence in and connected to the AHC even when Information about health services that would benefit they are healthy and view the AHC as a partner in their • the patient or his or her family (e.g., stress reduction efforts to manage the health of all family members. classes, how to access credible medical literature in various media, how to access support groups for Such a system might offer the following caregivers of parents) in addition to those typically features to its patients: associated with the reason for a given visit • Access to credible health information via a portal • Ability to use electronic mail to contact physicians established and managed by the AHC directly for non-urgent questions related to ongoing Access to information about the services offered by care or contact triage nurses and receive rapid • response for questions about whether a patient the health system (e.g., by visiting their employer’s employee health office, public library, or searching needs to schedule an appointment the Internet from home) presented in a format that • Invitations to education sessions that might be of represents the viewpoint of the public rather than interest to them (e.g., visiting lectures, community the organizational structure of the AHC and inte- presentations) and notices or bulletins from the AHC grated with insurance coverage information (e.g., to inform the patients about new information on will services be covered and how much will patient topics of concern to the patient or family members pay out of pocket) • Access to designated parts of their medical records • Portfolios of services developed for patient conve- to download into their personal health managers nience (e.g., babysitting services available for fami- (that were provided to the patients at their initial lies with young children or counselors available to visit to the institution) and upload information (via families of terminally-ill patients following visits the Internet or during visits) for key elements of with physicians) information that his or her physician is interested in Access to a designated health coach (either on-line tracking • or in person) who assists in navigating health sys- • Access to billing information to reconcile health tem services and in developing a comprehensive system bills and insurance statements. health plan • Reminders of needed health maintenance (e.g., well- child visits, periodic examinations for adults, flu or tetanus shots) perhaps as part of quarterly health statements that document how well patients are doing in meeting recommended health objectives for their demographic group • The option of scheduling appointments via the Internet (just as airline travelers are now doing) and receiving e-mail reminders of scheduled appoint- ments • Acknowledgement of their status (e.g., new, return- ing, frequent, out of town patient) and specific con- sideration of their needs (e.g., since you lasted visit- ed the following has changed at our clinic) • A single request for demographic, history, insurance, and clinical information upon initial contact with the health system and subsequent confirmation that information is up-to-date Score Retrieval File No. CGEY – HC003