Transparency is a trending word in health care these days and one that is packed with possibility. Executive Editor of The New England Journal of Medicine Gregory Curfman, M.D., boiled it down to this: providing patients with information and involving them as full partners in decision-making. That definition of transparency, which he gave in his introductory remarks at the roundtable discussion entitled “Innovation in Health Care Leadership: Transparency in Quality Data, Pricing, and Medical Records,” fundamentally changes the physician-patient relationship from a beneficially authoritarian, paternalist doctor-patient relationship to one in which the patient is fully informed and the provider has elicited patient preferences and goals. That new relationship hinges on one thing: that payers and providers give patients access to information. The public is eager for it and now providers and payers need to figure out how much and how best to provide it.
As Press Ganey’s Chief Medical Officer Thomas Lee, M.D., has said, “The arc of history is clearly in the direction of transparency.” The roundtable, co-sponsored by The New England Journal of Medicine Group and Harvard Business Review, had a panel packed with who’s who in health care from throughout the country who are disrupting the current asymmetry of health information by embracing transparency in three different areas: quality data, pricing, and medical records.
Amy Compton-Phillips, M.D., chief quality officer of Kaiser Permanente, led the first discussion on provider-driven, quality data transparency, calling her guests, Delos “Toby” Cosgrove, M.D., and Vivian S. Lee, M.D., Ph.D., M.B.A., “disruptive forces counteracting paternalism through transparency.”
When Cosgrove became CEO and president of the Cleveland Clinic 10 years ago, he tapped into his experience as a cardiac surgeon. “In cardiac surgery, we measured everything,” said Cosgrove. “We learned from our mistakes, improved and eventually created outcomes books and a national outcomes registry. It was our responsibility to the public and to our colleagues.”
Cosgrove wanted to bring that level of rigor of quality and transparency to the entire system, and asked each of the chairs of the Cleveland Clinic’s Institutes to do the same. He knew that the data was not so clear-cut in other specialties, so he asked each institute to develop their own set of metrics to measure quality and then make those outcomes available to the public. Today, Cosgrove said, the Institutes publish outcomes books that include around 1300 metrics. The books are widely distributed online and half a million books are printed.
Sharing outcomes data not only showed responsibility to the public, Cosgrove said, but also helped motivate physicians to change behavior and improve. “Data and peer pressure works with doctors,” said Cosgrove, who thinks it’s important to give physicians a sense of where they stand compared to their peers. “No one wants to be last in the class or last in a quality metric.” From a system perspective, the data allows them to celebrate the top 10 percent and manage the bottom 10 percent.
On a parallel track to transparency, Lee, Senior Vice President for Health Sciences, Dean of the School of Medicine and CEO of University of Utah Health Care, showed how data and transparency have been used to engage physicians, change culture, and transform the system into a value-driven organization by first improving the patient experience and then tackling costs.
The University of Utah’s data transparency journey began in 2008 with Lee’s predecessor, Lorris Betz, M.D., Ph.D., who launched a campaign to improve the patient experience. “You can’t be a great medical center if your patients don’t think you’re great,” said Betz, pointing to the system’s 18th percentile ranking for patient satisfaction. Transformation began by rigorously collecting data, via Press Ganey surveys, and then making it increasingly transparent to providers so they could see first their own scores and then how they ranked with their peers. “Most providers don’t like having all red,” said Lee. “They have the desire to improve but not the skills to get there.” The system then focused on providing enterprise-wide Lean training and leadership development to empower providers to change.
In December of 2012, Utah took transparency to the next level and became the first academic medical center to post patient satisfaction scores online with a familiar five-star ranking and patient comments. Lee said they filter less than one percent for defamatory comments.
The end game, Lee said, is to create value by linking patient satisfaction data and outcomes data with cost. That’s no easy task, since true cost data, not just charges, is scattered throughout the system. Two years ago, Lee sequestered a “crackerjack team” to develop a tool, called Value Drive Outcomes. The tool, called VDO, harnessed all of the institution’s data and organized it into a Web-based platform that provides a visual way to look at cost and variability for any given procedure and then drill down to specifics. The plot twist, said Lee, is that transparency with costing data helped providers define new quality and outcomes metrics, which is what they really care about.
Both leaders believe that data transparency and physician engagement are fundamental to success. Having good data, making that data transparent and putting it into the hands of providers has been transformative, said Lee. We need to give physicians tools, and the first tool is data, said Cosgrove. Not just any data, but data they believe and think are important. Lee added that we need to shift the paradigm of looking at data as a “gotcha” moment.” “It’s incredibly satisfying for providers to look at positive comments,” said Lee, and provides a great learning opportunity.
At end of day, it’s providers who lead health care organizations, Cosgrove said. We need to help them understand what the journey is. Communication is an enormous aspect of this. Lee agrees: “When trying to motivate this change, it’s so important to realize that the answers and the solutions are in the hands of providers. If we can unleash that capacity, transformation is going to be possible.”
It’s a journey of a thousand, halting difficult first steps, but we pick up cadence as we go along, said Cosgrove. The driving force to change is to provide better outcomes and better experiences – both physical and emotional – for patients. They’re our North Star when we come to fork in a road, he said. We’ll always make the right decision if we keep the patient in mind.
The New England Journal of Medicine Group and Harvard Business Review co-sponsored a roundtable discussion entitled “Innovation in Health Care Leadership: Transparency in Quality Data, Pricing, and Medical Records.” The event, hosted at the Massachusetts Medical Society in Waltham had both a live and online audience. Watch the full video above.
Some say telemedicine distances health providers from patients. Jonathan Linkous says it draws them close.
Speaking at U.S. News & World Report’s “Hospital of Tomorrow” forum, the American Telemedicine Association CEO spoke of telemedicine’s growing reach, making a persuasive case for its power to improve access to care and lower costs.
Telemedicine has been around for 20 to 30 years depending on how you define it. It started as a means to bring health care to most remote, rural areas.
“Today there are about 100 to 200 networks across country providing such services to about 1 million patients,” Linkous said. “But that’s just the tip of the iceberg.”
A lot of hype about mobile health is just that. But remote radiology is so prevalent it’s not even called tele-radiology any more, and many other specialties are going remote, from webcam visits with psychiatrists, neurologists and dermatologists to remote monitoring of ICU’s.
Verizon, as part of its health benefits package, offers its 700,000 employees 24/7 online access to urgent care providers. “More than 100,000 stroke patients were seen remotely by neurologists this year,” Linkous said.
There remain barriers to telehealth’s broader application, including inadequate bandwidth, privacy laws, refusal of insurers to pay for it and licensing restrictions. “It’s a big area. It’s somewhat controversial. A lot of state medical boards are looking into it. But the truth is, consumers want it,” Linkous said.
Perhaps the most tremendous growth in telehealth has been in remote monitoring of ICU’s. Sentara Healthcare built the nation’s first eICU in 2000. Today, about 13 percent of intensive care beds in the U.S. are remotely staffed in some way, shape or form, said Sentara’s eICU medical director, Steven A. Fuhrman.
Fourteen years ago, the motivating factor was a projected shortage in critical care personnel, chiefly due to an aging baby boom population. Intensive care patients are at their most vulnerable, arguably requiring the most intimate level of care, and trained intensivists are well-documented to improve outcomes, Fuhrman said.
In the early days the novelty of caring for a critically ill patient from 50 miles away “was often met with question marks,” Fuhrman acknowledged. But he said, telehealth’s refined care standards and advances in computerized alerts have measurably improved ICU outcomes.
ICU’s are a natural environment for telehealth because they provide acute, episodic care with lots of electronic monitoring. They’re data rich.
But telemedicine is proving to be useful even with management of complex, chronic diseases.
Robert L. Satcher Jr., assistant professor of orthopedic oncology at University of Texas’ MD Anderson Cancer Center said in the coming decades, cancer will become the most common cause of death in the U.S. and globally. A shortage of oncologists, especially in rural areas and developing countries, he said, virtually guarantees growth of tele-oncology, from online patient counseling and virtual “tumor boards” to remote diagnostics and robotic surgeries.
“Tele-oncology is not an all-encompassing panacea,” cautioned Satcher, noting that it can streamline and improve care or exacerbate inefficiencies and lead to suboptimal care. “Implementation of the technology should be controlled centrally and guided by local needs.
Value. It’s supposed to be the savior of U.S. health care, a fragmented and opaque delivery system where prices are completely divorced from costs, quality or customer satisfaction.
But as it often happens with buzzwords, “value” has become so ubiquitous and laden with importance that it’s nearly devoid of meaning. It’s unmeasured and misunderstood.
In health care, ‘value’ is “truly a fact-free zone,” said Harvard Business School Professor Michael Porter, Ph.D., Monday in his opening address at the US News & World Report’s Hospital of Tomorrow conference in Washington DC. “Before they can improve on value, health organizations need to do get clear on what they mean by value.”
Porter argues value should always be defined around the customer, or patients’ needs – a measure of outcomes achieved per dollar spent. But if that sounds simple, it’s far from easy.
Outcomes aren’t the same as outputs, said Porter, reflecting on a conversation he had with a physician who received an award for controlling the blood sugar levels of her diabetic patients. “She was wondering whether she should accept the award because, though she had done a good job, her facility had the highest amputation rate among leading hospitals,” Porter said. “HbA1c control is a good indicator that you’re on the right track, but you have to hold yourselves accountable to the actual outcomes, the actual results of care.”
Further complicating matters: outcomes are multi-dimensional, hierarchical and patient-specific. No single outcome encapsulates the value of care, said Porter. “Value is ultimately the outcomes we can achieve for dealing with a patient’s medical condition, whether it’s breast cancer or COPD, over the full cycle of care for that condition.”
This poses a measurement and health IT challenge. Focus solely upon the five-year survival rate for men treated for prostate cancer, for example, and you might miss variation in other key outcomes, such as erectile dysfunction and incontinence.
It’s ultimately also an organizational and leadership challenge, Porter said. “We need to move away from organizing around specialties, departments and lines of service to organizing around the patient’s problems. This is a substantial organizational transformation.”
For specialty care this means organizing around episodes of care, and for primary care, it means organizing around groups of patients with similar needs. “Primary care for frail, elderly people is completely different than primary care for a child or healthy adult,” Porter said.
On top of the organizational problem, there’s the vexing issue of getting a handle on costs. Not many health institutions can do it with specificity or in a way that’s tied to the patient. That’s the next step to measuring value, following by payment reform – moving from payment methods that reward volume to those that reward value, or keeping patients healthy and out of the hospital, Porter said. “We believe there is only one way of getting paid that actually aligns with the value of the patient, and that’s bundled reimbursement.”
Health systems can’t abandon volume entirely. “Volume in a medical condition enables value,” said Porter, referring to the economies of scale and quality achieved by focusing on doing one thing well, over and over again. “We need to start aggregating volume in fewer locations,” he said.
Expect more integration and collaboration, even consolidation of health systems, Porter agues. “Right now health systems are loosely confederated groups of stand-alone units that largely do their own thing.”
And expect health systems to expand their geographic footprints. “We’ve been a very localized industry and that has prevented us from having enough volume and reach to deliver enough value,” Porter said.
Taken together, all these pieces of the value puzzle are reinforcing. The question is where to start first?
Porter recommends that measurement be an early focus. “Measurement is very very powerful. If you don’t have a fact-free zone, you know what it really costs and you know what your outcomes really are, it gets a lot easier to agree,” he said. “We see marvelous things happening where you get the data in place. ...It’s doable and the improvements are real and substantial.”
He had ignored the pneumonia-like symptoms for weeks, but awoke Sunday so short of breath he feared having to miss a day of work — his first ever.
Clinics were closed and he didn’t want to go the ER, so Bob Pendleton, a hospitalist and Chief Medical Quality Officer at University of Utah Health Care, phoned a colleague to see if he could be squeezed in. “I just happen to be charting in clinic,” the doctor told Pendleton. “Swing by the office, but drop by radiology first. I’ll call up there and tell them to expect you.”
By the time Pendleton made the drive from radiology to the clinic, his doctor was waiting for him, chest x-rays in hand. Pendleton was diagnosed with pneumonia, given a prescription and back home in under 45 minutes.
“It really crystallized for me the patient-centered experience and where we need to be as a health organization,” he says. “It makes you pause and think, ‘Don’t all of our patients deserve that same level of care? What keeps us from making that happen?’”
Since publication of the Institute of Medicine’s landmark “Quality Chasm” report in 2001, the mantra in health care has been: Less doctor-centered, more patient-centered. But the hard-wired realities of our health system — its fragmented nature, outdated payment models and an ever-changing field of regulations — frustrate even the most tireless champions of patient-centeredness.
Clinicians are do-gooders by nature; they want the best for their patients. But they’re under tremendous pressure to balance an ever-increasing number of competing demands on their time.
“We have 648 different quality and safety measures to track and report to the government. That’s at the system level,” says Pendleton. “At the provider level it’s even more challenging. I’ve got my licensing and certification requirements and the inefficiencies of learning and maintaining a new electronic health record system. If you line up all those things our typical providers on the front lines are actually adding 184 hours a year of additional work.”
Is it any wonder that 36 percent of physicians nationally report symptoms of burnout?
Despite these seemingly insurmountable challenges, however, Pendleton remains optimistic. His recipe for keeping clinicians engaged, happy and motivated, despite all the disruptions to their workflow: Remind them of the end goal.
“It’s got to be about the patient,” he says. “We get so caught up in the day-to-day struggles and CEO speak. But for me as a physician straddling the old world and new world it’s most helpful to remember that we’re doing these things because we believe them to be winning strategies for the patient.”
Regulations, payment models and the brick-and-mortar infrastructure of health systems may seem tethered to the past, but it won’t be that way forever.
“We are in this five-to-ten-year period of choppy waters. It will be very challenging because we are living in two worlds,” Pendleton says. “But it’s also the opportune time to innovate and redesign care in a way that would be the kind of system we would want when we’re patients.”