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Tag: Hospital Compare

Making Transparency Work: Why We Need New Efforts to Make Data Usable

Ashish JhaGet a group of health policy experts together and you’ll find one area of near universal agreement: we need more transparency in healthcare. The notion behind transparency is straightforward; greater availability of data on provider performance helps consumers make better choices and motivates providers to improve. And there is some evidence to suggest it works.  In New York State, after cardiac surgery reporting went into effect, some of the worst performing surgeons stopped practicing or moved out of state and overall outcomes improved. But when it comes to hospital care, the impact of transparency has been less clear-cut.

In 2005, Hospital Compare, the national website run by the Centers for Medicare and Medicaid Services (CMS), started publicly reporting hospital performance on process measures – many of which were evidence based (e.g. using aspirin for acute MI patients).  By 2008, evidence showed that public reporting had dramatically increased adherence to those process measures, but its impact on patient outcomes was unknown.  A few years ago, Andrew Ryan published an excellent paper in Health Affairs examining just that, and found that more than 3 years after Hospital Compare went into effect, there had been no meaningful impact on patient outcomes.  Here’s one figure from that paper:

Ryan et al

The paper was widely covered in the press — many saw it as a failure of public reporting. Others wondered if it was a failure of Hospital Compare, where the data were difficult to analyze. Some critics shot back that Ryan had only examined the time period when public reporting of process measures was in effect and it would take public reporting of outcomes (i.e. mortality) to actually move the needle on lowering mortality rates. And, in 2009, CMS started doing just that – publicly reporting mortality rates for nearly every hospital in the country.  Would it work? Would it actually lead to better outcomes? We didn’t know – and decided to find out.

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HIT: How the VA Reform Bill Benefits Entrepreneurs


VA Chron

Earlier this month, the U.S. Senate passed a Department of Veterans Affairs health reform bill in response to scandals in patient care at VA centers. The $16.3-billion bill,signed by President Barack Obamaincludes measures that will attempt to overhaul information technology and introduce telemedicine procedures at VA clinics and hospitals.

But who’s going to implement these reforms? Infield Health President Doug Naegele talked with G2Xchange Health Cofounders David Blackburn and Eric Klos to understand how the bill might create new opportunities for health entrepreneurs. 

Can you talk for a minute about how some of the bill’s provisions make room for entrepreneurs?

This bill has a number of specific information technology mandates for the VA that are ripe for innovation. Many of the mandates are a direct response to excessive wait times, the need for information sharing when our veterans access care outside the VA, and the gaming that was done by VA staff to hide wait time issues at VA facilities. Three examples of opportunity areas for entrepreneurs include:

1)     Digital Waiting List – You may have seen billboards on the highway that show the Emergency Room wait time at a local hospital. This is an example of the type of transparency that would permit veterans to monitor the average wait times by facility and type of care.

2)     The VA has 90 days to establish a system to monitor and issue Veterans a “Veterans Choice Card,” which will facilitate the receipt of care from non-VA health providers.

3)     Data for patient safety, quality of care and outcomes must be extrapolated from the existing VA electronic health records (VistA) and published as a comprehensive database within 180 days. This data must be “fed”’ into the HHS Hospital Compare website. Again, transparency is a key driver for the VA.

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How Many Patients Did We Hurt Last Month? Learning (But Not Too Much) From The Best Hospitals

I was recently chastised by a colleague for being too negative in one of my pieces on hospital care. His is a remarkable story of what happens when things go well, and it has made me think a lot about why, in some places, things seem to work while in others, not so much.

He told me how a few months ago, soon after returning to Boston from a trip to China, he had started feeling short of breath. When his cardiologist convinced him to be evaluated, he found himself at the Beth Israel Deaconess Medical Center (BIDMC), arriving in the ER late one evening.  He was triaged within minutes, had an EKG within 15 minutes, at which time comparisons were made to previous EKGs.  After ruling out a heart attack, his ER physicians quickly ordered a CT Angiogram.

That test, completed within an hour of his initial arrival to the ER, revealed the reason for his shortness of breath:  he had a large saddle pulmonary embolus.  He was started immediately on IV heparin and sent quickly to the ICU, experiencing essentially no delay in care.  He spent three days there and reports receiving care that was attentive, expert, and consistently of the highest quality.  Even after discharge, he received two nursing visits at home to ensure he was doing OK.  In discussing his experience, he repeatedly emphasized the fantastic communication and teamwork that he witnessed.  Weeks after discharge, he continues to get better and feels the benefits of the excellent care he received.

This is the story we all hope for.  And when I heard it, I have to say that I wasn’t surprised.  There’s something about the BIDMC that’s unusual.  Of the 4,500 hospitals that report their mortality rates to Medicare’s Hospital Compare website, only 22 (less than 0.5%) have better than predicted  mortality rates for all three reported conditions:  heart attack, congestive heart failure, and pneumonia.  And, we know that the combined performance on these three conditions is remarkably good at predicting hospital-wide outcomes, including outcomes for pulmonary embolism.

If you are a patient and care deeply about good outcomes, BIDMC seems to be a good place for you.

So what’s so special about them?  What do they do that’s different?  I don’t know, specifically, all of their tactics, but I have some guesses about what seems to differentiate high performing institutions from the rest.  And in a word, it’s leadership.  BIDMC has had two CEOs over the past few years, and both of them have been unusually committed to achieving high quality care.  That commitment translates into real activities that make a big difference.  Let me divert us with a story of what this might actually mean.

A few years ago, I was working on a strategy for improving the quality and safety of VA healthcare.  As part of this effort, I called up senior quality leaders of major healthcare organizations across the nation.  One call is particularly memorable.  Because I promised anonymity, I will not name names but this clinical leader was very clear about his responsibility: every month, he met with his CEO, who began the meetings with three simple questions: “How many patients did we hurt last month? How many patients did we fail to help? And did we do better than the month before?

The CEO and the entire hospital took responsibility for every preventable injury and death that occurred and the culture of the place was focused on one thing: getting better.  When I looked them up on Hospital Compare, they too had excellent outcomes and they regularly get “A” ratings for patient safety from the Leapfrog Group.

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Transforming Care Through Transparency


By year’s end, the Department of Health and Human Services will announce plans for making its Physician Compare website into a consumer-friendly source of information for Medicare patients about the quality of care provided by doctors and other health care providers. In doing so, Physician Compare will take its place alongside Hospital Compare and more than 250 other websites that offer information about the quality and cost of health care. More importantly, perhaps, it will send an important signal that transparency in health care is the new normal.

To look at these 250-plus online reports is to see the good, the bad, and the ugly of the public reporting aspect of the transparency movement. Some make it easy for people to make choices among physicians and hospitals, and just as notably, let providers see where they fall short and need to improve care. But others ask too much, forcing users to sort through rows and rows of eye-glazing data and jargon that requires a medical degree to fathom.

The Affordable Care Act calls for Physician Compare to offer information about the quality of care, including what physicians and their practices did and the outcome for patients, as well as care coordination; efficiency and resource use; patient experience and engagement; and safety, effectiveness, and timeliness. That’s a lot of information, and it demonstrates the tall order facing the federal government to make the reports meaningful and accessible, so that physicians and patients will both be more apt to use them.Continue reading…

To Gauge Hospital Quality, Patients Deserve More Outcome Measures

Patients, providers and the public have much to celebrate. Recently, the Centers for Medicare and Medicaid Services’ Hospital Compare website added central line-associated bloodstream infections in intensive care units to its list of publicly reported quality of care measures for individual hospitals.

Why is this so important? There is universal support for the idea that the U.S. health care system should pay for value rather than volume, for the results we achieve rather than efforts we make. Health care needs outcome measures for the thousands of procedures and diagnoses that patients encounter. Yet we have few such measures and instead must gauge quality by looking to other public data, such as process of care measures (whether patients received therapies shown to improve outcomes) and results of patient surveys rating their hospital experiences.

Unfortunately, we lack a national approach to producing the large number of valid, reliable outcome measures that patients deserve. This is no easy task. Developing these measures is challenging and requires investments that haven’t yet been made.

The addition of bloodstream infections data is a huge step forward. These potentially lethal complications, measured using Centers for Disease Control and Prevention’s methods, are among the most accurately measured outcomes. In addition, the science of how to significantly reduce these infections is mature, and hundreds of hospitals of all types and sizes have nearly eliminated them. A program to reduce these infections that started at Johns Hopkins Hospital was spread throughout Michigan, and is now being implemented throughout the U.S., demonstrating substantial reductions.

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The Patient Will Rate You Now


These days, I’d never consider trying a new restaurant or hotel without reading the on-line ratings on TripAdvisor or Yelp. I seldom even bother with professional restaurant or travel critics.

Until recently, there was little patient-generated information about doctors, practices or hospitals to help inform patient decisions. But that is rapidly changing, and the results may be every bit as transformative as they have been in traditionally consumer-centric industries like hospitality. Medicine has never thought much of the wisdom of crowds, but the times, as the song goes, they are a-changin’.

Even if one embraces the value of listening to the patient, several questions arise. Should we care about the patient’s voice because of its inherent value, or because it can tell us something important about other dimensions of quality? How best should patient judgments be collected and disseminated – through formal surveys or that electronic scrum known as the Internet? And what are some of the unanticipated or negative consequences of measuring patient satisfaction and experience? All of these questions are being debated actively, and some newly published data adds to the mix.

Traditional Surveys

For the past few years, Medicare has been administering the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey to a random sample of 300-1000 patients discharged from every U.S. hospital. Results are now posted on Medicare’s Hospital Compare website. Starting in late 2012, hospital payments will be on the line, as part of Medicare’s pay-for-performance program, known as “Value-based Purchasing” (VBP).

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Research Shows … the Obvious

A couple of studies out today from Health Affairs belabor the obvious.

First, the one less covered: Hospital Compare, the government website that for the last seven years has provided the public with detailed information about hospital performance, had no discernible impact on improving outcomes. It had no impact on how well the studied hospitals treated heart attacks and pneumonia, and only a modest improvement in outcomes for patients with heart failure. “The jury’s still out on Medicare’s effort to improve hospital quality of care by posting death rates and other metrics on a public website,” says lead author Andrew M. Ryan, an assistant professor of public health at the Weill Cornell Medical College in New York City.

Comment: Since when has disclosure ever affected behavior? Has it stopped physicians from taking money from the drug industry? Has detailed nutrition labels ended the obesity epidemic? Look at how well it is working in campaign finance reform. We have more information than ever about how our elections are being bought and sold. Disclosure is the reform that avoids reform. The real issue for hospitals is how well they do in improving their performance on checklists of quality indicators, and whether that improves outcomes (the QUEST demonstration project at CMS suggests it does). Disclosure of poor performance may be a goad to action (or not, as this current study suggests). But it is not a substitute for action.

The second, more widely reported study showed that doctors with electronic access to patients’ prior imaging studies wound up ordering more imaging tests than doctors without access to such electronic records. Absent other incentives, why would anyone expect otherwise? Imaging is one of the great generators of “false positives” in the medical system. See something on a scan, better get a biopsy or do an angioplasty. Or at least another scan. Double the number of eyes seeing that scan and you double the number of false positives. The depressing fact is that under the current fee-for-service payment system, everyone gets paid that second time around.

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Welcome to the DMV. Your Clerk Will Be With You Shortly.


Have you ever tried to use Medicare data to research a hospital? If so, I bet you’ve been disappointed.

Let’s say you live in Las Vegas and you have heart problems. There are three hospitals nearby. You’d like to know the answer to a simple question. “If I ever have a heart attack where should I tell the ambulance to take me?”

Medicare’s Web site that holds this information is called Hospital Compare. If you visit and search for Las Vegas heart attack care, above is what you’ll find.

Is that helpful?

As you can see the three hospitals within your search are all rated “No Different than U.S. National Rate.” In other words, they are all average. Do the same search in every other city that has more than one hospital and you’re likely to find the same thing. Or you might find that there was not even enough data to calculate an average result.

If you want to find a hospital that’s exceptional, there’s no way to search for it. You can also can’t search for a dud.

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Minor League Report Cards

I was pleased to see the Chicago Tribune carry an op-ed piece this week by my friend and colleague Michael Millenson. The gist of the piece was that information about hospital quality is readily available online and we should use that information when choosing a hospital. Michael is right — there is no shortage of places to turn to get information about hospital quality. But I think he waxes too enthusiastic.

For one thing, it is not clear whether the widespread availability of quality information is a boon or a problem. Consider Medicare’s Hospital Compare website. Look up quality information for pneumonia and you are overwhelmed with nearly 20 different measures on four different web pages. I couldn’t possibly make sense of all this information even if I used sophisticated computer software; how could the average person sort through it all? One quality measure seems to stand out – mortality. But I wonder if this should be a major concern for pneumonia patients. Are we talking about 5 percent mortality rates, or 0.05 percent? I don’t know and Medicare won’t tell me.

HealthGrades.com is much simpler – it just reports mortality. The widely respected Leapfrog Group reports mortality for pneumonia and also reports another 8 general hospital quality measures, some of which are derived from even more measures.

When reading these report cards I find that my local hospital in Highland Park scores very well on mortality in the HealthGrades and Leapfrog reports but I can’t find it anywhere at the Medicare website. And I wonder if the low mortality rate is due to the hospital or due to the demographics of the patients. Michael Millenson pointed out that these report cards are risk adjusted, but he failed to mention that the available risk are pretty lousy – mostly controls for age, sex, and a few comorbidities. (Much better risk adjustment is possible but requires data not available to Medicare, HealthGrades, or Leapfrog.) Hospitals that get poor quality scores often report that their patients are sicker than the risk adjusters give them credit for. They might be right. Hospitals that get good scores never claim that their patients are healthier. Maybe they are hiding something.Continue reading…

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