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3. Measure quality at the level of the organization, rather than the clinician.

May 26, 2013• 1

By Berenson, Pronovost & Krumholz

Historically, the physician has been viewed as the leader of medicine, with responsibility for the care and outcomes of patients; in iconic photographs and paintings, the physician is seen as a lone, heroic figure. Such a view has led to natural interest in the measurement of individual physicians’ performance. It is therefore not surprising that some information brokers, including the U.S. News and World Report and many city magazines like the Washingtonian, provide ratings of “top doctors,” often based mostly on reputation, warranted or not.

However, this focus on the individual is flawed for most measures of quality and presents substantial technical challenges. Systems-based care is emerging as a key value within health care and a vital component of high-quality care, while the notion that an individual health professional can be held accountable for the outcomes of patients in isolation from other health professionals and their work environment is becoming an outdated perspective. For example, better intensive care unit staffing sometimes mitigates the evidence that surgeons who perform more procedures achieve better outcomes [21].

The communication and coordination of services across providers is required to ensure that patients, many of whom have multiple conditions, are assisted through various health care settings [22]. For some aspects of care, such as diagnosis errors and patient experience, measuring at the individual physician level might be considered. Nevertheless, focusing measurement on an individual runs counter to our goals in promoting teamwork and “systemness” as core health care delivery attributes.

2. Use quality measures strategically, adopting other quality improvement approaches where measures fall short.

May 26, 2013

By Berenson, Pronovost & Krumholz

While working to develop a broad set of outcome measures that can be the basis for attaining the goals of public accountability and information for consumer choice, Medicare should ensure that the use of performance measures supports quality improvement efforts to address important deficiencies in how care is provided, not only to Medicare beneficiaries but to all Americans.

CMS’ current focus on reducing preventable rehospitalizations within 30 days of discharge represents a timely, strategic use of performance measurement to address an evident problem where there are demonstrated approaches to achieve successful improvement [6]. Physicians and hospital clinical staff, if not necessarily hospital financial officers, generally have responded quite positively to the challenge of reducing preventable readmissions.

CMS has complemented the statutory mandate to provide financial incentives to hospitals to reduce readmission rates by developing new service codes in the Medicare physician fee schedule that provide payment to community physicians to support their enhanced role in assuring better patient transitions out of the hospital in order to reduce the likelihood of readmission [7]. CMS recently announced that after hovering between 18.5 percent and 19.5 percent for the past five years, the 30-day all-cause readmission rate for Medicare beneficiaries dropped to 17.8 percent in the final quarter of 2012 [8], simplying some early success with efforts to use performance measures as part of a broad quality improvement approach to improve a discrete and important quality and cost problem.

However, this Timely Analysis of Immediate Health Policy Issues 3“CMS’ current value-based purchasing efforts, requiring reporting on a raft of measures of varying usefulness and validity, should be replaced with the kind of strategic approach used in the national effort to reduce bloodstream infections.”approach is not without controversy.

Improvements have been modest, and some suggest that readmission rates are often outside the hospital’s control, so CMS’ new policy unfairly penalizes hospitals that treat patients who are the sickest [9]. And while readmission in surgical patients is largely related to preventable complications, readmissions in medical patients can be related to socioeconomic status. Also, some have questioned the accuracy of CMS’ seemingly straightforward readmission rate measure, finding that some hospitals reduce both admissions and readmissions—a desirable result—yet do not impact the readmission rate calculation [10]. And one of this paper’s authors (R. Berenson) has suggested a very different payment model that would reward hospital improvement rather than absolute performance, thereby addressing the reality that hospitals’ abilities to influence readmission rates do vary by factors outstside of their control [11].

1. Decisively move from measuring processes to outcomes.

May 26, 2013

Berenson, Pronovost & Krumholz

There is growing interest in relying more on outcome measures and less on process measures, since outcome measures better reflect what patients and providers are interested in. Yet establishing valid outcome measures poses substantial challenges—including the need to riskadjust results to account for patients’ baseline health status and risk factors, assure data validity, recognize surveillance bias, and use sufficiently large sample sizes to permit correct inferences about performance. We believe the operational challenges of moving to producing accurate and reliable outcome measures, though daunting, are worth the effort to overcome.

Patients, payers, policy-makers, and providers all care about the end results of care—not the technical approaches that providers may adopt to achieve desired outcomes, and may well vary across different organizations. Public reporting and rewards for outcomes rather than processes of care should cause provider organizations to engage in broader approaches to quality improvement activities, ideally relying on rapid-learning through root cause analysis and teamwork rather than taking on a few conveniently available process measures that are actionable but often explain little of the variation in outcomes that exemplifies U.S. health care.

However, given the inherent limitations of administrative data, which are used primarily for payment purposes, and even clinical information in electronic health records (EHRs), consideration should be given to developing a national, standardized system for outcome reporting [1]. A new outcome reporting system would not be simple or inexpensive, but current data systems may simply be insufficient to support accurate reporting of outcomes. An example is the National Health Care Safety Network system for reporting health care infections [2].

GE’s Wellness Program: Bright Shining Light or Dim Bulb?

May 26, 2013• 14

By Vik Khanna & Al Lewis

Health-contingent workplace wellness, the two-time darling of federal legislation codified in both the Health Insurance Portability and Affordability Act (HIPAA) and the Affordable Care Act (ACA), is now plagued by doubts about effectiveness and validity that are inexorably grinding away its legitimacy. This puts employers, particularly large employers who have committed to it so vocally and visibly, in an awkward spot. In the style of politicians nervously trying to change the terms of debate, wellness advocates are now walking back the assertions that have undergirded their entire construct for more than a decade. While some business leaders are apparently either unwilling or unable to back away from this self-inflicted wound, staying the present course is neither inevitable nor required. A course correction might actually prove quite liberating, especially for leaders of smaller and mid-sized businesses who must scratch their heads wondering how they’re supposed to reproduce a big-company style workplace wellness program or even why they should, given the dearth of data on effectiveness.

As a case in point, we offer GE, an iconic American multinational with 305,000 employees, $147BN in revenues, and $16.1BN in earnings worldwide in 2012. The company offers its employees a much-lauded wellness program, saluted by the National Business Group on Health (NBGH) in a fawning 2009 case study. GE’s wellness program has several things to recommend it:

A top line focus on environmental change
An emphasis on strong and consistent positive health messaging to employees
The “Health By The Numbers” strategy that asks employees to commit to essential behavior changes (don’t smoke, eat more produce, walk more, and maintain a healthy body mass index [BMI]; there is wisdom in these choices, as they are the baseline activities for good health)

Beyond these obviously beneficial wellness program components, the GE wellness program veers off into a compendium of wellness convention, with encouragement for employees to take HRAs and get screenings, in particular, mammography, colonoscopy, cholesterol, and blood pressure. Some of the affection for diagnostics springs, of course, from GE’s corporate commitment to health care, which includes selling a broad variety of diagnostic devices to medical care providers who must, in turn, induce demand in order to pay for their contribution to GE Healthcare’s $18.2BN revenue stream.

As far as is discernible from publicly available documents, the wellness program targets GE worksites with over 100 employees, and GE claims in the NBGH case report that over 90% of employees worldwide participate. Beyond these data, however, it is remarkably difficult to understand what results GE gets and at what cost. The only publicly available insight on expense comes from GE wellness leader Rachel Becker in an essay published online by EHS Journal, in which she reports $100,000 per site as the wellness startup cost. Extrapolating this figure to GE’s more than 600 global worksites produces a wellness capitalization expense of about $60M, which presumably does not include annual wellness program operating costs. This might be why GE makes absolutely no mention of the cost or results of its wellness program in either its annual report or its 10K filing, although the NBGH quotes GE as saying the implementation was “inexpensive”. Even though $60M is equal to only 0.38% of GE’s 2012 earnings, it nonetheless might seem an untidy sum to skeptical shareholders.

THCB Marketplace: 2013 Tufts Health Communication Summer Institute

May 25, 2013

This summer, Tufts University School of Medicine’s Health Communication Program will be offering the 2013 Health Communication Summer Institute.

The Institute will feature three professional development courses, described below.

Mobile Health Design examines the impact and potential of mobile devices for consumer health at a national and global level. The focus of the course is on how to design evidence-based health apps that incorporate mobile user experience, predictive analytics, and big data to help people achieve their health goals. The online course runs May 22—June 26, 2013.

Health Literacy Leadership Institute is for those working to improve patient-provider communication and healthcare quality, and those working directly with patients or adult learners in educational settings. Participants work on curriculum development projects of their choice resulting in final products that are comprehensive, informed by research, and reflective of best practice. The course is offered June 10-14, 2013 on Tufts’ Boston Campus.

5th Tufts Summer Institute on Digital Strategies for Health Communication covers how healthcare and public health organizations develop and implement digital strategies to drive the success of their online presence, with a focus on how to use web, social media, and mobile technologies to reach a target audience. The case study is Massachusetts Medical Society. The course is offered July 14-19, 2013 on Tufts’ Boston campus.

Designing for Caregivers

May 25, 2013• 13

By Leslie Kernisan, MD

What user personas do healthcare technology designers and entrepreneurs have in mind as they create their products? And how often is it the family caregiver of an elderly person?

This is the question I found myself mulling over as I wandered around the Health Refactored conference recently, surrounded by developers, designers, and entrepreneurs.

The issue particularly popped into my head when I decided to try Microsoft Healthvault after listening to Microsoft’s Sean Nolan give a very good keynote on the perils of pilots and the praises of platforms (such as HealthVault).

As some know, I’ve been in search of apps and services that can help older adults and their families keep track of lengthy and frequently-changing medication lists. For years now I’ve been urging family caregivers to maintain some kind of online list of medications, but so far I haven’t found a specific app or service to recommend.

Why? Because they all require way too much effort to enter long medication lists. Which means they are hardly usable for my patients’ families.

Could HealthVault do better? Having heard generally promising things about the service these past several months, I signed up and decided to pretend I was the daughter of one of my elderly patients, who had finally decided to take Dr. Kernisan’s advice and find some online way to keep track of Mom’s 15 medications.

Sigh. It’s nice and easy to sign up for HealthVault. However, it’s not so easy to add 15 medications into the system. When I click the “+” sign next to current medications, I am offered a pop-up box with several fields to complete.

A Brief Introductory Course In Personalized Medicine: Read the Chart!

May 24, 2013• 9

By Ricki Lewis

While we’re busy debating the pros and cons of clinical genome sequencing and tossing around buzzwords like “personalized” and “translational” medicine, I’ve recently caught some health care providers ignoring the archaic skills of communication and common sense. So while we await genome analysis apps on our smartphones and DNA sequence annotators in our doctors’ offices, here are 3 suggestions on how to provide personalized medicine right now:

1. Read the patient’s chart (paper or digital)

2. Listen to the patient

3. Look at the patient

Disclaimer: Today’s blog is anecdotal and non-scientific, but may identify a trend.

My Missing Thyroid

A few weeks ago, I had a long-overdue check-up, with a nurse practitioner. It was my first visit to the practice, which had provided excellent urgent care.

On the medical history form, I described my circa 1993 thyroid cancer in intimate histological detail: papillary in left lobe, follicular in the right.

The NP spent an impressive 45 minutes asking questions and listening to me – or so I thought. During the brief physical exam, I told her all about my thyroid cancer, my daily Synthroid dose, and even brought her hand to my throat, having noticed that dentists get very excited at my lack of a thyroid gland. No thyroid tests needed, said I. My endocrinologist had recently done them.

So I was surprised when, early the next morning, a Saturday, my cell phone quacked.

The Doctor Is Happy

May 23, 2013• 17

By Rob Lamberts, MD

It feels dangerous to write this, but…my practice seems to be working.

I am now running and hiding from lightning bolts, meteors, or stray arrows shot in the air by a Scottish soldier. I am also expecting a raid on my office by the IRS, CDC, and BBC tomorrow morning. I don’t know why I wrote that.

But as afraid as I am to admit it, the thing that was once just a good idea is now actually growing and improving. We are up to about 300 patients (with a big infusion when a local TV network did a story on my practice) and have enough money to pay bills without a visit from uncle bouncy. While we’ve started to discuss when we will hire another staff person (probably a nurse), neither me nor my nurse Jamie (may her name be ever blessed) feel overwhelmed at this point. We can handle this volume, which speaks well for the future when we actually have a fully-working system.

The past few weeks have been totally consumed by my need to have an underlying system of organization. After fighting valiantly against the idea for the first two months, I succumbed to the necessity of building my own IT system and have been seeing the many benefits of that decision. Despite being totally obsessed with how data tables connect and whether I’ve left a parenthesis off of a script I’ve written, I now have a place to put data, have a pretty decent task management system, have an integrated address book, and have discussed integration with my phone system vendor, my secure messaging developer, and a lab order/result integration vendor. I’ve also found some strong local tech talent who gets what I am doing and yet doesn’t simply see the market potential for my software.

The reality is, my whole focus is on the practice model, and that model seems to work. As my business and medical care management systems click into place and become more functional, growing the practice should not be a problem. We continue to get several new patients signing up every day, and now the reluctant spouses of establish patients are joining (which is a very good sign – for both my practice and for their marriages).

Let me appease the gods and state clearly that this is by no means a sure thing. There are many, many things that could go wrong. A successful start-up requires not only a good idea and hard work; it also needs requires luck (or at least to avoid bad luck). I could get cancer, my building could burn down, or our city could be overrun by a mob of psychotic llamas. We all know the llama apocalypse is happening; it’s just a question of when, not if. So I accept the fact that I am, to a great extent, in the hands of the fates (and llamas).

The Oregon Experiment Revisited

May 23, 2013• 14

By Ashish Jha, MD

It has been a couple of weeks since the landmark Oregon Experiment paper came out, and the buzz around it has subsided. So what now? First, with passage of time, I think it is worth reflecting on what worked in Oregon. Second, we should take a step back, and recognize that what Oregon really exposed is that health insurance is a small part of a much bigger story about health in general. This bigger story is one we can’t continue to ignore.

So let’s talk quickly about what worked in Oregon. Health insurance, when properly framed as insurance (i.e. protection against high, unpredictable costs) works because it protects people from financial catastrophe. The notion that Americans go bankrupt because they get cancer is awful and inexcusable, and it should not happen. We are a better, more generous country than that. We should ensure that everyone has access to insurance that protects against financial catastrophe. Whether we want the government (i.e. Medicaid, Medicare) or private companies to administer that insurance is a debate worth having. Insurance works for cars and homes, and the Oregon experiment makes it clear that insurance works in healthcare. No surprise.

The far more interesting lesson from Oregon is that we should not oversell the value of health insurance to improving people’s health. While health insurance improves access to healthcare services (modestly), its impact on health is surprisingly and disappointingly small. There are two reasons why this is the case. The first is that not having insurance doesn’t actually mean not having any access to healthcare. We care for the uninsured and provide people life-saving treatments when they need it, irrespective of their ability to pay. Sure – we then stick them with crazy bills and bankrupt them – but we generally do enough to help them stay alive. Yes, there’s plenty of evidence that the uninsured forego needed healthcare services and the consequences of being uninsured are not just financial. They have health consequences as well. But, claims like 50,000 Americans die each year because of a lack of health insurance? The data from Oregon should make us a little more skeptical about claims like that.

So what really matters? Right now, we are pouring $2.8 trillion into healthcare services while failing to deliver the basics. To borrow a well-known phrase, our healthcare system is perfectly designed to produce the outcomes we get – and here’s what we get: mediocre care and lousy outcomes at high prices. Great.

Universal EHR? No. Universal Data Access? Yes.

May 23, 2013• 2

By William Hersh, MD

A recent blog posting calls for a “universal EMR” for the entire healthcare system. The author provides an example and correctly laments how lack of access to the complete data about a patient impedes optimal clinical care. I would add that quality improvement, clinical research, and public health are impeded by this situation as well.

However, I do not agree that a “universal EMR” is the best way to solve this problem. Instead, I would advocate that we need universal access to underlying clinical data, from which many different types of electronic health records (EHRs), personal health records (PHRs), and other applications can emerge.

What we really need for optimal use of health information is not an application but a platform. This notion has been advanced by many, perhaps most eloquently by Drs. Kenneth Mandl and Isaac Kohane of Boston Children’s Hospital [1,2]. Their work is being manifested in the SMART platform that is being funded by an ONC SHARP Award.