How can clinician and other patient care leaders move the U.S. healthcare delivery system forward to improve care quality and value? Data, information, and analytics will be absolutely essential, says Greg Poulsen, senior vice president and chief strategy officer at the Salt Lake City-based Intermountain Healthcare. And that is precisely the message that Poulsen shared with attendees on Oct. 25, in his plenary presentation, entitled “Using Information to Improve Clinical Quality and Value,” at the Health IT Summit in Washington D.C., one of the Health IT Summit Series sponsored by Healthcare Informatics, and being held at the Ritz-Carlton Tysons Corner, a Washington, D.C. suburb.
Poulsen walked his audience of healthcare leaders through a detailed narrative around quality and value, in a journey that ended with examples of some of the advances that he and his colleagues at the 22-hospital Intermountain Healthcare integrated system have made using data and information.
Early on in his presentation, Poulsen brought up the concept of capitation, framing it in a nuanced way. “The idea of capitation is more profound than payment: it’s what your idea of healthcare is,” he said. “What we’re trying to do is to maintain people’s health, or fix them when things go badly. It’s summarized well in this new book by Clayton Christensen, Competing Against Luck: The Story of Innovation and Customer Choice. Poulsen shared this quote from Christensen’s book: “The job [most people want to have done] is to be so healthy that they don’t even think about health. Yet, in systems where the providers of care are reimbursed for services they provide, they actually make money when members of their system get sick—it’s effectively ‘sick care’ rather than ‘health care.’”
Meanwhile, Poulsen noted, with regard to the final rule unveiled earlier this month that revealed the requirements for providers under the MACRA (Medicare Access and CHIP Reauthorization Act of 2015) law, “You’ve all seen MACRA—it’s very complex. It’s going to be a challenging set of priorities. But it’s clear in the final rule that they’re pushing healthcare organizations to become accountable care organizations. Those in APMs [alternative payment models] will be far more rewarded than those who stay in fee-for-service. And that’s a good thing. It’s a tough thing, but a good thing.”
But for providers to succeed under alternative payment models, or under the MIPS (Merit-based Incentive Payment System) program (for all those physicians who do not participate in APMs under MACRA), they will need to up their game by leveraging data, information, and analytics to improve their outcomes and resource use, Poulsen noted.
And working with data means working with evidence. In that context, Poulsen shared with his audience some details and insights around the creation of the Dartmouth Atlas, and eventually, the founding of the Dartmouth Institute, by John E. (Jack) Wennberg, M.D. As Poulsen, who knows Dr. Wennberg, recounted it, Jack Wennberg, in one of his first jobs, as a part-time medical director at the Department of Health of the state of Vermont, noticed huge variations in the rates of tonsillectomy among children in that state—from 5 percent in some towns to 95 percent in others. He did some research and found absolutely no difference in clinical outcomes based on whether a particular child underwent a tonsillectomy or not; instead, the differences in frequency of the surgery were based on clinician and parent preference.
From that modest beginning, Wennberg ended up creating the Dartmouth Atlas, dividing up the United States into 306 hospital referral regions, and investigating dramatic variations in the delivery of a variety of medical procedures and in their outcomes. By 1988, Wennberg had established his Center for the Evaluative Clinical Sciences at Dartmouth College, and the rest, as they say, is history.
Poulsen noted for his audience that, not only do unwarranted medical procedures come with a price; in addition, “there’s very little that’s done in the clinic or hospital setting that doesn’t have some risk associated with it.”
And it has been with that double focus—both the desire to carefully shepherd financial and human resources under value-based payment systems, and the desire to improve patient outcomes for their communities—that the senior leaders at Intermountain have been leveraging data and information to minimize variations in care and to improve outcomes across the board.
Among several examples he cited, Poulsen shared about a situation in which he and his colleagues examined the outcomes of cardiothoracic surgeries performed at two different hospitals, one, an Intermountain facility, and the other, a facility owned by a different health system. The key fact? They looked at the outcomes for the same six cardiothoracic surgeons, who were attendings at both hospitals. “The outcomes were very different,” he noted. “Hospital A had a 0.91-percent all-cause mortality rate, whereas the all-cause mortality rate at hospital B was 2.88 percent, case mix-adjusted (and the national average was 3.4 percent; all 2006 data). “The difference was the existence or non-existence of a high-performing team,” he noted. “In other words, patient care is becoming a team sport.”
What’s more, Poulsen noted, when healthcare leaders leverage data analytics to look at clinical and financial outcomes and variations in care and practice, physicians inevitably begin to lower their rates of variation in care practices, as they see data and discuss that data with their peers.
Looking at the big picture around variations in care delivery and outcomes, Poulsen told his audience that, as healthcare systems move forward, not only in the United States, but also worldwide, the shift in health conditions is going to force the leaders of patient care organizations to think differently. For example, he noted, “In 1950, the leading cause of death globally was communicable disease; by 2015, that had shifted dramatically.” He showed two charts, which showed that, in 1950, about 55 percent of global deaths coming from communicable disease, about 22 percent coming from accidents, and about 21 percent from non-communicable disease. The second chart showed about 18 percent of global deaths coming from communicable disease, about 18 percent from accidents, and about 62 percent from non-communicable disease, in 2015. As he explained, the vast majority of these deaths from non-communicable disease are now connected to chronic illnesses such as diabetes, congestive heart failure, and COPD (chronic obstructive pulmonary disease).
In the United States, Poulson noted, the CDC (Centers for Disease Control and Prevention) has documented the following:
Ø Half of all adults have one or more chronic health conditions
Ø Seven of the top ten causes of death are chronic diseases
Ø More than one-third of Americans are obese
Ø Diabetes is the leading cause of kidney failure, blindness, limb amputation, and a key cause of heart disease
Ø 86 percent of U.S. healthcare spending is for people with chronic disease ($2 trillion)
Ø Chronic disease prevalence is increasing far more rapidly than other health issues
Ø Most chronic disease can be impacted or even prevented by lifestyle and treatment
The bottom-line implication of all of this? “We collectively are going to have to be more engaged with people,” in order to bring down U.S. healthcare system costs and improve outcomes and the health of individuals,” Poulsen said. What’s more, because people are living longer in the U.S., “Increasingly, we’re seeing more and more [medically] complex people. We’re living longer. And each issue has a medication associated with it.” As a result, he noted, “Half of people over 65 use five or more prescription medications; and 70 percent of these patients have received these prescriptions from multiple physicians without coordination.” And that has created an emerging danger: “The incidence of polypharmacy complications has risen by 110 percent since 2000.”
After delivering his presentation, Poulsen sat down with Healthcare Informatics Editor-in-Chief Mark Hagland. Asked what he would say in particular to the CIOs of patient care organizations about all of this, Poulsen responded, “I would tell them to make information actionable. You’ve got to depend on your team to be able to see that information is actionable. Sometimes, data is just academically interesting, and that’s great. But what’s much better is when you can see the implications of the data—sometimes clinical, and sometimes operational.”
What can CIOs and other healthcare IT leaders do to help lead the charge or facilitate change? “Something I know is true—and I’ve spent time at Kaiser and chatted with our friends at Cleveland Clinic and Geisinger Health—something I know,” Poulsen said, “is that the leaders who are pioneering change in those organizations look for clinical champions who aren’t necessarily the formal clinician leaders. If you find ones who are formal leaders, that’s great. But sometimes, not.” And often, non-formal physician and other clinician leaders can be just as effective as champions, he emphasized.
Finally, given all the challenges facing healthcare leaders in the U.S. right now, how optimistic or pessimistic is Poulsen about our healthcare system’s ability to change, on a scale from 1 to 10? “Oh, I’m an 8,” he said immediately. “It’s terrifying to think of the magnitude of chronic illness, but with good information and motivation, we can do this.”
