In Dallas, UT Southwestern’s Leaders Push Ahead on their Ambulatory Quality Initiative
Things continue to move forward at the University of Texas Southwestern Medical Center health system (UT Southwestern) in Dallas, where that organization’s Ambulatory Quality Outcomes (AQO) initiative has been pathbreaking in many ways—so much so that it led the editors of Healthcare Informatics to name the UT Southwestern team as the first-place-winning team in our 2016 Innovator Awards Program.
As we reported in our January/February 2016 issue, UT Southwestern leaders there have succeeded in creating a clinical quality initiative that has been broad, deep, fast-moving, substantive, and agile—and replicable. Indeed, at UT Southwestern, clinician, clinical informatics, IT, analytics, and administrative leaders have come together to create the AQO Project, which is improving processes and outcomes across 40 medical specialties, and using rapid-cycle improvement processes to improve care delivery and care management, physician collaboration, and the capability to participate in meaningful quality outcomes benchmarking. And all of this work continues to be supported by intensive development work on the part of IT and analytics leaders at the organization.
And, as part of our report on the AQO initiative in our January/February 2016 cover story package, we noted, “One very broad specific goal of the initiative was to create robust patient registries in all the specific medical specialties. To date, the leaders of the initiative have built 58 specialty-specific patient registries, created 134 process and outcome measures covering 77 primary and 44 additional medical conditions, created 111 new clinical decision support tools within the EHR, and created 97 new workflows across 40 specialties. Very importantly, 58 patient registries have been created, with over 16,000 patients documented to date, in those registries.”
Among the several leaders of the initiative have been Duwayne Willett, M.D., UT Southwestern’s CMIO; Jason Fish, M.D., the health system’s assistant vice president for ambulatory quality and associate CMIO; Mark Rauschuber, UT Southwestern’s CIO; Jacqueline Mutz, R.N., assistant director of ambulatory quality; and data analysts Ki Lai, assistant vice president for enterprise data services; and Vasihnavi Kaanan EHR [electronic health record] and clinical decision support specialist.
Recently, Healthcare Informatics Editor-in-Chief Mark Hagland reconnected with Dr. Willett to get an update on the AQO initiative. Below are excerpts from that interview.
Dr. Willett, it’s great to reconnect with you regarding the evolution of your team’s work at UT Southwestern. How has the AQO Initiative evolved forward since we spoke at the end of 2015
It’s continued to move progressively forward. Obviously, we’ve been learning lessons as we’ve progressed, and have been able to apply those. We initially did a single registry, and they’ve gotten an appetite for more. We had initially started out with 43 registries; we currently have 81. And 52 of the registries have quality measures associated with them. Sometimes, we’ve just wanted to identify populations for care-gap closure. As a project at first, it’s turned into an ongoing program, and leadership-driven, tied to incentive programs for physicians. And a big push into patient-reported outcomes. We just did an update yesterday, actually. We had representatives of MD Anderson Cancer Center visiting us. And we noted for them that we’ve had 3,200 patients who have completed one or more questionnaires, so something like 225,000 questions have been answered. Over 80,000 of our patients have been put onto registries. In fact, most patients in practices are on at least one registry.
How has the standardization of process and documentation, which were key elements in the initiative at its outset, played out, over the past two years?
We’ve been very thankful we’ve done things in that standardized way. We now have fewer FTEs connected to [the day-to-day management and operations of] the program, but have continued to expand outwards in terms of activity. And we know the set of tools in the toolbox to use. What’s more, the code to calculate the quality measures has been templated out, so they literally now do a “save as,” and so we have a single power-BI [business intelligence] dashboard that can look at all the registries, all from a single data set. So that’s been very helpful.
What kinds of lessons have you learned, as a CMIO, broadly, in the past two years?
One lesson is that there is always this presumption that if you feed people data, esp. physicians, that it will stimulate action. And it’s been very confirmatory of that, that doctors like data, use data, and are willing to take action when they receive data they believe in. And because physicians have been involved in selecting the conditions for the registries, and designing the tool, they’ve been very supportive. One example was in our rheumatology department. The guidelines for care are that they’d like to have them on a disease-modifying rheumatic drug. And it turns out they were actually doing a very good job of that already; were not doing such a good job of assessing patients’ symptom burden—how the patients rated their levels of symptoms. So they set up two measures—one was a process measure. They wanted to know, were they prescribing the right medications?
And second, were they documenting effectively? And what they did was, they said, we have a gap of 3 or 4 percent, in terms of patients who weren’t on optimal medical therapy for their conditions; and they got that percentage down to about 1 percent. And in terms of patients doing self-assessments—in other words, providing us with patient-reported outcomes—essentially, that’s increased.
And that would be particularly valuable in rheumatology as a medical specialty, correct?
Yes. The symptom burden is really key, in terms of patient quality of life. So that was another process—are we collecting this patient information? And then, how are patients doing? So we’re starting to see a shift, with patients reporting fewer symptoms. That’s what we’re hoping to get to. And the challenge coming from our leaders was, process measures are good, but we want to get to outcomes measures. And we see patient-reported measures, we see that as a really fruitful area in terms of determining where we are with all this.
What are the key elements of success in designing, building, and executing on a broad strategy such as the one you and your colleagues have executed on, with the AQO program, from your perspective as a CMIO?
To me, there’s a key technical aspect, and a key sociocultural aspect. On the technical side, what’s important is just thinking through when there’s important real-world information about patients, and asking, where do we want to store that? And being consistent about that. It saves so much reconciliation work—just to store things in a particular location. And among physicians, there’s all this angst about EHRs [electronic health records]. So the tack that I’ve found helpful is, one of the only ways we’ll get more efficient with EHRs is when we record information as soon as possible, and use the heck out of it. So the ability to reuse data, and analyze it, is key.
Meanwhile, and on the sociocultural side, it really is all about simply having the people who actually do the work, being involved in the design of the initiative. That was a major lesson we had learned earlier, when we did some initial projects in which a physician leader made a decision, but that physician was less clinically involved; and those became more difficult to actualize. So Dr. Fish and his team really insist that he and his nurses be involved all the way. Being involved in the quadrad [as the quadri-partite group of stakeholders is known inside the organization]—the actual specialists themselves—has been incredibly important.
That speaks to the classic adage in the business world that “culture eats strategy for lunch.” One of the ingenious elements of your and your colleagues’ strategy at the outset with the AQO initiative, it seems, is that you designed a strategy that acknowledged culture and how human beings think, correct?
Yes, that’s an important point. And while we believe the general principles are replicable, you’re spot on—how this would be accomplished would need to be tailored to culture. And our culture is a very physician-centric culture. And our clinical departments and divisions have traditionally been fairly autonomous. It would not have worked to develop this in a top-down fashion. And it’s not that the central organization isn’t strong; that’s who challenged us to do this. But driving this top-down, would not have done as well here.
So you have to figure out how to use the existing physician culture to change itself, essentially, correct?
Yes, exactly: you have to figure out how to use the culture itself as a strength, rather than battling against it. And most cultures, unless they’re toxic, have real strengths. And tailoring your approach to your local culture, optimizes your chances of success.
What would you say to encourage others to try something like this, organization-wide?
Framing the issue in a positive way, I think, was helpful for us. There had been some cultural weight around the idea that, well, I’ll only deal with the problem list, things I’ve put on there. Our consistent message was to make this patient-centric: if a patient has diabetes and endocrine issues, they still have that when they have other issues as well. And it’s important to create this registry, particularly around trying to move people to accept a standard place to create data, because we want the patient’s record to be complete and accurate, to help their patients. There’s altruism in terms of doctors wanting to do the right thing for patients. That was a helpful way for us to do this, to emphasize that these were patient-centric registries. And you’re the expert in this area, and we want to learn from you, how best to do this across organization.
What will happen in the next couple of years, going forward with the AQO initiative/
We have a couple of challenges to face. Over the past couple of years, we’ve gotten to nearly all the specialties; and we’re building on additional registries. So the two main challenges for us are, one, moving to outcomes measures—our leadership is committed to sharing clinic outcomes with patients. And we’re in a clinically integrated network now with Texas Health Resources. And they’re largely a community hospital network, which is very complementary to us as a tertiary/quaternary medical center. And we have a very large cachement area in the Dallas-Ft. Worth region. So, expanding geographically, and organizationally outside UT-Southwestern to our partners, will be a major focus of work going forward. And once culture and buy-in will be big elements in moving towards success; and they’re very excited about it at THR.
