Integrating Research and Practice Health System Leaders Working Toward High-Value Care: Workshop Summary (2015) / Chapter Skim
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10 Continuous Learning as an Executive Agenda Priority
10 Continuous Learning as an Executive Agenda Priority
Pages 119-148
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From page 119... ...
These networks allow the systems to leverage their investments in information technology by investigating questions that can be best addressed using data from multiple organizations. • CEOs can create a forum and the mechanisms by which clini cians and patients can pose questions and where researchers and analysts can work out approaches for answering those questions, Raymond Baxter said.
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From page 120... ...
• Taking cost out of the system will not happen without moving toward population health and providing value, and both of those steps require knowledge of the sort that a learning health system can produce, Steven Corwin said. • In the absence of knowledge to refine the blunt measurement of cost and utilization, Corwin commented that he fears that the health care system will bifurcate into one that has hospitals that treat the "haves" and hospitals that treat the "have nots," which would be problematic for the country as a whole.
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From page 121... ...
This panel, which also discussed whether a shared value proposition is the key to sustainability, consisted of Raymond Baxter, the senior vice president for community benefit research and health policy at Kaiser Permanente; David Labby, the chief medical officer at Health Share of Oregon; Patricia Smith, the president and CEO of the Alliance of Community Health Plans; Janice Nevin, the chief medical officer for the Christiana Care Health System; and Russ Waitman, an associate professor of internal medicine at the University of Kansas Medical Center. A second panel discussion, moderated by Lewis Sandy, the executive vice president for clinical advancement at UnitedHealth Group, featured short comments by four health system leaders: Glenn Steele, Jr., the president and chief executive officer of Geisinger Health System; Ronald DePinho, the president of the MD Anderson Cancer Center; Rodney Hochman, the president and CEO of Providence Health and Services; and Steven Corwin, CEO of New York-Presbyterian Hospital.
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From page 122... ...
Prior to the conception of the REDUCE MRSA trial, HCA had already been using a procedure, modeled on what is done in European hospitals, that screened patients for MRSA and then isolated them if they were positive. With support from the CDC, and together with other academic partners, HCA tested the effectiveness of this approach against two other promising strategies: decolonizing MRSA-positive patients with a chlorhexidine antiseptic sponge bath and 5 days of antibiotic therapy delivered via nasal ointment versus universal decolonization of everyone prior to their entry into the intensive care unit.
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From page 123... ...
For example, HCA selected its academic partner for the REDUCE MRSA trial for its expertise in administering large clinical trials and in patient consent issues. It may also be necessary to challenge a health system's clinicians to embrace research that has the purpose of improving performance, which if successful will generate pride that is self-reinforcing.
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From page 124... ...
"We think it's fun and enjoyable to be part of a learning health system." In response to a question from Steele about whether HCA is "monoga mous with randomized controlled trials," Perlin said that the answer was no and that the organization is open to other validated methods of conducting CER. Commenting on the methodological aspects of the trials, Richard Platt of the Harvard Pilgrim Health Care Institute, which was the main academic partner on the REDUCE MRSA trial, noted that the reason it was possible to do this study so effectively was that it relied solely on information that was collected as part of routine care and on data that was available in HCA's clinical data warehouse.
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From page 125... ...
At the same time, a team of Kaiser Permanente researchers, acting at the instigation of Kaiser's National Research Council, queried Kaiser's chiefs of staff and other clinical leaders in the organization to find out what questions they thought most needed answering in order to meet the triple aim. In response to this request, Baxter received 342 questions, which he realized could be an operational agenda for relevant research in a learning health care organization.
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From page 126... ...
David Labby, HealthShare Oregon Labby began his comments by noting that, 2 years earlier, Oregon had adopted the concept of using coordinated care organizations for its
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From page 127... ...
Labby noted that the state cajoled competitive organizations to participate by threatening them with a 30 percent rate cut if they did not join. The carrot was that the state gave these coordinated care organizations the freedom to transform care in ways that best served their interests and the interests of patients at lower cost.
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From page 128... ...
"What they need is a trauma recovery program," he said, "and so our medical home for that population serves as a trauma recovery program." Because this population needs help connecting with peers in their community, Oregon created a certification program for peer wellness specialists who, once they have been certified, become part of the health care workforce. Boards of directors are interested in costs and meeting contracting budgets, Labby said.
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From page 129... ...
In 2011 Christiana created an entity called the Value Institute whose express purpose is to bring together quality improvement and operational excellence and marry them to health care delivery research. "The perspective of our CEO is that the Value Institute is a way for us to focus on value as our fundamental strategy for service," Nevin said.
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From page 130... ...
Performing these measurements requires data, and data require an infrastructure that captures data efficiently, at low cost, and in ways so that the data can be integrated with other data sources. This last issue -- making sure that data can be integrated -- is where much of the initial focus of PCORnet lies, Waitman noted.
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From page 131... ...
• How do you see this agenda really being advanced in the real world that you live in every day? Glenn Steele, Geisinger Health System Geisinger Health System, as Glenn Steele described it, is a "Petri dish for innovation because of our structure and our culture and our demography." Indeed, the organization's most important strategic aim is fundamental innovation in how it provides and pays for care, and continuous innovation based on dynamic data feedback is the means by which the organization goes about realizing that aim.
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From page 132... ...
As such, Ronald DePinho said, MD Anderson has a solid perspective on the cancer field that relates to the quality of care throughout the United States and the world. "There are significant knowledge and competency gaps," he said, "as cancer is an extremely complicated disease, requires multidisciplinary care, and is very technology intensive and knowledge intensive with respect to how to apply, for example, genome profiling to the care of patients." When he arrived at MD Anderson 3 years ago, DePinho said, the institution had a homegrown EHR with 70 different transactional systems, all of which are now being standardized into an Epic-centered EHR.
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From page 133... ...
He also said in closing that there is no difference at MD Anderson between clinical care and research. "Two-thirds of patients do quite well with standard of care," he said, "but for a third of cancer patients who fail standard of care treatment, their standard of care is clinical trials." DePinho concluded, "Research-driven, multidisciplinary care of the patient is the standard of care for MD Anderson." Rodney Hochman, Providence Health and Services Providence Health and Services, Rodney Hochman told the workshop, is the third or fourth largest nonprofit health care system in the country, with 4,500 physicians and 35 hospitals providing care in Alaska, California, Montana, Oregon, and Washington.
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From page 134... ...
Steven Corwin, New York-Presbyterian Hospital Steven Corwin said that he and his colleagues at New York-Presbyterian Hospital regard PCORnet as a strategic imperative because the current framework for taking cost out of the system is, from his perspective, a blunt instrument that uses price and utilization but little knowledge. Taking cost out of the system will not happen without moving toward population health and providing value, and both of those steps require knowledge of the sort that a learning health system can produce.
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From page 135... ...
Anything we do has to solve those three problems." Stephen Grossbart of Catholic Health Partners said that one of the big challenges that he sees is that quality departments are not adapted to using financial data and presenting it in a way that finance people understand. "So from a CEO perspective," he said, "placing expectations on finance and quality to work collaboratively would be helpful." He stated that every hospital system chief financial officer should be a quality champion, in contrast to the situation that he sees today, where the finance department does not understand the relationship between quality and savings.
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From page 136... ...
"The learning that comes out of a network like this has to be in real time and has to be continuous," Hochman said, "and we have to figure out how to do that." Steven Lipstein from BJC Healthcare said that tapping into PCORnet will help reduce transaction costs by increasing the size of the database with which to conduct research and generate knowledge without having to resort to having to build a dataset from the ground up with each research project. Jeffrey Grossman from the University of Wisconsin Medical Foundation reiterated earlier comments about the challenges of executing and getting desired outcomes on a system-wide basis.
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From page 137... ...
"Medicaid coverage does not equal access," he said, "and the farther you happen to live away from a metropolitan center where there is a mission-driven organization that runs primary care centers, the less likely it is that you're going to have access." What is needed, O'Donnell said, is organized access through medical homes, adequate case management, and a global payment system, but what is happening in the real world is that states are growing frustrated with Medicaid and are turning to proprietary plans that will, he said, "stick with fee-for-service until the cows come home because they feel that they can still eke out just that extra penny of profit if they're managing on a fee-for-service basis as opposed to locking in their profit by globally farming out the cost to a willing provider." Selby said that part of the agenda for improving health systems should be to study new models of coverage, including access. Disparities and the Safety Net When asked to provide his thoughts on what could be done to make his job as a health system CEO easier, Joel Allison from the Baylor Health Care System said that one of his biggest challenges is figuring out how to allocate resources and capital to create a learning health system and engage in the research needed to improve quality and reduce costs while also hav
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From page 138... ...
He added that the transition to a pay-for-performance system must happen faster if the goal is to move more quickly to a population health approach. Scott Hamlin from Cincinnati Children's Hospital Medical Center agreed with that comment, while wondering where the next few hundred million dollars will come from to make that happen and to keep current efforts to develop a learning health system going during this transition.
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From page 139... ...
The second example was the work the CDRNs are doing to expand the capacity to collect novel data, particularly patient-reported data and outcomes, and the third was providing tools for real-time, evidence-based clinical decision support. Corwin commented that the future of precision medicine based on personalized genomics will depend on complementary data collection and new analytical tools to handle what will eventually be enormous datasets of dissimilar data.
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From page 140... ...
Rita Redberg said that she is enthusiastic about the idea of PCORnet as a way to facilitate practical clinical trials because there are some things that will be impractical or impossible to study using the gold-standard randomized clinical trial. She was not as excited about clinical decision supports because, she said, they are often not as good in execution as they are in theory, often because physicians are already fatigued by all of the information in an EHR and more often than not ignore the messages that decision support systems provide in the EHR.
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From page 141... ...
He said that this type of effort would have the potential of addressing the fact that investigators who submitted wonderful grants to AHRQ or NIH have not been scoring well with PCORI because they do not understand patient engagement. Robert Kaplan from AHRQ asked Selby if PCORI is thinking about how to spread the message about the value of research and learning to the majority of institutions that are not part of the academic medical center community.
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From page 142... ...
One is to have the insurance companies associated with major health plans, such as Geisinger's insurance company, work with other providers to try to reproduce the special relationship that exists when you have provider and insurer under the same organizational umbrella. The second approach is through consolidation, where organizations that engage in continuous learning and change take over those organizations that cannot figure out how to change and that do not have a sustainable business model.
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From page 143... ...
I think there's much more in common than what separates us, and I think it is important for us to understand what's important at the academic center and the nonacademic health system, and this will not be successful unless we bring those large systems into the discussion in a tangible way." Wyatt Decker from the Mayo Clinic Arizona spoke of the need for speed in driving waste out of clinical practice and moving to a population health model. In his view, he said, most of this effort does not involve research but merely small tests of change and lean process redesign.
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From page 144... ...
Department of Defense said that the Department has had to redesign its health system over the past 12 years in order to address the casualties from the Iraq and Afghanistan wars and that part of this redesign involved creating the Defense Health Agency, which has the specific goals of serving as an integrator in a system of care and to incorporate advanced analytics, measurement, improvement, and coordination across the Department's health system. He said that this effort has been informed by the experiences of Geisinger and Kaiser Permanente and that the Department's financial resources may allow it to experiment in ways that other systems may not have the luxury of doing and therefore contribute to the overall effort.
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From page 145... ...
Doing research collaboratively, he said, would make this a sustainable investment for many health care systems. The second point he made is that cost data need to be incorporated into the clinical data networks.
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From page 146... ...
Hochman agreed with Corwin and said that Providence Health is spending much more time thinking about what the architecture of the health care system should look like beyond the walls of the hospital. For example, Providence is creating a new division of population health that will coordinate learning and knowledge transfer across the entire system.
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From page 147... ...
Lisa Harris from Eskenazi Health, a safety net health care system serving the inner city of Indianapolis, noted that her system has been building an EHR for more than 40 years and has been using these data to improve almost every aspect of quality, safety, effectiveness, and efficiency of care. "We are thriving as a safety net health care system because of basically being a learning health care system over four decades," she said, adding that her system is going to engage in an effort to use its experience to teach physicians nationwide how to use an EHR effectively.
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