Measuring the value of healthcare and using the data to influence outcomes isn't a distant goal. It's happening now and physicians are starting to get the message.

The message to physicians and healthcare executives couldn't be any clearer: Since your outcomes performance is more and more a matter of public record, you had better get a handle on the value you deliver before the public does.

After attending the Health Catalyst Analytics Summit last week in Salt Lake City, I am convinced that health leaders are not just talking about measuring value sometime in the future. They are doing it today and driving better outcomes, using that data transparency to get through to recalcitrant physicians and healthcare executives.

One such leader is Jay T. Bishoff, MD, director of the Intermountain Urological Institute at Intermountain Healthcare. He has to convince his fellow urologists and surgeons to pay attention to a series of dashboards displaying prostate cancer patient outcomes, including not only the cancer's progress or control, but also side effects such as incontinence or impotency.

Fellow urologists "get really sensitive about it," Bishoff told conference attendees. "They say, why are you doing this? I say, 'I'm doing this to help your patients have a better outcome because somebody is going to measure that, and they're going to put it online, whether you like it or not. So let's work together now to get better outcomes.'"

Out in Front
To get ahead of public reporting of these outcomes, Intermountain is working quickly to publicly report its prostate cancer treatment potency and continence rates, individually by surgeon, Bishoff says.

The Great Transparency Movement?

Intermountain's "obligation to deliver a measured experience" also translates into fewer biopsies for prostate cancer, saving money and reducing unnecessary discomfort and pain to patients.

The effort starts by constantly scouring medical literature for evidence-based, but as-yet unimplemented protocols, some more than a decade old. Intermountain urologists perform 65,000 prostate-specific antigen (PSA) tests per year. Taken in isolation, a PSA measurement of 3.0 wouldn't seem to indicate a need to do a biopsy. But when clinicians risk-stratify, considering factors such as race and age, risk of an aggressive prostate cancer can rise to where a biopsy is definitely in order.

"There's only one other integrated healthcare system in the United States who's interested in incorporating that same logic," Bishoff says. "That is something that [other] healthcare systems could do."

Risk Stratification
By stratifying risk, Intermountain was able to drop its number of biopsies by 30%, while still finding those patients whose PSA might be 3.0, but "we want to find it when his PSA is 3.0, not when it's 30," Bishoff says. "We will spend less money on that guy by screening him and identifying his progressive cancer early than when we're trying to treat him later."

The patient also gets a say in the treatment conversation after the risk stratification. "So we have a meaningful conversation, and we let patients decide," Bishoff says. "Our own insurance company loved it."

Drawing this line between transparency, technology, and value is the top takeaway from conferences such as these.

"One of the things we find here, what has become pervasive in the industry… is lending more structure to how clients find that value," says Vi Shaffer, research vice president and global industry services director for healthcare providers at research firm Gartner.

While the knowledge transfer is getting a bit more organized, trying to keep on top of the firehose of case study-sharing at conferences such as this can still drive healthcare executives crazy.

"It feels like a zillion knowledge clouds out there with independent networking and no cohesion to it," Shaffer says. "That's going to happen for a while. I'm certain it's going to happen with the explosion of genomics and all these other use cases, now that people have clinical data in their warehouses and there's more benchmarking and more collaboration and it's easy to do technically."

A Vigorous Response
The response of many organizations at last week's event was to swarm the conference by sending entire analytics-savvy teams.

"We have now trained in our organization over 500 people in quality improvement and analytics, and they all understand what annotated run charts look like, and control limits," says Frederick C. Ryckman, MD, interim chief operating officer and senior vice president of medical operations at Cincinnati Children's Hospital Medical Center.

That figure represents 15% to 20% of the hospital's workforce. "More than that [percentage] from a clinical point of view are highly trained in analytics, so it's made the journey easier, but the early days were really an uphill climb," Ryckman says.

Reducing variations in care through analytics-driven process change allowed Cincinnati Children's to pass along $25 to $30 million worth of savings to families last year, with a total of $50 million in savings across the institution, he says.

"Our goal in our strategic plan for the next five years is to decrease our costs by 2% per year and make sure that that we keep the cost of patient care at exactly the same or 2% less per year over the course of the next five years while we improve outcomes by no less than 2 to 3% per year."

Curbing Costs
While many health systems have similar aspirations to cut costs, few are as under-the-gun as providers in Massachusetts, where legislation mandates the rate of cost growth in healthcare to no more than 3.6% per year, says Tim Ferris, senior vice president of population health at Massachusetts General Hospital Partners Healthcare in Boston.

"Given [that] the national inflation rate of healthcare in the 5% range, [makes it] a distinct challenge for us," Ferris says. "I'm more optimistic. We do have the data now. Data that is real-time and data that is clinically accurate. Our clinicians appropriately demand that we show them data, that data is accurate, that data is attributable, and the data is risk-adjusted."

Partners has signed different risk contracts with six different payer entities. "Each one of those contracts provides different methods for calculating the benchmark," Ferris says. "They provide different measures for assessing the quality. So our performance is different, but we don't treat patients differently depending on whether they come in with one commercial health plan or Medicare or in the Medicaid program.

"So as long as we don't have a national standard for how to do performance-based risk contracting, providers are going to live in a world where they are chasing multiple targets at the same time. It sounds like a full employment act for analytics."

"That was supposed to be a joke," he quips, and the audience laughs.

As providers chase elusive value goals which constantly get moved and increased by payers, including the government, I have no doubt that anyone in healthcare with analytics tools at the ready will have plenty to think about and do.

The forces that are making health information exchanges essential include exchanging summaries of care when EHR integration is not yet present and responding to business pressures such as accountable care.

This article appears in the September 2015 issue of HealthLeaders magazine.

As the industry turns its attention to interoperability, the nation's health information exchanges—some regional in nature, some statewide—are helping clinicians avoid productivity-sapping phone calls and faxes, and meet some challenging meaningful use requirements.

The forces that are making these HIEs essential include streamlining workflow utilizing Integrating the Healthcare Enterprise's EHR-to-EHR integration and Direct secure messaging connectivity built into meaningful use–compliant EHR software, exchanging summaries of care when EHR integration is not yet present, and responding to business pressures such as accountable care.

Pennsylvania: Making the transition

The Keystone Health Information Exchange connects 20 hospitals, 239 physician practices, and 30 home health locations primarily located in 31 counties in central, northern, and northeastern Pennsylvania, as well as 69 long-term care facilities spread throughout the state.

"We first went live in 2007 with a pretty rudimentary system of just connecting a few provider portals that were being offered by different healthcare systems and making it available through a single platform," says Jim Younkin, director of KeyHIE. Younkin is also IT director for external customer relations at Geisinger, a system that operates and participates in KeyHIE and itself serves more than 2.6 million residents throughout 44 counties in central and northeastern Pennsylvania.

In 2009, with funding from the U.S. HHS Office of the National Coordinator or Health Information Technology's Beacon Communities program, KeyHIE enabled a registry and information repository based on Cross Enterprise Document Sharing (XDS), a health IT standard developed by the nonprofit organization IHE, for storing and retrieving documents for providers who belonged to KeyHIE.

In fall 2013, use of KeyHIE leapt when it activated a notification service. "Any time a patient presented at a hospital or emergency department participating in KeyHIE, either as an inpatient or at an ED, we would send those alerts," Younkin says.

At the same time, KeyHIE successfully connected EHR software that had the ability to consume records via IHE's XDS protocol and present these records to clinicians as part of their regular workflow—a marked improvement from traditional HIEs, which require separate log-in via a physician portal to access information. In May 2015, 559 users of the HIE accessed information via the portal, with 461 using XDS-powered access within the EHRs themselves.

Those users include one of Geisinger's area competitors, Susquehanna Health, a four-hospital integrated health system, Younkin says. From within Susquehanna's Cerner Soarian EHR, clinicians can click on a link that will connect them to KeyHIE and bring back a list of documents associated with that patient. "My understanding is that that is just at a document-level consumption at this point, but we have similar functionality with customers using Allscripts; Epic does consuming, and there's a regional EHR called Medent, and we have set up with that as well," Younkin says.

KeyHIE is just in the process of finishing a multiyear migration of its HIE technology platform from an earlier technology offering by Caradigm to Orion Health HIE technology, he says.

One challenge for KeyHIE has been the varying degrees to which participating organizations obtain consent from patients to release their records to other members of the HIE. For instance, Geisinger asks registering patients to sign an authorization allowing Geisinger to share their information with other members of the care team. But those patients would have to sign the same authorizations at other organizations where they registered.

"The challenge is that some organizations were good at asking patients to sign this, and some were very lax, and as a result, the organizations that were good at getting them signed were the ones who were frustrated, because when they went to access data from organizations that were lax at getting them signed, they found many times the data wasn't available," Younkin says.

Another KeyHIE feature helps participating healthcare organization bridge an oft-criticized gap in care coordination by connecting data from long-term care facilities and nursing homes to inpatient and ambulatory EHRs.

Those facilities often lack EHRs of their own, which prompted KeyHIE to offer them its Transform service, a low-cost software tool that allows nursing homes and home health agencies—with or without an electronic health record—to contribute patient assessment information to any HIE.

"Transform allows us to take patient assessment data from a nursing home or a home health agency that normally would be sent to CMS or their billing process," Younkin says. "We've used the HL7 standards as well as IHE profiles to generate a Continuity of Care Document from the nursing home and home health settings." CCDs facilitate transitions of care that are required for providers participating in the meaningful use EHR incentive program.

Four hospitals and four group practices in KeyHIE saved money by using the organization's patient portal to fulfill meaningful use stage 2 requirements to have a patient portal, despite efforts by the EHR vendors of those organizations to sell them separate patient portals, Younkin says.

New Jersey: Pockets of success

Four regional HIEs divide the state of New Jersey, says Linda Reed, RN, vice president of behavioral and integrative medicine and CIO at Atlantic Health System a Morristown, New Jersey–based system with multiple hospitals and more than 1,599 licensed beds, which is a founding member of Jersey Health Connect, one of the four HIEs. Providers in the state hope to bring all four together but face funding and technological challenges.

Now integrating 30 hospitals, Jersey Health Connect uses RelayHealth technology and, at the end of 2014, says it saw a sharp increase in providers contributing health summaries via the HIE, rising from around 100 in November to nearly 900 in December.

One reason Jersey Health Connect has grown rapidly is that the HIE was set up so patients had to explicitly opt out of the HIE; if they didn't, their records would be available throughout the HIE, Reed says. "It looked like our governor at one point was going to go after opt-in, but we all rallied, got our government people involved, and he did just let it ride as an opt-out. Otherwise, we would have just had to close up shop."

Jersey Health Connect's success so far has been driven by the hospitals because they collectively realized it was the right thing to do for patients, Reed says.

"New Jersey is a small state," she says. "We've got a hospital on every corner. As a patient, you could be at an Atlantic Health facility today, you could be at a St. Barnabas facility tomorrow, and you could get Robert Wood Johnson the next day."

The CIOs of the respective hospitals realized that the best patient care comes from sharing results, Reed says. "We then convinced some of our colleagues in our facilities that it was the right thing to do, and I think some of them still are concerned that maybe it's not; but when the accountable care organizations started coming around, they now needed to know what's going on down the street: 'Because now I'm the accountable party for this care, and I didn't know that they were in the Robert Wood Johnson ED two weeks ago,' " he offers as an example.

Also, 14 participating hospitals were able to use Jersey Health Connect in 2014 as a means to meet the meaningful use stage 2 requirement for patients to view, download, and transmit records.

Now New Jersey as a state is facing the challenge of integrating three other regional HIEs into a shared infrastructure to handle, among other things, the typical HIE challenge of patient IT matching, but across a state of nearly 9 million people.

The New Jersey Institute of Technology, which itself runs a small HIE based in Newark, hopes to model a new overall statewide health information network after Michigan Health Information Network Shared Services, an HIE hub that oversees and coordinates information from seven regional HIEs in Michigan, Reed says. "It's not unlike the conversation about interoperability in electronic medical records," she says, "except that you have a bigger issue with the patient matching, especially because of the multiple medical records."

The elephant in the room, Reed says, is that vendors now power many HIEs, just as they power EHRs. "They are still going after proprietary stuff, and we see similar things moving into HIE technology," Reed says.

Some vendor-introduced differences are as mundane as whether a vendor takes one identifier in a data field instead of two. Reconciling these differences makes the job of an HIE that much more difficult, Reed says. Even in supposedly well-defined data standards, "There was enough wiggle room for them to interpret some of these things differently."

Another challenge all HIEs face is to go beyond the usual utilization metrics they publish, to much more difficult-to-capture metrics of how the HIE has affected patient outcomes, Reed says.

And finally, the new statewide initiative faces funding challenges. New Jersey is applying for a federal grant but will need more resources. "That's been one of my concerns," Reed says. "We don't want to put any more financial requirements on our members."

New Mexico: Reboot marks rebuilding phase

The New Mexico Health Information Exchange grew out of the state's HIE Cooperative Agreement Program originally funded by ONC in 2010. Operated today by nonprofit firm LCF Research, the HIE faced a major setback in 2012 when a vendor discontinued the product powering the HIE, although the HIE was able to get by until it transitioned to a new technology vendor.

Through a combination of continuing to run that older technology while migrating to new Orion technology, New Mexico's HIE has avoided the fate of some other states, whose HIEs completely shut down.

"We've been fortunate here that the state Medicaid program, Centennial Care, has been a great supporter of this, and they help through their managed care organizations to participate in this," says Thomas East, CEO and CIO of LCF Research. "They're using the HIE for care management for the Medicaid population, so we've been able to spread the costs out to not just healthcare organizations and providers but also payers."

The NMHIC HIE contains 1.2 million uniquely identified persons out of a total state population of just over 2 million. "We make sure the New Mexico Centennial Care Medicaid population is all represented in the master patient index," East says.

In its current rebuilding phase, NMHIC has been able to gain commitments of participation from a statewide diagnostic imaging organization, and the New Mexico Primary Care Association is funding participation for 15 federally qualified health centers, East says. "There's a number of different organizations in the state, and records don't always easily flow when patients move from care setting to care setting, so folks are anxious to get access to records that haven't made their way very effectively the traditional ways via paper or fax," he says.

A challenge NMHIC and other HIEs face is the lack of comprehensive patient records among participating healthcare practices. "We'd ideally like to see folks move closer to a meaningful use 2 transition of care record," East says.

One New Mexico medical practice that finds value in NMHIC is ABQ Health Partners, a 220-physician, multispecialty group based in Albuquerque. ABQ Health Partners was acquired by DaVita Healthcare Partners in 2012.

"The exchange is our only way of getting information easily across systems," says Robert White, MD, MPH, medical director of informatics and quality at ABQ Health Partners.

White recalls seeing a patient "a couple years ago where I was able to see documents that drastically changed what I did with the patient. Compared to asking the patient or calling somebody else and having something faxed, it's far, far better."

While White and his fellow physicians have been able to exchange summaries of care over NMHIC, moving documents via Direct messaging has been difficult. "In the HIE, it's sort of designed to give me the document as well as discrete test results and discrete vital signs," he says. "It's the note about the exam the patient had that I want to see that tells me what to avoid or what needs to be done in follow-up."

As the HIE matures, much of its power will simply live inside EHR software, White says.

"We're going to continue to work with our HIE to embed it in our EHR so clinicians are not having to think about two different systems," he says.

But White also echoes the importance of the New Mexico approach versus HIEs powered exclusively by EHR software itself.

"The payers and the state are really critical, because the HIE doesn't have an automatic business case," White says. "In fact, a lot of people, including some imaging centers and hospitals, don't want to see it succeed, because sequestering data makes their lives easier and more financially productive."

Reprint HLR0915-7

The cumbersome process of scheduling interviews between medical residency programs and candidates usually involves a torrent of emails and phone calls between exasperated candidates and equally exasperated residency program directors. That may be about to change.

Scheduling interviews between residency applicants and medical education residency program coordinators is about to get easier, if one startup's promise to automate the process holds true.

Each summer, a bit of computer science commences which optimizes U.S. healthcare behind the scenes. The Electronic Residency Application Service (ERAS), operated by the Association of American Medical Colleges (AAMC), starts accepting fourth-year medical student applications for residency programs starting the following July. Candidates submit their transcripts, grades, letters of recommendation, personal statements, and an application fee, and hope for some good responses.

Invitations to interview follow from residency programs, and then a round of in-person interviews between residency programs and candidates. Then a second service, the National Residency Matching Program (NRMP), accepts the rankings of both the interviewers and the interviewed, and via an algorithm recognized with a 2012 Nobel Prize in Economics, produces the final matches, which are released on Match Day, usually the third Friday in March.

As wondrous as this process is, there has been a cumbersome productivity-drain and stress-inducing process in arranging those interviews. That is because ERAS produces a list of candidates for each residency program, which then invites potentially hundreds of candidates to choose from perhaps 20 potential interview dates, but it's left up to the prospective residents to arrange the actual dates and times of each interview.

Believe it or not, at least one residency program still uses the U.S. postal service to arrange the entire thing.
 
Mostly, administrative officials at each school are besieged by a flood of nearly-simultaneous emails and phone calls from hundreds of applicants trying to confirm their preferred dates and times. "We interview about a 170 to 200 people, so you get all those emails back, trying to get everybody scheduled in, so it's hundreds of emails and phone calls and stuff," says Amy Matenaer, anesthesiology medical education residency program coordinator at the Medical College of Wisconsin (MCW) in Milwaukee.

Clearly, there was a need to more efficiently match available times to candidates and interviewers, and even to establish waiting lists, since in the scrum of candidates trying to reach their most desired interviews, there was bound to be variations in interview demands based on the prestige of the residency program.

Last fall, MCW's anesthesiology program became one of a handful of residency programs which turned to Thalamus, a service open to all specialties, which charges programs a modest fee, $250 to $1000 per year, and in return offers an online interview reservation and scheduling system, including wait lists, not unlike some airline reservation systems.

Thalamus is the creation not of some venture capital-based startup, but of an exasperated residency candidate and an equally exasperated anesthesiology residency program director.

The service's founder and CEO Jason Reminick is that former residency candidate. He describes the problem: "It becomes this big email race… So everyone emails back as quickly as they can. They arbitrarily just pick a few dates. And then a coordinator on the other side is going email by email, filling out a date planner, filling out an Excel spreadsheet, a completely manual process until they hit a roadblock."
 
"The idea for this came when I actually got stuck in New York City during Hurricane Sandy, and several of my interviews were cancelled," he says.

After Reminick returned home to his medical school, the University of Rochester School of Medicine and Dentistry, and met with his mentor (and Thalamus co-founder and secretary), Suzanne Karan, MD, vice chair of education and residency program director for anesthesiology, she told him of her own frustrations with arranging interviews from the program side of the process.

"We sat down and came up with this idea of trying to hit it from all sides to make this one-shop stop for everyone." Reminick says. "I was completing a combined MD/MBA degree and I had one more course that I needed to complete for my business degree, so we decided that together we would write the business plan as part of that course, and Thalamus is what came of it."
 
"We're not so much reinventing the match process, but there's a byzantine process that precedes getting to the match that we are making into a more modern process," Karan says. She and Reminick used their network of residency program directors, interviewing physicians, administrators, and applicants who needed a solution for this problem. Last year, the Thalamus community included Stanford, Mount Sinai, and the University of Miami.

One beauty of Thalamus is that candidates can select interview dates that allow them to minimize the amount of cross-country travel during interview season by coordinating interviews within a particular geographical region, instead of just arbitrarily picking dates and then facing stiff travel costs and too much time in airports.

Then there is the waiting that is eliminated. Under the old email-and-phone call system, residency administrative personnel spend hours and hours thumbing through paper calendars or spreadsheets, and might respond to a candidate with an interview time three or four weeks later. Using Thalamus, they can reduce this process to under a minute.

In addition, Thalamus accommodates those students who are left without their most-preferred prospects at the end of the early round of interviews in January, says Michael Wadja MD, vice chair for education and residency program director for the NYU School of Medicine Department of Anesthesiology.

Trimming Fat from the System
"Some applicants are spending between $10,000 and $20,000 just on the interview process in terms of travel costs," says Reminick, who eventually chose Stanford University Hospital and Clinics/Lucile Packard Children's Hospital and just completed his second year of combined residency in pediatrics and anesthesiology there. Reminick cites an estimate from Forbes that the entire process wastes between $300 and $400 million.

Considering that medical residents don't exactly rake in the big bucks in terms of salary— another controversy entirely—anything that can cut costs of these programs is obviously good for those programs in light of widely reported physician shortages.

And those wait lists? Thalamus handles them automatically as interview candidates change their plans and interview slots open up. "They actually get an email saying this date just opened, would you like to move your date to here?" Matenaer says. "So it's more of an automated system, versus the manual going back and forth and everything like that."

"There's fat in the system, and some of the fat in the system is the administrative cost of running these residency programs," Karan says. "Being able to take a third of one person's job and cut it into minutes is a huge time and cost savings for our department. So I was thrilled, my chair was thrilled, and my other program director friends were thrilled."

Gaining Traction
Another Thalamus believer is Brian Tse, a 2015 UCLA Medical School graduate who began his anesthesia residency at Stanford last month.

"Several of the programs I interviewed at started to use Thalamus, which didn't take away the anxiety of emailing back ASAP, but did eliminate the lag time of emailing back in order to confirm dates," Tse says. "I started to look forward to those programs that sent out interview invitations through Thalamus and loved how simple the process is."
 
This fall, Thalamus continues to gain traction, much of it by word of mouth. There is also the possibility of integrating it with travel services, or even analyzing prior application data and telling applicants what their probability of matching at a particular program might be, Reminick says.

AAMC also deserves some credit for freely sharing necessary data with Thalamus and other programs while it works on enhancing ERAS' own capabilities in this regard. Such openness and cooperation is admirable, and could be better emulated throughout the healthcare IT field.