The benefits of implementing standardized best practice to reduce unwarranted variation and enable value-based care are well known.
Despite the occasional tension between physicians accustomed to decision-making autonomy and business-minded healthcare executives, it is becoming increasingly clear that to deliver care in a world of increasing life spans and chronic disease, the system must change. With value-based care heralded as the solution to delivering high quality care at low cost, those organizations at the bleeding edge are innovating and transforming their systems with concerted effort. However, each organization usually goes through its own long and resource-intensive process of designing, piloting, implementing and rolling-out new value-based ways of working. Letting a hundred flowers blossom and a hundred schools of thought contend may be a valid market-driven approach to innovation, but when facing system-wide failure, is it really plausible to have each player invest in successfully or unsuccessfully figuring things out for themselves?
Leading Integrated Delivery Networks, Accountable Care Organisations and large Health Systems are where one sees value-based innovation designed and delivered at scale. These organizations generally have scale across multiple care settings, are long-time EHR users, have been collecting a wealth of data for some time and have the management capacity, capability and resource to deliver transformation. Leaders at such organizations have been aware that the value-based train is approaching and have invested in the cross-continuum infrastructure required to support change. The mode for identifying priority areas of improvement and designing and implementing new ways of working appears to be similar across the board.
According to Stan Huff, CMIO at Intermountain Healthcare, although providers have to pay attention to payer incentive to change through mandatory and voluntary bundled payments for funding reasons, as an organization they are more driven by their own research into improvement areas.
Step 1: collect and analyze data
Those lakes of big data that organizations have been storing in enterprise data warehouses, with the hope it will one day become useful, finally comes to the fore. Tim Sielaff, CMO at Allina Health, says “as early adopters we have been system-wide on EMR since 2004 so we have rich data to drive improvement by linking outcomes data to financial data to identify and evidence areas for improvement in value creation.” At Intermountain Dr. Huff and colleagues analyze population data in their warehouse to link outcomes with cost and supply evidence to physicians to support institutional best practice. In addition to self-examination, those with process improvement backgrounds such as Ginger Baker, System Director of Operational Excellence at Appalachian Regional Healthcare System, will also have their eyes open. “Consistent unsanctioned workarounds by staff are a sign that changes need to be made, and are the perfect opportunity to engage staff in sustainable process improvements.”
Step 2: set up your team
Once areas for improvement are identified and agreed upon, the next step is often to appoint a clinical champion, with the mandate of ensuring successful design and implementation through securing clinical stakeholder buy-in and participation. According to David Dugdale, Medical Director, Care Management & Population Health at UW Medicine in Seattle, clinical champions are paired with a program director to drive the program to completion, often over a number of years.
Step 3: design new delivery models
With a program team in place, next comes analysis of ‘as is’ and ‘to be’ scenarios; delving into the root cause of inadequate performance to identify specific areas for operational and clinical improvement. Often, the centuries-old practice of academic paper review is used to identify and reconcile tried and tested approaches and guidelines. Combined with in-house knowledge and organizational peculiarities, new care processes and pathways are iterated upon, internally and, if an organization is outward-looking, by external clinical thought leaders, until approved for implementation.
Step 4: implementation
Where elegant designs go to die. At this stage, new ways of working are piloted, and then rolled out across an organization, ideally alongside updating all relevant systems. Compromises and concerted efforts are made to ensure usability and compliance among users. Measurements, metrics and reporting methods are updated to ensure changes are having the desired effect in impacting quality and cost outcomes. Some organizations track and measure individual physicians, including at independent clinics under their umbrella to identify and reward best practice, and find that sharing information and outcomes data by itself triggers desired changes in behaviour.
Step 5: rinse and repeat
If all the above is successful, an organization may choose to publish their efforts in an academic journal, or present their work at conferences, to communicate their success to the wider world. So, the cycle continues.
There is obvious waste of time, resource utilization and expense involved in hand-crafting new value-based care pathways to each and every clinical and operational pathway in each and every organization. Though they may look externally for guidance whilst designing new pathways, processes and metrics, each department and organization are essentially reinventing the wheel each time they go through the motions of change. Why?
Competition
The way healthcare systems are incentivized, is competitive in nature. Even under value-based care, quality-lead reimbursements are negated by loss of fee-for-service revenue. The way providers hope to retain their margins is by expanding their share of the pie through attracting new patients and retaining loyal ones. This is exacerbated within the same geographic region, meaning that providers are innovating to stay ahead of their competition, and are therefore reluctant to share those innovations with their competitors, even if it is for the improved wellbeing of the population. Organizations such as Intermountain do “collaborate with other organizations outside our catchment areas, and participate in national registries and databases” maintains Dr. Huff, but “much of what we do comes from our own data”.
Lack of access to national, approved evidence-based guidelines
Although many providers participate in non-competitive collaborations, and in national registries and databases, much of what they do comes form their own data and research. In the UK the National Institute for Health and Care Excellence (NICE), a Department of Health body, publishes up-to-date national guidelines and quality standards in pathway format. Granted, these are purely digitized workflows and a huge effort has to be undergone to operationalize, but, they are a trusted starting point where all can access online evidence-based up-to-date guidance in one place. In this way, the onus is on the expert national body to assign resource to identify and review best practice, wherever they find it. This takes the burden of finding, reviewing and collating the latest research off the providers, and ensures those implementing pathways are all starting with the same standardized guidelines, allowing implementation at scale and speed across wider populations.
The fallacy of uniqueness
Organizations, like people, like to think they are unique. Healthcare payers and providers think their patient populations are particular, their situations more difficult or complex. Healthcare as an industry finds itself unique among others. Of course there are nuances which may require adaptations between organisations and industries. However, there are far more commonalities than there are differences. Most healthcare professionals work within fewer than a handful or organizations in their career, often in the same state. Very few have experience of other industries entirely. When it’s difficult to have the elevation to find the patterns of commonality, it becomes easy to resort to finding unique solutions to common problems.
The burden of evidence
When lives are at stake it is natural patient safety is paramount and the benchmark for proof is set high. However, whereas randomized controlled trials may be the gold-standard for determining safety and efficacy of pharmaceuticals, oftentimes improvements to patient outcomes are determined by the operational and administrative pathways that underlie clinical processes and decisions. In this way practice-based evidence from the field where operational pathways are optimized, implemented and adapted based on real-time data can and should be tested on its own merit – rather than held to the same standards and metrics as clinical change programs. Part of the issue is getting buy-in and acceptance from the medical community that operational improvement is just as important, and just as much a part of medicine, in delivering quality of care as clinical advances are.
How can we address the waste of resource spent when each organization reinvents a unique solution to a common problem? A national body reporting to the HHS analyzing and consolidating research and clinical guidelines from the various academic medical centers and medical associations may be a long shot. In the meantime, payers have a substantial role to play. They have the greatest leverage when it comes to changing behaviour and implementing standardized pathways, as they hold the purse strings. They also have data and visibility far greater than that of one individual provider or health system within and between geographies and so are better equipped to make decisions at a population health level. At Highmark, Jeb Dunkelberger, Director, Value-based Reimbursement, Strategy and Innovation recognizes the challenges that providers have in dealing with payer requirements, and the impact on transformation, so they are “taking steps towards a prudent amount of collaboration with other payers” to reduce this burden.
Regardless of national guidelines of payer incentives, providers themselves will always have the greatest effect on care delivery, being at the point of delivery and making minute-to-minute decisions on whether to follow systems and processes, or not. If we can rethink how we see ourselves, our commonalities with other providers across the country, and get over the competitive hurdles to affect system-wide change for the benefit of the patient; there is a space where communities of clinical and operational experts can come together and design, share, test and grow the best practices of the future.
What will trigger the recognition and acceptance that even innovation needs to be delivered in a different way? There’s no silver bullet. Roy Smythe, CMO Health Informatics at Philips suggests harnessing public opinion and collective intelligence to demand change of regulators. “Global communication of the art of the possible, what could be achieved and what it could do for people and their families when data is shared, incentives are changed, variation is eliminated, outcomes are improved and costs are lowered.” The USA consistently lags behind other OECD countries when it comes to health outcomes, particularly when compared to cost of care. It’s about time people demanded better. They can only demand better if they know better.
Corrina Kane, Head of Strategic Marketing, Lumeon
@Corrina_Kane @Lumeon_
corrina.kane@lumeon.com
Corrina Kane, Ph.D. is Head of Strategic Marketing at digital health company Lumeon. She researches, writes and speaks on the topics of healthcare policy and regulation in the USA and UK, the global digital health industry and women in technology.
Corrina has held multiple operational management roles developing and marketing new products and entering new international markets in the healthcare technology and life science arena. Previously she served as a strategy consultant to European pharmaceutical and consumer health companies across R&D and commercial areas.
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