Interesting things have been happening lately at Mercy Health Partners, a seven-hospital integrated health system based in Toledo that is one of the regional divisions of the Cincinnati-based Catholic Health Partners, which, with 29 hospitals, is the largest health system in Ohio.
As part of a broader strategy aimed at optimizing resource use and improving patient outcomes, leaders at Mercy Health Partners have been working with the Cleveland-based Explorys, a big data-focused analytics vendor. And as at other Catholic Health Partners health systems, the Mercy Health Partners folks are making progress in improving outcomes across entire physician groups. Kenneth Bertka, M.D., vice president of physician clinical integration for both Mercy Health Partners and Catholic Health Partners, spoke recently with HCI Editor-in-Chief Mark Hagland regarding the activities that he and his colleagues are involved with these days. Below are excerpts from that interview.
Tell us about the origins of your organization’s quality initiative?
We have an ambulatory quality committee, which I chair. And we looked across the organization and found that we didn’t really have any organization-wide way of measuring quality. And that’s because until the end of 2011, we didn’t have any organization-wide EHR [electronic health record], but we finally at the end of 2011 had everyone on CarePath, which is what we call Epic. And we had a scorecard, and worked on Explorys to build that out. And the physicians can look at how they’re doing.
What are you up to in terms of big data?
There are different aspects to our overall IT strategy. With regard to clinical care, our goal is to make the clinical data in the electronic health record [EHR] available whenever and wherever it’s needed by physicians, other clinicians, and patients, to make the best possible medical decisions. We also want best-practice alerts, clinical guidelines—clinically meaningful alerts, if you will. That helps us take care of individual patients.
The second aspect of our strategy is around how we manage populations. And on the big-data side, that requires us to develop quality measures. So we developed a clinical quality scorecard that we’re using. That went live, using Explorys, in January of last year [2012]. So we’ve been live for just over a year.
What things are you looking at?
We began by focusing on primary care, and started with eight measures, all pretty much National Quality Forum measures, across all of Catholic Health Partners, which have been launched on behalf of all patients who have a CHP physician as their primary care physician. These are the eight measures we’re tracking system-wide:
> Breast cancer screeningrates in women 40-69
> Colorectal cancer screening rates for adults 50-75
> For diabetics 18-75, control of their hemoglobin
> For patients with ischemic vascular disease, LDLs of less than 100 (75A and 75B): both are LDL for patients over 18 with coronary artery disease
> Pneumonia vaccination for patients over 65
> Tobacco cessation intervention for patients over 18 who use any form of tobacco
> Screening for tobacco use
One of our regions has been tracking, and this coming year, our entire system will be tracking, a composite of five diabetic measures—the one I gave you plus controlled blood pressure, controlled LDL, hemoglobin a1c, non-smoking status, appropriate use of aspirin, and the composite score. It’s widely used, and is called the “Diabetes 5,” or “D5.”
So, with the system you’ve implemented, the physicians have a dashboard and are able to see their scores live at any time?
Yes. We bring the data over every night, so the data is very fresh. You’re essentially looking at the system as it was yesterday. So technically, if you wanted to, you could track this every day. And in our PCMH practices, we ask them to do it a minimum of at least once a month; some do it more often. So they can see how their patients are doing. This is all primary care-oriented; this coming year, we’re going to move into specialty measures. But they can see how they’re doing, how their partners are doing, and how their practice is doing as a whole.
Most importantly, per population health management, our physicians can see not only how they’re doing—and I’m looking at my diabetics with controlled blood pressure right now—and I can see what percentage of my own patients—I’m still practicing part-time myself—have controlled blood pressure. And more importantly, I can click on an icon and see a list of my patients with uncontrolled blood pressure. And with our PCMH [patient-centered medical home] initiative in 2012, we focused on six of these measures. In fact, as part of our NCQA [National Committee for Quality Assurance] application process, practices are asked to look at three chronic conditions and three preventive care services. For our chronic conditions, we looked at diabetes hemoglobin a1c management; general hypertension management; and tobacco use cessation counseling. Those were our three chronics. And then for prevention, we looked at our rates of breast cancer screening, colorectal screening, and pneumonia vaccination for patients 65 and over.
What have been some of the results?
A year ago, our rate of diabetic patients whose hemoglobin a1c was controlled to below the level of 8 was at 34 percent; as of December 13, we ended the year with a 51-percent rate, a huge improvement. And hemoglobin a1c, or glycosylated hemoglobin, doesn’t change rapidly, so typically, you only measure it once every three months; so this is a huge improvement within one year. With regard to our patients with controlled hypertension, we went from 54 percent to 65 percent. For tobacco cessation, per counseling, we went from 22 percent to 41 percent.
Meanwhile, our rate of breast cancer screening rose from 51 percent to 59 percent, while our pneumonia vaccination rate for patients over 65 went from 23 percent to 31 percent. So we did show some significant improvement in those areas. But keep in mind that, at the beginning of 2012, we didn’t have any measures at all. So we put in an EHR, and needed to put in a dashboard that was meaningful and easy to use. And Explorys is very simple to use and meaningful. I can train someone in a half-hour.
So we went from not even knowing how we’re doing to getting the data, and then the practices started doing things to move those numbers. What happened was that, for the first time, our physicians knew which patients needed breast cancer screening or pneumonia vaccination, and were able to send out letters and contact patients to get those things done. We were finally starting to do some actual population health management.
This is a journey of a thousand miles, isn’t it?
Absolutely, and it’s one that can only be done one step at a time. And that’s why we didn’t take on 20 different measures all at once for our patient-centered medical home practices. And in terms of breast cancer screening for women ages 40-69, you could argue that younger women whose mothers and sisters had breast cancer should be screened sooner; and that’s true. But we felt we should start by working with our general screening rate, which started at 21 percent.
What we’ve found is that it’s better to move the bar significantly on only a few measures at first. It’s like anything in life; you can’t do everything at once. You absolutely have to focus. And we’ll continue to focus on areas we haven’t yet done well on; and we’re expanding our focus this year. For example, with the pneumonia vaccination, we’re kind of modeling our work after what one of our other regions did. So we won’t stop what we’re doing on these patient-centered medical homes and six measures. We won’t stop; but some of it will be a little more automatic going forward, and we’ll now go into doing the D5.
So by the end of 2013, in the patient-centered medical home, we won’t be looking at just six measures anymore, we’ll be looking at 11. But you absolutely have to take it a bite at a time or a step at a time. But you have to have the data, it has to be easy to use, it has to be fresh data, which is why Explorys has been so nice, because it’s updated every night.
I always like to say, you measure what you get, and you get what you measure. Before we started measuring diabetes care, I thought I was doing a pretty good job on my patients with diabetes; and I probably was, with my patients who were coming in every three months. But the other thing that Explorys does is that it brings me data on patients I’m not seeing regularly and probably didn’t know about before. And that’s one of the underlying principles of value-based purchasing; that you’re responsible for a whole population, and now I can reach out to patients and focus in on their diabetes, without having to wait for them to come in for care.
Do you have any particular advice for non-clinician CIOs with regard to this work?
I think these initiatives need to be led by clinicians. And the data needs to be up-to-date, clear, easy to use, and I might even go so far as to say that a simple, more basic system that’s easy to use and gets used, is better than a more complex system that doesn’t get used.
