As chief medical and scientific officer of the Cambridge, Mass.-based Institute for Healthcare Improvement (IHI), Don Goldmann, M.D. has been advocating passionately for transformational change in healthcare for years. Dr. Goldmann is not only the CMO at IHI; he brings his clinician background and perspective to his work advocating the diffusion of the principles of the Triple Aim (improving the health of populations and enhancing the patient experience, while optimizing costs), the core set of principles that IHI leaders are working to universalize across the U.S. healthcare system.
The editors of Healthcare Informatics are delighted to host Dr. Goldmann as the opening keynote speaker at the Healthcare Informatics Executive Summit, being held April 30-May 2 at the Mark Hopkins Hotel in San Francisco.
As he prepares to share his perspectives and insights with executive Summit attendees in May, Dr. Goldmann spoke with HCI Editor-in-Chief Mark Hagland regarding the IHI’s ongoing work, the Triple Aim, and clinical transformation. Below are excerpts from that interview.
What should healthcare IT leaders understand about the IHI and its advocacy of transformational change in healthcare right now?
Right now, I’m planning on a working title for my presentation of “What What Quality Improvement Experts Need from HIT.” I’m going to talk about IHI, because many audience members won’t know about IHI, and then talk about improvement science is, which is the core of what we do. I think most people think it’s running collaboratives or running a PDSA [plan, do, study, act] cycle, but improvement science in healthcare is so much broader than that.
What is it that some healthcare IT leaders might not understand about the broader concept of what quality improvement is?
It depends on the person and organization, of course. But some people believe it’s all about measuring and benchmarking and PQRS [the physician quality reporting system] and HEDIS measures [the Healthcare Effectiveness Data and Information Set from the National Committee for Quality Assurance (NCQA], and similar things; others would say it’s all about PDCA, Lean, etc., and things like that; that it’s about tools to take out waste.
But instead, it’s about prediction and learning, in a rigorous way. In its simplest form, it means that you have a very clear, measurable aim, and a measurement framework to help you reach your aim, and that you have clear ideas about what you want to achieve, and predictions about what you want to achieve; so it’s a causal pathway towards a desired outcome, described in a conceptual or logical model clearly showing the ramps or pathways towards what you hope to achieve. And it needs an execution theory or implementation strategy; what are the activities you plan, and what are the expected outputs from those activities, and how will those change the outcome? So if you say, I want to lower blood pressure, and your theory is that you’ll encourage patient lifestyle change, then that’s the content theory or causal pathway towards an outcome.
So then, how do you embed that into practice? Do you employ nurses to support it in your medical practice? That’s the execution theory. And very often, people will say, here’s the guideline for an age cohort; and here the guidelines, and then you’re done. And if it were that easy, the majority of people with hypertension would be under control, and they’re not. So you have to go through iterative PDSA cycles.
And what’s important for HIT people to understand is that HIT systems are not built around quality concepts, but around administrative needs—billing, basically. If we had built EMRs based on patient needs, they’d look very different, and probably a heck of a lot better. But they’re built off administrative data needs. And I’ll talk about learning from variation—what can you learn from looking at the impact of creating change.
How do you conceptualize the CIO, CMIO, and HIT leader roles in the context of healthcare transformation and continuous quality improvement work?
It’s really difficult these days, because the technical requirements are so high not only to understand EHR and analytics concepts, but also, we’re asking healthcare IT professionals to have an understanding of the clinical aspects of this. So really, they have to become part of a high-functioning, multidisciplinary team. And if a chief information officer has never been to the ward or looked at a clinical pathway and understood the struggles, that’s a bad place to be. I know of one experiment where a clinical pathway was being rolled out, and they still haven’t gotten off paper, because there was virtually no understanding of how to launch that pathway and keep it up to date.
So non-clinician CIOs really need to better understand clinical care?
Yes, and improvement work; they’re used to understanding wireframes and improvement processes in informatics—and some of those same concepts apply to clinical improvement work.
So IT people do need to understand the mechanics of care delivery and quality improvement work, right?
What I would say is that for somebody who is a CIO, there’s a lot they can relate to, including systems thinking, data analytics, and the need for taxonomy.
When you look at accountable care organizations, bundled-payment contracts, patient-centered medical homes, and population health management initiatives, where do you see IT facilitation fitting into those models of care delivery and payment?
Most of all, I see a need for communication during transitions of care, whether patients are in hospitals, EDs, nursing homes, or their homes—you really need to be able to manage patients across the continuum, and most EHRs don’t do that. And HIE [health information exchange] isn’t there yet in terms of maturity.
How do you see things unfolding in the next five years?
I think it’s going to be a period of enormous frustration and transition, because most organizations are spending a bundle to purchase, implement, and sustain commercial EHRs. And that’s an enormous enterprise in terms of money, and even more importantly, people and will. Because once you do that kind of thing, you don’t have the appetite to do much more in the next years. So we’re going to be faced with a situation where some of these broader initiatives stall out as a result. Meanwhile, consumers will be turning to apps; hundreds of millions of people globally will have consulted a healthcare website or online tool, by 2015. So I think it will be a challenging time; we’re going to have these very expensive, somewhat inflexible, hard-to-change platforms, that do not reconcile or connect with, personal apps, health websites, provider apps like UpToDate, etc. So I think it’s going to be really challenging; it’s going to be a time where some strong voices are going to be needed in order to move us forward.
