Can the leaders of patient care organizations really engage physicians in understanding the costs of patient care and in changing elements of their practice to improve value? Many would think that an absurd proposition. But as Charlton Park, chief analytics officer at the Salt Lake City-based University of Utah Health Care, explained it on Tuesday, that is just what happened at that integrated health system.
Park gave a presentation, entitled “Creating a Data-Driven Organization through Physician Engagement,” to an audience gathered at the Health IT Summit in Miami, sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization to Healthcare Informatics through parent company the Vendome Group LL).
On Feb. 2, Park shared with his audience at the Ritz-Carlton Coconut Grove the narrative around his organization’s journey into value, and the role that physician engagement has played in it.
At the core of that narrative has been a commitment from the health system’s executive leaders on down to push forward into improving the value that the organization was providing through its care delivery—value that involves a constant attempt to optimize high levels of clinical outcomes and lowered cost, along with increased efficiency.
Moving ahead has meant being transparent about all the processes involved. Quoting another healthcare executive, Park said he believes in the statement, “Everyone wants transparency to be a trick. It isn’t a trick. Transparency doesn’t start with the outside, it starts with the inside.”
Fundamentally, when it came to value, Park told his audience, “Our journey started with patient satisfaction. We had to leave the attitude that we were the academic hospital on a hill, and patients were lucky to be treated with us. We needed to change our patient satisfaction scores.”
So, Park, said, “We started with data transparency. Most clinicians had no idea we even were keeping scores” prior to the initiative, Park reported. “We transitioned away from snail-mail surveys with few responses; we needed more data to make it meaningful. So we were among the first academics to begin e-mailing satisfaction surveys on their first visit to their clinic. And physicians are scientists, so if they see an ‘n’ of 13, they’ll say, this is meaningless, we need more data. So the first step was gathering more data, making it meaningful, and then making it transparent. So the first step was internal transparency, explaining and educating the physicians.
Taking it step by step
Knowing that it would be a complex journey to engage physicians around quality, cost, and value, Park told his audience, “We started off with peer-to-peer data in blinded form: Dr. Smith, compared to everyone else, on satisfaction. Then we took baby steps forward, as the doctors became more acclimated and accepting of the transparency. We were the first academic to provide online reviews” of physicians by their patients,” he noted. If you go to healthcare.utah.edu, you can look up any provider and see their patient satisfaction scores, and it’s unfiltered except for derogatory comments or profane language. And that was a huge step,” he underscored. “We got comments from physicians saying, ‘You’ll ruin us!’ But to change our satisfaction scores, we needed not only to be transparent internally, but externally as well.”
In fact, when Park and his colleagues at the University of Utah Health Care started out, their organization started out only in the 29th percentile in a nationwide patient satisfaction ranking, so there was a long way to go.
First, he said, they began by providing physicians with twice-yearly individual physician scorecards for patient satisfaction, based on patient judgments coming in over a rolling 12-month period. The next step was peer-to-peer scorecards, in which an individual physician would see his or her satisfaction scores, compared with other physicians in her or his specialty, though the other physicians’ names were blinded to the individual. Over time, University of Utah leaders have moved to a system of scorecards that are offering both interdepartmental and individual outcomes comparisons. A key help here has been physicians’ natural competitiveness, Park says. Showing a slide in which ten doctors’ outcomes are compared and the doctors are described as Doctors A, B, C, D, E, F, G, H, I, and J, And Dr. A has the best documented outcomes along a particular dimension, he underscored that “Physicians, like most of us, are a competitive bunch. And they all want to be in first place. They all want to be Dr. A.”
After these developments, Park said, “Finally, we went to public scorecards. That is a transition that took about five years. But it’s now part of our culture, and [the participation in the scorecard process] is an expectation for all of our physicians. Still, it took quite a while to turn this ship around, and required a lot of investment.”
There have been several critical success factors involved, Park told his audience. “To get a return on this type of investment, you first need data transparency.” But committing significant resources to any such initiative is also critical, he said. “Physicians are busy people; they also need resources to help them with these kinds of improvements. So it started with that team approach. And system-wide, you need a call to action. And it required everyone’s involvement to turn around our overall patient satisfaction scores.” In short, he told his audience, the factors involved have included team-driven improvement, plus a common focus, plus local innovation, plus system-wide diffusion.
So the first steps were taken, and then, Park said, the initiative required “spreading best practices form clinic to clinic. And as we did this, we made that journey, steering that ship, to where we’ve changed our system’s overall patient satisfaction ranking from the 29th percentile in 2011, on a national scale, to the 85th percentile in 2014.”
What’s more, a majority of physicians affiliated with the University of Utah Health are now above the 90th percentile nationally in patient satisfaction, when only 4 percent were at that percentile in 2009. That figure has gone up steadily, from 4 percent in 2009, to 9 percent in 2010, to 22 percent in 2011, to 27 percent in 2012, to 46 percent in 2013, to 50 percent in 2014.
Even more importantly, the system’s physicians are “used to having data that’s actionable,” Park said. “And now we’re using that element and helping us in our transition from volume to value.”
A System-wide push
Park reinforced for his audience that the directive to move forward on value has come all the way from the top of the organization, specifically, Vivian Lee, M.D., Ph.D., CEO of the University of Utah Health Care. As Park noted, The New York Times published a report back in September 2015 that provided an account of the origins of the overall initiative. The Sep. 7 report began thus: “Only in the world of medicine would Dr. Vivian Lee’s question have seemed radical. She wanted to know: What do the goods and services provided by the hospital system where she is chief executive actually cost? Most businesses know the cost of everything that goes into producing what they sell — essential information for setting prices. Medicine is different. Hospitals know what they are paid by insurers, but it bears little relationship to their costs.”
Times reporter Gina Kolata continued, “No one on Dr. Lee’s staff at the University of Utah Health Care could say what a minute in an MRI machine or an hour in the operating room actually costs. They chuckled when she asked. But now, thanks to a project Dr. Lee set in motion after that initial query several years ago, the hospital is getting answers, information that is not only saving money but also improving care. The effort is attracting the attention of institutions from Harvard to the Mayo Clinic. The secretary of health and human services, Sylvia Mathews Burwell, visited last month to see the results. While costs at other academic medical centers in the area have increased an average of 2.9 percent a year over the past few years, the University of Utah’s have declined by 0.5 percent a year. ‘We have bent the cost curve,’ Dr. Lee said.”
Other national media outlets, including the NBC Nightly News have also reported on the story, Park noted.
Importantly, Park told his audience, “We now collect, analyze, and report value-driven outcomes through costing at the utilization level, using clinical data. And our model is flexible and extendible.” Significantly, he said, “If new data is available, we can adapt to it in the model.” Indeed, he said, “We’ve got dozens and clinical data sources” available to the leaders and managers of the health system going forward.
Park walked his audience through a series of slides showing how the University of Utah Health is sharing detailed costing data with physicians, giving them utilization and other data to help guide them to understand their individual cost profiles. With regard to that ongoing process, he said, “In terms of engaging physicians in this data, the first step is that you have to have meaningful data. Our institution made this incredible investment to create data that could work for us. So they sequestered a team of 20 of us three days a week for six months. We had subpoena power to get any experts up to help us. Our expectation was a prototype within three months and an operational analytical tool within six months, on our sequester team.”
Having built the model, now, Park said, “All the data sources involved now flow up into our data warehouse. And we’ve designed dozens and dozens of cost allocation methodologies. So we apply one of those to assign specific individual costs to individual encounters at the encounter level. And we use those to develop cost and outcomes measures that can be sliced and diced and aggregated in our reporting, to support clinicians.”
Park shared a number of examples with his audience, including detailed explanations of specific areas in which the University of Utah Health has made significant progress in engaging physicians around cost, quality, and value. One of many examples, he said, is the Ambulatory Surgery Value Explorer report. “Each surgeon can look at any procedure they do and compare their costs with those of others in their department,” he said. “So, for example, I could click on laparoscopic hysterectomy. The chart immediately updates to show the variation from the mean in costs. This provider is a little more costly on labor and labs,” he said, pointing to one sample chart from that program, “but less costly in terms of pharmaceuticals and supplies. So every provider has some potentially opportunity for improvement. This colleague has fewer inpatient days, but with higher supply costs. So the provider can compare him/herself with everyone else on line items, such as on the use of pharmaceuticals, to see how they’re spending compared to other providers. And most of our providers have never even seen costs data. Their first reaction is, I had no idea what that cost, and I don’t even need it!—with regard to a specific drug, for example.”
Among the lessons learned in all this, Park said, is that “Our first stop in this is to engage physicians to be a part of the process and be problem-solvers. The physicians are involved in the analytics,” as leaders and as individuals. “And you create this environment where the physicians can’t wait to see the updated report.” It is very important, he added, to “include metrics that are meaningful for the providers.”