Yale New Haven Health System Shares Lessons Learned On its Value Journey

Last week, I had the benefit of attending the first annual National Symposium on Value Innovation at Yale, hosted by Yale New Haven Health System (YNHHS) leadership.

The event was a collaboration with YNHHS, the Yale School of Management, the Center for Outcomes Research & Evaluation (CORE), the Yale Center for Biomedical and Interventional Technology (CBIT) and health IT vendors Strata Decision Technology and PeraHealth.

The goal of the event, according to YNHHS leadership, was to share the health system’s lessons learned and best practices as part of its ongoing journey toward improving quality and lowering cost across the system.

What struck me was that this was a health system that includes Yale-New Haven Hospital, the primary teaching hospital for the Yale School of Medicine, and regularly ranked among the best hospitals in the country, openly sharing its struggles and challenges as it transitions from volume to value with an audience that included healthcare leaders from hospitals and health systems throughout the country.

I’ve been covering the health IT space for less than a year, yet it’s my understanding that up until very recently, healthcare was very insular. Yet, it seems that we’re starting to see the wheels turning on more open discussions and sharing of best practices.

And in my time covering health IT, I’ve also noticed that while discussions about value in healthcare have been occurring for quite some time, it still seems that there is such a struggle for healthcare organizations to achieve it. And this fundamental issue seemed to be the impetus for the Symposium.

In its written materials, YNHHS leadership introduced the Symposium thus: “The way healthcare is organized, delivered and reimbursed is in the midst of profound and far-reaching change as we transition from volume to value. As revenues shrink and margins tighten, the time has come for us to shift focus to quality and cost optimization if we are to remain successful.”

“Like you, we at Yale New Haven have been working to prepare for these changes. Over the last four years, we’ve begun to measure quality and cost variation for every patient we serve. Our hope is that by sharing our story—including the lessons learned—we can start a conversation that will help accelerate the collective journey toward improving quality and lowering cost.”

In the keynote address to launch the Symposium, YNHHS president and CEO Marna Borgstrom, said the health system’s leadership is focused on integrating care and services to “make healthcare more accessible, easier to use and to deliver value” to patients.

And, according to Borgstrom, YNHHS leadership first deconstructed value and developed a specific definition: value equals quality of care, safety and patient experience divided by cost/price.

Borgstrom outlined a number of strategies being deployed across the health system to enhance value, including the integration of selected clinical and administrative services and creating an enhanced patient experience, “because if we don’t have an experience that makes them feel safe, we won’t get to second base in this game,” she said.

The health system has also focused on eliminating unnecessary variation. And, finally, the health system also embraced public policy advocacy and the use of information technology and analytics. “In this area [IT], we actually pulled back and asked, ‘What do we need? How do we mine what we have?,” Borgstrom said. She noted that the key to being data-driven is not necessarily more data but better information for clinicians.

Stephen Allegretto, vice president of strategic analytics and financial planning at YNHHS, discussed the revenue challenges that YNHHS leadership recognized five years ago.

“There’s incredible pressure on the revenue stream, payer consolidations, public exchanges and Medicare cuts. With the transition from volume to value that would lead us to, as an organization, receiving less revenue for every patient that we treat,” he said.

Throughout the day, health leaders on the “front lines” at Yale New Haven drilled down into more specific details about these initiatives to use data to drive improvements in quality and cost.

“It has taken a village to get us here. And this initiative has been driven by integration strategies, the thoughtful deployment of technology, the EHRs, predicting outcomes, a local definition of quality and measuring quality variation with every patient we see and partnering with external collaborators,” he said. Specifically, YNHHS formed strategic partnerships with organizations such as Strata Decision Technology and PeraHealth to accelerate Yale New Haven's transition to value-based care delivery.

YNHHS is a 2,130-bed health system that operates three hospitals in Connecticut, including Yale New Haven Hospital, a 1,541-bed tertiary medical center. In early 2012, YNHHS implemented a number of key multiyear strategic initiatives aimed at improving overall value, including the installation of a common electronic medical record. The multiyear clinical redesign work, which was anchored to an advanced cost accounting system, also included an initiative to identify quality variations in a way that was meaningful and actionable to physicians and nurses.

As part of the health system’s $125 million Value Improvement Initiative, YNHHS’ financial and clinical leaders developed a Quality Variation Indicators (QVIs) methodology, essentially a way for health system leaders to “speak the same language” on cost and quality metrics in order to reach the health system’s goal of reducing variation, improving patient outcomes and decreasing overall costs, according to Allegretto. The QVIs feature 27 summary categories of negative clinical outcomes, such as deep vein thrombosis (DVT), respiratory failure, shock, vascular catheter infection, implant complication, transfusion reaction and allergic reaction.

These tailored indicators are an amalgam of Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs), hospital-acquired infection (HAI) indicators, as well as other types of measures based on certain diagnosis-related groups and ICD-9 codes. The goal with using the QVI methodology has been to reduce Medicare’s financial revenue penalties and achieve standardization in clinical practice so that patients consistently receive better care at a lower price, YNHHS leaders said.

On average, YNHHS found that cases with any of these negative clinical outcomes, or QVIs, resulted in patients staying three times longer and the cases cost four times more than cases without QVIs.

While the health system set a target of reducing spending by $125 million, it beat its target and sustained $150 million in savings over three years, while at the same time maintaining and improving quality and cost at a service line level, according to Abe Lopman, senior vice president of operations at YNHH, while speaking at the event. Health system leaders were able to achieve this using robust cost accounting data combined with EMR and quality data. The data then led to actions that improved quality and lowered costs. In fact, as part of the health system’s partnership with Strata Decision Technology, the company began licensing YNHHS’ QVI methodology and that methodology is now implemented as part of Strata’s cloud-based, SaaS financial analytics and performance platform.

During panel discussions, health leaders also focused on issues relative to safety and the patient experience, which also factor into the value equation as defined by YNHHS. Senior executive leaders highlighted the health system's ongoing journey to zero safety events and hardwiring safety across the system. At the time of the Symposium, it had been 13 days since a Serious Safety Event (SSE) across the health system, according to Allegretto.

Harlan Krumholz, M.D., a cardiologist and healthcare researcher at Yale University and Yale-New Haven Hospital, spoke about the need for true patient engagement, which entails data transparency and access. Krumholz, who is the Harold H. Hines, Jr. Professor of Medicine and Director of the Yale Center for Outcomes Research and Evaluation (CORE), noted that patient-powered tools are going to be the “linchpins” that positon organizations for success in healthcare.

“My vision is patient-powered, data-driven healthcare. We have to put the data in patients’ hands,” he said. “We can't run healthcare like it’s 1950. In order to make smart decisions, they need to have access to data.”

There also was much discussion during the Symposium about the “thoughtful deployment” of health IT tools, including the integration of tele-ICU technology with the EHR systems, the utilization of clinical decision support tools and the use of health IT for more effective patient recruitment for research trials, according to Lisa Stump, interim CIO at YNHHS.

While the health system had made tremendous advances toward value-based care, it’s clear that the health system’s journey to improving quality and lowering cost is not over. “The road ahead in healthcare is challenging and our ability to thoughtfully innovate will enable us to build on our success,” Stump said.

I find it encouraging that as leading health systems make this journey, the leaders of these organizations are sharing their lessons learned to perhaps make the road ahead smoother for other hospitals and health systems. But, more importantly, these lessons learned need to spark continued conversations, collaboration and information sharing so that the healthcare industry can collectively and effectively make that transition to value-based care.