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HL20: Harlan M. Krumholz, MD, SM—Collaboration Critical to Discovering Best Practices

 |  By Chelsea Rice  
   December 02, 2013

In our annual HealthLeaders 20, we profile individuals who are making a difference in healthcare. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in the evolution of healthcare. This is the story of Harlan M. Krumholz, MD, SM.

This profile was published in the December, 2013 issue of HealthLeaders magazine.

"In the end, it was always about whether our work was likely to result in something that would benefit the patients or population."

When pharmaceutical and medical device companies align with physicians, sometimes the patient is seen as the third wheel. One cardiologist and researcher at Yale University School of Medicine is trying to change that. Harlan M. Krumholz, MD, SM, credits the collaborations he's made for advances in industry transparency and patient safety innovations, not biased prescriptions or ignored patient interests.

In June 2013, Medtronic, the medical device giant, released the findings of two research groups it commissioned, led by Krumholz, which investigated the company's back-surgery device Infuse. The two research teams concluded the device was no more effective than an older technique but also carried additional risks to the patient. These findings were released to the public immediately. This corporate experiment in transparency is exactly the kind of relationship Krumholz enjoys being a part of.

"My philosophy was always to work to develop strategic partnerships. Bring the science and clinical perspective to work with people eager to bring other perspectives and data. It was never about negotiating access to the data," says Krumholz. "We were always trying to figure out how to work in a collaborative or collegial way. In the end, it was always about whether our work was likely to result in something that would benefit the patients or population."

Whether examining care coordination or communication at the point of discharge, as the director of the Robert Wood Johnson Clinical Scholars Program at Yale and director of the Yale-New Haven Hospital Center for Outcomes Research and Evaluation, Krumholz has shined a light on outcomes-based quality metrics with a focus on collaboration and transparency. His work has directly led to improvements in the use of guideline-based medications, the timeliness of care for acute myocardial infarction, public reporting of outcomes measures, and the current national focus on reducing the risk of readmission.

Over the years, that initial collaborative effort at Yale has expanded to include a lot of strategic partnerships and "good friends" working with the center to try to make a difference.

"By working together, we can make sure we promote the common good and avoid the potential for unintended adverse consequences," says the cardiologist.

Krumholz is pleased with where healthcare is headed today. Hospitals are beginning to learn from one another and share best practices as the industry grows and expands. The industry is having conversations it never would have had five years ago, he says.

After graduating from Yale College, Krumholz took advantage of traveling fellowships in 1981, studying models of rural healthcare delivery in the United Kingdom, India, and China. The simple ways healthcare could shift in its delivery and dramatically impact a population influenced him greatly at this early point in his career.

"It sensitized me to think about what results are being achieved by all different types of healthcare systems and the variety of experiences individual patients can have with that system," says Krumholz. "In medical school, we're trained that our job ends when someone goes out the door in a hospital. We are told our job is to reduce the census and help people move out of the hospital, but patients think in terms of episodes and they aren't done with that episode when they go home."

After medical school at Harvard University in 1985, Krumholz served as an internal medicine resident at the University of California San Francisco and later decided to specialize in cardiology in part because he felt the field offered a breadth of opportunities; but the field was also attracting a lot of physicians and there "was a lot of action." He became more and more excited about combining science, data-based research, and policy studies to do work that would help clinical decision making not only at the bedside, but that also would help guide larger policy questions to reshape the industry.

Beginning in 1995, Krumholz also started a series of projects that revealed readmissions as a problem and tested interventions to reduce patient risk. This work placed readmission in public view and later work, with the Centers for Medicare & Medicaid Services, resulted in national measures that were publicly reported and subsequently incorporated into the Patient Protection and Affordable Care Act.

In 2004, Krumholz's work with timely treatment of heart attacks showed that only 33% of heart attack patients were receiving angioplasty within 90 minutes of their admission to the hospital. With National Institutes of Health funding, he pioneered methods to study top performers, including combining quantitative and qualitative studies that contributed to a national campaign to translate the research into action. Within three years more than 90% of patients were treated within guideline recommendations.

Krumholz credits his teams at the university, the hospital, and the Robert Wood Johnson Foundation as the force behind his contributions to the way healthcare is delivered in the United States today. Krumholz's team at CORE has expanded to include a lot of strategic research partnerships over the years, including insurers, Medicare, and the medical device and pharmaceutical industries, where he says his team is trying to make a larger difference in the market through studying best practices to influence clinical decision making.

"It isn't just about understanding why the provider is making the right or wrong choices, but also figuring out how to ensure that high-quality decisions are being made. There's an unlimited opportunity in the market to affect performance and make the system more responsive," says Krumholz. "I saw the best opportunity to impact practice was to produce knowledge that could be immediately applied."

When Krumholz began his research on readmissions, there was no incentive in the industry to pay attention to the rates at which patients were returning to the hospital. Despite their findings, Krumholz and his team were searching for subjects and participants, but hospitals didn't adopt their initial findings "because there was no incentive to do it." Almost no hospitals that did participate in the readmissions pilot program continued.

"You only have to look closely at the lack of systems we have in place that truly help people make a transition to realize how broken this system is. Anyone who has been in the hospital knows that returning home is a rocky transition and usually little is done to help them," says Krumholz. "Readmission rates are starting to drop but it will take several years to replace a mind-set that's existed for decades."

Chelsea Rice is an associate editor for HealthLeaders Media.
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