Caritas Christi Health Care has announced a partnership with Microsoft on a system-wide data and patient relationship strategy that the Boston-based hospital network says will improve quality and reduce healthcare costs.
Using the Microsoft Amalga Unified Intelligence System, Caritas will aggregate patient data that was previously stored across multiple systems. The move will provide physicians with a real time, complete picture of a patient's medical history at the point of care, say Caritas officials.
"I think hospitals are starting to look at patient relationship management . . . and that we are going to go move from a fee-for-service model where doing more things makes us money to being in a mode where understanding patients' disease and preventing disease actually makes us money," says Todd Rothenhaus, MD, senior vice president and CIO at Caritas.
"The key to that, I think, is really understanding what kind of care is being delivered to our patients no matter where it occurs."
Caritas Christi serves 55 communities throughout Massachusetts and Rhode Island, so officials were searching for a way to solve data challenges faced the multiple providers, including inadequate tools for reporting and analysis, difficulty extracting data for reuse over time, and challenges connecting critical patient data stored in multiple systems.
The Amalga system will help address those needs, providing physicians and staff members with a single point of access to all data stored across many systems and a comprehensive view of patients, say Caritas officials.
"Our relationship with Microsoft will use technology to integrate our healthcare delivery system and accelerate our mission of using the full leverage of our six hospitals and 13,000 employees to deliver world class, community-based care," said Caritas Christi Health Care CEO Ralph de la Torre, MD, in a statement.
Also under the agreement, Caritas will enable patients in its communities to access their personal health data both inside and outside the hospital using Microsoft HealthVault, the personal health information platform.
This "patient empowerment" strategy will enable patients and caregivers access to and storage of their personal health information, including medical summary data, provider information, appointments, and insurance and billing information. Patients can then share this information, if they choose, with their physicians through HealthVault.
"You can look at data that's acquired through their personal health record and you are able to identify people who are at risk for the development of diseases and thereby intervene," Rothenhaus says. "If we know through HealthVault that their daily weights are increasing, we can intervene and call the patient and have them adjust their medication so they do not end up in the ER or hospital again."
Rothenhaus says the new system will "absolutely" improve quality and lower costs, most notably by giving Caritas staff and patients an "early warning" system.
For example, Caritas plans to use the system to identify patients who are in the hospital and may have suddenly developed abnormal vital signs, or possibly even have laboratory data that hasn't been reported back yet. This will be done in a formal fashion to understand which patients may be in need of higher of care like moving to the ICU, Rothenhaus says.
"Conversely, it can give us the ability to look across the system to see people who might no longer need ICU care, and can be put a step down to a floor bed and thereby conserve some resources," he says.
Caritas will also implement the Amalga UIS Quality Measures module to facilitate compliance with the Centers for Medicare & Medicaid Services core quality measures. The module captures data on all patients as they enter the hospital and determines whether a patient is a core measurement candidate, allowing the hospital to track and measure compliance.
"We view our adoption of Amalga and HealthVault as strategic drivers that will help us achieve our core goals of empowering patients and their caregivers, advancing data interoperability, and ensuring better health outcomes at a lower cost, while at the same time providing flexibility to react and respond to changing industry requirements," Rothenhaus says.
I've known Wayne for about four years, so the news came as a shock, especially since from every angle I've seen him over that time, it always seemed like he was committed to patient power as the key piece of cutting costs and improving quality in healthcare. He's always been a pioneer—from the drive to make healthcare prices transparent to the consumer to building a staff of employed physicians at the health system. Heck, three of the system's hospitals were recently named among the 100 "best value" hospitals. So what gives?
Well, so far, few are talking, including Sensor himself, but the writing on the wall is pretty obvious. Medical staff at two of Alegent's largest hospitals recently revealed a vote of no confidence against him, and that means dollars, ladies and gentlemen. Essentially, powerful physicians on the medical staff were saying with their no confidence votes that unless he was gone, they would henceforth be taking their business elsewhere. I'm told many of them already did that. Sensor offered his resignation, and the board, faced with a physician revolt that in the short term could have eviscerated the health system in favor of its competitors, accepted.
As I took the stage to moderate a panel on the difficulty of culture change in healthcare, the irony couldn't have been more stark. I talked with a good source on the drama the other day. He says the board insists that Sensor's resignation was not related to his drive to employ physicians at the expense of the affiliated medical staff, but let's be honest here: it couldn't have helped.
Everywhere you look, the old medical staff model of healthcare is breaking down. Hospitals, squeezed by reimbursement struggles, are hitting the financial shoals, and they need patients—especially the high-dollar kind whom specialists treat—to fulfill their mission. Employing physicians means their interests are much better aligned with those of the hospital or health system. But employing specialists is where it gets tricky. Independent physicians still wield tremendous power over patient referrals and most importantly, where they perform their high-margin services, not to mention power over the implants and surgical materials that hospitals must buy. No wonder CEOs feel squeezed at both ends.
When you start moving into specialists' space, you're stepping on toes when there's not a population increase to demand a general increase in the number of specialists in a market, my source says.
Hospitals and health systems held up in the healthcare reform debate as examples of cutting waste and unnecessary duplication of services, not to mention coordination of care, don't have this vexing medical staff problem. Why? A big reason is that they employ their physicians, and as salaried employees, those physicians don't have economic incentives that are contrary to the hospital's. With the medical staff model, they can take their patients and go elsewhere on a moment's notice if their demands aren't being met to their satisfaction. In Alegent's case, they did just that.
So you alienate independent specialists at your own peril. Sensor apparently alienated them once too often. Managing a transition from affiliated to employed physicians is filled with land mines, especially when you are hiring physicians to perform the same work that referring physicians do. According to published reports, many of these physicians felt left out of decision-making by Alegent administrators, and felt the system was moving toward a system where it used primarily its own employed physicians.
I'm not privy to conversations between leadership and the medical staff at Alegent, but hasn't this strategy been obvious for a few years now? Regardless, the fact remains that transforming those organizations into employed physician shops is extremely difficult, even with the strident support of the board, which Sensor apparently did not have.
At every step of his four-year tenure, Sensor has been following a game plan to which many of the most innovative hospital CEOs I've ever met have increasingly turned. Does that mean he wasn't alienating a key constituency? No. Does it mean he didn't make some tactical mistakes? No. Does it mean the strategy is poor? Absolutely not.
Assuming the board's decision to accept his resignation is based on the physician employment question, does this put Alegent on the wrong side of history? Only time will tell, but statistics aren't on their side, long term. Many physicians coming out of medical school today want to be employed by a hospital or health system. Why? It focuses them more on taking care of patients and takes them out of running a business—not the reason most of them went to medical school in the first place.
But I, and many others, including those interested in taking perverse incentives out of healthcare, feel that Alegent's board strategy will end up penny wise—and pound foolish. I'd love to hear whether or not you agree.
Hospitals participating in the first year of the Premier healthcare alliance's national collaborative, QUEST: High Performance Hospitals, saved an estimate 8,043 lives and $577 million by focusing on areas to improve healthcare, according to study results released this week.
At the beginning of QUEST, which stands for Quality, Efficiency, Safety, and Transparency, 157 hospitals voluntarily came together for this three-year project to basically try "to answer the very difficult questions: How do you simultaneously improve cost, quality, mortality, harm, and patient satisfaction at the same time," said Susan DeVore, Premier's president and CEO, at a Washington, DC conference unveiling the results.
"This group of hospitals did agree to be transparent with each other," she said. "They shared all of their data—good, bad, and otherwise. They talked about what their best practices were, and they worked together to really figure out how we were going to measure this, how we were going to automate this, and how we were actually going to improve this."
Premier, an alliance of nonprofit hospitals, learned from an earlier initiative with the Centers for Medicare and Medicaid Services (CMS) that looked at how to improve the implementation of evidence-based care. "We had huge success in that demonstration, but what our hospitals said to us is we've to get to systematic outcome measures. We've got to be ready for reform in whatever form it takes," DeVore said.
QUEST had 157 hospitals initially participating; another 31 were added later. They were from all over country and represented 31 states and all types of hospitals—big, small, urban, rural, teaching, and nonteaching, DeVore said. Healthcare reform means being "informed about what works. So what we're really doing is testing what might work—what might move the mark, what doesn't move the mark."
Working with the Institute for Healthcare Improvement, QUEST was used to help move hospitals to new levels of performance. Data from Premier's clinical database was used to determine the "baseline" level of performance for the areas of cost, mortality, and evidence-based care delivery. The hospitals then were challenged to find ways, by sharing data, on how to overcome main factors that lead to deaths, errors, errors, and excessive costs—while measuring themselves against one another.
Overall, in the first year, the QUEST hospitals reduced the cost of care by an average of $343 per patient and increased the delivery of recommended patient care measures by 8.74% and increased delivery of every recommended evidence-based care measure to an average 86.3% of the time. In addition, the hospitals reached a 14% reduction in observed mortality (compared to what was expected).
In the process, 32 hospitals were able to simultaneously move themselves to the "top performance threshold" in all three area at the same time improving in the areas of cost, quality, and mortality, DeVore said.
"There was clear executive leadership that was required in top performers and a clear line of site, so that top performers understand patient-centered care and understand how their mission translates all the way to performance," DeVore said.
"It is sort of that road to high-value healthcare if you think about it that way," DeVore said. "And knowledge transfer—it's the thing that's hardest [to achieve] in the healthcare industry. Today it takes 17 years to get standard practice implemented across the country. We're trying to condense that into a year or two years or three years so that we can get standard practice implemented more quickly."
The challenge the participating hospitals had "quite frankly is they did all this with basically no reward," DeVore said. "There is no reward pool. There is no financial incentive."
"In fact, there are financial disincentives to doing this because it might affect their revenue streams, and payers don't share the money back with them. They've done it anyway because they think it's the right thing to do for patients," she said.
The ads in the latest installment of Kaiser Permanente's "Thrive" campaign at first evoke thoughts of TV spots for a computer company or financial organization, rather than those of a healthcare organization.
The stunning visuals and topical content have propelled the commercials to go viral online—one of them, "Emerald Cities," has been viewed more than 5,000 times on YouTube. But the Oakland, CA-based organization's marketers will tell you that the ads' distinction is part of why the five-year branding campaign has achieved such success.
Kaiser launched the campaign in 2004 to differentiate the 35-hospital organization in the eight regions in which it operates. After conducting research on other healthcare organizations' messaging, marketers decided one way Kaiser could differentiate itself was to promote health as opposed to healthcare—reinforcing their emphasis on preventative care.
"Thrive is almost a public service message to the marketplace that says this isn't just about our Kaiser members—it's about the fact that we want our communities to thrive," says Debbie Cantu, vice president of brand marketing and advertising at Kaiser. "Everyone benefits when people are healthier. We ultimately started to evolve that message to talk more about the KP differentiators."
When creating the visual palate for the campaign, designers set out to craft realistic ads.
"We wanted to create real moments in people's lives where they're eating healthier or dancing or out mowing or just enjoying life," says Mark Simon, executive creative director at Campbell-Ewald, an agency based out of Detroit and Los Angeles. "We wanted that energy to come through."
The campaign consists of print, TV, radio, cinema, a microsite, social media, and outdoor, including billboards, cabs, bus sides, and public transit.
One of the difficulties in building a long-lasting branding campaign is the possibility that it will become outdated. Simon says he's had this obstacle in mind from the campaign's inception and he isn't afraid to tweak certain elements when necessary.
For example, in the early stages of the campaign, designers set certain keywords in a larger font than the rest of the text on the print and outdoor ads. It made sense during that time period, says Simon, but it is a style they no longer use.
"We're not talking a massive shift in art direction, but I just felt that if you look at how culture and style evolves it felt dated to me," he says. "It's not an earth-shattering revelation, but I think it's important in making sure that this campaign remains relevant, which is what Thrive is all about."
This year's three latest ads, "Emerald Cities," "Connected," and "Invest" tackle electronic medical record (EMR) technology and the current economic crisis—topics that Thrive hasn't addressed before. Marketers made sure to mold these new messages in a way that they would still fall under the brand umbrella.
"If we change our voice significantly, it's a disruption to the marketplace and a disruption to the campaign," Cantu says. "How we deliver that message is varied slightly, but it's always in the context of the bigger brand voice."
Emerald Cities emphasizes that EMR implementation would benefit the environment, and then some.
"It wasn't just about helping the environment, but it was also about the ability to share info that would ultimately change people's lives and make the world a better place," says Simon. "You can look beyond the technology of it and look at how it benefits people, and not even just Kaiser Permanente members but people all over the world."
The Connected ad approaches EMRs from a different angle and attempts to demystify a technology that may be confusing to many consumers.
"The challenge was how to keep it within in the personality of the brand, but talk about something that is pretty technical," says Simon. "We had to merge technology with the campaign, which is inherently human. Kaiser's philosophy is that it's technology in service of humanity."
The ad promotes benefits to the user by featuring the patient as much as the technology.
"Part of what we wanted to do was redefine what an EMR should be and have it truly reflect the patient," Cantu says. "We wanted to talk about that, but talk about it in a way that communicates its benefits to the members."
The Invest ad is Kaiser's 2009 wellness message, one of a series that they put out every year. However, this year's message is different—it broaches the current financial crisis.
"The ad has a wink and a nod to the fact that people are very skittish in investing in the market and their financial portfolio right now," Cantu says. "We're flipping that on its head and saying, but now is really the time to invest in your health. Even if everything else has gone away you still can invest in your health."
Since the campaign launched in 2004, Kaiser's north and south California markets have seen double-digit increases in perception, which represents brand awareness and whether non-members are considering switching to Kaiser.
The Thrive campaign has kept Kaiser competitive in its markets nationwide because its marketers are constantly adapting the content to reflect the current times. "It has evolved slightly over that time," says Simon. "In this year's work we've developed a creative equity and a consistency of the campaign we've evolved certain things here and there to keep it relative, fresh, and contemporary."
It seems today that the C-suite of hospitals and medical facilities is filled with an alphabet soup of M-degrees: Master's of business administration (MBA), master's of medical management (MMM), master's of public health (MPH), and master's of health administration (MHA).
More physician executives are currently pursing post-graduate business degrees, according to a new report, 2009 Physician Executive Compensation Survey, from Cejka Search, a healthcare executive and physician search organization, and the American College of Physician Executives (ACPE).
"There is a marked differentiation of physician [executives] that have MBAs and those that don't," said Lois Dister, executive vice president and managing director of Cejka Search in St. Louis about this year's report based on 2008 data.
Currently, one-third of physician executives (33%) possess an MBA, MMM, MPH, or MHA, according to the report. Based on a survey of more than 2,000 members of the ACPE, researchers found the following data:
53% of physician executive respondents have an MBA
28% have an MMM
13% have an MPH
6% have an MHA
They most often fill the roles of medical director, chief medical officers, division chiefs and department chairs, and vice presidents of medical affairs.
Advanced career options
Why do physicians spend the extra time and money for advanced business and management degrees? For many, it's a pathway to advancing their career.
"More and more, I'm hearing that a master's or post-graduate business degree is required," said Dister.
Although a growing number of physicians are taking the helm as CEOs, it's rare that these physicians do it without formal financial education. The M-degree is becoming the prerequisite to becoming a CEO or another high level leader.
Some physicians ask themselves the question, "Is an MD enough these days?" Unlike the practice of medicine, which requires formal education and a diploma as the stamp of approval, there's no such degree requirement for physician executives—yet.
"I used to say that experience trumps an MBA. Now, it's changed. Now, for most of my clients that are true physician executives—a top leadership role in a healthcare organization, like a chief medical officer, chief medical information officer, CEO, or chief operating officer—it's a ticket to enter into the game. You can't even be interviewed without it. It's a qualification," said Dister.
The old model is dying. While physicians used to learn business skills on the job, doctors are today learning about practice management in the classroom.
"If you go back in time, [people] got this training through the school of hard knocks. People picked up these skills the hard way with on-the-job training, either teaching themselves or having a mentor," said Jonathan H. Burroughs, MD, MBA, FACPE, CMSL, senior consultant at the Greeley Company in Marblehead, MA.
"There's really a better way of doing it now because we can systemically get that education before we go into the board room or the C-suite," he said.
After earning his MD from Case Western Reserve and receiving certification as a physician executive from ACPE, Burroughs went on to earn his MBA business degree from Isenberg School of Management at the University of Massachusetts. Altogether, Burroughs has been in school for 10 years for clinical and management education (four years of medical school, four years of internship and residency, and two years at business school).
Compensation
When asked if money was a motivating factor to hit the books again, Burroughs said, "Believe it or not, I did not purse it for money."
"Physicians generally make more money practicing clinical medicine than they ever will at any management position … I wanted to dispel that illusion that if you get an MBA, you make more money," he said.
Although there were no golden handcuffs for some physicians pulling them toward business school, the Cejka Search survey indicated that physician executives with advanced degrees does, in fact, correlate to a better salary.
With an average salary of $288,000, physician executives earn more based on their degrees. For example, they earned the following amounts compared to those who didn't have a post-graduate degree:
An average of 11% more with an MBA
An average of 10% more with an MHA
An average of 8% more with a MMM
Talking the talk
That extra salary acts as compensation to physician executives who possess business and management skills.
Physicians who possess duel degrees can act as a liaison among physicians, the medical staff administration, and the board who all communicate very differently—some in clinical terms, some in business terms.
"Having this financial background enables you to become bilingual," to speak "the language of the spreadsheet," as Burroughs called it.
Fixing healthcare in America
Although it varies by individual, most physicians ultimately take on the task of the M-degree because they see it as a way to fix healthcare, according to Barry Silbaugh, MD, MS, CPE, FACPE, and CEO of the ACPE.
"Everyone is aware of the deficiencies in our healthcare system and what needs to be done about it," he said.
Silbaugh said the extra work can be onerous, but rewarding.
"It's a lot of extra work and a lot of extra schooling, but it's worth it. Those of us that decide to do this is because we see a system that is dysfunctional in many ways, and we want to heal a system, just like when we heal patients," he said.
Karen M. Cheung is associate editor at HCPro, Inc., contributing writer for HealthLeaders Media, and blogger for HospitalistLeadership.com. She can be contacted at kcheung@hcpro.com.
The latest financial charts from California hint that hospitals in the Golden State might be starting to emerge from the recession.
They show total margin, which in the 4th quarter of 2008 had dropped to -4.9%, and operating margin, which had dipped to -1.1%, on an upward trajectory to +8.1% and +3% by the second quarter of 2009.
And they show that the percentage of the 387 hospitals operating with a negative operating margin going downward, from 50.1% in 2004 to 41.5% in 2008. The percentage of hospitals with negative total margins declined as well, from 41.3% to 34.6%.
"Just since the 4th quarter of 2008, things do appear to be going in a different direction.," says Kenny Kwong, accounting and reporting section manager for the Office of Statewide Health Planning and Development (OSHPD), the agency that keeps the largest state database of hospital financial and utilization information in the country.
Representatives of the California Hospital Association aren't so sure, and say many hospitals have been hit with an unprecedented number of fiscal pressures from which they may take much longer to recover, including the increase of underfunded patients and the state's daunting seismic mandates.
Hospitals have suffered enormously because of a precipitous drop in their investment portfolio, the charts show. Investment income reported to those hospitals in 2004 of $427 million went to $486 million in 2005, to $803 million in 2006, to a little over $1 billion in 2007, but plummeted in 2008 to $134 million.
"The data definitely support the fact that their investment income went way down," Kwong says.
OSHPD's data represents about 85% of the state's 450 hospitals. Those affiliated with Kaiser Permanente, the military, and the Veterans' Administration, state hospitals, psychiatric facilities, Shriner's hospitals, and long-term care emphasis hospitals are excluded.
Anne McLeod, vice president of finance policy for the California Hospital Association, says it's way too soon to even think that hospitals might be coming out of financial darkness. "I can't speculate what the numbers are going to look like," she says. "Our hospitals have reported to us they've taken significant hits on any investment portfolios they've had and seen significant increases in expenses for interest on capital cost."
Many hospitals said they have lost their bond covenant agreements because they lack cash flow or cash on hand.
There also have been significant increases in the number of uninsured and Medi-Cal (Medicaid) patients, for whom government reimbursement dollars do not come near to matching costs, and a decrease in volume for elective procedures. "Consumers are making a choice to not get care because they don't want to pay deductibles or because they lost their job and lost their coverage," McLeod says.
"Based on those elements, we anticipate not seeing a very good picture when the annual reports finally come out," McLeod emphasizes.
In July, the CHA issued a report, "California Hospitals and the Economy — Ongoing Credit Crisis Jeopardizes Seismic Compliance Mandate," which called the recession's impact on hospitals "unprecedented."
"More than a quarter of hospitals statewide (28%) have seen interest expenses increase in the first quarter of 2009, while many others have been frozen out of the credit market entirely. As a result, hospitals across the Golden State are faced with limited access to capital and increased cost of borrowing," it says.
What's worse for hospitals in California is that many of them will soon be forced by state laws to make seismic improvements—some even rebuilding their entire hospitals—by 2013 or 2020 or 2030 or else shut down. The Rand Corporation estimates the price tag for seismic hospital retrofit is $110 billion, not including financing costs.
In summary, McLeod says, "California hospitals are taking hit from all sides."
The door may be open to revisit state-mandated insurance coverage for certain medical tests and procedures when Georgia lawmakers reconvene in January. Georgia law provides that many health insurance policies cover certain tests and procedures, including mammograms, pap smears, colorectal screening, ovarian cancer screening, and prostate cancer screenings. But lawmakers are considering introducing legislation that would allow employers to offer workers the option of health policies that don't include all the now-mandated procedures and tests.
As the H1N1 influenza vaccine trickles into clinics and pharmacies over the next few weeks, public health officials and doctors desperately hope that pregnant women will be at the front of the line for the shot. Past influenza pandemics have proved that they're at increased risk for severe complications—and they appear to be even more vulnerable to this new flu strain. But pregnant women have a well-established antipathy toward vaccinations, with only 15% getting the flu vaccine in any given year, compared with 30% of the general population.
New York state health officials have suspended a ruling that would have forced healthcare workers across the state to get vaccinated against the swine flu by the end of November or risk losing their jobs, saying in a decision issued Thursday that they did so because the vaccine is in short supply. New York will be getting only about 23% of its anticipated supply of the vaccine for the swine flu virus by the end of the month, and that should be reserved for those most at risk for serious illness and death, according to Gov. David Paterson's office.
Elizabeth G. Nabel, director of the National Heart, Lung, and Blood Institute and one of the public faces of its parent, the National Institutes of Health, will be the next president of Brigham and Women's Hospital and Faulkner Hospital in Boston. Nabel, 57, is a cardiologist and clinical researcher who graduated from Cornell University Medical College and trained at Brigham and Women's in the 1980s. She was elected as its president in a unanimous vote by the board of trustees that oversees the hospital and its affiliate, Faulkner Hospital. She will begin her new job Jan. 1.
