A recent paper caught my attention because of what it says about the anticipated increased involvement of patients in their own care. The study, released in March and conducted for NEJM Catalyst, is titled, "Care Redesign: What Data Can Really Do for Health Care," The study looked at the attitudes of healthcare executives, clinical leaders and clinicians about what data is most important now in healthcare and how they anticipate that will change in the future.
In the NEJM survey, respondents were asked to identify what they believed to be the most useful sources of data today and then what those would be in 5 years. Today, clinical data rated highest by far at 92% while at number two and number three were cost data (56%) and claims data (45%). However, when asked about what they believed would be the most valuable data sources in 5 years, claims data is anticipated to drop off significantly in value (scoring only 32%), and clinical and cost data will be joined at the top by patient-generated data and genomic data (both scoring 40%).
Participants in this study were also asked to select what they believed to be the biggest opportunities for use of data in healthcare, and 81% of them put care coordination at the top of the list, followed closely by improved decision support (79%).
In short, the surveyed leaders point to the rapidly growing importance of patient-reported outcomes, measures of care coordination, and improved decision support. These areas need to be prioritized if we are to truly navigate to value in healthcare. These data are patient-centric, and patient-reported, and they form the foundation for greater collaboration between patients and providers as well as greater coordination between teams of providers. Let me provide an example.
Turning the Data into Opportunities
Many studies have shown a big difference between what healthcare providers consider to be medically indicated and what patients prefer when they are fully informed of their conditions and options. Therefore, we need to improve how we inform patients of their options and collaborate with them to arrive at the best decision.
In my book, Navigating to Value in Healthcare, I write about the 3-talk model of shared decision-making; Team Talk, Option Talk and Decision Talk. It's too involved to detail in a blog article but basically the 3-talk model consists of inviting the patient and initiating deliberate collaboration with him or her; followed by an option talk to describe the options, benefits and risks while supporting the patient as he or she moves from initial to informed preferences about the available options; and then a discussion about the decision when the patient is ready. In the decision talk, you make sure the patient’s preferences are informed and then confirm your understanding of them.
In the book I also detail two patient-reported measures for assessing the shared decision making and improving the patient experience called CollaboRATE and IntegRATE. CollaboRATE helps us understand how well we are doing as we seek to understand what matters most to patients and work to ensure that knowledge underpins the care plan. IntegRATE helps us to assess, from the patient’s perspective, how well our care teams are working together. Both measures are used to evaluate and continuously improve. These data can then be combined with other patient-reported outcomes to document changes in health status. Cost allocation methods are also used to monitor the costs to your organization for the goods and services associated with the changes in health status. That is the definition of calculating value.
Dealing with a Data Disconnect
Just as there can be huge differences between what well-informed patients want and what healthcare providers think they want, it appears there is a similar contrast between what healthcare leaders see as important and the overhyped dreams of big data vendors.
Leaders in healthcare are dealing with greater chaos and uncertainty today. When it comes to the information they need to assess where they are and where they are going, they are often flying blind. Essential data on the value of the services is lacking or missing. What they need most consist of outcomes that matter to patients and the costs associated with achieving those outcomes. Yet, few organizations have started to develop the capacity to measure patient-reported outcomes, to understand the costs of producing the care they deliver, and to govern change.
Navigating from volume to value will be more difficult and take longer than we’ve been promised because the system we have now is profitable for many of us, but it is not financially sustainable in the long run, not for patients, communities, nor the healthcare system as a whole.
For the necessary changes to happen we need to create systems and processes that reliably produce high-quality outcomes, keep their costs under control, accurately identify patient preferences, and coordinate care to meet patients’ needs. In my experience, the resistance to those changes can be overcome when we measure what matters to patients and create an environment that emphasizes learning from those measurements.
One last point. The NEJM study found that leaders believe the lack of interoperability is the biggest barrier to functionality in healthcare information systems, most notably in EHRs. I believe the interoperability challenge is overblown. It has, in fact, been solved in other industries. It is no longer a matter of not knowing how to achieve interoperability, it is a matter of getting it done.
In the previous blog article I wrote about the attributes of leaders, teams, and organizations that are necessary for success in navigating toward value in healthcare. To get those elements in place you need to create a compelling project that builds organizational motivation. To identify the right project, you need to know where and how to find value opportunities.
When looking for value opportunities keep in mind the fundamentals: Value increases when outcomes improve, or when outcomes remain steady but costs are reduced.
We do not measure value particularly well. Many healthcare organizations fall short of measuring the fundamentals. Value is the quotient derived from dividing the outcomes relevant to patients by the costs associated with achieving those outcomes. To begin effectively measuring value an organization must start with a true understanding of outcomes that matter to patients and then determine the costs of achieving those outcomes.
For this, you need the right data.
Dealing With the Data
Most organizations have access to volumes of data in two major forms:
1. External. This is publicly available, and can include data regarding utilization rates, patient experience, costs, reimbursements, and performance on a number of clinical and operational measures among regional competitors and top performing hospitals. These data can be helpful as a starting point for your transformation efforts, or for providing a clearer focus for them.
2. Internal data. Remember the fundamentals above. Value increases when outcomes improve, or when outcomes remain steady but costs are reduced. Also remember that the most valuable outcomes you measure will be outcomes that matter most to your patients. This data can only lie within your organization, which makes internal data critical to navigating to value.
Your organization does not need to invest in an enterprise-wide data infrastructure project if it uses the external data to identify medical conditions and care processes with the most room for improvement and cost savings. However, transformation requires more intimate knowledge of what happens within your organization and what patients care about most.
How do you know which measures are necessary for tracking and improving the value of care you deliver? How do you best collect, retrieve, organize and display your data for what you are trying to accomplish? When you think of how you are going to use the data available to you to navigate to value, you might want to take a journalist’s point of view. Before you can get to the big “How,” you need to know the “What, Where, Who and When,” aspects of your data.
What you decide to measure deserves careful thought and study. In healthcare, we often default to an existing or easily available measure that does not really get to the bottom of what we are trying to improve. Does this measure matter to patients? Have you asked them how much it matters? Measures such as A1C or FEV1 or even blood pressure provide useful information to clinicians, but they are not outcomes that matter to patients. Because there is a cost associated with tracking every measure, you need to choose thoughtfully, looking at existing literature or someone with more experience with the topic to help guide you to a pragmatic list. Try to include at least one measure that matters to patients and a way to measure the cost of achieving that outcome.
Your data points reside in many places, including in medical records, condition-specific registries, billing and appointment systems, and even in online resources that monitor physician, clinic, hospital, and regional performance. If you will be collecting your data, where do plan to store them? The complexities of retrieving data from multiple sources and linking these sources to a specific patient or group of patients may require the assistance of a data engineer. The first few efforts of a data engineer tries to pull and organize the data from your systems may be clumsy, but over time, it will become easier to automate the retrieval, organization, and display of common data points.
Who will retrieve, organize, and display your data? Will it be a single person or several? Were these people involved in planning the project implementation? Many well-intentioned projects begin by defining the what, where, and when of a measure that matters to patients and costs, but then fail because not enough thought is given to who handles the data and how much they know about the intent of the project.
When will the data be retrieved, organized, and displayed? Data that are as close to real time as possible have the most influence on processes. Displays based on data that are months or even years removed from the process have little influence, and can breed cynicism and resentment in the team.
To make your improvement and transformation to run smoothly and successfully, the retrieval, organization, and display of measures that matter to patients and drive value needs to become routine.
In the next article I will look in more detail at outcomes that matter to patients.
To learn more about my thoughts on data and value in healthcare, see Navigating to Value, where you can find the table of contents and several reviews. The book is available for pre-order now and will be in print later this month.
Successfully navigating from volume- to value-based care cannot be mandated down from leadership, nor can it rise up organically from a star performer among the ranks. Even though as individuals any one of us might like to believe that I alone can make profound changes in the world or in our organizations, transformations on the scale needed in healthcare require much more than extraordinary personal effort. Healthcare is complicated. Successful transformations don’t come easy or overnight. Navigating to value in healthcare takes solid leadership, the right team, and an organization that not only appreciates what lies ahead but also is fully committed to getting there.
I have come to learn, through both successes and setbacks, there are key attributes that help ensure successful change. These attributes are found in five vital areas—the project team, project leadership, organizational leadership, organizational support, and mindset and expectations.
The Project Team
Perhaps most importantly, members of the project team must know and feel that they are empowered to make decisions that drive improvement. They have to believe what they’re doing is valuable and will make a positive difference. They must also be agile. For transformation efforts to succeed, project team members must be able to adapt quickly to dynamic work environments.
In order to develop the vital sense of empowerment in the project team I mentioned above, you need project leaders who value input and feedback from the team. Leaders need to be able to break through departmental and hierarchical boundaries to develop relationships across the organization. In order to better connect with and lead the team, they must have working knowledge of the data analysis techniques and tools that are being used by the team to help drive the transformation.
Organizational leaders must be accessible and be able to clearly align change efforts with the organization’s vision, ethics and expected outcomes. They need to be visible and actively encouraging change efforts. This type of support is made visible by being attentive and inquisitive about the change process, working to remove barriers, and creating time for high-quality personnel to participate.
To implement change efforts more quickly, create a centralized cluster of coaches, data engineers, and patient architects across the organization that have experience in transformation efforts. These personnel act as mentors for those on the current project team and help to manage rapid change in the organization by sharing the lessons they have learned in the past. Because these mentors also have their own full time jobs in other departments, they, in turn, need support from the organization to give them ample time to participate as mentors.
Mindset and Expectations
Again, healthcare is complicated. Complex systems often require complex solutions. People involved in transformations must appreciate that although lessons learned from prior efforts can be valuable, each project has its own dynamics, and there is no one comprehensive answer that will bring success to every effort. The key is to learn by doing and to keep the organization learning.
So far we have explored how to harness variation in the organization and some of the elements in empowering and building teams to create greater value, but what is value? How do you know it when you see it? In the next article, we will focus on how to look for value opportunities in your organization.
To those of you have reached out via LinkedIn, Twitter, and Facebook, thank you! I appreciate the encouragement and feedback. Please keep the comments coming here, through social media, or email.
Variation can be a powerful agent for creating value within healthcare organizations. Harnessing variation can create better outcomes and service for the money we spend and greater value is needed because inefficiency and waste in our current healthcare system create a sizable drag on our economy.
But that is the big picture.
When you are starting a process improvement program, the people on your staff don’t see it in those terms, so getting their buy-in for change needs to happen on a more personal level.
In the previous article, I addressed how efforts to harness variation can create fear in organizations. Taking advantage of the opportunities variation presents means fostering an environment of collaboration, innovation, and adaptation. But how do you avoid progress-killing fear in order to move forward?
One of the greatest sources of anxiety in organizations is the unknown. Why are we embarking on this program and gathering all of this new information? Why now? Why us? What are they going to do with all of this data once they get their hands on it?
As a leader, you need to anticipate these questions and answer them before they are even asked. Your goals need to be well thought out and well communicated. At a minimum, you should be able to comfortably and concisely answer these questions:
The next major hurdle is convincing people that the purpose of your efforts is not to find the “weak links” in the process and punish people who are “responsible” for the variation. It is not sufficient to merely reassure people verbally that the focus of your efforts are not to find fault. The improvement process needs to be designed in such a way that guarantees its conduct is blame-free.
You do this by blinding the data. Remove any identifying features. Although many people like to think they are top performers, their greatest fear is that they are near the bottom. As your improvement process continues, people begin to realize that they likely float somewhere in the middle, with some high marks and some lows. This tends to put them at ease and helps them realize that there are things they learn from their peers, and also things they can teach them.
The improvement process should be designed to build shared knowledge, shared language, and mutual respect—the hallmarks of a learning organization. Taking these small steps can help you remove fear from the variation equation to get everyone past it and moving forward.
In the next article I will address the potential of people to induce substantial improvement and positive change in systems, and the attributes you should be looking for in individuals, teams and the organization in order to make transformation efforts successful.
Exposing variation can inspire investigation, learning, improvement, or excuses. Which will you choose?
A few years ago, when I started writing and organizing my upcoming book, "Navigating to Value in Healthcare," the first outlines I imagined involved starting off with big, bold concepts to address challenges in healthcare and then finally drilling down to detailed explanations of key pieces of building value within an organization. The more I wrote, the more I came to see that I had it backwards.
As it turned out, all of the big-picture healthcare concepts I had thought should be at the front eventually found themselves at the back of the book. The key pieces of building value that needed to be at the front were less flashy but undeniable. And the first element that called for the most attention, was variation.
The major emphasis of my academic and consulting work is helping healthcare organizations create clinical and financial success in a new payer environment that is based on providing value rather than relying on volume. To do this requires instilling a deep understanding into the organization of how the quantity and quality of their services compare to similar organizations, and by driving their performance toward outcomes that matter most to patients.
Variation looms heavy over everything you try to do to get there, and at times can be seen as a dark nemesis. Instead, I would like to suggest it is a shining opportunity. It is an opportunity because the answers you need are frequently “right there” in the data. Best practices within an organization can be identified and by simply asking and listening you can find what is needed to achieve those best results.
While I believe that almost everyone in healthcare wants to provide the best outcomes, and safest, highest-quality care at the lowest cost, reality does not match those lofty goals. Unwarranted variation in healthcare delivery has been studied for nearly a century for its negative effects. It has been consistently shown there are variations in the outcomes, quality, and costs associated with the delivery of healthcare services everywhere, much of which is not easily explained between healthcare organizations that are considered “best in the world.” Moreover, a great deal of variation exists even within “best in the world” organizations and when these findings are revealed it creates fear and anger.
We need to talk about the fear variation can create in organizations because we have to get past that fear so we can do our good work.
The biggest thing people fear about exposing variation is that the organizations or individuals involved will be ranked, and then those on the “bad end” will be spanked—called out for their underperformance and punished. Next, they are often left in the dark by their leaders about how all of this data they are collecting will be used in the end. This creates anxiety around how the data is collected, retrieved, organized, and displayed. This can raise hostility because people can come to feel as if they are unfairly evaluated.
If you want your organization to evolve into one that is characterized by anger, fear, cynicism, and resistance, just dump in a bunch of data without explanation and start “ranking and spanking.”
If you would rather create a transformative, agile learning organization that exceeds the expectations and needs of the people it serves, you need to harness variation and use it to create greater value. To harness variation, wise leaders must inspire people to collaborate, innovate, and adapt, in order to harness the opportunity that variation presents. In the next article, I will offer a few techniques and tips for making that happen.
In order to thrive in tomorrow's healthcare delivery environment, leaders need to be able to build organizations with the capacity to adapt and innovate based on patient-focused methods of measuring healthcare quality and value. It is one thing to understand the concept of value; it is another to figure out what needs to change in an organization and how to make that transformation happen.
Responding to new challenges and improving underperforming areas requires new types of information, knowledge, and skills. Leaders need to raise their awareness of outcomes that matter to patients and financial performance, as well as how the quantity and quality of their services compare to similar organizations. This work is not easy, yet these changes are key to an organization's health and survival.
While well-informed and inspiring leaders are critical for creating decisive action toward success, it is important to remember that healthcare delivery occurs in teams. After creating the vision, achievable first steps must be identified and momentum must be built to overcome resistance to change.
I created this blog to delve into the issues of creating greater value in healthcare, including how to harness variation, look for value opportunities, measure what matters to patients, and then make successful changes to improve the delivery of healthcare. Over a 25-year career, I have been fortunate to work with teams and organizations facing an ever-changing landscape of healthcare reform and navigating the transition from volume to value based payment systems. Now, several times a month I hope to provide insights from my book, Navigating to Value in Healthcare, that will help you on your way. I look forward to sharing my experience and learning with you.