Founded in 1837, Cleveland’s MetroHealth System is an integrated health system operating three hospitals, one of which, MetroHealth Medical Center, serves as Cuyahoga County’s public safety-net hospital. Annually, the health system handles more than one million patient visits, including more than 100,000 in the emergency department, one of the busiest in the country.
In many ways, MetroHealth is at the forefront of health IT and the use of technology to enhance clinical care. In 2014, the health system was designated as Stage 7 on the ambulatory electronic medical record adoption model (A-EMRAM) by HIMSS Analytics, the research arm of the Chicago-based Healthcare Information and Management Systems Society (HIMSS). Stage 7 represents the highest level of EMR adoption and indicates a health system’s advanced electronic patient record environment. MetroHealth was among the first safety-net health systems in the country to reach Stage 7 status, and the first to do so using the Verona, Wis.-based Epic Systems. In addition, the health system continues to move forward into population health management and value-based care and payment models.
David Kaelber, M.D., Ph.D., is the chief medical informatics officer (CMIO) at MetroHealth System, a position he has held for the past nine years, and is leading or involved in a number health IT initiatives at the organization. Dr. Kaelber, who also has a Master of Public Health degree, is slated to be a speaker at Healthcare Informatics’ Cleveland Health IT Summit at the Hilton Cleveland Downtown on March 27 to 28. Among other topics, Dr. Kaelber will share MetroHealth’s road to success with regard to the health system’s MetroHealth Care Partners Accountable Care Organization, one of 30 successful Medicare Shared Savings Program (MSSP) ACOs. Healthcare Informatics’ Associate Editor Heather Landi caught up with Dr. Kaelber to discuss his top priorities right now as it relates to IT initiatives at MetroHealth, as well as the healthcare technology developments that are on his radar in 2018. Below are excerpts of that interview.
What are your top priorities right now?
The MetroHealth System is trying to move very quickly into value-based care instead of fee-for-service, and accelerate our move into more pay for performance. Within the MetroHealth system, we see that there is a huge technology catalyst that needs to occur to make that happen. So, it’s a big chunk around analytics, and within analytics, I’d put predictive analytics into that. We’re really trying to get our data processes better, as well as reporting and those predictive tools. The best data set or analytics or predictive tool is only as good as whether people can use that to make some change that otherwise wouldn’t be possible. So, analytics is not the end, it’s the end of the beginning. It’s necessary but not sufficient.
One hallmark that demonstrates our competence in that is, last year, we were one of a relatively small number of organizations that succeeded in our Medicare Shared Savings Program ACO (accountable care organization) contract. My view of that is it was informatics or health IT-enabled success. I think if I pulled out the informatics rug from underneath what the population health team was doing, I don’t think we would have been successful because most of what they did was enabled by both the analytics and the workflow tools that we put into our system, and these are the tools that all the providers as well as care coordinators and the population health team used to enable us to achieve that success. That has been a major push, and I think it continues to be a major push. We’re not doing the same population health that we were doing last year. Every year, not only is the bar being risen by the payers, but we’re also trying to get new contracts with more and more payers. So, I think that’s huge.
Another area I’d point to is patient engagement. We’re trying to be very aggressive with our personal health record. I think it’s particularly of note that we have a very diverse patient population, both socio-economically and educationally diverse patient population. Traditionally, you would expect that a personal health record for patient engagement might not be quite as high on the strategy. But, for us, we see that as a significant tool for the future.
We’ve implemented this thing called fast pass. Patients can already self-schedule most of their appointments, and many of their procedures, online. What the fast pass does is if another patient cancels an appointment for a time slot much earlier than your appointment, the system would automatically send you an email or text to let you know that the doctor has an opening, and if you want the earlier appointment, it will then automatically reschedule you. We’ve been live almost a year now. At this point we have almost 100 appointments being automatically re-self-scheduled per week. The average is about 23 days earlier that the appointment gets moved up. It’s a win-win for everybody. Patients like it because they get to see their doctor earlier. As a system, we like it, because it fills our schedules and it does it in an automated way.
You mentioned patient engagement efforts as it relates to the personal health record and the socio-economic diversity of your patient population. Why is that a challenge?
We published, back in the spring, an article in the Journal of the American Medical Informatics Association (JAMIA), where we saw a direct correlation between broadband internet access and MyChart sign-up and usage. We know that neighborhoods where the population is of lower socio-economic status, broadband access it’s not as prevalent. What our study showed is that if you live in a zip code where broadband service is less, then your sign-up for electronic health record portals also is less. (Editor’s note: The study concluded that the majority of adults with outpatient visits to a large urban health care system did not use the patient portal, and initiation of use was lower for racial and ethnic minorities, persons of lower socioeconomic status, and those without neighborhood broadband internet access. These results suggest the emergence of a digital divide in patient portal use. Find the full study here.)
Another area of interest that we’ve studied, but haven’t published any findings, is that we’ve found that while it may be true that in some lower socio-economic areas, home internet access is not as prevalent as other areas, smartphones seem to be relatively ubiquitous. And, that has helped inform our personal health record strategy. We’ve had a number of conversations about this with the Epic Corporation, and our view is perhaps the prioritization of features and functions of the smartphone should take priority over personal health record functions developed for desktops or laptops or for the website. The way I would frame that is, people of higher socio-economic status probably have good home internet access and a smartphone, so presumably, they could be using a website, desktop or the smartphone, versus other people who might not have easy access to home internet or desktops, but still probably have close to the same penetration of the smartphone.
Looking broadly at the health IT industry, what are the trends are you interested in, and what developments are you watching?
There are a couple of things. I still think this idea of big data, predictive analytics, I still say it gets a lot hype, and I think that “there is a there there somewhere.” But, as a CMIO, I can’t really live so much by “I hope it’s going to work,” I have to live in the world where I need to do things that I have high confidence will work. I still don’t know where to put my money on, in that space, to a large degree, so I’m watching that area a lot.
Health information exchange is another area I’m watching, and we’re trying do a lot in that area at MetroHealth. As we move more into the ACO and pay for performance space, I think the idea of having complete information on a patient becomes more and more important. At the MetroHealth system, we’re pretty well ahead of the game because we have all providers/patients on one system (the Epic electronic health record). But, even in that model, when we’ve looked at it, something like two-thirds to three quarters of our patients get at least some care today or historically have gotten some care at another healthcare system, and if we don’t have good insight into that care that occurs and if we don’t get as much discreet data about that care as possible, then we’re not providing the highest value care to the patient. We have a number of initiatives, with the Social Security Administration, with the VA (U.S. Department of Veterans Affairs) or through the eHealth exchange and the Sequoia Project, and now with our state-based HIE and our Epic-based HIE, to really try to get as much data as possible.
Then this is moving more into stage 3 of Meaningful Use, where there is this requirement to reconcile external information. We’re spending a lot of time figuring out how to do that in a seamless way. I think there are many opportunities to figure out how that could work better. At this point, I see patients where I might have a medication list of 20 medications from the Cleveland Clinic and I’m trying to mesh that with the 15 medications that I have in my healthcare system already and that takes a lot of time and energy to do that. On some level, it should be value-add because you want the complete medication list on a patient, but a lot of times, it ends up being a very inefficient use of a physician’s time. So how can we make that all work better?
I’m also interested in staff satisfaction. People talk about the triple aim of health care, and then that morphed into the quadruple aim, and the difference is that the fourth aim is around staff satisfaction. We’re really trying to think about how can we use the HER, not only to help with value-base care and population health to achieve things like decreased cost, improve the health of populations and improve patient experience, but, in addition to those three things, how can we also really improve the staff experience? There have been studies that show that providers and physicians are spending hours per day charting. How can we change that paradigm so that the EHR is really improving and enhancing, not only the patient experience, but also the staff experience in taking care of patients through the EHR? That's an area that I am interested in as well.