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MetroHealth’s CMIO on Leveraging IT To Push Forward into Value-Based Care and Patient Engagement

January 24, 2018
by Heather Landi
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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.


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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.

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How a Data-Driven Approach Can Bolster the Fight Against Opioid Abuse

October 12, 2018
by Steve Bennett, Ph.D., Industry Voice
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I want to tell you about Andy. Andy’s mom, Pam, is a colleague of mine. Growing up an only child, Andy was a happy kid. He was a straight-A student, loved to play the violin, and spent a year as an exchange student in Europe. Andy had two loving parents. But Andy suffered an injury in college, and needed to have some minor surgery performed to repair his sinuses. Following that surgery, his doctor prescribed opioid pain medication for him, to which he became addicted. Despite several years of effort, Andy was unable to shake the addiction, and tragically lost his life to a heroin overdose two years after his surgery. This was a normal kid with a normal family, like mine, and like yours.

Andy’s story is an important story. The opioid epidemic has led to the deadliest drug overdose crisis in the history of the United States, killing more than 64,000 people in 2016 alone – the last year numbers were available. This is a true national epidemic, and one that continues to get worse. For the first time in nearly 60 years, life expectancy for Americans has dropped for two years in a row due to the opioid epidemic.

The opioid crisis has been so difficult to curtail, in part, because of the inability to integrate data from various stakeholders and systems. With so many players and data sources, today’s information is partial, fragmented, and often not actionable.

While this disconnect applies directly to the opioid epidemic it is a systematic problem that affects the healthcare community at large. Better data and analytics can help develop better treatment protocols for a wide array of medical and public health challenges that affect the general public. For opioids, that could be to develop better pain management programs or for better, more-targeted remediation and rehabilitation for those that become dependent on drugs.

A Data-Driven Healthcare Approach: Making Information Real


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Ample data has been collected on the opioid epidemic, but disparate sources are not communicating with one another. Addressing this disconnect and lack of communication is something that can provide researchers, lawmakers and the public with improved insights.

Data-driven healthcare can help provide this guidance by using available data and analytics to help create programs that can make a tangible difference on population areas that need the most help. By looking at the data, lawmakers, hospital administrators and doctors can begin to make impactful changes throughout the system.

While much can be learned from this data, most of it is not being analyzed in a way that brings true benefits. It has been put in a silo and/or it is not organized in a way that is interoperable with other data systems.

The 21st Century Cures Act, which established the Health Information Technology Advisory Committee, shows the commitment of national leaders to improving healthcare information sharing. Analytics can take this data and turn it into something real. Subsequent visualization of this analyzed data presents the information in a way that can truly tell a story, making sense of data that analysts sometimes miss. Analytics can arrange and organize data in different ways and pick up previously undetected trends or anomalies. This information can be turned into real programs that produce real outcomes for those affected.

The data management and integration process can also help us understand where our knowledge gaps are, revealing flaws in data quality and availability. Organizations may learn that they lack sufficient data in a certain area where they want to learn more, but are currently limited. They can then make changes to data collection efforts or seek out different sources to fill these larger gaps. They can resolve data quality issues across systems and arrive at a consistent, reliable version of the truth.

As organizations get better at assembling and managing the data, automating processes to generate standard reports and file exchanges can ease the burden on analysts. Streamlining the user interfaces for prescription drug monitoring programs and other systems allows analysts and medical informatics staff to spend less time working on the data itself and more time enabling and encouraging the use of predictive modeling and “what-if” scenario capabilities.

Helping to Solve a Problem

The national opioid epidemic is a terrible and complex issue. It is not something that can be solved with just one action, approach or program. It is a layered issue that will require systematic changes to how patients are treated and how the healthcare system operates. Some of the nation’s best continue to work on providing operational solutions to these problems, but as the statistics show, they need more help.

A data-driven approach can be that help. Using data analytics to find better and deeper insights into the root problems of this epidemic can help decision-makers make real change. While opioids are the focus now, there will come a day when a new problem emerges. Having data and analytic solutions in place can prepare these organizations to tackle these future challenges as well.

64,000 people died in 2016 as a result of opioid abuse. But 64,000 is more than a large number – it’s also Andy and his family. With analytics and a data-driven approach, government and healthcare leaders can make better decisions that can help people in need.

Steve Bennett, Ph.D., is the director of SAS' global government practice. He is the former director of the National Biosurveillance Integration Center within the Department of Homeland Security

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DOJ Approves CVS-Aetna $69B Merger, On Condition Aetna Divest Part D Business

October 10, 2018
by Heather Landi, Associate Editor
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The Department of Justice (DOJ) has approved a $69 billion merger between mega-pharmacy retailer CVS Health and health insurer Aetna, after Aetna entered into an agreement with the DOJ to divest is Medicare Part D prescription drug plan business.

According to a statement released by the DOJ on Wednesday, the settlement, in which Aetna will sell off its Part D business, was a condition of the merger’s approval and resolves the DOJ’s “competition concerns.”

The deal is the latest in a wave of combinations among healthcare companies, including many pharmacy benefit manager (PBM) and insurer integrations. Last month, the Justice Department approved Cigna’s $67 billion takeover of Express Scripts.

CVS Health announced in early December 2017 its intention to acquire Aetna in a $69 billion-dollar merger, marking the largest ever in the health insurance industry. Woonsocket, R.I.-based CVS operates the nation’s largest retail pharmacy chain, owns a large pharmacy benefit manager called Caremark, and is the nation’s second-largest provider of individual prescription drug plans, with approximately 4.8 million members. CVS earned revenues of approximately $185 billion in 2017. Aetna, headquartered in Hartford, Connecticut, is the nation’s third-largest health-insurance company and fourth-largest individual prescription drug plan insurer, with over two million prescription drug plan members. Aetna earned revenues of approximately $60 billion in 2017.

Following news of the deal back in December, there was speculation that antitrust regulators might not approve the deal. Back in January 2017, a federal judge blocked a merger that would have resulted in Aetna acquiring Louisville, Ky.-based insurer Humana, which at the time was the largest acquisition of its type in the history of health insurance in the U.S., reported at $37 billion. At the time, U.S. District Judge John D. Bates in Washington said that proposed deal would “violate antitrust laws by reducing competition among insurers.” Similarly, a proposed combination of two other health insurers, Anthem and Cigna, was also shot down last year.


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According to the DOJ’s statement issued today on the CVS-Aetna deal, the Justice Department’s Antitrust Division had significant concerns about the anticompetitive effects of the merger with regards to the Medicare Part D businesses. CVS and Aetna are significant competitors in the sale of Medicare Part D prescription drug plans to individuals, together serving 6.8 million members nationwide, according to the DOJ.

In a press release issued today, CVS Health said, “DOJ clearance is a key milestone toward finalizing the transaction, which is also subject to state regulatory approvals, many of which have been granted.” CVS Health's acquisition of Aetna remains on track to close in the early part of Q4 2018, the company said.

“DOJ clearance is an important step toward bringing together the strengths and capabilities of our two companies to improve the consumer health care experience,” CVS Health president and CEO Larry J. Merlo, said in a statement. “We are pleased to have reached an agreement with the DOJ that maintains the strategic benefits and value creation potential of our combination with Aetna. We are now working to complete the remaining state reviews.”

Merlo also said, “CVS Health and Aetna have the opportunity to combine capabilities in technology, data and analytics to develop new ways to engage patients in their total health and wellness. Our focus will be at the local and community level, taking advantage of our thousands of locations and touchpoints throughout the country to intervene with consumers to help predict and prevent potential health problems before they occur. Together, we will help address the challenges our health care system is facing, and we'll be able to offer better care and convenience at a lower cost for patients and payors.”

Following the close of the transaction, Aetna will operate as a standalone business within the CVS Health enterprise and will be led by members of its current management team.

The American Medical Association (AMA), an industry group that has been opposed to the merger, issued a statement saying the agreement that Aetna divest its Part D business doesn't go far enough to protect patients.

"While the AMA welcomes the U.S. Department of Justice (DOJ) requiring Aetna to divest its Medicare Part D drug plan business, we are disappointed that the DOJ did not go further by blocking the CVS-Aetna merger," Barbara L. McAneny, M.D., president, American Medical Association, said in a statement. "The AMA worked tirelessly to oppose this merger and presented a wealth of expert empirical evidence to convince regulators that the merger would harm patients. We now urge the DOJ and state antitrust enforcers to monitor the post-merger effects of the Aetna acquisition by CVS Health on highly concentrated markets in pharmaceutical benefit management services, health insurance, retail pharmacy, and specialty pharmacy."

Agreement with DOJ Resolves “Competition Concerns”

Late last month, Aetna agreed to sell its Part D business to WellCare. According to a Securities and Exchange Commission (SEC) filing from WellCare Health Plans last month, WellCare entered into an asset purchase agreement with Aetna to acquire the company’s entire standalone Medicare Part D prescription drug plan business, which has 2.2 million members. According to the agreement, Aetna will provide administrative services to and retain the financial risk of the Part D business through 2019. In that filing, it states that Aetna is divesting its Part D business as part of CVS Health’s proposed acquisition of Aetna.

“Today’s settlement resolves competition concerns posed by this transaction and preserves competition in the sale of Medicare Part D prescription drug plans for individuals,” Assistant Attorney General Makan Delrahim of the Justice Department’s Antitrust Division, said in a statement. “The divestitures required here allow for the creation of an integrated pharmacy and health benefits company that has the potential to generate benefits by improving the quality and lowering the costs of the healthcare services that American consumers can obtain.”

In its statement, the DOJ referred to WellCare as “an experienced health insurer focused on government-sponsored health plans, including Medicare Part D individual prescription drug plans.”

The Department’s Antitrust Division, along with the offices of five state attorneys general, today filed a civil antitrust lawsuit in the U.S. District Court for the District of Columbia to enjoin the proposed transaction, along with a proposed settlement that, if approved by the court, would fully resolve the Department’s competitive concerns. The participating state attorneys general offices represent California, Florida, Hawaii, Mississippi, and Washington.

In a complaint filed to the U.S. District Court, DOJ attorneys argued that without the divestiture, the combination of CVS, which markets its Medicare Part D individual prescription drug plans under the “SilverScript” brand, and Aetna would cause “anticompetitive effects, including increased prices, inferior customer service, and decreased innovation in sixteen Medicare Part D regions covering twenty-two states.” DOJ attorneys also argued that the loss of competition between CVS and Aetna would result in “lower-quality services and increased costs for consumers, the federal government, and ultimately, taxpayers.”

Under the terms of the proposed settlement, Aetna must divest its individual prescription drug plan business to WellCare and allow WellCare the opportunity to hire key employees who currently operate the business.  Aetna must also assist WellCare in operating the business during the transition and in transferring the affected customers through a process regulated by the Centers for Medicare and Medicaid Services (CMS).


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A Data-Driven Effort to Tackle Indiana’s COPD Problem

October 9, 2018
by Rajiv Leventhal, Managing Editor
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One patient care organization in Indiana has leveraged a robust data analytics platform to reduce avoidable COPD readmissions and improve the overall health of the community

Although reduction in avoidable readmissions after chronic obstructive pulmonary disease (COPD)-related hospitalizations is a national objective, in one Indiana community it’s moved its way up to the very top of the healthcare priority list.

In Jackson County, Indiana, the COPD population is roughly two times the national average. And considering that COPD is the third-leading cause of death in the U.S., working to fix the problem has taken precedence at local hospitals—including Schneck Medical Center, a community hospital in Seymour. Says Susan Zabor, vice president of clinical services at the medical center, “We have a high obesity population and a high smoking population, so in Jackson County, COPD is very prevalent. When we looked at our 2014 data, we knew it was an issue and we knew that it was a high-volume diagnosis for us, ranking second in our [hospital] readmissions.”

Indeed, at the time, Schneck Medical Center had a raw readmissions rate of nearly 14 percent for the specific COPD patient population, and these re-hospitalizations were leading to substantial added readmissions costs—upwards of $300,000 per year, according to Zabor. “We needed to put a focused intervention in place,” she attests.


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Susan Zabor

The fines for failure to meet the Centers for Medicare & Medicaid Services’ (CMS’) avoidable readmissions reduction criteria, as part of the government’s Hospital Readmission Reduction Program (HRRP), focus on six conditions: heart attack, congestive heart failure, pneumonia, COPD, elective hip and knee replacements, and for the first time starting in 2016—coronary artery bypass graft surgery. The current focus in the HRRP is on readmissions occurring after initial hospitalizations for these selected conditions, and hospitals with 30-day readmission rates that exceed the national average are penalized by a reduction in payments across all of their Medicare admissions.

As such, it’s clear that in healthcare’s future of value-based care, treating patients outside of an organization’s four walls will be critical to an organization’s success. What’s more, drilling down into the data and being able to specifically predict and target patients who are at high risk for readmissions has become a key point of emphasis for many hospitals.

At Schneck Medical Center, clinical IT leaders launched a data analytics initiative with IBM Watson Health, whereby they were able to analyze treatment patterns, costs, and outcomes data for their own hospital and compare those with peer group hospitals around the country. It was this analysis which showed that Schneck was experiencing much higher than average numbers of complications, readmissions, and patient deaths related to COPD.

Zabor notes that the hospital was “doing well on process measures and publicly-reported measures, but we weren’t doing so well on some bigger issues like complications, mortality and length-of-stay, and we leaned on CareDiscovery [a Watson Health solution] to give us actionable data that was as close to real time as possible to help us improve.”

Using this data, hospital leadership was able to pull together teams focused on closing those gaps. Schneck’s organizational efforts for COPD patients included developing a long-term care practice, which currently includes a physician medical director, a full-time physician, three nurse practitioners and two medical assistants, as well as the hospital’s respiratory care department. This team makes weekly respiratory care visits, incorporates sleep studies into its observations and conducts patient discharge planning. In addition, the hospital put in place new protocols that included the installation of a transition team to help with patient discharge, follow-ups with recently discharged patients, and annual facility education regarding COPD.

Indeed, the data available in the Watson Health’s CareDiscovery solution helped the hospital focus efforts to improve care for COPD patients, eventually resulting in an 80-percent reduction in its unplanned COPD readmission rate and hundreds of thousands of dollars in savings—representing a 99-percent decrease in costs related to readmissions.

“We started doing a better job of managing patients’ chronic illness in whatever setting they were in— be it long-term care, home care, or primary care. Before long, they didn’t need to come into the hospital,” Zabor says. To this end, the hospital also witnessed a 55-percent decrease in patients admitted with a COPD diagnosis from 2014 to 2017. Zabor notes that reducing primary admissions actually was an unplanned result of the organization’s efforts, but one they were happy with nonetheless.

As many hospitals and health systems remain in a position today in which they are straddling two payment worlds—fee-for-service and pay-for-performance—one might ponder if it’s truly in the organization’s best interest to keep patients away. But Zabor says that for Schneck Medical Center’s executive leadership, it was never a question. “For our patients and our community, keeping them out of the hospital is the best thing to do, whether you are making money or not,” she says.

“Zabor adds, “We [do have] one foot in value and one in volume, which is difficult, but we have a patient-first culture here. Yes, have a finance pillar, but it does not overpower our quality of care or customer experience pillars, which all support that patient-first culture.”



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