At Butler Health System, a 311-bed community hospital in Butler Pa., hospital leaders have come together to use data analytics to improve a range of patient care delivery processes and outcomes. Working with an analytics solution from Information Builders, a New York City-based business intelligence and integration company, Butler Health System clinical, IT, and financial leaders have been moving forward to focus in particular on examining and improving specific diagnostic and care delivery processes whose outcomes have financial impacts.
In all this, the leaders at Butler Health System are fortunate to have A. Thomas McGill, M.D., leading the charge. Dr. McGill, a practicing infectious diseases specialist, has been vice president of quality and safety at Butler Health for 10 years, and for the past four years, he has also been the organization’s CIO. Thus, his title and responsibilities encompass both quality improvement and IT activities and efforts at the health system. McGill spoke recently with HCI Editor-in-Chief Mark Hagland regarding the work that he is helping to lead at Butler Health. Below are excerpts from that interview.
You have a unique perspective on all this, being both the vice president of quality and patient safety for ten years at your organization, and also, for the past four years, the hospital’s CIO. Tell me about your and your colleagues’ pursuit of clinical performance improvement through data analytics.
Certainly. Especially because of my dual titles, in our analytics work, we are focusing on a combination of quality and safety improvement, as well as on financial analytics. And our particular focus has become all the metrics for which we are held accountable by external organizations—payers and regulators. We had long been working on analyzing some metrics, but the evolving mandates coming from the Medicare program and the commercial payers have particularly spurred activity here. Medicare has all its adjustment programs, and the commercial payers have their incentive programs. For example, the healthcare-acquired conditions program under Medicare penalizes a wide range of conditions acquired while patients are being treated—some of them infections and other conditions non-infectious.
A. Thomas McGill, M.D.
For example, we started working on venous thromboembolism [VTE] prophylaxis early on. We looked at the actual costs of patients in the same DRG [diagnosis-related group]—looking at whether they had a clot or not. And we found that per case, patients with a clot were costing us $9,000 per case. I was really surprised by that level of expense. We immediately saw something like 50 episodes or events involving venous thromboembolism, when we started doing our analysis back in 2012. So our baseline measurement was that we had found that we had been experiencing basically 50 or 60 such cases a year, and we were able to get that number down to 9 or 10. The drug Lovenox was still a brand-name drug. So when we first started, we said, OK, we’re going to spend $25 a day on this prevention—we knew it was the right thing to do for the patients, but didn’t know what it would be like financially, and even financially, it was a home run to prevent blood clots. In fact, we ended up avoiding a quarter of a million dollars in costs just through that improvement.
And you just start doing these one after another, and they start accumulating. And outside of infectious disease, that’s one of our best examples of where clinical care quality improvement has saved money.
Could you share any other examples?
Basically, at the turn of the century, we started doing active MRSA surveillance to find out whether patients were carriers of MRSA [the methicillin-resistant staphylococcus aureus bacterium] when they came into the hospital for care. And therefore, we wanted to know if they were carriers of MRSA when they came in, were we inadvertently spreading that to other patients and amplifying the amount of MRSA in our community? So Dr. Jernigan from the CDC [Daniel B. Jernigan, M.D., M.P.H., Deputy Director of the Influenza Division at the National Center for Immunization and Respiratory Diseases, for the federal Centers for Disease Control and Prevention] had this idea, and we bought into it and started looking at screening everybody. So we did a baseline study again: we were screening incoming patients, and made those results available to doctors considering potential antibiotic treatment. We found that our amplification rate was 25 percent, meaning that for every 1,000 people who were coming into our hospital as carriers of MRSA, 125 were going out, confirming that we were adding to the burden of MRSA in the community. So we started screening and treating for MRSA upon admission. And we didn’t see a change in the burden until we had done active surveillance. We didn’t affect our overall amplification rate until 80 percent of our units were under this program. And we understand that many healthcare workers move from unit to unit. What our data showed was that the hospital-based spread of MRSA can be prevented.
In other words, you and your colleagues found that clinicians were spreading the disease inadvertently?
Yes. You would go see a patient on another floor, and you’d get it on your stethoscope and clothing, and we know that hand hygiene is imperfect, and therefore, it was easy to inadvertently spread the disease. We fluctuate between a rate of 100 and 106 now.
That’s excellent; you’re close to zero added MRSA burden from hospital-based spread. Have you benchmarked that rate against the rates of any other organizations?
We’re aware of a hospital that got as low as 104. And they were using a PCR test, which costs $50 and gives you a result in an hour or so. We were using a culture method that gave us a result within 24 hours. We have to be frugal as a community hospital. But we found that we were able to bend the curve cost-effectively. So then the fallout of that program in the current era is that MRS and hospital-acquired MRS sepsis is now a quality measure, and we basically have one case every year or two, extremely low rates of that, and I attribute that to this program, in part, anyway.
I love the fact that you’re an infectious disease specialist, head of quality, and CIO.
It was just a career evolution. So you’re responsible for infection control, and you need data, and have to make some changes. And when I was functioning as a physician in this infection control role, I was always going down to IT or administration saying, we can do this better. So that led into my quality role. And then that led into further involvement in data and information system. And so I became the functional CMIO while I was head of quality, and our CIO announced his retirement rather unexpectedly, so my boss asked me to be the interim, and after six months, he asked me to stay on.
How do CIOs and IT, clinical informaticists, and clinician leaders, move forward in all these areas, leveraging data?
You certainly need the data, and someone has to turn it into information or understanding; and then this ability to make change, to change your institutional and your individual behavior. And I can tell you, you can get pretty far just by doing that. But in the absence of incentives, you sort of hit a certain ceiling. So then really, to go farther, you need incentives. So we have institutional incentives in the form of penalties or upsides from our payers. And I’ve been examining the projects where we’ve had total success or failure or so-so results, and the question is, are the incentives aligned? That’s the differentiating factor. And you can do almost anything in a year, but if the incentives aren’t aligned, you won’t sustain it.
And then, organizationally, in the transformation of our industry that is now taking place because of the cost crisis, the ability to do this requires buy-in and capability on the part of every department in the organization. I can manage some finite number of projects, right? But to really be successful in payment reform—for an organization our size, we would have to be doing dozens of these a year, sustaining them, and going onto further dozens a year. So it can’t be a special function. So what we really want it to be is part of how people function and manage.
So my perception is that certainly, the managers in healthcare, at least in our organization, were not hired with these skill sets or aptitudes in mind; and it’s also true of many physicians. Medicine is an applied science, which is kind of like engineering. So the way I think about medicine now is, if these changes are fairly close to how you’re practicing now and need to make an incremental change, the applied scientists are pretty good about that. But if you have to discover new knowledge to make change, as in changing care processes, only a very small percentage of physicians have that attitude. Because you’re having to apply new knowledge.
Could it also require cultural change among physicians?
Yes, but I would say that culture overlaps considerably with new knowledge-based change.
We’re systematizing care delivery, though, right? And that in itself is a cultural change.
I would agree. And what we’re doing with the data is giving individuals and groups the data, and that is very effective. Physicians are competitive; they’ve always been the best in their groups. They don’t want to be the worst in their groups. But you have to have the right incentives.
Will you be participating in any Medicare or commercial ACOs [accountable care organizations]?
We haven’t done that yet; we’ve been sitting on the sidelines to see what happens. The passage of MACRA [the Medicare Access & CHIP Reauthorization Act of 2015] is sort of forcing the issue. We do have gainsharing agreements with two of our payers now. And our area is one of the mandated ones for total joint replacement. But we haven’t done it yet; it takes a lot to get all the systems in place. And to me, the infrastructure costs versus the savings—you know, it’s been our costs and the payers’ savings. And when you’re following the money, that’s the way it’s ended up so far. And we’re frugal here, so we’ve been watching and trying to figure out where the niches are, where this is practical.
And we’re a self-insured organization, at risk for our own employees’ health status, and so that’s a population we’re actively working on in terms of wellness and related areas.
Going forward, what will the next two years be like for you?
Our health information system is Meditech Magic, and we’ve had it for 24 years. So that will be an all-hands-on-deck effort for that one. But we’ve also formed a PHO, so with quite a few of the independent docs in our community, as well as our employed docs; so we’re working on performance improvement through that, to demonstrate effectiveness. So our goal there would be to get some different kinds of contracting, to acknowledging our cost-effectiveness and clinical effectiveness.
And that will be involving some risk, correct?
Yes, involving some upside risk, and I think you’ve got take some downside risk as well, and pick a number you’re comfortable with failing on.