Exciting things are always happening at Cleveland Clinic, the multi-hospital integrated health system based in Cleveland. The 10-hospital integrated health system has long been on the leading edge in terms of clinical quality improvement, clinical integration, and IT innovation. C. Martin Harris, M.D., Cleveland Clinic’s CIO and the chairman of the organization’s Information Technology Division, will speak of the organization’s work when he presents a keynote speech, titled “The Role of Integrated Technologies in the Innovation of Medical Practice,” at the Health IT Summit in Miami, sponsored by the Institute for Health Technology Transformation (iHT2—a sister organization of Healthcare Informatics under our corporate parent organization, the Vendome Group LLC), on Feb. 10 at the Ritz-Carlton Coconut Grove Miami Hotel, in Miami, Fla.
As the conference’s description states, “During his talk, C. Martin Harris, M.D. reviews several real-world examples that illustrate how technology professionals and clinical practitioners are working together to create services that will fundamentally transform the 21st century’s model of healthcare delivery.
In anticipation of his presentation, Dr. Harris recently gave an interview about his keynote address to HCI Editor-in-Chief Mark Hagland. Below are excerpts from that interview.
What are some of the latest developments these days at Cleveland Clinic?
We’re transitioning out of what I call the transactional phase of information management, and are really moving into what most people call the analytics phase. And my view is that there’s a third phase, the knowledge management phase. In the analytics phase we really are focused on driving the combination of strategic and tactical goals, and the practical implementation of information technology. So we’re spending far less time on the technology, because most of the big systems, at least at CC, are already in. so put the network in, put in your EMR, build the data center, put your processes in, put in an enterprise supply chain and HR system, consolidate your systems, and so forth. That’s all been done.
Now, all of those systems generate a wealth of data, and we’ve been using that data in a tactical way: the blood tested high, that kind of thing—alerts. Very simple transactional kinds of activity, and simple reporting. So the analytics phase to me says, now that we have all those systems in and all those caregivers using the systems, and they’re used to the alerting, to change their focus. We will always be caring for patients one by one; what we need to add to that is the ability to think about subpopulations and entire populations of patients, whether or not they’re sitting right in front of us.
So if you go to industry meetings, you will see hundreds of conversations in this space. But what is top of mind for us is actually translating those ideas into practice. So the big models of operations for us are care paths—that’s a model that is really quite individual right now… You can’t buy a fully developed care path from a single vendor in the marketplace. And if you went to 10 different healthcare organizations and asked for a care path, you’d be looking at 10 different things. So we’ve put a significant amount of investment into figuring this out, and to summarize, it’s about purpose, people, process, and technology.
So we’ve really been focused on creating these teams that are interdisciplinary, with shared outcome and process goals, to reach the value equation. An example is hip and knee replacements. We now have an operational care path, what this should look like, for hip and knee replacements.
Are you and your colleagues essentially creating templates for care delivery, then?
Yes, though it’s broader than that. Let’s save that we’ve got maybe 100,000 patients in our system—and I’m just making that number up—who have osteoarthritis of the hip and knee, now most of those can be managed. And the patients start out in the medical management part of that care path. And ideally, the patient can remain in the medically managed portion of the care path. And we don’t want all 100,000 people to end up getting a joint replacement. So everyone’s getting medical management, getting therapy, and are being trained to do range-of-motion exercises. And we’re collecting data on their functional status on a regular basis. And those with osteoarthritis who remain stable remain on the medical management portion of the care path. Now, for those whose functional status declines over time, we will move those patients into the surgical portion of the care path. So we have appropriateness tools that say, have you done everything prior to sending this patient to surgery, that you can? And is their functional status appropriately low.
It’s basically evidence-based medicine, correct?
Yes, but it’s applied evidence-based medicine. In a review article in the clinical literature, you can define evidence-based medicine, but it doesn’t translate to what’s actually delivered. So we call this the applied care path, and use it to measure outcomes and processes. So we can see the patient on the care path, and everything from 30 days before the surgery to 90 days afterwards, is built into the care path. And the process measures—did you get your medication on time? Did you get to rehab? What was the outcome of your rehab? And what we want is that your lowest level of functioning will be the day after surgery—the valley in the middle—and we want to see a steady improvement in your functional status.
So demonstrating the value is what’s top-of-mind for us, getting that done in a way that we can represent it to all of our constituents, our patients first, and payers as well in the process, and our other stakeholders.
Where are your organization’s physicians in terms of accepting what’s going on and buying in?
In most organizations, and it’s certainly true for us and for most academic medical centers, and for most hospitals above 400-500 beds, you essentially have two populations of providers, when you think about information technology. The original rollout of an EMR speaks most clearly to the primary care physicians. So for them, the rollout of the EMR brought real benefit, but for subspecialists, it was far less. This care path idea evens the playing field. So when you see the attachment that comes from being able to see a peer review article living in the tools you use every day, that’s where you get the attachment from the subspecialists. Because now, they have a way of seeing their population that they could not see with the general rollout of the EMR. So in my mind, when you’re getting both sides of the organization up to the same level, and with these analytics tools, we’re moving forward, and that will then enable real knowledge management forward.
Are we at a tipping point yet in terms of shifting to day-to-day operations based, on value-based versus volume-based, payment?
Well, it obviously depends on the market you’re in. If you’re in Minneapolis, I would say it’s tipped already; but nationally, it’s still early in the game. And the operational tipping point will occur when you can no longer drive operational goals simply by driving volume. So if you’re only in a 1-percent risk-based market, you could do very poorly there—still drive volume—and it’ll be OK at the end of the day. So to me, the tipping point is when you can no longer do that. And my sense is that it’s right around a real penetration of 40-percent risk-based [contracting]. Once you’re there, it is very difficult to drive volume hard enough to make up for loss on risk-based contracts. And what’s driving that faster is principally the Medicaid program. So in the states where the Medicaid program expansion was implemented, you’re seeing a huge change.
Now, the other big tipping point will have to do whether the commercial side drives volume enough. It sounds as though about 9.5 million people signed up on the commercial side, for the Affordable Care Act; and then you have all those who signed up into the Medicaid program. But if you’re driving 40 million people into the healthcare system, and if they come as purchasers of value that will drive the tipping point. So it depends on the state you’re in, whether or not they implemented Medicaid expansion, that will be the determinant.
At Cleveland Clinic, we’re somewhere around a 20-percent-ish level overall in terms of risk-based payment, but that’s a very general estimate.
What would your advice be for your peers nationwide, based on the biggest lessons you’ve learned so far?
My recommendation would be, go visit your colleagues who are living in the risk-based, value-based world, before it ever comes to your market. Because it’s hard for you to imagine it, and it’s a lot easier to sit and go and learn what it is to operate with it. Because I think the marketplace of technology is less likely to drive the big single solution for this challenge, versus the basic EMR, which supported the volume-based world reasonably well. I think the role of the CIO will be far more about matching operational change to technology, than it has been about acquiring technology, as it was in the last decade. And going forward, it will be a lot more likely that if you had a failed technology, you didn’t have a clear model of operation so that the technology could be used in an appropriate way.