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Clinical Transformation: Brian Patty’s CMIO Perspective on Health System Change

March 22, 2017
by Mark Hagland
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Rush University Medical Center CMIO Brian Patty, M.D. talks about the journey ahead around clinical transformation

As the purchasers and payers—both public and private—of U.S. healthcare continue to push providers forward to deliver value for the monies spent on providing care to patients (the employees and enrollees of said purchasers and payers), provider leaders are increasingly drilling down towards the core of patient care delivery to improve the clinical and financial outcomes demanded. In that, they inevitably are coming to recognize the need for clinical transformation—the reworking of care delivery and clinical practice—to make those deeper changes.

Clinical transformation was cited by the editors of Healthcare Informatics as one of the Top Ten Tech Trends the magazine named in its March issue, which will be published in print in the coming days. And this week, the Trends are being presented online, including the clinical transformation Trend. It was in that context that Editor-in-Chief Mark Hagland interviewed Brian Patty, M.D., CMIO at Rush University Medical Center in Chicago, in February; Dr. Patty was one of several clinician and industry leaders interviewed for the Trend. Below are excerpts from their interview.

What does clinical transformation look like to you right now, out in the field?

I think one of the coolest models I’ve seen is at Ochsner Health, with  their digital medicine model. They’ve formed a unit called their digital medicine unit. They asked, what are the two biggest barriers to home monitoring? Because we really feel we can drastically improve outcomes among our high-risk patients through home monitoring. And the two biggest barriers they found were that primary care doctors didn’t know what to do with the home monitoring-based data, and patients didn’t know how to set it up. So they created the Ochsner bar, the O bar, modeled after the Apple genius bars in the Apple stores. And basically, patients can go there. They have all the equipment available, like weight scale, blood glucose monitor, fitness tracker, etc., and they set it up to connect with the patient’s phone, the Epic MySite, and they set up the patients. Then they set up this group to monitor these key patients and do virtual coaching of these patients in between their primary care visits. So the PCPs write an order to refer patients to a virtual medical group they’ve set up. And the virtual medical group fills out a form. And then they monitor the patients. And they started out with hypertensives who have never been in blood pressure control and who are seen several times a year. They had 400 patients referred to them, and within three months, they had 76 percent of those patients under control.

And how do you interpret what they’ve done, in the context of clinical transformation?

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It’s a great example, because here, you’ve taken a difficult patient population that has not improved through traditional medical care delivery, and you’ve applied a new way of managing those patients—patients who had been chronically out of control for years. As a result, the patients are going to live longer and better, and will cost less.

And you had mentioned a virtual medical group aspect to this?

Yes, they’ set up an integrated practice unit—physicians, physical therapists, pharmacists, dieticians, nurses, social workers, etc. And this group of people said, what are the needs of these patients? What kind of team do we need? So this team manages these patients in between their physical visits with primary care docs, and they make recommendations, including for referrals to social workers, etc.

Is that where we have to go to achieve clinical transformation?

Yes, absolutely. And the side effect of this is that the patients become more engaged in their care.

In hospital organizations where it’s happening, what are the key elements?

The organizations where I’ve seen clinical transformation efforts work well are using Lean methodologies. And where we come in, it has to work in and through the EHR [electronic health record]. And if we can make a care delivery process work through the EHR, we can hardwire it. At HealthEast, we focused on that, on hardwiring processes through proper setup  in the EHR, so that the easiest way is the right way. And whether you’re using care pathways or workflow navigators, or all the tools in your EHR, you have to understand those tools.

So now, you can support the organization by designing the workflow and care steps in the EHR, to make it flow, and to make it the natural workflow of someone who wasn’t initially involved in the design of this workflow, but as they walk through their workflow, it’s natural to the way they do it.

One thing that many leaders talk about is the continuous “blessed cycle” of gathering data, analyzing that data, sharing it with clinicians and using it to inform and guide the reworking of care delivery processes, and then beginning the cycle again through gathering data on the reworked processes.

Yes, that’s all very important. And in that context, there are two things we look at from a Lean standpoint. You go through two different cycles. One is an SDCA cycle—“standardize, do, check, act”; and the other is a PDCA cycle—“plan, do, check, act.” The SDCA cycle involves looking at where there is variation within a cycle, and how to minimize that variation. The oscilloscope is going up and down a lot, and we want it to be a flat line, where everyone’s working to a standard. And then when you’ve got everybody working to a standard, then you see where your performance gaps are, and you figure out how to close those gaps, and make a big leap to get to a new standard. And you go back over and over again through SCDA and PDCA cycles. That is at the core of the work.

Do you see organizations transforming their clinical cultures now, as a part of the broader clinical transformation effort?

Well, you have to transform culture to get there. The way we do business hasn’t gotten us to the right place. We have to look at ourselves as organizations and figure out how we get to the next place. The buy-in comes from leadership, but then how we get there comes from front-line staff. And Lean works both top-down and bottom-up. Leadership defines the gaps, and front-line staff figure out what needs to be changed to get to that place. So leadership transforms the culture of the organization, and front-line staff gets us there. So the strategy is from leadership, and tactics from staff. Gemba: Lean term where the value is added, where the organization interfaces with the customer. Where the physician meets the patient is where the value is added.

Do you think that the majority of physicians now see where the puck is headed?

I think so. I think it’s a big shift to get from a fee-for-service, volume-based model, to a value-based, PMPM [per member per month] model. How that changes, how you approach care, involves a lot of complexity and change.  In a value-based model, I’m taking a more holistic approach. You’re looking at keeping people healthy, whereas in a fee-for-service world, you’re treating people when they’re sick. It’s a different mindset. Primary care’s gotten that all along; we’re really moving to more of a primary care-focused world, which is appropriate. We need to be holistically managing the patient.

What can and should CMIOs be doing in all this, to help lead change and to help lead clinical transformation?

In order to make any significant change in healthcare today, you need people, process and technology—all three elements. So if you create three circles in a Venn diagram, with those three elements, you’ll find that they intersect in the CMIO: I understand the technology, I understand the people and process, and I understand how they will use the technology. So I see myself as being in the center of that Venn diagram, connecting the people to the processes to the technology.

Where will we go in the next few years on this journey into clinical transformation? Well, the initial impetus towards value-based care came from CMS [the federal Centers for Medicare and Medicaid Services]; they were pushing it. But when I look at where I’m moving towards value-based care, it’s primarily from private payers. They’ve really taken the ball and run with it. So no matter what happens with the new administration and Congress, the private payers will be pushing VBC, and probably the only way they’ll engage with you is if you’re willing to take on some risk with them. So it’s going to happen. And if you look at the major next wave from CMS, it’s MACRA [the Medicare Access and CHIP Reauthorization Act of 2015] and MIPS [the Merit-based Incentive Payment Program within the MACRA law] and APMs [alternative payment models, also within the MACRA law]. And [MACRA] had bipartisan support; it passed in the Senate with 98 percent or something. So no matter what they do with the ACA [Affordable Care Act]—and they’ll probably make some adjustments, and everything needs adjustment—MACRA’s not part of that. And MACRA is really how we’re getting paid, and CMS is saying, I’m going to incent you to move to a value-based payment model with MACRA, and that’s how it’s going to be. So MACRA will move forward. And ultimately, you’ll see CMS incenting you to move towards a value-based payment model via APMs, as well as with the quality measures under MIPS. This year, 60 percent of your payment comes out of the quality piece, but eventually, the percentage of your payment coming out of cost, will increase over time.

Are you optimistic about the path forward and about the rate of progress being made in patient care organizations right now?

The organizations that succeed by skating ahead of the puck are going to be the ones that survive this phase of change. If you say, I’m going to stay stuck in the fee-for-service world, you’re not going to survive, because private payers are moving in that direction, too, and the better you get at [at-risk-based care delivery], the more likely you’ll survive. Because that’s where this is headed, and the only ones that will survive will be those that move in that direction. And as we move forward, we have to engage in new ways to engage patients. For years, medicine has taken a paternalistic approach—these are the pills you need to take and how you need to take them. It’s becoming a partnership. So the strategies we can use to engage patients in their care—whether telemedicine or home monitoring or patient education—the more successful we’ll be.

 


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The Modern Healthcare CIO, CMO, and CTO

December 10, 2018
by Lori Williams, Industry Voice, vice president of fulfillment, Gigster
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Disruption in the healthcare space comes primarily from the expansion of data’s role in the industry, and the healthcare C-suite’s familiarity with that expansion will help drive company and industry success

For the healthcare C-suite executive, the industry has never been more complex—nor has it ever contained so much potential. Emerging technologies mixed with political uncertainty has created an environment where incredible amounts of healthcare data are revolutionizing how patient care is handled, but patients remain uncertain about the future of their own health. With better data and the means to draw insights from it, healthcare CIOs, CMOs and CTOs are in a position to help address patients’ uncertainties and make hospitals and clinics more accessible and effective than ever before.

Here’s a look at how the role of the modern healthcare CIO, CMO and CTO is changing:

The Modern Healthcare CIO
The modern healthcare CIO’s role has evolved to become more innovative. No longer a title reserved strictly for engineers and IT professionals, today’s healthcare CIOs are focused on information science instead of simply setting up network infrastructure or providing back-end support. The trend towards a more data-centric role began as hospitals rolled out electronic health records, equipping individuals with better access to healthcare provider data. Through enterprise data warehousing, CIOs are becoming masters of data management, governance and predictive analytics, and passing along the many benefits of those knowledge bases to patients.

The Modern Healthcare CMO
The confusing healthcare landscape makes the role of a healthcare CMO more necessary than ever before. Thanks to ongoing regulatory changes, uncertainty surrounding the Affordable Care Act, and shifting consumer expectations for on-demand services, healthcare CMOs are responsible for helping patients navigate their way through a complex and opaque industry. As patients continue to assume the role of consumers, carrying out comparison shopping as they would for any other industry, CMOs must be adept in crafting a healthcare provider’s brand and messaging.

At the same time, CMOs must also ensure that healthcare providers offer a modern online experience, ensuring websites are mobile-optimized and social media accounts are generating engagement. This also means CMOs need to help move marketing efforts into the 21st century, transitioning away from direct mail or billboards towards digital marketing and CRM tools. Because if they don’t, there are plenty of med tech startups that will promptly eat into their market share.

The Modern Healthcare CTO
Unlike healthcare CTOs of the past who remained siloed off from the rest of the organization, today’s modern healthcare CTO is fully engaged with healthcare providers and their technology stacks, utilizing new software and hardware to improve daily workflows. The CTO is enabling the transition to patient-oriented self-service operations, enabling patients to carry out administrative tasks like scheduling appointments or refilling prescriptions over the internet. Because medical data is often stored in a variety of different sources, it’s critical for the CTO to be able to keep these systems interoperable with one another. For hospitals riddled with legacy software, CTOs should expect to continue employing middleware solutions to bridge the gap between old and new.

Members of the healthcare industry C-suite have the power to transform lives, and the CIO, CMO and CTO have roles that directly affect a provider’s ability to carry out positive change. With better data from the CTO’s tech stack, the CIO can use better analytics to help providers determine the best solutions for their patients, marketed to consumers by the CMO through modern platforms in clear, easy-to-understand language.

Lori Williams currently serves as Gigster’s vice president of fulfillment. Prior to joining Gigster, Lori was the general manager for Appririo.


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What Does Your Magnum Opus Look Like? A Few Operatic Thoughts

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I was given the privilege and pleasure recently of presenting, for the second year in a row, a lecture on Richard Wagner’s “Ring” cycle, as the leading opera company in my city, a world-class opera house, has been putting on, in yearly succession, the four operas of the “Ring of the Nibelung” cycle by German composer Richard Wagner (1813-1883). Last year, the second opera in the tetratology, “Die Walküre,” was performed; this year, the third opera, “Siegfried.” After the concluding opera, “Götterdämmerung,” is performed, the entire cycle will be presented in festival format, always a major cultural event. I spoke on “Siegfried.”

I’ve been fortunate to have seen six complete “Ring” cycles in live opera houses in different cities, and I can tell you, it’s a life-changing experience, as this four-opera work (16 hours of music altogether), sits at the absolute summit of western art. Richard Wagner was a hideous human being himself, but spent numerous years working on something that changed the course of classical music and redefined opera.

What’s more, from the summer of 1848, when Wagner wrote a first sketch of the libretti, or texts, of the operas, until their true compositional completion in 1871, more than 23 years were to pass; and it would be another five years before the tetralogy was fully presented, in a purpose-built new opera house in the Bavarian town of Bayreuth. It was a herculean feat to create the entire text of these four long operas, and compose 16 hours of music that would completely redefine the concept of opera. Indeed, when the crowned heads of Europe, the great living composers, and the 19th-century European intelligentsia and glitterati, gathered at the new Festspielhaus in Bayreuth in 1876, many were so overwhelmed by what they saw and heard, that they were rendered speechless. Even now, 142 years later, first time Ring-goers are overwhelmed by the breadth and sweep, the musical and dramatic audacity, and uniqueness of the “Ring” operas, with their story of gods, giants, dwarves, flying Valkyries, Rhinemaidens, one huge dragon, humans, gold mined from a river, magic swords and spears, and of course, a gold ring whose possessor can control the world and its fate.

Even just looking at the third opera, “Siegfried,” Wagner struggled mightily. For one thing, being essentially a grifter and a cad, Wagner borrowed/took money from everyone who would lend/give it, and often had affairs with the wives of the patrons bankrolling his compositional work, leaving his life in constant chaos, as he fled from one city to the next. One such wife, Mathilde Wesendonck, inspired the opera “Tristan und Isolde,” groundbreaking operas that Wagner wrote during a 12-year hiatus in his composition of “Siegfried.” And “Tristan” itself changed the entirety of classical music, its tonality-challenging chromaticism.

Well, no one is expecting anyone to match the unique creativity of Wagner’s “Ring” cycle. But the leaders of U.S. patient care organizations are doing a lot of important things these days, including using formal continuous improvement methodologies to rework core patient care delivery processes in order to transition into value-based healthcare. What’s more, as our Special Report on Leadership outlines, the entire role of the CIO is being rethought now, as the demands for leadership and strategic capabilities are catapulting that role forward; and patient care organizations are beginning to make real headway in advancing equality for women and people of color among the ranks of healthcare IT leaders and managers.

So while no one is expecting anyone to create an operatic tetralogy that will change the face of music, there are plenty of heroic endeavors open to anyone willing to envision the healthcare system of the future. The opportunities are as limitless as the imagination.

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Using Performance Management to Scale

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Performance management is so much more than just a year-end performance review
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Performance management and goal setting have always been part of my DNA. It’s like a compass that tells us we are steering the ship in the right direction or gives us a chance to course correct if we wander off track. It’s hard for any organization to determine how they are doing unless there are clear measurable objectives. CIOs and their leaders need monthly, quarterly and annual goals to measure how you and your team are doing against the plan. I also firmly believe they should be S.M.A.R.T. goals: Specific, Measurable, Achievable, Relevant and Time-based.

Once the goals have been established, you need a written plan. I like three-year rolling plans so you can look into the future and describe your vision of what your organization will look like 36 months out. Then you can work back to the second year, and eventually the first year, to give you the framework for what you need to accomplish in the next 12 months. I suggest you do it with your managers. It makes them accountable to the organization since they are involved in the formation of the plan.

Your plan must be a living document to be used frequently during team meetings throughout the year to see how you are performing as a team and individually. This is not a process you invest in to review at year-end to see how you performed. By then it’s too late. It must be reviewed on a consistent basis to make sure everyone is on track. Performance management is so much more than just a year-end performance review. If there are individuals who are not performing against the plan, you can use the plan as a tool to performance manage them to re-engage as an important member of the team. 

I just returned from the Scale-up Conference in Denver and learned so much about taking goal setting and performance management to a whole new level by adopting the "Rockefeller Habits," as written by Verne Harnish. After reading the book, everything changed for me in the way we will be doing our planning, goal setting and performance management forever. It’s so brilliant and easy to understand. Here they are:

Rockefeller Habit #1: The executive team is healthy and aligned

Rockefeller Habit #2: Everyone is aligned with the #1 thing that needs to be accomplished this quarter to move the organization forward

Rockefeller Habit #3: Communication rhythm is established and information moves through the organization accurately and quickly

Rockefeller Habit #4: Every facet of the organization has a person assigned with accountability for ensuring goals are met

Rockefeller Habit #5: Ongoing employee input is collected to identify obstacles and opportunities

Rockefeller Habit #6: Reporting and analysis of customer feedback data is as frequent and accurate as financial data

Rockefeller Habit #7: Core values and purpose are “alive” in the organization

Rockefeller Habit #8: Employees can articulate the key components of the company’s strategy accurately

Rockefeller Habit #9: All employees can answer quantitatively whether they had a good day or week

Rockefeller Habit #10: The company’s plans and performance are visible to everyone

Accountability is no longer hard to measure since the entire plan is visible to everyone throughout the organization. Each part of your team should have key people accountable for every functional part of your organization. No more guessing is required. I’ve read countless books about leadership, performance management and goal setting, as I’ve been an avid student on the subject for decades.

These ten habits, once adopted and measured regularly, can change any organization that wants to grow and scale, and keep everyone accountable along the way.

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