Cleveland Clinic Grapples with Changes in Healthcare

While the renowned Cleveland Clinic, one of the most respected nonprofit health systems in the nation, has traditionally relied on its ability to provide high-priced specialty care, the system, along with every stand-alone community hospital and large academic medical center, is being forced to remake itself. Patients are increasingly seeking care outside the hospital — in a family health center, a doctor’s office, a drugstore or at home. Medicare and other insurers are moving away from volume-based payments to new models, to pay less for better care.

Dr. Delos M. Cosgrove, a 74-year-old former heart surgeon who took over as chief executive about a decade ago, likens what is happening in health care to the upheaval decades ago in the steel industry, where companies disappeared when they were unable to respond to change and new competition. “The disruption is going to happen,” he said. As an inevitable shakeout takes place among health care institutions, a look at how the clinic is responding underscores the industry’s challenges and the flurry of activity taking place as institutions try to adapt.

https://www.nytimes.com/2015/03/18/business/cleveland-clinic-grapples-with-changes-in-health-care.html

We briefly talked about these different medical options for patients.  It's interesting to read how Cleveland Clinic is responding to the "disruption."  Thoughts?

Economic Rules of the Dysfunctional Medical Market

At the end of Chapter 1 of E. Rosenthal's book, American Sickness, (on D2L, Week 3), she sites these economic rules of the dysfunctional medical market.  I post them here for review:

1. More treatment is always better.  Default to the most expensive option.

2. A lifetime of treatment is preferable to a cure.

3. Amenities and marketing matter more than good care.

4. As technologies age, prices can rise rather than fall.

5.  There is no free choice.  Patients are stuck.  And they're stuck buying American.

6.  More competitors vying for business doesn't mean better prices; it can drive prices up, not down.

7.  Economies of scale don't translate to lower prices.  With their market power, big providers can simply demand more.

8. There is no such thing as a fixed price for a procedure or test.  And the uninsured pay the highest prices of all.

9.  There are no standards for billing.  There's money to be made in billing for everything and anything.

10. Prices will rise to what the market will bear.

Cleveland Clinic and Patients First Case

Cleveland Clinic's overall strategy is to create measures such as improving structure, processes, and outcomes of patient care that would push Dr. Cosgrove's central message, "Patients First!"

The Clinic is doing well in having this integrated electronic medical record system that basically records patients reports and allows physicals to review the care being delivered to their patients. It had also enable information technology to support any measurement, learning, and improvement by teams.

The clinic has also made measures such as shared savings that would enable the Clinic to achieve cost reduction and this payment reform would then allowed teams to manage care paths more effectively.

I think that the overall message of "Patients First" is really good. I also like the idea of having an online portal (Open notes) where patients are able to review their sessions with doctors or physicians as well as their health records online. A distant relative uncle of mine past away in Malaysia from some illness, that was only discovered after transferring from an Adventist hospital to another clinic. And by the time, it was discovered it was already in the last stage of life. What frustrated my family relatives was that the doctor from the Adventist hospital refuses to provide the new hospital of my relative's health records, and any treatment prescriptions that they have provided to him in the months he stayed at the Adventist hospital. It delayed my uncle's medical treatment, and like Regina's husband, my uncle wasn't able to make it through. If there was something like Open Notes in Malaysia, or if the doctor of the Adventist hospital would be more cooperative, and would listen to my uncle's story more, my uncle would have gotten better treatments and he would have lived.

I really feel like it would help make patient care more efficient and easier for patients to get health care in a different area. But there's still the question of how much customer services should healthcare industries provide.

Cleveland Clinic & Patients First

1. Value for patients seems to always have been at the heart (no pun intended) of Cleveland Clinic’s objectives. It began almost 100 years based on the principles of cooperation, compassion and innovation. Everything they’ve done since then has seemingly kept this in mind and they also implemented strategies for perpetual growth. One example of this involved becoming the most frequent provider coronary artery bypass operations (1970’s) while at the same time becoming the first patient outcome registry where they would contact patients, at home, post-surgery to see how they were doing. This commitment to quality continued through the early 2000’s when they adopted a focus on evidence-based practices (who would have thought). This also coincidentally aligned with their goals of growth in helping to provide compliance for reasons of accreditation.

The year 2004 also showed to be a pivotal moment in the company with their development of the motto “Patients First”. At the heart of this was creating an atmosphere of multi-disciplinary teams amongst all the different medical disciplines in the Clinic, “upsetting traditional organizational hierarchies”. Different institutes were created under the umbrella of Cleveland Clinic with this multi-disciplinary approach at the heart of it. The idea of evidence-base approach continued in this as the Clinic’s head, Dr. Delos Cosgrove, implemented measurements for improving “structures, processes and outcomes”. The Clinic also invested heavily in information technology to help in these measurements and allow patients full transparency of their medical records.

2. Measurable results showing that the policies Cleveland Clinic have in place are having success. They improved in overall satisfaction from the 55th percentile in 2008 to the 92nd percentile in 2012. Components of this include an increase in room cleanliness from the 4th percentile in 2008 to the 71st percentile in 2012, as well as drastic improvements in nurses’ communication, doctors’ communication, communication about medication, pain management, staff responsiveness and discharge information; all respectively from 2008 to 2012.

3. I have a dose of skepticism (healthy, I hope) regarding the transformation to “patient first”. As the health care industry has a strong component of capitalism at its core with a willingness to participate in already questionable lobbying engagements, the entities that are changing to this motto would just be following along the lines of the “customer first” in any normal service industry. I suppose though any consideration of the patient (or customer) is better than none. Initially, I was put off in knowing that Cleveland Clinic doctors were still making equivalent compensations to that of their equals in other clinics, hospitals, etc. If their overall plan was to keep costs as low as possible for the customer, why are compensating at such an amount.  Unfortunately, the inefficiencies in the healthcare market have led to exorbitant costs in medicine, procedure, equipment, etc. which probably forces Cleveland Clinic into having to pay such salaries.  If they don’t, they wouldn’t be able to attract the doctors to provide the necessary care to their patients. Hearing that they charge at Medicare rates provided some balance. If more clinics adopted such a non-profit approach as the Cleveland Clinic, that might represent progress for me. 

However, as long as for-profit systems exist in health care, it will continual to be an uphill climb against patients receiving the short end of the stick in terms of costs, no matter how its dressed up. Cutting into such inefficiencies and costs, it does give hope to hear of technologies such as Blockchain that could revolutionize how EHR’s are kept, among other processes in the healthcare industry. Additionally, hearing of how discussion boards allowing common patients to communicate, (e.g., e-patient Dave) also give hope. Like any change, or revolution, it has to come from the people. Hearing the voices we’ve heard thus far into the semester provides hope that systemic issues in healthcare can be ransacked, reversed, reinvented, reformed, and given an appropriate Rx.

Clevland Clinic and Patient First

1) The Cleveland Clinic's overall strategy was to redefine how they treated patients in their care. With the message of "The patients are why we are here", the Cleveland Clinic did just that. Headed by Dr. Cosgrove, the clinic "tore down the hospital's organization and started over". The multidisciplinary teams were organized them to be more around the patient perspective and defined around disease systems or organ systems. Even offices were moved around and new institutes were set up to be led by a respected physician who was committed to a team culture with excellent managerial and interpersonal skills. "Support Institutes" were made and included patient care experience, legal, finance, marketing and human resources. By 2014, the Cleveland Clinic's patient satisfaction had improved and patients complaints dropped measurably. The Cleveland Clinic measured their success by focusing on the ability to learn and quality improvement by the teams. Transparency allowed the clinic to learn form their mistakes and grow from them.

2) One example of the Cleveland Clinic doing something well, was their cost reduction. The Cleveland Clinic focused more on having their physicians knowledge about the process of care and not just an analysis of charges. With transparency, the clinic was able to compare different cost approaches. With this new strategy, cost reductions resulted to $481 million, with $152 million indirect costs and $329 million in clinical costs. Another example of the Cleveland Clinic doing something well was their use of MyChart. MyChart included digital data and images, test values, doctors' reports, and extracted values from non-digital data. MyChart allowed both physicians and patients to view the same information. Patients were enabled to have control over all of their data, created and cancle appointments, request prescription renewals and contact their doctors.

3) In my experience, there has been a mix of both patient first care and just another sick person that a doctor had to deal with. The Children Hospital in Orange County, CHOC, was a place where I felt that their only interest was to treat the children with the best care possible. Although I was a young during my time there, and not looking at things like patient records, or costs, I felt that they truly looked after my wellbeing both physically and mentally. I would be regular checked on by my physicians and nurses periodically talked and did activities with me. On the other had, I have been in doctor care where it felt very impersonal, where money was the second most talked about topic and then followed up with where will the next time I see you. Which translated to me as when will you pay me next. So in my opinion, once patients experience a patients first type care, they will started demand or go to places where this is the number one strategy.

Cleveland Clinic

After reading the cases in regards to Cleveland Clinic, I did some follow up research to see what the Cleveland Clinic would be doing in the future as of recently with all of the innovation within technology.

The article talked a lot about the focus of "Patients First" and how that the hospital was doing alot of changes and improvements based on the Patients. The article doesn't necessarily talk about the patients from outside the hospital perspective but Cleveland Clinic has been working to improve that experience aspect as well.

http://www.crainscleveland.com/article/20171008/news/138041/cleveland-clinic-more-accessible-insurance-products

Explains how the Cleveland Clinic has recently teamed up with major Insurance product companies such as Humana and Blue Cross Shield to improve the experience of "Patient First" outside of the hospital as well. Working with these insurance product companies allows the hospital to provide improvements with health plans that are more affordable for the public. Overall, this is a win-win situation for the hospital, gaining more patients, and providing major insurance companies with the opportunity to work with major corporations such as the Cleveland Clinic

Cleveland Clinic and Patients First Case

I think the biggest thing Cleveland Clinic has done to improve the value for their patients is patient education. The case spoke about the importance of patient satisfaction and the importance of ongoing engagement with patients. This means that it is crucial for the patients to know what is going on with their health, as well as what the next steps with treatment will be. Cleveland Clinic’s system gives their patients educational materials including post-evaluation information after visits for treatment of chronic to severe conditions. This information can easily be accessed online for free. 

This leads to the next way the clinic is improving the value for their patients, that is open medical records. Although the Cleveland Clinic has medical records open for their patients for several years, recently, the clinic has been creating new ways to access personal health records online. Within the past few years, 3.5 million lab results as well as images have been made available for patients to view online. Also, patients are now able to access the notes from a visit that were written by their physician. Another way Cleveland Clinic has driven value for their patients is the series of pilots projects they launched. These projects allow patients to input their personal data on their own which enables a flow of information between doctors so they can track a patient’s progress. Overall, the Cleveland clinic has improved the value for their patients by providing follow-up advice, clear communication channels that are easily accessible, and created new ways for physicians to track their patients progress.

One thing that stood out to me that Cleveland Clinic is doing well is the open access scheduling. Open access scheduling was a significant change in the clinic since it streamlined the way patients scheduled appointments. All of Cleveland Clinic’s health centers have the ability for patients to access the patient portal so they can see their provider’s availability, and patients can also schedule their own appointments. This is important for both the clinic and patient’s because it reduces the time needed to schedule the appointment.

I think that there is a “patient first” transformation in place for several different reasons. First off, this case spoke about several ways the clinic is putting people first. For example, the open access scheduling, doctor follow-up / progress tracking, and accessible visitation notes are all ways of putting the patient first. Aside from this case, one thing that stood out to me from this class about putting patient’s first was from the Escape Fire movie. In one section of the movie, a primary care doctor was emphasizing the importance of teaching preventive ways to prevent diseases. I think there is currently a movement for putting “patients first”, but I think it is too small for what it should be.

Cleveland Clinic and Patients First! Come Discuss With Me!

Since as of this post, there's no one else I can reply to, I think I'll try to stir up some discussions under here!

One of the big things that struck out to me in the article was the use of Information Technology in the clinics. The use of a software called MyChart allowed patients who signed up to immediate manage all of their information and to edit it as they saw fit, allowing physician's a chance to go over it before they saw the patient. This, coupled with MyPractice, created an easy way of sharing information between the Clinic and it's patients.

In terms of IT, what other softwares or kiosks could a clinic potentially use to improve the patient care experience? Eliminating paper work and making everything digital is a good start as long as the data can't be compromised, but where do you go from there to continue innovating?

Although most clinics already use an electrical system for appointments, many places could use an upgrade in this department. Checking in patients, gathering information for average times per patient depending on factors such as age, disease, and doctor, could help create a more efficient patient flow, leading to severely reduced wait times (Ever had an appointment for 1pm that didn't even start until 2:30pm? I see room for improvement there).

Health Care Fanatics and Patients First!

From the HBR article, "Health Care's Service Fanatics," and the HBS Case Study, "Cleveland Clinic: Growth Strategy 2014," the CEO at the Cleveland Clinic (also posted in D2L under Written Assignments), Dr. Delos "Toby" Cosgrove’s central message to employees had been Patients First!, which demanded relentless focus on measurable quality. Ensuring quality, in Dr. Cosgrove’s view, included improving structure, processes and outcomes. “This included constant attention to patient safety, respect for the patient’s dignity, excellence in housekeeping services and facilities, and genuine concern for the patient’s emotional wellbeing and care experience.”

Dr. James Merlino became Chief Experience Officer in 2009. Merlino defined the patient experience as "everyone and everything people encountered from the time they decided to go to the Clinic until they were discharged.” He worked to make patient experience insights more tangible by asking the question: “How can processes and metrics drive improvements in the patient experience.” He identified three critical areas: effective processes, caring caregivers, and engaged patients.

Consider these questions as you read and reflect on this case (and the other articles posted on this topic).  Remember to interact by replying to posts, rather than posting individually your responses.

1. What is the Cleveland Clinic’s overall strategy for improving value for patients? 
2. Are there examples of what Cleveland Clinic are doing well, or areas where they may still need improvement? 
3. What do you think of other efforts presented in the class schedule, or examples of your own, that make you feel like there is a “patient first” transformation in place or are you skeptical? Explain.

Draft Proposal - I'd Appreciate Feedback on Any Ideas!

For my area of focus this semester I am planning to further pursue the advancement and adoption of standardized Personal Health Records (PHR). While the idea of the PHR has been around for quite some time, and many hospitals and clinics across the nation now have them in some form, adoption among consumers has been mixed and likely far below where it should be. There are a number of individual portals for things such as finance, social media, academics, and shopping that have advanced and been adopted at a much greater pace than PHRs. Arguably, wide ranging and equitable access should be a hallmark of healthcare in the very near future.

There is a lot of research on this issue existing, and I have a couple of ideas regarding gathering primary data to investigate future adoption of PHRs. First, in order to gauge patient sentiment, I would like to conduct a primary survey of patients. By patients, I am planning on surveying a wide range of people, and not necessarily within the vicinity of a healthcare facility at the time of surveying, as most can be considered patients of the healthcare system at one point or another. I would like to include questions on this survey to gather interest in using a personal health record. Questions would gather data on if patients currently use a PHR through a care provider, if they would prefer a consolidated PHR or multiple portals, and how frequently they would access their PHR. I think one hard thing about this topic is I do not know exactly where I could find unique data sets to analyze, or how I could observe the process.

When it comes to a centralized portal for access to your PHR, there are a number of implications that should be noted. The first is that providing patient access to a wide-ranging personal health record provides one more area from which data can be compromised and exploited. Some patients may build accounts with weak levels of password protection for example, exposing their information to theft and compromise from malicious actors. Another concern is that if there was to be one centralized system online where PHRs were accessible, from hospitalizations to eye appointments, who would manage and develop the platform? Would it be a private entity that somehow was able to form partnerships and attain access to this data, or would the project be federally administered? Maybe a technology like block chain could be employed to ensure confidentiality of patient information. Additionally, some patients could possibly push back against having their information all located in one place, or in the possession of another group aside from their direct medical providers. Even if these issues were to be overcome, it is safe to assume that it would be a large capital expenditure to develop and coordinate such a strong system. There are a number of complications that could mean there are significant delays, or that it is never fully developed.

In the coming decade, or maybe just the coming years, I’d love to see a more comprehensive and accessible PHR portal be developed. Personally, I would use this information to check my immunization history, view transcripts from doctors’ appointments, and review my prescription history. Regardless of care provider or time, having all of this information quickly accessible in one place would be extraordinary for the average patient, let alone those who deal with chronic or terminal health conditions. Between now and then, I am hoping that through firsthand surveying I can gauge what patients are seeking and hoping for in this next wave of technology based healthcare advancement. If you have suggestions or ideas on what you’d like to see from my research, please let me know.

Triple Aim Video

As part of the systems project proposal (first draft), I wanted to introduce you (many times) to the Triple Aim Initiative, upon which the project is based. The video is now available publicly, rather than having to see it from the webpage.

Here is a link to the systems project on D2L (you have to sign on to D2L to see it).  In the meantime, watch the short video explaining the Triple Aim.


 


Once you watch the video, here is a pdf to the Concept Design for the Triple Aim.  It provides examples of the measurements and other details.  Only 3 pages.