Is the healthcare system prepared for the shift from “volume-based” to “value-based?” Are patients prepared?

The 85/65 dilemma:  The value of “Second Opinions” and the EMR

What if 85% of the time your primary physician got the “issue” (what was wrong) correct, but in only 65% of the situations, got the treatment right?   The good news?  There are new processes and ways to catch that 20% and fix it before it becomes a bad outcome, and they’re part of the move from volume-based medicine to value-based medicine.  It’s more complicated than simple “quality vs quantity.”  And it comes down to things like patient involvement and engagement, and proactive self-monitoring, as well as the new M-Health (mobile health) devices and smart systems.

Last week we were at a talk from C. Martin Harris, the CIO of Cleveland Clinic, a world leader in healthcare innovation and service quality.  He was presenting a talk called “Reimagining Healthcare Delivery Models” at the UC Irvine Center for Digital Transformation.

Doctor Harris opened his talk by saying that healthcare has been a “volume business” for the last 250 years.  But with 10,000 Americans retiring every day, that delivery system will not continue to work.

Fundamentally, he said, “we need to move from paying for volume to paying for value.”   According to Harris, paying for value shifts the focus to quality, safety, and reliability.  And this is made even more important as more and more care moves from an inpatient experience to an ambulatory setting.

To make more tangible how big a change has occurred here, Cleveland Clinic has 250,000 inpatient visits a year but 5,000,000 ambulatory visits.   That’s 20X.  Harris says this movement means they need to be able to manage the patient quality of care whether the patient is visiting them in a bed, via ambulatory visits, a “minute clinic,” and even an outside provider.

These changes means that the information management infrastructure needs to enable an extended clinician care team to work closely together for best outcomes and to avoid duplicative costs.

Fundamental to making this reality at the Cleveland Clinic is the electronic medical record. It has become the “atomic entity” for everything that they do.  

From an IT techie standpoint, Cleveland Clinic’s view of the EMR is very similar to a configuration item in a configuration management database.  IN other words, it is the core or source reference data container for everything that the many systems and applications touching it.

Just like a CMDB in IT, every application and service in the healthcare system builds off the electronic medical record.  At Cleveland Clinic, their applications send and receive information to the electronic medical record.   While not novel in that aspect, the way Cleveland Clinic uses the EMR is a great example of the power and potential of an extensible system.

Cleveland Clinic’s basket of applications provides clinical, patient, scheduling, and analytical insights. They have names like My Chart, My Consult, and My Monitoring.  My Monitoring ingests and aggregates data to share with clinicians from all forms of intelligent monitoring devices and then detects issues and directly alerts a physician.  This includes implanted devices like pacemakers and increasingly the new class of mobile devices like glucose monitors and wearable blood pressure and heart monitors.  A rules-engine then helps them sort out what matters and what is actionable.  According to Harris, they want to be the “virtual On Star System for healthcare” and then turn all this data into healthcare informatics.

Not surprisingly, Cleveland Clinic is seeing its data size grow. They have 6.7 million patient records, 49 million encounters, 104 million prescriptions, and 330 million orders.  And they need the system to work regardless of patient encounter type.  As part of this, they have cut a deal with CVS where “Minute Clinic” nurse practitioners cannot only view Cleveland Clinic records but also append them for services that they provide.  Harris believes that their EMR system needs to work both inside and outside their hospital and this is what they have built.

Like many other EMR advocates, Harris sees mobility as the game changer. You should be able to make an appointment from wherever you are.  Mobility is about improving standard of care. In a short period of time they have grown to over 9,000,000 users of their mobile healthcare apps.  They are using Health Vault to create the inside/outside view.  Harris wants to create care teams that collaborate across different healthcare exchanges.  An example given was “Second Opinions.”

Here’s how “Second Opinions” works:  A patient outside their system can go into the Cleveland Clinic Online System and register to get what they call the Second Opinions “pizza box” sent to them.  They use it to send copies of everything about their medical condition.  The patient pays for this service with a credit card and then an appointment gets scheduled for pizza box.  

Afterwards, a “Second Opinion” is sent to the patient as well as their Doctor.  Harris said that they serve more heart patients this way than anyone in the world.   

Harris says that their data shows the most important factor in improving a condition is often simple behavior change.  Harris says the reimbursement system needs to recognize this.  “We need move from managing the procedure to managing the patient.”  Harris says this is a key element of moving from a volume business to a value business. He says that it is essential that healthcare takes this step or it will suffer the fate of Kodak.  “Making this real, we need to move the investment from volume to value.”   

And as teased at the beginning of this blog post, their Second Opinion service has found that 85% of the time the initial physician gets the issue right but only 65% do they get the treatment right.  Harris is clearly right here in saying that we are entering a new world of healthcare.

What do you think about the shift from Volume-based healthcare delivery to Value-based healthcare delivery?

Come join-in on the discussion over at our LinkedIn group. 

2 responses
Interesting post. I was curious if you could point me to citations or a contact for the following: the "Second Opinion service has found that 85% of the time the initial physician gets the issue right but only 65% do they get the treatment right. " Thanks, Steve Wilkins stwilkins at gmail dot come
Dr. Harris is one of the few visionaries we have to help transition from volume based to value based healthcare. It is an imperative if we are to scale our system for the coming wave of baby boomers into our health delivery system. A key process concept he shared with me 5 years ago that still rings true today is we can not have healthcare interoperability without first having operability. That is the key notion of a consistent EMR across all care continuums. I have met with him on these discussions and found his vision, approach and execution strategy to be second to none. We need more inspired leadership across the healthcare spectrum. The technology is here today to deliver the value. It is leadership and vision at the senior executive level that is needed now. Dr. Harris is the model of that leader.