How To Improve Health Care Through The Cgi Initiative

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1 CGI INITIATIVE FOR COLLABORATIVE GOVERNMENT S spring 2013

2 The CGI Initiative for Collaborative Government We focus on helping government leaders collaborate effectively while retaining strategic alignment, control and accountability. Products, including leadership interviews, reports, in-person events, webinars, e-newsletters, videos, blog posts and digital white papers, bring together the initiative s mission and expert analysis to provide thoughtful, incisive, ready-to-use information. Leadership Interviews The CGI Initiative for Collaborative Government s Leadership executive journal gives voice to top senior executives who are addressing the most important issues confronting the United States and the globe. These interviews feature practical management approaches and insights that are applicable across the government, private and nonprofit sectors. Reports Together with leading academic experts, the CGI Initiative publishes reports and Q&As to provide practical, actionable ideas about top-of-mind challenges for government executives on topics ranging from job creation to large IT project management. Events The CGI Initiative brings together leaders from government, academia and associations for executive dialogues on critical issues, including budget savings, information security, data sharing, transparency, health IT and more. Webinars and Digital White Papers The CGI Initiative has hosted webinars featuring leaders spanning the U.S. Army, Recovery Board, Energy Department and the Environmental Protection Agency. From these webinars, the initiative produces online Executive Guides, a form of digital white paper, capturing best practices, lessons learned and carefully chosen links. Videos, E-Newsletters Evolving continuously to connect most effectively with government executives, the CGI Initiative uses video to deliver expert analysis quickly and directly on the Web. Using cutting-edge publishing technology, the initiative creates and delivers a daily e-newsletter, Collaborative Government Today.

3 Editor s Note Welcome to the Winter 2013 issue of Leadership, the CGI Initiative for Collaborative Government s executive journal. Leadership gives voice to thoughtful executives who are creatively and effectively addressing the most important issues confronting the United States and the world. Each edition focuses on a theme that challenges leaders of diverse organizations and features profiles of executives whose practical insights and observations are borne of success and are applicable across the government, private and nonprofit sectors. This edition of Leadership examines health care, one of the country s biggest challenges. Specifically, we look at how big data and data analytics are key parts of the future of health care. To illustrate that, we gathered the perspectives of leaders across domestic and foreign government, industry and academia. To set the stage, we start with a candid Q&A with Brig. Robin Cordell, head of medical strategy and policy for the United Kingdom s Defence Medical Services. Other thought leaders include: Dr. Mark Chassay, deputy executive commissioner for the Office of Health Policy and Clinical Services, Texas Health and Human Services Commission. David Cordani, president and chief executive officer, Cigna. Dr. Robert Jesse, principal deputy undersecretary for health, Veterans Health Administration. Tony Trenkle, director and chief information officer, Centers for Medicare and Medicaid Services. Dr. Michael Wagner, president and CEO, Tufts Medical Center. I want to thank them for taking time out of their difficult schedules to share with us their ideas on data-driven health care. Thank you to each of you for the insight and dedication to mission that you shared with us. This issue also includes analysis on our theme from CGI Initiative Fellows Dr. James Peake and Dr. John Loonsk, who have served as advisers on this project. Dr. Peake was secretary of the Department of Veterans Affairs from 2007 to 2009 and U.S. Army surgeon general from 2000 to He retired from military service with a rank of lieutenant general. Dr. Loonsk is the former director of interoperability and standards at the Office of the National Coordinator for Health Information Technology. He also was the associate director for informatics at the Centers for Disease Control and Prevention. Finally, a special thank you to CGI Initiative staff members Andrew McLauchlin, Sarah Lindenau and John Adams for managing and guiding this project to completion. Andrew s leadership from starting this publication through this latest edition has been an important contribution. Also thank you to our editorial partner, 1105 Media. Molly O Neill Senior Fellow CGI Initiative for Collaborative Government Spring 2013 COLLABORATIVEGOV.ORG/LEAD Leadership 1

4 Leadership SPRING 2013 In This Issue 4 Thinking Big Decoding big data s health care potential depends on leadership, technology, and collaboration. 8 Global Collaboration Brigadier Robin Cordell Defence Medical Services, UK Brigadier Robin Cordell instills a spirit of collaboration within the UK s Defence Medical Services 12 Carrying the Torch Dr. Mark Chassay Texas Health and Human Services Commission Dr. Mark Chassay teams data with policy for Texas health care delivery 2 Leadership CGI INITIATIVE FOR COLLABORATIVE GOVERNMENT SPRING 2013

5 20 Setting the Pace David Cordani Cigna Partnerships and embracing uncertainty underscore Cigna CEO s accountable care approach 28 Tools of the Trade Dr. Robert Jesse Veterans Health Administration Dr. Robert Jesse focuses VHA health care fixes on patient needs 36 On a Mission Tony Trenkle, Centers for Medicare and Medicaid Services Tony Trenkle advances health reform through technology modernization 44 Making the Grade Dr. Michael Wagner Tufts Medical Center Dr. Michael Wagner helps Tufts Medical Center deliver on health care promises SPRING 2013 COLLABORATIVEGOV.ORG/LEAD Leadership 3

6 Thinking Big Decoding big data s health care potential By Drs. John Loonsk and James Peake The health technology community is buzzing about big data and for good reason: with this emerging technology come big promises of being able to access, integrate and apply different types of data to establish the full picture of a patient and then mesh that context with health system data to create more efficient, patient-friendly outcomes. Volume is a hallmark of big data, with critical information carved from terabytes and petabytes of data. But in health, big data is also big because it documents and manages complex and vast health concepts. It is big when it begins to describe intricate parts of a living entity, such as a human genome. It is big when it begins to document the comprehensive clinical state of an individual. It is big when it articulates the research lessons that person holds for the broader population. With these advancements come big challenges, which, while frustrating, also have the potential to foster creative solutions and provide an opportunity to rethink and renovate the health care experience for everyone involved, from individual patients to entire populations and from doctors to major medical health care providers. Imagine the Possibilities Big data-enabled capabilities are rapidly becoming ingrained in health care. Doctors use digitized radiologic images, microscopic sections, freetext operative notes and discharge summaries. Data characterizing the full patient status can help protect against drug and allergic reactions, for example, or adjust medication dosage for genetic ability to metabolize. Big data can make for more efficient scheduling of operating rooms by 4 Leadership CGI INITIATIVE FOR COLLABORATIVE GOVERNMENT spring 2013

7 EHR Spending (in billions) $2.18 billion estimated compound annual growth rate of 18.1 percent $6.05 billion Source: University of Illinois at Chicago sequencing cases and ensuring the right instruments are available. For recovering patients, it can predict the date of hospital release and coordinate people involved in discharge: pharmacies, rehab services and caregiver pickup. But big data can do more than give a better view of the status quo. Predictive analytics use big data to paint a picture of what could be. Big data is central to describing, managing and measuring the road between the two. It underlies our ability to improve patients safety, maximize hospital resources, optimize hospital stays and decrease the likelihood of readmission. Data used to provide individual feedback can even modify patients behavior and guide them toward a healthier lifestyle. At the same time, big data can boost efficiency and cut costs. Breaking Down Walls This new realm of data possibilities requires a greater integration of data inside hospital walls and beyond and new ways of thinking. It s not enough to implement electronic health records (EHRs) that convert existing health processes. Workflows and processes must change to take advantage of the new capabilities. Big data is eroding some traditional barriers to data sharing, but this reform is also about changing mind-sets, which is never simple. It is still easier to follow the traditional course and defer to proprietary business concerns, legal postures and distrust among health care constituencies. Incentives are only slowly being realigned to hold providers and health systems accountable for care outcomes, but expectations and policy are advancing rapidly. spring 2013 COLLABORATIVEGOV.ORG/LEAD Leadership 5

8 Most health-related data is still in paper form and even when it has been digitized, it often lacks a high level of structure, making meaningful and consistent aggregation difficult. Technology continues to advance, however, providing new tools to deal with these new data problems. Big data tools offer ways to store and process greater quantities of data faster than ever. They can also help set standards. In a big data construct, applying analytics to both structured and unstructured data is promising. Navigating Obstacles From a technical standpoint, sharing data can be challenging. Specifically, no standards exist for digital data, health information technology incentives vary and most existing systems were set up to stand alone. Standardizing data is difficult because different health specialties have different requirements. For instance, a medical center might have specialists in endocrinology and anesthesiology with different workflows and information needs. A commercial solution doesn t cut it, and opensource software is not a panacea, either. Instead, standardization requires management and integration into the ecosystem. Beyond technology, the medical community must broaden its perspective to embrace the idea that big data means health care is about more than caring for individual patients. It s about taking care of populations. Because data gleaned from one person can be applied to others through predictive analytics, health professionals can reverse it and use population data to help individual patients. To do this, different data sources, storing and managing large amounts, must be linked in new ways to deliver new information. This also means recognizing that bringing together large data sets is an important step in improving health care but it is not the solution. Solutions and improvements will be made when we begin using this data to rethink fundamental elements of health care. If we can surmount these technical and behavioral challenges to unleash the data, make it avail- Dr. Loonsk John Loonsk, M.D., FACMI, is a CGI Initiative for Collaborative Government Fellow with experience in health information technology spanning government, commercial and academic environments. In 2009, Loonsk was appointed chief medical officer at CGI. Previously, he held the position of director of interoperability and standards at the Office of the National Coordinator for Health IT. In this role, Loonsk led the architecture of the Nationwide Health Information Network and advanced the interoperability processes of the American Health Information Community. Loonsk also was associate director for informatics at the Centers for Disease Control and Prevention. There, he led the creation of the Public Health Information Network. He was also instrumental in designing the National Electronic Disease Surveillance System and initiating the BioSense program. 6 Leadership CGI INITIATIVE FOR COLLABORATIVE GOVERNMENT spring 2013

9 able in electronic formats and begin the analysis process, health care outcomes will improve and costs will diminish. The Path Forward Achieving the potential of big data will take big leadership. Although interoperability will be elusive for many health systems and programs in the near term, bringing together unstructured data, connecting it with existing structured data and analyzing all of that information with big data tools will allow for quick, significant patient and population benefits. The push for EHRs and the combination of clinical and payment data mean organizations are going to have a lot of data to deal with. The biggest problem they face is how to harness the capability of big data to push health care forward faster. The proper approach is a combination of actions focused on the justified concerns of people and businesses. We must apply new big data technology options incrementally, acknowledging the need for an extended perhaps perpetual period when organizations will operate with a hybrid of older and new data sources and systems. The key is creating a convergence model to pull all the pieces together. Another point to consider is cloud technology, which can efficiently process large amounts of data at commodity pricing. We also need to encourage mobile communication and website redesign to effectively deliver information in a way that consumers want to see it and use it and can understand it. This might include a hosted analytical tool by which individuals can model the effects of their behaviors. IT solutions can join data and analytics, but a successful health care environment requires improvement in collaboration and partnership among all stakeholders. As we begin to gain more access to these large data sets, we must remember that availability and storage are not the end game. We will fall short if we do not use the data to ask questions that will improve health care. The promise of big data and emerging analytic tools is here now, and the American health care system needs to commit to using this new wealth of data in new ways to achieve significant improvements in health care. n Dr. Peake James Peake, M.D., is a CGI Initiative for Collaborative Government Fellow. In December 2009, Peake was appointed senior vice-president for the health industry at CGI. Prior to joining CGI, Peake was nominated by President George W. Bush to be secretary of the Veterans Affairs Department on Oct. 30, 2007, and unanimously confirmed by the Senate on Dec. 14 of that year. He served from December 2007 through January Peake was the principal advocate for veterans in the U.S. government and directed the nation s second largest Cabinet department, responsible for a nationwide system of health care services, benefits programs and national cemeteries for America s veterans and dependents. He previously was U.S. Army Surgeon General from 2000 to As such, he commanded 50,000 medical personnel and 187 Army medical facilities worldwide. Before that, he served as commanding general of the U.S. Army Medical Department Center and School, one of the largest medical training facilities in the world with 30,000 students annually. spring 2013 COLLABORATIVEGOV.ORG/LEAD Leadership 7

10 Perspectives from Brigadier Robin Cordell Head of Medical Strategy and Policy, Headquarters Surgeon General, Defence Medical Services, UK Brigadier Robin Cordell is responsible to the Surgeon General for Defence Medical Services (DMS) strategy and medical policy, including the DMS Information Strategy, and is co-chair of the US-UK Task Force working group on mental health. He is also the military representative on the Royal British Legion chaired Medical Advisory Group. The DMS is staffed by nearly 7,000 uniformed medical and dental personnel from the Naval Service, British Army and Royal Air Force. It provides health care to approximately 196,000 servicemen and women ensuring they are medically fit for duty. Cordell was previously Allied Command Operations Medical Advisor where he was responsible for the medical direction for all NATO operations, the International Security Assistance Force (ISAF) mission in Afghanistan being the main focus. He was first commissioned as an infantry officer in 1977, serving in Belize prior to medical school. 8 Leadership CGI INITIATIVE FOR COLLABORATIVE GOVERNMENT spring 2013

11 Q. The Defence Medical Services moved from a provisional model by the Army, Navy and Air Force independently, to a unified model, and providing an electronic medical record for its patients. What are some of the hurdles you are facing? A. The main challenge has been a cultural one. Moving away from a Service stovepipe system required a change in emphasis. We moved from using electronic information systems that were different in each Service, connected as local networks within each primary health care center and used almost exclusively for health care record management, to a Defence Medical Services - wide system that allows data capture to improve health care delivery. At the same time, it still supports record keeping and clinical decision making. The challenge was to move people from the independent provider way of thinking, entering data in the way that suited their individual preference, to a system where we would require them to enter data in a standard coded way that is easily analyzed. By actually looking at the codings from consultations, you can build a picture of the health issues that affect our people and how we can prevent ill health. This single electronic medical record is the central spine for our health information system. This allows the health care provider access to those records from anywhere in the world, in permanent bases and on military operations. Q. How did you convince providers to move from a medical model to a public health model? A. It was difficult at first. What worked was forming user groups so that we were able to show the benefits to our patients without having to take a topdown approach. Providers found it useful to have additional health information, particularly in the military context. Having that detailed information allows us to advise commanders on how to prevent illness and injury, which is better than having to manage the injury after it occurs. We therefore got the message across: This is the way you can best help our patients. We can provide information that you can then use to help prevent illness and injury, but this all depends on you using coding in consultations in a consistent way. The other benefit is improved health care quality. Within the UK s National Health Service we have a number of measures, called quality framework indicators. If civilian doctors make those targets they get additional payments as an incentive. The motivation for military doctors is to demonstrate the quality of the health care they provide is just as good or better. The psychology of this is that professional pride takes over and they want to do better. Being one of the best performers is motivational. Q. As head of medical strategy and policy for the Defence Medical Services, you play a significant role in transformation and managing change. What would you consider some of your major achievements in this area? What would you say are the biggest challenges? A. As in the United States, each of the UK Armed Services is proud of their traditions and is accustomed to operating a certain way. We are in the process of implementing the new Defence Primary Health care structure, which will bring together uniformed and civilian medical staff delivering primary health care in the UK and in the Firm Base Overseas. This brings benefits of scale, and therefore efficiency, but does mean a change in approach to some degree. From our experience on deployed operations which are almost all jointly delivered, and have delivered truly excellent results, this unified approach will deliver primary health care more effectively and more consistently across Defence. The key to successful transformation is two-fold. The first is for all those who need to make this happen to agree and strive toward a vision that all providers can buy into. This is to deliver the best possible health care wherever our people are. The second is to build a new culture that embodies the vision. Q. You talk about collecting and analyzing more data to deliver better care to the patients. How is this progressing? A. It is happening now through the Defence Medical Information Capability Program (DMICP). We have introduced templates which automatically code the diagnosis and treatments given to patients. It has taken some time, but we are now getting some good information out so we can compare practices with each other from a quality point of view. Q. The Defence Medical Services provides a range of services in many spring 2013 COLLABORATIVEGOV.ORG/LEAD Leadership 9

12 Brig. Robin Cordell, as ACO Medical Advisor, led one of three working groups assembled to discuss strategic, operational, and tactical-based information management during the NATO Medical Conference in Istanbul, Turkey April different facilities inside and outside the UK. It s a very collaborative environment. What is your approach to collaboration? How do you coordinate care and share data with the various stakeholders? A. Placing the focus on our core outputs allows the Defence Medical Services and its stakeholders to share a common purpose and vision. These include advice to commanders on health threats and how the risk of ill health and injury might be managed, and the provision of world-class military health care focused on optimal patient outcome. Shared values are important. In the Cold War era, where large numbers of casualties were expected, the emphasis of the military medical services was on preventing ill health. In regard to health care in the field, the need was to provide a system that had the resilience to withstand damage to the health care infrastructure itself, and this necessarily led to a do the greatest good for the greatest number philosophy. Our values now are rooted in excellence in care provided for every casualty. Perhaps with the exception of the US, no nation can realistically provide excellence in health care everywhere in the modern military operational environment and so greater collaboration with a small number of allies is necessary, usually within the North Atlantic Treaty Organization (NATO) of which we and the US are key contributors. The learning we get from collaborating with other nations is highly beneficial. In terms of sharing data, there is always a tension between protecting information that might harm one s own troops through exposing vulnerabilities, and the need to share information for the protection of troops. Achieving data sharing is difficult due to the understandable security concerns, and also because the effectiveness of preventive activities (and so the benefit of sharing information) can be difficult to prove. In addition to excellent work that is already undertaken within NATO, a recent initiative that the UK is contributing to is the Deployment Health Surveillance Capability in Munich. This is a branch of the NATO Military Medical Centre of Excellence based in Budapest. Q. How do you agree on a common standard to exchange and share data? A. It s a really big job and it isn t just a medical issue. The technical issues include information systems being able to talk to each other. In terms of hard progress what we do have is the Defence Health Surveillance Capability. We are starting to put the structures in place to better understand what the health threats are on the ground and react to them as they arrive. Another area we have made some progress is the NATO trauma registry, which is compatible with the US Joint Theatre Trauma Registry. There is now a single repository on the outcome of various injuries, interventions and a mechanism for learning how to make continual improvement. There is a lot of emphasis on sharing information and experience, but there is still a way to go in terms of a comprehensive approach to this. Q. Sounds like you are doing interesting things with information already. What is possible down the road? A. We have gained a better understanding of why we need the information and what we are going to use the information for. We use this information for the benefit of patients in preventing ill health, and also to improve the quality of the care we give. In terms of what will happen in the future, I think there will be greater collaboration between nations. The way we deliver health 10 Leadership CGI INITIATIVE FOR COLLABORATIVE GOVERNMENT spring 2013

13 care on operations now is very much on a multinational basis. We need to not only share information but also improve the interoperability and connectivity between our nations. Q. You have had significant international experience, including your job as the Allied Command Operations Medical Advisor. How do you approach this type of environment and what are the challenges in providing health care in a multinational environment? A. The essence of it is to understand the culture- the national, military and medical culture. Once you start to understand culture you can start to engage those who really are the key influencers and these may not necessarily be the most senior in rank. Understanding them is the key to effective leadership. People are a product of their upbringing and specific environment. Understanding the values people hold helps to predict how people will react. Even though medical staff across the world have a common set of values in terms of the Hippocratic Oath, there are some differences in how people approach providing care in the complex environments in which we operate. In the case of the UK, our military medical services are largely embedded in the National Health Service, where our hospital specialists work between deployments. Our casualties from Afghanistan and elsewhere return to the National Health Service, specifically the Queen Elizabeth University Hospital in Birmingham. We have had a few challenges to introducing some common ways of working. One example was the timelines for reaching casualties on the battlefield. There were two perspectives: there was a slightly more pragmatic approach and a more prescriptive approach. By speaking with the key stakeholders, we were able to get a satisfactory agreement and now have something in place that works really well. Language is also important. Misunderstandings can arise even between native English speakers from different nations. There is unique language used within the military culture, which can vary between the individual Armed Services and between the military and civilians. The key lesson is to use all your senses to ensure that people really understand you --even if they are native English speakers--listen carefully to what they say, observe their reaction and feel the atmospherics. This is why videoconferencing is useful, but to be really effective needs to have been founded on face-to-face meeting beforehand. Q. How much training do you need to provide those working on the ground? A. The key point is not only individual training, but team training. What has been highly successful in regard to the UK-led hospital at Camp Bastion in Afghanistan is having US doctors and nurses that form a significant part of the hospital staff to come to our Army Medical Services Training Center and work with the people they will work with in Afghanistan. We look at how we will manage casualty loads, how we will treat host nation civilians and detainees. It also enables people to understand how they relate to one another and how they work as a team. As a result of our experience we have recommended that it makes sense to continue training with our US colleagues to prepare for any future missions after the end of the current operation in Afghanistan. Q. Are there changes in strategy, approach or technology that will make this easier today than it was five years ago? A. We will examine how we can best leverage emerging technology to inform the health advice we provide and to support health care delivery. At present our system is based on a server model, but opportunities presented by cloud technology could be useful. Deploying cloud technology would help us enhance the linkages between command, aviation, military medical and civil health care systems within our own nation, and also between our international partners. We are likely to see collaboration in the provision of medical support between nations as the norm for future operations; transferring information will be enhanced between Medical Evacuation (MEDEVAC) helicopters and the receiving hospitals, between field hospitals within the operational theater, between the field hospital and the strategic aeromedical evacuation assets, and with the receiving home base hospital. Better information in regard to each step in the pathway provides opportunities to improve. We are providing an excellent standard of health care on operations. Continued improvement in information support will allow us provide better advice we give regarding the promotion and protection of health, and excellence in restoring the health of the sick or injured soldier, sailor, airman and marine - and others we look after. n spring 2013 COLLABORATIVEGOV.ORG/LEAD Leadership 11

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15 Carrying the Torch Dr. Mark Chassay teams data with policy for Texas health care delivery By John Stein Monroe Photography by Lance Rosenfield Dr. Mark Chassay has always been a planner with a vision. Soon after finishing medical school, he applied to become a volunteer physician for Team USA. Although the wait was more than five years, he figured by that time he would have enough experience to land the job. spring 2013 COLLABORATIVEGOV.ORG/LEAD Leadership 13

16 There are a lot of times you are successful, but the winners are always the ones who learn from their mistakes, changing things up just a little bit. In the end, his persistence paid off, and in 2003, he was accepted into the U.S. Olympic Committee s volunteer training program in California. He worked as a medical officer at the 2008 summer Olympics in Beijing and more recently was appointed Team USA s chief medical officer for the 2012 London Paralympics. Chassay has always enjoyed sports he played varsity football and baseball in high school and always wanted to be a doctor, but it wasn t until he was in medical school that he decided to combine his love of both. A friend tipped him off to fellowships in sports medicine that he could apply for when he was finished with his residency. The goal, after my fellowship in California, was to go back to where I grew up in the Houston suburb of Sagemont and treat my friends and my friends kids. He returned to his roots in Texas, where he co-founded a private practice focusing on family and sports medicine. Along the way, I got a job as the head team physician for Intercollegiate Athletics at the University of Texas at Austin. Recently, he decided to take on a new challenge: health care policy. In January 2012, he became the deputy executive commissioner for the Office of Health Policy and Clinical Services at the Texas Health and Human Services Commission (HHSC). I decided this would be a good way to continue doing some policy work and get involved in the complexities of health care, he said. At the same time, it allows me to get a little out of my comfort zone since I had been doing the same thing for a while. Whether in athletics or health care, leaders know that good data is indispensable when it comes to training. It s all about being prepared, Chassay said, and in order to be prepared, you need data. 14 Leadership CGI INITIATIVE FOR COLLABORATIVE GOVERNMENT spring 2013

17 It s important to constantly review past performance and assess what works, what doesn t and what can be done differently the next time around, he said. In athletics, you make mistakes, Chassay said. There are a lot of times you are successful, but the winners are always the ones who learn from their mistakes, changing things up just a little bit. The same holds true in health care, he said. If we see that things, either through claims or quality, are going a little bit awry or are not up to the standards that we would like, we can make more interventions, whether it s education or advocacy for certain items. Health care providers, insurance companies and state agencies collect a vast array of healthrelated data: on the quality of care, the cost of care and the outcomes. The key is to analyze the information and get it into the right hands, where it can be used to make changes in health care services, Chassay said. Jump-starting Innovation In one of his first tasks, Chassay is helping lead an effort to improve the exchange of information in Texas between state agencies and between the public and private sectors. The goal is not new, but it was given new impetus after the state legislature created the Texas Institute of Health Care Quality and Efficiency in 2011 to study how to improve health care. Chassay envisions creating a life cycle of health data, where data is transformed into information, information into knowledge and knowledge into wisdom. Once we get data to flow, people can get more information to be more knowledgeable about different areas, he said. And ultimately, the wisdom is giving managed care organizations information that might help them improve the quality of their care. The institute got off to a fast start, by necessity. The legislation that created the institute, Senate Bill 7, directed it to develop a report by Dec. 1, 2012, recommending how data could be more effectively collected and used to improve the quality and efficiency of health services in the state. The institute is run by a board of directors and is supported by Chassay and his team. Senate Bill 7 was a comprehensive piece of legislation aimed at revamping the state s health care infrastructure, with provisions to expand managed care, streamline Medicaid, foster new health care collaboratives, and move Medicaid and the Children s Health Insurance Program (chip) to reimbursement models tied to innovation, costefficiency and performance. Chassay and his staff needed to coordinate their work with several related committees and numerous HHSC departments. The key to this coordination, Chassay said, was having a clear guiding objective sharing data and then breaking that down into manageable pieces. If you tackle the challenge a little bit at a time, it works out, he said. Before the first meeting concluded, the board broke into groups to develop action plans around four specific issues: make full use of existing health care data, collect and use a broader range of data, make information on the quality and cost of health services available to consumers, and recognize health facilities for outstanding quality and efficiency. The institute s task was feasible because its objectives were clear and compelling, with many parties in both the public and private sectors having a vested interest in improving health care services. Being a physician, Chassay said, has helped him put some of the things he is trying to do in perspective. When someone says, We need a provider to do this, I say, Let s focus on the most important issues. We have to take little steps for people to evolve the position. Like in sports, it s going to take a group effort, teamwork and collaboration. The board ended up making 25 recommendaspring 2013 COLLABORATIVEGOV.ORG/LEAD Leadership 15

18 tions in its report, drawing on the research of the first three groups. The fourth group concluded that the market did not need any more awards or recognition programs. The institute is now waiting on direction from the state legislature. Data Sharing and Delivery HHSC, which has an annual budget of $16 billion and 9,300 employees, is the result of a consolidation of a number of state agencies in It also administers more than half a dozen programs, such as Medicaid, chip and the Texas Women s Health Program. Although all fall under the purview of HHSC, Chassay acknowledges that each group has been accustomed to owning its own data rather than sharing it. Whatever direction the institute goes, the commission now understands the importance of breaking down its own information silos. There are a lot of organizations that have come together over time, he said. We are trying to make sure that we can map out all the information sources and what data we can share with whom. Figuring out who can share data is one of our biggest challenges internally and externally, Chassay said. There are other agencies outside Data-driven Health Care: Options to Consider The board of directors of the Institute of Health Care Quality and Efficiency provided the Texas legislature with 25 recommendations in four categories. Here is a sampling in each. Improving Public Policy and Decision-making Expand public reporting of health outcomes measures at the facility level, beginning with a small set of patient safety indicators. Expand data collection in high-priority areas, such as hospital emergency department claims. Reduce barriers to data sharing among state agencies and speed the availability of data in the public domain. Publicly share data on health care facilities regarding potentially preventable readmissions and potentially preventable complications. Encourage (but do not mandate) public/private-sector collaboration to expand information available on health services utilization and reimbursement for the commercially insured population. Ensure the protection of any sensitive personal information that might be included in any future centralized health care database. Identify and eliminate any data collection requirements that provide little or no public purpose. Improving Transparency and Aiding Consumer Purchasing Develop and offer a high-deductible health plan with a health savings account (i.e., a consumer-directed health plan) to state employees. Provide participants in the state s Employees Retirement System and the Teacher Retirement System of Texas with price and quality transparency tools. Improve access to information regarding consumers out-of-pocket financial obligations for health care services. Generally promote efforts in the private sector to increase the public availability of information on health care quality, costs to the consumer, outcomes of care and patient safety. Improving the Use of Quality-related Data Develop a consumer-friendly website offering health care quality information to consumers, including a dashboard of publicly reported health outcome measures. Conduct a comprehensive study of consumer behaviors, preferences and the best ways to maximize consumers use of health care information. Recognizing Exemplary Performance by Health Care Facilities The board determined that no new recognition program was needed. 16 Leadership CGI INITIATIVE FOR COLLABORATIVE GOVERNMENT spring 2013

19 Dr. Chassay served Team USA at the summer Olympics in Bejing our HHSC enterprise that we would like to exchange information with, Chassay said, adding that privacy, security and confidentiality policies must be in place first. Access to more information makes people more knowledgeable about different areas, Chassay said. But the data is only useful if it is accurate, and data collection, even automated, is not a perfect science. The challenge is for agencies to scrub data as quickly as possible and deliver it to health care providers who need it, Chassay said. There is so much data coming in and out. The biggest concern for government entities is making sure the data is correct, that it has been scrubbed, that it s as accurate as possible, Chassay said. Because if people outside government are going to make decisions based on non-scrubbed data, it could lead to incorrect suppositions. Technology can help, thanks to increasingly sophisticated business intelligence software that can sort through and analyze large amounts of information. In this era of big data, it is possible to create exponentially larger data stores that can be mined for intelligence. A Local Approach One recommendation the institute made in its initial report is to collect, analyze and deliver health care information back to providers in a particular region rather than on a statewide basis. Although such an approach involves smaller samples, it also provides a more efficient feedback loop. The spring 2013 COLLABORATIVEGOV.ORG/LEAD Leadership 17

20 Dr. Chassay at the baseball College World Series with the University of Texas It s all about being prepared, and in order to be prepared, you need data. regional perspective also has the benefit of reflecting how care is actually provided. A person undergoing treatment for a cardiac condition is likely to visit other health care providers in the same area. Although each regional collaborative will have its own approach for assessing the effectiveness of its services, the groups might also find it useful to share data with one another, so they get a better idea of how they are performing compared to others, Chassay said. One model for such an approach is the Dallas- Fort Worth Hospital Council Foundation, a nonprofit public/private partnership involving more than 80 organizations, including hospitals, clinics, insurance providers and government agencies. The foundation has created a regional database that can give partner organizations insight into 18 Leadership CGI INITIATIVE FOR COLLABORATIVE GOVERNMENT spring 2013