In June, the Center for Medicare & Medicaid Innovation awarded the HVHC $26 million to expand its search for best practices in heart failure, high blood pressure, diabetes, and sepsis. Pneumonia, weight loss surgery, asthma, labor and delivery, and are on the list, too. An important component of that grant is to establish the best systems for enabling informed choice (shared decision-making), so patients have realistic expectations for procedures they agree to undergo, Weinstein says.
The collaborative now brings together 50 million patients from 15 organizations and their health systems, and every week, he says, "another healthcare system calls us asking to join. This is evidence of a groundswell of desire by these systems who understand that we're not getting this right. We better step up and do something."
The collaborative's next project, diabetes care, poses dozens of questions. "Do you need expensive medication versus a cheaper drug? How many times should we check blood sugar levels? And how many office visits do we need? And should we strive for a hemoglobin A1c of 7% or 6%? There's no protocol that's nationally accepted. Everybody now just does their own thing," Weinstein says.
Various procedures will be measured and worked into protocols that are tested and retested. "And I'm sure that we'll see lower cost and lower utilization of resources with better outcomes and more satisfied patients and providers as a result," he says.
While the HVHC may be the largest such collaborative, many others are launching smaller or system-specific projects. In addition to participating in HVHC, Intermountain has looked at practice variation within its hospitals, says VanNorman.
"It really requires a medical staff that has a culture of openness and sharing of data," he says. Some 60 physicians of the 250-member medical staff went through formal training to accomplish this, and the teams "are now accustomed to having our numbers put up on the wall."
At one Intermountain hospital, 245-licensed-bed Dixie Regional Medical Center in St. George, Utah, removing practice variation throughout the system resulted in a half-day reduction in length of stay for pneumonia patients, and readmission rates were reduced by 5 percentage points between 2009 and 2011, from 14% to 8.8%.
"One of the things we learned is that we didn't have the patient and the family engaged enough. They weren't that clear why they were in the hospital to start with, much less what they had to do to get out of the hospital," says VanNorman. Now the patients and their family members receive a brochure that identifies on day one, day two, and day three, how much oxygen a patient is expected to use or what distance they should be able to walk.
"And by day three, you're probably doing everything you're supposed to and you can go home," he says.
Another Intermountain effort focused on better recognition of the earliest signs of inpatient sepsis, which has reduced its severity, cost, and length of stay, VanNorman says.