The Power of Data – is it Right Hands, Right Time? Or Wrong Hands, Wrong Time? By Dr Thishi Surendranathan, Beacon UK

Can you imagine a healthcare system where doctors and other health professionals can access the totality of a patient's healthcare record online? Or where doctors and patients communicate via secure e-mail to help manage care outside the doctor's office? Or where doctors share data on their activity in real-time for the purposes of enhancing performance?

It already exists thanks to Kaiser Permanente, a not-for-profit health insurer and hospital chain based in California, United States. In this blogpost, I report back from a seminar-led by Kaiser Permanente's Murray Ross and Joy Lewis, and hosted by Reform in London on Wednesday 19th September.

For those of you clinicians and patients who are sceptical of taking home lessons from across the pond, where overall costs are horribly bloated by profit-making insurers and cherry-picking "fee-for-service" providers naming their price, I would advise you to pay closer attention to the high quality of its care, the level of patient satisfaction and the overall efficiency of the Kaiser Permanente operation.

For the fourth straight year, Kaiser Permanente is the only health plan in California to earn a 4-star rating - the highest possible - for overall quality of care by the California Office of the Patient Advocate, and has also achieved the highest possible rating for patient satisfaction. By virtue of its system of prepayment rather than fee-for-service, Kaiser has created a compelling model of integrated, high-quality, accessible health care.

As per Joy Lewis' introduction, Kaiser Permanente has 3 branches: a not-for-profit health plan, a not-for-profit community hospitals and 8 independent self-governed Permanente Medical Groups. With more than 7 million members in California alone and a further 2 million in 6 regions across the US, Kaiser serves a population greater than that of London.

Joy, who is Manager of Kaiser Permanente International, explained that the role of technology within the organisation is as an enabler, and nothing more. It's power depends on the users and the pervading cultures: without engagement from doctors the technology cannot be used to improve clinical effectiveness or improve the patient experience. It boils down to a simple equation:

Large new IT system + Old Organisation = Costly Old Organisation.

Could she have been referring to the NHS Programme for IT?

Murray Ross, Director of the Kaiser Permanente's Institute for Health Policy, went onto describe the role of data as one part of a triad of key components in Kaiser's success. These are:

1) Physician Leadership
2) Mindsets & Behaviours
3) Data & Reporting

The first part of the triad will be very interesting to those who are afraid that data will be used by managers as a malevolent tool to control doctors' behaviour. The overarching principle here is to preserve autonomy at the individual clinician level. Each of the medical groups providing care has an elected physician board i.e. the system relies on doctors leading other doctors. Promising leaders are identified early and each of these are given management training: further enhancing engagement of medical staff.

The second part of the triad refers to the culture of continuous improvement, knowledge-sharing and team-working that has enabled Kaiser to outperform its peers. Over decades, Kaiser has evolved a policy of pro-active, preventative, integrated care over reactive, fragmented care. The popularity of Kaiser amongst prospective physician recruits helps, there being a typical 10 applicants per post: Kaiser is able to pick and choose the most engaged and talented medics.

The last member of the triad is data and reporting. Over the past decade, Kaiser has spent over $4bn on an Electronic Health Record system developed by Epic. The most obvious benefit of this is that doctors can see ALL of their patients' medical information at the click of a few buttons: at the right place, at the right time. But just as useful to the organisation are the "matrix searches" possible on the vast amounts of data. Information can be pulled up by doctor, department, diagnosis and many other dimensions.

There a number of exciting consequences for this including:

• the activity/behaviour of doctors can be measured against peers in real time
• care can be given proactively e.g. diabetes sufferers can be searched and all those requiring foot check/retinal screening/HbA1C check can be approached
• whole populations can be tracked/measured to develop screening programmes.

Of these, the most anxiety-provoking for a British doctor may be the sharing of activity data "unblinded" amongst peers. However, the culture is not punitive, it is more about the development of good clinical practice. Doctors, who are usually all "A" students, naturally don't like coming last, so the mere sharing of data promotes competition by forcing doctors to simply ask: why? i.e. why am I different to those at the other end of the curve? The usual challenges include, "my patients are sicker" or "the data is wrong". Here it becomes especially important that Kaiser is built on physicians leading physicians. Outliers are recognised via a culture of openness and transparency, and, through discussion with and learning from their peers, those outliers improve their clinical practice.

Of course it would be difficult for the Kaiser Permanente model effectively provide high-quality, affordable care without appropriate alignment of incentives. Physicians working in the Kaiser system receive a 10% bonus if both the facility they work in and the individual physician achieves specific quality measures. There are no incentives based on volume, costs, utilisation or other financial measures. This idea is particularly relevant to NHS where the payment system mostly rewards activity.

The presentation closed with the observation that the affordability of latest health care reform in the United States was envisaged to depend on "delivery system reform", and the concurrent rise of the Accountable Care Organisation "...a group of physicians teamed with a hospital with joint responisbility for the quality and cost of care provided to a large (Medicare) population" as an alternative to lowering fee-for-service payment rates. This, according to Kaiser, is what they have already been doing for 60 years and, if successful, will change the way care is organised and delivered in the US.

Internship at Bupa by Agneish Dutta, 5th year Medical Student, Imperial College London

I was most pleased to hear this summer that I had been accepted onto Bupa’s summer internship scheme for medical students, and equally daunted to learn that I was the first.

Setting out to work for the month I had off this summer, I began at Battle Bridge House, based in King’s Cross, having met my supervisors, Drs. Wai Keong Wong and Jenny Leeser at Bupa House, Holborn. I was struck by how friendly and enthusiastic everyone was to me, and I quickly settled in with my task. I spent the first two weeks conducting an audit with the aim of improving the way review appointments are made in occupational health. Working in this particular department allowed me to understand how workers of the railway are looked after, the prevalent health issues that affect this population and a whole new side to medicine that I would not have encountered through medical school alone. I had ample opportunity to sit in on clinics taken by technicians, nurses and doctors in equal measure. I took away a lot from my time spent talking to these staff and patients, which I am sure will enhance my development as a future healthcare professional.

The audit I conducted itself was an interesting insight into how the private healthcare insurance system works, and how practice is continually monitored to keep it efficient and cost effective. I was guided by Dr. Leeser through my tasks with prompt feedback, and was encouraged to write up my findings and procedure, which I would later present at a clinical governance meeting. Throughout my time at Bupa, such meetings were organised for me to be present at which revealed to me a commercial side of healthcare. I began to realise the challenges of the running of a private company, which in turn put into context the issues the NHS is now facing. It was a unique opportunity to hear from heads of different branches of the company and read the financial reports. They also had some delightful tea, a major perk.

Towards the end of my short time at Bupa, I visited centres around the country, including the highly impressive modern headquarters in Staines where I was privileged to sit in on some most intriguing work. Another trip took me to Manchester, specifically the Salford Quays where Bupa runs their remote health service. There I listened in on calls made and was told about how the department works. It gave me yet more of an idea of how healthcare is evolving; a cost effective service, and one I’m sure we will see in increasing use in all major healthcare services.

Throughout my time at Bupa I was helped whenever required, and plans were always made in advance. There was a good balance of using initiative and self learning and being taught new skills. I made friends and useful contacts in my time there. I feel very lucky to have had the opportunity to work at Bupa and miss it having returned to medical school! I sincerely recommend if you’re a medical student to apply, a thoroughly worthwhile and rewarding internship.

"Calling drepreneurs everywhere - Healthbox are in town" by John Lee, Head of Operations for Clinical and Investigative Sciences at Imperial College Healthcare NHS Trust

I got a tip off about an interesting company, Healthbox, who are moving into the European Healthcare space. They have had a lot of success supporting small startups across the pond. I was intrigued so called up a couple of entrepreneurs, from podmetrics and destinationdoc, and wandered in to the dragons’ den in the city on Tuesday evening.

Boom - started with intense networking where ideas were flying all over the place; I heard about remote control elderly care, innovative rehab, find a doctor app, junior doctor handover apps to name but a few. There were a bunch of suits, trainer-wearing Mark Zuckerberg wanabees, techies, docs, academics and healthcare innovators. We had a quick drink before a brief informal, presentation about what Healthbox want to do in Europe.

Healthbox, along with its principal UK partners Serco and Bupa, intends to unleash innovation to make material improvements for patients, as quickly as possible. They will do so by helping enthusiasts translate our transformational ideas from the garage in their 2-up 2-down to the patient bedside. They will help us take ideas to marke and scale ideas much quicker than if we are left alone to make it work by ourselves. They do this by injecting cash, expert coaching from business gurus and through a strong tech network of potential customers.

Sounds good? Well this is not a charity exercise. There are some big names behind it who are interested in seeing a return on their investment. But I don't think that is something to be worried about - profit is not the reason d'être here. The market will speak for itself. If the idea solves an important healthcare issue it will sell and scale. So if the ideas are successful, investors will get their return, entrepreneurs get their lucky break, and ultimately, and most importantly, patients will get better care.

I think Healthbox are on to something here. In my experience, the majority of the best ideas in healthcare come from our clinicians and people working on the frontline. However these enthusiasts have to wade through ten tonnes of treacle to get anywhere and often lack the networks and know-how to spread ideas quickly. Unfortunately in the NHS, the door is so often closed before the idea can even be tested effectively. I hope that Healthbox, and other similar initiatives, will help our amazing individuals, and their ideas, thrive.

Healthbox's arrival in the UK is timely. It is clear that we are going to have an unprecedented time of austerity with four years of flat cash. With this in mind, the NHS needs some help - a message that came through again and again today at the inspirational Darzi fellows' 'Beyond the Bill' conference. Nick Seddon's outstanding contribution to a panel debate hailed the need for an entrepreneurial revolution. He recognised that 'necessity is the mother of invention', as such Nicholson's £20 billion challenge is opening the door for entrepreneurs to thrive.

Good luck to all those drpreneurs out there who are trying to break through. 2nd September is the deadline for this round of Healthbox: www.healthboxaccelerator.com

Workforce Planning Round Table with Reform, by Subashini M, Clinical Research Fellow at Department of Surgery at Imperial College

This meeting was held under the Chatham House Rules, hence neither the identity nor the affiliation of the speaker(s) nor that of any other participant can be revealed.

I was delighted to attend the discussion at Reform, an independent non-party think tank focused on public service delivery, on workforce planning. A group of 20 senior administrators, policy advisors and senior clinicians were invited to this roundtable discussion.

As a junior doctor, my interest was personal. Is there a light at the end of the training tunnel? We are all familiar with the anxiety and uncertainty facing junior doctors applying for specialty training and I was keen to find out how the current changes to healthcare service delivery model will affect doctors at the frontline.

The roundtable discussion commenced with the interesting fact that in the next 20 years, the number of people in England who are 65 and over is predicted to rise by 51% and the demands on our health and social care system will be very different. The key challenges brought up by this demographic shift were discussed in great detail. The term ‘horizon scanning’ was introduced. It was acknowledged that short-term cost-cutting does not and has not worked, hence the need to focus on long-term thinking; looking into probable futures in 15-20 years’ time. Although it is not possible to predict the impact of a potentially groundbreaking technology or life-saving drugs on workforce or the population, it is possible to postulate future healthcare needs with the Centre of Workforce Intelligence’s Horizon scanning system.

In order to meet the healthcare needs of the future, two main streams of solutions were identified. First was the less attractive and unpopular change in payment model, i.e. reviewing the range of services available free at point of delivery on the NHS. Second stream was to improve workforce motivation and efficiency. It was agreed that the second stream should be the focus at present to address the challenges highlighted.

Following on from that, the five habits to improve productivity in healthcare workforce were discussed. This was based on research performed by KPMG, titled ValueWalks. The detailed report is due to be published in autumn this year; an abbreviated version is available here
http://www.kpmg.com/UK/en/IssuesAndInsights/ArticlesPublications/Documents/PDF/Market%20Sector/Healthcare/preface-value-walks-june-2012.pdf
One of the habits outlined was mandatory training for clinicians in service re-design and business innovation. It was emphasised that clinical leadership and engagement is essential for re-modelling care. The common practice of successful healthcare teams around the world was to look at the precise aspects of care and to continuously improve each micro-process. In order for this practice to be adopted, staff had to be empowered. This, in turn, improves efficiency.

There was also discussion about the shift of healthcare delivery from hospital-based care to community-based care and doctor-led to nurse-led care. Although one of the driving forces is cost, this model has been noted to be successful in other countries. It was felt that task shifting and blurring the boundaries of healthcare workforce was another way to maximise the efficiency of the current staff.

There were several radical and thought-provoking ideas brought up during the discussion. Although there was consensus regarding the real and present challenges faced by the NHS, there was no panacea for this issue. Each professional group (providers, analysts and clinicians) had different ideas of how to rectify this issue. One of the guests described the current situation as a ‘perfect storm’, which was the perfect opportunity for us all to get back to the drawing board and innovate a solution to heal our NHS.

I came away from the meeting with several thoughts. However, most importantly, I felt that it is crucial for junior doctors to be acutely aware of the changing shape of healthcare. It must be emphasised that clinical leadership and interest in service design and delivery are important, yet often over-looked areas of professional development. The traditional role of doctoring and hospital-based care structure are changing and we should use this as an opportunity to re-align ourselves to fit into this brave new world of healthcare of the future.

Diagnosis Salon with the Trainee Group of FMLM on 27th June 2012 - What is the value of value? by Dr Nisha Mehta NIHR Academic Clinical Fellow in Psychiatry at King's College London

It was a real pleasure to attend yet another lively and educational Diagnosis Salon where a nuanced and informative debate was enjoyed by all who attended. Co-hosted with the Faculty of Medical Leadership and Management, we were treated to a panel of experienced speakers put together by the Diagnosis team.





Speaking broadly in favour of the concept of value we heard Dr Rupert Dunbar-Rees and Dr Emma Stanton encourage us to reflect on the ways in which we can get maximum 'value' out of each stage of the health supply chain, which includes efficiency, focus, drive and team working.





Emma drew some fascinating parallels with her time sailing round the world in a yacht race, comparing this to her current NHS work as a neuropsychiatrist hearing about the inefficiencies in a system that causes frustration to staff and patients on a daily basis within the NHS.





The debate hotted up with a contribution from Dr Peter Lachman who suggested that the word 'value' is perhaps bandied about too freely and in such a loosely defined way as not to be entirely helpful to the healthcare debate in its current form. Peter worried that the use of the term 'value' is code for 'cost cutting' and suggested that it is important not to allow this to happen, because combined with competition and free market forces in health we risk eroding the values of the NHS.





Harvard Business School's Michael Porter's controversial 'value in healthcare' paper was discussed during Dr Anas El-Turabi's talk, in which he suggested that although they contain some merit, Porter's ideas for value in healthcare do not correspond to the corporate model from which his concept of 'value' originates through a failure to build in sustainability and factor in equity in the model. This opened up the debate to the floor nicely - from which point we heard several excellent arguments from the audience.





These included a discussion about whether the new 'value' agenda is simply a re-hashing of the pre-recession 'quality' agenda. We also heard an interesting debate about the exact definitions of 'value' and the role of cost, quality, supply chain, health services organisation in all of this.





I had recently had a very interesting discussion with Professor Uwe Reinhardt, Professor of Political Economy and Economics at Stanford University, that any discussion about value ought to take into account the value system of the health service in question - whether this be free market, egalitarian or somewhere in between - given that this will have a clear impact on the 'value' that any given society places on a life. This reflection seems to chime with the theme of the evening - that 'value' is a multi layered, complex phenomenon within healthcare, and that definitions are important, as are practical applications of the theory and concept.





Value seems here to stay (whether we like it or not!) and it cannot be ignored. I was thrilled that the Diagnosis Salon gave me a great opportunity to crystallise my own thinking on the subject and that it has inspired me to find out more! Thanks very much to the Diagnosis team for all their hard work and looking forward to the next Salon!

Elective in Health Policy by Edward Maile, Academic Foundation Doctor, Oxford University Clinical Academic Graduate School

I have been interested in health policy, public health and medical leadership since the start of medical school and this interest deepened after reading books by Atul Gawande (www.gawande.com), a surgeon and public health researcher. I felt that discussion of population-level approaches to healthcare delivery was lacking during my undergraduate degree. This is understandable in the context of an intensive course where producing safe junior doctors who can interact effectively with individual patients is the priority. With this in mind, when presented with the blank canvas that is the elective period it represented a golden opportunity to find out more about public health.





Harvard School of Public Health is one of the world-leading centres for public health. Therefore I set about emailing doctors there and eventually, with the help of Diagnosis' Dr. Emma Stanton, arranged a placement. This was a fantastic experience. I worked as part of a multidisciplinary team whose focus was to analyse health services and provision of care which exposed me to core disciplines of public health such as epidemiology and biostatistics. My role was to collect data on recent US health policy changes and to work with statisticians and physicians on analysis and interpretation. Additionally, I spent time with a cardiologist which provided front line context for my experience of public health. The facilities in Boston are hugely impressive but exist in a system which, like many others, faces challenges of equity of access to health services.





A particular personal highlight was the opportunity to attend seminars and conferences dealing with public health, policy, leadership and management. Speakers included Elliot Fisher, a key thinker behind the concept of Accountable Care Organisations which are an important feature of the Affordable Care Act. I also heard Gary Gottlieb speak, President and CEO of Partners which is one of the leading non-profit healthcare systems in the USA, as well as Lucian Leape, a pioneer and international leader of the patient safety movement and Joseph Newhouse, a distinguished health economist. I was able to visit the Institute for Healthcare Improvement (www.ihi.org) in Cambridge to learn about Quality Improvement (QI) and the IHI Open School which offers online courses in QI including a practicum element which walks learners through their own QI project.





There were many learning points which I took back to the UK. It was particularly interesting to observe the strong culture of medically-qualified leadership in the US, in contrast to the UK where many managers and CEOs don't have a clinical background. This led me to consider how I might develop my own management skills. I also noted a strong "can-do" attitude in the US, where no challenge is too large. I intend to retain this sentiment as I begin life as a doctor. My interests in public health, policy and medical leadership are still coalescing but I left HSPH feeling inspired, motivated and determined to learn more. I would highly recommend visiting HSPH to anyone that has the opportunity.

Leadership for Improvement: The Kings Fund Seminar 22nd May 2012 – by Rebecca Minton, Clinical Leadership Fellow & Psychological Therapist

I had the privilege of attending a fantastic seminar hosted by The Kings Fund on ‘Leadership for Improvement.’ The event brought together 80 key names in the field of healthcare leadership and we heard talks from four experienced and inspiring leaders.





Maureen Bisognano, President and CEO for IHI presented three inspiring case studies where applying ‘improvement science’ led to better patient care and improved outcomes at a lower cost. One example: Southcentral Foundation’s Nuka model of care – designed with the Alaskan population at the heart – listening to their views, designing a system around their values and preferences, providing integrated health and social care, and focusing on wellbeing rather than disease. Can the NHS do more of this? And should ‘improvement science’ be included in clinical training? – the majority of the roundtable believed so. Maureen Bisognano said clinicians have two roles: clinical work and improving care. Would all clinicians agree? I do! The IHI holds R&D days where staff are given problems to solve in order to learn new ways to use improvement science – could the NHS adopt this too?






David Fillingham, CEO of AQuA, stated that successful leaders need technical know-how, improvement know-how, and personal effectiveness to achieve results, not hierarchical power. He also stressed the importance of having the time and headroom to develop these skills, and career opportunities structured for breadth, not just depth, gaining learning from elsewhere (the Diagnosis Intern Network perhaps!?)






Bettina Fitt, General Manager at GE Healthcare, talked about the open, collaborative, ‘we’ culture where staff engagement is key, leaders inspire and listen to their staff, and results from staff opinion surveys are used to drive performance.






Professor Richard Bohmer promoted the need for clinical leadership and emphasised that clinical leadership is: a) respectable and b) work - so needs to be valued (yeh!).






So key points to take away:





- Communicate purpose and model leadership behaviours
- Talk about tomorrow not today
- Focus on how problems can be prevented rather than solved
- Learn from the voices of patients
- Step outside the walls of the hospital
- Look outside and understand the real needs of the population
- Engage and listen to others
- Use improvement science (or learn it first!)


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It was very exciting to be in a room with so many great people and hear everyone speak so passionately about leadership. I feel very privileged to have had this opportunity to hear the knowledge and wisdom of respected healthcare leaders from across the world (thanks for the invite Emma!). It was great to hear that they want to encourage and learn from young emerging leaders and I’m now even more inspired in my role as a new clinical leader. Now I can’t wait to tell my cohort of clinical leadership fellows all about it!...