Podcast Q&A: Dr. Peter Pronovost on Driving Value, and UH’s “Very Different Approach to Innovation”

When most people hear the name Peter Pronovost, they think about checklists, and for good reason. Nearly two decades ago, Dr. Pronovost developed a set of steps to eliminate infections from catheter lines, an innovation that helped save thousands of lives while also transforming the delivery of care. Now, he’s leverage that same approach to improve value.

And although Pronovost still believes checklists are an essential tool in providing quality patient care, what’s just as important — particularly as healthcare shifts to a value-based model — is changing the narrative. Recently, he spoke with healthsystemCIO about the three-part strategy he’s using to drive a new narrative at University Hospitals, where he has served as Chief Clinical Transformation Officer since 2018. He also talked about the data model they’re using to develop a more holistic view of the patient, how his team has leveraged technology to care for patients during the pandemic, why value means much more than just cutting costs, and the three characteristics that are necessary for successfully driving change.

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Key Takeaways

• One of the foundational pieces in University Hospitals’ innovation strategy is the data model that looks at three key areas: patient cohorts, provider outcomes, and utilization.
• By leveraging machine learning – and combining technologies such as chatbots and smart scheduling – UH has created automatic triggers that make it easier for patients to receive care.
• UH has partnered with Agility to provide real-time feedback “on a variety of measures that help hospital throughput and quality,” including asset tracking, which saw a 22 percent boost.
• “Too often technology is a shiny object that’s looking for a problem to solve,” Pronovost noted. Organizations that are able to flip the switch and first ask ‘what problem are we solving?’ are more likely to succeed.
• An “enormous” opportunity for telehealth? Improving communication between joint specialists and primary care providers, which can help reduce readmissions.

Q&A with Peter Pronovost, Part 2 [Click here to read Part 1]

Gamble: Part of it using technology in more innovative ways. Can you talk about like how that has been done at UH?

Pronovost:  Sure. We’re doing some really cool stuff. We had to build a data model that allowed us to look at our patients really almost at three levels.

First, we need to look at cohorts of patients — who has diabetes or heart failure. We have to be able to look at providers — who’s having worse outcomes than others. We have to look at utilization — who’s being admitted to the ED or the hospital, and so we built an EDW that integrated our claims data, EHR data, billing data and appointment data, so that we can really get a holistic picture.

Then, we partnered with our data scientists to create a strategy for how we can support data science to help improve care.

Let me give you a couple examples. Given that we’re trying to improve defects in care and we have a lot of investments to make sure people in our system get a high level of care, we want to make sure our clinicians use our health system. In other words, keep care in network. And so we’ve created a dashboard where physicians get a report of what percent of their encounters are in our network. The denominator is the percent of encounters or dollars in Ohio, and the numerator is the percent that are within UH, and we monitor and give feedback on improving that.

To do this type of outreach, as we did for the patient using the machine learning model, we now build these automatic outreach triggers for a variety of conditions. We combined it — and I think this is a great example of the innovation we’re seeing combining multiple therapies — with a chatbot. In this case, we used Conversa to enable navigation, so that the chatbot directs them to a call center where they could either arrange care or divert them from the ED.

There’s also scheduling. We can send a text link for self-scheduling which would say something like, ‘You haven’t had an appointment in this long,’ or ‘you’ve missed your mammogram.’ We run triggers for a variety of things. The idea is, ‘we’d like you to get into care, please click here to schedule.’ It’s using practical, innovative ways of combining technologies. The chatbot provides education, the outreach tells them to make an appointment, and the smart scheduling makes it easy for them to do that.

 

Getting real-time feedback

During Covid, we had helped a company called Masimo get FDA approval for a disposable home pulse ox monitor. And so, when we were really worried about our capacity and how we can care for patients, and how we can prevent sick patients from being exposed to Covid, we quickly stood up home monitoring with wireless pulse ox using a patient self-reported monitoring platform from Doctella. It syncs with the patient’s cell phone and sends their vital signs to a command center monitored by nurses. They call patients if an alarm is triggered; they also call twice a day just to check on them. The patients just love it. Almost every patient has told us how comforting it is to know someone’s watching them. They had read articles about how COVID could cause unrecognized hypoxemia, and so that they were very comforted to know someone was looking at my pulse ox and I’m safe. And many of them are so lonely that just that twice a day call from the nurse was something people really look forward to.

We’re also putting a management system into what we call our system operations center. As part of that management system, we’re able to look at whether we have real-time feedback about behaviors. Sometimes it’s really hard to get those, and so we’ve partnered with a company called Agility to be able to provide real-time feedback on a variety of measures to help our hospital throughput and quality. Those are displayed in a command center that we monitor and have oversight of, to really drive performance in our health system.

I’ll give you one more. There’s a company called Trackonomy that does asset tracking for other industries. I had published a piece on the Health Affairs blog about labor productivity which found that nurses waste something like 22 percent of their time hunting for supplies, because nobody managed the last 10 feet of supply chain. RFID has some roles but it doesn’t have as big of a range, and it’s kind of expensive

This technology is literally like putting a piece of duct tape on any device you want to monitor. There’s another really inexpensive piece of tape that’s a reader that enables you to monitor any device on a dashboard. We’ve deployed that to monitor devices and save nursing labor time. It’s a very cool innovation; imagine if you can grow nursing productivity by 22 percent by saving them hunting for supplies. The impact is enormous.

 

Gamble:  Absolutely. A lot of cool things are happening, and it seems like the technology is being leveraged in these innovative ways, without putting more on clinicians.

Pronovost:  I think that’s the difference in what we’re doing here. Too often, technology is viewed as a shiny object that’s looking for a problem to solve. I get five emails day that say ‘I have this widget for you’ — that’s great, but what problem are we solving? Where’s the value? And so we started with the defect in value; we’re losing productivity because nurses are hunting for supplies, and so we looked for the best technology to solve that. It’s a very different approach to innovation.

 

Gamble:  Right. I’ve read about some of the results UH has already achieved in getting more patients being referred to in-network skilled nursing facilities and reducing length of stay. Is it important to emphasize that it’s not just about dollar savings, but other components as well?

Pronovost:  That’s exactly right. We believe that we have to measure all the components of value. Is care quality is going up? Is patient experience going up while cost is coming down? What’s so exciting about the work we’re doing is most people estimate that 30 percent of healthcare spend is waste — our article suggested that about 1.3 trillion, which is about 30 percent of the trillions we spend on healthcare. In one year, we were able to reduce healthcare spend by about 9 percent, and our framework is probably 20 percent deployed. We’re hopeful that as we deploy the rest of it, we can get to that 30 percent reduction in waste, which would be truly transformative. It’s hard to tell what role Covid played, but our 2020 spend appeared to be down another 9 percent. It’s pretty exciting.

 

Gamble:  How much does digital health play into all of this? Certainly we’ve seen huge spikes during Covid, but it seems like there’s a lot of potential for long-term benefits.

Pronovost:  I completely agree. I think there are tremendous opportunities in people having more access to care through televisits.  There’s enormous potential for joint specialists and primary care with telehealth, because one of the main reasons for readmissions with chronic disease is the specialist and the primary care doctor almost never talk; literally there’s no communication. With telehealth, it can be done, and so I think you can easily arrange that. There’s just enormous opportunity for us to leverage technology.

Our home monitoring and hospital-at-home programs are exploding. We monitor about 1,600 patients through home monitoring, and we’re constantly adding more services so you can give medicine and get physical therapy at home. We can send a mobile van to do labs or x-rays. You can literally create a hospital at home for probably 10 times less money than it takes do it in a hospital, and you’re in the comfort of your own bed. You’re eating your own food, you’re surrounded by your own loved ones. It’s just so much better.

 

Centers of Excellence

The other piece we’re working on is creating centers of excellence around procedural defects in value. For example, many procedures could be done in ambulatory rather than in the hospital, or they’re not appropriate procedures. There are pretty good data which suggest that 25 to 30 percent aren’t needed if clinicians use objective criteria to determine who really needs it. But those haven’t been broadly applied, so we’re developing and applying those and then making sure that the hospital that does it or the ambulatory surgery center and the surgeon meet volume thresholds and have standard checklists for how to do it because too many patients have procedures done by someone who’s done just one or two in the last year. We know from the relationship between how many procedures are done and the outcomes that it’s almost linear. The more you do, the better off you’re going to be. These are just enormous ways of driving value.

 

Gamble:  It’s really interesting. My last question is about culture — I would imagine so much of this has to revolve though around building the right culture and having that willingness to question whether things can be done better.

Pronovost:  Completely agree, and I’ll end with this. When I think about the values that are most necessary to drive these types of improvements, there are three simple values. I am humble, I am curious, and I’m compassionate. And without those, you’re never going to make progress. Because if you’re arrogant and think you’re doing everything well, you’re never going to look at whether things could be better. If you’re not curious to say well, where can I go find a good idea? You won’t find them. Trackonomy is not even in healthcare; we were the first one to deploy it in this space. We took a risk and deployed it

Finally, it’s having compassion — both for our patients and our colleagues — that many of these things aren’t going to work, and that’s okay. We’re going to learn fast, and then we’ll move on and find something else that does.