When David Kaelber took on the role of MetroHealth System’s first CMIO, he believed that if he could identify one or two issues and solve them, he could help transform care across the organization. What he learned, however, is that healthcare is far more complex than that. “There is no one thing that’s going to change healthcare,” he said during an interview with Kate Gamble, Managing Editor at healthsystemCIO.com. However, “if you do a whole bunch of things well and intelligently, you’re going to move the needle in a way that was impossible to do without health IT.”
At MetroHealth, his team has led several initiatives to help improve care delivery, care quality, and clinician efficiency, whether it’s through medication adherence flags, electronic support for adverse event reporting, or sepsis prediction tools. It’s all part of the overarching goal of getting technology to work for the healthcare system, said Kaelber, who strongly believes “IT’s value is in being a strategic partner.”
During the discussion, he talked about his evolving strategy as CMIO; the critical role social determinants can play in shaping the health of the community — if leveraged properly; the enormous value he gleans from having regular meetings with stakeholders and listening to their concerns; and why imitation is a good thing, particularly now.
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- As a CMIO and practicing physician, Kaelber’s core objective is “to get technology to work for the healthcare system.” It starts by identifying the key constituencies, then determining how technology can make an impact.
- Everything we do is “based on a technology framework. We would not be doing as well as we are in value-based care without the informatics or health IT foundation.”
- By utilizing medication adherence flags, clinicians can access information about whether a patient is taking (or even has filled) a medication, which can “change the whole tenor of the conversation.”
- Contrary to widespread belief, there aren’t one or two things that can transform healthcare. Instead, “if you do a whole bunch of things well and intelligently, you’re going to move the needed.”
- One of the biggest problems technology can help solve? Helping patients get routine care such as screenings, Kaelber said.
Q&A with David Kaelber, MD, CMIO, The Metro Health
Gamble: To start, can you give a very high-level overview of MetroHealth just in terms of where you are and number of hospitals, things like that.
Kaelber: The MetroHealth system is an integrated healthcare delivery network in Northeast Ohio. We pride ourselves on our ability to take care of people regardless of their ability to pay, and so we consider ourselves a safety net or essential hospital, which is a very practical matter. It means about three-quarters of our patients are either Medicare, Medicaid, or self-pay, and only about a quarter are commercially insured.
In terms of our geographic footprint and our patient footprint, we’re one large academic medical center affiliated with Case Western Reserve University in Cleveland, and we have two smaller hospitals. We have a couple dozen outpatient clinics throughout Northeast Ohio, and four emergency departments.
We do a lot of special care; school health is a big component, along with correctional health and foster care health. In terms of some of our big sort of numbers, we have about 325,000 sort of unique patients that we would take care of on a yearly basis, probably on the order of about something like one-and-a-quarter million visits throughout our ambulatory network, about 125,000 ED visits per year, about 25,000 inpatient visits per year or hospitalizations.
Gamble: And you’ve been with the organization for a while?
Kaelber: Yes. I actually started as a medical student in 1999. I did my residency here in internal medicine pediatrics. Then I went away to do a fellowship in clinical informatics, and then I’ve been back as MetroHealth’s chief medical informatics officer since 2008.
Gamble: So you’re very familiar with the organization. What would you say are your core objective as CMIO?
Kaelber: To me, it’s to get technology to work for the healthcare system. That’s the one-million-feet perspective. Let’s get a bit more granular. First of all, who are the biggest constituents of the healthcare system? The answer is patients. Epic’s CEO gave a talk seven or eight years ago and asked, ‘What’s your biggest constituency as a healthcare system?’ Most people were thinking physicians or nurses, but patients are the biggest users of your EHR if you’re doing this right. At MetroHealth, about 70 percent of our 325,000 patients are using the personal health record. We only have about 8,700 employees, and so, whether you’re talking about nurses, physicians or students, there are only hundreds or thousands of them, compared to hundreds of thousands of patients. And so, we need to think about how we get technology working to help all the different users.
It’s also thinking about all of the different domains. We’re trying to increase revenue, improve quality, and help with efficiency and patient experience. There are all sorts of different users and categories where technology should have a play.
For me, I’m at the behest of the system’s priorities. The way I think about it, the EHR is like the nervous system of the healthcare system. With everything that our board or CEO wants us to do better, there’s probably a role for the CMIO and for my team in doing that. For some initiatives that’s not the case, but in general, there are all sorts of things we’re trying to do that have a technology underpinning.
Gamble: That makes a lot of sense. Can you get into some of the specifics in terms of what you’re doing?
Kaelber: To me, that has to do with the vision of the healthcare system and then piggybacking on top of that. Like many other systems (and maybe a little bit more than some), we are running toward value-based care. But we don’t feel like many of the payers are moving quickly enough.
As an example, we were one of the first Epic sites to become a direct contracting entity with CMS. What that means is we’re basically 100 percent at risk with CMS. We’ve been doing this for a while with the Medicare Shared Savings Program, so we know that we just provide extremely high value, so high-quality low-cost care relatively speaking, but we wanted to get as much of the financial incentives of doing that as possible, but that is all based on a technology framework. The way I describe it is we would not be doing as well as we are in value-based care without the informatics foundation or the health IT foundation. But you want to think carefully about that analogy because you don’t want to live in a house if there’s only a foundation; on the other hand, you probably don’t want to live in another part of the house if it doesn’t have a good foundation.
Technology empowerment: SDoH, virtual care
As far as some of the other areas where we’re technology enabled or empowered, we’re doing a lot with identifying and trying to address social determinants of health. It’s a hot topic in healthcare, and we think, because we’re 75 percent Medicare, Medicaid, or self-pay, that social determinants of health probably affect our patient populations a little bit more than other populations.
I’d be remiss if I didn’t say something about the pandemic. To me the pandemic has all been about trying to virtualize care more. Obviously there’s a huge technology part in that.
And then there are things on the backend in normal day-to-day activities, like how can the informatics team make processes run smoother or run easier. I’ll give you an example. As health information exchange becomes more and more of a thing, it sounds great on the surface, but you really have to grease the wheels with some intelligent things.
Leveraging technology to “do things differently”
For a while, we’ve been getting fill information about patients through other healthcare systems, through pharmacies, through payers into our electronic health record. This is important because it’s estimated that only about 60 to 70 percent of prescriptions are filled by a patient. Obviously, if they’re not filled, then they’re not taken. And so, if the doctor had some insight into what was happening, they could really do things differently.
Medication Adherence flag
Here’s an example from my practice. A patient came with high blood pressure; he was already on a blood pressure medicine, and so the nurse said to me, ‘he was just here for a blood pressure check. I think we need to add a second medication.’ We had just turned on a medication adherence flag in our Epic EHR that made it easy to see the patient’s compliance with that medication. I hovered over it and saw that the patient’s adherence with this prescription was only 23 percent. And so, instead of adding another medication, we should really try to talk to the patient. ‘It doesn’t really seem like you’re taking the medicine we already prescribed. Did you not know we prescribed it? Did you run out and not know where to get it? Were you having side effects?’ It changes the whole tenor of the conversation when we realize it’s not that the medicine isn’t working; it’s that the patient isn’t taking the medication. That’s just an example of how we can leverage all of this external information that we’re starting to get through health information exchange, and bring it to the point of care to make a meaningful impact on the care that we’re delivering.
Queries & auto-reconciling
Another one we spent a lot of time on is Covid tests and vaccines. We know that a lot of our patients might not necessarily get that testing or that vaccine within our healthcare system. They might go to the CVS, Walgreens, Rite Aid, or whatever. We spend a lot of time regularly querying all these other systems and then doing auto-reconciling. What many systems do is periodically query another system and then put that outside information behind a glass door. If someone looks at the information and wants to bring it into your system, great. Bring it in.
The problem is that with COVID, we don’t want to rely on episodic things. If someone had a COVID positive test somewhere else, we want to know about it the instant they hit the door. We don’t want to wait for someone to do or don’t do something and they just infected or exposed a bunch of our staff or patients before we knew they had the positive test.
“Healthcare is really complicated”
Gamble: Having this type of information when it’s needed at the point of care is a concept we’ve heard about for so long; to see it coming to fruition must be incredibly satisfying for you as a physician.
Kaelber: Yes. It’s great. To me, the challenge is that healthcare is really complicated, whether you’re a patient or physician. Everybody’s wondering, ‘If we could just do this one thing, that would be helped so much.’ And honestly, the first several years of CMIO, I really felt that if I could just find those one or two things, I was going to transform healthcare for the MetroHealth System.’ One of the lessons I’ve learned over the last decade is there is no one thing or even two or three things. But if you do a whole bunch of things well and a whole bunch of things intelligently, you’re going to move the needle in a way that literally was impossible to do without health IT. It’s not just one or two things, it’s a whole ecosystem effect.
A lot of the things we do have like single digit or low double-digit percentage impacts. Nothing gets you to orders of magnitude improvement in things, and that’s okay. But I think a lot of times people don’t appreciate that because in the abstract they think that the impact of a health IT intervention is going to be much greater than it actually ends up being.
Exploiting health IT to improve health
Gamble: Really interesting. One thing I really want to talk about is the concept of exploiting health IT to improve health and making sure you have the numbers and backing to support it. How is that weaved into your strategy?
Kaelber: We live that. We were actually the first public or safety net healthcare system to ever win a Davis award with Epic. We did about 17 or 18 different case studies that actually show data on every single area where we’re literally able to improve health.
To give you some of the bigger buckets, I’m a primary care provider, internist, and pediatrician, and so one thing that’s very important to me is just getting routine care done; preventative screenings for evidence-based care that just doesn’t get done 100 percent of the time. And so, we’ve set it up so that every health maintenance reminder — things like, ‘get your colorectal cancer screening’ or ‘get your mammogram — are not only showing to doctors at the point of care, but they’re also showing to patients through the personal health record. In addition, some type of automated text message, phone call, or automated My Chart reminder is sent out to encourage people to do these things that are extremely evidence-based and recommended. We’ve seen that these measures improve the rate of getting these things done.
Number needed to treat
Another concept we’re focused on is number needed to message. It’s similar to number to treat. One example of that is if someone has high cholesterol, I put them on a cholesterol-lowering medication. Why? To lower cholesterol, yes, but the reason I’m concerned about your cholesterol is because I know if you have higher cholesterol, you’re more likely to get a heart attack and you’re more likely to get a stroke. The question is how many people who have high cholesterol do I need to put on a cholesterol-lowering medication to save one heart attack or one stroke? That’s the number needed to treat. In most cases, the number needed to treat is probably more than a hundred (or several hundred, in fact). The idea is you have to put something like 150 people on a cholesterol-lowering medicine to just save one heart attack or stroke over the next decade.
Number needed to message
In the number needed to message category, we’ve seen that you usually have to message somewhere between three and six people to get one person to do something. It also depends on your perspective. For example, let’s say 50 percent of people get the mammogram when they’re supposed to, and so you message the other 50 percent who didn’t get the mammogram, and 1 in 5 of those five of those acts differently based on the message. That only means 10 percent of that 50 percent is actually going to get the mammogram, and so your mammography screening rate will increase from 50 to 60 percent. This was a simple intervention, and it caused you to get 10 percent more of your population to get their mammogram done.
Two Livers Saved
Another example is a study we published about a year ago called, Two Livers Saved. Hepatitis C screenings are recommended for everybody now. We did normal care where we had the alert to the doctor and the patient, versus advanced care, where we pre-ordered the screening test for patients and said, ‘This is what hepatitis C screening is. You don’t even need to talk to your doctor. We’ve already ordered it; all you have to do is go to one of our conveniently located labs and you can get your test done.’ It doubled the rate of hepatitis C screening; and the reason I called the “two livers saved case” is because we identified two people as positive for hepatitis C who otherwise wouldn’t have known about it. We now have them in treatment.
Electronic support for vaccine adverse event reporting
Kaelber: There’s been a lot of concern about Covid-19 vaccine side effects. If you’ve been vaccinated, you have the opportunity to download an app and you could report any side effects to the CDC. The problem is that it relies on a patient or a doctor to do extra work to identify and report a side effect. We know that in those models, side effects are very underreported. Through grants we’ve received over the years, we’ve developed electronic support for vaccine adverse event reporting where we have a brain that’s continuously mining the EHR to say things like, ‘David Kaelber got his Covid-19 vaccine three days ago. Now he’s in our emergency department with vomiting and diarrhea.’ The doctor he’s seeing doesn’t know that he got the Covid-19 vaccine. Let’s send an alert or a message to identify people who might be at risk for a vaccine adverse event. And if that team agrees, all they have to do is click ‘submit’ and automatically send that information to the CDC. And when we look at this in other vaccines, it increases event reporting to the CDC by 30-fold.
Gamble: Right. These examples show that the easier it is to go through these steps, the better participation you’re going to get. It’s a concept that may seem basic, but there’s so much required to get to that level.
Kaelber: Yes. We have tons of examples. In some of our infection control examples, we’ve saved lives because we’re able to standardize care more so that the chance that somebody gets a hospital-acquired infection is decreased. When we look at what our rates before and after an intervention, we see that they are improving.