Desperate for Data

Ten days ago I returned from Washington DC where I attended the first Care Innovation Summit sponsored by the Center for Medicareand Medicaid Innovation.


I recognize we are living in tough political and economic times.  The national debt, unemployment, partisan conflict, struggling schools, and disenfranchised groups all come to mind when I think of serious political concerns.  But the problems in the healthcare system feed into many of the larger issues our country is facing.  Healthcare as it exists today is destroying American prosperity and the American dream.  With 17.9% of the GDP spent on healthcare, it is imperative that we jail break the health care system at a price we can afford.  We need to change the system so that value is incentivized over volume (i.e. how many patients are seen, how many tests are ordered, etc.) while keeping the patient’s personal experience at the center of all we do.

For such big problems there are obviously no easy answers.  The political gridlock we’ve seen in Washington in recent years contributes to the perception that everyone on Capitol Hill is motivated by personal agendas with little concern for the greater good.  But today I want to show you another side of what’s going on in Washington.  I want to familiarize my readers with the innovators in this country committed to reforming the healthcare delivery system, fixing the SGR, and reforming the way payments are made to reward quality and innovation.

The list of speakers that I had the privilege of listening to is much too extensive to cover here, so I’m choosing to highlight two amazing voices on the healthcare scene that left the strongest impression on me.  The first is Susan Dentzer, the Editor-in-Chief of Health Affairs which is the nation’s leading peer-reviewed journal focused on the intersection of health, health care and health policy in the US and internationally.  Susan used the words of the renowned writer from Stanford’s MBA school, Jim Collins, to talk about how we need a healthcare system that is built to last.1 

America is full of many corporate successes.  This is because our capitalist culture generously rewards true innovation that is successfully implemented.  Financial incentive encourages risk takers with boundless optimism and extraordinary creativity to come up with solutions to some of our toughest problems.  This drive to innovate is rooted in the American spirit.  Susan Dentzer pointed out that we need a partnership between the private and public sectors to come up with the best answers for the healthcare crisis.  By taking this approach we should be able to step away from the in-fighting in Washington because “innovation is not a partisan issue.  It comes in purple, not blue or red.”

The second speaker whose words I want to spread is Atul Gawande, MD, MPH who is a surgeon at the Harvard Medical School as well as a writer of three New York Times bestselling books2,3,4 and a public health researcher. Dr. Gawande contrasted the medical system in the pre-penicillin era5 to today’s much more complex environment.  One hundred years ago healthcare was cheap, but completely ineffective.  Dr. Gawande pointed out that today we have 13,600 unique diagnoses for human diseases, and 6000 different medications we can prescribe or operations we can perform.  Per his count we have 13,600 service lines that we are trying to roll out to every person in every community!

Dr. Gawande astutely concludes that the reason healthcare costs are so out of control is that innovations in delivery systems have not kept pace with the scientific and medical discoveries we can now leverage.  The old system rewarded the cowboys, physicians who could enter a room, take control, and do it all.  But the paradigm of individual clinicians trying to do it all on their own isn’t working.  Instead of cowboys, Dr. Gawande eloquently explained that we now need highly effective pit crews where humility, accountability, and self-discipline are what’s valued.

But how do we know if the pit crew is doing a good job or not?  How can the struggling crews identify the more effective teams and implement their secrets of success?  The answer lies in the ability to capture, analyze and report the DATA!!!  Without data we have no ability to recognize success and failure.  Dr. Gawande pointed out that at the turn of the century the American people were facing a crisis in the ability to produce and deliver enough food to its citizens.  At that point in history 40% of the family budget was going to food costs.  To address this serious problem the government collected data in the form of comparative effectiveness research and created regulations and incentives to encourage farmers to use processes that were proven to work.  The government also created the national weather service, which provided the farmers with important information to protect their crops.  Over the course of 20 years the percentage of the family budget that went towards food dropped from 40% to only 20%.  We need to do this in healthcare today.

The widespread adoption of electronic medical record systems (EMRs) by physicians has us on our way, but simply having a system doesn’t mean it’s being used in a way that provides structured data that can be studied.  CMS is trying to make this possible by demanding that physicians adopt CCHIT (Certified Commision for Health Information Technology) certified EMRs which use HL7 CCD (Health Level 7 Continuity of Care Document) programming to promote the exchange of health information between providers and facilities involved in a patient’s care.  This will lead to a profound reduction in healthcare spending because test results will be accessible, and expensive imaging studies will not need to be repeated.  Having access to the patient’s complete medical history will also help physicians to make accurate diagnoses and appropriate treatment plans.

In the words of Dr. Gawande, analyzing the data available to us today is like driving a car with a speedometer that tells us how fast everyone else on the road was going four years ago – not very helpful!  He pointed out that we know much more about how the crops and cows are doing in our country than the human beings.  We have a big problem in our healthcare system, and it needs to be fixed STAT!  Data is the oxygen for innovation, and right now we’re suffocating.  I feel strongly that patients should have a universal patient identifier (UPI) so that physicians don’t have to rely on having a conscious patient with a good memory and enough medical knowledge to understand what is or isn’t important regarding their past medical history.  I acknowledge that this is a controversial issue, and to see both sides of the story I invite you to read an article in the Wall Street Journal a couple of weeks ago that addresses both sides of the argument.

But I agree with Dr. Gawande that if we can’t access data on patient outcomes, it will be impossible to understand our current baseline.  Without this basic understanding, we will not be able to identify either problems we can fix in the current system, or opportunities to provide better delivery of healthcare to our citizens.  It is difficult if not impossible to set goals for improvement in medical delivery and quality of care without access to relevant and reliable data.  We also need data so that after implementing changes we can assess progress and identify teams who achieve superior outcomes at reasonable costs.

I share Dr. Gawande’s belief that we are fighting a war to preserve the soul of American medicine.  Regardless of political affiliation we all want people to survive and live their lives to their fullest potential.  I came home from Washington imbued with hope that if the citizens, the doctors, the innovators, and the politicians work together to capture the data floating around in our current healthcare system, we can achieve the goals of the three part aim – better health, better care, at reduced costs. 

1Built to Last: Successful Habits of Visionary Companies, James C. Collins, Jerry I. Porras, 1997 A Harper Business Book


2The Checklist Manifesto, Atul Gawande, 2011, Metropolitan Books


3 Better: A Surgeon’s Notes on Performance, Atul Gawande, 2007 Metropolitan Books


4 Complications: A Surgeon’s Notes on an Imperfect Science, Atul Gawande, 2002 Picador


5The Youngest Science: Notes of a Medicine-Watcher, Lewis Thomas, 1983 Penguin Books



About Kara Nance MD

Kara Nance, MD FACP currently works in private practice in Rolling Meadows, IL. Dr. Nance approaches the care of her patients with a very holistic attitude that targets the many factors that contribute to overall wellbeing. She is a mother of 4 young children, and often brings her personal life experiences into play when helping her patients solve problems relating to life balance. In addition to her clinical practice, Dr. Nance is passionate about electronic medical records and the establishment of electronic health exchanges. She consults with local physicians, hospitals, and medical groups about transitioning over to electronic medical records. Kara also participates in advocacy activities relating to primary care. As a Fellow in the American College of Physicians and a member of the ACP's Northern Illinois Council, Dr. Nance frequently travels to Washington to lobby for important issues in health care reform.
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5 Responses to Desperate for Data

  1. Christine Pagliaro says:

    Lots of interesting information here, much of which I can relate to since I have been experiencing the health care system from a very young age and have had to encounter a lot of what you discussed. The main issue that hits home for me is the ongoing history of medical records that I have had to maintain over the past 30 years since all of the information has been piece-mealed between various physicians. As you stated, I have researched my medical issues along the way and luckily understand a lot more than the average person, so I can relay my history in an accurate manner whenever I meet with a new physician. But that is not the case for all, which unfortunately leads to an incomplete treatment plan for many patients as well as duplication of tests.So I think that the implementation of a central computerized database for each patient’s history is great but as you say, it’s just a starting point. It is still only as good as the information entered and people’s use of it. I recently found that X-rays taken within the last couple years were not logged into the central system in one of my doctor’s offices. If I had not recalled that I had more X-rays done, they wouldn’t have gone looking for them and they would have been left out of my history. So, for now, we as patients still need to be very much aware of what is happening with our health and treatment plans. But my hope is that the centralized system will help tie all the different specialists’ information together so that the physicians are able to provide a more homogeneous treatment plan that takes into account all of the patients health issues, rather than just their specialty.Thanks for the thought provoking blog Dr. Nance 🙂

  2. Yes, many thoughtful ideas here. How can the medical delivery system be optimum if the providers don’t have access to reliable and thorough data on the patients. The parallel with the food delivery system in the turn of the previous century was on point – and gives hope that this too can be solved. Thanks for being in there, striving to improve our medical system. How can a people thrive if they are not able to be well? How can they maintain health if the medical providers are handicapped by an antiquated system?

  3. Dana Zielinski says:

    Here, here Sista (I can say that because I’m literally Kara’s sister)!!!I thoroughly enjoyed your blog. You have officially entered into the world I preach day in and day out. Data should be the basis of how we do everything. There are so many examples, daily, where people make critical decisions with nothing but intuition. I’m by no means saying that there isn’t a balance between analysis paralysis and quick decision making, but our government does not hold themselves to the same standards that are expected from Corporate America. A data driven culture takes discipline and patience to establish a foundation for easy data collection, that is "actionable" and meaningful. Establishing the "Key Performance Indicators" is critical to the success of an industry, but once this milestone is accomplished, enhanced processes combined with technologies such as EMR make decision making easy! If we turn over our healthcare capabilities to the government we can we be sure that we will sacrifice any chance to promote an entraprenurial spirit combined with the structure of a disciplined organization required to have measurements in place to demonstrate success. Thank you Kara for introducing concepts to the heathcare industry that are non-negotiable in Corporate America. Why would we give the medical areana a "get out of jail free" card when dealing with such an important asset … Our health!

  4. Nice comments Kara, but I’m going to push back a tad on your analysis of driving down health care cost. Food cost as a % of household began a serious decline when farm subsidies (corn) started in the late 60’s and the "innovative" use of corn as substitute for sugar. Thus began the high use but cheaper cost of all sorts of foods with the added high fructose corn syrup and changing the feed of cattle from grass to corn. Yes, food prices became cheaper but we also saw the rapid rise of obesity in the population and all the cost that in encumbered from the resulting decline in health of the population. Fast food, 20 oz sodas etc have become the American diet. I recommend the Documentary "King Corn" for a great analysis.A good start at bending the health care cost curve will be changing the diets of most Americans. If we eat better we will be healthier and thus lower visits to emergency rooms. You are clearly trying to do that with your work on obesity. I agree 100% with your comments about data. Enjoyed your blog, T

  5. HI Kara,Last week I testified in Washington DC to the Health Subcommittee of the Ways and Means Congressional Committee (Pete Stark ranking member, Wally Herger Chair). Here is a link to my testimony, my 5 minutes starts at 24:30, the HealtTeamWorks pilot proved that front loaded, quality driven Patient Centered Medical Homes (PCMH) produced tremendous reductions in global costs, and improved safety and efficiency at the same time. Wellpoint and Aetna announced in the Wall Street Journal last month that they are going national with PCMH payment model based on their 2 year experience in Colorado (which someone in the Washington DC read, hence my invite to testify) HIT implementation, NCQA level III recognition, Meaningful Use attestation all help, but the best part of the pilot was generating my own data, reporting it to the payers, and then being judged based on my data, not the claims data alone. Also the registry interactions of the pilot allowed me to see how I compared to other practices around Colorado in the same pilot. If my metrics were worse, or better, we could compare work flow innovation storys in an FTC-proof (no price fixing!) manner as competitors, clinicaly integrated, yet on separate EHR’s, to all improve our quality over time.Market place reforms can work, IF primary care is front and center….Sincerely,John L Bender, MD, FAAFP

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