The Center for Data Innovation spoke with Dr. Joshua Sharfstein about efforts to use data to improve health care in Maryland. Dr. Sharfstein was appointed by appointed by Governor Martin O’Malley as Secretary of the Maryland’s Department of Health and Mental Hygiene in 2011.
Daniel Castro: What do you want Maryland’s health system to look like in 10 years, and how can data help make it happen?
Joshua Sharfstein: Ten years from now, I hope that we’re doing even more to keep people healthy, rather than waiting to care for them until they’re already seriously ill. Though we’ve made some progress in recent years, our system of care is still too skewed towards taking care of patients after serious complications have occurred. We can provide incredible care for a stroke, but many patients still don’t receive basic care to keep their blood pressure under control and prevent strokes from happening. Shifting incentives to reward improvements in population health is a necessary step to encourage more balance. And data makes it happen. The keys will be improving the way we collect data, using analytics to unlock the potential of that data, and using mapping functions to connect health care to public health. This will enable us to harness data to make better public health decisions and address geographic patterns of poor health through creative and local efforts. We’re starting to see progress, and data is a core element of this success.
Castro: Why do you think Western Maryland Regional Medical Center was able to innovate and better integrate data into its operations so quickly?
Sharfstein: Western Maryland Regional Medical Center is one of 10 hospitals in Maryland that has been funded through a global budget for three years. This type of funding approach is profoundly different than the traditional fee-for-service arrangement. As Governor O’Malley likes to say, “we should get away from paying hospitals like they are hotels, by the number of beds they have filled.” Unlike most other hospitals in the nation, Western Maryland Regional Medical Center benefits financially when it admits fewer patients, so long as key quality and access standards are met. So the hospital has had both the incentive and the flexibility to innovate and use data and unusual partnerships to achieve better outcomes at lower overall cost. Of course, it also helps that the hospital has had terrific leadership to manage this transition.
Castro: What were some of the challenges to implementing this project, whether legal, cultural, or technical?
Sharfstein: There are significant legal issues involved with all-payer approaches to health care delivery, such as Maryland’s hospital rate setting system. The system hinges, in part, on Medicare’s willingness to pay the same rates as all the other payers (Medicaid, private insurance, etc.) in our state. We have the benefit not only of state law going back 40 years, but also of a provision in the Social Security Act that supports Medicare participation in our system. At the same time, however, this legal structure would crumble if the system didn’t work—if we weren’t able successfully to control costs. We now see other states bringing insurance carriers and public programs together for all-payer initiatives, based on common interest. It’s important to have legal support for this kind of coordination.
Cultural barriers require leadership to overcome. In talking to the CEO of Western Maryland Regional Medical Center, Barry Ronan, one appreciates the magnitude of the shift required to move the staff from traditional hospital care to more of a prevention focus. He even joked with me that to support the shift he considered posting signs that say “Thank you for coming to the hospital. We hope to never see you again.”
Technically, having access to the right data makes it possible for our rate-setting agency to design innovative payment approaches in urban and suburban areas where hospitals are close to each other. And from the health system’s perspective, the right data makes many creative efforts to achieve better outcomes and lower cost possible.
Castro: Data sharing, especially across organizations and jurisdictions, is an issue many states have struggled with. What are some of the ways Maryland is making sure health data flows smoothly?
Sharfstein: Maryland’s hospital payment system has a history of making data available, so patterns of care can be understood and explored by hospitals, payers, and others. The new Health Information Exchange (HIE) is a huge leap forward for connectivity—it allows physicians across our system to access clinical data.
For example, thousands of times a day, doctors check to see whether a patient has had previous admissions, scans, or lab results—so as not to duplicate tests and to better understand the patient’s history. Thousands of times a day, when a patient is admitted to a hospital, the patient’s primary care physician receives an immediate and secure email notification. This allows the primary care doctor to reach out and participate in the patient’s care and transition back to the community.
Our HIE is overseen by the Chesapeake Regional Information System for our Patients, otherwise known as CRISP. Every hospital and the great majority of labs and radiology facilities participate. In Maryland, CRISP is a verb, as in “Have you crisped the patient yet?”, meaning have you checked for lab, x-ray, and hospital data from other sites for the patient in your care? Ensuring that health care providers have robust access to this data is making a huge difference in terms of our efforts to improve outcomes and control costs.
Castro: Since Maryland’s HIE has been a remarkable success story, what lessons can other states learn from your efforts?
Sharfstein: I’d mention four lessons. First, cooperation to enhance data and connectivity helps the entire system—and patients most of all. Second, having the right incentives in place encourages use of a HIE. For example, because of incentives to reduce unnecessary readmissions, hospitals asked for and now receive real-time reports on readmissions of their patients across the state. Third, the health information exchange is a common platform that can be extended into many different areas. For example, we used CRISP to create an integrated provider directory for all of our health plans in the individual market and Medicaid managed care plans. So a Marylander can enter a zip code, a health plan, and rheumatology and find the nearest in-network care for rheumatoid arthritis. (To try this out, visit: http://providersearch.crisphealth.org)
Fourth, and finally, state leadership is needed to set a vision and bring it to reality. From the beginning of his administration, Governor Martin O’Malley set a goal of creating the best HIE and he worked tirelessly with the health care system, legislators, and state officials to achieve it.