How ‘radical transparency’ can transform patients’ health

In 2011, New York state cardiologists were trying to do the right thing for their patients, but they weren’t always successful, said Dr. Nirav Shah, the former health commissioner of New York State.

In fact, about a quarter of percutaneous coronary interventions, a procedure that uses a balloon to unclog a heart artery, were being done inappropriately, according to state health department data. If a patient doesn’t require that procedure, it can lead to bleeding, infections and even death.  

“When we saw that, we were appalled,” Shah said in this week’s Health Matters webinar, organized by the Center for Health Journalism.

Shah saw transparency as the answer. Despite some protests from the medical community, the department released the data, first to physicians so they could gauge their own performance, and, eventually, to the public.

In just 18 months, the rate of inappropriately interventions dropped to 8 percent, an improvement Shah credits to the simple act of releasing data.

“It changed culture,” he said. “One of the hardest things to do in healthcare and in medicine is to change physician culture.”

Even gradually increasing transparency among peers can drive improvements across a system, said Shah, now the senior vice president and chief operating officer for clinical operations for Kaiser Permanente’s Southern California region. Shah was joined by ProPublica journalist Marshall Allen, one of the creators of the Surgeon Scorecard, which has published the complication rate for about 17,000 surgeons who perform eight common elective procedures.

While health care’s transparency movement has received criticism for not achieving its promises, both speakers insisted more widely available data is the path to better patient care — even if early efforts are imperfect.

Transparency drives improvements

In his current role at Kaiser, Shah is using transparency to drive improvements throughout the health system. He pointed to hip replacement surgery, which typically involves a three- to five-day hospital stay.

At Kaiser’s Downey Medical Center, though, up to half of hip replacement patients can go home the same day, Shah said.

Now, before a hip replacement surgery, a team visits a patient’s home, educating them and making sure their home is set up for their recovery. Surgeons schedule hip replacements first thing in the morning. Physical therapists are waiting at their home for their first appointment, a doctor calls them at home that night, and the nurse arrives the next morning. Patients have their follow-up appointment the following morning at the doctor’s outpatient office.

As a result, the hospital-acquired infection rate drops dramatically and patients are more satisfied with their overall experience, he said.

The approach only works if everyone on the team is completely transparent about their role and care.

“How do you actually blow up a model?” he said. “You become radically transparent about every step of the process to everyone else on the team.”

Kaiser used the same open approach in treating cancer, reducing the number of treatment pathways from an unwieldy 2,000 to a more manageable 400. They also used data to determine the average age of breast cancer patients they were treating was 72, an age at which patients are more likely to experience a life-threatening infection. That allowed doctors to “pre-treat every woman they treated” for that potential infection.

“Doctors always want to do the right thing but they need actionable data at the point of care,” Shah said. “Peer pressure can drive behavior change and ultimately lead to culture change in a short amount of time.”

Scoring surgeons and sharing the results

While Shah mostly highlighted the ways in which transparency can drive change internally, among providers and hospitals, journalists can also play a major role in sharing how well providers are performing with the public.

ProPublica, a nonprofit investigative news organization, decided to create its own Surgeon Scorecard after hearing numerous accounts of patient harm.

“The problem is kept secret and the self-policing within the medical industry generally speaking doesn’t work,” reporter Allen said.

Patients often struggle to choose a surgeon since there is very little available data for elective procedures.

Allen described the “enormous challenge” of creating the scorecard, especially since perfect data wasn’t publically available. They used Medicare billing data, which did not include complete clinical records. To account for high-risk patients, they worked with a team of outside experts that included a Harvard biostatistician. (Read more about the methodology here.)

After compiling results, Allen took the data to hospitals and providers around the country to crosscheck the data and to report out the real-life stories behind the numbers. They also engaged the public through a “Patient Safety” Facebook page, and questionnaires. With each step, they leaned on experts in the field, Allen said.

The findings were often surprising.  

“We knew we’d find variation, but what surprised us was how much variation we found within the same hospitals,” he said.

The ProPublica team received positive feedback from surgeons who said they were pleased the public could finally see their good results. Other physicians and researchers lambasted their methodology, and said the news organization shouldn’t have acted “as judge and jury.”

With such critiques in mind, ProPublica is working on a 2.0 version of the scorecard, which will add clarify language and use more precise risk adjustment to reflect surgeons who treat more underserved patients — one of the criticisms of the first version of the scorecard.

“This is a starting point for transparency, not the end,” Allen said. “… Transparency really spurs providers to improve.”

Shah credited efforts such as ProPublica’s for creating a signal amid the noise of a host of different quality measures in health care. People might react strongly to the initial weak signal, without realizing it’s just the first step along a long pathway, he said. “You don’t have perfect signal to noise ratio, but at least there’s a signal when none existed. You start somewhere.”’

In the Q&A, speakers discussed the future of transparency initiatives, which Allen said will likely be driven by the payers and medical community, since patients still have “so little power and knowledge.”

That’s changing, though, Shah said. Historically, medicine has taken the form of a hierarchy, with the surgeons at the top and patients at the bottom.

“Transparency empowers everyone to take charge of their care in a way few other things do,” he said. “The power of radical transparency will drive behavior.”

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Watch the full webinar here: