SALT LAKE CITY — Doctors in this mountain city are chasing answers that could transform medicine nationwide.
Their quest is unfolding not in a lab or an operating room, but on the screen of an iPad that asks patients a straightforward question: What do you want from your care?
A father with a bad knee might answer that he wants to dance at his daughter’s wedding. A woman with back pain might simply want to regain focus at work. It sounds so simple. But it’s a radical step in a health care system that traditionally defines success by technical benchmarks and government quality metrics — not by the patient’s own goals.
“That’s the holy grail for me,” said Dr. Vivian Lee, chief executive of the University of Utah Health Care system, a network of four hospitals, a cancer institute, and 10 neighborhood clinics. “Now we’re really going to start to define value in terms that matter to the patients.”
Lee has revolution on her mind.
During the last decade, her health system has repeatedly challenged the conventions of medical care and upended the relationships between doctors and patients.
In late 2012, it became the first hospital system in the country to post unedited patient reviews of its physicians online. Right there, on the official hospital website, patients could, and did, accuse specific doctors of being rude, rushed, or always running late — and rank them on a five-star scale. (They also offered plenty of compliments.)
Two years later, Lee’s staff built a database the size of multiple football fields to track the health care system’s costs to the penny, another unheard-of step in an industry where most hospitals have only a vague notion of how much they actually spend to, say, replace a knee, or deliver a baby, or evaluate a patient rushed in with chest pains.
But Lee says this next step — giving patients the power to determine whether their care has been successful — is the one that matters most. It is also a massive undertaking.
Physicians across the sprawling health care system are now collecting data from patients about how their illnesses affect their daily lives. The reports are instantly uploaded into electronic medical records, so everyone working with the patient can discuss those goals and lay out a plan to achieve them. Whether this effort, known as patient reported outcomes, will significantly improve performance is an open question.
Talking ‘cow tipping’ at Harvard
But Lee is not the type of person you’d want to bet against.
She grew up as one of the few Asian kids in Norman, Okla., where her parents both worked as university professors. Lee said she was not overly ambitious, and did not take Advanced Placement classes. She got into Harvard anyway, because she was gifted in math and a great test taker.
When students in Cambridge asked her about Oklahoma, she indulged them with stories about cow-tipping that they actually believed.
Lee earned a Rhodes Scholarship at Oxford, completed medical school at Harvard, and was a rare female surgical resident at Duke. In her first days in Durham, N.C., she vividly remembers an encounter with a woman handing out uniforms in the hospital laundry.
“She gave me this white, triangle skirt — heavily starched,” Lee recalled. “It would have stood on its own. I said, ‘Can I just get some pants?’ And she said, ‘Honey, we don’t have any girl’s pants. You want those, you bring yourself over to the mall.’”
Lee went and bought herself some pants.
She opted not to pursue surgery, switching to radiology before finding her way into an administrative position overseeing research at New York University’s Langone Medical Center.
In July of 2011, Lee took the top job at University of Utah, where she oversees a $3.3 billion annual budget. In addition to the hospitals and clinics, the system includes an insurance plan and five colleges within the university, including the school of medicine.
A slight, energetic woman with a fringe of bangs across her forehead, Lee, 50, is warm and optimistic. She is a rare hospital administrator who easily breaks away from health care jargon to tell an amusing story. When she wants to emphasize a point, she lowers her glasses and looks at a person squarely, as if to chase away any doubts.
Her health system’s flagship hospital in Salt Lake City is a mix of the old and new. A gleaming facade leads into a large atrium where a pianist plays in the corner, next to one of Utah’s busiest Starbucks. Arresting views of the mountains distract from the bustle of cars and ambulances.
Lee’s days there are busy, but time at home is even busier. She and her husband have four daughters, ages 8, 10, 12, and 14.
To clear the way for quality family time, she organizes like crazy. Lee cooks lasagna and curry dishes in bulk. She stocks a “birthday present closet” with books, glow-in-the-dark watches, and rolls and rolls of stickers that her girls can give as gifts when they’re invited to parties. There is no TV in the house, so time together is spent face-to-face.
“I can’t guarantee that their socks match every day or that their rooms are neatly organized,” Lee said of her daughters. “I just try to spend time with them and have fun.”
Lee works 12- to 14-hour days that are typically jam-packed with meetings and begin and end with a flurry of urgent emails. If she has time at night, she reads — about whatever grabs her attention. One of her recent selections was “Drive,” by Daniel H. Pink, which focuses on the art of motivating people. It asserts that certain workers, like those in health care, are intrinsically motivated and don’t need aggressive, top-down management.
It is something Lee believes deeply. Her management style is to set goals and let her employees figure out how to reach them. And she embraces ideas from her staff, too.
At one of her hospitals, for instance, doctors hit upon the idea of building a day care for the maternity ward, so big siblings would have a place to play while the parents focused on their newborn.
While describing it, Lee hopped up from her office chair and sketched the rough outline of the day care. “The guys who run the clinic just came in one weekend, took about this much space, and drywalled it themselves,” she said. “I just love that. They came up with it completely by themselves.”
Message to doctors: Get thicker skin
So far, that management philosophy is working.
Last month, University of Utah Health Care was named No. 1 for quality in a prestigious annual ranking of academic medical centers, beating out Mayo Clinic in Minnesota, Cedars-Sinai in California, and several other top institutions.
Lee’s work has attracted gobs of attention, too. Harvard professors have visited to study the new cost accounting practices, and so has Sylvia Mathews Burwell, the Department of Health and Human Services secretary. Hospitals nationwide have begun replicating her methods to improve doctor performance and patient satisfaction.
Dr. Thomas Lee, chief medical officer for Press Ganey, which administers patient surveys for University of Utah and other hospitals, still remembers his reaction when Vivian Lee told him she was going to start posting unedited patient reviews of doctors: “I said, “You are (expletive) kidding me?”
“I couldn’t believe she was doing it, but at the same time I realized how great it was,” said Thomas Lee, who is not related to Vivian Lee.
“We’re really going to start to define value in terms that matter to the patients.”
Dr. Vivian Lee, University of Utah Health Care
Within a year, Piedmont Healthcare in Atlanta and Wake Forest Baptist in North Carolina were also posting reviews. Others soon followed, including Geisinger Health System in Pennsylvania, Brigham and Women’s in Boston, and Cleveland Clinic.
“We certainly didn’t have this level of transparency before” the University of Utah began posting its reviews, said Dr. Adrienne Boissy, chief of patient experience at Cleveland Clinic. “The idea that transparency can drive behavior change in clinicians, and in a market that didn’t think that way, was compelling.”
Getting the reviews posted online wasn’t easy. Some doctors thought it was bad business and would undermine their reputations.
“I remember my cellphone just burning,” said Chrissy Daniels, University of Utah Health Care’s director of strategic initiatives, who fielded angry calls from physicians. “I felt like crawling under my desk.”
Lee attended a packed staff meeting to listen to complaints. Her response was direct: “We are going to need to get thicker skin.”
Traffic to the University of Utah’s website has jumped more than 127 percent since patient reviews were first posted. And doctors’ national rankings on patient satisfaction surveys have improved.
“Nobody likes to get negative feedback,” said Dr. Eric Volckmann, a bariatric surgeon. But he couldn’t ignore it: When patients complained that he kept them waiting, he tried to improve — or at least explain the delays to them. “It makes you look hard at your practices and think how you can do things better,” he said.
A quest to track costs, to the penny
The patient reviews grabbed plenty of national attention. But Lee said the decision to post them was the prelude to a more fundamental change. She wanted to shake up the relationship between the hospital’s doctors and patients, and make the cost of care a much bigger part of the equation.
The problem in Utah — and at hospitals nationwide — was that no one knew how much it actually cost to deliver care to patients. Most hospitals calculate average per-patient costs that give them a rough idea of how much they are spending. But such data don’t tell you anything about what is driving the costs, where the waste is, or how to eliminate it without undermining the quality of care.
Lee called a meeting in 2012 to discuss how to track costs through University of Utah’s hospitals. The plan tumbled into place quickly: She rented some office space, put up a cube farm, and assembled a team of the hospital’s top accountants and data managers.
She separated them from their day jobs and gave them six months to figure it out. On late nights, she bought them pizza.
Lee kept a close eye on the project — and everyone in the health system knew it. When the data team wanted answers from medical staff, they got them.
“We could just say, ‘We need you up at research park’ and they would be there,” said Charlton Park, chief of analytics at the University of Utah. “The whole institution knew about the project and that Dr. Lee was sponsoring it. … A roadblock was not something anybody wanted to be.”
The resulting database was enormous: 200 million rows of information, each one as wide as football field.
It documented the cost of every interaction with a patient: supplies used, medication dispensed, doctors consulted. The team determined, for instance, that a minute in the emergency room costs the health care system 82 cents. A minute in the intensive care unit costs $1.43.
After about four months, Lee took the team’s work to a conference sponsored by the Robert Wood Johnson Foundation. She was not a featured speaker; she just had a slot on a small panel to present her new data tool.
But her talk stirred so much buzz, the conversation soon took over not just her panel’s room but the large conference room next to it. “All these senior executives were saying, ‘Wow, I can’t believe you guys did that,’” Lee said. Many said they had tried to do the same thing but were told it was impossible.
“It was really embarrassing,” she said. “There was just so much unexpected attention.”
Weeding out wasted expense
Once built, the database could be used to see how much different doctors spent to care for similar patients.
Practices started to change.
Surgeons who perform laparoscopic hernia repair, for instance, noticed a wide variation in costs, from $700 to $1,800. A deeper look revealed that some surgeons were using a $400 balloon dilator that didn’t appear to be associated with improved outcomes — a discovery that could end up saving the system hundreds of thousands a year.
Orthopedic surgeons, meanwhile, noted that getting patients out of bed after joint replacement surgery could make a huge difference. That led to a staffing change to ensure that physical therapists, who typically worked 8 a.m. to 5 p.m., would be available for patients who got surgeries later in the day. They also started discharging a greater percentage of patients to their homes, instead of skilled nursing facilities, producing a drop in 30-day readmission rates.
The hospital also developed a new protocol for treating sepsis. Physicians began looking at the data of patients who developed the infection — and saw that they’d been missing some key warning signs.
“That was jaw-dropping,” said Dr. Robert Pendleton, a hospitalist whose job is to prevent such infections.
Physicians developed a composite index to track signs of sepsis and send an automatic alert to the nursing staff when a patient’s score gets to 7 or above on a 1 to 10 scoring system. So far, the hospital has seen a 4 percent reduction in mortality from sepsis and a dramatic improvement in the timeliness of treating patients, from nearly eight hours to under four.
The next step, said Lee, is to bring patients more directly into the conversation about their care — and their expectations. The hospital plans to add that information to its existing data — and overlay it with quality measures designed by its own doctors and the federal government.
Lee calls the resulting metric the “perfect care index,” a tool to measure which targets are met. Did the patient avoid infections? Did she regain mobility? Can she play with her kids?
And once that’s done, the hospital can redesign its care, make it more affordable — and use the proof of its performance to compete with other top providers nationwide. “Then you would have this market force thing that we’re all looking for,” Lee said, “to drive care higher and better.”