Download 1995Ann Thorac Surg 59:486A Cardiothoracic Information System

A Cardiothoracic Surgery Information System for
the Next Century: Implications for Managed Care
Timothy A. Denton, MD, Aurelio Chaux, MD, and Jack M. Matloff, M D
Department of Cardiothoraeic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
The United States health care system is under tremendous pressure to cut costs while m a i n t a i n i n g quality.
One m e c h a n i s m to reduce costs is managed care--a
system with both risks and benefits for patients, providers, and payors, and one that requires large v o l u m e s of
data to ensure optimal medical and financial decisionmaking. In this review, w e describe the types of information needed by managed care systems, including medical outcome data (satisfaction, survival, quality of life,
and complications) and financial data (costs and longterm resource utilization). From a p r o v i d e r ' s p o i n t of
view, the customers for these data range from i n d i v i d u a l
patients to large self-insured corporations, and w e describe the data required for each potential customer.
Finally, as a concrete example of h o w data can be
collected and analyzed to i m p r o v e a p r o v i d e r ' s competitiveness, w e describe the Cedars-Sinai Medical Center
cardiothoracic surgery database from a managed care
perspective. The concepts presented are generalizable to
other subspecialties, and w i l l become more important in
the increasingly competitive m i l i e u of American health
care.
It is a very sad thing that nowadays
there is so little useless information.
necessary for effective competition in a m a n a g e d care
e n v i r o n m e n t a n d define the customers for w h o m these
data are relevant. In the latter half of this review, we
provide details on the Cedars-Sinai Medical Center cardiothoracic surgery d a t a b a s e - - i t s structure a n d function
and how these data are u s e d to i m p r o v e care a n d
competitiveness. Though this presentation focuses on a
cardiac p r o c e d u r e - r e l a t e d database, we believe these
concepts are sufficiently generic to allow t h e m to be
generalized to other medical specialties.
Oscar Wilde
he medical profession has never b e e n u n d e r greater
p r e s s u r e to change. Because of rising health care
costs, frustrated public a n d private sectors are moving
away from the fee-for-service system t o w a r d m a n a g e d
care [1, 2]. This m o v e is forcing providers to compete with
each other on price while at the same time a t t e m p t i n g to
maintain q u a l i t y - - t h e catch-22 of m a n a g e d care.
Though m a n a g e d health care m a y have multiple definitions [3, 4], generally it is a medical service delivery
process that provides economic incentives for patients to
use specific providers, i m p o s e s a set of utilization and
quality controls on those providers, a n d allows the providers to achieve financial benefits in return for a s s u m i n g
financial risks [5]. Systems of m a n a g e d care usually
contain m a n y t h o u s a n d s of m e m b e r s in o r d e r to diminish
risk. Because of these large numbers, payors who control
t h o u s a n d s of patients have t r e m e n d o u s influence in
establishing prices a n d quality controls. As in any freem a r k e t (capitalistic) system, those who wish to provide
services to the masses m u s t r e s p o n d to the dynamics of
the marketplace. To attract a n d keep patients a n d payors,
providers m u s t couple excellent quality with competitive
pricing. Successful delivery systems will use clinical,
administrative, a n d financial information to their advantage.
In this review, we describe the kinds of information
T
Accepted for publication Oct 21, 1994.
Address reprint requests to Dr Denton, Cedars-Sinai Medical Center,
Room 6215, 8700 BeverlyBlvd, Los Angeles, CA 90048.
© 1995 by The Society of Thoracic Surgeons
(Ann Thorac Surg 1995;59:486-93)
I n f o r m a t i o n : T h e C u r r e n c y o f M a n a g e d Care
C o n s u m e r s a n d payors are d e m a n d i n g outcome data to
use in m a k i n g decisions about health care [6, 7]. The
Health Care Finance A d m i n i s t r a t i o n [8], N e w York State
[9], a n d Pennsylvania [10] were a m o n g the first organizations to p u b l i s h medical outcome data for the general
public on a range of providers. Cardiac surgery has b e e n
a p r i m e subject for study b e c a u s e of its high visibility a n d
high associated costs. T h o u g h d e b a t e still rages r e g a r d ing the data's accuracy a n d the n e e d to adjust for case
mix, such information will continue to be p u b l i s h e d a n d
u s e d b y consumers to m a k e health care decisions [9, 11].
M a n a g e d care is a prime example of a d a t a - d r i v e n
system in which health care decisions are m a d e on the
basis of cost a n d quality information [12-17]. The ability
to p r o v i d e these quality-of-care m e a s u r e s is an advantage to providers who are c o m p e t i n g for m a n a g e d care
contracts.
M a n a g e d care organizations are interested in four
specific types of information: medical outcomes, m e t h o d s
to assess the quality of medical decisions, systems for
c o n t i n u o u s quality i m p r o v e m e n t , a n d financial outcomes.
0003-4975/95/$9.50
0003-4975(94)00875-8
A n n Thorac S u r g
1995;59:486-93
Medical Outcomes
The four important medical outcomes of interest are
survival, complications, quality of life, and patient satisfaction. These outcomes are, to various extents, measures
of the quality of the process of care.
Historically, surgical survival has been a major focus
because it is unambiguous and the data are easily collected. Surgical survival will continue to be an important
measure, but interest is expanding to long-term survival
as a better measure of procedural benefit. The collection
of routine long-term follow-up data by providers demonstrates a commitment to patient care that extends
beyond the perioperative period. This long-term view is
important because many insurers are seeking alternate
methods of payment, such as an "episode of care"--the
entire care of a patient with chest pain, including all
procedures performed and the long-term follow-up care.
Capitation is the extreme example of this financial approach in which a single monthly amount is given to a
provider to care for the patient for the rest of their life. In
this context, there is interest in defining outcomes with a
bottom-line measure--the cost of a day of wellness
[18J--and providers will become more focused on longterm costs.
Postprocedural complications are a measure of quality
of care and have a considerable impact on cost. Postoperative bleeding, infections, arrhythmias, strokes, pleural
effusions, and all other complications increase cost by
increasing the lengths of stay, the rates of readmission,
the number of office visits, and the number and quantity
of medications. Managed care systems are more concerned with the long view--an entire episode of cardiac
care--than they are with, for example, a simple 7-day
admission for a bypass graft procedure. Thus, their
evaluation of delivered services often begins with postoperative complications.
Cardiac procedures are not always done to improve
survival, but also to improve a patient's quality of life.
Quality, rather than longevity, is often the most important consideration; thus, objective, patient-provided
measures of quality of life are slowly being integrated
into routine follow-up care, and will become an important part of outcomes measurement under a managed
care system. Though quality of life can have many
dimensions, the four that are common to most instruments are (1) overall well-being, (2) physical function, (3)
psychologic status, and (4) social and role status. A
multitude of instruments are available that have been
validated and are easy to administer [19-21]. The ability
to report long-term survival and quality-of-life data will
be an advantage to providers of cardiac services because
procedural benefit can then be judged in terms of
periprocedural quality (surgical mortality and complications) and the long-term impact of care (survival and
quality of life).
Patient satisfaction is extremely important in the eyes
of payors [22], and can be measured by prevalidated,
published instruments [23], custom questionnaires, or
group discussions with patients. These methods generate
D E N T O N ET AL
I N F O R M A T I O N FOR M A N A G E D CARE
487
data regarding patients' opinions concerning their care,
administrative procedures, hospital facilities, family support [24], and likelihood of return to the hospital, and also
determine whether the patient would recommend the
facilities to others. Demonstrating high patient satisfaction and improving service where patients are dissatisfied are important parts of managed care. Word of mouth
has often been the best advertisement for medical care,
and managed care organizations anticipate that satisfied
patients will be an important sales force.
Quality of Medical Decision-Making
Quality of care is not only defined by the quality of the
process, but also by the quality of the decision leading to a
particular therapy. The American Heart Association, the
American College of Cardiology [25], and the RAND
Corporation [26] have published appropriateness criteria
for the performance of bypass operations based on consensus. These instruments are used by payors in the
preapproval and utilization management processes, and
managed care organizations often ask what guidelines
are used by providers. The ability to monitor the appropriateness of a procedure is an important differentiating
factor for providers, and demonstrates a commitment to
optimizing the individual patient decision-making process.
Continuous Quality Improvement
Gathering and disseminating data are insufficient by
themselves--one must do something with the data to
bring about an improvement in patient care. Many managed care organizations are requesting evidence that a
provider is continuously improving care. Continuous
quality improvement is a formal process by which data
are collected regarding a particular problem; these data
are then used to make systematic changes in an effort to
improve outcomes, and the outcomes are measured
again to determine if the changes have made an impact
[27-29]. Implementation of a formal continuous quality
improvement program demonstrates a serious commitment by providers to improve the system of care, and will
be viewed favorably by payors.
Financial Outcomes
Because the present health care debate has been driven
primarily by rising costs, providers wishing to be competitive under a managed care system must be costeffective. By having accurate and timely financial information, a provider can relate true costs to reimbursement
and calculate the value of a given service [30-33]. Financial data are necessary to implement financial continuous
quality improvement to contain costs while maintaining
quality [34], and are key to determining the financial
benefits of individual contracts. Because the essence of
managed care is to place the provider at financial risk,
not all managed care contracts are profitable, and providers need to evaluate each contract separately [35]. A
capitated population that contains many high-risk patients with heart disease may lose money if the capitation
rate is set too low.
488
D E N T O N ET AL
I N F O R M A T I O N FOR M A N A G E D CARE
Individual physician profiling [36-38] is becoming
more popular as a mechanism to determine cost-effectiveness and quality of care. Usually physicians are
stratified according to their medical outcomes--mortalities, procedural complications, and patient satisfaction.
But, given monetary constraints, some health care systems are measuring the cost differences a m o n g physicians providing care to similar patients. Physicians whose
patient care costs are low and who achieve good quality
care are an advantage. Those physicians whose costs are
high with no corresponding difference in the quality of
the outcomes in their patients may be identified as a
drain on the m a n a g e d care system. W h e n hospital privileges are tied to such data, this process is termed
economic credentialing.
Who Needs the Information?
Under a m a n a g e d health care system, the decision as to
who will provide the care is made by a variety of entities.
The most obvious are the health insurance corporations
to which patients pay their premiums, and who, in turn,
pay their enrollees" health care costs. Large health insurance corporations are rapidly developing local and
national m a n a g e d care networks, and will always be
important sources of patients. The federal government,
through Medicare, also provides patients to m a n a g e d
care systems [39].
Other, less obvious, players are also emerging as
patient sources [40]. First, corporations are now selfinsuring because of the cost savings involved [41]. A
corporation may hire a health insurance firm to develop
and administer its insurance plan, but the primary decis i o n - m a k e r - w i t h respect to providers--is the corporation. In this case, providers have to satisfy the corporation
first, not necessarily a health insurance company. Large
corporations are developing networks with other corporations so that they can gain negotiating power. These
networks, called business coalitions, serve as a major force
in determining quality standards and the pricing of
health care for their employees. In m a n y ways, they fulfill
the role of the Alliances proposed in Clinton's Health
Security Act of 1993 [42].
Trade unions also play an important role. Individual
members may prefer one provider over another on the
basis of satisfaction and excellence of outcome. Thus, the
union may insist on that particular provider in the next
contract negotiation. Finally, individual patients m a y be
able to decide their choice of plans, and may choose
based on the presence or absence of a particular provider
on a listwthus direct marketing to patients will remain
important.
All of these groups need different types of information
to make their health care decisions. The insurance corporation will probably focus on financial aspects, while
individuals, unions, and self-insured c o r p o r a t i o n s - though concerned about c o s t s - - m a y focus more on quality of care, access, and m e m b e r satisfaction. The data
presented to each group should correspond to their
primary concerns.
A n n Thorac S u r g
1995;59:486-93
H o w Providers Must Respond
The rules have been rewritten and competition in medical care has become a mechanism to control costs.
Competition will become more intense, resulting in consolidation over the next few years. Large systems with
good, documentable outcomes will be at an advantage.
Further, because single providers (individual physicians
or hospitals, or both) cannot be competitive in a m a n a g e d
care environment, they must join together and develop
networks of care [43-45] to improve their marketability.
These integrated health care systems must also develop
corresponding integrated information systems to provide
all c u s t o m e r s - - m a n a g e d health care plans and selfinsured groups at the local regional, and national leve l s - a c c e s s to important clinical, administrative, and financial data [46].
In addition, third-party payors are often required to
present clinical data to the corporations they insure
(including governmental agencies). For example, the
Health Plan Employer Data and Information Set is a
series of performance measures (data and formal data
analyses) developed to allow an employer to determine
the value of a health plan and hold the plan accountable
for care [47]. Health care delivery systems that can
provide this information to clients have a significant
marketing advantage.
The Cardiothoracic Surgery Database at Cedars-Sinai
Medical Center
To provide a concrete example of how data for m a n a g e d
health care can be collected, analyzed, and presented, we
describe the structure and methods that are currently
being used in the Cedars-Sinai Medical Center cardiothoracic surgery database. This system was built on a
foundation of almost 20 years of data collection, and has
recently been modified to adapt it to a m a n a g e d care
setting. It has much in c o m m o n with other well-known
databases, but these have been developed for purposes
other than health care delivery in a m a n a g e d care system
[48-51]. Ours is singular, in that it links administrative,
clinical, and financial databases into one system that
allows constant tracking of medical and financial outcomes. We will discuss the database structure, the process of data collection, and how these data are used in a
competitive m a n a g e d care realm.
Database Structure
The database resides on a Digital Equipment Corporation (DEC) VAX cluster running RDB as its database
engine. The interface and analysis routines are written in
a fourth generation language (PowerHouse; Cognos, Burlington, MA). The structure is open, such that any user
connected to the hospital network (directly or via modem) can access the database through custom screens, or
through SQL (structured query language).
Figure 1 is a logical diagram of the database. The core
contains a series of tables corresponding to each of the
relevant datasets, which will be described. The database
is linked to the hospital's central administrative, financial and physician databases. This linking of databases
A n n Thorac S u r g
1995;59:486-93
D E N T O N ET AL
I N F O R M A T I O N FOR M A N A G E D CARE
Follow-up data (complications) are obtained by liaison
nurses from the time of the patient's admission to 2
m o n t h s after discharge. Long-term follow-up is conducted by m e a n s of a n n u a l mailings or office visits, or
both, a n d consists of questions on s y m p t o m status, resource utilization (readmission, office visits, and repeat
procedures) a n d a formal quality-of-life assessment tool
[52, 53]. The long-term follow-up at our institution exceeds 90%.
Hospital
Administrative
Database
Financial
Database
Hospital
Physician
Database
Input
Form
489
ry
Fig 1. The logical structure of the Cedars-Sinai Cardiothoracic Surgery database. The core database (inside dotted lines) has direct
links to the hospital's central administrative, financial, and physician databases (left). Data access is accomplished by means of the
clinical interface, the automated report system, and a client~server
tool for ad hoc and research purposes (right). (H&P = history and
physical examination data.)
strengthens the i n h e r e n t weaknesses of each a n d eliminates the need for double-entry. All other data are i n p u t
from forms collected at the site of data generation.
The data elements d e e m e d i m p o r t a n t e n o u g h to collect
were selected on the basis of our prior experience a n d
our findings from the review of other databases. Each
data e l e m e n t was carefully reviewed in terms of its
relevance to clinical care, its administrative necessity,
a n d its importance in a m a n a g e d care e n v i r o n m e n t .
Patient privacy is closely guarded by providing multiple
security levels. Access to the hospital network is controlled by the hospital's information systems department,
a n d access to the surgical database is further controlled
by the d e p a r t m e n t of cardiothoracic surgery.
Process o f D a t a Collection
Data are prospectively collected at the source of generation. All data definitions are on the collection forms, a n d
all p e r s o n n e l have received special training in the proper
methods of collection. The reliability of the data collected
is assessed through routine a n d ad hoc quality assurance
procedures. Demographics a n d the patient's physician
information are obtained by an electronic link to the
hospital's central database. History a n d physical examination data are obtained by clinical staff by m e a n s of
patient interviews, chart reviews, and referring physician
contacts, all before the procedure. The surgical data are
collected by the perfusionists from direct interviews with
the surgeons a n d anesthesiologists d u r i n g the procedure.
Within m i n u t e s of the completion of the procedure, the
data are entered by specially trained p e r s o n n e l and a
preliminary operative report is generated a n d automatically faxed to all referring physicians. Though at present
these data are not an official part of the medical record,
we envision them b e c o m i n g an aspect of a hospital-wide
electronic patient record w h e n such a system is installed.
H o w the D a t a A r e Used
The most important goal of the database is to provide
clinical data in an easy-to-use interface. The clinician
interface consists of a single screen that is easily accessed
from within the hospital or the physician's office or home,
a n d contains three types of data: clinical information,
information on protocols of care, a n d decision aids (Fig
2). This small dataset of 55 variables provides the primary
physician, emergency room physician, or invasive cardiologist with sufficient information to care for a patient
from the time of discharge to m a n y years of long-term
follow-up.
Second, the clinical interface allows access to information on our r e c o m m e n d e d protocols of care. A c o m m o n
question from referring physicians is " W h a t antibiotics
are you r e c o m m e n d i n g for a patient with an artificial
valve during a dental procedure?" The physician can
now obtain this information a n d information on other
related protocols directly from this screen.
C_VSNumber: 12532 MRN: 2•030786123
Birth Date: 112/28
Surqery: 2112/94
CABG Yes
LAD
LITA
Diag#1
Diag#2
Diag#3
Inter
SVG
Cx
CxMarg#1
CxMa~I#2
CxMarg#3
RCA
RVMarg
PD
SVG
PL
Other
St: Alive
Name: Smith, John
Primary Surgeo..~ Smith, Jane
Referdnq MD: Smith, Janet
Valve Surgery Yes
Repair Method
Mffral
CE-Ring
Aortic
Tricuspid
Pulmonic
!n-Hosp C o m p l
Prol Intub
Leg Infec
Chest Infec
PostOp SVT
PostOpVTNF
Perm Pacer
Neuro Compl
No
No
No
Yes
No
No
No
Prosthesis
St. Jude
Short-termCompl
Arrhythmia
No
Leg Infec
No
Chest Infec
No
ProLongHeal Yes
Thoracentesis Yes
PermPacer
No
Neuro Compl No
Elec_t.rical Surqery No
Pacemaker
No
Arrhythmia Surg No
AICD/PCD
No
O'(her ~;urflery
Heart Xplant
Lung Xplant
Vascular Sx
Congenital
Other Surg
No
No
No
No
No
Fig 2. An example of the clinical user interface consisting of simple
administrative variables, along with limited coronary artery bypass
grafting, valve, in-hospital, and short-term follow-up data, in addition to information on other procedures, The 55 variables were chosen from among the hundreds of variables in the entire database as
being those most relevant to patient care in the near or long term.
(AICD ~ automatic implantable cardioverter defibrillator; CABG =
coronary artery bypass graf~ng; CE = Carpentier-Edwards; Compl
= complications; CVS = cardiovascular surgery; Cx - circumflex
artery; Infec ~ infection; inter = intermediate; LAD ~ left anterior
descending artery; LITA -- left internal thoracic artery; Marg =
marginal; MRN - medical records number; PCD = pacer/cardioverter/defibrillator; PD - posterior descending; PL posterolateral;
Prol Intub prolonged intubation; RCA ~ right coronary artery;
RV = right ventricle; St = status; SVG = saphenous vein graft;
SVT = supraventricular tachycardia; Sx - surgery; VT/VF = ventricular tachycardia/fibrillation; Xplant - transplantation.)
490
D E N T O N ET A L
I N F O R M A T I O N F O R M A N A G E D CARE
Ann Thorac Surg
1995;59:486-93
Fig 3. The financial screen, demonstrating 12 cost
and charge categories in addition to indirect costs,
and estimated and actual reimbursements. ( C V S cardiovascular surgery; D R G - diagnosis-related
groups; E R
emergency room; I C U = intensive
care unit; M R N - medical records number; O R =
operating room; Rx = drugs; S t = status.)
Cedars-Sinai Medical Center
Financial Information
CVS Number: 12532
St: Alive
MRN: 21030786123
Costs Routine Care
Costs ICU
Costs OR
Costs Lab/Path
Costs Rx
Costs Supphes
Costs Pulm
Costs )(ray
Costs Cardiac
Costs Rehab
Costs ER
Costs Other
5,783.53
7,194.22
6,181.99
1,560.22
634.91
745,66
321.55
258.11
2,679.12
163.92
0.00
241.55
Charges Routine C a r e
Charges ICU
Charges OR
Charges Lab/Path
Charges Rx
Charges Supplies
Charges Pulm
Charges Xray
Charges Cardiac
Charges Rehab
Charges ER
Costs Direct
15,257.42
Costs Indirect Variable 7,126.04
Costs Indirect Fixed
3,178.32
Total Costs
Fig 4. A random sample of qualityof-life scores from patients after cardiac surgical procedures. The four
dimensions are well-being, physical
functioning, social functioning, and
psychologic status.
Charges Other
10,612.1315
15,388.46
12,362.61
3,002.44
1,268.31
1481.55
643.12
628.18
5,149.36
317.33
0.00
538.44
Total Charges
33,541.77
Estimated Reimbursement
Actual Reimbursment
32,689.00
17,367.00
25,325.12
Total Units of Service
DRG
ICU Days
Finally, the clinical interface provides the physician
with decision aids. Using models developed in our database, physicians can enter individual patient characteristics and receive immediate estimates of surgical
survival. Estimates of procedural benefit (in terms of
improvement in survival and quality of life), cost estimates, and appropriateness models will be added to the
system as they are developed [54].
The second goal of the database is to increase the
competitiveness of the department through the imple-
Name: Smith, John
576
104
7
mentation of administrative efficiencies and cost containment.
The administrative portion of the database allows members of the department to access all clinical and follow-up
data, our referring physician database, financial variables, and the reporting module. The financial module
allows reference to procedural costs, broken into 12
categories, as noted in Figure 3. Costs are calculated by
the hospital financial system and include all hospital
overhead costs, salaries, and benefit costs for the hospital
staff. Professional fees are not yet included. Using pre-
Overall Well-Being
Physicial Function
7OO
1,400
6OO
1,200
5OO
1,000
800
~. 3oo
~= 600
2OO
400
100
2OO
0
0
10 20 30 40 50 60 70 80 90 100
Score
0
0
Social Function
10
20
30 40
Score
50
60
70
Psychological Status
2,000
1,000
1,,500
800
i 600
P 1,000
~"
400
5OO
0
2OO
0
10 20 30 40 50 60 70 80 90 100
Score
0
0
10 20 30 40 50 60 70 80 90 100
Score
A n n Thorac Surg
1995;59:486-93
DENTON ET AL
INFORMATION FOR M A N A G E D CARE
Did the doctor listen to you and
answer all of your questions?
491
What did you think of the MEDICAL CARE
while in the Cardiothoracic Surgery Section?
loo !
lOO
80
60
n
u
0
40
o_
20
40
20
0
Yes
0
No
Overall, what did you think of your care
Pleased
No opinion
Displeased Vely Displeased
Would you refer a friend or
in the Cardiothoracic Surgery Section?
relative for care?
100
100
80 I- . . . . . . . . . . . . . . . . . . .
n
VeryPleased
oolmo o
.....
40
20 t m .
0
I
m
..........................
i
I
~
VeryReased
Pleased
80
~.
40
20
0
Noopinion DispleasedVeryDispleased
Yes
No
Fig 5. Four representative questions from the 12 asked in the patient satisfaction survey. The results of these are used in presentations to prospective payors, and for feedback to the respective sections of the department of cardiothoracic surgery for purposes of quality improvement.
operative clinical information and cost outcome data, we
have developed financial models to provide patientspecific cost estimates before a procedure. In addition,
with these data, we are able to accurately calculate
capitation levels for tertiary surgical care.
A departmental "report card" [55], generated from our
reporting module, includes information regarding the
department's activities, case mix, and demographics, as
well as detailed information on mortality as a function of
the procedure, perioperative complications, appropriateness, the quality-of-life assessment, and patient satisfaction. Figure 4 shows the quality-of-life scores (from our
report card) for a typical subset of patients who have
undergone various cardiac surgical procedures. The four
graphs represent the four dimensions of quality of life as
measured by published, validated instruments [52, 53].
Figure 5 shows the findings from four representative
questions on our most recent patient satisfaction quest i o n n a i r e - a l s o from our report card.
Data from the information system and report card are
actively used for the purpose of continuous quality improvement. Over the past 3 years, we have reduced the
length of hospital stay in patients undergoing coronary
artery bypass grafting by 36% through the use of guidelines and the feedback of data to physicians. We are now
undertaking projects to reduce the use of blood transfu-
sions and the occurrence of w o u n d infections. The database has also allowed us to respond quickly to requests
for proposals, often within as little as 24 hours. The data
and report card are actively used in marketing efforts,
and have had an impact on our ability to attract contracts
from large payors.
As already mentioned, the future of health care lies in
the creation of large, integrated systems. We have designed our database in such a way that it can become the
hub of a large network of primary and tertiary care
providers. Figure 6 shows what we envision the information flow will be within a hypothetical network. In it, links
between primary care physicians, specialists, and the
central database are established around a primary hospital which shares data with affiliated hospitals and
medical groups in real time. Further, we are developing a
link to third-party payors, so that clinically relevant
individual patient information can be transmitted to
them for quality assurance purposes and to satisfy governmental regulations (eg, the Health Plan Employer
Data and Information Set).
Where From Here?
No matter what the federal government imposes in the
form of health care reform, the die has already been cast
492
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INFORMATION FOR MANAGED CARE
Ann Thorac Surg
1995;59:486-93
I
G
Fig 6. An example of a hypothetical network for a cenlval hospital
(CSMC) with links to referring physicians and support personnel.
Additional links are supplied to affiliated hospitals and to payors for
the purpose of exchanging relevant clinical and financial information.
by m a r k e t forces. The f u t u r e of o u r s y s t e m lies in the
active c o o p e r a t i o n of p r o v i d e r s p a r t i c i p a t i n g in large,
c o m p e t i t i v e n e t w o r k s . I n d i v i d u a l patients, g o v e r n m e n t a d m i n i s t e r e d p r o g r a m s , unions, s e l f - i n s u r e d c o r p o r a tions, b u s i n e s s coalitions, a n d h e a l t h i n s u r a n c e c o m p a nies will c o n t r a c t w i t h n e t w o r k s to p r o v i d e q u a l i t y care at
the l o w e s t p o s s i b l e price. This n e w s y s t e m will be data
driven. P r o v i d e r s w i t h access to r e l e v a n t a d m i n i s t r a t i v e ,
clinical, a n d financial data will t h e r e f o r e b e t h e m o s t
competitive.
T h o u g h physicians h a v e not p l a y e d a major role in the
restructuring of health care, t h e y m u s t b e c o m e actively
i n v o l v e d in the health care debate [56] and in d e v e l o p i n g
the data to s u p p o r t a health care system b a s e d on excellence. Physicians m u s t supervise the m a n a g e m e n t of the
data [57], and m u s t realize that the database itself will
b e c o m e a m e a n s to i m p r o v e care [58]. A n o p p o r t u n i t y exists
to objectively d e m o n s t r a t e the benefit of h i g h - t e c h n o l o g y
care while m a i n t a i n i n g excellence at reasonable cost. It is
time for us to take the lead in this effort.
References
1. Carrol MS. Managed care programs: an employer perspective. Top Health Care Financ 1993;20:10-6.
2. Weinberg SL. Managed care: an assault on medicine's professional imperatives [President's Page]. J Am Coll Cardiol
1994;23:988 -9.
3. Mechanic D. Managed care: rhetoric and realities. Inquiry
1994;31:124-8.
4. Well TP. Managed-care plans: the future under national
health insurance. West J Med 1991;155:533-7.
5. Inglehart JK. The American health care system: managed
care. N Engl J Med 1992;327:742-7.
6. Dragalin D, Perkins P, Plocher DW. Institutes of quality:
Prudential's approach to outcomes management for specialty procedures. Qual Rev Bull, March 1990:111-5.
7. Dallek G, Harper A, Jimenez C, Daw C. Medicare riskcontract HMOs in California: a study of marketing, quality,
and due process rights. Los Angeles: Medicare Advocacy
Project, 1993.
8. Health Care Financing Administration. Medicare hospital
mortality information, 1987, 1988, 1989 (HCFA Publication
#00744). Washington, DC: U.S. Department of Health and
Human Services, 1990.
9. Hannan EL, Kilburn H, Racz M, Shields E, Chassin MR.
Improving the outcomes of coronary artery bypass surgery
in New York State. JAMA 1994;271:761-6.
10. A consumer guide to coronary artery bypass graft surgery.
Harrisburg, PA: The Pennsylvania Health Care Cost Containment Council, 1992.
11. Ballard DJ, Bryant SC, O'Brien PC, Smith DW, Pine MB,
Cortese DA. Referral selection bias in the Medicare hospital
mortality prediction model: are centers of referral for Medicare beneficiaries necessarily centers of excellence? Health
Serv Res 1994;28:771-84.
12. Hampshire DA, Rosborough BJ. The evolution of decision
support in a managed care organization. Top Health Care
Financ 1993;20:26-37.
13. Welge WL. Managed care is limited by the information
system. Top Health Care Financ 1992;19:23-32.
14. Lipson EH. What are purchasers looking for in managed
care quality? Top Health Care Financ 1993;20:1-9.
15. Goldfield N. Measurement and management of quality in
managed care organizations. Alive and improving. Qual Rev
Bull Nov 1991:343-8.
16. Miller RH, Luft HS. Managed care plan performance since
1980. A literature analysis. JAMA 1994;271:1512-9.
17. Leatherman S, Peterson E, Heinen L, Quam L. Quality
screening and management using claims data in a managed
care setting. Qual Rev Bull, Nov 1991:349-59.
18. Matloff JM. The practice of medicine in the year 2010. Ann
Thorac Surg 1993;55:1311-25.
19. Guyatt GH, Feeny DH, Patrick DL. Measuring health-related
quality of life. Ann Intern Med 1993;118:622-9.
20. Cook DJ, Guyatt GH, Juniper E, et aL Interviewer versus
self-administered questionnaires in developing a diseasespecific, health-related quality of life instrument for asthma.
J Clin Epidemiol 1993;46:529-34.
21. Visser MC, Fletcher AE, Parr G, Simpson A, Bulpitt CJ. A
comparison of three quality of life instruments in subjects
with angina pectoris: the sickness impact profile, the Nottingham health profile, and the quality of well being scale. J
Clin Epidemiol 1994;47:157-63.
22. The Health Poll, Metropolitan Life Insurance Co. Business
and Health, Aug 1990.
23. Cleary PD, McNeil BJ. Patient satisfaction as an indicator of
quality care. Inquiry 1988;25:25-36.
24. Gustafson DH. Expanding on the role of patient as consumer. Qual Rev Bull, Oct 1991:324-5.
25. Guidelines and indications for coronary, artery bypass graft
surgery. A report of the American College of Cardiology/
American Heart Association Task Force on Assessment of
Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee on Coronary Artery Bypass Graft Surgery). J Am
Coil Cardiol 1991;17:543-89.
26. Leape LL, Hilborne LH, Kahan JP, Park RE, Kamberg CJ,
Brook RH. Coronary artery bypass graft: a literature review
and ratings of appropriateness and necessity. Santa Monica,
CA: RAND, 1991.
27. Berwick DM. Continuous improvement as an ideal in health
care. N Engl J Med 1989;320:53-6.
28. Hammermeister KE, Johnson R, Marshall G, Grover FL.
Continuous assessment and improvement in quality of care:
a model from the Department of Veterans Affairs Cardiac
Surgery. Ann Surg 1994;219:281-90.
29. Laffel G, Blumenthal D. The case for using industrial quality
management science in health care organizations. JAMA
1989;262:2869-73.
Ann Thorac Surg
1995;59:486-93
30. Eddy DM. Connecting value and costs: whom do we ask, and
what do we ask them? JAMA 1990;264:1737-9.
31. Gregg SA. How can we achieve more value from our
managed care efforts? Top Health Care Financ 1992;19:89-95.
32. Dudley RA, Harrell FE, Smith LR, et al. Comparison of
analytic models for estimating the effect of clinical factors on
the cost of coronary artery bypass graft surgery. J Clin
Epidemiol 1993;46:261-71.
33. Malcolm CL, Fukui M. Specialty service contracting. Top
Health Care Financ 1993;20:68-75.
34. Jacobson JM. Promoting and measuring productivity in the
HMO. Top Health Care Financ 1992;19:75-82.
35. Lewis JB. Hospital strategic m a n a g e m e n t a n d m a n a g e d care.
Top Health Care Financ 1992;19:11-7.
36. Welch HG, Miller ME, Welch WP. Physician profiling. An
analysis of inpatient practice patterns in Florida and Oregon.
N Engl J Med 1994;330:607-12.
37. Kassirer JP. The use and abuse of practice profiles. N Engl J
Med 1994;330:635-7.
38. Shapiro DW, Lasker RD, Bindman AB, Lee PIL Containing
costs while improving quality of care: the role of profiling and
practice guidelines. Annu Rev Public Health 1993;14:219-41.
39. Clement DG, Retchin SM, Brown RS, Stegall MH. Access
and outcomes of elderly patients enrolled in m a n a g e d care.
JAMA 1994;271:1487-92.
40. Findlay S. What's ahead in 1994? Business Health 1993;11:
28-37.
41. Jones LF, Font JA. Meel~ng employer needs in the managed
care request for proposal. Top Health Care Financ 1992;19:
18-22.
42. Health Security: the President's report to the American
people. New York: Simon and Schuster, 1993.
43. Peters GR. Organizational and business issues affecting integrated delivery systems. Top Health Care Financ 1994;20:1-12.
44. Smith JR. Creating an integrated health care delivery system: a regional nonprofit provider case study. Top Health
Care Financ 1993;20:82-8.
45. Masters GM. Managed care and competitive warfare in the
1990's. Top Health Care Financ 1993;20:vi-viii.
DENTON ET AL
INFORMATION FOR MANAGED CARE
493
46. BrookePP. S u c c e s s f u l l y m a n a g i n g m a n a g e d c a r e : o r g a n i z a tional skills n e e d e d by hospitals to compete in an era of
m a n a g e d care. Top Health Care Financ 1992;19:1-10.
47. Health plan employer data and information set a n d user's
manual. Washington DC: The National Committee for Quality Assurance, 1993.
48. Anderson RP. First publications from The Society of Thoracic Surgeons Nation Database. A n n Thorac Surg 1994;
57:6 -7.
49. Clark RE. The Society of Thoracic Surgeons National Database status report. A n n Thorac Surg 1994;57:20-6.
50. Edwards FH, Clark RE, Schwartz M. Coronary artery bypass
grafting: The Society of Thoracic Surgeons National Database experience. A n n Thorac Surg 1994;57:12-9.
51. Edwards FH, Clark RE, Schwartz M. Impact of internal
m a m m a r y artery conduits on operative mortality in coronary
revascularization. A n n Thorac Surg 1994;57:27-32.
52. Abramson JH, Ritter M, Gofin J, Kark JD. A simplified index
of physical health for use in epidemiological studies. J Clin
Epidemiol 1992;45:651-8.
53. Jette AM, Davies AR, Cleary PD, et al. The functional status
questionnaire: reliability and validity w h e n used in primary
care. J Gen Intern Med 1986;1:143-9.
54. Diamond GA, Denton TA, Matloff JM. Fee-for-benefit: a
strategy to improve the quality of health care and control
costs through reimbursement incentives. J Am Coll Cardiol
1993;22:343-52.
55. Topol EJ, Califf RM. Scorecard cardiovascular medicine. Its
impact and future directions. A n n Intern Med 1994;120:
65-70.
56. Thief SO. Health care reform: who will lead? A n n Intern
Med 1991;115:54-8.
57. Friedman BA, Martin JB. The physician as a locus of authority, responsibility, and operational control of medical systems. J Med Syst 1988;12:389-96.
58. Pryor DB, Lee KL. Methods for the analysis and assessment
of clinical databases: the clinician's perspective. Stat Med
1991;10:617-28.