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A program of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and other funders

Community Health CheckupExecutive Summary4th Report

Measurement Matters

W I N T E R 2 0 1 0

To THE CommuniTy:On behalf of Better Health Greater Cleveland, I am pleased to submit our fourth Community Health Checkup, which reports the efforts of multiple stakeholders to improve the health care and outcomes of Greater Clevelanders with chronic health conditions. In this Checkup, we begin reporting on quality care standards for heart failure and again report the care and outcomes of our adult patients with diabetes.

The theme of this Checkup is that measurement matters. As our partnership begins its fourth year, we have seen our measurement activities and community-wide cooperation play out in important ways. The metrics we measure continue to improve across diverse primary care practices and groups of patients. Our clinician partners who see their numbers are acting to improve them, using their professional pride and competitiveness to find solutions. Participation has grown dramatically in our Quality Improvement Learning Collaborative, where clinical partners gather to learn and share their challenges and successes. We have begun to use our results to discover and disseminate Replicable Best Practices in order to accelerate improvement across the region. Health information technology is a key resource for Better Health and creates the infrastructure to multiply improvement in our growing alliance. Fueled by federal initiatives to catalyze increased adoption of electronic medical records by primary care physicians to improve care and lower costs, new stimulus funds are reaching into northeast Ohio as this report goes to print. We are pleased that the collaboration we began in 2007 will be able to grow to include new partners to help us achieve our mission to improve care and eliminate disparities among our patients with chronic medical conditions.

These initiatives will take time, and parallel efforts are needed to motivate better coordination of care, including payment reform and the transformation of health care delivery to be more patient centered. And we know that better clinical care will not by itself solve the problem of chronic health conditions. Improving diet and exercise habits, and eliminating tobacco use, are challenges that extend far beyond the physician’s examining room. Better Health’s public health partners are equally committed to addressing these important underlying causes of chronic health conditions, and many regional employers have begun to recognize that they can favorably influence the health behaviors and wellness of their employees.

We are hopeful that the gathering strength of our collaboration will help to produce community-wide solutions.

Randall D. Cebul, M.D., Director, Better Health Greater Cleveland

BeTTeR HeALTH GreAter CLeveLAnD – An ALLIAnCe FOR IMPROveD HeALTH CARe

Front Cover Photo:Better Health Greater Cleveland

Quality Improvement Learning CollaborativeMarch 5, 2010

Randall D. Cebul, MD

1BeTTeRHeALTHCLeveLAnD.ORG

THe POWeR OF PARTneRSHIP

inTRoDuCTionusing Electronic Health information “meaningfully”. Better Health Greater Cleveland is one of 15 regional organizations that participates in the Robert Wood Johnson Foundation’s Aligning Forces for Quality program. Like other organizations in this signature national initiative, Better Health is committed to measuring, publicly reporting and collaborating to improve the care and outcomes of their residents with chronic medical conditions. Better Health is unique among these organizations in its predominant use of electronic medical records (eMRs) for measurement and its efforts to identify and eliminate disparities in care and health outcomes among patients of its clinical partners. We highlight use of eMRs because they help us measure our achievement in a timely and granular way, provide feedback to ourselves and our patients, and facilitate clinical decision support to improve our outcomes. We report our regional results in patient subgroups by insurance, including the uninsured, and by race, income and educational attainment, because we believe that Greater Cleveland must recognize and address disparities to improve our region. These themes have coalesced nationally in the past year under the expression “Meaningful Use”; that is, the adoption of eMRs not simply for record-keeping, but, more importantly, as a tool to coordinate and improve care in meaningful ways.

How Better Health uses Practice-Centered Data. Measurement and data are at the heart of all Better Health efforts to improve health and eliminate disparities. Better Health’s Data Management Center receives and analyzes data from our partner practices for three main purposes: 1) to publicly report and provide feedback to health care systems and practice sites about their achievement and improvement on nationally endorsed and locally vetted standards of care; 2) to enable Better Health’s Quality Improvement Learning Collaborative to identify potential Replicable Best Practices to disseminate across partner sites (more about this below); and 3) to identify specific goals in the care of chronic health conditions to motivate practices and patients to establish more effective partnerships to improve outcomes. Our measurement goals are highlighted on our consumer-friendly website betterhealthcleveland.org. Our Consumer engagement Committee has developed posters and educational materials that emphasize the importance of measurement and of partnerships between patients and their health care providers.

identifying and Disseminating Replicable Best Practices. In our first Checkup in 2008, we used our data to identify exceptionally high achieving practice sites and asked them to share their care processes with others through our Learning Collaborative, a partnership of primary care practitioners who gather to learn about and share strategies to improve their patients’ care and outcomes. Over the ensuing Community Health Checkups, including this one, we also tracked changes in achievement over time, enabling us to identify exceptional improvers on our standards. Over the past six months, we formalized our definition of Replicable Best Practices with the expectation that disseminating these processes could accelerate improvement throughout the region. To identify a potential Replicable Best Practice, we carefully examine all of our results. When we find a pattern of exceptional achievement or improvement -- by a physician, practice site or health system -- our Best Practices Team interviews

Thomas E. Love, PhD, Director of Better Health’s Data Management Center. The Center is responsible for secure collection, aggregation, analysisand display of achievement and improvement data.

At the end of 2009, the federal Centers for Medicare and Medicaid Services and the Office of the National Coordinator (ONC) for Health Information Technology established definitions for Meaningful Use, identified financial incentives for health care providers who document their Meaningful Use and eventual penalties for those who do not. We are pleased that Greater Cleveland is ahead of the curve in Meaningful Use of EMRs, although we have much work ahead to achieve our goals.

2 BeTTeR HeALTH GreAter CLeveLAnD – An ALLIAnCe FOR IMPROveD HeALTH CARe

the relevant provider or site leaders. These conversations allow us to determine whether systematic efforts or changes in processes led to the results and whether these processes might be transferable to other sites or systems. These potential Replicable Best Practices are then shared with Better Health’s partners through public convening events, day-long Learning exchanges, site coaching and publications such as this Checkup. Converting a potential Replicable Best Practice to one that has demonstrated its usefulness requires a more demanding test – that others have employed it and documented similar improvement. We are encouraged with early results and share them below.

new in This Checkup. With this Checkup, we add our achievement on standards of care for heart failure and report region-wide results for our eMR-based systems (Cleveland Clinic, Kaiser Permanente, and MetroHealth) in this executive Summary. Also new to this Checkup are explicit comparisons of achievement among sites that use eMRs for measurement with those that use paper-based medical records systems. We recognize that several forces may confound the relationship between measurement source (eMR or paper record) and achievement, including the fact that our current partners with paper-based systems provide care for patients who are relatively more disadvantaged. nonetheless, we have learned that ready access to robust patient data and eMR tools, such as reminders to order recommended tests, can facilitate both better care and more rapid improvement. Finally, in this executive Summary we report changes in our partners’ achievement in diabetes care and outcomes, highlighting gratifying improvement as well as persisting disparities in improvement across different patient subgroups.

Federal Forces and organizational Changes. exciting initiatives at the federal and state levels are complemented by changes within Better Health and our current and future clinical partners. The American Recovery and Reinvestment Act (ARRA) is helping Ohio commit more than $50 million to establish Regional extension Centers to accelerate adoption and meaningful use of eMRs and to develop state-wide Health Information exchange. While these funds are inadequate to support all that needs to happen in northeast Ohio, they enable the newly formed Ohio Health Information Partnership to establish infrastructure to enhance the region’s capacity to coordinate and improve health care. In related ARRA initiatives in Health Information Technology (HIT), Better Health’s partners at our Federally Qualified Health Centers last summer received remarkable support for capital improvements that will be used to support the purchase (neighborhood Family Practice, Care Alliance) or improvements in existing eMRs (neOn). Finally, related regional HIT proposals enabled by ARRA would, if funded, expand the HIT workforce in Greater Cleveland as well as the scope and depth of Better Health’s activities to measure and improve health care in the region.

Better HealtH PaRTnERSFounding PartnersThe MetroHealth System, Robert Wood Johnson Foundation granteeThe Center for Community SolutionsHealth Action Council Ohio

Primary Care PartnersCare Alliance Health CenterCase Western Reserve University Practice-Based Research NetworkCleveland Clinic, Main Campus and Family Health CentersHuron Hospital, Community Health CenterKaiser Permanente-OhioLouis Stokes VA Medical CenterMetroHealth, Main Campus and Center for Community HealthNeighborhood Family PracticeNortheast Ohio Neighborhood Health Services (NEON)

University Hospitals Family Medicine

Hospital PartnersCleveland Clinic Health System Hospitals

Cleveland Clinic Main CampusEuclidFairviewHillcrestHuronLakewoodLutheranMarymountSouth Pointe

MetroHealth Medical Center

Employers and Health Plan PartnersCareSource Health Action Council OhioOhio MedicaidAetnaKaiser Health Plan Medical Mutual of OhioUnited Healthcare

Organizations and AgenciesAcademy of Medicine of Cleveland and Northern OhioCenter for Health AffairsCleveland Department of Public HealthCuyahoga County Board of HealthCuyahoga County Public LibraryDiabetes Association of Greater ClevelandNetWellness.orgOhio Department of Job & Family ServicesOhio Department of HealthOneCommunitySMART Center, Case Western Reserve University Bolton School of Nursing

Other Valued SupportersRobert Wood Johnson FoundationMt. Sinai Health Care FoundationThe MetroHealth SystemWellpoint FoundationHealth Action Council OhioThe Center for Community SolutionsMedical Mutual of OhioOneCommunity



PaRTnER PRaCTiCES anD PaTiEnTSBetter Health continues to expand the number of physician practices that participate in measuring care and outcomes to improve their patients’ lives. Represented in this report is a diverse mix of eight health care systems with 375 primary care physicians at 45 primary care practices across the region (Table 1). As in previous reports, these include the practices of three large health systems with eMRs (Cleveland Clinic, The MetroHealth System and Kaiser Permanente-Ohio) and the practices of five systems with paper-based records. The achievement of all 45 practices and their 25,698 qualifying patients with diabetes are reported in this Checkup. In this executive Summary, we report aggregated regional results, and we provide detailed results by site in our complete report at betterhealthcleveland.org. Collectively, almost 90% of the patients with diabetes in this report are from our 32 eMR sites. These patients are more likely to be covered by Medicare or Commercial insurers (86%) than are patients cared for at the 13 sites of our paper-based practices (29%). Patients in the paper-based practices also are more likely to be non-white (86% vs. 40% in the eMR sites), poorer (median household income of $27,000 vs. $43,000 in eMR sites) and have lower high school graduation rates (71% vs. 81%). The 5,331 patients with heart failure included in this Checkup are cared for in the eMR-based practice sites, whose data were more accessible than those in paper-based systems. Compared to patients with diabetes from these same eMR sites, patients with heart failure are older (71 vs. 58 on average) and, not surprisingly, more likely to be insured by Medicare (73% vs. 35%).

TaBlE 1. CHaRaCTERiSTiCS oF PaRTnER oRganizaTionS anD PRaCTiCE SiTES

Better Health Population

Range of Valuesacross Sites

EmR-Based Systems

Paper-Based Systems

Health Systems, number 8 - 3 5Practice Sites, number 45 - 32 13

Primary Care Physicians, number 375 - 321 54

Qualifying Diabetes Patients, number 25,698 82 – 1,814 22,906 2,792

Qualifying Heart Failure Patients, number 5,331 14 - 781 5,331 Not Measured

Diabetes Patient Characteristicsinsurance [%] Medicare Commercial Medicaid Uninsured Medicaid + Uninsured

35.444.49.111.120.2

5 - 502 - 720 - 350 - 810 - 92

37.448.56.87.214.0

18.610.228.143.171.2

Race/Ethnicity [%] White African-American Hispanic Other Non-White

53.937.65.52.946.1

2 - 971 - 970 - 650 - 583 – 98

60.331.65.13.039.7

14.174.98.62.485.9

average age 57.8 50 - 63 58.3 54.3% Female 54.3 38 - 77 53.6 60.6High School graduation Rate, [%] 79.9 66.2 – 89.9 80.9 70.9median Household income, [$] 40,821 22,846 – 66,735 42,505 27,118

Heart Failure Patient Characteristics, EmR Practices only

insurance [%] Medicare Commercial Medicaid Uninsured Medicaid + Uninsured

21 - 883 - 410 - 430 - 240 - 52

72.920.14.72.47.1

Not measuredRace/Ethnicity [%] White African-American Hispanic Other Non-White

2 - 980 - 970 - 510 - 292 – 98

62.833.22.61.437.2

average age 53 - 78 71.2% Female 33 - 70 50.6High School graduation Rate, [%] 62.4 – 89.7 81.0median Household income, [$] 23,364 – 67,323 42,754


aCHiEVEmEnT againST naTional HEalTH PlanS anD nCQa STanDaRDSAs in our first three Checkups, we compare the achievement of Better Health’s partners to nationwide health plans on diabetes standards reported by the national Committee on Quality Assurance (nCQA) for health plans nationwide (“HeDIS” standards). Four points are worth noting about our sample and methods. First, to make fair comparisons, Better Health mimics the nCQA eligibility criteria by including patients with diabetes between the ages of 18 and 75 who have visited their primary care physician at least twice during the one-year measurement period. Second, because Better Health’s partners provide detailed patient results, we can report our achievement on nCQA’s standards, even though nCQA thresholds for certain tests (such as blood pressure values less than 130/80) differ from those that Better Health has selected. Third, this Checkup reports results from the one-year period between July 1, 2008, and June 30, 2009, while nCQA’s report draws its data from an earlier period, calendar 2008. While comparing our more recent results to nCQA’s older results may bias comparisons against the health plans if there were subsequent favorable trends in the plans’ results, national trends were flat for many key measures in 2008, breaking a 12-year run of significant progress. Importantly, we believe that our more current data better allow practices to act on their results. Finally, there are no health plans for the uninsured. Thus, results for Better Health’s uninsured patients have no direct comparator, requiring that we compare results for our uninsured to patients with Medicare, Medicaid, or commercial health plans.

Table 2 compares our practices’ achievement with health plans reported by nCQA. Better Health’s eMR-based and paper-based partners’ results both are included. The region achieved better results than the average for health plans nationwide for virtually all standards. The results for our uninsured patients were better than the national average for patients in Medicaid health plans for most standards.

Table 2. Regional Achievement (2008-2009) Compared to Health Plans nationwide (2008). national data from The State of Health Care Quality 2009, ncqa.org.

TaBlE 2 — REgional aCHiEVEmEnT (2008-09) ComPaRED To HEalTH PlanS naTionwiDE (2008)

Measure Group Medicare Commercial Medicaid Uninsured Overall

Hb A1c testing performed RegionNational Mean

94.988.3

94.189.0

92.580.5

92.7 -

94.1-

Poor Hb A1c Control (>9)(lower values are better)

RegionNational Mean

13.429.4

19.428.4

29.944.8

31.4-

19.6-

Eye Exam performed RegionNational Mean

67.160.8

61.056.5

46.852.8

50.4-

60.7-

LDL Screening RegionNational Mean

89.186.3

90.584.8

76.874.1

79.2-

87.5-

Good LDL Control (<100) RegionNational Mean

60.848.7

54.145.5

38.733.8

38.1-

53.3-

Monitoring Nephropathy RegionNational Mean

92.687.9

91.6 82.4

89.676.6

88.6-

91.5-

Blood Pressure Control (<130/80)

RegionNational Mean

41.331.8

42.033.4

34.730.7

35.2-

40.3-

Blood Pressure Control (<140/90)

RegionNational Mean

69.159.5

74.065.6

60.556.9

63.3-

69.8-

Regional Patients, # (%) RegionNational Mean

9,085(35.4)

11,402(44.4)

2,349(9.1)

2,862(11.1) 25,698

What is HEDIS? The Healthcare Effectiveness Data

and Information Set (HEDIS) is used by most American health plans to

measure the performance of health care systems on a broad range of important health issues, including

comprehensive diabetes care.



Better HealtH’S STanDaRDS Diabetes. Table 3 summarizes Better Health’s nine standards for patient care processes (4) and outcomes (5) in diabetes and the criteria we use for composite Care Process and Outcome Standards. These are the same standards reported in the earlier Community Health Checkups. We continue to believe that Care Processes mostly reflect provider or health care system actions, while Outcomes also represent patient resources (such as insurance, monetary and educational factors), patient behaviors and the effectiveness of patient-provider partnerships. each practice site’s Outcomes are reported individually and by the percentage of patients with diabetes who meet at least four of the five Outcome standards. each practice site’s Care Processes also are reported individually and by the percentage of patients who meet all four Care Process standards – setting a higher bar for Care Processes than for Outcomes.

REgion-wiDE DiaBETES RESulTS aCHiEVEmEnT anD imPRoVEmEnT Figure 1 describes the region’s achievement on Better Health’s diabetes composite standards for Care Processes and Outcomes. The Figure compares overall achievement in the most recent reporting period (July 1, 2008 to June 30, 2009) to that observed one year ago (July 1, 2007 to June 30, 2008.) In the most recent period, we report results for 25,698 patients with diabetes cared for by 375 primary care physicians at 45 practice sites in eight health care systems. Figure 1 documents modest but continued improvement in our Outcome standards and more impressive improvements in Better Health’s standards for Care Processes.

Figure 2 shows changes in achievement in Care Process and Outcome standards for 34 practice sites that provided data in all four reporting periods to date. Thirty-three of these sites improved – either in Care Processes alone (6 sites), Outcomes alone (2 sites), or both Care Processes and Outcomes (25 sites, in the “northeast” corner of the diagram). One site’s achievement fell modestly on both standards (in “southwest” corner).

TaBlE 3. BETTER HEalTH’S inDiViDual anD ComPoSiTE STanDaRDS FoR DiaBETES

CARE PROCESSES4 standards for good routine care:

• Blood sugar control test done• Screening or treating kidney problems• Annual eye exam• Pneumonia vaccine given

Composite Reported: Percentage of patients who met all 4 standards

CLINICAL OUTCOMES5 standards of good control:

• Blood Sugar (HbA1c< 8%)• Blood Pressure (<140/80)• Cholesterol (LDL Cholesterol < 100 or statin)• Weight (Body Mass Index < 30)• Documented non-smoker

Composite Reported: Percentage of patients who met at least 4 standards

Figure 1. Regional Achievement on Care Processes and Outcomes, 2007-08 and 2008-09

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PERSiSTing DiSPaRiTiES in aCHiEVEmEnT anD imPRoVEmEnT Despite overall region-wide improvement in diabetes care and outcomes, we continue to observe systematic differences by insurance type, race, and estimated household income and educational attainment. Figure 3 shows continued disparities by insurance, with the poor (Medicaid) and uninsured faring more poorly; African-Americans and Hispanics doing less well than whites; and patients with lower income and educational attainment doing less well than those with greater financial and educational resources. In addition, with the caveats we described earlier, we find that practices using paper-based records for measurement achieved less well than eMR-based practices both on care and outcomes.

Figure 4 shows changes in achievement by patient characteristics and measurement source over all reporting periods for the 34 sites that have reported since 2007. While all subgroups improved either in Care Processes alone (“northwest” corner of the figures), Outcomes alone (“southeast” corner) or both (“northeast” corner), those with fewest resources improved least. Outcomes among the uninsured improved slightly and Care Processes declined, and commercially insured improved most. Hispanic patients’ outcomes declined, while Outcomes and Care Processes improved most among whites. Patients in the lowest third by estimated income and education improved least. Practice sites that use paper-based records for measurement improved less than those sites using eMRs.


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Figure 2. Change in Percent of Patients Achieving Composite Standards for Outcomes and Care Processes from 2007 to 2008-09. All but one of 34 practices that have reported results since 2007 improved since their first report.

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Figure 3. Regional Achievement on Care Processes and Outcomes by subgroups, 2008-09

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Figure 4. Changes in Diabetes Achievement by Patient Characteristics and Measurement Source over all Reporting Periods from 2007 to 2008-09. See text on Page 6 for discussion. While all subgroups improved either in Care Processes (“northwest” corner of the figure) or both Care Processes and Outcomes (“northeast” corner), it is clear than those with greater resources, including both patients and practice sites with eMRs, improved more than those with fewer resources.



REPliCaBlE BEST PRaCTiCESAs noted earlier, we examine our data closely and interview site leaders with high achievement or improvement to identify systematic processes that can be shared with Better Health’s partners to accelerate region-wide improvement. This process requires that we effectively disseminate these processes, then measure and re-measure outcomes over time. The demanding test of these potentially Replicable Best Practices (or “RBPs”) is whether they actually can be replicated by others and produce similar positive change. Below, we briefly summarize one process that we believe meets the demanding standard of a RBP, as well as data related to a second potentially Replicable Best Practice that we are sharing with Better Health’s partners.

improving Pneumococcal Vaccination Rates in Patients with Diabetes. During analyses for our first Checkup in 2008, we recognized that nine of the top 10 practices in giving pneumococcal vaccinations were from a single health care organization. Interviews with the system’s leaders uncovered a systematic approach that used teamwork, their eMR and standing orders to enable nurses to vaccinate patients. The MetroHealth System’s detailed protocol was described in the June 2009 Checkup at betterhealthcleveland.org and shared with the other systems though Better Health’s Learning Collaborative, reports, and practice site coaching. In the next Checkup, vaccination rates improved over 5% in the region, the largest improvement of any individual Care Process standard, with similar improvements across both eMR-based and paper-based systems and sites. We refer to this RBP simply as “Standing Orders” and believe it could be replicated in other systems and sites. Figure 5 displays the changes in vaccination rates at MetroHealth, whose achievement remains high, and for the other systems in the region, which improved substantially -- from 68% to 74% in 2008-09 over the previous year.

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Figure 5. Percent of Patients with Pneumonia vaccination in MetroHealth as compared to All Other Systems, 2007-08 to 2008-09

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MeTROHeALTH

ALL OTHeR SYSTeMS

Christopher J. Hebert, MD, MSDirector

Caroline Carter, MS, LSWCo-Project Manager

Stephanie Lessick, MA, RHIA, CCS Co-Project Manager

Better Health Greater Cleveland Quality Improvement Learning Collaborative Leadership and Staff


improving outcomes: using Data to Discover a Replicable Best Practice. During analyses for the current Checkup, our Best Practices Team identified a site that had improved its diabetes Outcomes substantially more than other sites between 2007-08 and 2008-09. As shown in Figure 6, paper-based site “H” improved its composite Outcomes by 9 percentage points (from 14% to 23%). This improvement contrasts with trends over the same period in which paper-based sites not only achieved less well (Figure 3) but also improved less than did eMR-based sites. Practice site “H” improved in several individual Outcome standards, including LDL cholesterol (65% to 73%; an 8-point improvement), and body-mass index (0% to 37%; a 37-point improvement.) Parallel improvements were achieved in Practice H’s Process standards: for eye examinations (35% to 40%; a 5-point improvement), kidney management (62% to 86%; a 24-point improvement) and pneumonia vaccinations (0% to 17%; a 17-point improvement). While the baseline levels of these measures were low in 2007-08, the improvements are dramatic, and suggest that something systematic was happening in Site H. What did they do?

According to the nurse Certified Diabetes educator at Practice H, Better Health’s data motivated the system’s CeO: “After (our CeO) saw our baseline data, we began to focus on all of these measures,” she said. “It made us see that we weren’t doing all the things we thought we were doing. The measures were the driver.” Indeed, while several components contributed to the resulting processes – not the least of which was motivated and effective leadership – our RBP Team has begun to refer to this potential RBP simply as “The Checklist”, because Practice H created a checklist of evidence-based tests, treatments and immunizations that should be provided to virtually all of their diabetic patients. The Checklist is used in a three-step process:

1. A medical assistant (MA) reviews the patient’s record before a scheduled appointment and highlights missing items on the Checklist;

2. The MA calls the patient. If missing items had been ordered and should have been completed by the appointment time, the MA determines whether the patient will be able to have them completed before the visit, and if not, whether the appointment should be rescheduled.

3. When the patient arrives for his appointment, the updated checklist is attached to the registration information. The physician and her assigned MA work together to address identified gaps, perhaps with a prompt from the MA to the physician: “Could you order these today if you think it’s appropriate?”

The use of simple steps, goal-driven teamwork and additional details of the Checklist approach are being shared with Better Health’s practice partners with expectations of accelerating similar improvements.

Patients play an important role in achieving Care Process and Outcome

standards. Better Health developed a new educational brochure for

its partner practices that includes information on standards of good

care and outcomes, tips for partnering with providers and a magnet-backed

notepad that cues patients to write questions for their physicians.



Heart Failure. We used the same procedures to establish standards for heart failure as those used for diabetes. Our Heart Failure Subcommittee reviewed relevant standards of the national Quality Forum (nQF), nCQA, Department of veterans Affairs, Agency for Health Care Research and Quality (AHRQ) and several cardiovascular disease specialty associations. The subcommittee distinguished standards for evaluation from those for Treatment of patients with heart failure. Detailed evidence-based rationales for its recommendations were submitted to and reviewed by the Clinical Advisory Committee and approved by Better Health’s Leadership Team.

Table 4 summarizes Better Health’s four individual evaluation Standards and two Treatment Standards along with relevant composite (or “summary”) standards for heart failure. Included are all patients with diagnosed heart failure who are 18 years or older and seen at least twice in their primary care practice during the measurement year. The evaluation standards include tests that should be done to determine the cause and extent of heart failure (called “Heart Function test”); blood tests to detect complications or risks for treatment, and routine monitoring of weight and blood pressure at the time of doctors’ visits. The composite evaluation Standard requires that all four individual evaluation standards are met for each patient. That is, the achievement of a practice site, and the region as a whole, represents the percentage of patients with heart

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Figure 6. Change in % of Patients Meeting Diabetes Outcomes Standards from 2007-08 to 2008-09

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Practice H

Worse Better

After a presentation by a Kaiser Permanente practice at Better Health’s Learning Collaborative session in September 2009, a group of practitioners from MetroHealth wanted to learn more. They followed up with a “field trip” to Kaiser, which shared its approach to ePopulation Health in managing care for broad panels of patients.


met all four standards. The Treatment standards include a prescription for one or both types of medications that are known to benefit patients with moderate or severe heart failure, defined as those with inadequate heart pump function. Patients with documented allergies or intolerance to both types of medications are excluded from the assessment of Treatment achievement. Achievement on the composite Treatment Standard is represented as the percentage of patients in the region, or the percentage cared for at a particular site, who have been prescribed either one or both types of medications.

HEaRT FailuRE RESulTS: EmR-BaSED SiTESIn this executive Summary, we summarize regional achievement against nationally endorsed and locally vetted standards for heart failure (described in Table 4. Further information on the achievement of Better Health’s individual practices is provided in the complete Checkup at betterhealthcleveland.org. The regional summary includes the results of more than 5,300 patients treated by more than 270 primary care physicians in 32 practices, all of which are part of three large health care organizations that use eMRs: The MetroHealth System, Cleveland Clinic and Kaiser Permanente. The data represent a “snapshot” of heart failure evaluation and treatment in Greater Cleveland between July 1, 2008 and June 30, 2009. We describe regional achievement on the four individual evaluation Standards and the two individual Treatment Standards, along with corresponding composite standards. Results are summarized on composite evaluation and Treatment standards by insurance, race, and estimated household income and educational attainment.

TaBlE 4. BETTER HEalTH’S inDiViDual anD ComPoSiTE STanDaRDS FoR HEaRT FailuRE

Evaluation Standards4 Standards of good assessment

Treatment Standards2 Types of Evidence-Based medications

Heart Function Test Done (“echo” to see how well your heart is pumping)

Blood Test Done Each year (Basic Metabolic Panel to check blood chemistry)

weight Checked Regularly (Look for fluid retention to monitor heart function)

Blood Pressure Checked Regularly (High Blood Pressure can signal serious heart problems)

ACE/ARB Medication (Improves heart and kidney function

and lowers blood pressure)

Beta-Blocker Treatment (Blocks stress hormones, which make

your heart work harder)

Evaluation Composite: Percent of patients who meet all 4 standards

Treatment Composite: Percent of patients with moderate or severe heart failure who received

at least one of the medications



REgional aCHiEVEmEnT on ComPoSiTE anD inDiViDual STanDaRDSFigure 7 highlights the region’s overall achievement on our composite evaluation standard and its four component standards during the measurement period. As described above, achievement on our Composite evaluation Standard reflects the percentage of our patients with heart failure who meet all four individual evaluation Standards. Overall, 75% of our patients met this target in 2008-09, with the remaining 25% meeting three or fewer standards. Achievement on individual standards was generally high, with some variation. Collectively, 89% had a heart function test; 97% had recommended blood tests; while 87% had their weight and 98% had their blood pressure checked regularly.

Figure 8 highlights regional achievement on our composite Treatment standard and its two components. This measure includes 2,274 patients with moderate or severe heart failure (left ventricular systolic dysfunction), which represents about 43% of the 5,331 heart failure patients in Figure 7. Overall achievement on the Composite Treatment Standard reflects the percent of our patients with moderate or severe heart failure who meet either of our two individual Treatment Standards. Collectively, 95% of our patients met this target in 2008-09; 85% of these patients had a documented prescription for beta-blocker therapy and 86% had a prescription for an ACe-inhibitor or ARB medication.

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Figure 7. Achievement on Better Health’s Composite evaluation Standard and its Four Individual Standards, 2008-09

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Figure 8. Achievement on Better Health’s Composite Treatment Standard and its Two Individual Standards, 2008-09

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HEaRT FailuRE aCHiEVEmEnTFigure 9 summarizes the region’s overall achievement on our summary evaluation and Treatment standards, stratified by subgroups for 2008-09. Unlike our findings in diabetes, we find remarkably little variation across these demographic and socioeconomic strata, with high and very high achievement on our composite evaluation and Treatment Standards, respectively, across patient subgroups.


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CommEnTS on HEaRT FailuRE aCHiEVEmEnTRegional achievement on our heart failure standards is remarkably good compared with virtually any benchmark in the published literature, and we observed no substantial disparities across subgroups by insurance and other socio-demographic factors. Perhaps most notable is that more than nine in 10 of our patients were prescribed one or both of the evidence-based classes of medications that are recommended for treatment of persons with significant heart failure. While we view these results as a source of some pride, we also note that our results come from eMR-based practices with mostly well-insured patients and that they represent provider-centered actions and not patient-centered outcomes. That is, neither patient adherence to these medications nor more important outcomes, such as hospitalization or mortality rates, are yet part of our measurement system. Collectively, 93% of our heart failure patients have Medicare (73%) or Commercial insurance (20%), while only 5% were insured by Medicaid. Because this patient group is mostly older, only 2% are uninsured. Likewise, compared with our diabetes patients, fewer heart failure patients were non-white or lived in neighborhoods with low educational attainment or income levels. Finally, the achievement reported here reflects the accomplishments and documentation of eMR-based practices in large integrated delivery systems. Whether these exceptional regional results will hold true as we add smaller and paper-based systems to our report awaits future study.

mEaSuREmEnT maTTERS: SummaRy CommEnTSThe theme of this Community Health Checkup is that measurement matters. We improve the things that we measure. We shine a light on them, and professional pride, even competitiveness, prompts a search for solutions. We collaborate. We share our best practices but compete on their execution.

We acknowledge that systems and patients have different resources on which to draw, so we shine a light on that, too. We are beginning to understand that differences in the resources available in health organizations, particularly in medical record systems, enable different levels of care quality and care improvement. We also believe that practices’ improvement is as important as achievement on our standards, so we identify potentially Replicable Best Practices from our data and spread discoveries of improvement processes that we think others can replicate. Finally, we must acknowledge that we are not yet measuring all that we believe is important: the quality or length of our patients’ lives, and the costs and consequences of hospitalizations that would not have occurred if care were better coordinated across different sites of care. Recent nationwide county-by-county reports are beginning to use these measures and challenge us to include them – as well as other measures related to underlying causes of poor health -- if we are to meaningfully improve the health status of our region.

To read more about environmental and other factors that affect health, visit countyhealthrankings.org.


“It gives us a safe place to collaborate with practices from

other health care systems and learn what works and what doesn’t.”

— Nathan Beachy, MDMetroHealth

We are optimistic that we will meet these more important goals. Our partnership is dedicated and growing. Although Better Health’s clinical collaborators are dominated by early and mature adopters of electronic medical records, we represent less than half of the region’s primary care practices and recognize that other systems and sites, especially smaller and independent practices, are still using paper-based medical records. We are committed to help “saturate” the region with eMRs and to connect health information across different systems to improve care coordination and to document gaps in care so that we can reduce them. Our public health partners are equally committed to addressing important underlying causes of most chronic medical conditions. And many regional employers have begun to recognize that they can favorably influence the health behaviors and health of their employees. Since most experts agree that better health care alone would reduce premature deaths in the United States by only 10-20%1, complementary efforts of all regional stakeholders are critical to our success.

The 15 Aligning Forces for Quality communities. Like Better Health Greater Cleveland, all are dedicated to multi-stakeholder collaboration to improve the quality and value of health care in their regions.

1. Schroeder SA. Shattuck Lecture. We can do better – improving the health of the American people. New england Journal

of Medicine. 2007; 357: 1221-1228.

© Better Health Greater ClevelandAll Rights Reserved. printed Winter 2010

BeTTeRHeALTHCLeveLAnD.ORG


OUR MISSION Better Health Greater Cleveland is a multi-stakeholder partnership that improves the health and value of health care provided to people with chronic medical conditions in Northeast Ohio.

We are committed to:• improving care and outcomes of all people with

chronic conditions;

• eliminating disparities in health observed among disadvantaged populations by insurance, race and income; and

• transparency across collaborating organizations, and, through public reporting of patient care data, with our community.

visit our web site to learn more about Better Health Greater Cleveland and our partners. Learn how others are playing their part for better health, and find resources. And get involved.

We all have a role to play in a healthier Greater Cleveland.

visit betterhealthcleveland.org today.

A program of the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative and other funders

Randall D. Cebul, m.D., DirectorDiane Solov, Program ManagerThomas E. love, Ph.D., Director, Data Management CenterCarol Kaschube, Project Specialist

216.778.8024 betterhealthcleveland.org

T H E P O W E R O F P A R T N E R S H I P

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