By David Brown
Washington Post Staff Writer
Thursday, July 23, 2009 4:13 PM
The Cleveland Clinic, the renowned medical center visited by President Obama on Thursday, embodies many features that experts believe are essential to both improving health care and controlling its cost.
Among the attributes that set it apart are a salaried staff, an engineered delivery system, electronic record-keeping, strong interest in the patient's experience, and a work culture committed self-improvement.
Once best known as the hospital where fabulously wealthy foreigners came for heart surgery and other high-risk procedures, the 88-year-old institution now includes eight community hospitals, as well as numerous outpatient offices, surgery centers, and urgent care sites all along the south shore of Lake Erie.
"It is a very well-established group practice that has over time become an integrated delivery system, both horizontally and vertically," said Eugene Nelson, a professor at Dartmouth Medical School who is an expert in measuring the quality of health care.
The clinic has been particularly successful in controlling the cost of state-of-the-art care, at least compared with its silk-stocking competitors.
In a study published in the British Medical Journal in 2004, Dartmouth researchers compared the health-care bills of Medicare patients treated at 13 institutions on the "Best Hospitals" list of U.S. News and World Report.
The average spending on a Medicare patient with severe chronic disease during the last two years of life was $35,455 at the Cleveland Clinic, which was the cheapest. Massachusetts General Hospital came in at $47,880, Johns Hopkins at $60,653, and UCLA Medical Center led the list at $72,793.
As with some other admired medical systems, such as the Mayo Clinic and Kaiser Permanente, the Cleveland Clinic has drawn on principles of engineering and industrial production to make sure that medical care is delivered in a predictable, reproducible way.
This consists largely of breaking complicated series of events into small units of activity that are monitored closely.
"It's a way of ensuring that what really should be done gets done," Nelson said.
For surgery patients, this includes at-home preparation, gathering of records and test results on the morning of operation, safety checks in the operating room, protocol-based post-op care, clear plans for follow-up visits, and a call to every patient within 48 hours of discharge from the hospital.
The clinic's electronic medical record was one of the first to allow patients to interact with physicians, contribute data (such as daily weights, kept by many patients with congestive heart failure) and make appointments.
"They have a fantastic health IT system, which is a necessary component of changing the game," said Ezekiel J. Emanuel, a doctor who is one of the chief architects of the Obama administration's health policies.
The record system is used to improve care by giving practitioners "clinical prompts" about what tests or therapies might be best in certain circumstances. It is also used to gather data on patient outcomes, which the clinic makes public.
A random sample of patients discharged from the hospital and treated in the clinics are interviewed in depth about their experience at all steps of clinical care.
"They have invested a good deal in trying to measure, understand and improve the patients' experience," Nelson said.
An important, if-hard-to-quantify, characteristic of successful medical systems is the shared commitment to self-improvement.
"It has a very strong physician culture -- people who believe in the organization and mission and are committed to excellence," said Donald M. Berwick, head of the Institute for Healthcare Improvement in Boston.
The Cleveland Clinic has 3.3 million patient visits and 50,465 admissions a year, for its main hospital, which is called The Cleveland Clinic.
Like the Mayo Clinic, the Cleveland Clinic has also built satellites far from the mother ship. In the Cleveland Clinic's case, they are in Florida, Toronto and the Persian Gulf emirate of Abu Dhabi.