INVITED COMMENTARY
The Road to High Performance Is Paved With
Data
Jeffry G. James
Data is a necessary component of any organizations
move toward accountability. This commentary describes
Wilmington Healths use of high-tech and low-tech data
sources in its journey to succeed as an accountable care
organization. This commentary also discusses shortcom-
ings in the availability of data and the lack of transparency
regarding cost and quality.
W
ilmington Health, PLLCa physician-owned, phy-
sician-governed, fully integrated multispecialty
group practice with more than 160 providersis a good
example of health care reform in the trenches. With a focus
on the demonstration of quality, Wilmington Health is lead-
ing the way in providing excellent health care, reducing
costs, and improving the patient experience.
Wilmington Health has provided health care to the
residents of Southeastern North Carolina for more than
40 years and has been instrumental in leading the region
toward accountability. It developed the regions first
accountable care organization (ACO) and is a participant in
the Medicare Shared Savings Program (MSSP) of the Centers
for Medicare & Medicaid Services (CMS). Wilmington
Health has demonstrated year-on-year improvement in
nearly every MSSP measure of performanceincluding both
cost and qualityand it has performed significantly better
than other ACOs in its MSSP cohort (the 104 other ACOs
that started the program on January 1, 2013). Wilmington
Health maintains a partnership with Blue Cross and Blue
Shield of North Carolina that includes an ACO agreement
for shared savings, and last year Wilmington Health shared
the stage with Kaiser Permanente as a recipient of the
American Medical Group Associations prestigious Acclaim
Award, which recognizes health care organizations prog-
ress in moving toward a delivery model that is safe, effective,
patient-centered, timely, efficient, and equitable.
Wilmington Healths drive to become a high-performing
health system has necessitated a comprehensive, multifac-
eted, wholesale organizational transformation. This type of
transformation has required the development of leadership
at all levels and has been mobilized through a formal data-
driven program of change. The program of change followed
by Wilmington Health is well described in a 1993 McKinsey
Quarterly article by Dichter and colleagues, titled Leading
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Organizational Transformations [1]. This program of cul-
tural transformation includes 3 main elements: top-down
direction setting, bottom-up process improvement, and core
process redesign. Top-down direction setting is established
by Wilmington Healths 7-member physician board of direc-
tors, which is responsible for setting and monitoring the stra-
tegic direction of the organization and for communicating
that direction to the group. Bottom-up process improvement
comes from Wilmington Healths use of a Lean management
philosophy, which considers any expenditure of resources
that does not improve value for patients, employers, or pay-
ers as wasteful and subject to elimination. This philosophy
requires that the people doing the work must be the ones
to improve the work. The third element, core process rede-
sign, is where the other 2 elements come together. As the
Dichter article states, the goal of core process redesign is
to achieve breakthrough improvements in cost, quality, and
timeliness [1].
Central to all 3 of these elements is the need for data and
measurement systems. Some of these needs are obvious; for
example, the board of directors clearly needs data in order
to make course corrections in the strategic direction of the
organization. Likewise, systems cannot be improved if they
cannot be measured. The data derived from measurement
helps those who are involved in bottom-up process improve-
ment to understand the waste in the system and to develop
countermeasures to remove it. These types of data are often
derived from observation, information technology plat-
forms, and trial and error within the confines of the system
being evaluated.
In contrast, the data required for core process redesign
differs both from the data used by the board to set the
organizations strategic direction and from the data used
by Lean teams to drive waste from the system. Much of the
data needed for core process redesign does not yet exist,
either at Wilmington Health or in the health care system
as a whole. To achieve the ACO ideals of population health
Electronically published May 5, 2014.
Address correspondence to Mr. Jeffry G. James, Wilmington Health,
1202 Medical Center Dr, Wilmington, NC 28401 (jjames@wilmington
health.com).
N C Med J. 2014;75(3):191-194. 2014 by the North Carolina Institute
of Medicine and The Duke Endowment. All rights reserved.
0029-2559/2014/75308
191
and to become truly accountable for cost, quality, and the
experience of patients, we must identify, implement, mine,
and analyze data in a new way. Data must now encompass a
much broader representation of the continuum of care than
was previously possible in the American health care system,
which has traditionally been extremely fragmented.
The power of core process redesign comes from bringing
cross-functional elements together across the continuum of
care in a collaborative, data-driven model. The industry is
making great strides in collecting and coalescing data from
multiple sources, and innovations in technology are coming
at a rapid rate. Many ACOs have progressed to their second
electronic medical record (EMR) system and no longer view
this system as a mirror image of the paper chart; rather, it is
now viewed as a data warehouse that is connected to their
mission, vision, and strategic plan. EMR data and claims
data can now be linked to provide a clearer picture of cost
and quality across a single health care system. These same
data can also be used in predictive modeling that can greatly
enhance an organizations ability to focus resources in the
areas that are most amenable to improvements in cost and
quality.
However, there are still some shortcomings in the tech-
nology that inhibit collaboration across the continuum of
care and prevent true patient engagement. Health informa-
tion exchanges are still in their infancy, and they are just
now starting to develop in a way that will allow the types of
activities mentioned above to be accomplished over a broad
range of disparate electronic systems. The good news is that
this technology is moving forward quickly, and solutions are
imminent. Attempts to use data to accomplish the Institute
for Healthcare Improvements Triple Aim objectives
improving the patient experience, improving the health of
populations, and reducing per-capita costs [2]have been
limited not only by technology but also by the unwillingness
of various stakeholders to make cost and quality information
transparent. The lack of transparency in cost data reduces
patient engagement by keeping health care consumers in
the dark regarding a significant component of their health
care decision making. As economist Harold Miller noted in a
2012 article published by the Center for Healthcare Quality
and Payment Reform [3], this lack of transparency in cost
data also prevents health care providers from developing
new payment systems.
Wilmington Health has transformed itself by implement-
ing various systems that are allowing it both to redesign
its internal systems and to enhance its interactions with
external data environments. As might be expected, several
high-tech approaches have been implemented. For example,
point-of-service analytical tools allow for real-time notifica-
tion of gaps in evidence-based care when a patient presents
to any location in the Wilmington Health system, and an
application developed for handheld devices (smartphones)
can be used to inform a transition-of-care coordinator about
a high-risk discharge. In addition, a new system integrates
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practice management with the EMR system, and a popula-
tion health tool that has been bolted onto this integrated
system incorporates claims data from payers, provides
feedback, and facilitates predictive modeling for population
health initiatives.
In addition to these high-tech tools, Wilmington Health
uses several low-tech methods to transmit data and drive
change. For example, emergency department (ED) pro-
viders now have an easy button they can use to leave a
voicemail message about a patient who needs to be seen,
and Wilmington Health guarantees that that patient will be
seen the next day. Other low-tech efforts can be seen in the
handwritten graphs that line the walls of Wilmington Health,
which are used to measure and report daily progress on sev-
eral important initiatives.
Wilmington Health also uses both internal and external
working groups to analyze data and provide feedback and
comparisons. One of these groups is the internal pilots
group, which reviews the organizations many ongoing
experiments. This group vets the data and adjusts the exper-
iments before they are rolled out to the entire organization,
to increase the likelihood of early acceptance of the data. To
obtain external validation of the data process, Wilmington
Health has joined the Anceta Collaborative Data Warehouse,
which was established by the American Medical Group
Association. Including such notable organizations as the
Mayo Clinic and the Henry Ford Health System, this collab-
orative meets twice yearly to transparently share data, and
it normalizes these data across its 18 member organizations.
Whichever organizations are performing well on any partic-
ular measure openly share their best practices, and the col-
laborative engages in transformative discussions that help
shape the overall direction and implementation of evidence-
based medicine.
As a result of implementing and applying both data solu-
tions and cultural transformation, Wilmington Health and
its ACO partners have enjoyed some remarkable improve-
ments. Nearly every core measure of cost and quality has
improved over the past several years, and Wilmington
Health continues to perform significantly better than other
organizations in its ACO cohort.
For example, Figure 1 shows the number of hospital
admissions per 1,000 patient-years in Wilmington Healths
MSSP from 2010 through 2013, as well as the mean for the
other ACOs in the MSSP cohort at the end of 2013. Between
2010 and 2013, Wilmington Health reduced its number of
admissions per 1,000 patient-years by 19%, and it had 28%
fewer admissions per 1,000 patient-years in 2013 compared
with the mean for the other ACOs in its cohort.
Figure 2 shows the number of hospital readmissions for
any reason during the first 30 days following discharge, per
1,000 admissions, in Wilmington Healths MSSP from 2010
through 2013, as well as the mean for the other ACOs in the
MSSP cohort at the end of 2013. The readmission rate for
Wilmington Health decreased by 13% between 2010 and
 figure 1.
Number of Hospital Admissions per 1,000 Patient-Years in Wilmington Healths Medicare
Shared Savings Program (MSSP), 20102013

Note. The first 4 bars show data for Wilmington Health from 2010 through 2013. The last bar (far right) shows the mean
at the end of 2013 for the 104 other accountable care organizations (ACOs) that joined the MSSP on January 1, 2013.

2013, and Wilmington Healths readmission rate in 2013 was
17% lower than the mean rate for the other ACOs in its MSSP
cohort.
Figure 3 illustrates how the use of advanced imaging
changed as Wilmington Health transformed its practices;
specifically, this figure shows the number of computed
tomography (CT) scans per 1,000 patient-years performed
in Wilmington Healths MSSP from 2010 through 2013, as
well as the mean for the other ACOs in the MSSP cohort at
the end of 2013. In 2010, CT use at Wilmington Health was
significantly higher than the mean for the other ACOs in the
cohort; however, the number of CT scans per 1,000 patient-
years in Wilmington Healths MSSP dropped dramatically in
2011 and continued to decline in 2012 and 2013. The number

figure 2.
Number of Hospital Readmissions for Any Reason During the First 30 Days Following
Discharge, per 1,000 Admissions, in Wilmington Healths Medicare Shared Savings Program
(MSSP), 20102013

Note. The first 4 bars show data for Wilmington Health from 2010 through 2013. The last bar (far right) shows the mean
at the end of 2013 for the 104 other accountable care organizations (ACOs) that joined the MSSP on January 1, 2013.

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 figure 3.
Number of Computed Tomography (CT) Scans per 1,000 Patient-Years in Wilmington Healths
Medicare Shared Savings Program (MSSP), 20102013

Note. The first 4 bars show data for Wilmington Health from 2010 through 2013. The last bar (far right) shows the mean
at the end of 2013 for the 104 other accountable care organizations (ACOs) that joined the MSSP on January 1, 2013.

of CT scans per 1,000 patient-years was 34% lower in 2013
than in 2010, and Wilmington Health is now outperforming
the other ACOs in its cohort on this measure as well.
Wilmington Health has shown year-on-year improvement
for the past 4 years in almost every category for which data
are reported to CMS. One of the most-reviewed measures
is the total cost of care per Medicare beneficiary; on this
measure, Wilmington Health has achieved a cost that is 21%
lower than the average for the other ACOs in its MSSP cohort.
The challenge of many ACOs across the country is build-
ing a sustainable model in the absence of best practices.
Because there are few model ACOs from which lessons can
be learned, Wilmington Health is taking a very pragmatic
approach to the development and deployment of the neces-
sary population health data platforms. Thanks in part to this
approach, Wilmington Health has been able to accomplish
the results described above through normal operations,
having increased its staff by only 3 full-time-equivalent
positions.
Wilmington Health has learned 2 important lessons on
this journey: First, once physicians trust the information being
provided, regardless of the data source, they will do the right
thing even in the absence of financial incentives. Second,
total transparency of performance data can allow an organi-
zation to achieve remarkable results very quickly.
Jeffry G. James, CPA, MBA chief executive officer, Wilmington Health,
Wilmington, North Carolina.
Acknowledgments
Potential conflicts of interest. J.G.J. is an employee of Wilmington
Health.
References
1. Dichter SF, Gagnon C, Alexander A. Leading organizational transforma-
tions. McKinsey Quarterly. http://www.mckinsey.com/insights/or
ganization/leading_organizational_transformations. February 1993.
Accessed March 4, 2014.
2. Institute for Healthcare Improvement (IHI). The IHI Triple Aim. IHI
Web site. http://www.ihi.org/engage/initiatives/TripleAim/Pages/
default.aspx. Accessed March 4, 2014.
3. Miller H. Ten Barriers to Healthcare Payment Reform and How To
Overcome Them. Pittsburgh, PA: Center for Healthcare Quality and
Payment Reform; 2012. http://www.chqpr.org/downloads/Overco
mingBarrierstoPaymentReform.pdf. Accessed March 4, 2014.

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