Transforming healthcare

Mayo Clinic has a vision: to improve healthcare for its patients. How? By fostering teamwork, collegiality and integration. Julia Puppe spoke with CEO Denis Cortese about his clinic’s contributions to transforming healthcare – and what gets in the way.

With sites in Rochester, Minnesota; Jacksonville, Florida; and Scottsdale, Arizona, Mayo Clinic treats more than half a million people each year. The world’s largest private, not-for-profit healthcare organization employs more than 3,000 physicians and scientists and 46,600 allied health staff. Its residency program comprising 3000 residents is the largest in the country. With three-sited programs, like the clinic’s transplant program, Mayo has grown into a comprehensive healthcare institution providing large-scale, high-calibre care.

There’s more. Nearly 780 physicians and 12,400 allied health staff are employed by Mayo Health System organizations, a family of clinics, hospitals and healthcare facilities serving more than 60 communities in Minnesota, Iowa and Wisconsin. Last year, Mayo Health System served more than 2.5 million patients. Add to that Mayo Medical Ventures, which commercializes medical technology and operates outpatient pharmacies and a medical supply store. There’s also Mayo Collaborative Services with offerings such as medical laboratory, validation support, and clinical trial services. Don’t forget Mayo’s Research and Cancer Center – and Mayo Clinic Proceedings, the organizations’ peer-reviewed medical journal sponsored by Mayo Clinic and authored by physicians worldwide. You get the picture: Mayo Clinic is enormous both in size and reach.

A unified medical record

How do you keep a multi-sited, ever growing high profile institution like this together? Denis Cortese, president and CEO of Mayo Clinic since 2003, makes it sound easy: “By making sure Mayo’s three sites are integrated and work together as a single institution.” The pulmonary medicine specialist has been with Mayo Clinic for 37 years. Leading the institution, he says, isn’t much different from his previous professional experience. Along with the other physicians, he regularly travels to all three campuses – and shares responsibilities. Quite unique amongst healthcare institutions of its scale in America, Mayo Clinic is led by a physician administrator team. Its corporate spirit is teamwork. Cortese: “We deliver patient care in an atmosphere where everyone is expected to work in teams. Every single patient has a different team caring for them. An individual physician may be a member of 20 to 50 teams at any particular time.”

Teamwork also is an integral part of clinical research. To help foster a collaborative approach, in 2006, Mayo Clinic provided $170 million in research from its own resources, in addition to the $280 million from the National Institutes of Health (NIH) and other extramural sources. “Putting our own dollars on the table to help foster research collaboration is unique for any other academic center in the country. The amount is extraordinary. Our donors and benefactors really recognize the value of having a collaborative team approach to problem solving,” says Cortese with growing enthusiasm.

Cortese is passionate about building teams. He spends a lot of his time mentoring and coaching his peers to ensure he is keeping everyone in a team-like fashion and moving towards the clinic’s four strategic goals. These serve Mayo’s ultimate goal to improve its ability to be a learning organization.

This is further supported by an excellent comprehensive education program. The College of Medicine at Mayo Clinic includes five schools – Mayo School of Graduate Medical Education, Mayo Graduate School, Mayo Medical School, Mayo School of Health Sciences and Mayo School of Continuing Medical Education – with combined enrollment of more than 5,000 students. “We are doing all of this for the purpose of distributing and disseminating knowledge not just to ourselves but also to our patients, to the public and to the profession,” says Cortese.

Mayo stands out not only because it has one of the largest education programs in the country, but also because it has had a unified medical record since 1907. Cortese is proud of it: “I would challenge any other healthcare institution to demonstrate that they have a truly unified medical record today, let alone have had one for the last century. A unified medical record means that all the patients’ information is always available wherever they go.

Integrated and coordinated care

“The idea of working in teams is still foreign to healthcare in this country. The idea of integrated care with a primary physician who coordinates that care is also uncommon in this country,” says Cortese. “Probably the major problem in the US is that there still isn’t integrated and coordinated care for patients when they have multiple chronic problems. And there are only a few institutions now that are starting a system engineering approach to how they care for the patients.”

Once he has got going, it is difficult to stop the enthusiastic 63-year-old, who is genuinely passionate about the state of American healthcare. “The idea of focusing on patient care first and having education and research functions acting in support of patient care is unique to Mayo Clinic. The primary mission of other academic medical centers in this country is research. Education is a secondary mission and patient care is just something that they do in addition to research and education. In non-academic medical centers, such as traditional community hospitals, the focus is not on research or education, but it’s not on patients either. Their primary customers are physicians because they bring the patients into the hospital.”

Mayo Clinic, Cortese devoutly believes, is different: “We are not a hospital, we are a clinic with hospitals. Only about 17 percent of the patients we care for ever get admitted to the hospital. Any time there’s an admission to a hospital, I call that a failure of the medical system,” exclaims Cortese, adding: “Hospitals are not the center of medical care, the patient is the center of medical care. I have never met a patient in my whole experience that ever wanted to go in a hospital. So the whole country really needs a dose of recalibrating because we tend to think of everything being hospital-centric. If we had a successful medical system all the hospitals would be closed. Or most of them would be closed, they would just have to cover trauma and some acute illnesses that occur.”

Combined wisdom

Cortese’s focus is to treat patients for what they need. Some patients, he admits, do need to go into hospital, but he tries his very best to keep them out of it. “It’s a totally different approach to medical delivery and Mayo Clinic has been that way since the Mayo brothers started it 130 years ago.”

The story of Mayo Clinic’s beginning as a small town medical practice in 1889 is also a story of two extraordinary brothers: Dr. William J. Mayo and Dr. Charles H. Mayo. Together, they developed the group practice concept, convinced that the combined wisdom is greater than any individual. A then revolutionary way to practice medicine, the group evolved naturally as physicians, medical professionals and administrators worked together to solve practical problems. Following the opening of Saint Mary’s Hospital in Rochester in 1889, the Mayo brothers attracted an ever-growing number of patients. New Mayo associates were appointed, including Dr. Henry Stanley Plummer, whose foresight in developing a simple, easily retrievable medical record system produced a unique research archive in 1907.

Today, Plummer’s paper system has evolved into a highly computerized electronic medical record – a move that was recognized by the Center for Health Transformation as a healthcare transforming example. Cortese, however, is rather matter of fact about it: “From the country’s perspective, the idea that we automated and went to a single electronic record seems like it was a major transformation. That’s because no other healthcare organization had a unified medical record before the electronic record became available. We did. For us, the transformation happened in 1907. So the fact that we went electronic was just a change in format. It took us a few years to get the conversion done because we were asking our staff to vacate the very excellent unified paper record they were used to. However, now that we have made the move, 87 percent of our physicians would not go back to paper.”

Starting in 1993, it took three years to combine five million records into a single database. The system is designed to protect data security and patients’ privacy. The integrated records are comprehensive: patient files, X-rays, lab results and electrocardiogram results. Since 2004, they also include data mining and pattern-recognition tools, which are utilized to discover relationships among specific proteins, genetic makeups, and treatment responses. Cortese hopes that these efforts will help generate new therapies and lead to genuinely personalized medicine. As a result of Mayo Clinic’s efforts, information can now be shared even faster than before – instantaneously. An unlimited number of physicians can conduct a virtual consultation on any patient because the electronic record is available in all three sites. “They can simultaneously be looking at the same information talking to each other via video conference. That was transformational for us,” says Cortese.

Transforming examples

Mayo Clinic is not the only institution that has contributed to transforming healthcare. George Washington University Hospital’s voice recognition feature of its Picture Archiving and Communications System (PACS) has significantly improved the quality and speed of patient care. A web-based medical record, which is linked to Miami Children's Hospital’s laboratory systems and point of care testing devices, allows them to visualize data obtained at the bedside almost instantaneously, from any location, and in graphic form. All of these efforts, praises the Center for Healthcare Transformation, are key to transforming the current healthcare system to one that provides better healthcare and more choices at lower cost.

What remains a challenge, at least from Cortese’s perspective, is an insurance company: “Medicare’s board of directors is Congress. And Congress has interfered with the delivery of healthcare in the US to an extent that Medicare has encouraged the worst value of care – the lowest quality, the lowest safety, the lowest service, and the lowest level of integration and coordination. But Medicare can’t afford it and is not buying the value that it needs to be purchasing. The members of Congress who are running Medicare think short-term. Healthcare, however, is a long-term issue.”

Mayo Clinic is the largest provider of Medicare services in America. Reason enough for Cortese to be fierce about the insurance company: “We are on the leading edge of what is going to happen to the rest of the country in the next five to 10 years as many of us start to enter the Medicare age. Individual practitioners, smaller clinics, and other hospitals are seeing more Medicare age patients, but those patients are not getting access to care because doctors and hospitals do not want to deal with Medicare. It is an aggressive insurance company. It doesn’t negotiate at all on prices. Mayo Clinic loses money on every patient that comes in from Medicare. And Medicare audits physicians in a manner that leaves us guilty until we prove ourselves innocent. It’s not a friendly environment to be working in,” Cortese asserts disapprovingly.

Early risk identification

The Medicare challenge, explains Cortese, is why Mayo Clinic has got involved in national health policy: to bring attention to the problem. “We cannot improve healthcare until the US comes to grips with the fact that it has no healthcare system. We have been saying the healthcare system is broken. This has led to the idea that if something is broken, you can fix it – but there is nothing to fix, nobody ever designed a system. We can’t hold anybody responsible for this whole mess, which actually makes the whole problem easier. We just need to take a step back and design one that is best for the patient.”

What is best for the patient, says Cortese, is early risk identification, and thorough treatment of these risks, or of early-stage diseases, to prevent illness and complications long-term: “In other words: let’s pay for primary care. Let’s have insurance systems that reward heathcare organizations that keep individuals healthy, so that the insurance companies get a return on their expenditures by keeping patients out of the hospital 20 or 30 years down the road.” For him, the biggest challenge for healthcare in the US remains Medicare. Apart from that, the CEO says that Mayo’s common mission unites all 65,000 staff and ensures that all three sites work together as a single institution: “The needs of the patient come first. Every Mayo employee knows that, and if they don’t believe in putting the patient first, they realize that Mayo Clinic is not the place for them.”

1. William J Mayo: “The best interest of the patient is the only interest to be considered, and in order that the sick may have the benefit of advancing knowledge, a union of forces is necessary.”
2. Denis Cortese: “If we had a successful medical system all the hospitals would be closed.”
3. Denis Cortese: “We cannot improve healthcare until the US comes to grips with the fact that it has no healthcare system.”

Denis Cortese received his medical degree from Temple University in Philadelphia. He began his internship and residency at Mayo Clinic in 1970. Cortese left to serve in the US Naval Corps in 1974, returning to Rochester, then the sole Mayo Clinic location, two years later as a pulmonary medicine specialist. In 1993, he moved to the new Mayo Clinic Site in Jacksonville, where two years later he was appointed to the board of governors. He returned to Rochester in 2003 to serve as president and CEO. The 63-year-old oversees an annual budget of $5 billion, saw patients until he became CEO, and teaches in Mayo Clinic College of Medicine.