The Mayo Plan

By Dan Beckham

The revered clinic takes its “patient first” model of health care to a national insurance proposal.

A single black-and-white photo demonstrates that Mayo Clinic had become a national treasure by 1935. It shows Franklin D. Roosevelt smiling broadly as he sat in the backseat of a convertible between Will and Charlie Mayo. The clinic had become worthy of the patronage of American presidents as well as the loyalty of hundreds of thousands of less illustrious patients.

Since then, Mayo’s reputation has only grown. That reputation has meant an obligation to use its influence to address what was ailing American medicine. As Will Mayo observed in 1921, “The medical profession can be the greatest factor for good in America. The greatest asset of a nation is the health of its people.... Medicine’s place is fixed by its service to mankind; if we fail to measure up to our opportunity, it means state medicine, political control, mediocrity and loss of professional ideals.”

Integration
What has always made Mayo different is its lack of walls. Mayo’s mission statement indicates that it “will provide the best care to every patient every day through integrated clinical practice, education and research.” The distinguishing word here is integrated. When Will and Charlie conceived of Mayo Clinic, they imagined something much different from the health care of their day. Rather than individual physicians proudly entrenched in their own practice and specialty holes beholden to no one, they saw physicians of many specialties working collaboratively with only the interests of their patients to consider.

Supporting the physicians on this team were lay administrators who were afforded the greatest respect by their physician colleagues. Physicians and administrators were, in turn, supported by a uniquely integrated infrastructure that dramatically increased the efficacy, efficiency and responsiveness of care. This distinctive medical model and the passionate commitment of its advocates explain how one of the world’s great organizational and technological enterprises came to rise like Oz’s Emerald City among the rolling hills of southeast Minnesota.

It was across these same hills that Will Mayo took long motorcar rides with the clinic’s first administrator, Harry Harwick. At the time, Will feared he was dying. So he felt compelled to share in detail his dreams for Mayo Clinic with the man he was confident could provide the management discipline necessary to bring them to fruition. There was no line between medicine and management in that car on those country drives. Medicine and management were all one thing, and so they’ve remained at Mayo Clinic to this day.

The Necessity of Cooperation
Just as Harwick sat next to Will Mayo, today Bob Smoldt sits in the office next to Denis Cortese, M.D., Mayo’s physician CEO. Smoldt is the latest in a revered line of top administrators at Mayo. He is the embodiment of a rich legacy of “professional management.” Cortese, a pulmonologist, represents a tradition of “physician leadership” that reaches back to Will and Charlie Mayo. Cortese is responsible for a $5 billion enterprise, but he still sees patients and teaches, like all his CEO predecessors. Together, Cortese and Smoldt are what Mayo has been from its beginnings--medicine and management--unified around the patient.

As Mayo’s leaders have consistently emphasized, Mayo is “physician led and professionally managed.” While it is not unusual for other health care organizations to declare they intend to “emulate Mayo,” they rarely appreciate what this aspiration entails. Many hospital administrators choose to ignore the “physician led” part. Many physicians ignore the fundamental importance of “professional management.” Very few recognize the depth of collegial partnership that characterizes the relationship between physicians and administrators at Mayo Clinic.

The Mayo brothers did not create their clinic alone. The groundwork was laid by their father, William Worrall Mayo, who drilled into them the necessity of cooperation, suggesting that “no one is big enough to be independent of others.” Harwick designed the clinic’s business and administrative practices. Mother Alfred Moes, through her sheer determination, built St. Mary’s Hospital, where the Mayos would rely on the sisters’ assistance as they perfected their surgical skills. But when it came to inventing the organization that would knock the walls out of Mayo, much of the credit goes to Henry Plummer, M.D.

Early Harbinger of EMR
Plummer was a gifted physician. His work with hormonal disorders led to numerous advances. He was also an exceptional engineer of both tangible and intangible things.

Plummer designed the clinic’s extraordinary patient record system. Referred to within Mayo as the “unit medical record,” it was a dossier that contained both inpatient and outpatient data in one file linked to a unique Mayo Clinic identification number and stored in a central repository. This single dossier preceded the patient wherever he or she went in the clinic, thus providing the appropriate physician with the benefit of an integrated perspective. It brought patient, physician, laboratory tests, radiology reports and medical record into one room at the same time.

Without Plummer’s system, it would not have been possible for Mayo to offer patients timely and coordinated consults with the appropriate mix of specialists or to provide the option of next-day surgery. Although Plummer launched this innovation in 1907, outside of Mayo most patient records remain scattered throughout the offices of multiple independent physicians and hospitals. Mayo converted Plummer’s paper system to an electronic version in the mid-1990s. Its ability to produce an up-to-date, integrated medical record on every Mayo Clinic patient remains one of its hallmarks.

It was Plummer, too, who designed the network of conveyor belts, drop slots and phone lines that helped make the integration of care possible at Mayo. When representatives of the phone company told Plummer that the kind of internal communications system he envisioned for the clinic was not feasible, he showed them how to make it work. And when the clinic outgrew its facilities, Plummer designed and oversaw the construction of new buildings that represented a revolution in the way medicine was organized and delivered. Like Mayo’s medical record, waiting areas, exam rooms and offices were standardized with a careful eye to the needs of the patient.

Embracing the Mayo Way
When Mayo Clinic built its revolutionary clinic in Minnesota, it also created a revolution in American medicine. That many Americans came to embrace the Mayo way is well represented by the thousands who arrived without an appointment and waited hopefully at its doorstep. But to health care providers satisfied to work without the benefit of teamwork and infrastructure, Mayo was a threat.

The Mayo way was denigrated and resisted by many for decades. Many physicians simply dismissed it as socialized medicine. Despite this, the Mayos felt a responsibility to carry beyond Rochester, Minn., what they deeply believed to be a superior approach. They were tenacious in their quiet Midwestern manner, and their way spread. Clinics based on the Mayo model sprung up and grew on varied terrain--not only in rural locales like Marshfield, Wis., and Sayre, Pa., but also in cities like Cleveland, Boston, Houston and New Orleans.

Beyond Clinic Walls
Over the past few years, Cortese, Smoldt and many of their colleagues have worked diligently to use the strength of Mayo’s reputation as a catalyst for significant reform. The preponderance of the quality, cost and access problems facing health care today are piled at the bottom of the organizational walls built between specialists, departments, payers and providers, as well as between medicine and management. Mayo is a proven example of the power of knocking down walls.

Mayo Clinic is doing well enough in the current health care system. It is internationally respected, growing and financially viable. Why should it dedicate itself to health care reform? Smoldt put it simply, echoing Will Mayo’s concerns: “We need to be involved in national health care reform because we believe the needs of the patient come first.”

In early 2006, Cortese and Smoldt co-authored an article outlining their ideas for creating substantial reform in health care by 2011. In it, they saw the engineering legacy of Henry Plummer renewed and expanded to significantly improve processes of care. They envisioned that all the information about patients be immediately available with a click of a computer key anywhere in the world.

And they prescribed a new era of professionalism characterized by perpetual learning. Learning would be encouraged not only within organizations but also between them, so that new ideas would be quickly shared. Such intraorganizational sharing and transparency would provide a rising tide to lift all ships.

Universal health care would be provided by removing government from its role as insurer and replacing it with a market-based model that allows consumers to choose providers on the basis of performance. Government would turn its attention to supporting innovation, facilitating the setting of standards as well as financing and coordinating coverage for Americans unable to afford insurance. Insurers would compete based on their ability to improve the health of their enrollees.

Sharing Systems and Protocols
Having articulated Mayo’s view of desirable health reform, Cortese and Smoldt launched an ambitious effort to generate input from leaders in academia, business, government and health care. A national symposium held in May of 2006 in Rochester was the first step. This interactive exchange of ideas focused on identifying innovative solutions while keeping the discussion centered on the needs of the patient.

Additional national symposia are planned. Recommendations emerging from the symposia will be shared in national policy forums where they will be honed into actionable plans. A third element of the effort will be leadership summits to inform, educate and build consensus for change among leaders positioned to influence health care reform.

Results of Mayo’s first national symposium emphasized the importance of building a public and business mandate for significant change. Cornerstones of that mandate include transparency among hospitals and physician practices to allow caregivers and consumers to learn from each other. Another cornerstone is the fostering of increased integration in health care through new organizational structures, shared clinical and management protocols, as well as linked information systems. Finally, the symposium members recommended payment systems that reward patients, health plans and providers based on performance consistent with high quality.

In reaching outside Mayo Clinic to a wide range of experts and organizations, Cortese and Smoldt reflected an important variation of William Worrall Mayo’s original assertion that “no one is big enough to be independent of others.”They were demonstrating that “no organization is big enough to be independent of others.”

Data Warehouse
Of course, Mayo’s leadership on issues related to health reform could hardly be expected to resonate if the clinic itself did not reflect what it was advocating for others. One effect of Plummer’s patient record system was to create a storehouse of a century’s worth of data that could be integrated to a degree impossible in any other health care organization in the world, then or now. Today, a Mayo-IBM collaborative is leveraging the integration that Plummer put into place more than a century ago.

While researchers at Mayo were always able to pull patient records and look across them for relationships and patterns, their power was limited by sheer volume as well as their inherent lack of ready interconnection and correlation.

The problem with these records gave new meaning to Will Mayo’s reflection on an interchange he once had with a colleague: “A prominent specialist in gastrointestinal diseases once asked, ‘How is it possible that you, a general surgeon, see so many of these cases while I, who am devoting all my time to this work, see so few?’ I could only answer, ‘The thickness of the abdominal wall prevents you from seeing them.’” In this instance, it was the thickness of a paper file that kept the Mayo Clinic from seeing the meaning buried in its patient data.

Economist Kenneth Arrow once described a firm as an “incompletely connected network of information flows.” Cortese and Smoldt saw the power of freeing up the flow of information so it makes its way more easily to those most likely to put it to good use. As Cortese observed, “The clinic was among the world’s pioneers in systematically keeping patient records and then using them in treatment. For years, Mayo has employed researchers it calls ‘abstractors’ who comb through paper records looking for patterns of disease and treatments to help doctors. Now, we’re envisioning doing all this electronically so the information systems of Mayo and perhaps the whole country will be a repository of all knowable information about how to care for a patient.”

Mining the Data
A first step in the collaborative involved scanning the medical histories of more than 6 million of Mayo’s past patients, including their X-rays, cardiograms and lab tests, as well as more esoteric data related to genetic and protein makeup. To this massive database, IBM is applying data mining and pattern recognition technology already used by financial institutions to spot fraud and by marketers to target their campaigns. IBM is also using artificial intelligence to “cleanse” data that might compromise patient identities.

The data mining extends beyond Mayo patient records and incorporates public databases such as those maintained by the National Cancer Institute. The result will be an integration of data that allows scientists, researchers and practitioners at Mayo to better see patterns related to disease and treatment.

The collaborative relies on one of the most powerful supercomputers in the world--IBM’s Blue Gene. According to Cortese, “We are at a point with standards in technology and new genomic-based analytic techniques where we can achieve more in the next 10 years than we’ve achieved in the last 100, and we see in IBM a partner with unique capacity to deliver expertise and innovation.”

Yielding Answers
IBM’s Blue Gene provides real-time access to specialized algorithms for molecular modeling. By better understanding protein structure and function, it will become possible to prescribe with much greater precision, customizing treatments to the makeup of individual patients rather than simply using the blunt instrument of protocols generalized from large patient populations.

Hugh Smith, M.D., a cardiologist and a past chair of the board of governors at Mayo Clinic Rochester, speculated on the possibilities: “Wouldn’t it be marvelous if a doctor knew not just the exact location of the patient’s cancer but its gene characteristics and the outcomes of therapy in the last 500 patients with cancer in that identical location and with those identical genetic characteristics? To do this, there needs to be a consistent way to link these kinds of data, not just in a single hospital, but regionally, nationally and globally.”

Nina Schwenk, M.D., a Mayo specialist in internal medicine who has worked on the IBM collaboration emphasizes: “The goal is to allow a doctor examining a patient to ask an online computer system how the last 100 Mayo clinic patients with the same gender, age and medical history responded to particular treatments. You’ll be able to pull all the charts, see what treatments patients got and how they responded.”

Already, screening and recruiting of candidates for Mayo research studies that once took 13 months to complete can now be done in 16 seconds. Mayo researchers recently reached the surprising conclusion that many patients diagnosed with multiple sclerosis (MS) don’t get worse. The researchers collected patient records on 162 MS patients in southern Minnesota who were treated at Mayo in 1991. Then they tracked down all but one of them and concluded that less than half the patients developed worsening disabilities within 10 years, and only 20 percent had moved into wheelchairs.

The Importance of Connectivity
Cortese echoes Mayo’s founders, as well as the input of the national health care symposium Mayo sponsored, as he puts the IBM partnership in context: “Because science and medicine are becoming ever more complex, it’s increasingly unlikely that we can rely only on our own discoveries, so we have to be connected to a degree we haven’t been in the past. If there’s a big difference in how we are today and how we have to be in the future, it has to do with relationships.”

By serving as a catalyst for health reform and by putting its reputation, resources and passion behind what it advocates, Mayo is helping invent the future its founders envisioned and its patients hoped for: a system without walls, where care is connected and whole. And a place where the patient’s interest is the only interest.

Dan Beckham is president of The Beckham Company, a strategic consulting firm based in Bluffton, S.C. He is also a regular contributor to H&HN OnLine.