This document proposes a platform for measuring the quality and cost-effectiveness of gastroenterology care delivery directly from patient-reported data. The platform would involve patients completing standardized questionnaires about their GI symptoms before and after office visits. It would also collect quality ratings for each visit. Anonymized data would be uploaded to the cloud for analysis. The goal is to identify which treatment plans actually improve patient health outcomes and which may not. The proposing physician believes engaging patients directly in tracking their own progress and collaborating with insurers on cost data could provide a true picture of quality in a way that benefits both patients and the medical field. However, biases in self-reported data would need to be addressed.

1. Gastroenterology Care Delivery
Measuring true quality of care and
cost, and sharing what we learn --
A Platform Concept by Rajat
Chander, MD

2. Professional Background
Rajat Chander, M.D.
Amanda Kelly, BSN, CGRN
North Raleigh Gastroenterology, PA
6080-C Six Forks Rd.
Raleigh, NC 27609
Rex Medical Office Building
1505 SW Cary Parkway, Suite #309 PRACTICE DISTINCTIONS
Cary, NC 27511 • Professional & Experienced Team – Office
919-846-9011 Manager, nurse, and office administrator all employed
www.nrgi.org since 1998
www.twitter.com/gi • Resident Gastroenterologist @NCSU Student Health Center
www.myphysical.com • Extensive experience with Irritable Bowel Syndrome, Peptic
Ulcer Disease, Celiac, and Inflammatory Bowel Disease
EDUCATION & TRAINING • Accessibility
• Graduate of Columbia College, Columbia University, NY. • We pride ourselves in giving as much time as needed to
(B.A. in Computer Science) patients to see that they fully understand diagnosis and
treatment plan
• M.D. from Duke University School of Medicine
• Residency (Internal Medicine) and GI Fellowship from Ohio
State University Hospitals QUALITY OF CARE
• Board-Certified in Gastroenterology • Friendly staff
• Amanda Kelly, distinguished board-certification in GI • Privileges at accredited endoscopy center
• Hospital privileges, Wake Med Cary
• No litigation
• Call Group of eight gastroenterologists, with 24-7 coverage

3. How do people choose a doctor?
 Word of mouth from work colleagues and friends
 Online – small # reviews: Angie’s List, Google Places (currently
integrating with Google+ Local), Yelp, RateMDs.com
 Insurance website – geographically close or randomly from listed
network.
 United has Healthinnumbers.com
 BCBS has tried Zagat reviews.
 In GI, new attempts to measure quality of care using registries:
AGA registry, GIQuIC (from ACG). These measure mostly endoscopy
procedure quality and adherence to guidelines. Registries will take
years to build, and rely on the integrity of the person reporting
data.
 Additionally, many EMRs (e.g., eClinicalWorks) are attempting to do
analytics. But, these may be insular ecosystems with limited
usefulness.

4. Why should physicians embrace a true
quality and value model?
• Most physicians know when they have done a good job
taking care of a patient.
• Most physicians have a lot of integrity. Nurses and
physicians (in that order) are the most trusted members of
society.
• To keep the public’s trust, we could open our practices to
quality and cost measures.
• The quality measures imposed by the government, like
“meaningful use” EHR certification, are becoming the bane
of our professional existence. Rather than embracing only
mandated government measures, we could encourage our
own measures to show quality and cost-effectiveness of
our care.

5. Proposal to measure true quality from
the patient directly
• Gastroenterology has a lot of structure. That is, there are some very common symptoms we all see:
Abdominal pain (localizing pain often narrows differential quickly), GERD, Rectal
Bleeding, Constipation, Diarrhea, Abdominal bloating, increase in LFTs, Nausea/Vomiting, for
example.
• PRE-VISIT: Let’s have patients fill out a specific review of systems based on their GI symptoms.
• POST-VISIT: Then, after the physician’s care, let’s ask the patient to specifically quantify their
symptoms and whether they have improved.
• Insurance companies, like BCBSNC, already have the cost information. That is, CT scan
ordered, ultrasound, labs, endoscopies, and more.
• Anonymize this data (cautiously, will amplify later) onto the cloud so that we can say how much
better a patient really is after the medical office visit.
• My proposal is to build modules around the 20 most common GI symptoms and chief complaints.
Importantly, these modules can be implemented and modified on patients in my practice
(Cary, Raleigh, NC State students). If patients do not feel like typing in the review of systems on
their own, my nurse can call them before and after the office visits (care must be taken not to
introduce biases via the nurse – will discuss later).
• As a complement to this patient symptom data, I would also ask patients to add a “Good” or “Not
Good” quality measure for each office visit.

6. What’s in it for the patient?
• Why would the patient want to enter this data
before and after office visits?
• Will make the office visit more time efficient.
• Also, if the patient wants, they can track their
own progress. May be especially useful in
chronic diseases like Ulcerative
Colitis, Crohn’s, and syndromes like IBS.

7. Cautions/Biases
• When people self-report, there may be biases in the data.
New medications may have been started by other
doctors, there may be cultural differences in pain
perception, gender differences, etc.
• Another bias is that the patients who fill out these surveys
will be more tech-savvy; we need a way to also engage the
rest.
• When the nurse or doctor reports, he or she may introduce
biases with leading questions.
• HIPAA Privacy Rule – data must be properly anonymized on
the cloud, so that it can be shared with the patient’s
doctor, insurance company, and stored for analytics.

8. Suggestionsand Questions
• First, I want to emphasize that I am flexible with the platform. It must adapt to what the users
(patients) actually feel is worthwhile. It’s important not to have too rigid a vision.
• Second, I would like to listen to what your ideas are and what you think are the most important
issues in health delivery analytics. What would be most useful to you?
• My practice has the experience to build these 20 modules very quickly. I also have support from
another gastroenterologist who is interested in working with me on this.
• I believe that I am well-positioned to implement these modules “on the ground”. After they are
adapted to one or two practices, they can be rapidly scaled up to other interested GI practices in NC
and the country. Once in place for GI, the platform can be adapted to other specialties.
• I am interested not only in cost-effectiveness, but also effectiveness of health care. I believe that
the fully scaled platform will help us learn which accepted treatment plans in GI actually yield
improvement in patient health, and which ones do not.
• I believe a “patient-centered medical home” works better if the patient can actively participate in
their care. Some models to date rely on just the physicians and providers. Please see my earlier
effort at www.myphysical.com. This is just a demo (start with the video), but now can evolve to
serve as a platform for this new model of measuring quality and value.
• If this presentation has been a little discursive, it’s because I quickly put it together this morning.
Happy to make a more formal presentation, if SAS has any interest in collaborating.
• I recognize that there are lots of approaches that others may have, but feel that we are uniquely
positioned to implement and develop a platform for measuring GI care.
• Would be great to work with you -- thank you! My email is rc478@columbia.edu.