This is a presentation that I gave at the annual international healthcare conference hosted by the Cayman Islands government. It summarizes the international standards and frameworks for planning and managing the health of a nation. One of the most fun parts of a very fun career was the time that I spent working and living in the Cayman Islands and serving as the CIO of the national health system. The Cayman Islands national health system sat at the intersection of three very influential healthcare ecosystems-- the United States, United Kingdom, and the Pan-American Healthcare Organization. As a result, I was fortunate enough to learn from these international settings and contrast that to the US healthcare system. Other healthcare systems tend to benchmark themselves internationally more so than the United States, where we tend to benchmark ourselves internally. Unfortunately, those internal US benchmarks are the lowest in the developed world by almost every measure of national health.

1. Elements of a National Health Strategy:
Key Metrics and Performance
Indicators
Healthcare 20/20: Cayman Islands International Healthcare Conference 2011

2. Introduction
 Dale Sanders
 Twitter: @drsanders
 Text: 1-345-925-8329
 Email: dale.sanders@hsa.ky
 LinkedIn: http://www.linkedin.com/in/dalersanders
 Blogs
 http://callitanything.blogspot.com/
 http://healthsystemcio.com/tag/dale-sanders/
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Text, email, or tweet your questions during the presentation

3. Overview
 National Health Accounts: What Are They?
 Sources of Benchmarks for National Healthcare
Policy and Management
 Related Health Services Authority Metrics
 All HSA/Cayman metrics are preliminary and need
refinement
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4. Key Messages
 The old but true cliché: You can’t manage what you can’t
measure
 An effective national health plan requires national healthcare
indicators and metrics
 We have some Cayman Islands metrics already and our
“data momentum” is increasing
 But we should probably increase our focus and efforts
 Becoming a “data driven culture” in healthcare is not easy
 There will soon be three major skills shortages in healthcare
 Physicians, nurses and…
 Data analysts
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5. Data Quality Journey
PerceptionofData
Quality
Lifecycle of the Data Driven Organization
High
Low
Hope & Illusion
Gloom, Despair, And Agony
Young Mature
Perseverance &
Commitment

6. If I had kids, I can imagine this would
be the conversation…
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7. National Health Accounts (NHA)
 WHO, OECD, World Bank and Gates Foundation
 In lay terms- NHAs are an international standard for
healthcare accounting at the national policy level
 “NHA constitute a systematic, comprehensive and consistent
monitoring of resource flows in a country’s health system
financing.”
 “…helps in developing national strategies for effective health
financing and in raising additional funds for health.”
 “…concerns itself primarily with the health care goods and
services consumed by residents, irrespective of where that
consumption takes place.”
 Healthcare IT vendors should support NHA standards
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8. +
NHA Healthcare Financing
Schemes
 Government
 Compulsory social insurance
 Voluntary health insurance
 Out-of-pocket payments
 Foreign aid programs
 Charitable programs
Agents
 Government departments
 Social insurance funds
 Insurance companies
 Households
 Foreign countries
 Charities & foundations
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9. 9

10. 10
Progression of Disease and the Provision of Healthcare Goods and Services
Adapted from Norman, 2003

11. + Sources of Metrics &
Benchmarks for National
Healthcare Policy
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12.  World Health Organization, Pan American Health
Organization
 Somewhat focused on the issues of Third World countries
 TB, HIV, Drinking Water, Malaria, Improved Sanitation Utilization,
parasites, etc.
 Sometimes tainted by political agendas in the United Nations
 Organization of Economic Cooperation and Development
 Focused on the 34-member organizations
 Very thorough, very focused on the ratio of Cost-per-Outcome
 The Commonwealth Fund
 Private US foundation, less prone to politics
 Motivated to change the US healthcare system
 Benchmarks against major democracies
 All of these ignore mental and spiritual health measurement
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13. WHO/PAHO Categories
1. Life Expectancy And Mortality
2. Cause Specific Mortality And Morbidity
3. Selected Infectious Diseases
4. Health Service Coverage
5. Risk Factors
6. Health Workforce, Infrastructure, And Essential Medicines
7. Health Expenditure
8. Health Inequities
9. Demographic And Socioeconomic Statistics
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14. Deaths By 19 Leading Factors,
By Country Income Level, 2004

15. OECD Categories
1. Health Status: Life Expectancy, Mortality, Chronic
Conditions
2. Risk Factors
3. Health Workforce: Number Of Physicians, Nurses, etc.;
Remuneration Of Physicians And Nurses
4. Consumption Of Healthcare: Diagnostics, Treatments,
Pharmaceuticals
5. Quality Of Care: Life Threatening Acute Care; Chronic
Disease
6. Healthcare Expenditure: Costs And Financing
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16. Public Spending on Health Care per Capita, 2006
Adjusted for Differences in Cost of Living
$1,906
$2,011$2,027
$2,408
$2,591$2,591$2,597
$2,750
$3,074
$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
$3,500
United
States
France Switzerland Canada Germany United
Kingdom
OECD
Median
Australia* New
Zealand
Source: OECD Health Data 2008, “June 2008.”
Cayman Islands?
$150M/50K = $3,000 per capita

17. Source: OECD and International Diabetes Federation (IDF) (2009), “Diabetes Atlas, 4th edition”.
Prevalence Of Diabetes
Adults Aged 20-79 Years, 2010
5.8% of HSA patients have a
diabetes diagnosis…but this
number is probably low.
Further analysis required.

18. The Number Of Physicians Per Capita
Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).
Cayman Islands:
About 4
physicians per
1,000 population

19. Commonwealth Fund Categories
1. Quality Care
2. Access
3. Efficiency
4. Equity
5. Long, Healthy, Productive Lives
6. Health Expenditures per Capita
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20. 20

21. 54
41
53
83
70
61
50
45
82
72
80
0
25
50
75
100
AU
S
CA
N
FR
G
ER
NETH
NZ
NO
R
SW
E
SW
IZ
UK
US
Percent
Wait Time for Specialist Appointment
28
41
28
7
16
22
34 31
5
19
9
AU
S
CA
N
FR
G
ER
NETH
NZ
NO
R
SW
E
SW
IZ
UK
US
Less than 1 month Two months or more
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
Base: Needed to see a specialist in past two years.

22. Obesity (BMI>30) Prevalence in 2004
30.6%
23.0%
22.4%
20.9%
13.0%
12.9%
10.9%
9.5%
3.2%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
United
States
United
Kingdom
Canada New
Zealand
OECD
Median
Germany Netherlands France Japan
a
a
a2003
b2002
a
b
Source: The Commonwealth Fund, calculated from OECD Health Data 2006.
Cayman Islands…?

23. 0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
U.S. Population Health Expenditures
Health Care Costs Concentrated in Sick Few—
Sickest 10 Percent Account for 64 Percent of Expenses
1%
5%
10%
49%
64%
24%
Source: The Commonwealth Fund. Data from S. H. Zuvekas and J. W. Cohen, “Prescription Drugs and the
Changing Concentration of Health Care Expenditures,” Health Affairs, Jan./Feb. 2007 26(1):249–57.
50%
97%
$36,280
$12,046
$6,992
$715
Distribution of health expenditures for the U.S. population,
by magnitude of expenditure, 2003
Expenditure
threshold
(2003 dollars)

24. +
Cayman Islands Metrics
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25. Perspective
 Director of Public Health (Dr. Kumar) and team have been
reporting PH metrics to PAHO for a number of years
 Challenged by the technology for data extraction from our
Cerner system– the data is there, but wrapped in a
proprietary programming language
 Last two years at HSA – Financial Survivability & Stability
 Next two years– Chronic Disease Management & Patient
Satisfaction
 Slowly gathering “Metrics Momentum”
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26. As Reported in the Compass
 CI Government spend $93.4 million on health care in the last
financial year
 17.5% of the national budget
 22% (about $20.5 million) was spent on overseas referrals
for 2,500 persons;
 More than $12 million per year on overseas referrals for the
indigent population alone
 CINICO budget: $59M for 13,000 covered lives
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27. Australia
Austria
Belgium
Canada
France
Germany
Italy
Japan
Netherlands
Norway
Spain
Sweden
Switzerland
U.K.
USA
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$25,000 $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000
PerCapitaHealthSpending
GDP Per Capita
Total Health Expenditure per Capita
and GDP per Capita,
US and Selected Countries, 2008
Cayman Islands…?
Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350-
en (Accessed on 14 February 2011).
Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates.

28. 28

29. 29

30. Leading Causes of Death in CI
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%

31. Top Ten Procedures (CPT) at HSA
1. Supplies and materials provided by a physician
2. Level 3 office or other outpatient visit
3. Blood glucose monitoring
4. Therapeutic, prophylactic or diagnostic injection
5. Level 1 office or other outpatient visit
6. Comprehensive metabolic panel
7. Emergency department visit
8. Therapeutic, prophylactic or diagnostic injection
9. Physical therapy re-evaluation
10. Level 2 office or other outpatient visit
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32. Top Ten HSA ICD9 Diagnosis
1. Hypertension
2. Diabetes
3. Routine health check for child
4. Upper respiratory infection
5. Change or removal of non-surgical wound dressing
6. Care involving physical therapy
7. High cholesterol (hyperlipidemia)
8. Pregnant
9. Long term anticoagulant use
10. Observation for unspecified conditions
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33. Other Key Performance Indicators
Metric 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11
Total Admissions 4,766 4,889 5,071 5,718 5,574
Bed Occupancy Rate 65% 68.6% 68.8% 73.5% 63.7% 59.4%
Average Length of Stay 4 4 4 4 4 4
Total ER Visits 25,302 26,901 27,041 29,859 34,032 33,172
Total Outpatient visits including
Pharmacy
158,364 150,632 155,162 186,460 180,030 181,947
Total Surgeries 2,509 2,660 2,726 2,912 3,101 2,977
Total deliveries 628 634 647 664 691 695
Total C- Sections 228 252 247 270 281 280
Total Specialist Clinic visits 24,036 23,973 24,445 25,614 32,038 30,869

34. HSA Patients (Cayman
Islands Residents) with
an encounter during
Oct 2010 – Sep 2011
These reported rates
are artificially low,
probably because the
data relies only on
diagnosis code
(ICD9). Further
analysis required.
Chronic Disease Rates for HSA Patients
Chronic Disease
Patient
Count
Percent of
all Patients US Rate
Hypertension 3571 10.80% 33%
Diabetes 1903 5.80% 10%
Mental Disorders 1619 4.90% 3.30%
Respiratory Disease 539 2.50% 4%
Cardiovascular Disease 407 3.00% 12%
Cancer 356 1.10% 4%
Kidney Disease 235 0.70% 2%
Osteoarthritis 208 0.60% 23%
Chronic liver disease 142 0.40% ?
Osteoporosis 94 0.30% 3%
Paralysis and cerebral
palsy 46 0.10% ?
AIDS/HIV 16 0.00% 0.40%

35. HSA Patients with Cancer
Cancer Type Patient Count
Percent of all
Patients
Breast 93 0.28%
Prostate 83 0.25%
Leukemia and Myeloma 30 0.09%
Other Non-Melanomatous Skin Cancer 28 0.08%
Colon 26 0.08%
Gynecologic 25 0.08%
Urinary Tract 19 0.06%
Non-colon GI 14 0.04%
Head and Neck 12 0.04%
Melanoma 11 0.03%
Lung 11 0.03%
Non-Hodgkin Lymphoma 9 0.03%
Lymphosarcoma and Reticulosarcoma 6 0.02%
Bones/Soft Tissue 5 0.02%
Hodgkin Lymphoma 4 0.01%
Brain 3 0.01%
Endocrine 3 0.01%
Carcinoid Tumors 2 0.01%
Pleural Mesothelioma 1 0.00%
All Cancer patients (patient can have two
cancer types) 365 1.10%
HSA Patients
(Cayman Islands
Residents) with an
encounter Sep10 -
Aug11 with a
cancer diagnosis
These reported rates
are artificially low,
probably because the
data relies only on
diagnosis code
(ICD9). Further
analysis required.
4% of the US population
has some form of cancer.

36. +
Closing Thoughts
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37. Keeping It All In Perspective
What surprises you most about humanity?
Dalai Lama:
"Man. He sacrifices his health in order to make money. Then
he sacrifices money to recuperate his health. And then he is
so anxious about the future that he does not enjoy the
present; the result being that he does not live in the present
or the future. He lives as if he is never going to die, and
then dies having never really lived."
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38.  We are entering the “Data Driven Age” of
healthcare that informs…
 Government leaders and national policy
 Physicians and patient management
 Healthcare leadership and administration
 Patients and healthcare consumers
 Employers
 Is it time for a national initiative to define and
baseline our key performance indicators?
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