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Through

the looking
glass
A practical path to improving
healthcare through transparency

KPMG International

kpmg.com
2017 KPMG International Cooperative (KPMG International). KPMG International provides no client services and is a Swiss entity with which the independent member firms of the KPMG network are affiliated.
Contents
Executive summary 04

What is a transparent health system? 06

The global health systems


transparency index
08

Health system transparency: A


powerful force for good or ill
12

What does the future of healthcare


transparency look like?
16

Seven features of successful healthcare


transparency
22

Appendix 35

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4 | Through the looking glass

Executive
summary
Transparency in healthcare matters, but
to date has failed to live up to its promise
of transforming quality and cost. Too
often progress has been symbolic and
has given rise to bitter disputes between
political ideologues and resistant provider
and professional groups. Even countries
that have led the field are now facing
difficult questions about what value is
really created for all their effort. Awash
with data, some systems are finding it
more difficult than ever to work out what
is going but used strategically, this study
suggests there is considerable potential
waiting to be unlocked from health
system transparency.

2017 KPMG International Cooperative (KPMG International). KPMG International provides no client services and is a Swiss entity with which the independent member firms of the KPMG network are affiliated.
Through the looking glass | 5

The objective of this study is to establish by data requirements that distract


what health systems need to do to from the real business of healthcare Methodology
make transparency into the powerful, improvement and support punitive
This study involved several
positive change agent that it can be. cultures of naming-and-shaming,
research stages:
We present insightful research into the ultimately leading to less transparent
state of play of global health system performance and decision making. Summary literature review
transparency; explore what makes a This report signals a different, far of the evidence on health
health system transparent; examine the more positive way forward. Where systems transparency
benefits, risks and opportunities; and transparency is applied in a disciplined
25 interviews with experts
delve into what the optimum future for way by national and local health
transparency could look like and how to systems we believe it can make a Development of the
achieve this. substantial contribution to the quality transparency framework
and value of healthcare. Key features and sense-testing with
We begin by explaining what makes
of this strategic approach include a KPMG heads of health and
a health system transparent and
selective, phased approach to data interviewees
comparing the worlds major health
publication, learning from innovative
systems by their level of progress on Completion of the
providers and promoting high trust
some of the most important dimensions transparency scorecard by
cultures alongside independent
of the concept. leaders of KPMGs health
narratives from selected groups.
practices in 32 countries
Transparency in healthcare: We highlight where this future is
Transparency scorecard data
Good governance or political happening now, with 16 global case
collected and analyzed by
studies from countries such as Australia,
distraction? Denmark, Germany, the Netherlands,
country
Evidence from our research shows UK and US.
that, like any tool, transparency can be
While our global index of health system
used to create benefit or harm, or a bit
transparency shows huge variation in
of both. On the one hand, there is good
progress, no countrys health system
evidence of data publication leading
is truly pursuing transparency in a
to quality improvement drives, better
strategic way. To realize the full value
data collection and even improved
of this trend, a whole-system approach
health outcomes. On the other, it can
is needed that aligns the different
undermine trust, lead to too much focus
dimensions of transparency, the
on particular measures, and lead to
means to deliver these dimensions,
erroneous conclusions and policies.
the methods for communicating this
If current trends continue, it is easy to information, and the levers to facilitate
imagine health systems overwhelmed positive change.

What should your organization be


doing to successfully apply transparency
1. A consistent strategy
2. Take the lead from innovative providers
3. Measure what matters to patients
4. Fewer measures, more meaningful data
5. Provide personalized price transparency
6. A give-and-take approach to safeguarding patient data
7. Promote independent narratives to improve understanding

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6 | Through the looking glass

What is a
transparent
health system?
Transparency in healthcare is a contested concept, with a wide range of
interpretations based on country, care setting, and stakeholder group. This diversity
of terminology is symptomatic of a lack of strategic clarity about what constitutes an
effective, transparent health system. Here we present a unified definition of the most
important components.

Across the literature reviewed and our interviews, 3. Finance: price and payments transparency,
six main dimensions of health system transparency and the public nature of accounts for healthcare
recurred.1,2,3,4,5,6 These dimensions cover the main issues organizations.
of concern according to health systems, organizations
4. Governance: open decision making, rights and
and stakeholder groups globally and form the basis of our
responsibilities, resource allocation, assurance
definition of transparency, as well as foundation for the
processes and accountability mechanisms.
global health systems transparency scorecard:
5. Personal healthcare data: access, ownership, and
1. Quality of healthcare: transparency of provider-
safeguarding of patients individual health data.
level performance measures, especially the quality
of outcomes and processes. 6. Communication of healthcare data: the extent to
which all the above is presented in an accessible,
2. Patient experience: patient perceptions of their
reliable and useful way to all relevant stakeholders.
healthcare experience and outcomes.

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Through the looking glass | 7

Drawing these concepts together, our definition of transparency in global health systems is:

A health system that provides accessible, reliable, useful and


up-to-date information to all interested stakeholders so they
can acquire meaningful understanding of the quality, patient
experience, finance, governance, and individual health data
associated with the health system, and make judgement on
its fairness.

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8 | Through the looking glass

The global
health systems
transparency
index

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Through the looking glass | 9

To understand how different countries health systems compared against this framework,
we constructed a scorecard of key indicators by which to measure their progress on each
of the six dimensions. After validation with a reference group of transparency experts and
health system leaders, KPMG health practices in 32 countries completed the scorecard
based on their knowledge of what data was published, sometimes with assistance from
the Ministry of Health or other authorities.

While the full scorecard and scoring very simple scoring system that asked state of play for most of the worlds
methodology can be found in the whether a minority, majority or all major health systems. From this, several
appendix, the grid below gives a providers (or hospitals) in the system conclusions can be drawn:
summary of its 27 key indicators. routinely followed a particular practice,
There is a high level of variation
These were selected by considering: with each indicator weighted equally.7
across countries in overall health
the practices of leading healthcare
organizations and systems; measures
Results system transparency, with
scores ranging from 74 percent
likely to highlight meaningful variation Completed transparency framework
to 32percent. The average score
across health systems; concepts scorecards were received from
of 55percent is relatively low,
likely to translate easily across 32countries, covering most OECD and
suggesting that there is still much,
different health system types; and G20 countries. Composite scores for
much more that countries have not
policies identified as important by our each dimension and an overall score
yet done.
interviewees. Most indicators used a were then compiled to give a global

Dimension

Quality of Patient Finance Governance Personal Communication


Healthcare Experience Healthcare Data of Healthcare Data

Mortality/ Patient reported Financial Freedom of Electronic patient An accessible


survival rates for outcome performance Information records system data portal
individual medical measures legislation
conditions and Prices patients Shared clinical Extent to which
treatments Patient are charged Patient rights documentation data is up-to-date
satisfaction
All-cause Prices health Procurement Patient data Ease of
mortality/ survival Patient approval insurers/ payers processes and privacy and comparing
rates are charged decision-making safeguarding providers and
Patient policy services
Hospital re- complaints Disclosure of Public decision
admission rates payments, gifts making Information on Use of open data
and hospitality to use of patient file formats
Waiting times for healthcare staff Patient/Public data
emergency care involvement

Adverse event
reporting

Hospital-acquired
infection rates

Indicators: To what extent is information publicly available8 on

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10 | Through the looking glass

Comparing performance across the Similarly, Canada performs strongly


different dimensions, the highest on transparency of Governance (81 Health warning
scores go to Governance and percent ) and Communication of
Finance (averaging 67 percent Healthcare Data (79 percent ), but When interpreting these scores, it
and 66 percent respectively). The less strongly across other categories. is important to remember that:
lowest scores are for transparency New Zealand reported the most It is not necessarily good to
on Quality of Healthcare (averaging extreme variation across dimensions, have a high ranking because
44percent ), suggesting this is where with a score of 94 percent for transparency can be harmful
transparency is less advanced across transparency of Governance but only as well as beneficial
health systems, and countries have 38 percent for Quality of Healthcare.
been more reticent to make progress. The data shows what health
In terms of the specific policies systems are currently doing,
The four Scandinavian countries which indicators measured for each not whether the transparency
Denmark, Finland, Sweden and country, the highest scoring (and is well managed, or achieving
Norway achieved the highest therefore most widely practiced) good or bad results
overall scores little surprise to measures were:
those that know these systems
Presence of national patient data
well. A dive into the dimension-
privacy and safeguarding policy
specific results shows that this Disclosure of payments, gifts and
impressive performance reflects Explicit patient rights setting hospitality made to healthcare staff
particularly strong scores on out exactly what patients are
Shared clinical documentation
Finance, Governance, and Personal entitled to and can expect from
a patient portal where patients
Healthcare Data. However, these providers
can contribute to or edit their
top ranking countries do not perform
Existence of a Freedom of personal health data
consistently well. There is still room
information law
for improvement in the way that Publication of patient reported
healthcare data is communicated, The lowest scoring, and therefore outcome measures or approval
and ongoing policy debates in several least common, practices are: ratings
of these countries highlight an open
question over what value is really
being generated from all this progress.
Healthcare transparency in the USA: Leaders and laggards
The second tier of countries
comprises Australia, Netherlands, The scoring methodology for this study involved taking an overall snapshot
New Zealand, the UK, Portugal of healthcare data publication practices in each of the countries studied, and
and Singapore, followed by Brazil, summarizing these into overall scores. While internal variation existed to
Canada and Spain. Those lower down some extent in all countries, in no system did we find such a high degree of
the rankings despite having otherwise internal dissimilarity and fragmentation than the US.
high performing health systems
include Germany, Italy, Switzerland, Due to the state-based nature of many healthcare regulations, but also the
Korea, Ireland and Japan. These may coexistence of many large and complex payer and pricing systems both private
feel they should be doing better in and public (operating at federal and state levels) a summary score for the entire
comparison to their peers. country was not felt to be a helpful guide as to progress.

The lowest tier of performers While absent from the results table below, the US undoubtedly exhibits many
includes China, India, South Africa, of the leading transparency practices described in this report, as well as falling
Saudi Arabia and Mexico. However, victim to many of the pitfalls. The issue is high profile and rapidly evolving
these should not be judged too healthcare systems regularly report on more than 500 different indicators
harshly as they are lower income to payers, regulators and other bodies. However, there are no objective
members of the OECD or G20, standards for many of these measures (such as quality, patient satisfaction,
included purely because of their etc.) and few organizations are well positioned to integrate them although
size and global importance. Hence many publish data about their own particular piece of the system.
they are being compared against The Affordable Care Act had some impact by making pricing more
countries that mostly spend many transparent especially to the patient. Similarly, evolving payment models
times what they do on healthcare. such as value based pricing are likely to drive greater integration of data
Beyond the headline scores, across different silos. Still, there is great uncertainty around how the Trump
many countries perform highly Administration will revise regulations in this area, and whether this will lead to
inconsistently across different an acceleration or stalling of progress.
dimensions. For example, Iceland US case studies and evidence are drawn throughout this report to demonstrate
scores particularly well on good and bad practice. But given the unique complexity of this picture, the
transparency of Finance (75percent) current system does not easily lend itself to our single score method.
but less well on other categories.

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Through the looking glass | 11

Table 1: Global health systems transparency index composite results (%)


1. 2. 3. 4. 5. 6.
Overall Quality of Patient Finance Governance Personal Communication
Score Healthcare Experience Healthcare of Healthcare
Data Data
Denmark 74 67 62 83 94 93 50
Finland 72 48 46 83 88 86 93
Sweden 71 81 69 75 69 79 50
Norway 69 67 62 83 81 71 50
UK 69 57 85 83 81 57 57
Australia 68 52 62 83 88 64 64
New Zealand 67 38 54 83 94 64 79
Netherlands 67 57 85 75 69 50 71
Portugal 64 48 46 83 63 86 71
Singapore 63 57 77 83 81 43 43
Israel 62 48 92 50 56 79 57
Brazil 61 48 69 67 81 64 43
Canada 61 57 46 50 81 50 79
Spain 61 76 46 42 75 71 43
France 60 48 62 67 75 50 64
Germany 56 29 54 75 63 64 64
Italy 54 57 31 67 56 64 50
Iceland 53 43 54 75 63 50 43
Switzerland 53 33 69 67 69 57 36
R. of Korea 52 29 31 83 56 50 79
Poland 50 29 46 67 56 57 57
R. of Ireland 49 29 31 67 75 79 43
Luxembourg 47 29 46 50 63 50 50
Russia 47 33 38 67 63 50 36
Austria 46 29 31 58 56 64 43
Japan 46 48 31 67 56 43 29
Greece 43 29 38 50 69 50 29
Mexico 42 33 46 42 50 36 50
K. Saudi Arabia 38 29 31 50 50 43 29
South Africa 37 33 31 33 44 50 29
India 36 29 31 42 44 43 29
China 32 29 31 50 31 29 29
Average Score 55 44 51 66 67 59 52

70% and over 60% and over 50% and over 40% and over Lower than 40%

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12 | Through the looking glass

Health system
transparency:
A powerful force
for good or il
To inform the often fractious political debate that surrounds
healthcare transparency, we searched the literature for
evidence about its real world impact. What emerged is
that there is no doubt transparency has the potential to
significantly change behaviour, although this can both
enhance and undermine value.

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Through the looking glass | 13

Evidence was concentrated around six main effects:


1. Public reporting encourages quality 3. Publishing poor quality data
improvement efforts diminishes transparency
There is good evidence that public Publishing data about a health system
reporting stimulates quality improvement is not helpful if that data is incomplete,
activities, particularly at hospital level.9,10 inaccurate, out-of-date, or not comparable.
For example, Canadian hospitals were The wrong conclusions will be drawn
found significantly more likely to report and inappropriate actions taken. In the
quality improvement initiatives in UK, the Vascular Society was the first
response to publication of mortality rates; medical association to release outcomes
initiatives included new clinical pathways, data and the publication of poor data led
and care maps for clinical management.11 to mistaken assumptions.21 Surgeons
Similarly, large clinical practices in have been incorrectly identified as poorly
Wisconsin, US were found to have performing because of mistakes in how
engaged in quality improvement efforts as data is reported.22,23 For example, first
a result of comparative public reporting.12 publication of named surgeon-specific
In the Dutch hospital setting, care outcomes in England was based on
quality appears to have improved faster raw data without risk adjustment and
in hospitals mandated by government from pre-existing national surgical audit
to publish patient experience data than databases not designed for this purpose.21
in hospitals that were not.13 Several False identification creates suspicion
studies also report clinician-level quality and resistance to transparency because
improvement activity. A US national of the associated stigma that results
survey, for instance, found that patients from naming and shaming.24 Therefore,
with vascular disease were prescribed attention and resources should be given
aspirin by fewer than 50 percent of to data quality and completeness and
physicians, but in Minnesota which to validation processes that will achieve
publicly reported use of aspirin, the rate this, particularly for clinical databases.21
was 95 percent.14 Published data is also unhelpful if it is not
measuring meaningful indicators.
2. Transparency is associated with mostly Badly communicated data prevents
improved, but sometimes poorer necessary improvements in care quality.
outcomes Hence, comparative performance data has
Publishing performance data has had little value if all reported scores are average
differential effects in terms of improved with no real differentiation. For example,
health outcomes, with evidence from until recently Centers for Medicare and
systematic reviews showing mixed Medicaid Services (CMS) in the US
results.15,16 Some research studies displayed performance ratings for hospitals
record a positive impact, for example, in three major categories compared with
reporting of cardiac mortality data for
individual surgeons in the UK is viewed
a success, being linked with clear
improvements in mortality.17,18 Other
studies demonstrate no beneficial
effects, for instance analysis of
Theres no virtue in
claims data for US Medicare patients benchmarking yourself to
discharged from hospital showed public a substandard norm.
reporting had no impact on readmissions
or mortality outcomes.19 A few studies
suggest negative effects. For example, Paul Levy
a recent US study found that publishing Former President and CEO, Beth Israel
mortality rates for acute conditions was Deaconess Medical Centre, Boston,
associated with poorer outcomes than currently Senior Advisor Lax Sebenius LLC,
for non-reported conditions.20 Massachusetts

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14 | Through the looking glass

the national average (worse, no example surgeons selecting only low-


different, and better). Since most risk patients in order to improve their
hospitals were labelled average and mortality rates.29 While some clinicians
Price data are not always fewer than 5 percent worse, and express reluctance to operate on high-
the data was often more than two risk patients after the implementation
what they seem to be. years old, there was little motivation of public reporting30, such gaming
There is sometimes for providers to invest resources in has not proved widespread. No
information on costs improving outcomes.25 country has shown evidence of
systematic risk-averse behaviour
and charges but almost Much of the price data published in
through avoidance of high-risk cases
the US can mislead since it bears
nobody pays either little relation to what patients will end
following new publication practices.
of these amounts, up paying for their care. It frequently There are also concerns that
and costs are rarely fails to take account of out-of-pocket providers might take actions to
costs for premiums or deductibles, or improve performance without
known. Even when total costs across the care pathway. actually improving quality, such as
there is transparency focusing on reported measures to
of charges, the closest 4. Transparency improves the quality the detriment of other areas of care,
or changing the way data is recorded.
thing we have to prices, of healthcare data reported
Again the evidence shows this is
it isnt necessarily useful Despite the risks of making initially not a widespread practice, however
imperfect health data transparent, it
because it doesnt mean will improve the quality of the data
there are a few studies which suggest
such actions occur, for example,
anything. reported. Giving stakeholders open providers changing how they assess
access to the information allows pain in order to improve performance
critical response. Publication of scores.31
Helen Darling
imperfect data by its very existence
Interim President and CEO National
enables attention and debate on what,
Quality Forum, Washington 6. Transparency can become a
how, and why the data is measured.
distraction if not targeted carefully
UK experience from cardiac surgery
shows that publication helped improve The number of metrics reported
data quality.26 has expanded greatly over time in
many health systems. This is often
Transparent electronic patient
in response to provider and clinician
records provide another example. The
demands for more accurate and
process of making patients records
specific measures. While these
available electronically has magnified
measures may provide reliable and
the flaws of the current medical
detailed understanding of what is
record, and accelerated clinicians
happening at the clinical level, the
desire for improvement.27 Publication
sheer weight of data can make
also pushesprofessional societies
identification of what is important
responsible for data measurement
in terms of patient outcomes, more
and collection to set clear performance
difficult. Since data collection is
standards.28 Additionally, several of
frequently cost and resource-intensive
our interviewees argued it is better
there is the additional risk that by
to trigger change and improvement
focusing on the little rather than big
through publication than hold back
things, transparency turns into a
from reporting to participate in a
demotivating waste of resources.32
lengthy, time-consuming quest for the
There are active debates about
perfect measure or method.
the burden and cost of publishing
increasingly large numbers of metrics.
5. Some gaming but not as
In the Netherlands, hospitals deliver
widespread as the rhetoric
up to a thousand quality indicators to
suggests
external parties each year, the vast
Fears have been expressed that majority of which are structural and
public reporting of performance data process measures often with poor
will lead to gaming by providers, for data quality.33

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Through the looking glass | 15

Publishing a plethora of data is time consuming and


doesnt add to real transparency in fact it can even
undermine it. Many countries end up not seeing the
wood for the trees, so its important to think about the
value and true meaning of data, not just the quantity.

David Ikkersheim
KPMG in the Netherlands

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16 | Through the looking glass

What does the future of


healthcare
transparency
look like?
It is clear that across the worlds health systems both high and middle income there
is a steady rise in calls for transparency and implementation of new policies to promote
it. To some this represents a growing encroachment into professional autonomy that at
best distracts from the real work of caring for patients and at worst creates a fear-based
culture of public exposure and blame. It is easy to imagine a dystopian future if this kind of
transparency is left to run unchecked with systems awash with meaningless or actively
misleading data, providers averse to any risks that might lead to their being named-and-
shamed and an increase in top-down micro-management of frontline delivery.

This is not the future we foresee, however. Increasing out poor performance, the limitations of this approach are
understanding of the risks and benefits of transparency becoming more apparent. Resistance among providers
should give cause for cautious optimism about its use in much of it justifiable and the lack of supportive evidence for
health systems of the future. There is no doubt that the trends name and shame strategies is forcing health systems to tip
towards greater transparency will continue the explosion the balance in favour of partnership, not penalty. Transparency
in the amount of healthcare data and rising consumer will come to be seen more as a strategic enabler of smarter
expectations of patients and the public make that almost decision making: whether it be government policy and
inevitable. For those providers and payers that are prepared, investment decisions; civic organizations judging the fairness
the opportunities will outweigh the threats. The following is of the allocation process; purchasers deciding which services
our considered prediction of the world we can reasonably to commission or providers designing care pathways.
expect to see develop over the next five years, with case
Since the most significant improvements resulting from
studies interspersed of where this is happening already.
transparency have come through peer-to-peer learning
Less name and shame and review, this is something that is likely to be seen as a
more common first stage in future (exemplified by global
While some of the movement to publish more healthcare data movements such as ICHOM). Clinicians have proved far
has been ideologically led, and often associated with rooting more willing to share performance information within their

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Through the looking glass | 17

As a nation, we dont always have a particularly


mature attitude to transparency. Were not yet
consistently talking in the language of signals
and verification, were still talking the language
of judgement.

Emma Doyle
Head of Data Policy, NHS England

When even sharing among peers is knowing when to redirect patients to


perceived to be sensitive, an alternative other less busy Trust hospitals.
approach is to individually show providers
The types of data which could
their relative performance without
potentially be made transparent are also
naming others. For example, at the
expanding thanks to new technology,
Beth Israel Deaconess Medical Center,
such as live-streamed video through
Massachusetts, they collected data on
the eyes of the clinician. In Michigan,
withdrawal times of colonoscopy scopes
twenty bariatric surgeons recently
since some doctors were thought to
agreed to have their technical skills
do it too quickly and miss things. Each
rated anonymously by peers using
own clinical communities at first than doctor was sent a bell curve of the
a video of themselves performing
straight to public reporting. It is felt range of times done by everyone in the
a surgical procedure. Skill ratings
this approach creates a safer, non- hospital with only their individual position
were then assessed against clinical
judgemental environment on which to highlighted. This confidential approach
outcomes. The results showed higher
focus on improvement. They will also prompted measurable improvement in
peer ratings of surgical skill were
tolerate less robust data when using it quality, without the need for anyone to
associated with lower rates of post-
for internal quality improvement. feel discredited.
operation adverse events.35 Video can
At Helios, a 112-hospital group in Real-time data with also be used to make decision making
Germany, they have used peer review transparent the board meetings of
expanded formats and forms Englands top executive agency for the
for over 10 years to guide clinician-led
improvements. Quality indicators, A common complaint about published NHS, for example, are now routinely live
derived from routine data and health system data is that they are streamed to the public.
referenced against the averages from out of date often by years. As data One area of potential threat to
all German hospitals, are publically platforms among providers improve it transparency from the big data
reported for each hospital in the will be possible to turn this into more revolution is the rise of algorithms
group. Whenever an indicator shows real time diagnostics, making it far more and artificial intelligence to drive
below-average outcomes for a Helios useful and accessible. For example, decision making in the system.
hospital, the peer review process is the East Kent Hospitals University While the evolution of these systems
initiated: clinician colleagues from other NHS Foundation Trust uses a business is undoubtedly helped by data
Helios hospitals analyse the medical intelligence system to display on its transparency, they are often so complex
records of deceased patients treated website, live A&E waiting times and the that they are often barely understood
in the hospital concerned and provide number of people waiting at each of the even by the organizations that use them.
improvement suggestions in detailed Trusts four hospitals. The information is Concerns have been expressed about
protocols. Evidence indicates this peer also available to hospital staff through the possibility of such an algocracy
review process has had significant a smart phone app. This real-time arising if AI becomes widespread in
impact on mortality rates for a range of data system helps control patient making health decisions it could
conditions, with 710 saved lives over flow into A&E, and enables managers result in care systems even less
the study period 20042011.34 and clinicians to manage demand by transparent than before.36

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18 | Through the looking glass

More consumer access and accessible to consumers, however.


use of data Firstly, information portals are learning
which measures are really of value to
One of the most widely shared
With doctors you can conclusions of the transparency
patients (and having them select the
things to measure themselves), how to
say weve done this data movement so far is that patients visualize and explain concepts in a way
analysis and we know its are not making widespread use of that is easy to understand. The provision
health system data. Very few patients
not perfect, but it gives currently use comparative performance
of decision aids and brokers/advocates
also makes it much easier for patients to
you a reflection of how information to inform their provider process healthcare data into actionable
you benchmark against or treatment choices.37, 38 As a result, information.
there is minimal consumer pressure on
yourself six months ago providers to improve outcomes. Perhaps the most important lessons
or how you benchmark of recent years is that patients are
While consumers now use price particularly receptive to information
against your colleagues. and quality review sites routinely for associated with their personal situation,
And doctors will say thats almost every form of purchasing, such as the costs and quality outcomes
very interesting Im going there has not been a surge in interest for a particular procedure tailored to
to carry this behavior over when they their specific circumstances.39,40,41
to use that, its going to need healthcare. Reasons include Patient accessible and editable
change what I do. lack of skills to comprehend the data, electronic medical records are another
inappropriate data being published, the great example.
urgency of many treatment decisions
and lack of options to act on information. The OpenNotes initiative in the US gives
Brian Ruff
The army of armchair auditors has not patients access not only to their medical
CEO Partner Professional Provider
materialized, so that even in the most records, but the appointment notes
Organization Services, Johannesburg
transparent countries healthcare still written by their clinicians. Evaluation
remains a black box to most people. studies report improved communication
and trust between patients and
Lessons are gradually being learned that clinicians, confidence in self-care, better
will make healthcare information more medication adherence and compliance,

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Through the looking glass | 19

and accuracy of records.42,43 Having will increase the ability of outsiders


begun in 2010 with just 100 doctors and to conduct their own analysis and
19,000 of their patients, OpenNotes is bring together different data silos.
now used by health systems across the Even then, there will always be some Much more needs to be
US, giving more than 6 million patients data individual health outcomes, for
unrestricted access to their medical example which cannot be published. done to enable consumers
records. Kaiser Permanente has found In these cases, responsible third parties or purchasers of care to
that this combination of personalization, (either not-for-profit or for-profit) will understand their own
interactivity and transparency has be given special permission to have
attracted patient engagement like no access to this data in order to form an healthcare experience,
other system before. independent view and conduct the or to make choices in
Open data for independent
kind of sophisticated analyses that healthcare. I would say
are possible with big data but many
third party narratives governments simply do not have the were very much at the
Health systems will see the rise of resources or expertise to conduct beginning of a transparency
privileged or approved challenger themselves. process here.
organizations acting as independent The Leapfrog Group in the US is one
interpreters of healthcare data for the example of an organization that has
system. The ability to challenge official successfully pushed and advocated Dr. David Blumenthal
narratives about what is going on is for such access.44 Every six months, President,
one of the fundamental foundations this independent national non-profit Commonwealth Fund
of healthcare transparency but it is organization publishes the Hospital New York
currently hard for organizations to do Safety Score, grading hospitals based
this when only some health system data on their patient safety performance. In
can be published often with individual response to their campaigning efforts,
level data only available to government. the number of hospitals providing
Health systems will increasingly begin performance measures has increased
publishing data in machine-readable over 15 years from 200 to 2,500, and
formats under open licence, which Leapfrog are also able to access

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20 | Through the looking glass

data from several national agencies price information available for patients.
collecting metrics on healthcare quality. Price transparency initiatives have
A panel of patient safety experts developed in the private sector with
They (Kaiser Permanente) oversees the selection of measures some insurance companies providing
used and the scoring methodology. The cost estimates via online calculators. A
found that if patients sign Safety Score gets significant media few companies now offer personalized
on to portals they can be coverage which prompts attention and price information.
managed more efficiently, interest from hospital board members
Open and honest responses
and hospital staff as well as community
and OpenNotes is what and patient organisations. Exposing to adverse events
gets them onto the portals. providers to themselves, on a regular While the threat of sanction and legal
It also makes them more basis, has proved beneficial in driving action has deterred many providers
hospitals to be continuously more
likely to stick with the vigilant about safety.
from being too open about failures in
care, many healthcare systems and
health system. individual providers are beginning
Price transparency tools to
to buck this trend. Recognizing the
reduce health spending importance of giving context to cold
Dr Tom Delbanco In some systems the potential financial statistics and getting ahead of a media
Co-Director OpenNotes, rewards from price transparency tools,
Professor of General Medicine and offering consumers price information
Primary Care, Harvard Medical School,
on health services, are considerable.
Boston
One organization estimated reduced
health spending in the US of US$18
billion over 10years45, another
calculated that only a 3 percent
uplift each year could save US$16
billion by 2020.46 Nevertheless,
price transparency tools have so far
failed to lower healthcare spending.
Most patients are not using the data
to choose best value services and
continue to rely on their doctors
recommendations. A key reason is
low take-up.47, 48 The current product
offering fails to engage patients: price
data is frequently provided without
data on service quality, it is not
personalized, and there is often no
information on out-of-pocket costs.
To be helpful price information needs
to provide a meaningful estimate of a
patients total expected costs.49,50
Recent developments, particularly
in the US, are prompting change.
Adjustments in the US health
insurance market have meant
commercially insured patients now
bear a larger proportion of spending
through increased deductibles,
co-payments and co-insurance.
More than half of US states have
passed legislation establishing price
transparency websites or mandated
that hospitals or health plans make

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Through the looking glass | 21

environment that is all too ready to deaths which being rare makes patient
ascribe blame, policies that promote a identification likely). The management
proactive approach to error will become view is that adverse events are
more common. system not individual-related and Transparency will only be
should be used to learn and improve
An example of one such proactive
not penalize. New employees are a meaningful and effective
approach that is quickly spreading is
Sykehuset stfold, a private hospital
informed on their introductory day that policy if third parties have
organization in Norway. If there is an
if they report adverse events they will the ability to construct
always be supported. Within a year
adverse event, the hospitals patient
of its introduction other Norwegian their ownnarratives of
harm group will meet to consider all
the collected evidence, decide what
hospitals started following this model fairness.
and it has recently been adopted as
should be done differently to prevent
government policy for all hospitals.
repeat occurrence, and help ensure Tim Kelsey
necessary changes are implemented. Still, there is a long way to go globally: CEO Australian Digital
A full report of the incident and only 38 percent of countries completing Health Agency,
improvement policy and practice is the transparency scorecard said there Australia
placed on the hospital website (except was public reporting of adverse events
in the case of suicides or birth/infant by hospital providers.

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22 | Through the looking glass

Seven
features
of successful
healthcare
transparency
We have highlighted a critical need for
transparency to be far better managed if it
is to deliver its future potential. The largely
optimistic scenario painted in the previous
chapter will not materialize if health systems
continue to misunderstand the benefits and
risks of transparency and misuse it as an
ideological symbol rather than a strategic tool.
Our research identifies seven different features
of successful approaches that health systems
should pay attention to. We illustrate each of
these features with case studies of where
health systems have got this right or wrong.

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Through the looking glass | 23

1 A consistent strategy iii. National agency for patients 1


rights and complaints, and
While piecemeal progress is better
reporting of adverse events Key actions for
than none at all, to fully unlock the
This operates as a one-stop governments:
benefits of transparency at scale
portal for patients wishing to file
it helps to take a strategic and
a complaint about diagnostics, Develop a whole-system
planned approach that ensures
care, treatment, or rehabilitation approach to transparency
every initiative is pushing in the
in the Danish healthcare with a positive policy and
same direction according to the
system, or report an adverse legislative environment,
same values. Thegovernment
event. Patient safety legislation underpinned by governance
of Denmark thehighest
mandates that healthcare focused on quality of care
scoring country in our index
professionals report all adverse
acts as an excellent example of Legislate to measure and
events they become aware of in
this strategic approach, having report quality of healthcare
connection with treatment and
successfully created a positive data including patient
care; this process is blame and
policy and legislative environment, experience and PROMS, at
sanction free. The agency also
supported by a governance unit and provider level
administers the reporting system
model that focuses on quality of
for adverse events and ensures Ensure communication of
care and quality management. It
that knowledge gained from all care quality data is accessible,
incorporates several national-level
incidents is used system-wide to understandable and up-to-date
transparencyinitiatives: 51
improve care quality.
Publicly set out the individual
i. Public reporting on quality
iv. National system measurement rights of patients
of care Care quality data,
using patients unique identifier
including information on patient Ensure there is public reporting
Denmark has well-developed
experience, waiting times, and of adverse events
health registries and a unique
hospital ratings, is publically
patient identifier that enables Establish a clear patient
available on the official Danish
all registries to include patient- complaints system
e-health portal, Sundhed.dk. The
level data, and combine the
data is updated daily. This enables
data across care pathways
patients, clinicians, policy officials 1
into sophisticated quality
and politicians to freely access all
performance measurements.
available healthcare information. Key actions for
Results are adjusted for case
In a secure part of the portal, providers:
mix to ensure comparability of
patients can access their
data at unit, hospital, region, and Measure and report patient
personal medical record.
national levels. Clinicians and experience data including
ii. National surveys on patient managers receive the results PROMS
experience A key aspect of on a monthly basis. Structured
healthcare policy, reflected in audits are undertaken including Establish and publish a policy
Danish legislation, is to measure interpretation and evaluation of to protect whistleblowers
and report patient experience the results and suggestions for (staff who report concerns
in order to develop services for improvements. After auditing the about the quality or safety of
patient benefit. Results from results are released publicly. healthcare) from any negative
the Danish National Survey of repercussions
Patient Experience are publicly 2 Take the lead from innovative
providers Ensure communication of
reported at unit, hospital, care quality data is accessible,
regional and national level. At While examples abound of understandable and up-to-date
the unit level, the data is used unintended consequences from
for identification of improvement centrally-designed, top down
areas, benchmarking, and transparency initiatives, the track
monitoring of improvement record is much better where policy
efforts over time. is led by what the best payers and

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24 | Through the looking glass

providers in a system are already work he took the case to the Civil
doing. Regulation and legislation Ombudsman and won; the hospital
alone do not change hearts and was blamed for the incidents. This
minds, and healthcare is simply sent a clear message, not just to
The biggest push is from an too complex for transparency his workforce but across Norway,
elite group of providers who initiatives to be successful if they that staff would be protected if they
really want to get better are done to the system. Most reported errors the important
constructive innovation happens thing was to learn from them.
and better. Theyre amazing locally by individual organizations
and they push us all on that are inspired to improve. Even
Other strategic actions that have
helped Sykehuset stfold embed a
transparency. if a system has laggards and those
culture of transparency are:
that resist change, it is always safer
to look at what is already working when national comparative
Leah Binder well somewhere and expand it, performance results data showed
Chief Executive, The Leapfrog Group, than impose new practices that Sykehuset stfold scoring less
Washington sound good on paper but create than average on 30-day survival
unnecessary burden and confusion outcomes, Just Ebbesen did not
on the front line. question the figures, but stated
it was important the transparent
Just Ebbeson, CEO of Sykehuset
data was made available
stfold in Norway is one such
innovative provider leader. In 2016 an internal peer-review
he personally won the Norwegian improvement programme used
2 to highlight variations has led to
transparency award (penhet),
from across all Norwegian quality improvements e.g. two
Key actions for sites had 40 percent differences
organisations not just healthcare.
governments: Sykehuset stfold, a publicly- on stroke survival, so they closed
Encourage recruitment of owned healthcare group, provides the smaller one and saw instant
provider CEOs who will lead specialist healthcare services to increases in survival levels
on promoting internal and around 280,000 people through
bringing in Transparency
external transparency three hospital sites in stfold
International to help reform
County in south east Norway. Just
Offer policy incentives and purchasing and procurement
Ebbesons leadership approach is
funding for provider initiatives practice to reduce suspicion
a mix of challenge and support,
on transparency about conflicts of interest
underpinned by the view that
transparency must be used to build all staff have tablet computers
Spread learning nationally from
a learning organization. For him linked to patients they are
good local provider transparency
transparency is not an ideology responsible for, so they can get
models and innovations
but a strategic tool to drive the personal alert messages
behaviour changes that enable The experience of Just Ebbeson
2 continuous improvements in safety provides some valuable lessons
and quality. When he started as about transparency at the individual
Key actions for CEO in 2009, the hospital group provider level:
providers: did not score well on quality
performance indicators and he Strong visionary leadership from
Include the role and looked for early wins to change innovative providers is a good
responsibility to lead on the culture. One of his first actions basis for national policy, such
promoting internal and helped establish the culture that as the hospitals adverse events
external transparency in job mistakes and errors are systemic, system which is now common
descriptions for CEOs and not individual, failures. Two staff practice across Norway (see
other leadership posts members were under review for page 14)
Reward CEOs who introduce malpractice by the national quality Data can be used effectively to
transparency initiatives that inspectorate. Just immediately improve care quality if clinicians
successfully improve care complained that the hospital, not are on side and feel a sense of
quality the staff, should be held to account ownership in development of the
for these harms. When this did not measures

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Through the looking glass | 25

To raise care quality, it was feedback publicly available on NHS


judged more important to websites in order that patients and
focus on the hospitals internal the public could use the information
improvement targets and to make choices about hospital
benchmarking, than comparative care. The FFT asks a single question
The population is
performance with other as to whether the user would increasingly expecting
Norwegian hospitals (the size and recommend the service to friends this kind of transparency.
situations being so varied) and family if they needed similar
care or treatment, and offers a range
Either we react to it slowly
Team competence and
of responses. The methodology is and it happens to us... or
organizational systems
determine outcomes, not
based on the Net Promoter Score, we are active and drive it,
developed as a measure of brand
individual performance
loyalty, and widely employed in the
and shape it ourselves,
Being open and transparent private sector to evaluate customer which helps us to learn
changes the approach of the satisfaction. and build trust and a better
media; they are less inclined
to attack and more prepared to
Although individual hospitals had conversation around
present the steps being taken to
been using the FFT for some healthcare.
time, early reviews of its national
avoid the same mistake again
implementation were highly critical,
3 Measure what matters to patients raising several concerns test
Just Ebbesen
scores misunderstood by the
Information on patient experience CEO,
public, data being gamed; provider
is a key motivator in attracting more Sykehuset stfold,
comparison being unreliable
consumers to use performance data Norway
because there was no standardized
in healthcare decisions, and should
way of administering the FFT, and
be a prime concern in deciding what
the results being published without
data to measure and publish.52 Social
adjustment for patient mix. In
media platforms such as TripAdvisor,
response, NHS England introduced
RateMyTeachers, 311, and Yelp,
several significant modifications to
where people can share and review
the methodology, implementation,
their service experiences have
and use of the FFT54:
proved popular as well as effective in
improving service standards. Clearly set out what was
appropriate use of the data: to
PROMS are a particularly rich source
gather feedback from people
of information, having been linked
using services that can be fed The friends and family
to care quality improvements,
predicting the likelihood of hospital
directly to the staff that provide question
their care; to provide a broad
re-admission53, and identifying We would like you to think about
measure of patient experience
safety issues. Yet currently process your recent experience of our
that can be used alongside other
measures are more likely to be services. How likely are you to
data to inform patient choice;
reported than patient outcomes. recommend our (ward/practice
and, to identify areas where
Patient outcome and experience etc) to friends and family if they
improvements can be made so
data is routinely published by need similar treatment?
practical action can be taken
only 22percent of the countries
completing our transparency Sophisticated analytical tools
scorecard. used to identify when test data
has been gamed
In this context, the English NHS
introduced the Friends and Family Publication of the number
Test (FFT) in 2013, offering patients of responses alongside the
the opportunity to rate local services FFT scores to indicate levels
they use by providing real-time of participation within an
information on their experience. The organization
primary objective was to make this

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26 | Through the looking glass

3 A clear message that it should indicators to clinical registries. The


not be used as a comparative majority of these indicators related
Key actions for measure of quality of care across to process and structure, very few
governments: the country to clinical outcomes. In the main
they had limited relevance to quality
The addition of a free text
Publicly report patient ratings improvement, and their collection,
comments box
on whether they would costly in terms of time and effort,
recommend health services The FFT has subsequently been was resented. Santeon Hospitals,
they have used to others rolled out across most English NHS an association of seven teaching
services. It has proved a powerful hospitals, decided the number of
Use patient experience data
tool for service improvement, by reported metrics needed to be cut
alongside other quality data to
increasing the emphasis placed on and that only indicators of value to
inform patient choice
patient experience, and promoting a patients and the quality of their care
Provide real-time feedback better staff culture of responsiveness should be measured and reported.
to staff of patient experience to patient feedback. The FFT is In 2013 they introduced the Care for
data to enable rapid quality also popular among patients as a Outcome programme, initially for a
improvements where data source about the quality of range of different cancer types and
necessary services. Since 2013, the FFT has followed later by other diseases. The
collected more than 25 million ratings ambition is to have outcome indicator
Communicate clearly
from patients of their healthcare sets for the 25 most expensive
to citizens how patient
experience, making it the biggest diseases that currently account for 45
experience data will be used
source of patient opinion in the percent of Santeon Hospitals costs,
world. Machine learning techniques by 2020.
employing predictive algorithms
3 Key features of the program include:
are being considered to analyze and
Key actions for make more use of the open text Agreement on a compact set
data collected by the FFT, potentially of 67 relevant and measurable
providers: a rich source of patient experience indicators for each condition, in
Measure whether patients information.55 consultation with patients and
would recommend health clinicians based on patient-
services they have used to 4 Fewer measures, more relevant measures identified from
others meaningful data existing literature and informed by
value-based healthcare theory
Communicate clearly to There is a difficult balance to be
patients how the patient struck between the increasing ease A scorecard for each condition
experience data will be used with which healthcare data can be with the selected indicators and
collected and published and the what and how these should be
Use patient experience data
realization of many service leaders measured
internally to empower staff to
that transparency is most powerful Results for every indicator publicly
make patient-led changes and
when focused on a smaller number reported by every Santeon hospital
stimulate local improvements
of indicators that really matter. While
Publicly report any changes transparency is blamed in many Variation identified and analyzed,
made in response to findings countries for creating a huge burden and possible improvements
from patient experience data of data collection, for the most part discussed by multi-disciplinary
the opposite is trueitdraws teams including doctors, nurses,
attention to how much data was patients and a health insurer (to
being collected anyway, allowing for initiate discussion on outcome
a more intelligent debate about what payment linked to quality)
should be collected and why. Shared learning across clinical
Such a debate is currently ongoing teams about which quality
in the Netherlands. At the start improvements introduced in
of the decade hospitals there response to variation, work and
were reporting a large volume of do not work

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Through the looking glass | 27

Benchmarking the outcomes have been a recent introduction 4


of local innovations, and then in the private sector. In line with
implementing the best across all evidence on what consumers seek Key actions for
Santeon hospitals from price data to support choice, the governments:
information made available reflects
The program has shown that with a
actual costs for individual patients. Assess the relevance
minimal set of published outcome
Castlight Health in the US is one and value of reported
indicators, which reduces the
such company providing this type healthcare metrics to quality
administrative burden for hospitals
of price transparency tool. It offers improvement, and whether
and clinicians, care quality can
a personalized benefits platform to they can be reduced in
improve across clinician teams. For
employees of client companies (self- number
example, as a result of identified
insured employers). Employees can
poor outcomes from the low volume Put focus on reporting
compare prices and quality across
of prostatectomies conducted at measures to identify variation
healthcare services and providers.
Eindhoven hospital, operations were where quality improvements
The data shown in the toolbox is
relocated to one of the other Santeon might be possible, not on
sourced from the insurance claims
hospitals, Canisius Wilhelmina. performance management
of health plan administrators, and
This centre was undertaking a high
a range of national organizations
volume of prostatectomies using
providing information on care quality. 4
robotic facilities. The Eindhoven
Employees can add their own
Hospital clinicians were trained to
satisfaction scores. Key actions for
use the robot and supervised by their
Canisius Wilhelmina colleagues. The Castlight Health has had to manage providers:
two clinician groups shared learning complex challenges in implementing
Involve patients and clinicians
and experience about what worked its price transparency tool. There are
in deciding the most
well and what did not. Subsequently, several important lessons associated
important outcome measures
serious complications declined at with this experience:
both hospitals from 8 to zero percent. Work collaboratively with
They started with larger employer
The rate of positive surgical margins clinical registries and
clients because they needed
also declined: at the low volume regulators to determine the
large amounts of data and
hospital from 51 to 24 percent and most meaningful measures to
wanted the employers advocacy
notably at the high volume hospital collect and report
power in making the case to
too, from 40 to 22 percent.
health plan administrators Use a limited number of key
outcome measures internally
5 Provide personalized price to drive improvement among
transparency clinician groups
Price transparency can play a
significant role in stimulating
provider choice among consumers
and ensuring they are not ripped
off. This is particularly important in
Just work with the outcome measures and ignore all the
countries such as the USA where indicators that are not relevant... Our doctors are very
the private sector dominates happy because they see the relevance of the measures
health care provision, but also in
single-payer health systems where
and they really can use them to analyze and to study
there are some private providers. because of the variation, and learn from each others best
However, price transparency can be practice. This is working very well to improve the quality
challenging to achieve; some private
insurers and providers are reluctant
of care.
to make prices transparent for fear it
will result in loss of market share.
Leonique Niessen
Price transparency tools offering Director, Santeon Hospitals,
personalized information to patients Netherlands

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28 | Through the looking glass

5 More progressive clients, some sharing and wider access of


who really want to drive price individual-level health data in terms
Key actions for consumerism, have most of service improvement, developing
governments: supported employee use of new treatments and predicting who
the Castlight Health platform, is likely to become ill. On the other
Legislate for providers to educating them in its benefits hand, the possibilities of bio banking
clearly and promptly give and how to use it and big data come at a time where
patients total prices they there is decreasing expectation that
To support wider adoption,
should expect to pay for any organization can keep its data
clients need to see cost savings
individual medical conditions fully protected, and suspicion of the
from their employee use of the
motivations of some stakeholders
Legislate for insurance platform this is not immediate
that wish to access it.57,58 As the
companies to provide and takes time
differences between patient access
personalized price
Using data from across a to records (13 percent of countries)
transparency tools
range of different health plan and patient privacy legislation
Publicly report total prices administrators and care quality (91percent of countries), personal
health insurers/payers information sources is difficult privacy is usually the more powerful
are charged by healthcare and complex; data quality varies of these two camps. Transparent
providers for individual considerably, there are data gaps, data security and information
medical conditions and and a lack of consistency governance has become a
treatments making the data transparent has necessity, but how to manage it in
however, resulted in data quality the right way?
Legislate against contractual
improvements
arrangements between health Such concerns were manifest in the
insurers and providers that Contractual arrangements recent backlash to the proposed
restrict price transparency between some large health implementation of care.data in the
insurers and providers restrict UK. This was a program to link data
Castlight Health in the price data between general practitioners (GPs)
5 they can show consumers, the and hospitals, launched in 2013
provider may even prevent them by NHS England. It was explained
Key actions for showing anything; market power to the public that data was to be
providers: being used to limit transparency extracted from GP practices with
certain personal identifiers available
Publicly report total prices Nevertheless, among users the price
and others removed, for example the
patients should expect to be transparency tool appears successful
patients NHS number but not their
charged for individual medical in reducing costs for some healthcare
name or address. The data would
conditions and treatments services. A recent study showed that
be made available to a public body,
(and where appropriate, care its use was associated with lower
allowed by law to manage sensitive
pathways) total claims payments for laboratory
personal data, which would link the
tests, advanced imaging, and to a
Challenge contractual data to hospital records; enabling
lesser extent, clinician office visits.
arrangements with health patient outcomes to be tracked
The study analyzed the 20102013
insurers that restrict price across the care pathway. All personal
medical claims of over half a million
transparency identifiers would be removed as
patients, insured by 18 employers
soon as the data was linked and
providing the platform for their
only authorized organizations
employees.56
would have this data released to
them. There would be complete
6 A give-and-take approach to transparency concerning how the
safeguarding patient data data was used so the public could
Health systems must walk a fine see the benefits of data sharing.
line in their treatment of patient However, since the program raised
data. On the one hand, there is concerns about patient privacy, all
widespread recognition of the patients were given the right to opt
potential benefits of allowing out of the initiative.

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Through the looking glass | 29

During this process, the media care information will be used, 6


reported two influential news but benefits shouldnt just be
stories. First, that individual- theoretical or for the system Key actions for
level data could be accessed by tangible personal improvements governments:
authorized pharmaceutical and for patients are effective at
insurance companies. Second, allaying many concerns. Develop a data privacy
an NHS organization had released and safeguarding strategy
Unlocking the benefits of mass
individual-level data to third parties, for personal patient data,
individual level health data
at least one of which was passing it including obligations
requires a completely transparent
on to other organizations. The media and responsibilities of all
approach to data security and
and public outcry, alongside more stakeholders
governance
than one million people opting out
Involve patients and their
of the scheme, led NHS England to Patients must be closely involved
families as well as other
postpone the program. in the design and continuous
stakeholders in determining
evaluation of the system
In response, the government this strategy
introduced legislation permitting use While the popularity of social
Put legislative safeguards in
of patient data for only health and media has led to a cultural shift
place for personal patient data
care purposes. They also launched in terms of willingness to self-
sharing with clear consent/opt
two parallel reviews of data security publish personal data, there is
out arrangements
across the NHS.59,60 The review still widespread concern around
findings showed there to be broad sharing personal health data In communications, put
support for personal data being emphasis on patients having
A consent/opt-out model should
used in running the health and social access to their own personal
be made available to give people
care system when the benefits of medical record summary,
a clear choice about how their
doing so are clearly explained, but control over its contents, and
data is used for purposes beyond
people did not fully understand what who can access it
their direct care
options they have in relation to use
of their information, and found the Emphasis in public
system difficult to comprehend. After communications should be on 6
publication of these findings, the people having access to their
care.data program was closed. own personal health record Key actions for
and control over what goes providers:
A wholly different approach was
into this, and who can access Provide clear communications
taken in Australia, which relaunched
it; not on third party access to patients about the data
its My Health Record in 2016, and
which is difficult to explain and privacy and safeguarding
was able to learn from the care.
comprehend strategy for personal patient
data story. Promotion of its new
tool puts emphasis on personal as data, including consent/opt
well as organizational access 7 Promote independent narratives out arrangements
the program includes a secure to improve understanding
In communications, put
summary of a persons health Independent data assessment emphasis on patients having
information that they can access and interpretation enables better access to their own personal
online, control what goes into it, and understanding of the impact and medical record summary,
who has access to it. Secondary outcomes of healthcare policies, control over its contents, and
use of My Health Record data for performance, and markets. Having who can access it
beneficial research, policy and informed, alternative narratives
planning purposes is currently open to those provided by executive
to community consultation.61 authorities requires the sharing of
Lessons for future initiatives to share data in open and machine readable
individual level health data include: formats. This is challenging for
governments because it involves the
Extensive public dialogue is loosening of control over how data
needed about how health and will be used.

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30 | Through the looking glass

Dr Foster was one of the first cases hospitals identified as


organizations to provide this function sub-standard were investigated,
for a national health system. They and the public enquiry into mortality
launched their first Hospital Guide to outcomes at Stafford hospital
That whole debate, English hospitals in 2001, providing concluded that without Dr Foster,
that whole concern information and analysis of variation comparative mortality statistics
about privacy wasnt in healthcare outcomes, for patients, would not be published as quickly or
the public and professionals. The as fully as they are now.62
managed. project was founded on the basis
In the US, the Health Care Incentives
it would serve the public interest.
Improvement Institute (HCI3) uses
This was underlined by the creation
Charlotte Alldritt of an independent committee to
advanced analytic techniques to
Director provide valuable independent third
oversee its work, with rights to
RSA Public Services and party narratives. For example,
curtail activities if found counter to
Communities, and Open Public they published an analysis of
the public interest. A key aspect of
Services Network New Hampshires claims data for
making data sharing possible was
UK hysterectomies, showing indicators
the agreement Dr Foster struck with
of low quality care.63 HCI3 were
government, whereby they would
facilitated in doing this analysis
give several days advance notice of
by New Hampshire providing
any publication.
their health databases in machine
Despite strong reactions from both readable format. New Hampshire
7
those who agreed and disagreed also allows publication of third party
with the information Dr Foster data narratives as long as
Key actions for
published, it had significant impact they are shared with the state
governments: on the debate around care quality prior to publication.
Publish data in open and improvement in England. In some
machine readable formats
and under an open licence,
allowing independent data
processing and analysis
Publish methodology and
calculations used to report Its creating a lack of transparency if all you have is one
data (including underlying account of what data means. With Dr Foster we said
data used in algorithms), to can we have the underlying data, and when we re-
allow other organizations to
replicate, verify or challenge analysed it in quite a different way, it showed where
interpretations there was a problem. Simply publishing mortality or
Set up agreements with third survival rates does not create transparency.
parties over how information
is released
Roger Taylor
Chair
7 Open Public Services Network,
London
Key actions for
providers:
Publish data in open and
machine readable formats

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Through the looking glass | 31

How KPMG can help


Transparency of Transparency of information can be a powerful positive change agent that
can reduce the cost and improve the quality of healthcare. However, there
information can be are potential challenges that need to be addressed or overcome to realize
a powerful positive the benefits transparency can create.

change agent that The healthcare industry is impacted by many factors, such as aging
populations, budget pressures, increased costs of treatments and rising
can reduce the demands from patients. The availability of timely, accurate and relevant
cost and improve data to provide and evaluate the effectiveness of care provided to patients
is essential to ensure consistent, efficiency, effectiveness, and quality
the quality of of care. However, this information will not have the appropriate impact if
healthcare. However, unavailable to the appropriate stakeholders.

there are potential Although there are no standardized data sets nor processes for
accumulating, analyzing, and distributing health information today, there
challenges that need are various initiatives across the globe to create standardized frameworks
to be addressed to enhance the consistency and transparency of health data to improve
the efficiency and quality of care.
or overcome to
However, even without national or global standards, to be successful and
realize the benefits competitive over the long-term, healthcare systems need to focus on
transparency can ensuring the transparency of relevant data (e.g. cost, operating results,
mortality, medical mistakes, etc.) to each of their stakeholders.
create.
KPMGs Global Healthcare practice is a leader in healthcare, assisting
organizations across the healthcare ecosystem to work together in new
ways to help transform the business of healthcare. Our vision is to bring
the best of global practice to your organization through our network of
4,500 dedicated healthcare professionals across 152 countries. Our teams
offer a market leading portfolio of tools and services focused on helping
our clients establish appropriate strategies, design and implement new
business models, leverage technology, and data and analytics to guide
them on their path to providing timely, accurate and relevant data to each
of their stakeholders to reduce the cost and improve the quality of care.
To learn more about the lessons and examples in this report, please
contact the KPMG Head of Healthcare in your local region.

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32 | Through the looking glass

Authors and contributors Dr. Mark Britnell, Chairman and Partner Global Health Practice, KPMG in the UK
Mark is Chairman and Partner of the Global Health Practice at KPMG. Since 2009, he has worked in over
60countries, helping governments, public and private sector organizations with operations, strategy and
policy. He has a pioneering and inspiring global vision for healthcare in both the developed and developing
world and has written extensively on what works around the world (kpmg.com/whatworks).
Mark has dedicated his professional life to healthcare and has led organizations at local, regional, national
and global levels. He was CEO of high-performing University Hospitals in Birmingham and master-minded
the largest new hospital build in the NHS. He also ran the NHS from Oxford to the Isle of Wight before
joining the NHS Management Board as a Director-General. He developed High Quality Care for All with
Lord Darzi and recently published his first book In Search of the Perfect Health System, which won Best
Health and Social Care Book 2016 at the BMA Book Awards. @markbritnell

Marc Scher, Partner, KPMG in the US, and Global and US Healthcare Audit Sector
Leader
Marc is an audit partner in Orange County leading the Southern California Healthcare practice. He has
over 30years of experience focusing on large health systems, longterm care providers, hospitals, biotech
organizations, payers, healthcare purchasing cooperatives, medical research, and other healthcare service
providers. He has extensive experience providing advice and counsel in the areas of audit, financial
reporting, and tax exempt financings. In addition to his healthcare role, Marc serves as an SEC reviewing
partner and national instructor for KPMG healthcare professional development courses. He was also past
Chairman of the Healthcare Financial Management association, Principles & Practices Board.

Stefan Friedrich, Partner, KPMG in Germany


Stefan is an expert in hospital and healthcare management in the German health and social care industry.
Over the last 10 years he served numerous clients in Germany, China, the Middle East and Central Europe
to learn and benefit from international healthcare best practices. His areas of expertise include hospital
management, quality & margin benchmarking and improvement, governance, transparency & healthcare
regulation assurance solutions, the new healthcare economy and digital disruptive healthcare business
models. Stefan is also a lecturer for international healthcare systems at the Dresden International
University and author of numerous publications on healthcare management issues.

Larry Kocot, Principal, KPMG in the US and National Leader of KPMGs Center for
Healthcare Regulatory Insight
Larry is a Principal at KPMG in the US, and National Leader of KPMGs Center for Healthcare Regulatory
Insight. The Center follows healthcare regulatory and policy trends driving healthcare transformation and
industry convergence and the broader implications of operating in a more collaborative and integrated
US healthcare payment and delivery environment. He provides advice and counsel to companies on
corporate strategy and regulatory matters relating to public healthcare programs, including Medicare and
Medicaid. Larry is a former Senior Advisor to the Administrator of the Centers for and Medicaid Services
(CMS) at the US Department of Health and Human Services. In this capacity, he was involved in a wide
range of health care policy issues and operations related to Medicare and Medicaid. Prior to joining
KPMG, he practiced law at Epstein Becker Green, PC, and Dentons, US LLP, and was also Senior Vice
President and General Counsel at the National Association of Chain Drug Stores.

Prakash Wilson, Director, KPMG in Australia


Prakash has over 16 years of experience delivering advisory, internal audit, governance projects (including
development and implementation of policy governance frameworks), risk management, process analysis
and process reengineering. He currently acts as KPMGs National Risk Consulting lead for Education. In
addition to focusing on the public sector, he brings extensive private sector experience to his role.

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Through the looking glass | 33

Nick Rolfe, Senior Manager, KPMG in Canada


Nick is a Senior Manager, Healthcare at KPMG in Canada. Nick began his career with KPMG in the UK in
2004, where he provided audit services to a wide variety of healthcare payers and providers. He also worked
with major academic health institutions leading their internal audit services. After moving to Canada in 2015,
Nick became national leader for KPMGs Board Grip healthcare services network which focus on internal
audit, governance and risk. He currently leads the internal audit services to organizations like University
Health Network and SickKids.

Neil Thomas, Partner, KPMG in the UK


Neil is the UK Head of Healthcare Audit. He has worked extensively on healthcare, education and charity
clients since he joined KPMG, and currently splits his time between advisory engagements and leading a
number of audit clients. Some of his key clients have included both Foundation Trust and Audit Commission.
From his internal audit and other work Neil has developed and in-depth understanding of the financial,
accounting and governance regimes that exist across the public sector, as well as extensive knowledge of
the Monitor methodology for licensing and effective business planning within the hospital setting.

Wencke Van Der Meijden, Senior Manager, Head of Healthcare, KPMG in Norway
Wencke leads the health practice in Norway. She has extensive experience across all main healthcare
sectors including care, cure, insurance companies and government. Wencke has seen the healthcare
system from different angles and has great passion for improving healthcare together with medical
professionals. During her career she has led large projects to improve the quality and effectiveness of
healthcare institutions and a redesign of the Netherlands healthcare system. Wencke holds a Masters
Degree in Health Economics, and another in International Health Policy & Law from the Erasmus University
of Rotterdam.

Dee Dee Owens, Partner, KPMG in the US


Dee Dee is a partner in KPMGs Los Angeles office. She has over 15 years of project advisory and audit
experience with particular specialization in IT project management and IS governance. Dee Dee focuses
on advising her clients on highly technical skills related to large IT enabled technology transformations,
project management and quality assurance, third-party reporting, privacy and security, control design, risk
management and internal audit advisory, and internal audit and co-sourcing engagements. She specializes
in healthcare, state and local government industries and has worked with the largest US health plans and
healthcare providers, as well as many large state and local government agencies.

Dan Harradine, Partner, KPMG in Australia


Dan is a Partner in KPMG Australias Health, Ageing and Human Services (HAHS) Practice. Prior to joining
the firm in 2013, Dan held a range of senior government roles in Australia. He has over 17 years experience
working across the public and private sectors, and combines his understanding of government and the
public sector, private sector service provision and the broader healthcare environment to support strategy,
operational improvement, risk and issues management and large-scale healthcare transformation projects.
Dan has led major health system reform and improvement initiatives across a number of Australian
jurisdictions, including the implementation of national health reforms in one of Australias largest States,
Queensland. Dan is a member of the HAHS national leadership team, and leads KPMGs health advisory
services in Queensland and the Northern Territory.

With special thanks to Francesca Taylor and Jonty Roland who led the research and report drafting.

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34 | Through the looking glass

Interviewees
Charlotte Alldritt, Director, RSA Public Services and Communities, and Open Public Services Network, UK
Dr Sharon Arnold, Director, Agency for Healthcare Research and Quality, Washington
Leah Binder, CEO, The Leapfrog Group, Washington
Dr David Blumenthal, President, Commonwealth Fund, New York
Sheila Burke, Research Fellow, Malcolm Weiner Centre for Social Policy, John F Kennedy School of Government, Harvard
University, Massachusetts
Helen Darling, Interim President and CEO National Quality Forum, Washington
Dr Tom Delbanco, Co-Director Open Notes, Professor of General Medicine and Primary Care, Harvard Medical School,
Boston
Emma Doyle, Head of Data Policy, NHS England, UK
Andrea Ducas, Programme Officer, Robert Wood Johnson Foundation, New Jersey
Just Ebbesen, CEO stfold Sykehuset, Norway
Carlos Iglesias, Senior Researcher, Open Data, World Wide Web Foundation, Washington
Tim Kelsey, CEO Australian Digital Health Agency, Australia
Dr Ralf Kuhlen, Managing Medicine, Helios Kliniken GmbH, Germany
Paul Levy, Former President and CEO, Beth Israel Deaconess Medical Center, Boston currently Senior Advisor Lax Sebenius
LLC, Massachusetts
Malcolm Lowe Lauri, Executive Director, Cambridge University Health Partners
Jayne Lux, Head Global Business Group Health, Washington
Elizabeth Mitchell, President and Chief Executive Officer, Network for Regional Healthcare Improvement, Maine
Kristin Torres Mowat, SVP Health Plan Development & Data Operations, Castlight Health, California
Leonique Niessen, Director, Santeon Hospitals, Netherlands
Dr Ricardo Rodrigues, European Centre for Social Welfare Policy and Research, Austria
Dr Brian Ruff, CEO and Partner, Professional Provider Organisation Services (PPO Serve), South Africa
Dr Lewis Sandy, Senior Vice President, Clinical Advancement, United Health Group, Minnesota
Roger Taylor, Chair, Open Public Services Network, UK
Dr Juan Tello, Programme Manager, Health Governance, Division of Health Systems and Public Health, WHO Regional Office
for Europe, Denmark
Matthias Wismar, Senior Health Policy Analyst, European Observatory on Health Systems and Policies, Belgium

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Through the looking glass | 35

Appendix 1
Global Health Systems Transparency Framework Results

Table 2: Quality of Healthcare scores by country (Indicator Score)

Dimension 1: Quality of Healthcare


1.1. 1.2. 1.3. 1.4. 1.5. 1.6.
Mortality/ All-cause Hospital Waiting times Adverse Hospital-
survival rates mortality/ re-admission for emergency event acquired
for individual survival rates rates care reporting infections
medical
conditions &
treatments
Austria 1 1 1 1 1 1
Australia 1 1 2 3 2 2
Brazil 3 1 1 1 1 3
Canada 1 3 3 3 1 1
China 1 1 1 1 1 1
Denmark 3 1 3 3 3 1
Finland 3 1 1 1 1 3
France 3 3 1 1 1 1
Germany 1 1 1 1 1 1
Greece 1 1 1 1 1 1
Iceland 1 1 2 2 2 1
India 1 1 1 1 1 1
Israel 1 1 3 3 1 1
Italy 3 1 3 1 3 1
Japan 1 1 1 1 3 3
K. of Saudi Arabia 1 1 1 1 1 1
Luxembourg 1 1 1 1 1 1
Mexico 1 1 1 1 1 2
New Zealand 1 1 1 1 2 2
Netherlands 3 3 1 1 2 2
Norway 3 3 1 1 3 3
Poland 1 1 1 1 1 1
Portugal 1 3 1 3 1 1
Republic of Ireland 1 1 1 1 1 1
Republic of Korea 1 1 1 1 1 1
Russia 2 1 1 1 1 1
Singapore 1 3 2 2 3 1
South Africa 1 1 1 1 1 1
Spain 3 3 3 3 2 2
Sweden 3 1 3 3 3 4
Switzerland 1 3 1 1 1 1
UK 3 2 2 2 2 1

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Table 3: Patient Experience scores by country (Indicator Score)

Dimension 2: Patient Experience


2.1. 2.2. 2.3. 2.4.
Patient reported Patient Patient Patient
outcome measures satisfaction approval complaints

Austria 1 1 1 1
Australia 1 3 1 3
Brazil 2 2 1 4
Canada 1 2 1 2
China 1 1 1 1
Denmark 1 3 1 3
Finland 1 1 1 3
France 1 3 1 3
Germany 2 2 2 1
Greece 1 1 1 2
Iceland 2 2 1 2
India 1 1 1 1
Israel 3 3 3 3
Italy 1 1 1 1
Japan 1 1 1 1
K. of Saudi Arabia 1 1 1 1
Luxembourg 1 2 1 2
Mexico 1 3 1 1
New Zealand 1 1 1 4
Netherlands 2 3 3 3
Norway 1 3 1 3
Poland 1 1 1 3
Portugal 1 1 1 3
Republic of Ireland 1 1 1 1
Republic of Korea 1 1 1 1
Russia 1 1 1 2
Singapore 1 3 3 3
South Africa 1 1 1 1
Spain 1 2 1 2
Sweden 2 3 1 3
Switzerland 1 3 3 2
UK 3 2 3 3

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Table 4: Finance scores by country (Indicator Score)

Dimension 3: Finance
3.1. 3.2. 3.3. 3.4.
Financial Prices patients Prices health Disclosure of
performance are charged insurers/payers payments, gifts
are charged and hospitality to
healthcare staff
Austria 3 2 1 1
Australia 3 2 2 3
Brazil 1 3 3 1
Canada 3 1 1 1
China 1 2 2 1
Denmark 3 3 3 1
Finland 3 3 3 1
France 3 1 3 1
Germany 2 3 3 1
Greece 1 2 2 1
Iceland 2 3 3 1
India 2 1 1 1
Israel 1 3 1 1
Italy 1 3 3 1
Japan 1 3 3 1
K. of Saudi Arabia 1 2 2 1
Luxembourg 1 3 1 1
Mexico 2 1 1 1
New Zealand 1 3 3 3
Netherlands 3 1 2 3
Norway 3 3 3 1
Poland 1 3 3 1
Portugal 3 3 3 1
Republic of Ireland 3 3 1 1
Republic of Korea 3 3 3 1
Russia 1 3 3 1
Singapore 3 3 3 1
South Africa 1 1 1 1
Spain 2 1 1 1
Sweden 3 3 2 1
Switzerland 1 3 3 1
UK 3 3 3 1

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Table 5: Governance scores by country (Indicator Score)

Dimension 4: Governance
4.1. 4.2. 4.3. 4.4. 4.5.
Freedom of Patient rights Procurement Public decision- Patient/Public
Information processes and making involvement
legislation decision-making

Austria 3 3 1 1 1
Australia 2 3 4 2 3
Brazil 2 3 4 2 2
Canada 3 3 3 2 2
China 1 1 1 1 1
Denmark 3 3 4 2 3
Finland 3 3 3 3 2
France 3 3 2 1 3
Germany 3 3 1 1 2
Greece 2 2 4 2 1
Iceland 3 3 1 1 2
India 2 2 1 1 1
Israel 2 3 2 1 1
Italy 2 3 2 1 1
Japan 3 3 1 1 1
K. of Saudi Arabia 1 3 2 1 1
Luxembourg 3 3 2 1 1
Mexico 2 2 2 1 1
New Zealand 3 3 4 3 2
Netherlands 2 3 3 1 2
Norway 3 3 1 3 3
Poland 2 3 2 1 1
Portugal 3 3 2 1 1
Republic of Ireland 3 3 1 3 2
Republic of Korea 3 3 1 1 1
Russia 2 2 4 1 1
Singapore 3 3 3 1 3
South Africa 2 2 1 1 1
Spain 3 3 4 1 1
Sweden 2 3 2 3 1
Switzerland 3 3 3 1 1
UK 2 3 2 3 3

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Table 6: Personal Health Care Data scores by country (Indicator Score)

Dimension 5: Personal Healthcare Data


5.1. 5.2. 5.3. 5.4.
Electronic patient Shared clinical Patient data privacy Information on
Indicators records system documentation and safeguarding use of patient data
policy

Austria 1 1 4 3
Australia 2 1 4 2
Brazil 1 1 4 3
Canada 1 1 4 1
China 1 1 1 1
Denmark 3 3 4 3
Finland 4 1 4 3
France 1 1 4 1
Germany 1 1 4 3
Greece 1 1 4 1
Iceland 1 1 4 1
India 1 1 2 2
Israel 3 1 4 3
Italy 1 1 4 3
Japan 1 1 3 1
K. of Saudi Arabia 1 1 3 1
Luxembourg 1 1 4 1
Mexico 1 1 2 1
New Zealand 1 1 4 3
Netherlands 1 1 4 1
Norway 1 2 4 3
Poland 1 1 3 3
Portugal 3 3 3 3
Republic of Ireland 1 1 4 2
Republic of Korea 1 1 4 1
Russia 1 1 4 1
Singapore 1 1 3 1
South Africa 1 1 4 2
Spain 2 1 4 3
Sweden 2 2 4 3
Switzerland 1 1 3 3
UK 2 1 4 1

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Table 7: Communication of Healthcare Data scores by country (Indicator Score)

Dimension 6: Communication of Healthcare Data


6.1. 6.2. 6.3. 6.4.
Accessible data Up-to-date data Direct comparison Open data formats
Indicators of providers and
services

Austria 2 1 1 2
Australia 2 2 2 3
Brazil 1 2 1 2
Canada 3 1 3 4
China 1 1 1 1
Denmark 1 3 2 1
Finland 3 3 3 4
France 3 2 3 1
Germany 2 3 2 2
Greece 1 1 1 1
Iceland 1 3 1 1
India 1 1 1 1
Israel 3 2 1 2
Italy 1 2 1 3
Japan 1 1 1 1
K. of Saudi Arabia 1 1 1 1
Luxembourg 3 2 1 1
Mexico 2 1 2 2
New Zealand 3 3 2 3
Netherlands 1 3 3 3
Norway 2 1 2 2
Poland 3 3 1 1
Portugal 3 2 2 3
Republic of Ireland 1 2 1 2
Republic of Korea 3 3 2 3
Russia 1 1 1 2
Singapore 2 1 2 1
South Africa 1 1 1 1
Spain 1 2 2 1
Sweden 2 2 1 2
Switzerland 1 1 2 1
UK 3 2 2 1

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Appendix 2
Scoring methodology for the Global Health We acknowledge that in some countries different health
Systems Transparency Framework systems exist with different levels of transparency
(e.g.Ontario vs. Quebec in Canada). In these instances
The scoring methodology is simple and straightforward, judgement should be used to discern the best score to give
making the scorecard accessible and easy to complete, as for overall performance across the country.
well as suitable for replication over time. There is a three-grade
scale of 1 to 3 for each indicator, plus a bonus point on some Additional advice provided
indicators to reward excellence. Overall, no, or only a few/
Where the private sector in a country is very niche (maybe.
rarely earns 1 point; most/mostly earns 2 points; and, all/
less than 10 percent of activity), scoring should focus on the
always earns 3 points. Actual numbers need not be counted
public sector. Where private healthcare is more common than
for each indicator, but as a guide most/mostly = more than
that, and it can be argued an important part of the healthcare
50 percent.
delivery system, then it should be included.
The majority of indicators are scored in relation to hospital
To score 3 on indicators 1.11.6, data should be published
providers, intended to include public and private hospital
by individual hospital provider (not aggregated at provincial,
providers, but exclude small health clinics, niche or specialist
regional or Trust level). We have selected this scoring approach
providers just catering to a small population.
because only data published this way will enable patient
A few indicators are scored in relation to healthcare choice between individual providers on the basis of quality.
providers, intended to encompass any organizations It also allows for identification of hospital provider outliers
providing healthcare services (including hospital, community, where performance is relatively poor and improvement is
ambulatory, and mental health providers). Again, small likely to support better quality healthcare.
specialist or niche providers can be excluded e.g. if all major
providers follow a particular regulation but small e.g. private
elective providers are exempt, tick all.

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Appendix 3
KPMG Global Health Systems Transparency Framework
1. Quality of Healthcare
Indicator Description Score card
1 2 3

1.1. Mortality/ Is there public reporting of risk-adjusted No, or for only a few Yes, for most Yes, for all hospital
survival rates for in-hospital mortality or survival rates hospital providers hospital providers providers
individual medical for a range of common acute medical
Bonus point:
conditions and conditions or treatments (e.g. stroke,
Also for all individual
treatments cancer, transplants, hip replacement)?
clinical teams or
(total possible physicians providing
score = 4 points) in-hospital treatment

1.2. All-cause Is there public reporting of risk-adjusted No, or for only a few Yes, for most Yes, for all hospital
mortality/survival all-cause mortality or survival rates, hospital providers hospital providers providers
rates either in hospital or within 30-days of
(total possible
discharge?
score = 3 points)

1.3. Hospital Is there public reporting of unplanned No, or for only a few Yes, for most Yes, for all hospital
re-admission rates hospital re-admission rates for a range of hospital providers hospital providers providers
(total possible
acute medical conditions or treatments
score = 3 points) (e.g. stroke, cancer, transplants, hip
replacement)?

1.4. Waiting times Is there public reporting of average No, or for only a few Yes, for most Yes, for all hospital
for emergency waiting times for emergency care (e.g. hospital providers hospital providers providers
care between arrival and treatment at an
(total possible
Emergency Room)
score = 3 points)

1.5. Adverse Is there public reporting of adverse No, or by only a few Yes, by most Yes, by all hospital
event reporting events (an occurrence during treatment hospital providers hospital providers providers
(total possible
that results in patient harm or death)?
score = 4 points) Bonus point:
For each incident,
the improvement
process followed
as a result is also
published

1.6. Hospital- Is there public reporting of three or No, or for only a few Yes, for most Yes, for all hospital
acquired infections more hospital-acquired infections hospital providers hospital providers providers
(total possible
(e.g. catheter-associated urinary tract
score = 4 points) infections; clostridium difficile (c.diff) Bonus point:
or methicillin-resistant staphylococcus This data is also
aureus [MRSA])? published at ward or
clinical team level

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2. Patient Experience
Indicator Description Score card
1 2 3

2.1. Patient reported Is there public reporting of patient No, or for only a few Yes, for most Yes, for all
outcome measures reported outcome measures healthcare providers healthcare providers healthcare providers
(total possible
(PROMS) for a range of inpatient and
score = 3 points) outpatient medical treatments (e.g.
hip replacements, transplants).

2.2. Patient Are patient satisfaction measures No, or for only a few Yes, for most Yes, for all
satisfaction published, based on surveys of healthcare providers healthcare providers healthcare providers
(total possible
patients health care experience
score = 3 points) (e.g. how well staff communicated;
whether pain was well controlled;
how clean and quiet the care
environment was)?

2.3. Patient approval Is there public reporting of ratings No, or for only a few Yes, for most Yes, for all
(total possible
from patients on whether they healthcare providers healthcare providers healthcare providers
score = 3 points) would recommend the health
service they have used to others e.g.
friends and family?

2.4. Patient complaints Is there a clear complaints system No, or for only a few Yes, for most Yes, for all
(total possible
with details published of who healthcare providers healthcare providers healthcare providers
score = 4 points) patients can make a complaint
to about problems with their Bonus point:
healthcare, how a complaint will Information on
be handled, and a named person/ learning and action
organisation who can help them taken in response
make the complaint? to complaints is also
published

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3. Finance
Indicator Description Score card
1 2 3

3.1. Financial Do healthcare providers publish an No, or only a few Yes, most healthcare Yes, all healthcare
performance annual report with independently healthcare providers providers providers
(total possible
audited financial accounts?
score = 3 points)

3.2. Prices patients are Is there public reporting of total No, or for only a few Yes, for most Yes, for all
charged prices patients should expect to healthcare providers healthcare providers healthcare providers
(total possible
be charged for individual medical
score = 3 points) conditions and treatments?

3.3. Prices health Is there public reporting of total No, or for only a few Yes, by most Yes, by all healthcare
insurers/payers are prices health insurers/payers are healthcare providers healthcare providers providers or payers
charged charged by healthcare providers for or payers or payers
(total possible
individual medical conditions and
score = 3 points) treatments?

3.4. Disclosure of Is there public reporting of all No, or by only a few Yes, by most Yes, by all healthcare
payments, gifts payments, gifts and hospitality to healthcare providers healthcare providers providers
and hospitality to healthcare staff?
healthcare staff
(total possible
score = 3 points)

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4. Governance
Indicator Description Score card
1 2 3

4.1. Freedom of Does the country have a right-to- No, or applies Yes, but applies Yes, this applies
Information legislation information law that applies to only to national only to all public to all public and
(total possible
organizations providing, paying for or organizations organizations private organizations
score = 3 points) regulating healthcare services (this providing, paying providing, paying providing, paying
entitles citizens to ask questions and for or regulating for or regulating for or regulating
receive information about local or healthcare services healthcare services healthcare services
national services)?

4.2. Patient rights Are the rights of patients publicly set No, or applies only Yes, applies to most Yes, applies to all
(total possible
out, stating what individual patients to a few healthcare healthcare providers healthcare providers
score = 3 points) are entitled to and can expect from providers
providers in the healthcare system
including information, privacy, and
consent to treatment?

4.3. Procurement Is there publicly available information No, or for only a few Yes, for most Yes, for all
processes and about health service procurement healthcare providers healthcare providers healthcare providers
decision-making processes including offers to tender,
(total possible
terms and conditions, and the
Bonus point:
score = 4 points) decision-making process?
Procurement prices
and contracts
are also routinely
published

4.4. Public decision- Are the minutes from board and No, or for only a few Yes, for most Yes, for all
making committee meetings, including healthcare providers healthcare providers healthcare providers
(total possible
decisions made, published online?
score = 3 points)

4.5. Patient/Public Are patient/public representatives No, or for only a few Yes, for most Yes, for all
involvement involved in the strategic decision healthcare providers healthcare providers healthcare providers
(total possible
making of healthcare providers (e.g.
score = 3 points) patient/public representatives on
the boards or senior committees
of healthcare providers, or invited
to specific sub-committees to
share their views on planning and
performance)?

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46 | Through the looking glass

5. Personal Healthcare Data


Indicator Description Score card
1 2 3

5.1. Electronic patient Is there free and easy access for No, or only a few Yes, most patients Yes, all patients
records system patients to their up-to-date patient patients
(total possible
record online, including clinical Bonus point:
score = 4 points) testresults? If patients can share
access to their
electronic patient
record with any
other organizations
of their choice

5.2. Shared clinical Is there a patient portal where No, or for only a few Yes, for most Yes, for all patients
documentation patients can contribute to or edit patients patients
(total possible
their personal health data such as
score = 3 points) medical notes?

5.3. Patient data Is there a published patient data No, or for only a few Yes, for most Yes, for all providers
privacy and privacy and safeguarding policy providers providers
safeguarding policy setting out the obligations and Bonus point:
(total possible
responsibilities of all stakeholders If this is a legal
score = 4 points) for the protection of patient obligation (as
data, including how breaches of opposed to a policy
confidentiality or security will be or guideline)
managed?

5.4. Information on use Are patients informed about No, or only a few Yes, most patients Yes, all patients
of patient data third-party uses of their individual patients
(total possible
health data through an up-to-date
score = 3 points) confidential report or website on
how it has been used by other
organizations?

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Through the looking glass | 47

6. Communication of Healthcare Data


Indicator Description Score card
1 2 3

6.1. Accessible data Where metrics for Quality No, or only a Yes, most healthcare Yes, all healthcare
(total possible
of Healthcare and Patient limited amount of data data
score = 3 points) Experience indicators are healthcare data
reported

Is the data publicly available through


a dedicated website(s) that is: easily
located through a standard internet
search, free to access, and easy to
navigate with a site search function?

6.2. Up-to-date data Is the data reported kept regularly No, or rarely Yes, mostly Yes, always
(total possible
up-to-date (e.g. data reported
score = 4 points) annually is no more than a year old; Bonus point:
data reported monthly is no more If the data is always
than a month old)? reported in real-time

6.3. Direct comparison Can the data be customized to No, or rarely Yes, for most of the Yes, for all of the
of providers and a specific set of circumstances data data
services (by geography and service) to
(total possible
enable patients and doctors to
score = 3 points) make an informed choice between
different providers through direct
comparison?

6.4. Open data formats Is the data published in open and No, or rarely Yes, mostly Yes, always
(total possible
machine readable formats e.g. .csv,
score = 4 points) .xlsx, .xml? Bonus point:
If data also published
under an open
licence allowing
independent data
processing and
analysis

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48 | Through the looking glass

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2017 KPMG International Cooperative (KPMG International). KPMG International provides no client services and is a Swiss entity with which the independent member firms of the KPMG network are affiliated.
Through the looking glass | 49

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Publication name: Through the looking glass: A practical path to improving healthcare through transparency
Publication number: 133989-G
Publication date: April 2017