Achieving Affordability with Visual Analytics; Variation Reduction as a Tool to Engage Clinicians

Achieving Affordability with Visual Analytics

Variation Reduction as a Tool to Engage Clinicians

Ingenix User ConferenceMay 2011

Michael van Duren, M.D., MBASutter Health

A Project of the Sutter Medical Network and Sutter Physician Services

About us

California’s Highest Quality Health Care System*

Serving more than 3 million patients• Approximately 48,000 employees• 5,000 physicians

– Aligned under the Sutter Medical Network– Physician medical foundation and IPAs

Part of more than 100 communities• 25 DHS-licensed acute care hospitals• Home health & hospice and long-term care

services throughout Northern California

Partnering with providers, patientsand communities• Medical research and medical

education/training• 24 fundraising organizations

*Source: The Lewin Group, 2009

The Sutter Medical Network

• The Sutter Medical Network provides a leadership role in the development of a physician and provider network, coordinating patient care and creating a culture of quality, service and affordability throughout the Sutter Health system.

• SMN Standards of Participation create collective accountability that encompasses the entire spectrum of clinical and service quality:

• Clinical Pay for Performance• Primary care appointment wait times • Patient satisfaction with the care experience • Adoption of online services• Variation reduction efforts

Physician Organizations in the Sutter Medical Network

• Alta Bates Medical Group

• Brown & Toland Physicians

• Central Valley Medical Group

• Marin IPA

• Mills-Peninsula Medical Group

• Palo Alto Medical Foundation

• Sutter East Bay Medical Foundation

• Sutter Gould Medical Foundation

• Sutter Independent Physicians

• Sutter Medical Foundation

• Sutter Pacific Medical Foundation

Why Variation Reduction?

• What engages physicians?– Healthcare affordability– High deductible plans– High co-pays– Losing marketshare to competitors– Curiosity– Competitiveness– Do the right thing– Quality improvement, professionalism

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How To Engage Physicians

• Respect their intelligence & time• Trust their motives• Adult learning: peer setting

Solution: variation reduction program

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Variation Reduction Program Components

Which is the most important component?

Remove any one and it won’t work…

Data Display People Process Program

Leadership

DATA

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Purpose for Data Sharing Practical Implications

• Show clinicians how they differ from each other– Must be:

• Apples to apples• Simple and explainable• Clinically relevant• Compelling: “Aha, I see what I need to change”

• ETGs with drill down accomplishes all this• Hi-Lo Variation is typically 100 - 300%

– Therefore data needs only to be directionally correct

• Attribution: anything less than 50% loses credibility

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Data Issues for Provider Groups vis-à-vis Plans

• Less complete data– HMO: claims, but only for the risk that groups took

• Excludes facility costs (not a problem , but beware low cost outliers)

• Excludes out of network, behavioral health, negotiated carve outs, etc

– PPO: billing data, but only for care that was provided– Pharmacy: only what is provided by HMOs

• More complete data– Clinical sources– Outcome data: Blood Pressure, A1c, LDL– Rx written, not just filled– More recent data: yesterday

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Clinicians Are Very Discerning re Value of ETGs

• Problematic areas discovered:– Hernias

• All types (inguinal, abdominal, hiatal) together

– Gyn tumors• Uterus and ovaries grouped together

– Gyn irregular bleeding• Postmenopausal bleeding not distinct

– Knee procedures• Total knee and arthroscopy cases grouped together

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Provider Network Clinical Integration Issues

• Competitors can not share pricing– Work with data stripped of all pricing– Uniform charge master applied to all data

• Multiple data sources– Lab vendors– Pathology contractors– Surgery at multiple sites– Integrate all payers– Changing systems

DISPLAY


Why Is Visual Data Display So Important?

• Can not afford distractions: – Accuracy– Methodology– Detailed questions

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Source =

information & emotion

Driver =

engagement & motivation

Goal =

behavior change

Why Is Visual Data Display So Important?

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Source =

information & emotion

Driver =

engagement & motivation

Goal =

behavior change

• Must be all right brain, gut level, intuitive

“Aha, I see I am an outlier. I know what I should do differently!”

• Need to achieve this in seconds, without words

How to Speak to the Right Brain?

• Visual data; not words or numbers• Message must jump out on its own• Remove all extraneous text• Personal impact• Change desired must be obvious

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Example of Other Dashboards

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Visual Display of Variation

HMO Statin Prescription VolumePPO volume not included

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2nd Line Diabetes Drug

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12 Month Run Chart (volume of 30 day supply)

10.0

20.0

30.0

40.0

50.0

Month(# scripts)

% C

ozaa

r ut

iliza

tion

over

all

AR

B p

resc

ript

ions

Summary

LCL (varies)

CL = 30.

UCL (varies)

SMG-Solano ARB PrecribingMar 2010 - Feb 2011

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New Features: Frequency of Surgery

New Features: View Individual Episodes

Each Bar is an Individual Episode

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Curiosity About a Single High Episode

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Select and Episode to View Claims

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Claims View

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Claims View - Continued

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PEOPLE

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Philosophy of Physician Behavior

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Philosophy of Physician Behavior

Copyright 2009 VHA Inc. All rights reserved. Authorized use of this content is limited to reading and analyzing the content for its internal use, printing a copy of any page for its internal use and disclosing the content to other VHA alliance members . For internal VHA member use only.

Contextualist Approach

Deductive Approach

Contextualist Approach

COMPLIANCE

EMPOWER

Two Approaches

• Bottom up– Multiple small projects– Maximizes physician buy-in

• Top down– Standardized implementation– Maximizes savings

Guiding Principles for VR Facilitation

• Follow Curiosity• Pull, not push• Bottom up, not top down• Safety, fun• Non-punitive• Respect – sincere

– (no agenda other than being helpful)

• Talk about emotions – (before talking about the data)

Guiding principles for VR facilitation

• Transparency – names not blinded• Use natural competitiveness in a playful way• Talking about affordability is ok and

necessary (“I am not going to apologize”) • Must lead to a “project” –

– must result in an improved outcome – this requires some nudging

• Improvise, Adapt, Think Fast

Resources for Data & Emotions:Nudge, Switch

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Reactions from Physicians

“I haven't had this much fun since residency”

“I have been waiting for this for ten years”

“That was a lot more fun than I expected from the title of the meeting”

“When are you guys coming back?”

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PROCESS

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Variation Reduction Program Components

Phases

1. Introduce and orient dept chair

2. Meet with whole dept (5-15)

3. Explore various ideas, dig & clarify

4. Narrow selection to one project

5. Write charter, define goals, commit to interventions

6. Track progress, modify interventions

Improvement Project Sequence

Use SCPA to identify

variation reduction

opportunities

Clinicians agree on a standard

and define performance

metrics

Clinicians agree to launch an improvement

project

VR Project Charter

Sample process from one group

Problem Statement

• What is the problem we are solving for?– Duration, where, what, why

• In [time period], there were [count] patients with [diagnosis] who experienced [what undesirable care was done] and this is a problem, because [impact].

Problem Statement

• In 2010, 55% of 1182 patients with new onset Sinusitis were treated with antibiotics, other than Amoxicillin. This resulted in unnecessary pharmaceutical costs.

Goal Statement - AIM

• [increased/decreased] [metric] from [baseline]to [goal level] as measured by [XX] by [when].– Specific– Measurable– Achievable– Reasonable– Time bound

Goal Statement - AIM

• Increase the percent of patients with new onset sinusitis that receive treatment with Amoxicillin from 45% to 62% by the end of 2011.

• Reduce the average cost of initial antibiotic treatment for Sinusitis from $57 to $45 by the end of 2011.

0.0

20.0

40.0

60.0

80.0

Month (# of scripts)

% o

f Am

oxci

llin

Summary

LCL (varies)

CL = 45.

UCL (varies)

GMG Tracy: Sinusitis - % use of Amoxcillin as 1st line PrescriptionJan 2010 - Feb 2011 (All pts)

% of Patients treated with Amoxicillin

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Current Proposed Change

Avg Price volume Percent Avg Price volume PercentAmoxicillin 20.75$ 532 45% 20.75$ 732 62% 200Augmentin 89.02$ 87 7% 89.02$ 87 7% 0Azithromycin 82.62$ 535 45% 82.62$ 335 28% (200)Biaxin 61.90$ 12 1% 61.90$ 12 1% 0Cefdnir 179.63$ 15 1% 179.63$ 15 1% 0

1181 100% 1181 100%

Average 56.24$ Average 45.77$

Primary Metric

• How will you know you’ve made an improvement– Rate is percent of numerator/denominator– Denominator: [all patients with x]– Numerator: [patients who received treatment x]

• Inclusions/exclusions• Balance metric (how do we check that we are

not causing harm?)• Associated quality or outcome metric?

Project Metric

• Name of metric: Percent of all patients prescribed Amoxicillin as 1st line antibiotic for treatment of sinusitis

• Numerator: number of sinusitis patients prescribed Amoxicillin

• Denominator: all Sinusitis patients with antibiotic prescription

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Defining Patients

• Inclusion criteria for diagnosis:– 461 P ACUTE SINUSITIS – 461.0 ACUTE MAXILLARY

SINUSITIS – 461.1 ACUTE FRONTAL SINUSITIS – 461.2 ACUTE ETHMOIDAL

SINUSITIS – 461.3 ACUTE SPHENOIDAL

SINUSITIS – 461.8 OTHER ACUTE SINUSITIS – 473 P CHRONIC SINUSITIS – 473.0 CHRONIC MAXILLARY

SINUSITIS – 473.1 CHRONIC FRONTAL

SINUSITIS – 473.2 CHRONIC ETHMOIDAL

SINUSITIS – 473.3 CHRONIC SPHENOIDAL

SINUSITIS – 473.8 OTHER CHRONIC

SINUSITIS – 473.9 UNSPECIFIED SINUSITIS

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• Exclusion criteria:– Anybody with any of the

diagnoses in the prior 30 days (so that we are looking only at NEW onset sinusitis)

– PCN allergy– Exclude pts with

pneumonia or bronchitis in any of the other diagnoses

– OR use Epic linkage to pull only abx linked to sinusitis

– No recent abx use for anything else for 30 days

– No sinusitis in prior 12 months

Expected Benefit

• Improved affordability• Improved consistency• Enhanced adherence with clinical

guidelines / best practices

Implementation Plan

• 1st test of change (what are the changes you plan to make? How will they be implemented?)

• Who, what, when, where

Implementation Plan

• First “Test of Change”– Communicate to all ----- providers in meeting 4/1/2011– Distribute monthly run charts to individuals– Work on smart set for Epic / consistent documentation– Create guideline for consistent diagnosis of sinusitis: e.g. purulent

discharge (Dr W----- & Dr L----)• Other ideas (on hold for the future):

– Patient education “why you are seeing your ENT and still getting Amoxicillin”

– Also education for ER– Address outliers– Epic BPA– Other…

Balance measure

• Cure rate?• Are we seeing more failures on Amox?• Return within 30 days for same

diagnosis?• Track baseline, see if it changes…

Local Standard

• Sinusitis guidelines? Am Acad of Otolaryngology 2007 (?). AAO.

Formal Project Charter

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Variation Reduction: Projects in Process

Staging of Savings

Pharmacy

Imaging/Labs

Visits

Procedures

Additional Analytics Tools Needed

• Add in EMR data– More recent– All payers– Has outcome data

• Progress over time (SPC)• Simple drug comparisons of cost (3 bar)• Bubble chart

Success Factors

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•Trust, Safety, Openness

•Provides Clinical Context

•Learning is self-directed

Small Group of Peers

•Impact is on “right brain”

•Avoid analysis

•Allows pattern recognition

Visual Data

•Stimulate curiosity

•“pull” rather than “push”

•Creates ownership

Live, drill through

•Create safe space

•Guide discussion to discovery, mutual learning

•Convert exploration to improvement project

Expert facilitation

Roles Required for VR Projects

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Phase 1 (intro)

2 weeks

Phase 2 (generate)

2 weeks

Phase 3(explore)4 weeks

Phase 4(select)3 weeks

Phase 5(charter)1 week

Phase 6(implement)

75 weeks

VR Lead (Assoc. Dir.) 6 20 6 16 4 20

Project Coordinator 7 10 6 6 6 36

Business Analyst 0 4 32 10 10 10

Reporting Analyst 0 0 24 16 24 10

0

10

20

30

40

Tota

l Hou

rs

per P

hase

Hours per Project by Phase by Role

Questions?

Reactions?

[email protected]

916-402-7492

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Achieving Affordability with Visual Analytics; Variation Reduction as a Tool to Engage Clinicians

Health & Medicine

Transcript of Achieving Affordability with Visual Analytics; Variation Reduction as a Tool to Engage Clinicians