Population Health Analytics: Improving Care One Patient at a Time

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Improving Care One Patient at a TimeFebruary 4, 2015

Population Health Analytics


The Buzzword: Population Health ManagementWhat does it really mean?

• Managing the health outcomes of a population of patients with a similar condition?

• Going at risk with payers for the outcomes of a population of patients (Fee-for-Value)?

• Using care management to improve outcomes for high-risk, high-cost patients?

• Engaging patients and communities for better health outcomes?

© 2014 Health Catalystwww.healthcatalyst.comProprietary and Confidential 3

Common Thread: OutcomesProvide the highest quality care

with an optimal care experience

for a population of patients

at the lowest appropriate cost

Quality Outcomes

Experience Outcomes

Cost Outcomes

The key population health management question:

How do we systematically improve outcomes for a population of patients, one patient at a time?


3 Ingredients of Fire

Oxy

gen Heat

Fire

Fuel


3 Ingredients of Fire

Oxy

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Fire

Fuel

What should we be doing?

How are we doing?

How do we transform?

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Outcomes Improvement

3 Ingredients of Outcomes Improvement


A Tautology…

"Every system is perfectly designed to get the results it gets.” - Dr. Paul Batalden

... so re-design your system to get better results.


How systematic are we at Outcomes Improvement?

Oxy

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Fire

Fuel

https://xorl.files.wordpress.com/2011/03/img11.gif


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3 Systems for Outcomes Improvement


How are we doing?


© 2014 Health Catalystwww.healthcatalyst.comProprietary and Confidential9

Content System OverviewWhat should we be doing?

9

Map the Process Care improvement map – Includes workflow & clinician's decision-flow across care continuum

Identify Common Problems - Potential ImprovementsSpecific AIM Statements for outcomes and process to measures for focused improvement

Scope the problem – Define Precise Patient RegistriesSpecific clinical inclusion and exclusion criteria for the sub-cohort of patients for the AIM

Adopt Standardization Aids Checklists, order sets, and protocols to make it easy for clinicians to choose the best action

Produce Actionable Visualizations Scorecards and dashboards that promote best practice behaviors and invite action


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Analytics System OverviewHow are we doing?

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e.g. EPSi, Peoplesoft,

Lawson

e.g. Lawson,Peoplesoft,

Ultipro

Subject Area Mart Designer

Source Mart Designer

EMR

EMR Financial Patient Sat. HR Administrative Claims

FinancialPatient

Sat. HR Administrative Claims

e.g. Epic, CernerNextGen

e.g. Press Ganey,NRC Picker

e.g. API TimeTracking

e.g. MedicarePrivate Payers

Shared Frameworks & Tools for improvementComorbidity Analyzer, Registry Repository, Attribution Modeler, Common

Definition Repository, Hierarchies, CAFE, Atlas, IDEA, Eventalytics, Geospatial, Risk & Severity Profiling, etc

Metadata Driven ETL Engine

Enterprise Data Warehouse Platform

Analyze and Interpret Data• Show correlation and causation• Integrate clinical, financial, and

patient experience data• Predict outcomes and prescribe

actionsShared Reoccurring Data Tasks

• Cohort Definitions• Patient/Provider Attribution• Severity/Comorbidity Analysis• Calculation/Term Definition• Comparative Repositories

Source Data Integration• Automatically co-locate data from

different source transactional systems (EMR, Claims, Financial, Patient Satisfaction)

• Automatically connect data together with key identifiers (Patient, Location, Provider)

Infrastructure• Security and Auditing capabilities• Metadata Repository


Deployment System OverviewHow do we transform?

11

Improvement Capacity AssessmentEvaluation of organizational capacity for change, current capabilities, and gaps

GovernanceData Governance/Data Stewardship and Advanced Organizational Governance & Prioritization

Improvement MethodologySystematic improvement incorporating LEAN / PDSA principles, AGILE software development, etc.

Accelerated Practices TrainingSystematic training of Adaptive Leadership, Quality Improvement/LEAN skills, and Technology

11


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How are we doing?



Content System OverviewWhat should we be doing?

13

Map the Process Care improvement map – Includes workflow & clinician's decision flow across care continuum

Identify Common Problems - Potential ImprovementsSpecific AIM Statements for outcomes and process to measures for focused improvement

Scope the problem – Define Precise Patient RegistriesSpecific clinical inclusion and exclusion criteria for the sub-cohort of patients for the AIM

Adopt Standardization Aids Checklists, order sets, and protocols to make it easy for clinicians to choose the best action

Produce Actionable Visualizations Scorecards and dashboards that promote best practice behaviors and invite action


Care Improvement MapSepsis and septic shock


Identify Potential ImprovementsProcess AIMs and Outcome Goals

Transformation Process

Starter Set Content

Implement Intervention

Measure & Sustain

Review & Select AIM Define Cohort

Iterate on Metrics

Heart Failure: AIM #1

Starter Set Content

Implement Intervention

Measure & Sustain

Review & Select AIM Define Cohort

Iterate on Metrics

Heart Failure: AIM #2

Process Improvement AIM:Improve Follow-up Visit SchedulingFrom 43% to 90% by October 31, 2015

Process Improvement AIM: Improve Medication ReconciliationFrom 58% to 80% by June 30, 2015

Heart Failure Outcome Improvement Goal:Maintain and Improve Cardiac Function = Increase % of HF population with adequate cardiac function from 64% to 80% by December 31, 2015

2-4 Process Improvement AIMS should produce a significant outcome improvement


Standard Patient RegistryStart with administrative codes


Supplemental ICD9 (38,250)

Medications(72,581)

Problem List

(22,955)

ICD9 493.XX (29,805)

AdditionalPotential Rules

(101,389)

17Total Count of Distinct Patients = 106,714

Precise patient registryMove to clinically defined cohorts

Standard Registry

Precise Patient Registry


18

Adopt Standardization Aidsor Knowledge Assets

Admits/1000 membersIP days/1000 membersOP visits/1000 membersProcedures/1000 membersED visits/1000 membersReadmissions/1000 members

Utilization Who should get the care?

Cost/caseCost/procedureOR minutesL&D minutesOther LOS

Order Sets

Workflow

Cost per caseNursing hours by unitOR minutesL&D minutesCycle timesCost per ancillary testEnvironmental services

What care should be included?

How can care be delivered efficiently ?

Indications for Intervention

Diagnostic algorithms

Indications for Referral

Triage CriteriaTreatment and Monitoring

Algorithms

Health Maintenance and Preventive Guidelines

Standardized Follow-up Checklist

Post-acute care order setsIP (SNF, IRF)

Home health, Hospice

Clinical Ops Procedure Guidelines

Knowledge Asset Type

Substance Selection Clinical Supply Chain Management

Admission Order Sets Supplementary Order Sets

Pre-Procedure Order Sets

Post-procedure Order Sets

Bedside Care Practice Guidelines

Discharge Checklist

Patient Injury Prevention Protocol

Risk Assessment

Transfer Checklist

Question to ask

Examples Possible Measures


Home(Patient Portal)

* To Invasive Care Processes

Clinic CareNon-recurrent

Clinic CareChronic Acute Medical

IP Med-SurgAcute Medical

IP ICU

Invasive Medical

Invasive Surgical

Diagnostic Work-up

Bedside care

Triage to Treatment Venue

Substance Preparation

Invasive* Subspecialist

Chronic Disease

Subspecialist

Screening & Preventive Symptoms

Procedure


Diagnostic algorithms


Triage Criteria

Preventive, Diagnostic, Triage and Clinic Care, Algorithms; Referral & Intervention Indications (scientific flow)

Utilization

Treatment and Monitoring Algorithms

Treatment and Monitoring Algorithms

Health Maintenance and Preventive Guidelines

Substance Selection

Substance Selection

Clinical Supply Chain Management

Admission Order SetsAdmission Order Sets

Supplementary Order Sets

Pre-Procedure Order Sets

Post-procedure Order Sets

Order sets and indications for selection of substances and clinical supplies (scientific-flow focus)

Order Sets

Post-procedure Care

Discharge

Bedside care practice guidelines, risk assessment and patient injury prevention protocols, bedside care procedures, transfer and discharge protocols

Standardized Follow-up

Post-acute care order setsIP (SNF, IRF)Home health

Hospice

Clinical ops procedure guidelines and patient injury prevention

Implementation of protocols based on MD orders and clinical operations-initiated activities (Lean/TPS workflow focus)

Workflow

Care Process Models

Value Stream Maps

MD Population Knowledge Assets


= Negative Impact = Positive or Negative = Positive Impact

Knowledge AssetType

Discounted FFS Per Diem

Per Case Bundled Per CaseCondition Capitation

Full Capitation

CMS Commercial CMS Commercial

Workflow

Diagnostic Variation

Standing Orders

Medication Selection

Triage

Patient Safety

Ambulatory Treatment and Monitoring



Payment structure considerations


Actionable Visualizations


Poll Question #1Content System

What types of standardized content have you implemented to support Population Health Management? 192 respondents

A. Just Starting – 42%‒ We have not standardized content to support Population Health Management. Our

clinicians use their best judgment based on their individual training.

B. Mid-Journey – 49%‒ We have begun to standardize some content (e.g. CPOE to implement standardized

order sets – provided by our EMR vendor). We have not yet created standard content for both workflow and clinical domains across the continuum of care.

C. Mature – 9%‒ We have implemented standardized content to manage ambulatory and inpatient

care management (e.g., ambulatory treatment algorithms, order sets, bedside care protocols) and utilization criteria (e.g., diagnostic algorithms, triage criteria, indications for referral and intervention) regardless of what unit or facility a patient enters the same workflow and care delivery content is followed and measured.


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How are we doing?



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Analytics System OverviewHow are we doing?

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e.g. EPSi, Peoplesoft,

Lawson

e.g. Lawson,Peoplesoft,

Ultipro

Subject Area Mart Designer

Source Mart Designer

EMR

EMR Financial Patient Sat. HR Administrative Claims

FinancialPatient

Sat. HR Administrative Claims

e.g. Epic, CernerNextGen

e.g. Press Ganey,NRC Picker

e.g. API TimeTracking

e.g. MedicarePrivate Payers

Shared Frameworks & Tools for improvementComorbidity Analyzer, Registry Repository, Attribution Modeler, Common

Definition Repository, Hierarchies, CAFE, Atlas, IDEA, Eventalytics, Geospatial, Risk & Severity Profiling, etc

Metadata Driven ETL Engine

Enterprise Data Warehouse Platform

Analyze and Interpret Data• Show correlation and causation• Integrate clinical, financial and

patient experience data• Predict outcomes and prescribe

actionsShared Reoccurring Data Tasks

• Cohort Definitions• Patient/Provider Attribution• Severity/Comorbidity Analysis• Calculation/Term Definition• Comparative Repositories

Source Data Integration• Automatically co-locate data from

different source transactional systems (EMR, Claims, Financial, Patient Satisfaction)

• Automatically connect data together with key identifiers (Patient, Location, Provider)

Infrastructure• Security and Auditing capabilities• Metadata Repository


Strong Analytic System

Non value-add Value-add

Understanding the question

Hunting for data

Interpreting dataData distribution

Gather, compiling or running

Weak Analytic System

Strong Analytic SystemThe majority of time is spent analyzing and interpreting data

Understanding the questionHunting for data

Interpreting data

Data distribution

Gather, compiling or running

© 2014 Health Catalystwww.healthcatalyst.comProprietary and Confidential26Less Transformation

Provider

Patient

Bad Debt

Diagnosis Procedure

Facility

EncounterCost

Charge

Employee

Survey

House Keeping

Catha Lab

Provider

Census

Time Keeping

More Transformation Enforced Referential Integrity

Enterprise Data Modeling (Many Technology Vendors)

FINANCIAL SOURCES (e.g. EPSi, Lawson,

PeopleSoft)

ADMINISTRATIVE SOURCES

(e.g. API Time Tracking, Lawson HR)

EMR SOURCES (e.g. Cerner, Epic,

NextGen)

DEPARTMENTAL SOURCES (e.g. Apollo)

Pt. SATISFACTIONSOURCES

(e.g. NRC Picker, Press Ganey)

EDW


EMR SOURCES (e.g. Cerner, Epic,

NextGen)

Oncology

DiabetesHeart Failure

Regulatory

Pregnancy Asthma

Labor Productivity

Revenue Cycle

CensusPt. SATISFACTION

SOURCES(e.g. NRC Picker, Press

Ganey)


FINANCIAL SOURCES (e.g. EPSi, Lawson,

PeopleSoft)


(e.g. API Time Tracking, Lawson HR)

Redundant Data Extracts

Dimensional Data Modeling (EMRs & Healthcare Point Solutions)

EDW

Less TransformationMore Transformation


Metadata (EDW Atlas), Security and Auditing

Diabetes

Sepsis

Readmissions

Common, linkable vocabulary

FinancialSource Marts

AdministrativeSource Marts

DepartmentalSource Marts

EMR Source Marts

Patient Satisfaction Source Mart

FINANCIAL SOURCES (e.g. EPSi, Peoplesoft,

Lawson)


(e.g. API Time Tracking)

EMR SOURCEs (e.g. Cerner, Epic,

NextGen)


Pt. SATISFACTIONSOURCES

(e.g. NRC Picker, Press Ganey)

Adaptive Data Modeling

Less TransformationMore Transformation


Information Management

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DATA CAPTURE

• Acquire key data elements• Assure data quality• Integrate data capture into operational

workflow

DATA ANALYSIS

• Interpret data• Discover new information in the data

(data mining)• Evaluate data quality

DATA PROVISIONING

• Move data from transactional systems into the Data Warehouse

• Build visualizations for use by clinicians• Generate external reports (e.g., CMS)

Knowledge Managers (Data quality, data stewardship and

data interpretation)

Application Administrators (optimization of source systems)

Data Architects(Infrastructure, visualization, analysis, reporting)

= Subject Matter Expert= Data Capture= Data Provisioning= Data Analysis


Less Effective Approach “Punish the Outliers”

# of Cases

Current Condition

• Significant Volume• Significant Variation

# of Cases

Option 1: “Punish the Outliers” or “Cut Off the Tail”

Strategy• Set a minimum standard of quality• Focus improvement effort on those

not meeting the minimum standard

Mean

Focus on MinimumStandard

Metric

Excellent OutcomesPoor Outcomes Excellent OutcomesPoor Outcomes

1 box = 100 cases in a year


Effective Approach to improvement: Focus on “Better Care”

Excellent OutcomesPoor Outcomes

# of Cases

Current Condition

• Significant Volume• Significant Variation

Excellent Outcomes

# of Cases

Option 2: Identify Best Practice “Narrow the curve and shift it to the right”Strategy• Identify evidenced based “Shared Baseline”• Focus improvement effort on reducing

variation by following the “Shared Baseline”• Often those performing the best make the

greatest improvements

Mean

Focus on Best Practice Care Process

Model

Poor Outcomes

1 box = 100 cases in a year



# of Cases


# of Cases

Excellent Outcomes

# of Cases

Poor OutcomesExcellent Outcomes

# of Cases

Poor Outcomes

1

2

3

4Varia

bilit

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High

Low

Resource ConsumptionLow High

Improvement Approach - Prioritization

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Internal Variation versus Resource ConsumptionY-

Axi

s =

Inte

rnal

Var

iatio

n in

Res

ourc

es C

onsu

med

Bubble Size = Resources Consumed

Bubble Color = Clinical DomainX Axis = Resources Consumed

1

2

3

4


Prioritize: Pareto Analysis App

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of Total Cumulative %

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X-Axis = Care Processes by resources consumed (High to Low)

Y-A

xis

= Pe

rcen

t of t

otal

reso

urce

s co

nsum

ed Pareto Analysis >> Prioritization

Top 85 Care Processes account for 80% of the opportunity (+45)

Top 40 Care Processes account for 62% of the opportunity (+27)

Top 13 Care Processes account for 34% of the opportunity


Poll Question #2Analytics System

How is data from disparate transactional systems integrated? (e.g. EMR, Cost, Patient Satisfaction) 215 respondents

A. Just Starting – 37%‒ Analyst manually integrate data into spreadsheets.

B. Mid-Journey – 50%‒ We use one of our transactional systems (e.g. EMR or Financial) to integrate a

limited subset of data for some of our transactional systems for key operational reports.

C. Mature – 13%‒ We have implemented an Enterprise Data Warehouse Platform, fully automated

load from all of our transactional systems runs at least daily which integrates data based on common linkable identifiers (e.g. patient and provider IDs), with near-real time loads for selected data.


Poll Question #3Analytics System

What technical tools do you use to move your organization away from reactionary, emotional decisions toward data-driven decisions? 193 respondents

A. Just Starting – 27%‒ We don't use any technical tools to help us with data driven prioritization, although

we have some reports.

B. Mid-Journey – 57%‒ We use some spreadsheet analysis and reports to evaluate options but

opportunities are still typically selected based on politics, a crisis or the most vocal advocate.

C. Mature – 17%‒ We have robust applications which provide our centralized clinical and operational

governance team with objective criteria for use in prioritizing improvement initiatives, including identifying our key processes based on size and variability.


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How are we doing?



Deployment System OverviewHow do we transform?

39

Improvement Capacity AssessmentEvaluation of organizational capacity for change, current capabilities, and gaps

GovernanceData Governance/Data Stewardship and Advanced Organizational Governance & Prioritization

Improvement MethodologySystematic improvement incorporating LEAN / PDSA principles, AGILE software development, etc.

Accelerated Practices TrainingSystematic training of Adaptive Leadership, Quality Improvement/LEAN skills, and Technology

39

Organizational Assessment I October 15, 2014 I 40

Readiness Assessment Example1) Data Access Process

2) Registry Definition Process

3) Data Governance & Data Quality Process

4) Sustained Care Improvement Process

5) Standardized Criteria for Treatment & Venue

6) Cost Allocation Methodology

12) Data Integration Infrastructure

11) Missing Data Element Capture

10) Data-driven Prioritization

9) Prescriptive Modeling

8) Standardized Calculations & Definitions for Internal Reporting

7) Standardized Protocols for Population Health

Deployment

Content

Analytics


Small Teams (Designs Innovation)• Meet weekly in iteration planning meeting• Build DRAFT processes, metrics, interventions• Present DRAFT work to Broader TeamsOB

Innovators

Guidance Team (Prioritizes Innovations)

• Meet quarterly to prioritize allocation of technical staff

• Approves improvement AIMs • Reviews progress and removes road blocks

OB Newborn GYN

W&N

W&N

Innovators

Innovators

Early Adopters

Broad Teams (Implements Innovation)

• Broad RN and MD representation across system• Meet monthly to review, adjust and approve DRAFTs• Lead rollout of new process and measurementOB

W&N

W&N

W&N

Innovators

Early Adopters

Early Adopters

Executive Leadership Team

• Prioritizes sequence of formation of Guidance Teams• Approves Board Level Outcomes Goals• Reviews progress and removes road blocks


Improvement Types


Examples: Reduction in Mortality Rate; Hard Cost Savings; Time Savings (Soft Cost);

Improved Health Function

Diff

icul

ty to

Ach

ieve

Process Improvement

Examples: Process Step: % of Patients with scheduled follow-up visit at discharge; Data

Quality: % of Heart Failure Patients with Ejection Fraction captured in EMR

OpportunityIdentificationImprovement

Examples: Potential $ Savings from Variation Reduction (Key Process Analysis) ;

Potential $ Leakage reduction by encouraging providers to refer patients in

network


Requirements Gathering

Project Plan/ Estimation

Use Cases/ Functional Specs

Design Specifications

Code

Test

Fix / Integrate

High Level Stories

Vision

Release 1

Release 2

Release 3

Release 4

$

$

$

$

$$

$$

$$$$$

Documentation

Customer sees the product

Value to the

Customer

Traditional “Waterfall”

Agile

Sources: Adapted from various ideas taught by Alistair Cockburn and Martin Fowler – see alistair.cockburn.us and www.thoughtworks.com

Traditional Approach vs. Agile Approach


Accelerated Practices ProgramPREPARING HEALTHCARE TEAMS TO ACCELERATE OUTCOMES IMPROVEMENT

Immersive Quality Improvement Training

• 8 Session Course - taught over 4-6 months, 2 ½ days per month• Train the trainers – required for coaches and team leaders• Quality Improvement Theory applied on actual project with 2-4 person team

Executive Training

• 2 day executive course taught quarterly• Provides leadership visibility into training and high level principles

Just-in-time Training

• Library of 10-15 minute modules used as needed by permanent teams• Readily available to clinical, technical and operational team members


Poll Question #4Deployment System

How are teams organized to improve the quality of care and sustain improvements? 237 respondents

A. Just Starting – 33%‒ We have ad-hoc improvement teams organized on a project basis in a reactive mode

(e.g., to respond to a TJC sentinel event). After a project ends, many of the gains achieved may be lost because limited organizational infrastructure remains to sustain the gains.

B. Mid-Journey – 55%‒ Our Quality Resources Department provides support to Service Lines and Departments

apply quality improvement and workflow principles to improvement initiatives. Some individual units or facilities may focus on quality but dispersion of improvements to all units or all facilities is limited. Improvement is still project based.

C. Mature – 11%‒ We have organized permanent interdisciplinary cross facility teams, which include

clinical and technical subject matter experts with process improvement skills; these teams permanently own the quality, cost, safety and satisfaction of their care delivery domain. Senior executive leadership and Board meetings spend the majority of their time reviewing the goals and progress of these permanent improvement teams.



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Content System

Science Project CentricPockets of excellence, Limited roll-out of improvement across

all facilities

Research CentricAcademic ideas with no

practical application. Lots of published papers.

Information System Centric

“If we build it they will come.” Focus on reducing information request queue.

Automation Centric“Paved Cow Paths”

(Process is automated but not improved – many EMR

deployments)

Organization Centric

Management “Flavor of the month”

Clinicians disengage if evidence and measurement are both

missing

LEAN CentricUn-sustainable Improvements.

Can’t manually measure after 2 or 3 projects.

Ignite ChangeScalable & Sustainable

Outcomes Improvement in Population Health



Questions?


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Population Health Analytics: Improving Care One Patient at a Time

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Transcript of Population Health Analytics: Improving Care One Patient at a Time