Question of Quality Conference 2016 - Jonathan B. Perlin

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Learning Healthcare & Clinical Leadership in an Accountable Environment

Jonathan B. Perlin, MD, PhD, MSHA, MACP, FACMI

President, Clinical Services Group and Chief Medical Officer HCA / Hospital Corporation of America

Chair, American Hospital Association, 2015 Clinical Professor of Medicine & Biomedical Informatics, Vanderbilt University Adjunct Professor of Health Administration, Virginia Commonwealth University

Contact: [email protected]

It’s a Question of Quality Conference

London, England– February 25, 2016

1.  US: Accountability, Transparency and Health IT

2.  Transformation: Case-Studies from HCA US –  Learning & Improving at-Scale: The REDUCE MRSA Trial

–  Clinical Leadership: Billion-Dollar Babies

3.  Harvesting the (Big) “Data-Dividend”

Overview

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CMS (Medicare) Accountability / Payment Measures

Value-BasedPurchasing

Hospital-AcquiredCondi9onsReduc9onReadmissionsReduc9on

MSPB

HospitalInpa9entQualityRepor9ngProgram

Ex: CMS Value-Based Purchasing

CMS Hospital Compare: Transparency & Reputation

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• Numerous organizations issue reports ranking and rating hospitals. •  Use CMS and proprietary data •  Issue reports, provide websites, offer recognition •  Some provide a forum for customer/patient reviews •  Some are “pay to play”

• Organizational missions include: •  Consumer advocacy •  Consumer education •  Purchaser decision-making •  Product sales •  Consulting services sales

Third-Party Assessments

L

Third-Party Assessments

Transparency has driven better performance . . . and confusion!

Organizational Responses: -  Learning -  Celebrating Success

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BREAKING: CMS and health insurers unveil first set of standardized quality measures By Melanie Evans | February 16, 2016

The CMS and America's Health Insurance Plans, health plans' trade group, announced a new agreement to standardize measures of quality for the nation's doctors. Officials say the measures are necessary as payers and consumers seek to shop for high-quality care.

The agreement—which outlines seven sets of quality measures to be used across public and private payers—is the first to be announced by the Core Quality Measures Collaborative, which includes the CMS, AHIP, the American Academy of Family Physicians and the National Partnership for Women and Families. The National Quality Forum, an endorsement body for industry quality standards, was a technical adviser.

The announcement comes as industry stakeholders and policymakers struggle with how best to identify and reward high-quality healthcare. Measures of quality are increasingly tied to how much doctors and hospitals are paid and HHS said that by 2018 half of Medicare spending outside of managed care would be under contracts with rewards and potential penalties for quality. . .

Tuesday, February 16, 2016

MU is a Programme in the “HITECH” (Health Information Technology for Economic & Clinical Health) of ARRA:

•  An “Interstate Highway Program” for Health Information Technology –  Envisioned Interoperable Electronic Health Records

•  Offered Incentives to Eligible Hospitals & Providers (Doctors) to adopt Electronic Health Records over a rolling four year period to end NLT 2017 –  Over $30 BILLION in incentives have been distributed –  BTW, Hospitals not achieving MU would ultimately

experience (incapacitating) payment penalties

Health IT: The “Meaningful Use” (MU) Programme

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Earning Incentives / Avoiding Penalties Requires Hospitals & Providers to:

•  Use “Certified” Electronic Health Records (EHR) incorporating Specified Data Standards

•  Progressively Increase Use of EHR for –  Physician Order Entry (e.g., labs, medications, imaging) –  Demonstrate interoperability and information exchange

by sharing patient records with other providers and with patients

–  Providing certain public health data to authorities –  Demonstrating use of clinical decision support –  Submitting specified electronic measures of care quality

“Meaningful Use” (MU)

Crossing the Digital Divide . . .

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Crossing the Digital Divide . . . Physician Practices

The Data Dividend: Learning Healthcare

EHRUse

DecisionSupport

DataGenera9on

AdvancedAnaly9cs

>50%ofDoctorsand>95%Hospitalsmet

HITECHMeaningfulUse*

*ONC(hKp://dashboard.healthit.gov/quickstats/quickstats.php)

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EHRUse

DecisionSupport

DataGenera9on

AdvancedAnaly9cs

The Data Dividend: Learning Healthcare



•  Making “Meaningful Use” Meaningful



Overview

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Addressing a Significant Problem:

•  In the United States, ~ 1 in 20 patients hospitalized will develop a healthcare-associated infection (HAIs)

~ 1.9 – 2.1 million patients infected ~ 80,000 die ~ $20- 30 billion avoidable healthcare expenditures

•  Methicillin-resistant Staphylococcus aureus (MRSA), and other Staphylococcus aureus, account for approximately 25% of all deaths from HAIs

The REDUCE MRSA Trial – Background

*Updatedfrom:KlevinsRMetal,PubHlthRep,2007;122:160-6.

What Might be Learned Across a Large Health System ?

InternaZonalAnchorage

NWGA

NortheastC

TerreHaute

IdahoFalls

ColumbusAtlantaPanhandle**

Orleans

IdahoFalls

Tallahassee

WW

W

LasVegasWW

SanJoseW

WesternIdaho

Utah

SouthernCalifornia

Utah

W

Denver

W

WSanAntonioAusZnDallas/FW

Houston

KansasCity

OklahomaCity

WW

CorpusChrisZ

Brownsville

W

Wichita

W

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SanAntonioAusZn

Dallas/FtW

Wichita

ElPaso

New

CentralLouisiana

LafayeKe

C No.VA

CRichmondC

SWVACFrankfortC SWVAFrankfortFrankfort

Tampa

NorthCentralFlorida

TreasureCoast

EE

PalmBeach

DadeBroward

JacksonvilleColumbus

Panhandle

TerreHaute

MiddleGATrident/Charleston

GrandStrandAugustaChaKanooga

SWVA

AmericanGroup

NaZonalGroup

CentralLondon

WesternIdaho

SanJose

Houston

KansasCity

NWGAAtlanta

OklahomaCityNashville

25millionpa9entcontactsannuallyApproximately5%ofmajorhospitalservicesinU.S.:

•  Admissions >1.6million•  PaZentDays >7.6million•  Deliveries >0.25million•  TotalSurgeries >1.3million•  EDVisits >8million

Ø  170Hospitals,120FreestandingSurgery

Centers,>850PhysicianPracZces,>200UrgentCareCentersin23statesandLondon

Ø HospitalsrangefromcomplexterZaryreferral

andacademicmedicalcenterstourbanandsuburbancommunitymedicalcenters

Ø ~215,000employees,including~72,000nursesand30,000alliedhealthprofessionals

Ø  >50,000affiliatedphysicians,including>3,300employedphysiciansandpracZZoners

Ø Morethan38,000licensedbeds

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Pragmatic Research – Implemented in course of routine care, in routine setting, not dedicated research unit

Comparative Effectiveness study – Comparing (three) competing “best practices” to determine what is truly “best”

Cluster-Randomized (by hospital) trial design

1.  Screen & Isolate: Screen every patient and implement barrier isolation, if MRSA positive ( HCA’s “base case” with SIR < 0.7 )

2.  Targeted Decolonization: Screen, and if MRSA-positive, isolate and decolonize (using chlorhexidine antimicrobial soap and mupurocin nasal ointment)

3.  Universal Decolonization: Decolonize all patients on admission to ICU

Could MU in HCA Provide a Platform for REDUCE MRSA Trial?

Aggregate:43Hospitals;74,356pa9ents;282,803pa9ent-days

Arm116 Hospitals

(23 ICUs) N = 23,480

Arm214 Hospitals

(22 ICUs) N = 24,752

Arm313 Hospitals

(29 ICUs) N = 26,024

16 Hospitals N = 23,480



1 Hospital (2 ICUs) withdraws

AsRandomized

AsTreated

REDUCE MRSA: Timeline & Enrollment

Jan2010 Apr2010 Sep2011

Baseline12month

PhaseIn

Interven9on18month

HITECH(MUI)

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REDUCEMRSA–Cluster-RandomizedTrialDesignAnsweringQuesZonsAcrossMulZpleInsZtuZons

Arm1ScreenandIsolate

Arm2TargetedDecoloniza9on

Arm3UniversalDecoloniza9on

OverallP<0.0001

Arm1Arm2 Arm3Screen&Targeted UniversalIsolateDecoloniza9onDecoloniza9on

Arm2vs1P=0.04

Arm3vs1P<0.0001

Arm3vs2P=0.003

REDUCE MRSA: Results (All Pathogen Bloodstream Infection)

Propor3onal-hazardsmodelswithsharedfrail3es

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Decolonization reduces all blood stream infections (BSIs) by 44% and MRSA by 37%

•  For every 99 patients decolonized, 1 BSI was avoided •  Set a new standard for reducing BSIs in ICUs •  Policy: Demonstrated that (9) state-mandated

screening were expensive and inappropriate

REDUCE MRSA: Study Findings

•  Agency for Healthcare Research and Quality

•  CDC Prevention Epicenters Steering Committee

•  Harvard Pilgrim Health Care Institute / Harvard Medical School

•  Hospital Corporation of America •  Rush University •  University of California Irvine

REDUCE MRSA: Discussion Fostering a Learning Health System

•  REDUCE MRSA notable not only for its outcomes, but

for its methods: •  Speed: Did not take one hospital 64 years to amass the

power of the study – it took 43 hospitals 18 months •  Implementation: Not conducted by a single-purpose research

team, but by nurses and infection prevention professionals during routing patient care

•  Setting: Did not occur in a controlled research unit, but within community hospitals across the country, embedded in routine care . . .

•  Because of interoperable health information, REDUCE MRSA efficiently answered real-world questions, in real-world environments, that generalize to real-world situations

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•  Size: 33,000 Patients (vs. 75,000)

•  Efficiency: ALLHAT $80M (vs. $3M, including supplies)

•  Length of Study: 10 years (vs. 1½ years)

IT-Related Capabilities from Meaningful Use Investment: 1.  Standard information platform

•  Same EHR system in every hospital (MU Stage 1) •  Conventions to assure semantic interoperability (conceptual

consistency) 2.  Aggregation of data into one repository

•  n.b., Current work from enterprise clinical data warehouse 3.  Normalization of non-standardized data 4.  Continuous data quality assessment and feedback 5.  Analysis of aggregate data in situ assuring privacy &

security •  i.e., Secure “sandbox” for analytics; no transmission beyond

organization

What Made REDUCE MRSA Possible?

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0.671 0.6860.648

0.52

0.388

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

Q32012 Q42012 Q12013 Q22013 Q32013

UniversalDecoloniza9onPhasedIn

42% Reduction (3Q12 - 3Q13)

Sta

ndar

dize

d In

fect

ion

Rat

io

Source: National Healthcare Safety Network (NHSN)

HCA’s Standardized Infection Ratio for ICU Central Line-Associated Blood Stream Infection

$170,000/1,000 $19,720,000

InfectControlHospEpidmemiology.2014;35(S3):S23-S31

The REDUCE MRSA Dividend . . .

Are Learning Opportunities: - Rare ?

- Subtle ? - Esoteric ?

Case Study 2: Billion Dollar Babies

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Another Significant Question: When is Term Really ‘Term’?

37to39weeksbabiesaregenerallyrobust,butisthereascien9ficbasistosaytheyareequallyrobustwithinrange?

• HCA,alongwithMarchofDimes(MOD)andAmericanCollegeofObstetriciansandGynecologists(ACOG)“calledtheques9on”

• Doescontemporaryclinicalprac9ce=op9maloutcomes?

•  Whatwedid• Overa90-dayperiod,27hospitalscollectedoutcomesfordeliveriesat>37weeksgestaZon

• 17,794deliveriesmetcriteria

•  Whatwefound

•  37≠38≠39weeks

•  Whywedidit

• ACOGsuggestedMODapproachHCAtostudyquesZonatscale

• HCAcommiKedtousingdatatochangepracZce,ifindicated

• HCAdelivers~250,000babiesyearlyin110hospitals,represenZng~6%ofallU.S.births

*Clarketal,AmJObstetGynecol

17.8

8

4.6

02468101214161820

37Weeks 38Weeks 39+Weeks

%N

ICUAdm

ission

s

WeeksofGesta9on

Elec9veTermDeliveryandNICUAdmission*

PreventingAdverse Neonatal Outcomes

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•  Morbidity• Lungimmaturity,respiratorydistress• Unstablevitals,nutriZonalchallenge• SocialdisrupZonofbirthexperience

•  Long-TermMorbidity• Delayeddevelopmentandweakerschoolperformance

•  ExcessResourceU9liza9on• UnnecessaryNICUdaysanduseofhighlyskillednursesandphysicians

• Morefrequentcheckupsamerdischarge;lostworkZmeforparents

17.8

8

4.6

02468101214161820

37Weeks 38Weeks 39+Weeks

%N

ICUAdm

ission

s

WeeksofGesta9on

Elec9veTermDeliveryandNICUAdmission*

*Clarketal,AmJObstetGynecol

PreventingAdverse Neonatal Outcomes

Clinical Behavior Change:•  Trial2:

•  Hardstop(Group1)•  Peer-reviewmodel(Group2)•  Clinicaldiscussion(Group3)

•  Studydemonstrated‘hardstop’yieldedbestresultsinreducingearly,elec9ve‘pre-term’delivery

•  MoD,insurersandCMSnowpromoZngprevenZngpre-term&‘hardstop’asarecommendedpracZce

Transformative Clinical Leadership: Moving from Knowledge to Practice

*Clarketal,AmJObstetGynecol,2010

November 2010

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Learning opportunities are ubiquitous

Organizational learning has to be intentional •  EHR’s don’t yet automate “pattern recognition” (i.e., relationship

between gestational age, complications, type of complications and cost of potentially avoidable services)

Organizational improvement also has to be intentional •  Must obligate to using evidence

Clinical behavior change requires clinical leadership •  Compelling data change discussion from religion to evidence

Learning / Improvement Opportunities





Overview

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What if the results of REDUCE MRSA (of the strategies compared) were already present in data generated by previous care?

•  What if trials could have been performed “in silica?” •  In 18 minutes, not 18 months ? (REDUCE) •  In 9 minutes, not 90 days ? (Pre-term delivery)

What other answers to pressing questions (cost, quality, precision medicine, policy) might exist in the “collective memory” of our healthcare services?

How do we harvest the “Data Dividend?”?

What If REDUCE MRSA Didn’t Require 18 Months?

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Data sizes: US Library of Congress printed material: 10 Tb HCA: 120 Petabytes (12,000 Libraries of Congress) Google: Best Guess 15 Exabytes (1.5million Libraries of Congress, 100x HCA) Planet volumes: Moon: 2.2E-2 Jupiter: 1.4e3 (63,000 moons) Sun 1.4E6 (63 million moons) Units: Extabyte: 10^18 bytes Petabyte: 10^15 bytes Terrabyte: 10^12 bytes Gigabye: 10^9 bytes Note that the Library of Congress has at least 3 petabytes of digital content

What Could be Learned from the “Digital Dividend?”

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Care Informs Care: A Learning Health System

* National Research Council, National Academies of Science, “Toward Precision Medicine: Building a Network for Biomedical Research and a New Taxonomy of Disease.” 2011; p2.

*

Knowledge

Care Data

Wisdom

Care Changes Care: An Improving Health System

Afferent

Efferent

•  Study Design & Question: •  Large, two-arm,cluster randomized, pragmatic comparative-

effectiveness trial in 50 HCA hospitals (~300,000 patients) to assess the value of chlorhexidine bathing and MRSA decolonization in adult patients on non-critical care units

•  Key Outcomes: −  Unit-associated acquisition of MDROs −  Bloodstream infections: all pathogens

•  Additional Outcomes: −  Urinary tract infections: all pathogens −  Contaminated blood cultures −  Infectious readmissions: all pathogens −  Emergence of resistance among key pathogens −  Cost assessment

Active BAthing To Eliminate (ABATE) Infection Trial >600,000

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The “Data Dividend” . . . a Learning & Improvement Engine

The Full Dividend of Transparency, Accountability & Clinical Leadership:

A “Learning Health System”

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APPENDIX

•  Major Studies in Progress •  Bibliography

PlannedResearchPorqolio–SelectedStudiesProject HCAContribu9on Funder Poten9alImpact

1 ABATE:UniversaldecolonizaZonofinpaZentsnotinICUs

50affiliatedhospitals~600,000paZents NIH RecommendnewstandardinpaZent

caretopreventinfecZons

2INSPIRE:DevelopandtestmaterialsandmethodstoimproveempiricanZbioZctherapy

60HCAhospitals NIH Reduceunnecessaryandriskyuseof

broadspectrumanZbioZcs

3SWAPOUT:TestiodophornasalointmentasacomponentofICUdecolonizaZonregimen

120affiliatedhospitals~220,000ICUpaZents

CDCandClorox

ImprovethestandarddecolonizaZonregimenbylimiZngriskofresistancetocurrentagents

4CLUSTER:TestimpactofearlydetecZononsizeofinfecZonoutbreaksinhospitals

80hospitals CDC

Allowhospitalstomountearlyresponsetooutbreaks.Fullyautomatedsystemreducesburdenonstaff.

5 iMobile:Evaluateeffectofsecuremessagingamonghospitalteams 15hospitals AHRQ ImprovepaZentoutcomesthrough

efficientcommunicaZon

6 Sen9nelSystem:Assessthesafetyofmarketedmedicalproducts AllHCAhospitals FDA

ImprovenaZonalcapabilitytoidenZfyrisksofmedicaZons,biologics,andbloodproducts

7

PAICAP:AssessabilityofCMSdatatomonitortheimpactofpoliciestopreventhealthcareassociatedinfecZons

AllHCAhospitals AHRQInformnaZonalpolicyregardingqualitymonitoringandpaymentincenZvesystems

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Bibliography

Platt R, Takvorian S, Septimus E, Hickok J, Moody J, Perlin J, Jernigan J, Huang S. “Cluster Randomized Trials in Comparative Effectiveness Research: Randomizing hospitals to test methods for prevention of healthcare-associated infections.” Medical Care. 2010; 48:s52-57.

Huang SS, Septimus E, Kleinman K ... Perlin JB, Platt R. “Targeted Versus Universal Decolonization to Prevent ICU Infection.” New England Journal of Medicine. 2013; 368:2255-2265. DOI: 10.1056/NEJMoa1207290.

Platt R, Huang SS, Perlin JB. “A Win for the Learning Health System.” May 29, 2013. Commentary, Institute of Medicine, Washington, DC. Available at http://www.iom.edu/WinforLHS;

Huang SS, Septimus E, Avery TR, Lee GM, Hickok J, Weinstein RA, Moody J, Hayden MK, Perlin JB., Platt Richard, Ray GT. “Cost Savings of Universal Decolonization to Prevent ICU Infection: Implications of the REDUCE MRSA Trial.” Infection Control and Hospital Epidemiology. 2014; In Press.

Septimus E, Hayden MK, Kleinman K, Avery TR, Moody J, Weinstein RA, Hickok J, Lankiewicz J, Gombosev A, Haffenreffer K, Kaganov RE, Jernigan JA, Perlin JB, Platt R, Huang SS. “Cost-savings of universal decolonization to prevent intensive care unit infection: implications of the REDUCE MRSA trial.” Infection Control and Hospital Epidemiology. 2014;35(Suppl3):S23-31.

Huang SS, Septimus E, Hayden M, … Perlin JB, Weinstein R. “Effectct of Body Surface Decolonization on Bacteriuria and Candiduria in Intensive Care Units: an Analysis of a Cluster-Randomized Trial.” Lancet Infectious Disease. 2016;16(1):70-9.

©HCAMS,2014

Learning Healthcare & Clinical Leadership in an Accountable Environment

Jonathan B. Perlin, MD, PhD, MSHA, MACP, FACMI

President, Clinical Services Group and Chief Medical Officer HCA / Hospital Corporation of America

Chair, American Hospital Association, 2015 Clinical Professor of Medicine & Biomedical Informatics, Vanderbilt University Adjunct Professor of Health Administration, Virginia Commonwealth University

Contact: [email protected]

It’s a Question of Quality Conference

London, England– February 25, 2016

Question of Quality Conference 2016 - Jonathan B. Perlin

Healthcare

Transcript of Question of Quality Conference 2016 - Jonathan B. Perlin