Analytics: Means Harnessing Drive Healthcare Value‘Predictive Analytics: 'A Means to Harnessing the Power to Drive Healthcare Value‘ Wolf H. Stapelfeldt, MD ... ETL Processes Analytics

Predictive Analytics: 'A Means to Harnessing the Power to Drive Healthcare Value‘

Wolf H. Stapelfeldt, MDChairman, Department of General

Anesthesiology

Cleveland Clinic

• Vice Chairman, Surgical Operations, Medical Operations Division

• Vice Chairman, Information Systems & Technologies, Anesthesiology Institute

• Faculty, Samson Global Leadership Academy for Healthcare Executives

Learning Objectives• Review the key elements of Clinical and Business Intelligence (C&BI)

• Recognize the rationale for enlisting C&BI as part of organizational strategy

• Appreciate an example of the value of C&BI in affecting meaningful clinical and business outcomes

QualityCostValue =

QualityCostValue =

via the services that are being provided …

QualityCostValue =

via the services that are being provided …and by leveraging technology…

QualityCostValue =


QualityCostValue =


(Clinical & Business Intelligence)

Meaningful Outcomes

• In‐Hospital Mortality• Length of Stay (LOS)• Hospital Charges• Re‐admission Rate• 30‐Day Mortality

Clinical Challenge(Patients, Populations)

Actions/Interventions


Clinical & BusinessProcesses





Results Data


Outcomes



Results Data

Learning/Understanding Information


Outcomes



Results Data



Knowledge/Experience Actionable Information(Decision Support)

Outcomes



Results Data




Outcomes



Results Data



C&BI

Outcomes




Results Data



C&BI

Outcomes




Results Data



C&BI

Outcomes




Results Data




C&BI

Outcomes



Results Data




C&BI

Outcomes



Results Data




Device Integration

ETL Processes

C&BI

Outcomes



Results Data




Device Integration

ETL Processes

C&BI

Outcomes



Results Data




Device Integration

ETL Processes Analytics

C&BI

Outcomes



Results Data




Device Integration


C&BI

Outcomes



Results Data




Device Integration


Real-Time Processing

C&BI

Outcomes



Results Data




Device Integration



C&BI

Outcomes



Results Data




Device Integration



Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

Outcomes



Results Data




Device Integration




C&BI

Outcomes



Results Data




Device Integration




C&BI

Outcomes



Results Data



Device Integration




C&BI

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality




Results Data



Intraoperative Hemodynamics

Device Integration




C&BI




Results Data




Device Integration




C&BI


1. Current Status of Perioperative Care

1. Current Status of Perioperative Carea. Handwritten Anesthesia Record



Problems

1. Difficult to read (often not legible)2. Not updated in real time3. Not accessible electronically


Problems



Problems



Problems



Problems



Problems



1. Current Status of Perioperative Carea. Handwritten Anesthesia Recordb. Automatically-generated Record


ARKS


ARKS


ARKS

Advantages

1. Legible2. Accurate3. Queryable

1. Current Status of Perioperative CareWhat constitutes hypotension severe enough to worry about?

ARKS


ARKS


ARKS



Results Data




Device Integration




C&BI




Results Data




Device Integration




C&BI


Hypotension

Hypotension

MAP < 70 ?

< 60 ?

< 50 ?

< some other discrete value (such as 20% below baseline) ?

< 60 !

Hypotension

MAP < 70 ?

< 60 ?

< 50 ?


< 60 !

Hypotension

MAP < 70 ?

< 60 ?

< 50 ?


< 60 !

Hypotension

MAP < 70 ?

< 60 ?

< 50 ?


< 60 !

Hypotension

MAP < 70 ?

< 60 ?

< 50 ?


When does hypotension become significant?


… after 2 minutes? …5 minutes? …15 minutes?





MAP

MAP

MAP

MAP

MAP

MAP

MAP

Hypotensive Case 1 Case 2Threshold [cum min] [cum min]

55 10 074 20 16073 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP


55 10 074 20 16073 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP


55 10 060 10 14573 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP


55 10 060 10 14573 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP


55 10 060 10 14573 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP


75 20 16074 20 16073 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP

HypotensiveThreshold

75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

N=35904

at a MAP below

Average CumulativeTime Spent

Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive

Thresholds Ranging From 75 To 45

Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45


75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

N=35904

at a MAP below






75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

N=35904

at a MAP below

100%

50%

0%

Incidence






75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

N=35904

at a MAP below

100%

50%

0%

Incidence






75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

6%5%4%3%2%1%

N=35904

at a MAP below

100%

50%

0%

Incidence

30-dayMortalityAverage

CumulativeTime Spent





75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

6%5%4%3%2%1%

N=35904

at a MAP below

100%

50%

0%

Incidence

30-dayMortalityAverage

CumulativeTime Spent



Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45 and in 30-day mortality

10%

20%

30%

40%

50%

1020

3040

5060

75 70 65 60 55 50 45Spent at an MAP Below

CumulativeMinutes

normotensive (n= 21485, 60%)% Increase In Odds Ratio(30‐day

Mortality)

Percent Increase in the Odds Ratio for 30‐day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds

10%

20%

30%

40%

50%

1020

3040

5060


CumulativeMinutes


Mortality)


10%

20%

30%

40%

50%

1020

3040

5060


CumulativeMinutes


Mortality)

hypertensive (n= 14419, 40%)


10%

20%

30%

40%

50%

1020

3040

5060


CumulativeMinutes


Mortality)



10%

20%

30%

40%

50%

1020

3040

5060


CumulativeMinutes

% Increase In Odds Ratio(30‐day

Mortality)



20%

10%

20%

30%

40%

50%

1020

3040

5060


CumulativeMinutes


Mortality)



The line in red represents the same (20%) impact on the Odds Ratio for 30‐day Mortality

20%

10%

20%

30%

40%

50%

1020

3040

5060


CumulativeMinutes


Mortality)




20%

10%

20%

30%

40%

50%

1020

3040

5060


CumulativeMinutes

normotensive (n= 21485, 60%)

5 311

2137

Minutes


Mortality)




CumulativeTime SpentBelow

an MAP Threshold of

AssociatedIncrease inOdds RatioFor 30‐DayMortality


an MAP Threshold of



an MAP Threshold of


Cumulative Time Spent

Below

an MAP Threshold of

Associated withan Increase in

30‐day Mortality Odds Ratio of


Below

an MAP Threshold of




Below

an MAP Threshold of



Patients Carrying a PreoperativeDiagnosis of Hypertension


Below

an MAP Threshold of




Below

an MAP Threshold of




Below

an MAP Threshold of




Below

an MAP Threshold of




Below

an MAP Threshold of




Below

an MAP Threshold of




Below

an MAP Threshold of




Below

an MAP Threshold of




Below

an MAP Threshold of




Below

an MAP Threshold of



Patients Carrying a PreoperativeDiagnosis of Hypertension


Below

an MAP Threshold of




Below

an MAP Threshold of




Below

an MAP Threshold of




Below

an MAP Threshold of



0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

In‐Hospital Mortality Median LOS* 90th Percentile LOS*

Hospital Charges Readmission Rate 30‐Day Mortality

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

Lim

itsPe

rcen

t Patients E

xceeding

Lim

its

A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits

# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) . Below limits Exceeding Limits

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50



N=27,436

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

Lim

itsPe

rcen

t Patients E

xceeding

Lim

its


# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11

# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11


0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50



N=27,436

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

Lim

itsPe

rcen

t Patients E

xceeding

Lim

its


# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11

# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11


0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50



N=27,436

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

Lim

itsPe

rcen

t Patients E

xceeding

Lim

its


# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11

# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11


0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50



N=27,436

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

Lim

itsPe

rcen

t Patients E

xceeding

Lim

its


# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11

# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11

* Live discharges


0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50



N=27,436

* Live discharges

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

Lim

itsPe

rcen

t Patients E

xceeding

Lim

its


# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11

# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11


0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50



N=27,436

* Live discharges

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

Lim

itsPe

rcen

t Patients E

xceeding

Lim

its


# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11

# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11


0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50



N=27,436

* Live discharges

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

Lim

itsPe

rcen

t Patients E

xceeding

Lim

its


# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11

# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11


0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50



N=27,436

* Live discharges

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

Lim

itsPe

rcen

t Patients E

xceeding

Lim

its


# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11

# Limits Exceeded 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11 15 14 13 12 12 12 12 11 11 11


In‐Hospital Mortality Average LOS* Readmission Rate*(N=27,436 ) (N=26,940) (N=26,940)

0%1%2%3%4%5%6%7%8%9%

10%

1 2 3 4 5 6 7 8 9 100.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

1 2 3 4 5 6 7 8 9 100%

1%

2%

3%

4%

5%

1 2 3 4 5 6 7 8 9 105 10 15 20 25 30 35 40 45 50 5 10 15 20 25 30 35 40 45 50 5 10 15 20 25 30 35 40 45 50

* Live discharges

Hypotensive Exposure, Unadjusted (95% Confidence Interval)

Hypotensive Exposure, AHRQ Adjusted (95% Confidence Interval)

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012)

Percent Increase in Risk (Odds Ratio) per Exposure Limit Exceeded (DSS Alert)Portended by a Novel Risk Index for Adverse Postoperative Outcome

Based on the Number of Intraoperative Hypotensive Exposure Limits Exceeded(with and without adjustment for a set of 30 co‐morbidities identified by AHRQ)

In‐Hospital Mortality Average LOS* Readmission Rate*(N=27,436 ) (N=26,940) (N=26,940)

0%1%2%3%4%5%6%7%8%9%

10%

1 2 3 4 5 6 7 8 9 100.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

1 2 3 4 5 6 7 8 9 100%

1%

2%

3%

4%

5%

1 2 3 4 5 6 7 8 9 105 10 15 20 25 30 35 40 45 50 5 10 15 20 25 30 35 40 45 50 5 10 15 20 25 30 35 40 45 50

* Live discharges

Hypotensive Exposure, Unadjusted (95% Confidence Interval)

Hypotensive Exposure, AHRQ Adjusted (95% Confidence Interval)

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012)

Percent Increase in Risk (Odds Ratio) per Exposure Limit Exceeded (DSS Alert)Portended by a Novel Risk Index for Adverse Postoperative Outcome

Based on the Number of Intraoperative Hypotensive Exposure Limits Exceeded(with and without adjustment for a set of 30 co‐morbidities identified by AHRQ)



Results Data




Device Integration




C&BI




Results Data




Device Integration




C&BI



1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)


ARKS

EMR KnowledgeBase


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EMR KnowledgeBase


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EMR

DSS

KnowledgeBase


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EMR

DSS

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EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation (the right informationat the right time to make the right decision)


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EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation (the right informationat the right time to make the right decision)

± History of hypertensionRisk factors for hypotension(ex: hypertrophic obstructive CM)

Association between hypotensive exposure & outcome

(“Diving Charts”)

Increased risk for adverse outcome portended by progressive hypotensive exposure


ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation


ARKS

EMR

DSS

KnowledgeBase


Web-Based Secure (electronically, physical)Compliant with Standards (HL7, SNOMED ontology)Platform-IndependentScalableUniversally Applicable


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EMR

DSS

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EMR

DSS

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EMR

DSS

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EMR

DSS

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EMR

DSS

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EMR

DSS

KnowledgeBase




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EMR

DSS

KnowledgeBase



OR

SupervisingPhysician

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EMRDSS

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EMRDSS

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EMRDSS

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Allows adverse physiologic developmentsto be addressed before they become crises

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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EMRDSS

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Update the effective MAP Matrixto include the most recent minute of the case

Update the cumulative number of minutes spent below each of the MAP

thresholds (75 to 45 mm Hg)

Compare with the set of time thresholdsfor the selected level of risk (risk set)

Count the number of thresholds exceededfor the current minute

Count greater than the previous minute’s count?

Alert

executed every minutein near real time

Each alert portends a 5.1% increase in the projected odds ratio for death within 30 days (20% risk set)

5

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Odds of Mortality

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12:00:00 13:12:00 14:24:00 15:36:00 16:48:00

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Odds of Mortality

Odds of Mortality

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12:00:00 13:12:00 14:24:00 15:36:00 16:48:00

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Odds of Mortality

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12:00:00 13:12:00 14:24:00 15:36:00 16:48:00

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to be evaluated in a prospective randomized clinical effectiveness trial…



Results Data




Device Integration




C&BI




Results Data




Device Integration




C&BI




Results Data




Device Integration



C&BI

Hypotensive ExposuresNumber of Limits ExceededAlerts

in real time (every one minute),for every patient

MAP Matrix


Minute‐to‐Minute MAP DataMedical History (Hypertension)



Results Data




Device Integration



C&BI



MAP Matrix


BP




Results Data




Device Integration



C&BI



MAP Matrix

Targeted

Postop. Care


BP




Results Data




Device Integration



C&BI



MAP Matrix

Targeted

Postop. Care


BP




Results Data




Device Integration



C&BI



MAP Matrix

Targeted

Postop. Care


Hypotensive exposuresare difficult to detect…

…and impossible to avoid…

BP




Results Data




Device Integration



C&BI



MAP Matrix

Targeted

Postop. Care




BP




Results Data




Device Integration



C&BI

Hypotensive ExposuresNumber of Limits Exceeded


MAP MatrixBP

Targeted

Postop. Care





Alerts

References• Implementing Business Intelligence in Your Healthcare Organization. Cynthia

McKinney, MBA, FHIMSS, PMP, Ray Hess, MSA, RRT, FHIMSS, and Michael Whitecar, MIS, LCDR (ret.), MSC, USN. http://marketplace.himss.org/OnlineStore/ProductDetail.aspx?ProductId=3329

• Risk‐Based Decision Support Thresholds for Hypotension in Adult Patients Undergoing Non‐Cardiac Surgery. Wolf H. Stapelfeldt, M.D., Jarrod Dalton, Ph.D., Pamela Bromley, M.B.A., George Takla, Ph.D., Jacek Cywinski, M.D., Marc Reynolds, M.S., Bhaswati Ghosh, M.S. http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=9B5E43B933F1D63ABAED7E20D57A44D1?year=2012&index=14&absnum=4351

• Prolonged hypotension in surgery linked to poor outcomes. Michael Vlessides. Anesthesiology News 38 (12), December 2012. http://issuu.com/mcmahongroup/docs/mman0012_2012_tab/1?zoomed=&zoomPercent=&zoomX=&zoomY=&noteText=&noteX=&noteY=&viewMode=magazine

• Starter Question #1Where to begin with C&BI?

The opportunity for C&BI begins with a solid foundation of electronic acquisition of data that capture the essential clinical and business processes as well as indicators of their outcomes through device integration and ETL processes by interfacing with relevant data sources such as patient monitors, EMRs, patient registries etc.

• Starter Question #2What outcomes to focus on when it comes to C&BI?

These could be key reportable patient outcome measures such as mortality, quality indicators, process measures or parameters such as cost per case. It is important to choose the most relevant ones and keep these in constant focus while realizing that it is resulting informed actions and interventions which affect these, not C&BI per se.

• Starter Question #3What types of data parameters are most suitable to be concentrating on when applying predictive analytics?

While predictive analytics needs to account for any input parameters deemed relevant it is those that might be altered through intervention (“actionable information”) that would be most relevant. Example: hemodynamic management (alterable) versus certain pre‐existing co‐morbidities (very important, but not typically alterable).

• Starter Question #4How can predictive analytics be leveraged to affect relevant outcomes?

There are essentially two important requirements: both, the analysis of clinical and business data for “actionable information” as well as provider notification to this information must occur within a sufficient time frame to allow any necessary actions/interventions to still be instituted and take effect in order to influence outcomes.

• Starter Question #5What is the ROI of instituting C&BI?

It is the determined by the value attributed to the percent improvement in meaningful outcome(s) one can expect to attain as a result of the implementation of C&BI relative to the cost of instituting the latter. This is one reason why it is important, at the outset, to choose the highest impact outcomes to be affected (example: number of lives saved;incremental operating margin through reduction in LOS).

Documents

Analytics: Means Harnessing Drive Healthcare Value‘Predictive Analytics: 'A Means to Harnessing the Power to Drive Healthcare Value‘ Wolf H. Stapelfeldt, MD ... ETL Processes Analytics