Collaboration Is Key To Increasing Surgical Value

David Skarda, MDJeannette Prochazka, MSNKatie Liljestrand, RN, MBAWendy Gort, MBA

Intermountain has partnered with Empiric Health to commercialize ProComp

Disclosure

Objectives

Identify key components of a successful multi-disciplinary team

Discuss how data cohorts are created and maintained to make meaningful and comparable data to reduce variation in practice

Give examples of how collaboration with teams has reduced cost and improved surgical outcomes

Healthcare in 2017- Fitting a square peg in a round hole…

Financial Distress

Since 1975• 22 hospitals• 2,784 licensed beds

Since 1983• Health plans• 700,000+ members

Since 1994• 1,200 employed physicians• 558 advanced practice clinicians

Since 1997• 10 key service lines

A Highly-Integrated Health System

Hospitals

SelectHealth

Medical Group

Clinical Programs

System-wide physician, and clinical administrativeoperations leaders needed to implement best practice

Development teams identified and established

Clinical Management Infrastructure

Measurement System Implementation Support

Staff support personnel and systems necessary to measure clinical, financialand satisfactionoutcomes for key clinical processes

Staff and systemsnecessary to develop, disseminate, support and maintain the clinicalknowledge basenecessary to implement best practice

INFORMATION TECHNOLOGY

CLINICAL PROGRAM INFRASTRUCTURECollaboration BEGINS here

Information Management Infrastructure

Clinical Programs and ServicesWorking Together

Ne

uro

scien

ces

NursingImaging

RespiratoryPharmacy

RehabNutrition

Laboratory

Be

havio

ral He

alth

On

colo

gy

Prim

ary Care

Mu

sculo

skeletal

Card

iovascu

lar

Wo

me

n &

Ne

wb

orn

s

Surgical Se

rvices

Inte

nsive

Me

dicin

e

Pe

diatrics

Supply Chain

Development Team Structure

• Elements of a strong physician leader Who to pick & who to avoid

• What motivates this leader?

• Good data makes all of the difference!

Development Team Structure

Physician Lead(s)

Physician Representatives

Administration

Project Manager

ProCompNurse

SelectHealth

Supply Chain Pharmacy OR DirectorsClinical

Program Directors

Compliance/ Quality

Data Analysts

Development Teams: Key to Physician Engagement

AnesthesiaBariatric Surgery

Blood Management

EndoscopyGeneral Surgery

Geriatric Hip Fracture

Gyn Surgery ENT Plastics Robotics

Spine Total Joints Urology Vascular/CV

Multiple Clinical Program Collaboration

Houston….We have a problem…..Intermountain…We have a goal…

Variation in clinical practice and supply utilization

Incomparable cost and outcome data

Working in silos

Disengaged physicians and clinicians

Lack of transparency in cost and outcomes data

ProComp: a technology & services platform to encourage evidence-based clinical practice

Create a culture of

evidence-based

clinical practice

REDUCEunnecessary

clinical variation &

cost

Reach consensus

on best practice

ENGAGEclinicians with

personalized insight

Identify

procedural

variation and

waste

COMPARE procedures &

workflows

ProComp is the center of the

solution ProComp

Surgeons

Supply Chain Organization

Development Teams

Surgical Services Clinical

Program

Operating Room Staff

Central Processing

Empiric Health formed.

Empiric launched at HIMSS

History of Intermountain ProComp development

specialties 6

cohorts 15

savings $15M

specialties 8

cohorts 40

exhorts 10

savings $58M

specialties 12

cohorts 127

exhorts 39

savings $80M

2013 2014 2015 2016 2017

specialties 13

cohorts 236

exhorts 128

savings $92M

Intermountain launches

ProComp to reduce variation in

surgical services

Intermountain

cohort and savings

metrics

Delivering comparable and meaningful data

Identify procedural

variation and waste

COMPARE procedures & workflows

Creating Refined, Comparable, and Transparent Data

“I would rather look at a lower volume of cases knowing those cases were all alike versus looking at all of the encounters knowing that some of those cases didn’t really fit in.”

~Dr. Jay Bishoff, Urology

Co-developed

with physicians

Intermountain cohorts present truly comparable encountersTraditional Procedural Data Intermountain Cohorts

Procedures with the same primary

procedure code often have

additional secondary procedures

Cohorts define comparable

procedures exactly the way

physicians want to look at them

Currently

251 Cohorts,

131 Exhorts

All definitions

available for review

with physicians

Ability to create

new or refine

existing definitions

Lifecycle of a Cohort

Cohort TypesStandard Cohorts

• Primary Procedure (ICD or CPT)

• List of secondary ‘May Have’ or ‘May Not Have’ procedures

• May also use age, supplies, trauma levels, MSDRGs, etc.

• 72 distinct rules

• Currently 169 Standard Cohorts

Examples:

Lap Cholecystectomy Inpatient (>=15yrs)

Total Hip Arthroplasty

Total Knee Arthroplasty

Tonsillectomy and Adenoidectomy

Cohort Extractor - When a basic cohort just isn’t enough

Key terms are tagged in records and encounters can be included or excluded appropriately.

Examples include: prostatectomy, hysterectomy, bariatric, robotic, and spine procedures.

Cohort TypesCohort Extractor (Tagged) Cohorts

• Each case reviewed and tagged by an Outcomes nurse

• Primary procedure (posterior lumbar fusion)

• Approach (laparoscopic, robotic)

• Qualifiers (anterior, posterior, revision)

• Additional Details (complications, surgical technique)

• 14 distinct rules

• Currently 82 Tagged Cohorts

Examples:

Prostatectomy, Robotic Simple (CE) Levels

Total Laparoscopic Hysterectomy

Total Laparoscopic Hysterectomy with Lymphadenectomy

Cohort TypesExhorts

• Most cohorts contains a partner exhort

• Same primary definition as cohort, but falls into exhort due to additional procedures (ex. appendectomy and cholecystectomy in same case)

• Eliminates known variation

• Able to account for all cases for a primary procedure for analysis on volumes, SSI, etc.

• Currently 131 Exhorts

Cohort TypesProcedure Groups

• When there isn’t a cohort defined for a primary procedure, the case falls into a procedure group

• Able to account for all surgical services cases for analysis on savings, OR utilization, etc.

• Also used to determine potential defined cohorts

Examples:

15820 Blepharoplasty, lower eyelid

15824 Rhytidectomy

00500ZZ Destruction of Brain, Open Approach

00590ZZ Destruction of Thalamus, Open Approach

Reach consensus on

best practice

ENGAGEclinicians with

personalized insight

Collaborating across the system to engage caregivers

Engaging clinicians through Development Teams

“What matters to you and your patients….”

Identify best practice based on evidence

Standardize best practice throughout Intermountain

Look for variation in cost and outcomes

Align with Intermountain goals

Spine Development Team

Low attendance by surgeons

Data that was not meaningful

Cost reduction goal (without outcome data)

Engaging physician lead

Creation of clinically relevant data

Problems

Solution

Billing data (ICD and CPT) combines multiple fusion levels. This data is not comparable.

Spine Development Team Improvements

Created dynamic dashboard (unblinded data)

Encouraged input on meaningful data metrics

Increase in attendance by surgeons

Discussion of cost reduction- Reduction of implant suppliers led to $4.2 million savings

Participation in national registry for outcome data

Dashboard Component Examples

Outcome

Solution

Spine Development TeamCohort Extractor (Tagged) Cohorts

Facilities

Surgeons

Spine Development TeamCohort Extractor (Tagged)

Facilities

Surgeons

Consistent practice through standardized order sets

General Surgery Development Team:

Evidence-based practice

Physician decisions

Pharmacy and ID expertise

Operationalizing-standardized order sets

Dashboard development and tracking orders

General Surgery Development TeamStandard Cohorts (Lap Appendectomy and Lap Cholecystectomy)

Facilities

Surgeons

General Surgery Development TeamStandard Cohorts (Lap Appendectomy and Lap Cholecystectomy)

Some cohorts further defined during reporting by searching for

key terms on operative report

ex. ruptured (perforated, ruptured, gangrenous)

Facilities

Surgeons

Anesthesia Development TeamQuality Measure Variation Reduction

PSI-11 Post operative Respiratory Failure

Anesthesia Development Team- Identify root cause

Collaboration with Clinical Documentation Specialists, Respiratory Services

Education to: Intensivists, Surgeons, Resident Physicians

Continued ADT review of PSI 11 Failures

• Identification of high risk patients (OSA, multi-modal pain management)

3.30%

2.60%

1.40%

Quarter 1 Quarter 2 Quarter 3

PSI-11 Failure Rate (per 1000 discharges)

Engaging with the Individual Physician

• One physician was using a product 234% > any other physician.

• Product = $170/case

Opportunity Identified

• Nurse presented data on cost/case variation and related outcomes.

ProComp• Physician decreased

utilization over a few months and now rarely uses the product.

• Savings in one year = $36,000

Decreased Utilization

Create a culture of

evidence-based clinical

practice

REDUCEunnecessary clinical

variation & costIdentification of variation and

operationalization of best practice

T & A surgery within Intermountain

High volume, high variability in cost and complicationso 4,007 T & A surgeries (Cohort), 751 T & A surgeries (Exhort)

oHospital Mean Cost per Case- $1000-$2400

Meaningful Data Influences Physicians Behavior

Parent-reported study shows more expensive cautery does not improve outcomes.

Personalized data sent to ENT surgeons quarterly

T&A Cohort- over 4 year period

T&A Cohort- Over 3 year period

Results: Change in behavior and reduction of cost per case

One Appendectomy

Appendicitis is Common

• Most common surgical emergency in children

• Surgical technique is variable

• Outcomes are consistently good

• Cost to treat per child with non-ruptured appendicitis in USo $5,000 to $10,000

• Cost to treat per child with ruptured appendicitis in USo $10,000 to $30,000

• Ideal target to improve value

Less Expensive Alternatives Exist

Port

• Items available but not used

were over 81% less than what

was being used

Loops instead of staplers

• Loops are over 86% less than

Staplers

Endocatch bag • Use the bag $• No use $0

Disposable fascia closure device • Use the device $• No use $0

Heat source• Harmonic scalpel $• Ligasure $• Hook cautery $0

All Patients with Appendicitis

Historical Controls

N=346

Standardized Procedure

N=362 P Value

Mean

(95% CI) Mean

(95% CI)

Appendectomy Device Cost

$844.11 (838.65-849.56)

$305.32 (302.05-308.60)

<0.001

Skin to Skin OR Time (min)

34.8 (33.3-36.3)

37.0 (35.6-38.4)

0.006

Roll-in Roll-out OR time (min)

59.3 (57.6-61.1)

61.7 (60.0-63.3)

0.016

$195,041.98/year

No difference in Outcomes

3 Years Later—Cost Per Case Per Surgeon

Surgeons

Intermountain Healthcare Pediatric Sedation/Anesthesia/Procedural Care Policy

A “Principled Compromise” Solution

The Problem:

• There are well-defined “high-risk” populations• Premature babies

• Babies 0-12 months old

• Children ASA 3+

• 7 “high-risk” specific clinical scenarios

• System variability in “who can do what where”

• We had an event

• Mandate. . . “stop the bleeding. . . and make a policy”

Process:

• Created and met with a Stakeholder group

NORTH REGIONMatt Pollard Mike BroadbentDavid Harker Pat Watkins

Michael Cragun Larry HawsMarcie Sherner

CENTRAL REGIONNate Kofford Ruth ZimmerBill Hamilton Shannon PhillipsSabrina Cole Carolyn ReynoldsKelly Davis Pramod Sharma

Nancy Nelson Deanna WelchMark Ott

SOUTH REGIONJonathan Meyers Craig Grose

Darren Obray Becky DavisSteve Bigler Will ShakespeareGary Beck

SOUTHWEST REGIONTodd Plumb Steve Van NormanTyler Nelson

PRIMARY CHILDREN’S REGIONJeremy Meier Jeff Schunk

Douglas Barnhart Sheldon FurstChristopher Maloney

Process:

• Created and met with a Stakeholder group

• Analyzed external and internal data and guidelines

• Evaluated a number of potential options

• Came to a potential deadlock

• Generated a “principled compromise” solution

• Policy approved by IH clinical leadership

Spectrum of Pediatric Policy

No Policy• Everyone does what they want• Facility or Regional Control• Prior to Aug 1

Strong Regulation• System standards• Facility limitations• Central Control

“Principled Compromise” Proposal

Sweet Spot

Region-based AdministrationRegion-based Monitoring System-wide Adoption of UCR Policy

Criteria-based access to “high-risk” groups

You don’t have to “Pass It” to know what is “In It”

• Treats all facilities and all providers equally

• All facilities and providers can treat healthy children (7 months old and older, ASA 1-2)

• Defines “high-risk” populations and who can treat them

• Creates an ongoing pediatric SAP outcome monitoring process

Facilities

Surgeons

Facilities

Surgeons

Report Metrics

• Volumes• PACU Duration• Return to OR• Readmission• Mortality

PRBC Utilization

We Had a Problem• Intermountain used a lot of PRBCs

• 2009 cross matched PRBC Units transfused – 39,567

• Total of PRBC discarded products – 3,128

• Total Transfusion reactions – 222

• PRBCs are expensive. . . $1800-$2800/unit transfused

• PRBCs can cause problems

System PRBC transfusion Indications

PRBC Transfusion Reduction Project

Educate clinicians• Indications

• One unit at a time unless MTP

Monitor leading and lagging measures

Provide clinicians with feedback

Monthly Letter to clinicians that transfuse PRBC’sDear Esteemed Colleague:You are receiving this email because you ordered a PRBC transfusion in an Intermountain facility during the month of January. Intermountain Healthcare has a continued focus on reducing the number of unnecessary PRBC transfusions in the population. Thank you for your participation to decrease PRBC transfusions and I invite you to click on this link, Physician Blood Utilization Report, from a computer inside the Intermountain Healthcare firewall and using your standard Intermountain user ID/password, so you can view your transfusion data.Intermountain Ongoing Blood Utilization Goals:1. Minimize the frequency of two-unit transfusions2. Minimize the frequency of transfusion for Hematocrit > 22.9% Most patients do not need an elective blood transfusion for hematocrits above 21%. When a blood transfusion is appropriate, one unit instead of two units is usually the appropriate volume. Please consider giving your patient one unit of blood and then reevaluating the patient before routinely giving them the second unit of blood. We know that this is different from what you may have learned in medical school and residency, but is well supported by the best evidence based guidelines below.Please compare your personal blood transfusion practice to these best evidence based guidelines for transfusion indications based on hematocrit level and medical history:

Blood Utilization

Blood Utilization

Blood Utilization Cost Savings

> $4,000,000

Summary- How to fit a square peg in a round hole…

• Strong physician leader

• Multi-disciplinary team- expert opinions/insight

• Involve physicians in data refinement process

• Comparable and meaningful data

• Standardization of processes in large system is possible!