Population Health Analytics: Improving Care One Patient at a Time

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Improving Care One Patient at a Time

February 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?



Common Thread: Outcomes

Provide the highest quality care

with an optimal care experience

for a population of patients

at the lowest appropriate cost

3

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

4

Fire

Fuel



3 Ingredients of Fire

5

Fire

Fuel

What should we be doing?

How are we

doing?

How do we

transform?

Content System

Outcomes

Improvement

3 Ingredients of Outcomes Improvement



A Tautology…

6

"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?

7

Fire

Fuel

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

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



Content System

Outcomes

Improvement

3 Systems for Outcomes Improvement

8


How are we

doing?

How do we

transform?


www.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



Infr

astr

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g / H

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reAnalytics System OverviewHow are we doing?

10

e.g. EPSi,

Peoplesoft,

Lawson

e.g. Lawson,

Peoplesoft,

Ultipro

Subject Area Mart Designer

Source Mart Designer

EMR

EMR FinancialPatient

Sat. HR Administrative Claims

FinancialPatient

Sat.HR Administrative Claims

e.g. Epic, Cerner

NextGene.g. Press Ganey,

NRC Pickere.g. API Time

Tracking

e.g. Medicare

Private 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

actions

Shared 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



Content System

Outcomes

Improvement


12


How are we

doing?

How do we

transform?



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 Map

Sepsis and septic shock



Identify Potential ImprovementsProcess AIMs and Outcome Goals

Transformation Process

Starter Set

Content

Implement

InterventionMeasure &

Sustain

Review &

Select AIM Define CohortIterate on

Metrics

Heart Failure: AIM #1

Starter Set

Content

Implement

InterventionMeasure &

Sustain

Review &

Select AIM Define CohortIterate on

Metrics

Heart Failure: AIM #2

Process Improvement AIM:

Improve Follow-up Visit Scheduling

From 43% to 90% by October 31, 2015

Process Improvement AIM:

Improve Medication Reconciliation

From 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)

Additional

Potential 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 Aids

or Knowledge Assets

Admits/1000 members

IP days/1000 members

OP visits/1000 members

Procedures/1000 members

ED visits/1000 members

Readmissions/1000 members

UtilizationWho should

get the care?

Cost/case

Cost/procedure

OR minutes

L&D minutes

Other LOS

Order Sets

Workflow

Cost per case

Nursing hours by unit

OR minutes

L&D minutes

Cycle times

Cost per ancillary test

Environmental services

What care

should be

included?

How can care

be delivered

efficiently ?

Indications for Intervention

Diagnostic algorithms

Indications for Referral

Triage Criteria

Treatment and Monitoring

Algorithms

Health Maintenance and

Preventive Guidelines

Standardized Follow-up Checklist

Post-acute care order sets

IP (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 Care

Non-recurrent

Clinic Care

ChronicAcute Medical

IP Med-Surg

Acute 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

Indications for Intervention

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 sets

IP (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 Asset

Type

Discounted

FFS Per Diem

Per Case Bundled Per CaseCondition

Capitation

Full

CapitationCMS Commercial CMS Commercial

Workflow

Diagnostic Variation

Standing Orders

Medication Selection

Triage

Patient Safety

Ambulatory Treatment

and Monitoring


Indications for

Intervention

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.



Content System

Outcomes

Improvement


23


How are we

doing?

How do we

transform?



Infr

astr

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re: H

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ard

wa

reAnalytics System OverviewHow are we doing?

24

e.g. EPSi,

Peoplesoft,

Lawson

e.g. Lawson,

Peoplesoft,

Ultipro

Subject Area Mart Designer

Source Mart Designer

EMR

EMR FinancialPatient

Sat. HR Administrative Claims

FinancialPatient

Sat.HR Administrative Claims

e.g. Epic, Cerner

NextGene.g. Press Ganey,

NRC Pickere.g. API Time

Tracking

e.g. Medicare

Private 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

actions

Shared 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 data

Data distribution

Gather, compiling or running

Weak Analytic System

Strong Analytic System

The majority of time is spent

analyzing and interpreting data

Understanding the question

Hunting for data

Interpreting data

Data distribution

Gather, compiling or running

25



Less 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

Census



Ganey)

DEPARTMENTAL

SOURCES

(e.g. Apollo)

FINANCIAL SOURCES

(e.g. EPSi, Lawson,

PeopleSoft)

ADMINISTRATIVE

SOURCES

(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

Financial

Source Marts

Administrative

Source Marts

Departmental

Source Marts

EMR

Source Marts

Patient

Satisfaction

Source Mart

FINANCIAL SOURCES

(e.g. EPSi, Peoplesoft,

Lawson)

ADMINISTRATIVE

SOURCES

(e.g. API Time Tracking)

EMR SOURCEs

(e.g. Cerner, Epic,

NextGen)

DEPARTMENTAL

SOURCES

(e.g. Apollo)



Ganey)

Adaptive Data Modeling

Less TransformationMore Transformation



Information Management

2929

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

Minimum

Standard

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

4

Var

iab

ility

High

Low

Resource ConsumptionLow High

Improvement Approach - Prioritization

32



Internal Variation versus Resource ConsumptionY

-A

xis

= In

tern

al V

aria

tio

n in

Re

so

urc

es C

on

su

me

d

Bubble Size = Resources

Consumed

Bubble Color = Clinical DomainX Axis = Resources Consumed

1

2

3

4



Prioritize: Pareto Analysis App

34



0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% of Total Cumulative %

35

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

Y-A

xis

= P

erc

en

t o

f to

tal

reso

urc

es c

on

su

med

Pareto Analysis >> Prioritization

Top 85 Care Processes account

for 80% of the opportunity (+45)


for 62% of the opportunity (+27)


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.



Content System

Outcomes

Improvement


38


How are we

doing?

How do we

transform?



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 blocksOB 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

42

Outcomes

Improvement

Examples: Reduction in Mortality Rate; Hard

Cost Savings; Time Savings (Soft Cost);

Improved Health Function

Difficu

lty 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

Opportunity

Identification

Improvement

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

productValue 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.



Outcomes

Improvement

Content System

46

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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