The Imperative of Linking Clinical and Financial Data to Improve Outcomes

1. The Imperative of Linking Clinical and Financial Data to Improve Outcomes Charles G. Macias M.D., M.P.H. Chief Clinical Systems Integration Officer, Texas Children’s Hospital

2. Learning objectives Assess the effectiveness of an organization’s quality gaps to ensure organizational readiness, drive efficiency and leverage opportunities to improve quality. Illustrate how a blend of clinical and financial data informed by analytics from an enterprise data warehouse can improve outcomes. Describe how an EDW and care process implementation can encourage a culture of quality and safety, providing physicians with the necessary tools to integrate financial relevance into the practice of delivering high-quality healthcare. Discuss how strategy for integration of science, data and predictive analytics and operational improvement through improvement science can transform a system towards the triple aim.

3. Jenny Jones and the Challenges of a Fragmented System Within six months, Jenny had visited: One PCP Two Hospitals Three ERs Leading to: Six different Asthma Action Plans with conflicting discharge instructions

4. Quality Defined The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. • – Lohr, K.N., & Schroeder, S.A. (1990). A strategy for quality assurance in Medicare. New England Journal of Medicine, 322 (10):707-712. Importance of minimizing unintended variation in health care delivery Institute of Medicine domains: Safe Effective Efficient Timely Patient centered Equitable 1 2 3

5. The Healthcare Value Equation In an environment where cost is marginally increasing, healthcare must markedly improve quality. Adoption of EMRs and clinical systems should help push the quality agenda but alone may not be enough to deliver data intelligence. Quality Cost Value =

6. In Second Look, Few Savings from Digital Health Records New York Times: January 10, 2013 2005 RAND report forecasts $81 billion annual U.S. savings. “Seven years later the empirical data on the technology’s impact on health care efficiency and safety are mixed, and annual health care expenditures in the United States have grown by $800 billion.” Disappointing performance of health IT to date largely attributed to: • Sluggish adoption of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; • The failure of health care providers and institutions to reengineer care processes to reap the full benefits of health IT. • EHRs, Red Tape Eroding Physician Job Satisfaction • Most physicians express frustration with the failure to provide efficiency. • 20% want to return to paper

7. Variation in Care Describing variation in care in three pediatric diseases: gastroenteritis, asthma, simple febrile seizure • Pediatric Health Information System database (for data from 21 member hospitals) • Two quality-of-care metrics measured for each disease process • Wide variations in practice • Increased costs were NOT associated with lower admission rates or 3-day ED revisit rates Implications? • Optimal care may be delivered at a lower cost than today’s care! Kharbanda AB, Hall M, Shah SS, Freedman SB, Mistry RD, Macias CG, Bonsu B, Dayan PS, Alessandrini EA, Neuman MI. Variation in resource utilization across a national sample of pediatric emergency departments. J Pediatr. 2013

8. Consumer Care/Cost Uncertainty Consumers: • Trust their physicians • Hope for the best • Struggle to understand cost and care • Don’t often know what they are getting • Don’t always get great outcomes Value is what they want

9. Challenge of Healthcare Physicians are: • Driven by science and key values • Overwhelmed with medical literature • Not well trained to turn that experience into high quality patient outcomes Transparency of local data is part of the solution!

10. Poll Question #1 In your organization, what percentage of patient visits are your physicians talking about cost and care tradeoffs at the bedside? • 0-19% • 20-39% • 40-59% • 60-79% • 80-100% • Unsure or not applicable

11. Physicians and Care Cost Patient values and preferences Evidence Clinical Expertise Physician preferences Resource issues Source: SAEM. Evidence Based Medicine Online Course 2005

12. Once taboo, physicians should take cost into consideration: No Money No Mission No Expansion No Innovation • And so providers must….. • Understand what creates improvements • Understand the story that their data tells.

13. About Texas Children’s Hospital

14. A data management strategy to improve outcomes IMPROVED OUTCOMES from high quality of care Patient centric outcomes and institutional outcomes achieved DEPLOYMENTSYSTEM Operations CLINICALCONTENT SYSTEM Science and evidence Evidence Based Guidelines and Order sets, Clinical Decision Support, patient and provider materials Informatics, Electronic Data Warehousing ANALYTIC SYSTEM Data analytics and collaborative data Advanced Quality Improvement course, QI curriculum, Care process teams SOURCE SYSTEMS (e.g. EMR, Financial, Costing, Patient Satisfaction)

15. Creating a foundation for EB practice IMPROVED OUTCOMES from high quality of care DEPLOYMENTSYSTEM Operations CLINICALCONTENT SYSTEM Science and evidence Evidence Based Guidelines and Order sets, Clinical Decision Support, patient and provider materials ANALYTIC SYSTEM Data analytics and collaborative data SOURCE SYSTEMS (e.g. EMR, Financial, Costing, Patient Satisfaction)

16. Deep Vein Thrombosis Diabetic Ketoacidosis Fever and Neutropenia in Children with Cancer Fever Without Localizing Signs (FWLS) 0-60 Days Fever Without Localizaing Signs (FWLS) 2-36 Months Housewide Procedural Sedation Hyperbilirubinemia Neonatal Thrombosis Nutrition/Feeding in the Post-Cardiac Neonate Rapid Sequence Intubation Skin and Soft Tissue Infection Status Epilepticus Tracheostomy Management Urinary Tract Infection Evidence-Based Guidelines: EBOC Central Line-Associated Bloodstream Infections Closed Head Injury Community-Acquired Pneumonia Cystic Fibrosis – Nutrition/GI >12 y/o Autism Assessment and Diagnosis C-spine Assessment Intraosseus Line Placement IV Lock Therapy Postpartum Hemorrhage Acute Chest Syndrome Acute Gastroenteritis Acute Heart Failure Acute Hematogenous Osteomyelitis Acute Ischemic Stroke Acute Otitis Media Appendicitis Arterial Thrombosis Asthma Bronchiolitis Cancer Center Procedural Management Cardiac Thrombosis

17. Poll Question #2 In ambulatory settings, what is the best estimate for the percentage of questions for which evidence exists to answer clinical questions that affect the decision to treat? • 5% • 10% • 15% • 25% • 50% • Unsure or not applicable

18. Creating a foundation for data use IMPROVED OUTCOMES from high quality of care DEPLOYMENTSYSTEM Operations CLINICALCONTENT SYSTEM Science and evidence Informatics, Electronic Data Warehousing ANALYTIC SYSTEM Data analytics and collaborative data SOURCE SYSTEMS (e.g. EMR, Financial, Costing, Patient Satisfaction)

19. TCH’s EDW Architecture Metadata: EDW Atlas Security and Auditing FINANCIAL SOURCES (e.g. EPSi,) DEPARTMENTAL SOURCES (e.g. Sunquest Labs) Common, Linkable Vocabulary; Late binding FinancialSource Marts DepartmentalSource Marts • Clinical • Asthma • Appendectomy • Deliveries • Pneumonia • Diabetes • Surgery • Neonatal dz • Transplant • Operations • Labor productivity • Radiology • Practice Mgmt • Financials • Patient Satisfaction • + others AdministrativeSource Marts PatientSource Marts PATIENT SATISFACTION SOURCES (e.g. NRC Picker, ADMINISTRATIVE SOURCES (e.g. API Time Tracking) EMR Source Marts HRSource Mart Human Resources (e.g. PeopleSoft) EMR SOURCE (e.g. Epic)

20. Creating a foundation for QI deployment IMPROVED OUTCOMES from high quality of care DEPLOYMENTSYSTEM Operations CLINICALCONTENT SYSTEM Science and evidence ANALYTIC SYSTEM Data analytics and collaborative data Advanced Quality Improvement course, QI curriculum, Care process teams

21. Avenues for Dissemination QUALITY LEADERS National Programs and Partnerships ADVANCED • Classroom (e.g. AQI Program, Six Sigma Green Belt) • Project Required INTERMEDIATE • Online and Classroom (IHI Educational Resources, PEDI 101, EQIPP, Fellows College) • Project Required BEGINNER Online and Classroom (e.g. Nursing IMPACT (QI Basic). OJO Educational Resources, Lean Awareness Training) NEW Classroom and Department (e.g. New Employee Orientation, e-Learning, Unit/Department-based training)

22. Changes that result in process improvement Improvement Act Plan Study Do Act Plan Study Do Act Plan Study Do Adapted from: The Improvement Guide: A Practical Approach to Enhancing Organizational Performance, 2nd Ed. Gerald J. Langley, Ronald D. Moen, Kevin M. Nolan, Thomas W. Nolan, Clifford L. Norman, and Lloyd P. Provost; Jossey-Bass 2009 Ideas

23. Pareto 80/20 Principle in Healthcare

24. TCH’s Care Process Analysis Asthma Amount of Variation Improvement Opportunity: Large processes with significant variation Bubble Size = Case Count Size of Clinical Process

25. Driving clinical care improvement: linking science, data management, operations Clinical Program Guidelines centered on evidence-based care MD Lead MD Lead MD Lead MD Lead MD Lead Operations Lead Domain MD Lead #5 Care Process #4 Care Process #2 Care Process #3 Care Process #1 Care Process Clinical Director BIDeveloper DataArchitect Data Manager Outcomes Analyst Application Service Owner Permanent, integrated teams composed of clinicians, technologists, analysts and quality improvement personnel drive adoption of evidence-based medicine and achieve and sustain superior outcomes.

26. Balanced scorecard-expanded visualizations • Individual Ratings • Care Process Defined • Current Literature Research • Group Creates Final Scorecard • Aggregate Ratings

27. Severity Adjusted Variation

28. Data Drives Waste Reduction:Alternative Approaches 1.96 std Mean 1 box = 100 cases in a year # of Cases # of Cases Option 1: Focus on Outliers – the prescriptive approach Strategy eliminate the unfavorable tail of the curve (“quality assurance”) Result Ithe impact is minimal Excellent Outcomes Poor Outcomes Excellent Outcomes Poor Outcomes 27

29. Alternative Approaches to Waste Reduction 1 box = 100 cases in a year Mean # of Cases # of Cases Option 2: Focus On Inliers – improving quality outcomes across the majority StrategyEvidence and analytics applied through EBP clinical standards targets inlier variation Result Shifting more cases towards excellent outcomes has much more significant impact Poor Outcomes Excellent Outcomes Excellent Outcomes Poor Outcomes 28

30. Improving Cost Structure Through Waste Reduction

31. Care Redesign Methodology CXR utilization in patients with known asthma, steroids in bronchiolitis Quicker steroid delivery for status asthmaticus, goal directed therapy for septic shock Evidence against Evidence equivocal Evidence Supports Hypertonic saline and bronchodilators in select patients with bronchiolitis

33. Improving Cost Structure Through Waste Reduction

34. Process map before EBG

35. Process map after EBG

37. Improving Cost Structure Through Waste Reduction

38. Clinical Decision Support to Minimize Errors Streamlining and Improving Processes and Operations to Minimize Errors

39. Value =

40. EC: Early administration of Dexamethasone Expanding evidence based practice -Provider and staff inservicing -Clinical decision support -Bridging a continuum for home care: second dose 10% decrease in TID

41. Inpatient: prolonged LOS • 35% reduction in LOS • No change in 7 or 30 day readmission rate • No change in days of school/days of work missed • Direct variable cost ($60/hr) Evidence based approach to early medication weaning

42. Increase chronic severity assessment Improve accuracy Increase appropriate controller prescriptions Clinical decision support Increase influenza vaccination rate Increase number of culturally sensitive education encounters Increase number of social work/ legal support encounters The continuum: improved patient experience and outcomes Improved time to first beta agonist (ED or inpatient arrival) • AAP use went from 20% to 44% in first cycle to 52% in second • ACT use went from 0% to 30% in first cycle to 41% in second • Severity classification went from 10% to 35% in first cycle to 54% in second

43. Registry Financial Score Card

46. Asthma Care Outcomes Dashboard

47. Financial conversations

49. Examples Demonstrating ROI Improved clinical care • Decreases in LOS • Decrease in readmission rates • Decreased unnecessary test utilization • Millions in savings across several disease processes Reducing waste by systematizing reporting • EDW reports cost 70% less to build Clinical operations tools allow global views for increased operational efficiency

50. Organizational direction for data Improved outcomes for our patients and our enterprise Organizational evolution over time Predictive analytics Decision support --Linking likelihood of outcomes to care decisions driven with realtime data -Predicting financial outcomes and linking to clinical decisions for populations of patients -Linking outcomes across infrastructures Data analytics -Integrating best evidence into delivery system infrastructures -EMR based recommendations and alerts -Integrated plans of care across continuums Data reporting -Shortening event to reporting time -Transforming data and translating to action -EMR clinical reports -Financial reports