NAPH-UHC Clinical Improvement Tools NAPH Annual Conference June 20, 2002 David Burnett, MD, MPH

1. NAPH-UHC Clinical Improvement ToolsNAPH Annual ConferenceJune 20, 2002David Burnett, MD, MPH NAPH Annual ConferenceJune 19-22, 2002

2. UHC Information Tools to Support Quality, Safety, and Efficiency Improvement • Clinical Data Products • Patient Safety Net • Faculty Practice Solutions Center • Operational Data Base • Benchmarking

3. Comparative Clinical Data Offerings:A Source of Descriptive Data

4. Clinical Information Management Provides a Suite of Services • Clinical Data Base (CDB) • JCAHO ORYX Reporting • CDB-Pharmacy • State Databases • MEDPAR Analyses • Custom Analytic Services

5. The UHC Clinical Data Base Provides Comparative Data on Peer Academic Medical Centers • CDB pools clinical and financial data using discharge abstract summaries and UB-92 data • Key Outcomes: Cost, LOS, Mortality, Complications, Components of Cost • CDB data is fully risk-adjusted • CDB provides cost estimates, not charges

6. BMT BURNS CARDIOLOGY CARDIOTHORACIC SURGERY DENTAL/ORAL SURGERY DERMATOLOGY GASTROENTEROLOGY GYNECOLOGY HEART TRANSPLANT HIV KIDNEY TRANSPLANT LIVER TRANSPLANT LUNG TRANSPLANT MED ONCOLOGY MEDICINE GENERAL NEONATOLOGY NEUROLOGY NEUROSURGERY UHC Product Lines The 500+ DRGs have been assigned to 36 product lines NORMAL NEWBORNS OBSTETRICS OPHTHALMOLOGY ORTHOPEDICS OTOLARYNGOLOGY PEDIATRICS PLASTIC SURGERY PSYCHIATRY REHABILITATION RHEUMATOLOGY SUBSTANCE ABUSE SURG ONCOLOGY SURGERY GENERAL TRAUMA UNGROUP/INV UROLOGY VASCULAR SURGERY VENTILATOR SUPPORT

8. Web interface allows wide access throughout the institution

9. UHC Clinical Data Base ORYX Core Measure Service Online data entry tool or data upload capability Online reporting tool for Quality/Performance Improvement reviews Control chart creation for easy review of case data points

11. CDB-Pharmacy Report Generation (Examples) • What are my top generic drugs within a product line or DRG? • Where is Drug A being used most in the hospital? • What % of my CABG pts receive albumin compared to other HCOs? • Which glycoprotein iib/iiia inhibitors are other HCOs using in the cardiology product line? • What anticoagulants (DVT prophyx) are other HCOs using in pts undergoing total hip replacement (THR)? • Which physicians are using more antifungals in the BMT pt group?

12. The UHC Patient Safety Net

13. Toward an Epidemiology of Safety • Focus on actual or potential harm to patients, not error • Approaches tailored to the problem • Root cause analysis for rare, serious events • Data analysis for more common, less serious events • Measurement is the beginning of management • Establishing run rates for most common events • Identifying areas for more focused process improvement efforts

14. Design of the Patient Safety Net • Internet based (server at UHC in Chicago) • Point of care data entry for adverse events & near misses • Simple common classification system • Rapid event reporting • Fields for medication errors, ADR’s, falls, transfusion events, procedural events, complications, equipment issues, behavioral events, skin integrity, other • Secondary (password protected) fields for analysis of events by nursing, pharmacy, quality/risk management

15. Special Features of the Database • Patient, visitor, staff and other events captured • “Close call” or “near miss” reporting • Anonymous reporting an option • Customized site of care fields • Customized e-mail alert functions • Standardized and custom reports • Field for legal disclaimer • Comparative data for benchmarking, detecting trends

16. UHC-AAMC Faculty Practice Solutions Center Introduction and Overview May 21, 2002

17. Objectives of the Faculty Practice Solutions Center • Facilitate the open sharing of practice management and physician productivity data across institutions • Develop and provide access to statistically valid and stable comparative benchmarking data (physician productivity, departmental finance and operations, billing office performance) • Provide easy to use tools for clinical activity reporting and analysis • Facilitate knowledge transfer and experience sharing among academic practice managers • Provide access to UHC, AAMC, and third-party content on practice management issues

18. FPSC Features and Attributes • 50+ participating organizations (30,000+ MDs) • 5+ consecutive years of MD-level CPT billing data • Menu of routine and custom comparative reports/analyses, provided on a quarterly basis • Custom benchmarking • On-site training/implementation assistance • UHC, AAMC, and syndicated content for MD and practice management education • Community of users on line

19. Member Concern: existing comparative data not reflective of AHC faculty groups inaccuracies of “survey” data missing or misclassified data significant year to year variability in existing comparative data FPSC Approach: numerous faculty groups participating broad scope of specialties continuous feedback and refinement through member involvement data submitted electronically consistent methodology in RVU calculation individual MD detail allows exclusion of outliers and analysis of coding behaviors Design of the FPSC

20. Alabama Albert Einstein/Montefiore Arizona Arkansas * Baystate/Tufts Chicago Cincinnati Cleveland Clinic * Colorado Connecticut Duke East Carolina Emory * Florida George Washington * Georgia Harlem Hospital Harvard/Beth Israel-Deaconess Harvard/Brigham and Women's Harvard/Mass General Indiana Iowa Johns Hopkins * Kansas Kentucky * Loyola-Stritch Maryland UMass Med University of So Carolina Medical College of Wisconsin Michigan * Missouri-Columbia Missouri-Kansas City Mt Sinai (NYC) * Nebraska New Mexico North Carolina Northwestern Ohio State Oklahoma * Oregon Pennsylvania Rochester UHC-AAMC FPSC Participants • Sinai of Baltimore * • South Florida • Stanford * • SUNY-Stony Brook • Tufts (NEMC) * • UC-Los Angeles * • UC-San Diego • USAF Surgeon General • Utah * • UT-Galveston • Vanderbilt • Vermont • Virginia • Virginia Commonwealth • Wake Forest • Washington University-St Louis * • West Virginia • Wisconsin * • Yale * department-level participant

21. Automated Electronic Transfer Allows Efficient Data Capture FPSC participants send physician-level billing data to UHC. Data is electronically extracted and sent from the billing office. Data In (at the procedure-level): Total Billings for ea. Procedure Site of Service for ea. Procedure CPT Code for the Procedure Payer Class for ea. Procedure CPT Code Modifiers ICD-9 Codes (first four) Frequency of Billed Procedure Service Data & Posting Date Patient Demographics Data: age, sex, race, zip code

22. Converting Data to Management Support DataOut: Total and Work RVUs UHC Processes, Validates, and Converts the Data into Practice Management Measurements Billed Charges Productivity by Service Mix & Payer Class Physician & Department-Level Productivity

23. Anesthesiology Dermatology General Dermatology MOHS Surgery Emergency Medicine Family Practice Human Genetics Internal Medicine General Allergy/Immunology Bone Marrow Transplant Cardiology Invasive Non-invasive Critical Care Endocrinology/ Metabolism Gastroenterology Geriatrics Hematology/ Oncology Infectious Disease Nephrology Occupational Medicine Pulmonary Disease Rheumatology Neurology Benchmark Specialties • Physical Medicine • Physical Therapy • Psychiatry • Radiology • Diagnostic • Interventional • Nuclear Medicine • Radiology Oncology • Surgery • Cardiovascular • Colon/Rectal • General • Hand • Neurological • Oral • Orthopedic • Plastic • Sports Medicine • Vascular/Thoracic • Transplant Surgery • Heart • Kidney • Liver • Urology • OB/GYN • General • Gynecological Oncology • Maternal and Fetal Medicine • Reproductive Endocrinology • Urogynecology • Ophthalmology • Otorhinolaryngology • Pathology • Anatomic • Clinical • Surgical • Pediatrics • General • Allergy/Immunology • Cardiology • Critical Care • Endocrinology • Gastroenterology • Hematology/Oncology • Infectious Disease • Neonatal Medicine • Nephrology • Neurology • Psychiatry • Pulmonology • Surgery

24. Web-based tool provides flexible and interactive reporting.

25. What Other Measures Does the FPSC Provide? • Evaluation and Management (E&M) Coding Distribution • Scope and Mix of Services (Clinical Fingerprint) • Charge Lag Analysis • Charge Summary Statistics • Revenue Forecasting • Custom Peer Cohort Benchmarking • Others

26. FPSC Use in Safety Net Institutions Dealing with Similar Issues • Harlem physician staffing assessment • Developed safety net benchmark group • Assessed clinical workload/productivity • Evaluated barriers to enhanced productivity • Recommended system for ongoing management of physician productivity

27. Barriers to Realizing Productivity Enhancement Opportunities • Barriers common in Safety Net institutions • Variable operational support and resources • Shortage of nursing and clinical support staff • Legacy information systems • Lack of clinical and operational integration • High patient no-show rates

28. FPSC Provides Tool to Help Inform Practice Management • Data and reports useful input to • measure and manage productivity • monitor coding compliance • evaluate physician workforce sizing • Can be used in conjunction with other UHC tools to address/overcome identified productivity barriers

29. University HealthSystem Consortium Operational Data Base Program Overview THE POWER OF COLLABORATION

30. Operational Data Base Program • A data base reporting system and related services designed to provide UHC members and associate members with comparative operational data. • Focuses on operational characteristics of hospital departments (i.e., hours worked/unit of service, skill mix, labor and supply expense/unit of service, and operational practices). • Provides information for analyses to support performance improvement, budgeting, cost reduction, and identification of best performers • Creates direct networking opportunities among UHC participants and between UHC participants and non-UHC participants* • Facilitates the tracking of key performance measures resulting from UHC operational benchmarking projects *There are 59 UHC members and approximately 450 non-UHC participants in the data base.

31. Program Participants • UAB Health System • University Hospital of Arkansas* • UCLA Healthcare • UCSF • Stanford Health Care • UC San Diego Medical Center (2) • San Joaquin General Hospital* • Santa Clara County* • Denver Health* • Georgetown University Hospital • Shands HealthCare • Tampa General • Crawford Long Hospital of Emory University • Emory University Hospital • Medical College of Georgia • Grady Health System* • University of Iowa Hospitals and Clinics • University of Chicago Hospitals* • University of Illinois at Chicago Medical Center • Loyola University Medical Center • Wishard Health Services • University of Kansas Hospital • Brigham and Women’s Hospital • UMass Memorial Health Care • University of Michigan Health System • Hennepin County Medical Center* • Fairview University (MN) Medical Center • University of Missouri Health Care* • University Medical Center of Southern Nevada* • University for Medicine and Dentistry of New Jersey* • University of New Mexico Hospital* • SUNY Health Science Center at Syracuse • University Hospital and Medical Center at Stony Brook • New York Presbyterian (3) • University Health Systems of Eastern Carolina • University of North Carolina Hospitals • Wake Forest Baptist Medical Center • Medical College of Ohio • UHHS University Hospitals of Cleveland • Oregon Health Sciences • Thomas Jefferson • Methodist Hospital Division, TJUH • University of Pennsylvania Health System (4) • Penn State – Hershey Medical Center • Medical University of South Carolina • Vanderbilt Medical Center • Methodist Hospital (Houston) • University of Texas Medical Branch, Galveston* • University of Virginia Health System • VCU Health System Authority* • Harborview Medical Center* • Froedtert Memorial Lutheran Hospital • University of Wisconsin Hospital and Clinics *NAPH members

32. HBSI ACTION Highlights* • PC based software to support on-site data collection, reporting and analysis; migrating to web in 2003 • Quarterly staff and expense performance information using standardized data collection instruments • Up to nine quarters of data from over 500 institutions including more than 50 UHC members • Standard and user-defined cost center and facility reports which enable the user to customize analyses • Quarterly enhancements of methodologies, software and/or product documentation • Includes UHC data starting first quarter 1998 *The HBSI ACTION and PEERnext products will be combined in 2003 resulting in more data collection tools and greater participation.

33. Admitting/Patient Care Registration AM Admission Ambulatory Surgery Anesthesia Department Biomedical Engineering Cardiology-Invasive Cardiovascular Non-Invasive Diag Community Education Dental Clinic Education Services Electrodiagnostics Emergency Department Endoscopy/G.I. Lab Environmental Services Facility Information Financial Information Food & Nutritional Services General Accounting Health Information/Medical Records Home Health Care (4 departments) Hospital Administration Human Resources Imaging Services (six modalities) Information Systems Labor and Delivery Laboratory Laundry/Linen Marketing/Planning/Public Relations Materials Management Neurodiagnostics Nursing Administration Operating Room Orthotics & Prosthetics Services Outpatient Clinics (32 clinics) Functional Areas within HBSI ACTION • Outpatient Observation Unit • Partial Hospitalization Unit • Patient Accounting • Patient Care Units (70+ units) • Pharmacy • Physician Practice • Plant Operations/Maintenance • Post Anesthesia Care Unit • Radiation Oncology • Rehab (5 departments) • Respiratory Care • Security • Sleep Lab • Social Services • Sterile Processing • Telecommunications • Utilization Review

34. Statistics Worked Hours Paid Hours Overtime Paid Time Off Percentage Salary Cost (including skill mix) Supply Cost Direct Cost Workload (I.e., Patient Days, LOS, Billed Tests, OR Hours, ED Visits, Adjusted Discharges, etc.) Characteristics Do you send staff home when the census is low? Are ED observation patients held in the ED or sent to an observation unit? What percentage of your Neonates are born <1,500 grams What is your level of product standardization for select cases? Do you utilize protocols? Standard Elements Reported at the Department Level

35. Use of ODB Data By UHC Members • Majority of members are using data for budgeting/cost reduction: • Fifty-two percent will use the data for FY2003 budgeting • Ninety-one percent will use the data for budgeting and/or targeting areas for cost reduction • A variety of methods have been used: • The 25th or 50th percentile across the board for all departments • Target the 10 departments with the largest opportunities each quarter • Sliding targets based on the respective department’s performance (i.e., 40th percentile if at the 50th percentile, 60th percentile if at the 70th percentile, etc.)

36. UHC Makes Extensive Use of ODB Data in Support of Members’ Improvement Initiatives • Key Indicator Report • Integrated Report • Operational Benchmarking • Department specific analyses • Value Analysis Program • Novation Participation • Member Specific Engagements Related to Supply Chain Management • Member Advocate Program

37. UHC Benchmarking Program Overview

38. UHC Benchmarking Clinical Benchmarking Operational Benchmarking • Clinical decision making • Procedure/condition focused • Utilization management • Variation minimized • Clinical practice advancement • Care delivery and support • Process-focused • Unit cost management • Elimination of process defects • Efficiency optimization High-QualityEfficientPatient Care Do the Right Thing Do Things Right

39. Benchmarking UHC Model for Managing Value Value = Quality, Cost Clinical Operational Women’s Health * Pediatrics * Complementary Medicine * Performance Improvement Models * Medical Records Follow-up * Cardiology* Supply Cost Management* Claims Denials* Imaging Services * Clinics Billing and Coding * Managing Patient Flow * Blood and Blood Products ‡ IP Charge Capture, Bill.and Collect. Leadership and Mgmt Dev. Use of Decision Support Tools† Patient Accounting * Laboratory * Surgical Services **‡ † Employee Benefits * Imaging * Emergency Department * Adult ICU Phases I and II * Purchasing Process * Ambulatory Clinics * Medication Use Process * Medical Records * Trauma * Health Info. Technology * Inpatient Admitting * Customer Service * Clinics Organization and Registration * Kidney Transplant* CABG* PTCA* Hip Replacement* Bone Marrow Transplant* Stroke Congestive Heart Failure* Trauma * AMI Core Measure Integration† Diabetes*† Heart Transplant* Pediatric Asthma* Adult Asthma* Community-Acquired Pneumonia* Acute MI* Neonatology HIV/AIDS Cardiology Implementation ‡ Adult ICU Follow-up†‡ Small & Large Bowel† Transplant Services† ‡ ‡ ‡ † * Completed Future ‡ Joint clinical/operational benchmarking project

40. Gather data fromyour organizationand from “best-in-class” • Survey • Site visits Benchmarking Process Regularly monitor performance Adopt/adaptselected enablers Determineprocess(es)to be studied Compare/discover“best-in-class”enablers Identifyrelevantperformancedata

41. Benchmarking Project Outputs • Project Summary (web and written) • Performance Opportunity Summaries • Knowledge Transfer Meeting Materials • Survey Results • Customized Satisfaction Survey Results (select projects) • Case Studies • Implementation Strategies and Support Information is accessible through the UHC Web Site (www.uhc.edu under Improvement and Effectiveness)