Clinical Standards Work: ImplicationsonFinanceImplications on Finance · 2015-11-12 · Clinical...

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Clinical Standards Work: Implications on FinanceImplications on FinanceHFMA Region 9November 15, 2015 2:55‐3:45pm

Charles G. Macias M.D., M.P.H,Texas Children’s Chief Clinical Systems Integration Officery g

• Describe the role of variation in health care delivery and how it impacts quality of care• Describe the process of developing clinical standards across a health care

Learning Objectives

system.• Discuss opportunities for engagement of clinicians in linking clinical standards work with patient outcomes and financial 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.

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Johnny Jones

8 year old boy with a history of lung transplant

• Emergency department: his triage evaluation demonstrated heart rate and other findings consistent with early signs of shock

• Delivery of critical resuscitation fluids was slow and undertreated

• Antibiotics arrived hours after they were ordered

• Lung inpatient unit: a “Rapid Response Team” was called 3 ½ hours after the evaluation of concerning signs and symptoms

• Pediatric Intensive Care Unit• Blood pressure was not obtainable

P t til t• Put on a ventilator

• Aggressive drug therapies

• Procedural interventions to artificially oxygenate his blood

Johnny died 18 hours after he first arrived

Root cause analysis

• Diagnostic and therapeutic errors identified in the ED and theidentified in the ED and the inpatient ward by multiple provider types

• A gap in meaningful communication between providers created confusion in management plans

• Neither management guidelines th EMR idi li i lnor the EMR were providing clinical

standards or clinical decision support for practitioners

Systems were not well integrated

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A similar story in New York State…

• The Rory Staunton ActThe Rory Staunton Act• Hospitals shall have in place evidence‐based protocols for the early recognition and treatment of patients with severe sepsis/septic shock…

• Analytics: all severe sepsis/septic shock patients to be entered in the NYS database for annual risk adjusted mortality rates

• Targeting systems of care

P bli H lth L St t f N Y kPublic Health Law, State of New York,

Sections 405.2 and 405.4 of Title 10

Quality care delivery?

• The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge

KN Lohr, N Engl J Med, 1990

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The Healthcare Value Equation

Quality

•In an environment where cost is marginally increasing, healthcare must markedly

improve quality.

Value=

Quality

Cost

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Variability in pediatrics

• 16 hospitals treating children for bronchiolitis

• Quality metrics• Dx: chest radiograph, laboratory blood work

• Tx: antibiotics, breathing treatments, IV placement

• These variations in practices were NOT explained by severity of illness

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Macias et al. Variability in inpatient management of children hospitalized with bronchiolitis, Academic Pediatrics 2015

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Explaining variation: translating the evidence

IOM 2013

Describing variation in care in three pediatric diseases:

Correlation between quality and cost

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

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

Increased costs were NOT associated with lower admission rates or 3-day ED revisit rates

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The US Healthcare system is inefficient

Overuse for tests and therapies beyond established evidence

Procedural/surgical intervention vs appropriate watchful wait

36%

$765Bof healthcare expenditures is waste (2009)• Unnecessary services• Inefficiently delivered services• Excess administrative costs

P i th t t hi h

$210

Billion

Discretionary use of services or devices

Unnecessary choice of higher cost services

• Prices that are too high• Missed prevention opportunities• FraudIOM, The Healthcare Imperative 2010; Berwick JAMA 2012

Reforming health care

Institute of Medicine Best Care at Lower Cost 2013

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Clinical standards/practice guidelines

• Systematically developed statements or recommendations to assist the practitioner about appropriate health care for specific clinical circumstances.

Institute of Medicine (1992). Guidelines for clinical practice: from development to use

• Evidence based guidelines help control complexity• Summarize available evidence and translate to guidance for care• Address treatment uncertainties and reduces variation in care delivery where evidence lacks

• Help maximize use of health care resources: system efficiency• Improved patient outcomes: diagnostic accuracy and therapeutic effectiveness

• Enhance shared decision‐making between patients and physicians• Provide a framework for analytics

• Pareto principle• Pareto principle• 80/20 rule

• 20% of the problems cause 80% of the trouble

Adapted from Penney and Foy. Best Practice and Research, 2007

Evidence Based Outcomes Center (TCH): systematic development of clinical standards

Id tif i lit• Identifying quality gaps through big data

• High prevalence

• Resource intensive care

• High morbidity or mortality

• Marked variations in carecare

• EDW, analytics and the key process analysis

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EBOC process

1.Identify the quality problem/gaps: mortality, resource consumption, variability, prevalence

2 Search for existing guidelines and assess their applicability2.Search for existing guidelines and assess their applicability

3.Assemble a group of stakeholders (bottom up, never top down)

4.Identify the Patient Intervention Comparison Outcomes (PICO) questions

5.Search the evidence

6.Evaluate the evidence using an evidence rating AND recommendation rating tool

7.Vet with stakeholders7.Vet with stakeholders

8.Once approved, build into Epic with consider for clinical decision support

Evidence Based Outcome Center

Acute Chest Syndrome *updatedAcute Gastroenteritis Acute Heart FailureAcute Hematogenous OsteomyelitisAcute Ischemic Stroke

Days *updatedFever Without Localizing Signs (FWLS) 2-36

Months *updatedHyperbilirubinemiaIntraosseous Line Placement

Acute Otitis MediaApparent Life-Threatening Event (ALTE)Appendicitis *updatedArterial ThrombosisAsthma *updatedAttention Deficit Hyperactivity DisorderAutism Assessment and DiagnosisBronchiolitis *updatedCancer Center Procedural ManagementCardiac ThrombosisCentral Line-Associated Bloodstream InfectionsClosed Head InjuryCommunity-Acquired Pneumonia *updatedCystic Fibrosis – Nutrition/GI >12 y/o *updatedC-Spine Assessment

IV Lock TherapyKawasaki DiseaseMigraine Treatment-Emergency CenterNeonatal ThrombosisNutrition/Feeding in the Post-Cardiac NeonateObstetric Hemorrhage due to Uterine AtonyPerioperative Management of Anterior Mediastinal MassesPICC SecurementProcedural Sedation *updatedRapid Sequence IntubationRespiratory Management of Preterm Infants Septic ArthritisSeptic ShockSkin and Soft Tissue Infection p

Deep Vein ThrombosisDiabetes Perioperative ManagementDiabetic Ketoacidosis Fever and Neutropenia in Children with Cancer Fever Without Localizing Signs (FWLS) 0-60

Status EpilepticusSuspected Child Physical AbuseTracheostomy ManagementUrinary Tract Infection

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Clinical Systems Integration domains

“The means to facilitate the coordination of

patient care across conditions, providers,

settings, and time in order to achieve care

that is safe, timely, effective, efficient,

equitable, and patient focused.” ‐The

American Medical Association

Analytic System

Science and Clinical Standards

Implementation

Cross cutting elements: clinical care, operations, and finance

Clinical System Integration Executive L d hi C il

Clinical Systems Integration Governance Structure

EMR and all clinical technologies

Clinical Implementation

Team

Clinical Technology

Council

Quality Improvement and permanent care process teams

Content and Analytics Team

EBP and the Enterprise Data Warehouse are

part of this structure

Leadership Council

Develops clinical standards

(guidelines) and oversees clinical data/ predictive

analytics

Prioritizes and Assess technology initiatives that integrate with EMR or proposed as

independent solutions

Oversees development and implementation of clinical programs/

analytics and knowledge assets

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Population Health approaches: permanent teams drive PDSA cycles

Population health approaches: the permanent care process teamsp pp p p

Diabetes Pregnancy Asthma Bronchiolitis Pneumonia Appendicitis Newborn

Hospital Acquired Conditions

Sepsis and septic shock

Obesity

Transitions of care

Survey explorerSurvey explorer

Expansion for 2015: Neonatal diseases‐BPD, CDH, CLABSI, readmissions, unplanned extubations, cardiac illnessesSpine surgery, Tracheostomy, Hypospadias

Clinical Decision Support

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Measurement and analytics (EDW): Patient outcomesFinancial metricsUtilization metrics

Metadata: EDW Atlas Security and Auditing

Common, Linkable VocabularyFINANCIAL SOURCES

(e.g. EPSi,)

DEPARTMENTAL SOURCES

(e.g. Sunquest Labs)

TCH’s EDW Architecture for Data Transparency

FinancialSource Marts

AdministrativeSource Marts

DepartmentalSource Marts

PatientSource MartsADMINISTRATIVE

SOURCES(e.g. API Time

Tracking)

PATIENT SATISFACTIONSOURCES

(e.g. NRC Picker,

Operations• Labor

productivity• Radiology• Practice

Mgmt• Financials• Patient

Satisfaction+ others

Clinical• Asthma• Appendecto

my• Deliveries• Pneumonia• Diabetes• Surgery• + others

EMR Source Marts

HRSource Mart

EMR SOURCE (e.g. Epic)

Human Resources(e.g. PeopleSoft)

• + others

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Registry Financial Score Card from the EDW

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Data Drives Waste Reduction: Approaches

Mean

1 box = 100

1.96 std

Excellent Outcomes Poor Outcomes

# of Cases

1 box = 100 cases in a year

Excellent Outcomes

# of Cases

Poor Outcomes

Option 1: Focus on Outliers – the prescriptive approach

St t Id tif t ith th t ti l f hi h t f b d

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Strategy Identify extreme cases with the potential for high costs from bad outcomes and eliminate the unfavorable tail of the curve (“executive dashboard” approach)

Result If the outlier trim point is set at 1.96 standard deviations, only 2.5% of cases fall under the adverse outcome tail, so the impact is minimal

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Alternative Approaches to Waste Reduction

Mean

1 box = 100

Excellent Outcomes Poor Outcomes

# of Cases

1 box = 100 cases in a year

Excellent Outcomes

# of Cases

Poor Outcomes

Option 2: Focus On Inliers – improving quality outcomes across the majority

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Strategy Identify best practices through research and analytics and develop guidelines and protocols to reduce inlier variation

Result Shifting the cases that lie above the mean toward the excellent end of the spectrum produces a much more significant impact

Improving Cost Structure Through Waste Reduction

Ordering WasteOrdering Waste Workflow Waste Defect WasteOrdering Waste

Ordering of tests that are neither diagnostic nor

contributory


contributory

Variation in Emergency Care wait time

ADEs, transfusion reactions, pressure

ulcers, HAIs, VTE, falls, wrong surgery


contributory

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Use Cases and Business Drivers

CXR utilization inCXR utilization in patients with known asthma, steroids in

bronchiolitis

Evidence equivocal

Evidence Supports

Quicker steroid delivery for status asthmaticus, goal

directed therapy for septic shock

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Evidence againstHypertonic saline and bronchodilators in select patients with bronchiolitis

60%

70%

80%Asthma: Care Process Team Cohort, Percentage of Chest X-rays Ordered*

(Oct. 2010 - Apr. 2013)

51%

35%

0%

10%

20%

30%

40%

50%

60%

Per

cent

age

Feedback of rates to hospitalists and Emergency Center clinicians Order set

revisions

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Oct

. 10

No

v. 1

0

Dec

. 10

Jan

. 11

Feb

. 11

Mar

. 11

Ap

r. 1

1

May

. 11

Jun

. 11

Jul.

11

Au

g. 1

1

Sep

. 11

Oct

. 11

No

v. 1

1

Dec

. 11

Jan

. 12

Feb

. 12

Mar

. 12

Ap

r. 1

2

May

. 12

Jun

. 12

Jul.

12

Au

g. 1

2

Sep

. 12

Oct

. 12

No

v. 1

2

Dec

. 12

Jan

. 13

Feb

. 13

Mar

. 13

Ap

r. 1

3

Month year * Inpatient, Emergency Center (EC) and observation patients (Care Process Team cohort), P-Chart based upon EDW data extraction of 5/14/2013 (M& W).

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Ordering WasteOrdering Waste Workflow Waste Defect WasteWorkflow Waste


contributory


contributory





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• Identify opportunities for evidence infusion

Integrated into our shared savings model

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Ordering WasteOrdering Waste Workflow Waste Defect WasteDefect Waste


contributory


contributory






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Clinical Decision Support to Minimize Errors

*used by permission of BMJ Group

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Financial Impact‐inpatient

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$2,000

$2,500

$3,000

$3,500

$4,000

$4,500

$5,000 Asthma: Margin

‐$4,000

‐$3,500

‐$3,000

‐$2,500

‐$2,000

‐$1,500

‐$1,000

‐$500

$0

$500

$1,000

$1,500

2011 Q1 2011 Q2 2011 Q3 2011 Q4 2012 Q1 2012 Q2 2012 Q3 2012 Q4 2013 Q1 2013 Q2 2013 Q3 2013 Q4 2014 Q1 2014 Q2

EBG inCare Process

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‐$5,000

‐$4,500

$4,000 EBG in EMR

Process Team

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38 registries aligned g gwith clinical standards

Clinical operational and financial data in V3

ROI For Diabetes CPT An analysis of one improvement aim

Aim: Decrease length of stay for children with diabetic k t id i b d l t

CPT Cost = continuing human resource costs = time in meetings + % of employees designated to CPT

Did not include CPT start-up costs or hardware/software costs

∆ Net revenue = change in revenue for DKA admits + increased revenue from increased capacity compared to 2013

ketoacidosis by development of a Diabetic Care Unit

Unit opened in Summer 2014

Preliminary analysis suggests break‐even point achieved

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Lessons learned

• Wide variations in practice can be minimized with systematically developed clinical standards

• Quantitative assessments can help identify gaps in quality

• Systematic use of tools will help standardize approaches to the integrity of clinical standards

• Governance, and a clinical systems integration strategy are critical to effective uptake

• Evaluation of outcomes through analytics allows guided implementation and transparency of outcomesimplementation and transparency of outcomes

• Financial metrics may be linked to demonstrate and hardwire cultural attention to value and clinical standards work

Improving outcomes for populations…

Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012

[email protected]

Clinical Standards Work: ImplicationsonFinanceImplications on Finance · 2015-11-12 · Clinical...

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