iHT2 Health IT SummitAtlanta, GAApril 24, 2013John Doulis, M.D.CIOMedCare Investment FundsThe Chaos in Healthcare Today an...
 The problem The science Examples of the science atworkRoad Map
Clarion Call
Do the Right Thing69.1% (1999)1984CholesterolScreening75.5% (2001)1982Mammography48.1% (2000)1981Diabetic Eye Exam53% (200...
Do the Right ThingQuality of Pneumonia Treatment for Elderly, 200263.1 67.98129.60102030405060708090100Received 1stdose of...
Healthcare & Biomedical IT is HARD Individuals are highly variable biological systems. Clinical measurements rarely have...
Biomedical InformaticsDefinition:Science that deals with information, its structure, acquisitionand useCornerstones: Tech...
AutomationConnectivity DecisionSupportData MiningMismatch between ComputationalTechnique & Scale of Problem
Data MiningAutomationConnectivityDecisionSupportAggregateEHRDiseasemanagement dashboardsWork listsEvidence-basedadvisorsMa...
Managing Chaotic Events and Complexity Work at multiple scales Triangulate multiple signals for robustnessSatelliteDoppl...
REPOSITORIES•transactionprocessing•event lifecycleHolistic Informatics•modeling &simulationPlan•optimizationalgorithms•sur...
Architectural Components
EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACY...
EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACY...
EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACY...
EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACY...
EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACY...
#1 DataAggregation, InformationExtraction &CurationExamples ofInformatics at Work
Systems (ADT, Lab,Rad…)Dictation/TranscriptionNote Capture ToolsSourcesImage (PACS, EKG…)Fax/ScanTextReportsExternalizeCon...
Current DocumentationDocument OralCare HereDocumentHOB Here
Examples of Informatics atWork#2 Closed loop quality control
Evidence-Based Contributions toVentilator Management Ventilator weaning protocol reduces vent time (Ely; NEJM1996 Dec 19;...
Evidence-based MedicineConsistent ProcessVisualizationof Results vs. PlanIterativeImprovementOutcomesSystems Approach to C...
Ventilator Management Dashboard
Improvement Opportunities (Z=100%)TOTAL COMPLIANCE
Improved Performance (single unit)November 2007 January 2008February 2008March 2008
Rateper1000VentDaysVAP Rates – VUH: All ICUs
Tangible Results (2008 – 2011)1 SHEA Guideline, Infect Control Hosp Epidemiol 2007; 28:1121-1133: $22,875 per VAP ($9,986-...
Evidence-based MedicineConsistent ProcessVisualizationof Results vs. PlanIterativeImprovementOutcomesSystems Approach in P...
Source: UHC and Vanderbilt Data3. Mortality for VentilatorPatients Compare to allthe other Hospitals– Best in the U.S.1001...
Congestive Heart Failure Surveillance Algorithm Integrated Decision Support
EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACY...
EDWREPOSITORIESPATIENTSUMMARYSERVICEHIGHAVAILABILITYCACHERULESENGINEALERTSENGINESOAWEBSERVICESCOMMUNICATION SUBSYSTEMSYNCH...
1000FactsperDecision101001990 2000 2010 2020Human CognitiveCapacityNeed for Patient-Specific Decision Support AssistanceSt...
Summary Automation & connectivity get you only 60% In addition to automation and connectivity need to viewand leverage c...
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iHT2 Health IT Summit Atlanta 2013 – John Doulis, MD , CIO, MedCare Investment Funds, Former Assistant Vice Chancellor – Health Affairs Chief Operations Officer – Informatics, Vanderbilt University - Case Study: "The Chaos in Health Care Today and

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iHT2 Health IT Summit Atlanta 2013 – John Doulis, MD , CIO, MedCare Investment Funds, Former Assistant Vice Chancellor – Health Affairs Chief Operations Officer – Informatics, Vanderbilt University - Case Study: "The Chaos in Health Care Today and the Need for an Analytics Platform"

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iHT2 Health IT Summit Atlanta 2013 – John Doulis, MD , CIO, MedCare Investment Funds, Former Assistant Vice Chancellor – Health Affairs Chief Operations Officer – Informatics, Vanderbilt University - Case Study: "The Chaos in Health Care Today and

  1. 1. iHT2 Health IT SummitAtlanta, GAApril 24, 2013John Doulis, M.D.CIOMedCare Investment FundsThe Chaos in Healthcare Today andthe Need for an Analytic Platform
  2. 2.  The problem The science Examples of the science atworkRoad Map
  3. 3. Clarion Call
  4. 4. Do the Right Thing69.1% (1999)1984CholesterolScreening75.5% (2001)1982Mammography48.1% (2000)1981Diabetic Eye Exam53% (2000)1977PneumococcalVaccine64% (2000)1968Flu VaccineCurrent rate ofuseLandmark TrialClinicalProcedureBalas EA, Boren SA., Managing Clinical Knowledge for Health Care Improvement. Yearbook ofMedical Informatics 2000.
  5. 5. Do the Right ThingQuality of Pneumonia Treatment for Elderly, 200263.1 67.98129.60102030405060708090100Received 1stdose ofantibiotic within4 hours ofhospital arrivalReceivedrecommendedantibioticsconsistent withcurrentguidelinesHave bloodculturescollected beforeantibiotics areadministeredReceived allrecommendedtreatmentregimensMeasurePercentageofpatientsSource: Centers for Medicare & Medicaid Services, Quality Improvement Organization Program,2002.• 81% of Medicarepneumoniapatients get bloodcultures beforeantibiotics• 68% get the rightantibiotics• 63% get theirfirst antibiotic in atimely manner• Yet, only 30%get all of threerecommendedinterventions
  6. 6. Healthcare & Biomedical IT is HARD Individuals are highly variable biological systems. Clinical measurements rarely have precise meaning. Diagnoses lack clinical detail. Clinical work is a chaotic, opaque ecosystem. Perspectives vary by role.
  7. 7. Biomedical InformaticsDefinition:Science that deals with information, its structure, acquisitionand useCornerstones: Techniques to structure, discover, visualize & reasonwith information content Approaches to link people, process & technologytogether as a system Methods to evaluate systems and their technologycomponents Processes to facilitate change
  8. 8. AutomationConnectivity DecisionSupportData MiningMismatch between ComputationalTechnique & Scale of Problem
  9. 9. Data MiningAutomationConnectivityDecisionSupportAggregateEHRDiseasemanagement dashboardsWork listsEvidence-basedadvisorsMatch Computational Approach toComplexity of DataStead WW. Electronic Health Records. In: Rouse WB, Cortese DA, eds. Engineering the system of healthcaredelivery. Tennenbaum Institute Series on Enterprise Systems, Vol. 3. Amsterdam: IOS Press; 2009.
  10. 10. Managing Chaotic Events and Complexity Work at multiple scales Triangulate multiple signals for robustnessSatelliteDoppler RadarRain Gauge
  11. 11. REPOSITORIES•transactionprocessing•event lifecycleHolistic Informatics•modeling &simulationPlan•optimizationalgorithms•surveillance•visualization ofstatusActivationTaskManagementInformatics Foundation for Systems Approach to Care•Signal capture•edits•roboticsTaskPerformanceAnalysisGranular Automation
  12. 12. Architectural Components
  13. 13. EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACYRADIOLOGYLABHRFINANCIALGIE• Tagging• Logging• ProtocolConversion• One to ManyCommunicationPATIENTSUMMARYSERVICEHIGHAVAILABILITYCACHERULESENGINEALERTSENGINESOAWEBSERVICESCOMMUNICATION SUBSYSTEMTRANSACTION PROCESSINGSYNCHRONOUSASYNCHRONOUSGENERALEXTERNALIZEDTABLESROLESORDERABLESLABSCDRDEIDENTIFIEDIDENTIFIED
  14. 14. EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACYRADIOLOGYLABHRFINANCIALGIE• Tagging• Logging• ProtocolConversion• One to ManyCommunicationPATIENTSUMMARYSERVICEHIGHAVAILABILITYCACHERULESENGINEALERTSENGINESOAWEBSERVICESCOMMUNICATION SUBSYSTEMTRANSACTION PROCESSINGSYNCHRONOUSASYNCHRONOUSGENERALEXTERNALIZEDTABLESROLESORDERABLESLABSCDRDEIDENTIFIEDIDENTIFIEDRoleSpecificViews
  15. 15. EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACYRADIOLOGYLABHRFINANCIALGIE• Tagging• Logging• ProtocolConversion• One to ManyCommunicationPATIENTSUMMARYSERVICEHIGHAVAILABILITYCACHERULESENGINEALERTSENGINESOAWEBSERVICESCOMMUNICATION SUBSYSTEMTRANSACTION PROCESSINGSYNCHRONOUSASYNCHRONOUSGENERALEXTERNALIZEDTABLESROLESORDERABLESLABSCDRDEIDENTIFIEDIDENTIFIEDResearch
  16. 16. EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACYRADIOLOGYLABHRFINANCIALGIE• Tagging• Logging• ProtocolConversion• One to ManyCommunicationPATIENTSUMMARYSERVICEHIGHAVAILABILITYCACHERULESENGINEALERTSENGINESOAWEBSERVICESCOMMUNICATION SUBSYSTEMTRANSACTION PROCESSINGSYNCHRONOUSASYNCHRONOUSGENERALEXTERNALIZEDTABLESROLESORDERABLESLABSCDRDEIDENTIFIEDIDENTIFIEDDashboards& BusinessIntelligence
  17. 17. EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACYRADIOLOGYLABHRFINANCIALGIE• Tagging• Logging• ProtocolConversion• One to ManyCommunicationPATIENTSUMMARYSERVICEHIGHAVAILABILITYCACHERULESENGINEALERTSENGINESOAWEBSERVICESCOMMUNICATION SUBSYSTEMTRANSACTION PROCESSINGSYNCHRONOUSASYNCHRONOUSGENERALEXTERNALIZEDTABLESROLESORDERABLESLABSCDRDEIDENTIFIEDIDENTIFIEDWORKFLOW INTEGRATIONRoleSpecificViewsResearch& EducationPATIENTMANAGEMENTPOPULATIONMANAGEMENTz100 REPORTSOPERATIONSPLANNING &FORECASTINGDashboards& BusinessIntelligence
  18. 18. #1 DataAggregation, InformationExtraction &CurationExamples ofInformatics at Work
  19. 19. Systems (ADT, Lab,Rad…)Dictation/TranscriptionNote Capture ToolsSourcesImage (PACS, EKG…)Fax/ScanTextReportsExternalizeContent asDocumentsReport Headerplus Pointerto ImageIndex each Word orNumber for Cross-Patient QueriesElectronicPatient ChartAssemble “Documents”By Patient“Tag” ClinicalConcepts forCuration andDecision SupportClinical Data Repository
  20. 20. Current DocumentationDocument OralCare HereDocumentHOB Here
  21. 21. Examples of Informatics atWork#2 Closed loop quality control
  22. 22. Evidence-Based Contributions toVentilator Management Ventilator weaning protocol reduces vent time (Ely; NEJM1996 Dec 19;335(25):1864-9 ) Consistent use of low tidal volume and low airway pressuresreduces mortality by 25% (ARDS Network: NEJM 342: 1301-8, 2000) Activated protein C for Sepsis reduces mortality by 20%(Bernard; NEJM 2001 Mar 8;344(10):699-709) No need to normalize PCO2, drastic reduction in use ofarterial blood gases (ARDS Network: NEJM 342: 1301-8, 2000) PA Catheters not beneficial, 90% reduction in use (ARDSNetwork: NEJM 2006;354:2213-24) Consistent conservative use of fluids shortens ventilator timeby 3 days (ARDS Network: N Engl J Med 2006;354:2564-75) Wake up and breath; sedation holiday improves survival. (VUDelirium Group: Lancet 2008 Jan 12;371(9607):126-34)
  23. 23. Evidence-based MedicineConsistent ProcessVisualizationof Results vs. PlanIterativeImprovementOutcomesSystems Approach to Care
  24. 24. Ventilator Management Dashboard
  25. 25. Improvement Opportunities (Z=100%)TOTAL COMPLIANCE
  26. 26. Improved Performance (single unit)November 2007 January 2008February 2008March 2008
  27. 27. Rateper1000VentDaysVAP Rates – VUH: All ICUs
  28. 28. Tangible Results (2008 – 2011)1 SHEA Guideline, Infect Control Hosp Epidemiol 2007; 28:1121-1133: $22,875 per VAP ($9,986-$54,503), 9.8 day additionalLOS per VAP (7.4-11.5)2 IHI 5 Million Lives Campaign: $40,000 per VAPVAPsPrevented2008 822009 952010 1402011 168Total Prevented 485$ Saved (SHEA)1 $11,091,955$ Saved (IHI)2 $19,395,768Hospital Days1 4752ICU Days 1940Deaths 73UHC RANKINGO/E LOS O/E CostO/EMortality>96 Hours on Vent 1 1 1<96 Hours on Vent 2 6 3Baseline: 18.1
  29. 29. Evidence-based MedicineConsistent ProcessVisualizationof Results vs. PlanIterativeImprovementOutcomesSystems Approach in Practice
  30. 30. Source: UHC and Vanderbilt Data3. Mortality for VentilatorPatients Compare to allthe other Hospitals– Best in the U.S.1001502002503002005 2006 2007 2008 20091. Number of VentilatorAcquired Pneumonia(VAP) Cases/YearFiscal Year2009Results c/w2008VAPsPrevented 108DeathsAvoided 16$ Saved $4.3MHospitalDaysAvoided 1055ICU DaysAvoided 4312. Impact on ResultsSystems Approach to Care# 1O/E Vent MortalityO/E Length of StayO/E Cost
  31. 31. Congestive Heart Failure Surveillance Algorithm Integrated Decision Support
  32. 32. EDWREPOSITORIESCLINICALDOCUMENTATIONCPOESCHEDULING &THROUGHPUTSELIGIBILITY &REGISTRATIONSUPPLY CHAINMATERIALS MGMTPHARMACYRADIOLOGYLABHRFINANCIALGIE• Tagging• Logging• ProtocolConversion• One to ManyCommunicationPATIENTSUMMARYSERVICEHIGHAVAILABILITYCACHERULESENGINEALERTSENGINESOAWEBSERVICESCOMMUNICATION SUBSYSTEMTRANSACTION PROCESSINGSYNCHRONOUSASYNCHRONOUSGENERALEXTERNALIZEDTABLESROLESORDERABLESLABSCDWDEIDENTIFIEDIDENTIFIEDWORKFLOW INTEGRATIONRoleSpecificViewsResearch& EducationBIOVUREDCAPPATIENTMANAGEMENTPOPULATIONMANAGEMENTz100 REPORTSOPERATIONSPLANNING &FORECASTINGDashboards& BusinessIntelligence
  33. 33. EDWREPOSITORIESPATIENTSUMMARYSERVICEHIGHAVAILABILITYCACHERULESENGINEALERTSENGINESOAWEBSERVICESCOMMUNICATION SUBSYSTEMSYNCHRONOUSASYNCHRONOUSGENERALEXTERNALIZEDTABLESROLESORDERABLESLABSCDWDEIDENTIFIEDIDENTIFIEDWORKFLOW INTEGRATIONRoleSpecificViewsResearch& EducationBIOVUREDCAPPATIENTMANAGEMENTPOPULATIONMANAGEMENTz100 REPORTSOPERATIONSPLANNING &FORECASTINGDashboards& BusinessIntelligenceGIE• Tagging• Logging• ProtocolConversion• One to ManyCommunication
  34. 34. 1000FactsperDecision101001990 2000 2010 2020Human CognitiveCapacityNeed for Patient-Specific Decision Support AssistanceStructural Genetics:e.g. SNPs, haplotypesFunctional Genetics:Gene expressionprofilesProteomics and othereffector moleculesDecisions byclinicalphenotypei.e., traditionalhealth care
  35. 35. Summary Automation & connectivity get you only 60% In addition to automation and connectivity need to viewand leverage clinical systems for Information Liquidity Need for dashboards and knowledge engines that sit ontop of the information. Need BI/Analytics Platform that leverage the information. This architecture is scalable Managing Risk:◦ What problems are worth solving (BI)◦ Key interventions to reliably intervene (dashboards +automation of decision support)

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