Achieving Affordability with Visual Analytics; Variation Reduction as a Tool to Engage Clinicians Ingenix User Conference May 2011 Michael van Duren, M.D., MBA Sutter Health A Project of the Sutter Medical Network and Sutter Physician Services

1. Achieving Affordability with Visual AnalyticsVariation Reduction as a Tool to Engage Clinicians Ingenix User Conference May 2011 Michael van Duren, M.D., MBA Sutter Health A Project of the Sutter Medical Network and Sutter Physician Services

2. About us

4. 5,000 physicians

5. Aligned under the Sutter Medical Network

8. 24 fundraising organizations*Source: The Lewin Group, 2009

10. SMN Standards of Participationcreate collective accountability thatencompasses the entire spectrum of clinical and service quality:

11. Clinical Pay for Performance

12. Primary care appointment wait times

13. Patient satisfaction with the care experience

14. Adoption of online services

16. Brown & Toland Physicians

17. Central Valley Medical Group

18. Marin IPA

19. Mills-Peninsula Medical Group

20. Palo Alto Medical Foundation

21. Sutter East Bay Medical Foundation

22. Sutter Gould Medical Foundation

23. Sutter Independent Physicians

24. Sutter Medical Foundation

26. How To Engage Physicians Respect their intelligence & time Trust their motives Adult learning: peer setting Solution: variation reduction program 7

27. Variation Reduction Program Components Leadership Which is the most important component? Remove any one and it won’t work…

28. DATA 9

29. Purpose for Data Sharing  Practical Implications Show clinicians how they differ from each other Must be: Apples to apples Simple and explainable Clinically relevant Compelling: “Aha, I see what I need to change” ETGs with drill down accomplishes all this Hi-Lo Variation is typically 100 - 300% Therefore data needs only to be directionally correct Attribution: anything less than 50% loses credibility 10

30. Data Issues for Provider Groups vis-à-vis Plans Less complete data HMO: claims, but only for the risk that groups took Excludes facility costs (not a problem , but beware low cost outliers) Excludes out of network, behavioral health, negotiated carve outs, etc PPO: billing data, but only for care that was provided Pharmacy: only what is provided by HMOs More complete data Clinical sources Outcome data: Blood Pressure, A1c, LDL Rx written, not just filled More recent data: yesterday 11

31. Clinicians Are Very Discerning re Value of ETGs Problematic areas discovered: Hernias All types (inguinal, abdominal, hiatal) together Gyn tumors Uterus and ovaries grouped together Gyn irregular bleeding Postmenopausal bleeding not distinct Knee procedures Total knee and arthroscopy cases grouped together 12

32. Provider Network Clinical Integration Issues Competitors can not share pricing Work with data stripped of all pricing Uniform charge master applied to all data Multiple data sources Lab vendors Pathology contractors Surgery at multiple sites Integrate all payers Changing systems

33. DISPLAY

34. Why Is Visual Data Display So Important? Can not afford distractions: Accuracy Methodology Detailed questions 15

35. Why Is Visual Data Display So Important? 16 Must be all right brain, gut level, intuitive “Aha, I see I am an outlier. I know what I should do differently!” Need to achieve this in seconds, without words

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40. How to Speak to the Right Brain? Visual data; not words or numbers Message must jump out on its own Remove all extraneous text Personal impact Change desired must be obvious 21

41. Example of Other Dashboards

42. Visual Display of Variation 23

43. HMO Statin Prescription VolumePPO volume not included 24

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45. 2nd Line Diabetes Drug 26

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50. 12 Month Run Chart (volume of 30 day supply) 31

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53. New Features: Frequency of Surgery

54. New Features: View Individual Episodes

55. Each Bar is an Individual Episode 36

56. Curiosity About a Single High Episode 37

57. Select and Episode to View Claims 38

58. Claims View 39

59. Claims View - Continued 40

60. people 41

61. Philosophy of Physician Behavior 42

62. Philosophy of Physician Behavior 43

63. Contextualist Approach Deductive Approach COMPLIANCE Contextualist Approach EMPOWER Copyright 2009 VHA Inc. All rights reserved. Authorized use of this content is limited to reading and analyzing the content for its internal use, printing a copy of any page for its internal use and disclosing the content to other VHA alliance members . For internal VHA member use only.

65. Standardized implementation

67. Guiding principles for VR facilitation Transparency – names not blinded Use natural competitiveness in a playful way Talking about affordability is ok and necessary (“I am not going to apologize”) Must lead to a “project” – must result in an improved outcome this requires some nudging Improvise, Adapt, Think Fast

68. Resources for Data & Emotions:Nudge, Switch 48

69. Reactions from Physicians “I haven't had this much fun since residency” “I have been waiting for this for ten years” “That was a lot more fun than I expected from the title of the meeting” “When are you guys coming back?” 49

70. process 50

71. Variation Reduction Program Components Phases Introduce and orient dept chair Meet with whole dept (5-15) Explore various ideas, dig & clarify Narrow selection to one project Write charter, define goals, commit to interventions Track progress, modify interventions

72. Improvement Project Sequence Use SCPA to identify variation reduction opportunities Clinicians agree on a standard and define performance metrics Clinicians agree to launch an improvement project

73. VR Project Charter Sample process from one group

74. Problem Statement What is the problem we are solving for? Duration, where, what, why In [time period], there were [count] patients with [diagnosis] who experienced [what undesirable care was done] and this is a problem, because [impact].

75. Problem Statement In 2010, 55% of 1182 patients with new onset Sinusitis were treated with antibiotics, other than Amoxicillin. This resulted in unnecessary pharmaceutical costs.

76. Goal Statement - AIM [increased/decreased] [metric] from [baseline]to [goal level] as measured by [XX] by [when]. Specific Measurable Achievable Reasonable Time bound

77. Goal Statement - AIM Increase the percent of patients with new onset sinusitis that receive treatment with Amoxicillin from 45% to 62% by the end of 2011. Reduce the average cost of initial antibiotic treatment for Sinusitis from $57 to $45 by the end of 2011.

78. % of Patients treated with Amoxicillin 58

80. Primary Metric How will you know you’ve made an improvement Rate is percent of numerator/denominator Denominator: [all patients with x] Numerator: [patients who received treatment x] Inclusions/exclusions Balance metric (how do we check that we are not causing harm?) Associated quality or outcome metric?

81. Project Metric Name of metric: Percent of all patients prescribed Amoxicillin as 1st line antibiotic for treatment of sinusitis Numerator: number of sinusitis patients prescribed Amoxicillin Denominator: all Sinusitis patients with antibiotic prescription 61

83. Anybody with any of the diagnoses in the prior 30 days (so that we are looking only at NEW onset sinusitis)

84. PCN allergy

85. Exclude pts with pneumonia or bronchitis in any of the other diagnoses

86. OR use Epic linkage to pull onlyabx linked to sinusitis

87. No recent abx use for anything else for 30 days

88. No sinusitis in prior 12 monthsInclusion criteria for diagnosis: 461 P ACUTE SINUSITIS 461.0 ACUTE MAXILLARY SINUSITIS 461.1 ACUTE FRONTAL SINUSITIS 461.2 ACUTE ETHMOIDAL SINUSITIS 461.3 ACUTE SPHENOIDAL SINUSITIS 461.8 OTHER ACUTE SINUSITIS 473 P CHRONIC SINUSITIS 473.0 CHRONIC MAXILLARY SINUSITIS 473.1 CHRONIC FRONTAL SINUSITIS 473.2 CHRONIC ETHMOIDAL SINUSITIS 473.3 CHRONIC SPHENOIDAL SINUSITIS 473.8 OTHER CHRONIC SINUSITIS 473.9 UNSPECIFIED SINUSITIS 62

89. Expected Benefit Improved affordability Improved consistency Enhanced adherence with clinical guidelines / best practices

90. Implementation Plan 1st test of change (what are the changes you plan to make? How will they be implemented?) Who, what, when, where

91. Implementation Plan First “Test of Change” Communicate to all ----- providers in meeting 4/1/2011 Distribute monthly run charts to individuals Work on smart set for Epic / consistent documentation Create guideline for consistent diagnosis of sinusitis: e.g. purulent discharge (Dr W----- & Dr L----) Other ideas (on hold for the future): Patient education “why you are seeing your ENT and still getting Amoxicillin” Also education for ER Address outliers Epic BPA Other…

92. Balance measure Cure rate? Are we seeing more failures on Amox? Return within 30 days for same diagnosis? Track baseline, see if it changes…

93. Local Standard Sinusitis guidelines? Am Acad of Otolaryngology 2007 (?). AAO.

94. Formal Project Charter 68

95. 69

96. Variation Reduction: Projects in Process

97. Staging of Savings

98. Additional Analytics Tools Needed Add in EMR data More recent All payers Has outcome data Progress over time (SPC) Simple drug comparisons of cost (3 bar) Bubble chart

99. Success Factors 73

100. Roles Required for VR Projects 74

101. Questions? Reactions? vandurenm@sutterhealth.org 916-402-7492 75