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Achieving Affordability with Visual Analytics; Variation Reduction as a Tool to Engage Clinicians

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Achieving Affordability with Visual Analytics; Variation Reduction as a Tool to Engage Clinicians …

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

Published in Health & Medicine , Business
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  • Key Point: Value of understanding problems within context and involving key users in the problem solving processIssue is not what initially presentsIssue lies hidden in actual situation, not pre-definedTurn to context to uncover and then define issueObserve to understand the context we work in and the context our patients receive care in. By understanding the context we can more successfully uncover opportunities to improve practiceStory:

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  • 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
  • 3. California’s Highest Quality Health Care System*
    Serving more than 3 million patients
    • Approximately 48,000 employees
    • 4. 5,000 physicians
    • 5. Aligned under the Sutter Medical Network
    • 6. Physician medical foundation and IPAs
    Part of more than 100 communities
    • 25 DHS-licensed acute care hospitals
    • 7. Home health & hospice and long-term care services throughout Northern California
    Partnering with providers, patients
    and communities
    • Medical research and medical education/training
    • 8. 24 fundraising organizations
    *Source: The Lewin Group, 2009
  • 9. The Sutter Medical Network
    • The Sutter Medical Network provides a leadership role in the development of a physician and provider network, coordinating patient care and creating a culture of quality, service and affordability throughout the Sutter Health system.
    • 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
    • 15. Variation reduction efforts
  • Physician Organizations in the Sutter Medical Network
    • Alta Bates Medical Group
    • 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
    • 25. Sutter Pacific Medical Foundation
  • Why Variation Reduction?
    What engages physicians?
    Healthcare affordability
    High deductible plans
    High co-pays
    Losing marketshare to competitors
    Curiosity
    Competitiveness
    Do the right thing
    Quality improvement, professionalism
    6
  • 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
  • 36. 17
  • 37. 18
  • 38. 19
  • 39. 20
  • 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
  • 44. 25
  • 45. 2nd Line Diabetes Drug
    26
  • 46. 27
  • 47. 28
  • 48. 29
  • 49. 30
  • 50. 12 Month Run Chart (volume of 30 day supply)
    31
  • 51. 32
  • 52. 33
  • 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.
  • 64. Two Approaches
    Bottom up
    Multiple small projects
    Maximizes physician buy-in
    • Top down
    • 65. Standardized implementation
    • 66. Maximizes savings
  • Guiding Principles for VR Facilitation
    Follow Curiosity
    Pull, not push
    Bottom up, not top down
    Safety, fun
    Non-punitive
    Respect – sincere
    (no agenda other than being helpful)
    Talk about emotions
    (before talking about the data)
  • 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
  • 79.
  • 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
  • 82. Defining Patients
    • Exclusion criteria:
    • 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 months
    Inclusion 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