Big Data - Outcomes Performance Measured


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Slide from a webinar originally presented on November 21, 2013 by SuccessEHS Director of Government Affairs, Adele Allison.

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  • ACA By the Numbers
    23% of the Federal Budget currently goes to health care. The only line item that is higher than health care is the military – and together they represent nearly 50% of the total federal budget. 16% of the federal budget went to pay for Medicare last year; and, on average 57 cents of every Medicaid dollar is paid by the Federal gov’t.
    36 times ACA talks about Patient-Centeredness. The full continuum is called to patient-centeredness. Americans are unengaged as patients. We want to smoke our cigarettes, drink our beer, sit on the couch in a sedentary lifestyle and watch football – no where more so than in the SEC! Then when things start to go wrong and break, we want to go to someone and get a quick fix. This is about a cultural shift within your practice and with the relationship you have with the American patient.
    15 times ACA discusses a return to wellness, prevention and chronic disease management through the Medical Home – a model in patient centeredness for primary care.
    73 times ACOs are referenced. We are seeing uptick trends in the development and establishment of ACOs. A model of value-based purchasing through the creation of a care “community” and the use of health IT.
    93 times ACA talks about measuring quality – PQRS will be the vehicle for Medicare patient quality measures. Boomers are enrolling at a rate of 2.8 million/year – and will continue to do so for the next 18 years, essentially doubling the number of Medicare beneficiaries (what’s % of your payer mix does Medicare represent?). The health care industry is being called to action – this is your health care system. Data will be the barometer of your reimbursement, public comparison and comparative effectiveness. This requires the consistent capture and reporting of accurate clinical data on the patient, which is why …
    29 times ACA links quality to the reporting of Clinical Data
    100 times ACA talks about value-based and payment modifiers when it comes to reforming hospital and physician reimbursement.
    And, as a side note, the Supreme Court of the U.S. (SCOTUS) final opinion upholding ACA references “Broccoli” 12 times. During oral argument in March of last year, counsel argued that it was a slippery slope to allow the federal gov’t the ability to require an American to purchase something under threat of penalty. If they can require an American to purchase health insurance, then can they also require them to buy a certain type of care – or broccoli, because it promotes health.
  • Big Data - Outcomes Performance Measured

    1. 1. Big Data Outcomes / Performance Adele Allison, National Director of Gov’t Affairs SuccessEHS, Inc.
    2. 2. Big Data and Health Care • • • • • • Perspective on Data Federal Policy and Data Health IT Today Data and Performance Data Capture for Success Questions • 888.879.7302
    3. 3. Bits, Nibbles and Bytes • Bit = 1 or 0 (on / off) → Binary Digit • Nibble = 4 Bits of Data • Byte = 8 Bits of Data • 888.879.7302 Source: doi:10.1093/bioinformatics/btn582
    4. 4. Bits, Nibbles and Bytes Bit = 1 or 0 (on / off) → Binary Digit Nibble = 4 Bits of Data Byte = 8 Bits of Data Kilobyte (KB) = 1,024 Bytes Megabyte (MB) = 1,048,576 Bytes or 1,024 KB • 1 MB = 873 Pages of Plain Text (1,200 • • • • • characters) • 800 MB = Human Genome • 888.879.7302 Source: doi:10.1093/bioinformatics/btn582
    5. 5. Gigabyte (GB) • 1 GB = 1,024 Megabytes • 1 GB =7 Minutes HD-TV Video • 2 GB = 20 Yards of Books on a Shelf • 4.7 GB = Standard DVD-R • 888.879.7302 Source:
    6. 6. Terabyte (TB) 1 TB = 1,024 GBs 1 TB = All X-rays in large hospital 2 TB = Academic Research Library 7 TB = Amount of Tweets/Day 10 TB = All Printed Materials of U.S. Library of Congress • 45 TB = Data Amassed by Hubble Telescope first 20 years • • • • • • 888.879.7302 Source:
    7. 7. Petabyte (PB) 1 PB = 1,024 TB 1 PB = 20 Million, 4-drawer filing cabinets of text 1 PB = 13.3 Years of HD-TV Video 1.5 PB = Size of Facebook photos → 10 Billion 20 PB = Data processed by Google EVERY DAY! 50 PB = ALL Mankind’s written works from Beginning of Recorded History (All Languages) • 100 PB = Facebook data storage before IPO (2.1.2012) • 300 PB = Facebook data today! • • • • • • • 888.879.7302 Source:
    8. 8. Zettabyte (ZB) • 1 ZB = 1 Million Petabytes! • 1 ZB = 1,000,000,000,000,000,000,000 Bytes o That is 21 Zeros, or o 1 Sextillion Bytes • If 1 GB = 60 Watt Bulb, then … • 1 ZB = 15.7 years of energy from the Hoover Dam to power a 1 ZB Light Bulb for 1 hour • 888.879.7302 Source:
    9. 9. Who’s Using Big Data? • Snowden → NSA receives data from Google, Facebook, Yahoo, YouTube, Skype, AOL and Apple • Average Am. Stats o Avg. 150 Facebook friends/users (teens avg. 300) o Avg. 150 add’l email/phone contacts/person o Total Avg. Electronic “Contacts” = 300 • PRISM → NSA’s surveillance program 300 Contacts x Their 300 Contacts x Their 300 Contacts = 27 Million People • 888.879.7302
    10. 10. Who’s Using Big Data? • Facebook → Presto • 1,000 Employees o Run 30,000 interactive Queries per Day o Over 1 PB of processing • Open Source • Types of Queries → Trends, Marketing, Business Intelligence • 888.879.7302
    11. 11. Perspective • 1-40 MB = Average Size of a Patient’s EHR record o Excluding Images o 80 MB at Large Hospitals o Top Average Size, including imaging, 3-5 GB • 3,281 = Average Number of Active Patients for FP* Estimate: 12 MB x 3,200 = 38,400 MB / FP or 37.5 GB / FP • 888.879.7302 *Source: AAFP
    12. 12. Real Ambulatory Metrics • 653 DBs totaling 59.2 TB • Wide variance in DB size → Average 90 GB • Smallest 3.5 GB – Largest 1.7 TB o Average is > 50 users is 226 GB o Pictures, Word, Scanning, etc. ↑ Size Directly o Transactional data creates marginal increases • Examples: o NJ CHC 44 Providers → 2.6 TB o CA Ped. Practice 3 Providers → 10 GB o LA School Based 1 Provider → 3.6 GB • 888.879.7302
    13. 13. Health Care “Score” • Financial Data creates Individual Credit Score o Payment History Data o Amounts Owed o Length of Credit History o New Credit o Types of Credit • 888.879.7302
    14. 14. Health Care “Score” • Will Health Care data create Individual Health Score? o o o o o o Lifestyle Choices (E.g., Smoking, BMI) Worksite Wellness (E.g., Environment) Activity Levels (E.g., Sedentary, Exercise) Nutrition (E.g., Chips v. Broccoli) Adherence / Compliance (E.g., Meds) Behavioral Health (E.g., Quality of Life Questionnaire, Sleep) o Genomics (E.g., Genetic marker for Breast Cancer) • 888.879.7302
    15. 15. Measuring Knowledge • 888.879.7302
    16. 16. Big Data and Health Care • Perspective on Data • Federal Policy and Data • • • • Health IT Today Data and Performance Data Capture for Success Questions • 888.879.7302
    17. 17. Affordable Care Act – By the Numbers • • • • • • • 24 percent of federal budget goes to health care 36 times ACA mentions Patient Centeredness 15 times ACA references the Medical Home 73 times ACA mentions Accountable Care Organizations 93 times ACA references Quality Measures 29 times ACA links Quality to reporting Clinical Data 100 times ACA discusses Value-Based and Payment Modifiers as relates to Hospital/MD Reimbursement and Measures • 12 SCOTUS Opinion mentions Broccoli • 888.879.7302
    18. 18. Patient Centeredness and Policy • • • • • Behavioral Economics sought → About an Engaged Patient Federal Gov’t → Leadership role in Health Care Reform Transition → Episodic Care to Long-Term Healing and Wellness Patient Centered Care → Measured Quality Performance Federal Policymaking and Patient Centered Care o o o o Regs CMS Meaningful Use Stage 2 – 7 Measures Regs CMS Accountable Care Organizations (ACOs) – 7 Measures Regs CMS Value-based Purchasing – Differential Payment Regs CMS Public Measure Transparency – Physician Compare • 888.879.7302
    19. 19. Public Transparency • IOM → $105 Billion Annually in Waste due to o Lack of Competition o Excessive Price Variation • Obama Executive Order → CMS hospital pricing by Top 100 DRGs (May 8, 2013) o Charge vs. Medicare Allowable o E.g., Joint Replacement → $5,300 (Ada, OK) v. $233,000 (Monterey Park, CA) • Medicare Data Access for Transparency and Accountability Act (H.R. 2843, S. 1180) • 888.879.7302
    20. 20. CMS Proposed Rule – CY2014 • Physician Compare Website – CY2014 o o o o Provider Transparency PQRS GPRO 2012 and 2013 Performance Data ACO Performance Data CG-CAHPS Patient Experience Survey Data (All groups by CY2015) • 888.879.7302
    21. 21. Measuring Knowledge • 888.879.7302
    22. 22. Big Data and Health Care • Perspective on Data • Federal Policy and Data • Health IT Today • Data and Performance • Data Capture for Success • Questions • 888.879.7302
    23. 23. Value and Difficulty Continuum Data Analytics • Prescriptive o How can we make it happen? • Predictive o What will happen? • Diagnostic o Why did it happen? • Descriptive • 888.879.7302 o What happened?
    24. 24. Decision-Making and Health IT • 4 Habits of High Performing Health Care Systems (NEJM, Dec. 2011) 1. 2. Specification and Planning → Use data to trigger an “advanced plan” Infrastructure Design → Workflows that:   Simplify the process  3. 4. Deliver timely information at the right decision point Match the proper skills, resources to process Measurement & Oversight → Realtime, Data-driven Operations Self-Study → Apply measurements for ongoing learning and improvement • 888.879.7302
    25. 25. Data Impact Potential • 5 Potential Areas of Impact → Quality, Patient Engagement, Efficiency / Revenue, Clinical Research, Risk / Liability • Today, Market Remains … o Fragmented o Transaction-based o Acute Care / Reactive Care Delivery • Reform Goal: Morph into agile, responsive system that is … o Proactive with a focus on prevention o Engaging the patient for wellness lifestyles o Managing complex patient populations • Industry is Young → Health IT Hype Cycle • 888.879.7302
    26. 26. Gartner Hype Cycle Leading Edge Bleeding Edge • 888.879.7302
    27. 27. 5-10 Years • 888.879.7302 Big Data
    28. 28. EHR Adoption Rates • MU launched in 2011 → Physician Adoption around 20% • 888.879.7302 Source: Healthcare Technology Online, May, 2013
    29. 29. Measuring Knowledge • 888.879.7302
    30. 30. Big Data and Health Care • Perspective on Data • Federal Policy and Data • Health IT Today • Data and Performance • Data Capture for Success • Questions • 888.879.7302
    31. 31. MU Cultural Shift • 4 V’s of Health Care Data o Volume – Large data stores for research o Variety – Multiple approaches o Velocity  Info to Provider when with the Patient  Info to Patient when they can still make a behavior change o Value – Data that drives a cultural shift and ongoing process improvement • 888.879.7302
    32. 32. Incremental Approach • Incremental approach today positions for Incredible Future • Call to Action … o What do market and regulatory changes mean? o Evaluate the Must Do vs. the Must Do o Collaborate with stakeholders  Align goals with public health, hospitals, payers, patients, clinicians, vendors  Identify potential barriers and formulate solutions o Primary Care Health IT Application  New approaches to managing patient populations for prevention  Use of data for purpose-driven performance improvement • 888.879.7302
    33. 33. CDS Workflow • Great place to start! • MU1 → Implement 1 CDS Intervention and Track Adherence • MU2 → Implement 5 CDS Interventions, align with 4+ CQMs • MU3 → Implement 15 CDS Interventions • 888.879.7302
    34. 34. Text to Code Translation • Guidelines are Narrative → Human Readable • AHRQ eRecommendation for Technical Specification → Machine Readable • Consistency in coded logic statements aligns: o Development Costs o Implementation Timelines o Uniformity of data for comparative effectiveness • AHRQ 5-Rights of CDS o o o o o Get the Right Information To the Right Person In the Right CDS Format In the Right Technology Channel At the Right time in the Patient Workflow • 888.879.7302
    35. 35. CDS Workflow eMeasure NQF 0059; CMS CQM 122 → Hemoglobin A1c screenings of Poorly Controlled Diabetic Patients Report the percentage of patients age 18-75 with diabetes who had hemoglobin A1c > 9.0% during the measurement period The “Right” The Answer Redesign 1.Rule-logic pre-built? 2.Available in EHR? • Initial assessment of DM; target A1c value of ≤ 7% Get the Right Information • 888.879.7302 3.If pt. presents for unrelated issue, will system alert? • A1c at least 2x/year for stable patients. • More frequently for poorly controlled. 4.Can EHR generate list of non-compliant pts. for outreach based on pt. communication preference?
    36. 36. CDS Workflow The “Right” The Answer • Monitor and treat hyperglycemia with a target A1c of 7% Redesign 1.Who needs this information during clinic workflows? 2.Who needs this information for noncompliance tracking and outreach? To the Right Person • 888.879.7302
    37. 37. CDS Workflow The “Right” The Answer Redesign 1.What is the proper CDS Format(s) to manage DM A1c? • Alerts / Reminders • Reference Guidelines In the Right CDS Format • Condition-focused Order Sets • Pt. Reports • Flowsheets • Documentation Templates • Other • 888.879.7302 2.What can my EHR provide? 3.Can alerts, order sets and documentation templates be customized?
    38. 38. CDS Workflow The “Right” In the Right Technology Channel The Answer • Mobile Device • Internet Patient Portal • EHR • PHR • Other Alert! • 888.879.7302 Redesign 1.Will the alert be a popup note or will the user have to prompt? 2.Can communication for outreach be done via secure email? 3.Should an alert be sent to the Patient Portal?
    39. 39. CDS Workflow The “Right” The Answer Redesign 1.Can and should CDS information be provided at more than one time of the patient workflow? At the Right Time in the Patient Workflow • Pt. Registration • Assessment / Triage • Exam Room / PE • Treatment / Plan Dev. • Performing Orders • Check-out • Remote / After Hours • 888.879.7302 2.Can alerting be configured (E.g., based upon severity)? 3.Can patient education / information be customized?
    40. 40. Let Technology Work for You! CDS Type Patient Alerts Patient Reminders EvidenceBased Clinical Guidelines Point-ofCare Workflow X X X • 888.879.7302 Pop. Mgmt. Workflow X X X EHR Adoption Maturity Level BeginnerModerate Beginner BeginnerModerate Types of CDS Technology Solutions Rx Interactions, Formulary, Delinquent Orders and Deferred Orders Patient Portal, Secured Patient emails, Text Messages, Form Letters/Postcard s, Phone Call List, Auto-Phoning Pre-designed CDS rulesengine, Point-ofCare alerts, Intelligence Prompting, Patient Education Improves Improves Quality Patient Safety of Care X X X Cautionary Notes X Alert Fatigue can result in clinicians ignoring alerts. X System should automatically identify the patient’s preferred method of communication under HIPAA. X System needs to allow for customizable guidelines; variance in recognized standards of care
    41. 41. Let Technology Work for You! CDS Type Order Sets Flow-Sheets Dashboards EHR Adoption Point-ofPop. Maturity Care Mgmt. Level Workflow Workflow X X X • 888.879.7302 X Types of CDS Technology Solutions Wellness age 65+ and Moderate pediatric, Chronic Disease Management Vitals, Lab Moderate results, Antepartum, growth Advanced charts Timely followup, Results signed-off, Delinquent orders and Advanced deferred orders, appt. compliance, protocol compliance Improve Quality of Care Improve Patient Safety X X System needs to allow for customization. X System needs to allow for customization and graphing. X System should have metric drill-through for details; requires consist workflows for data capture. X X Cautionary Notes
    42. 42. EHR Adoption Point-ofPop. Maturity Care Mgmt. Level Workflow Workflow Let Technology Work for You! CDS Type Structured Knowledgebase Documentati on Templates Diagnostic Support Workflow Tools X X X • 888.879.7302 X X X Types of CDS Technology Solutions Intelligent prompting for differential diagnoses, Advanced clinical element prompting for symptoms, PE considerations Intelligence prompting for differential diagnoses, autoAdvanced monitoring based upon results (e.g. lab), recommended therapies Point-of-care alerting, waitModerate time analysis, mobile devices, Advanced Internet, compliance tracking Improve Quality of Care X X X Improve Patient Safety Cautionary Notes X While significant time savers, pre-filled forms/lists and autonegatives/positives can result in “cookiecutter” documentation. X Requires providers to break out of intuitive decision-making and adopt analytically decision-making. X Critical to CDS adoption, successful workflow integration requires the clinician’s time and involvement.
    43. 43. Do’s and Don’ts Don’t Practice “Cookie-Cutter” Medicine → Same Tests to all Patients with Similar Symptoms Efficient, but not necessarily Effective Seek all answers from a Data Warehouse • Big, powerful but … • Expensive and not suitable for many day-today needs Approach Data as a Hunter, Gatherer • Time consuming, expensive • Data is often not compatible • 888.879.7302 Do Practice Evidence-Based Medicine • Use HIE to look beyond 4-walls • Use Standardized Vocabularies E.g., Sys. 1→ High BP; Sys. 2 → Elev. BP; Sys. 3 → HTN; Instead use SNOMED CT Leverage MU2 CCDA/CCD to support patientspecific tasks • Use coded data to standardize terminology • Supports HIE • Helps with predictive modeling • Can fill-in record gaps Domesticate Data by “Normalizing,” if possible • Map/Document using structured vocabularies (E.g., SNOMED, LOINC) • Meets MU and other regs • Strive for consistent Data Capture
    44. 44. Do’s and Don’ts Don’t Do Wait to consider new ways to use your data • Don’t wait for Big Data to knock on your door • You have a wealth of enterprise data today Aggregate data wherever you can afford to do so • Does your vendor have a ServiceOriented Architecture (SOA) strategy? • Where can data come from? E.g., Financial, Operational and Clinical E.g., Medical devices, Labs, Questionnaires Limit your vision to your Health Care Organization; you will only be able to react to the market for competitiveness Use free Public Health Data for Strategic Planning • 888.879.7302 E.g., Univ. of FL merged health data with Google Maps to create “heat” sensitivity for chronic dz. Found 3 counties underserved for breast screening and sent mobile units.
    45. 45. Measuring Knowledge • 888.879.7302
    46. 46. Big Data and Health Care • • • • Perspective on Data Federal Policy and Data Health IT Today Data and Performance • Data Capture for Success • Questions • 888.879.7302
    47. 47. Here’s Your Patient • Miss West • Belligerent • Some kind of Liver Function Problem • Paranoia • Non-Compliant ALL the time • 888.879.7302
    48. 48. Patient Scenario • Patient presents for wart removal • Key → Must Consistently Capture Your Data • 4 CQM / PQRS Measures: o Influenza & Pneumonia Immunizations o Breast & Colorectal Cancer Screenings • What do you accomplish? • 4 • 888.879.7302 → 1
    49. 49. Consistent Data Capture • Consistent Data Capture = Strong Reporting • Data Reporting Drives Performance for VBP • Data Reporting Provides Credit for treat the “Miss West” Patient • Three Ways to Capture Data o Performed (Here or Elsewhere) o Not Performed (Medical Reason) o Not Performed (Patient Refusal) • 888.879.7302
    50. 50. Patient Complexity Data Health plans use claims data to build patient complexity profiles • 888.879.7302 The patient complexity profile must be repopulated annually using calendar-year claims data (i.e., patient complexity starts at baseline every year). Diagnosis Codes (ICD-9 and ICD-10) are used to calculate patient complexity.
    51. 51. The Impact of Documentation & Coding • 888.879.7302 Source: BCBSAL, Complete Picture of Health Documentation and Coding Improvement Initiative, Aug., 2013
    52. 52. CEUs or Copies White Papers Follow me on Twitter: Added to The BRIEF or Questions: • 888.879.7302
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