Leveraging Data And Strong Partnerships To Thrive In The Land Between Volume And Value presented by Pam Rush, RN, MS and William Katsiyiannis, MD

1. Leveraging Data And Strong Partnerships To Thrive In
The Land Between Volume And Value
Pam Rush, RN, MS
Dr. William Katsiyiannis

2. Objectives
• To describe the collaborative partnership between the hospital, health system,
and cardiology group.
• To explain the value and rationale for investing in an enterprise data warehouse
(EDW).
• To highlight the development of the Minneapolis Heart Institute (MHI) Center
for Healthcare Delivery Innovation as a framework to transition from volume to
value.
• To demonstrate, through specific case examples, the value of strong
partnerships and an EDW in driving meaningful change in cardiovascular (CV)
quality and outcomes.
2

3. Key Points
• Healthcare market forces are driving an increased need for complex data
analytics to improve value.
• Allina Health, in collaboration with Health Catalyst, has developed an Enterprise
Data Warehouse (EDW) that provides nation leading data analytic capabilities.
• A relentless focus on improving quality drives lower costs.
• Success requires 3 components:
 Physician Leadership
 Strong care team collaboration (MDs, RNs, Administrators)
 An EDW with access to accurate data analytic resources
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4. Allina:
Region’s Largest Health Care Organization
Allina Health is dedicated to the prevention and treatment of illness and enhancing the greater health of
individuals, families and communities throughout Minnesota and western Wisconsin.
Allina Health
• 13 Hospitals
• 82 Clinic sites
• 3 Ambulatory care centers
• Pharmacy, hospice, home care,
medical equipment
• 26,000 employees
• 5,000 physicians
• 2.8 million+ clinic visits
• 110,000+ inpatient hospital
admissions
• 1,658 staffed beds
• 3.4B in revenue
• 32% Twin Cities market share

5. Land Between Volume and Value
The mixed world is here to stay.
Likely to move to value dominant systems:
Medicare
Advantage | Fee-For-Service
Medicaid Less Certain
Fully Insured Commercial
Least Certain
Self-Insured Commercial

6. Power of Partnership:
Minneapolis Heart Institute (MHI) and Allina
Common
vision.
Aligned
interests.
Supportive
infrastructure.
Platform to
allow ongoing
investment.
Trust.

7. Power of Partnership: MHI and Allina
• Support of three types of innovation.
– New Treatments and Therapies
• Structural Heart Program.
– 500 transcatheter aortic valve replacement (TAVR).
– 30% increase in open heart volume.
– First in human mitral valve.
– New Care models to enhance experience.
– Cardiology curbside.
– Metro hubs.
– Heart Failure Care Coordination
– Increase value through demonstrating better outcomes at a lower cost.
– MHI Center for Healthcare Delivery Innovation.

8. US Healthcare Spending
U.S. Health spending—larger than the gross domestic product
(GDP) of most nations
• If all of that activity was separated into
its own sovereign nation, it would
constitute the fifth largest economy in
the world, behind only the United
States, China, Japan, and Germany.
$2.7 TRILLION
U.S. HEALTH SPENDING in 2011

9. Return on Investment
Source: OECD Data 2011
Life expectancy in the U.S. does not compare favorably to other
countries which spend less per capita.
0
1000
2000
3000
4000
5000
6000
7000
8000
70
72
74
76
78
80
82
84
PerCapitaSpending
AverageLifeExpectancy
Life Expectancy Per Capita Spending (International Dollars)

10. Healthcare Spending in Minnesota
Total healthcare spending in Minnesota
was $40 billion in 2012; expected to
grow 6.5% per year.

11. Forecasting the Future of CV Disease
Source: Heidenreich, P. A., Trogdon, J. G., Khavjou, O. A., Butler, J., Dracup, K. … Woo, Y. J. (2011). Forecasting
the future of cardiovascular disease in the United States: A policy statement from the American Heart
Association. Circulation, 123, 933-944.
A policy statement from the American Heart Association
CV Costs
Reach
$ 818 Billion
in 2030

12. Costs and Variation Among CV Conditions

13. Payment Reform Pressures
Target percentage of Medicare fee-for-service (FFS) payments linked to
quality and alternative payment models in 2016 and 2018.
All Medicare FFS (Categories 1-4)
2016
All Medicare FFS
30%
85%
FFS linked to quality (Categories 2-4) Alternative payment models (Categories 3-4)
2018
All Medicare FFS
50%
90%

14. CMS Proposes Mandatory Cardiac Bundles
14
1. New mandatory CMS bundles apply to acute MI and
CABG patients.
2. Bundles require hospital accountability for cost and
quality during inpatient stay and 90 days after
discharge.
3. Hospitals chosen from 98 randomly selected
metropolitan statistical areas.
4. Bundles would begin July 1, 2017.
5. CMS will pay quality adjusted target payments for
each episode of care.

15. Opportunities For Collaboration
• Relentless pursuit of:
– High quality outcomes.
– Optimized publicly reported measures.
– Reduced cost.
– Increased revenue.
– Improved patient experience.
– Increased affordability.
– Growth.
– Improved health of the community.

16. Quality of Care Focus
16
“Quality improvement is the most powerful
driver of cost containment.”
~ Michael Porter, PhD Harvard Business School

17. Need for CV Care Innovation
• The development of the MHI Center for Healthcare Delivery
Innovation places Allina Health as a national leader in driving
necessary change in our healthcare delivery system.
• Focused on reducing variation through:
• Standardized cardiovascular care protocols.
• Advanced risk-stratification tools.
• Real time decision support at the point of care.
• Innovative strategies for care delivery.
The Center leverages the existing infrastructure of Allina’s EDW and
cardiology participation in national registries to achieve the Triple Aim
goals of improving population health, reducing per capita costs, and
improving the patient experience.

18. Primary Care
•Healthy lifestyle.
•Weight management.
•Smoking cessation.
•Exercise.
•Lipid management.
•Routine treatment
protocols.
•Referral protocols.
Outpatient
Cardiology
•Timely access to
specialists.
•Guideline driven testing
and treatment.
•Comprehensive
diagnostic testing.
Sub-Specialty
Cardiology
• Complex patients
requiring further
evaluation and
treatment.
• Cardiac surgery.
• Arrhythmias.
• Structural heart
disease.
• Prevention.
Inpatient and
Emergency Services
• Level I program.
• ST-segment elevation
myocardial infarction
(STEMI).
• Critical limb ischemia.
• Aortic dissection.
• Abdominal aortic
aneurysm.
• Specialized inpatient CV
care.
Advanced Therapies
•Extracorporeal
membrane oxygenation
(ECMO.)
•Left ventricular assist
device (LVAD).
•Heart transplant.
•Trans-catheter aortic
valve replacement
(TAVR).
•MitraClip
•Percutaneous mitral
valve repair (MVR).
Developing The Healthcare Delivery Innovation Center
Optimize Care Across the CV Continuum

19. Introducing………….

20. POPULATION HEALTH
MANAGEMENT
• Quantify the
population needs and
measure adherence
to clinical guidelines.
• Develop strategies
and tools to improve
care access and
efficiency.
REDUCE CLINICAL
VARIATION
• Reduce unnecessary
variation in clinical
care.
• Standardize care
pathways and
protocols.
• Increase value.
TEST NEW PROCESSES
OF CARE & PAYMENT
MODELS
• Build on existing best
practice programs and
protocols to improve
quality and efficiency
in care delivery.
• Develop and test new
payment models.
LEVERAGE CUTTING
EDGE TECHNOLOGY
• Cardiomems
Monitoring.
• TAVR, MitraClip.
• Linq.
Improve health of the
population through
adherence to clinical
guidelines across the
continuum.
Transform care delivery
through the reduction of
clinical variation.
Transform care delivery
by piloting new and
creative processes and
payment models.
Explore new ways to
efficiently care for
patients.
MHI-HDI Foundational Pillars

21. Clinical Intelligence Tools
What happened? What happening? What may happen?
Retrospective Real time Predictive
GeneralSpecific
Potentially Preventable
Readmissions (PPR) Dashboard

22. 2012: Limited Tracking of
Performance Enhancement $
•Acute myocardial infarction (AMI) optimal
care.
•Heart failure (HF) optimal care.
•Coronary artery bypass (CAB) surgical care
improvement project (SCIP) optimal care.
•Bivalirudin or radial access increased from
25% to 55% in high risk bleeding patients.
•Revised and standardized HF, AMI and
percutaneous coronary intervention (PCI)
patient education documents.
•United HF readmissions reduced from
19.25% to 14.9%.
•Society of thoracic surgeon (STS)
dashboard developed.
•100% of cardiologist trained on the clinical
documentation improvement project
(clinical documentation).
•Length of stay (LOS) savings $73,000.
•$1.3M in supply cost savings.
2013 Performance
Enhancement: $12,074,221
•Bivalirudin use in high risk PCI pts: 69.0%
at Abbott Northwestern Hospital (ANW),
68.8% at Mercy Hospital, and 75.0% at
United Hospital.
•72% (124/173) patients seen in pre-op
clinic.
•Blood utilization.
•Goal: $461,641.
•Actual: $396,000.
•RBC: 2.14 1.98 u/case
•FFP: 1.43 .94 u/case
•Platelets: .72 .59 u/case
•HF dashboard developed.
•Cardiovascular (CV) LOS:
•104% baseline.
•102.6% Actual.
•Savings: $640,221.
•Supply chain savings: $2,670,600.
•Clinical documentation: $8,367,400.
•Willingness to recommend: 94%.
2014 Performance
Enhancement: $13,645,000
•160 more PCI patients at high risk for
bleeding had a closure device used.
•114 intensive care unit (ICU) days were
avoided for low risk ST segment elevation
myocardial infarction (STEMI) and
transcatheter aortic valve replacement
(TAVR) patients.
•481 more HF patients had care coordinated
by a HF care coordinator.
•13 more HF patients appropriately evaluated
by Advanced HF referrals for ventricular assist
device (VAD)/transplant.
•400 days saved through HF LOS efforts.
•886 fewer units of blood given to CV surgery
patients.
•22% more patients who developed Afib post
CV surgery were treated using the Afib
protocol.
•28,029 fewer unnecessary creatine, kinase,
muscle, and brain (CKMB) lab test completed.
•$2.9M: over utilization and LOS
improvements (8 improvements noted
above).
•$7.2M: clinical documentation.
•$3.5M: decreased variation in supply chain
contract.
Track Record of Success
2015 Performance
Enhancement: $6,374,690
•STEMI LOS $120,600.
•Advanced HF referrals $1,432,000.
•TAVR ICU days $153,500.
•HF care coordination $819,600.
•Troponin testing $29,500.
•CKMB Lab Testing $426,900.
•Closure device $395,100.
•Clinical documentation $2,094,000.
•Vascular supply chain $509,500.
•Afib protocol $393,990 (Jan14-Aug 15 at
ANW and United Hospital).

23. Examples: CV Dashboards
• PCI:
– Use of closure devices in high risk patients.
• Structural Heart Disease:
– Population management of severe symptomatic
aortic stenosis.
• Up to date on guideline recommended echo
surveillance.
• Role of primary care physician (PCP),
cardiologist, valve specialist.
• Survival curves with and without definitive
procedure.
• Cost implications.
• CV Surgery:
– Real-time physician scorecard.
– Bundled payments.

24. Example: PCI Bleeding Risk
• Area of Opportunity:
– Peri-procedural bleeding complications are
common following PCI (3-6%).
– Transfusion rates across Allina Health were
higher than national average for patients
undergoing PCI.
• Accurate Data:
– NCDR national PCI registry provides
standardized, nationally benchmarked,
abstracted data.
– EDW enables linking of multiple data sources
to evaluate the impact of novel care processes
on clinical quality and costs.

25. Impact of Closure Devices
4% 6%
23%
3%
6%
10%
0%
10%
20%
30%
Low Intermediate High
Any Complication
No Vascular Closure Device Yes Vascular closure Device
1.0% 1.7%
12.6%
0.7%
2.3%
5.9%
0%
5%
10%
15%
Low Intermediate High
RBC Transfusion
No Vascular Closure Device Yes Vascular closure Device
1% 1%
8%
0%
2%
3%
0%
5%
10%
Low Intermediate High
Bleeding with 72 Hours
No Vascular Closure Device Yes Vascular closure Device
0.3% 0.4%
6.8%
0.2% 0.1%
1.4%
0%
2%
4%
6%
8%
Low Intermediate High
Mortality
No Vascular Closure Device Yes Vascular closure Device

26. 26

27. 27

28. 28

29. 29
2011 2015-16

30. 30

31. Learnings: PCI Bleeding Risk Key Steps
• Accurately calculate a pre-PCI Bleeding
Risk Score for all PCIs across the Allina
Health System.
• Apply consensus guidelines in clinically
appropriate cases.
• Effectively communicate bleeding risk
to providers managing the patient’s
care.
• Track outcomes and provide timely
feedback.
Cumulative Savings of 1.8 M
Reduction of LOS for high bleeding risk from 3.8 to 2.4 days
Reduction in complications from 23% to 18% in high bleeding risk

32. Examples: CV Dashboards
• PCI:
– Use of closure devices in high risk patients.
• Structural Heart Disease:
– Population management of severe symptomatic
aortic stenosis.
• Up to date on guideline recommended echo
surveillance.
• Role of primary care physician (PCP),
cardiologist, valve specialist.
• Survival curves with and without definitive
procedure.
• Cost implications.
• CV Surgery:
– Real-time physician scorecard.
– Bundled payments.

33. 33

34. Survival Curve for Severe Aortic Stenosis with and without
conclusive procedure
34
95.7%
74.2%
86.6%
63.2%
81.3%
49.9%

35. 35
What’s the Cost of Waiting?

36. 36
Real-time Example:
90 year old patient wanted to
know what her risk of stroke was
for transcather aortic valve
replacement
Measure Name Numerator Denominator %
% with In-hospital Mortality 2 60 3.3%
% with Stroke 1 60 1.7%
% with Vascular Access Site Complication 1 60 1.7%

37. Examples: CV Dashboards
• PCI:
– Use of closure devices in high risk patients.
• Structural Heart Disease:
– Population management of severe symptomatic
aortic stenosis.
• Up to date on guideline recommended echo
surveillance.
• Role of primary care physician (PCP),
cardiologist, valve specialist.
• Survival curves with and without definitive
procedure.
• Cost implications.
• CV Surgery:
– Real-time physician scorecard.
– Bundled payments.

38. 38

39. 39

40. 40

41. 41

42. Key Points
• Healthcare market forces are driving an increased need for complex data
analytics to improve value.
• Allina Health, in collaboration with Health Catalyst, has developed an Enterprise
Data Warehouse (EDW) that provides nation leading data analytic capabilities.
• A relentless focus on improving quality drives lower costs.
• Success requires 3 components:
 Physician Leadership
 Strong care team collaboration (MDs, RNs, Administrators)
 An EDW with access to accurate data analytic resources
42

43. Lessons Learned
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• Strong, committed leadership is essential for success.
• A focus on innovation is required to navigate present and future
challenges.
• Collaborative teamwork is essential in order to realize the Triple Aim
• Robust analytics is a powerful tool to achieve the best quality and
cost outcomes.

44. Thank You
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