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

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

  1. 1. Achieving Affordability with Visual AnalyticsVariation Reduction as a Tool to Engage Clinicians<br />Ingenix User Conference<br />May 2011<br />Michael van Duren, M.D., MBA<br />Sutter Health<br />A Project of the Sutter Medical Network <br />and Sutter Physician Services<br />
  2. 2. About us<br />
  3. 3. California’s Highest Quality Health Care System*<br />Serving more than 3 million patients<br /><ul><li>Approximately 48,000 employees
  4. 4. 5,000 physicians
  5. 5. Aligned under the Sutter Medical Network
  6. 6. Physician medical foundation and IPAs</li></ul>Part of more than 100 communities<br /><ul><li>25 DHS-licensed acute care hospitals
  7. 7. Home health & hospice and long-term care services throughout Northern California</li></ul>Partnering with providers, patients<br />and communities<br /><ul><li>Medical research and medical education/training
  8. 8. 24 fundraising organizations</li></ul>*Source: The Lewin Group, 2009<br />
  9. 9. The Sutter Medical Network<br /><ul><li>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. 10. SMN Standards of Participationcreate collective accountability thatencompasses the entire spectrum of clinical and service quality:
  11. 11. Clinical Pay for Performance
  12. 12. Primary care appointment wait times
  13. 13. Patient satisfaction with the care experience
  14. 14. Adoption of online services
  15. 15. Variation reduction efforts</li></li></ul><li>Physician Organizations in the Sutter Medical Network<br /><ul><li>Alta Bates Medical Group
  16. 16. Brown & Toland Physicians
  17. 17. Central Valley Medical Group
  18. 18. Marin IPA
  19. 19. Mills-Peninsula Medical Group
  20. 20. Palo Alto Medical Foundation
  21. 21. Sutter East Bay Medical Foundation
  22. 22. Sutter Gould Medical Foundation
  23. 23. Sutter Independent Physicians
  24. 24. Sutter Medical Foundation
  25. 25. Sutter Pacific Medical Foundation</li></li></ul><li>Why Variation Reduction?<br />What engages physicians?<br />Healthcare affordability<br />High deductible plans<br />High co-pays<br />Losing marketshare to competitors<br />Curiosity<br />Competitiveness<br />Do the right thing<br />Quality improvement, professionalism<br />6<br />
  26. 26. How To Engage Physicians<br />Respect their intelligence & time<br />Trust their motives<br />Adult learning: peer setting<br />Solution: variation reduction program<br />7<br />
  27. 27. Variation Reduction Program Components<br />Leadership<br />Which is the most important component?<br />Remove any one and it won’t work…<br />
  28. 28. DATA<br />9<br />
  29. 29. Purpose for Data Sharing  Practical Implications<br />Show clinicians how they differ from each other<br />Must be: <br />Apples to apples<br />Simple and explainable<br />Clinically relevant<br />Compelling: “Aha, I see what I need to change”<br />ETGs with drill down accomplishes all this<br />Hi-Lo Variation is typically 100 - 300%<br />Therefore data needs only to be directionally correct<br />Attribution: anything less than 50% loses credibility<br />10<br />
  30. 30. Data Issues for Provider Groups vis-à-vis Plans<br />Less complete data<br />HMO: claims, but only for the risk that groups took<br />Excludes facility costs (not a problem , but beware low cost outliers)<br />Excludes out of network, behavioral health, negotiated carve outs, etc<br />PPO: billing data, but only for care that was provided<br />Pharmacy: only what is provided by HMOs<br />More complete data<br />Clinical sources<br />Outcome data: Blood Pressure, A1c, LDL<br />Rx written, not just filled<br />More recent data: yesterday<br />11<br />
  31. 31. Clinicians Are Very Discerning re Value of ETGs<br />Problematic areas discovered:<br />Hernias<br />All types (inguinal, abdominal, hiatal) together<br />Gyn tumors<br />Uterus and ovaries grouped together<br />Gyn irregular bleeding<br />Postmenopausal bleeding not distinct<br />Knee procedures<br />Total knee and arthroscopy cases grouped together<br />12<br />
  32. 32. Provider Network Clinical Integration Issues<br />Competitors can not share pricing<br />Work with data stripped of all pricing<br />Uniform charge master applied to all data<br />Multiple data sources<br />Lab vendors<br />Pathology contractors<br />Surgery at multiple sites<br />Integrate all payers<br />Changing systems<br />
  33. 33. DISPLAY<br />
  34. 34. Why Is Visual Data Display So Important?<br />Can not afford distractions: <br />Accuracy<br />Methodology<br />Detailed questions<br />15<br />
  35. 35. Why Is Visual Data Display So Important?<br />16<br />Must be all right brain, gut level, intuitive<br />“Aha, I see I am an outlier. I know what I should do differently!”<br />Need to achieve this in seconds, without words<br />
  36. 36. 17<br />
  37. 37. 18<br />
  38. 38. 19<br />
  39. 39. 20<br />
  40. 40. How to Speak to the Right Brain?<br />Visual data; not words or numbers<br />Message must jump out on its own<br />Remove all extraneous text<br />Personal impact<br />Change desired must be obvious<br />21<br />
  41. 41. Example of Other Dashboards<br />
  42. 42. Visual Display of Variation<br />23<br />
  43. 43. HMO Statin Prescription VolumePPO volume not included<br />24<br />
  44. 44. 25<br />
  45. 45. 2nd Line Diabetes Drug<br />26<br />
  46. 46. 27<br />
  47. 47. 28<br />
  48. 48. 29<br />
  49. 49. 30<br />
  50. 50. 12 Month Run Chart (volume of 30 day supply)<br />31<br />
  51. 51. 32<br />
  52. 52. 33<br />
  53. 53. New Features: Frequency of Surgery<br />
  54. 54. New Features: View Individual Episodes<br />
  55. 55. Each Bar is an Individual Episode<br />36<br />
  56. 56. Curiosity About a Single High Episode<br />37<br />
  57. 57. Select and Episode to View Claims<br />38<br />
  58. 58. Claims View<br />39<br />
  59. 59. Claims View - Continued<br />40<br />
  60. 60. people<br />41<br />
  61. 61. Philosophy of Physician Behavior<br />42<br />
  62. 62. Philosophy of Physician Behavior<br />43<br />
  63. 63. Contextualist Approach<br />Deductive Approach<br />COMPLIANCE<br />Contextualist Approach<br />EMPOWER<br />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.<br />
  64. 64. Two Approaches<br />Bottom up<br />Multiple small projects<br />Maximizes physician buy-in<br /><ul><li>Top down
  65. 65. Standardized implementation
  66. 66. Maximizes savings</li></li></ul><li>Guiding Principles for VR Facilitation<br />Follow Curiosity<br />Pull, not push<br />Bottom up, not top down<br />Safety, fun<br />Non-punitive<br />Respect – sincere <br />(no agenda other than being helpful)<br />Talk about emotions <br />(before talking about the data)<br />
  67. 67. Guiding principles for VR facilitation<br />Transparency – names not blinded<br />Use natural competitiveness in a playful way<br />Talking about affordability is ok and necessary (“I am not going to apologize”) <br />Must lead to a “project” – <br />must result in an improved outcome <br />this requires some nudging<br />Improvise, Adapt, Think Fast<br />
  68. 68. Resources for Data & Emotions:Nudge, Switch<br />48<br />
  69. 69. Reactions from Physicians<br />“I haven't had this much fun since residency”<br />“I have been waiting for this for ten years”<br />“That was a lot more fun than I expected from the title of the meeting”<br />“When are you guys coming back?”<br />49<br />
  70. 70. process<br />50<br />
  71. 71. Variation Reduction Program Components<br />Phases<br />Introduce and orient dept chair<br />Meet with whole dept (5-15)<br />Explore various ideas, dig & clarify<br />Narrow selection to one project<br />Write charter, define goals, commit to interventions<br />Track progress, modify interventions<br />
  72. 72. Improvement Project Sequence<br />Use SCPA to identify variation reduction opportunities<br />Clinicians agree on a standard and define performance metrics<br />Clinicians agree to launch an improvement project<br />
  73. 73. VR Project Charter<br />Sample process from one group<br />
  74. 74. Problem Statement<br />What is the problem we are solving for?<br />Duration, where, what, why<br />In [time period], there were [count] patients with [diagnosis] who experienced [what undesirable care was done] and this is a problem, because [impact].<br />
  75. 75. Problem Statement<br />In 2010, 55% of 1182 patients with new onset Sinusitis were treated with antibiotics, other than Amoxicillin. This resulted in unnecessary pharmaceutical costs. <br />
  76. 76. Goal Statement - AIM<br />[increased/decreased] [metric] from [baseline]to [goal level] as measured by [XX] by [when].<br />Specific<br />Measurable<br />Achievable<br />Reasonable<br />Time bound<br />
  77. 77. Goal Statement - AIM<br />Increase the percent of patients with new onset sinusitis that receive treatment with Amoxicillin from 45% to 62% by the end of 2011.<br />Reduce the average cost of initial antibiotic treatment for Sinusitis from $57 to $45 by the end of 2011.<br />
  78. 78. % of Patients treated with Amoxicillin<br />58<br />
  79. 79.
  80. 80. Primary Metric<br />How will you know you’ve made an improvement<br />Rate is percent of numerator/denominator<br />Denominator: [all patients with x]<br />Numerator: [patients who received treatment x]<br />Inclusions/exclusions<br />Balance metric (how do we check that we are not causing harm?)<br />Associated quality or outcome metric?<br />
  81. 81. Project Metric<br />Name of metric: Percent of all patients prescribed Amoxicillin as 1st line antibiotic for treatment of sinusitis<br />Numerator: number of sinusitis patients prescribed Amoxicillin<br />Denominator: all Sinusitis patients with antibiotic prescription<br />61<br />
  82. 82. Defining Patients<br /><ul><li>Exclusion criteria:
  83. 83. Anybody with any of the diagnoses in the prior 30 days (so that we are looking only at NEW onset sinusitis)
  84. 84. PCN allergy
  85. 85. Exclude pts with pneumonia or bronchitis in any of the other diagnoses
  86. 86. OR use Epic linkage to pull onlyabx linked to sinusitis
  87. 87. No recent abx use for anything else for 30 days
  88. 88. No sinusitis in prior 12 months</li></ul>Inclusion criteria for diagnosis:<br />461 P ACUTE SINUSITIS  <br /> 461.0 ACUTE MAXILLARY SINUSITIS  <br /> 461.1 ACUTE FRONTAL SINUSITIS  <br /> 461.2 ACUTE ETHMOIDAL SINUSITIS  <br /> 461.3 ACUTE SPHENOIDAL SINUSITIS  <br /> 461.8 OTHER ACUTE SINUSITIS  <br />473 P CHRONIC SINUSITIS  <br /> 473.0 CHRONIC MAXILLARY SINUSITIS  <br /> 473.1 CHRONIC FRONTAL SINUSITIS  <br /> 473.2 CHRONIC ETHMOIDAL SINUSITIS  <br /> 473.3 CHRONIC SPHENOIDAL SINUSITIS  <br /> 473.8 OTHER CHRONIC SINUSITIS  <br /> 473.9 UNSPECIFIED SINUSITIS  <br />62<br />
  89. 89. Expected Benefit<br />Improved affordability<br />Improved consistency<br />Enhanced adherence with clinical guidelines / best practices<br />
  90. 90. Implementation Plan<br />1st test of change (what are the changes you plan to make? How will they be implemented?)<br />Who, what, when, where<br />
  91. 91. Implementation Plan<br />First “Test of Change”<br />Communicate to all ----- providers in meeting 4/1/2011<br />Distribute monthly run charts to individuals<br />Work on smart set for Epic / consistent documentation<br />Create guideline for consistent diagnosis of sinusitis: e.g. purulent discharge (Dr W----- & Dr L----)<br />Other ideas (on hold for the future):<br />Patient education “why you are seeing your ENT and still getting Amoxicillin”<br />Also education for ER<br />Address outliers<br />Epic BPA<br />Other…<br />
  92. 92. Balance measure<br />Cure rate?<br />Are we seeing more failures on Amox?<br />Return within 30 days for same diagnosis?<br />Track baseline, see if it changes…<br />
  93. 93. Local Standard<br />Sinusitis guidelines? Am Acad of Otolaryngology 2007 (?). AAO.<br />
  94. 94. Formal Project Charter<br />68<br />
  95. 95. 69<br />
  96. 96. Variation Reduction: Projects in Process<br />
  97. 97. Staging of Savings<br />
  98. 98. Additional Analytics Tools Needed<br />Add in EMR data<br />More recent<br />All payers<br />Has outcome data<br />Progress over time (SPC)<br />Simple drug comparisons of cost (3 bar)<br />Bubble chart<br />
  99. 99. Success Factors <br />73<br />
  100. 100. Roles Required for VR Projects<br />74<br />
  101. 101. Questions?<br />Reactions?<br />vandurenm@sutterhealth.org<br />916-402-7492<br />75<br />

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