Best Practices in Implementing Population Health
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To manage population health, one needs to intimately understand the anatomy of healthcare and model how healthcare is delivered, in order to systematically improve healthcare outcomes. In this webinar, Dr. Burton draws on his 26-year executive career at Intermountain, Select Health, and Health Catalyst. He emphasizes the importance of linking administrative data (e.g., billing codes) to processes of clinical care to use the 80/20 principle to prioritize care processes within each venue to focus improvement initiatives on the things that matter most. He will also discuss a Clinical Integration framework to use in driving out waste by reducing variation in the ordering of care, the efficiency with which the care that is ordered is delivered and reducing defects in care delivery to make it safer.
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Best Practices in Implementing Population Health
- 1. © 2013 Health Catalyst ww©w.2h0e1a3lthHceaataltlhysCt.acotamlyst www.healthcatalyst.com Proprietary and Confidential Proprietary and Confidential Population Health Management David A. Burton, MD
- 2. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Emphasis on the Continuum of Care Outpatient Inpatient Skilled Nursing Facility Population Health Management Home Home Health Care Clinic Care Hospice Cemetery
- 3. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Population Health Management Paradigm Shift Acute Care-Centric Management Inpatient Outpatient Skilled Nursing Facility Home Home Health Care Clinic Care Hospice Cemetery Inpatient Population-Centric Management
- 4. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Poll question Outpatient Inpatient 1 2 Outpatient Inpatient HospiceHome Health 3 Outpatient Inpatient HospiceHome Health Clinic Care 4 SNF 5 Outpatient Inpatient HospiceHome Health Clinic Care Other combination
- 5. Population Health Management Anatomy of Healthcare Delivery Symptoms
- 6. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Population Health Management 6 Care Processes Clinical Integration hierarchy - Care Processes Home Clinic Care Outpatient Inpatient SNF Home Health Hyperlipidemia Acute Myocardial Infarction (AMI) Percutaneous Intervention (PCI) Coronary Artery Bypass Graft (CABG) Cardiac Rehab Hospice Coronary Atherosclerosis
- 7. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential 7 Population Health Management Clinical Integration hierarchy - Care Process Families Home Clinic Care Outpatient Inpatient SNF Home Health Hospice Hyperlipidemia Acute Myocardial Infarction (AMI) Percutaneous Intervention (PCI) Coronary Artery Bypass Graft (CABG) Cardiac Rehab Ischemic Heart Disease Care Process Family Coronary Atherosclerosis
- 8. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Population Health Management Vascular Disorders Care Process Family Heart Rhythm Disorders Care Process Family Heart Failure Care Process Family Clinical Integration hierarchy - Clinical Programs Home Clinic Care Outpatient Inpatient SNF Home Health Ischemic Heart Disease Care Process Family Cardiovascular Clinical Program Hospice
- 9. © 2013 Health Catalyst Proprietary and9Confidential www.healthcatalyst.com Clinical Integration hierarchy Clinical Programs – ordering of care Primary Care Care Process Families e.g., Diabetes CV Care Process Families e.g., Heart Failure W&C Care Process Families e.g., Pregnancy GI Care Process Families e.g., Lower GI Disorders Resp- iratory Care Process Families e.g., Obstructive Lung Disorders Neuro Sciences Care Process Families e.g., Spine Disorders Musculo- skeletal Care Process Families e.g., Joint Replace- ment Surgery Care Process Families e.g., Urologic Disorders General Med Care Process Families e.g., Infectious Disease Oncology Care Process Families e.g., Breast Cancer Peds Spec Care Process Families e.g., Peds CV Surg Mental Health Care Process Families e.g., Depression
- 10. © 2013 Health Catalyst Proprietary an10d Confidential www.healthcatalyst.com Clinical Integration hierarchy Care Care Process Families e.g., Diabetes Care Process Families e.g., Heart Failure Care Process Families e.g., Pregnancy Care Process Families e.g., Lower GI Disorders Care Process Families e.g., Obstructive Lung Disorders Care Process Families e.g., Spine Disorders Care Process Families e.g., Joint Replace- ment Surgery Care Process Families e.g., Urologic Disorders Care Process Families e.g., Infectious Disease Oncology Care Process Families e.g., Breast Cancer Peds Spec Care Process Families e.g., Peds CV Surg Clinical Support Services – delivery of care ordered 12 Clinical Programs (“Ordering of Care”) Primary CV W&C GI Resp- iratory Neuro Sciences Musculo- skeletal General Med Mental Health Care Process Families e.g., Depression ClinicalSupportServices(DeliveryofCare) Diagnostic Clinical Support Service (work flow models) (e.g., Pathology and Laboratory Medicine, Diagnostic Radiology) Therapeutic Clinical Support Service (work flow models) (e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy) Ambulatory Clinic Clinical Support Service (work flow models) (e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics)) Acute Medical Clinical Support Service (work flow models) (e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg) Invasive Clinical Support Service (work flow models) (Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])
- 11. © 2013 Health Catalyst Proprietary and Confidential www.healthcatalyst.com Heart Rhythm Disorders Vascular Disorders Ischemic Heart Disease Heart Failure CARDIOVASCULAR Care Process Families Clinical Program ICD9 Volumes I-II 17,674 Diagnosis Codes ICD-9 Volume III 3,903 Procedure Codes 2013 CPT® Code Set 9706 Codes CPT-4 Code Groupings ICD9 Procedure Code Groupings ICD9 Diagnosis Code Groupings CABGPCIAMIACSCare Processes
- 12. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Population Health Management 12 Medicare 2011 fee-for-service payments by venue Clinic Care Outpatient Inpatient SNF Home Health Hospice $ 31.7 Billion 12.3% 77.6 Billion 30.1% 90.6 Billion 35.1% $ 29.7 Billion 11.5% $ 18.4 Billion 7.1% $ 10.1 Billion 3.9% Clinic Care Outpatient Inpatient SNF Home Health Hospice
- 13. © 2013 Health Catalyst Proprietary and Confidential www.healthcatalyst.com
- 14. © 2013 Health Catalyst Proprietary and Confidential www.healthcatalyst.com
- 15. © 2013 Health Catalyst Proprietary and Confidential www.healthcatalyst.com
- 16. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Poll question How does your organization prioritize improvement projects • Respond to desires of highest volume physicians with loudest voices • Respond to regulatory and accreditation imperatives • Based on pre-defined strategic criteria (including objective and subjective factors) • Other
- 17. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Our Philosophy: Be Systematic 17 Late-Binding™ Data Warehouse Platform Data Warehouse,Architecture, Metadata Management, Security, and Auditing Analytic Applications Key Process Analysis, Dashboards, Advanced Analytics Services Installation Services, Critical Improvement Services Integrate Data and Measure Apply Evidence and Standardize Change Process and Behavior
- 18. © 2013 Health Catalyst Proprietary an18d Confidential www.healthcatalyst.com Less TransformationMore Transformation Catalyst’s Adaptive Data Model Metadata: EDW Atlas Security and Auditing Common, Linkable Vocabulary Financial Source Marts Administrative Source Marts Departmental Source Marts Patient Source Marts EMR Source Marts HR Source Mart Diabetes Sepsis Readmissions Departmental Sources (e.g., Apollo) Patient Satisfaction Sources (e.g., NRC Picker, Press Ganey) Human Resources (e.g., PeopleSoft) Financial Sources (e.g., EPSi, Peoplesoft, Lawson) Administrative Sources (e.g., API Time Tracking) EMR Source (e.g., Epic, Cerner)
- 19. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Catalyst approach 19 1 Metadata-driven platform 2 Content-driven applications 3 Application families Foundational Applications Discovery Applications Advanced Applications Late-Binding™Data WarehousePlatform Data Acquisition Engine and Storage Metadata Engine Late-Binding™ Data Bus
- 20. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Cluster = Hub Hospital/Region, Medical Group, Health Plan, Section/Division Clinical Integration Leadership Team (CILT) 20 Administration Vice-Chair CNO Vice-Chair Cluster CMO Cluster CNO Cluster Administrator CMO Chair Chief InformationOfficer Chief Knowledge Officer Cluster #1 Cluster #2 Cluster #3 Cluster # … Cluster #N Cluster CMO Cluster CNO Cluster Administrator Cluster CMO Cluster CNO Cluster Administrator Cluster CMO Cluster CNO Cluster Administrator Cluster CMO Cluster CNO Cluster Administrator
- 21. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential CV Clinical Program Guidance Team 21 Nurse Director Vice-Chair CV Physician Chair* CV MD Lead CV Nurse Lead CV Administrator Cluster #1 Cluster #2 CV MD Lead CV Nurse Lead CV Administrator Cluster #3 CV MD Lead CV Nurse Lead CV Administrator Cluster #4 CV MD Lead CV Nurse Lead CV Administrator Ischemic* MD Chair Heart Failure MD Chair Rhythm Disorders MD Chair Vascular Disorders MD Chair * One of the Clinical Implementation Team chairs also serves as the Guidance Team chair (Ischemic MD Chair in this example)
- 22. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Clinical Implementation Team (CIT) Heart Failure Care Process Family 22 Heart Failure MD Chair Cardiologist CV RN Director Vice-Chair Heart Failure MD Lead CV Nurse Lead Facility #1 Facility #2 Heart Failure MD Chair CV Nurse Lead Facility #3 Heart Failure MD Chair CV Nurse Lead Facility #4 Heart Failure MD Chair CV Nurse Lead
- 23. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential CIT Work Group 23 CIT Chair (MD) Scientific SME Clinical Operations Director Front Line Clinical Ops Workflow SME Provider/Patient Education Team Clinical Application Steward Administrative Application Steward * CMIO, CQO, Chief Patient Safety Officer, or Chief Analytics Officer provided individual has requisite qualifications and skills Data Architect Knowledge Manager Subject Matter Expert Data Capture Workflow Analysis Data Provisioning Data Analysis
- 24. © 2013 Health Catalyst Proprietary an24d Confidential www.healthcatalyst.com Workgroup Roles DATA CAPTURE • Acquire key data elements • Assure data quality • Integrate data capture into operational workflow DATAANALYSIS • Interpret data • Discover new information in the data (data mining) • Evaluate data quality DATA PROVISIONING • Move data from transactional systems into the EDW • Build visualization for use by clinicians Knowledge Managers Data Architects (Analysis) Knowledge Managers Data Architects (infrastructure) Data Architects (Visualization) Application Administrators (e.g., EMR Administrators, Financial System Administrators) Subject Matter Expert Data Capture Workflow Analysis Data Provisioning Data Analysis
- 25. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Poll question Which clinical organizational teams do you have • Executive team responsible for prioritization and governance of clinical improvement initiatives • Domain governance teams (e.g., CV Clinical Service Line teams) • Clinical implementation teams (e.g., Heart Failure improvement team) • Infrastructure personnel/work groups to support clinical improvement teams
- 26. © 2013 Health Catalyst Proprietary and Confidential www.healthcatalyst.com Implementation flow diagram
- 27. Kickoff • Mission • Cohort Discover • Data Analysis and Review • BMJ Best Practices • Building Multiple Potential AIM statements AIM Statement • Supplement BMJ content • Refine Cohort • Refine Metrics • Develop Draft Visualizations • Develop Recommended AIMstatement#1 Implementation Design • Cluster Reps Obtain Front Line Input • Finalize Cohort • Develop Additional metrics based on feedback • Develop Additional Visualizations to support • PDSA cycle Launch Approval • Cluster Reps Obtain Front Line Input • Improvement Plan • Implementation Plan • Develop cluster rep assignments, and deliverables Results Review • Collect cluster rep feedback • Prepare Initial Results from AIM statement#1 • Summarized report for historical review • Refine, recommend AIM statement #2 Standard “organizational” work Monthly Tasks and Checkpoints 7 Steps (Work Streams) GatherKnowledge Assets Define Cohort Select AIM Statement Select,Build, Refine Metrics Develop 5 ImplementationPlan for Process Improvement 6 Implementation Measure Progress 1 2 3 4 7 Select Initial Metric Build and Refine Build and Refine Build and Refine
- 28. © 2013 Health Catalyst Proprietary an28d Confidential www.healthcatalyst.com Pregnancy
- 29. © 2013 Health Catalyst Proprietary an29d Confidential www.healthcatalyst.com Surgical Services
- 30. © 2013 Health Catalyst Proprietary an30d Confidential www.healthcatalyst.com Discharge from hospital to post-hospital service
- 31. © 2013 Health Catalyst Proprietary an31d Confidential www.healthcatalyst.com Pressure injury prevention
- 32. Slide Decks Handbooks Standard organizational work MD Contract Templates Team Charters Job Descriptions Job Family Grids Deployment Process Outlines Compensation Grids MeetingAgendas Project Status Reports Lar g e Clinic Me dian Compe ns ation Data $ / hour Diff fr om Min Mid Max Gr oup 5 2 0 0 0 Data 2 0 0 1 Data 2 0 0 2 Data 2 0 0 3 Data 2 0 0 4 Data 2 0 0 5 Data 2 0 0 6 Data at 4 5 / wk me dian 0.80 1.00 1.20 17.55 CV Su rg 8 19.47 Ra d io lo g y (in terventional) 2 Ca rd io lo g y - Ca th -2 21.56 Ra d io lo g y (n o n-interventio nal) -7 Ort h o 306,403 349,697 351,221 366,732 389,997 402,003 412,004 176 -10 23.89 Me dian - Gr oup 5 3 0 6 ,2 0 2 3 5 2 ,8 4 9 3 6 3 ,1 1 1 3 8 7 ,9 7 3 4 0 0 ,1 2 4 4 1 8 ,5 4 7 4 3 6 ,3 1 1 1 8 6 3 1 1 ,9 7 7 3 5 4 ,1 1 6 3 6 9 ,4 2 1 3 9 0 ,6 7 7 4 0 7 ,0 8 1 4 3 1 ,4 7 8 4 4 3 ,3 4 6 1 8 9 $ 149 $ 1 8 6 $ 224Me an - Gr oup 526.46 S te p = $ 2 9 ,5 0 0 16 32.52 Ca rd io lo g y - Ge n e ral 261,000 279,470 304,994 320,000 312,010 350,000 359,004 153 6 Va s c u lar 281,143 289,918 310,401 320,210 336,820 321,131 355,000 152 5 36.03 Uro lo g y 264,175 285,500 310,964 319,000 322,000 343,769 346,633 148 251,083 282,501 307,500 314,495 330,008 338,256 344,960 147 1 039.94 A n e s thes iolog y Pla s tics 273,261 294,039 297,250 300,000 340,880 343,497 342,901 147 0 44.24 Ga s tro e n tero logy 240,000 246,500 271,503 300,000 304,994 314,495 340,010 145 -2 Ge n e ral Su rg e ry 250,251 273,956 294,925 287,915 309,021 320,689 336,694 144 -3 49.04 ENT 250,000 268,403 279,985 293,000 308,363 320,958 320,890 137 -10 54.34 Op h th 235,033 245,615 259,585 278,023 212,746 286,434 309,281 132 -15 Me dian - Gr oup 4 2 5 6 ,0 4 2 2 7 9 ,4 7 0 3 0 1 ,1 2 2 3 0 6 ,1 1 9 3 1 7 ,0 0 5 3 2 9 ,6 9 4 3 4 3 ,9 3 1 1 4 7 $ 118 $ 1 4 7 $ 176 60.24 Me an - Gr oup 4 2 6 0 ,4 1 0 2 7 3 ,9 8 9 3 0 2 ,3 0 2 3 0 4 ,4 8 8 3 1 7 ,2 6 5 3 3 1 ,4 2 3 3 4 3 ,7 7 9 1 4 7 S te p = $ 2 1 ,0 0 0 Gr oup 3 D.14 Clin ical Pa th olo gy 217,500 233,677 232,984 251,227 225,000 263,750 287,927 123 10 He ma t olo gy & M e d. On co logy 189,000 205,000 223,470 231,794 251,241 261,501 280,001 120 6 D.17 De rma to logy 185,339 204,283 217,294 228,270 241,498 255,568 279,000 119 6 OB-Gy n - Bra n c h 217,426 229,238 233,295 245,568 249,256 256,997 269,147 115 2 D.19 OB-Gy n 229,699 243,434 254,563 252,400 260,776 263,816 262,000 112 -2 D.20 Critical Ca re M e dicine 207,250 218,000 223,500 228,740 228,740 234,503 249,996 107 -7 Eme rg e n cy Ca re 189,286 202,690 211,000 221,927 232,749 238,523 248,227 106 -7 Ne o n atolo gy 206,003 203,971 218,703 213,139 236,378 249,409 247,829 106 -8 Me dian - Gr oup 3 2 0 6 ,6 2 7 2 1 1 ,5 0 0 2 2 3 ,4 8 5 2 3 0 ,2 6 7 2 3 8 ,9 3 8 2 5 6 ,2 8 3 2 6 5 ,5 7 4 1 1 3 $ 91 $ 1 1 3 $ 136N.13 Me an - Gr oup 3 2 0 5 ,1 8 8 2 1 7 ,5 3 6 2 2 6 ,8 5 1 2 3 4 ,1 3 3 2 4 0 ,7 0 5 2 5 3 ,0 0 8 2 6 5 ,5 1 6 1 1 3 S te p = $ 1 3 ,0 0 0 Gr oup 2 N.17 Pu lmo n a ry Dis e ase 188,250 201,714 200,000 205,764 218,000 223,273 234,885 100 12 Ne p h ro log y 187,000 191,661 196,752 204,617 214,751 217,757 225,504 96 8 N.19 A lle rg y /A sth ma 175,363 191,385 194,500 198,376 201,241 210,970 221,833 95 7 Ph y s ia try 176,617 180,953 187,252 183,337 201,993 207,004 219,992 94 6 Ne u ro lo gy 182,600 188,431 191,496 195,000 201,241 210,500 211,664 90 2 D.13 En d o crin olo gy 165,000 182,658 180,354 188,992 185,000 185,250 200,529 86 -2 In fe c tio us Dis eas e 161,447 164,894 179,473 186,896 178,627 189,615 197,996 85 -3 D.15 Urg e n t Ca re 142,906 157,368 161,785 165,559 168,143 187,000 197,820 85 -4 D.17 Oc c M e d 172,414 178,224 186,250 181,459 186,402 194,247 194,213 83 -5 Rh e u ma tolo gy 158,506 175,117 176,805 179,700 181,016 185,000 190,000 81 -7 D.19 Me dian - Gr oup 2 1 7 3 ,8 8 9 1 8 1 ,8 0 6 1 8 6 ,7 5 1 1 8 7 ,9 4 4 1 9 3 ,8 2 2 2 0 0 ,6 2 6 2 0 6 ,0 9 7 8 8 $ 70 $ 8 8 $ 106Me an - Gr oup 2 1 7 1 ,0 1 0 1 8 1 ,2 4 0 1 8 5 ,4 6 7 1 8 8 ,9 7 0 1 9 3 ,6 4 1 2 0 1 ,0 6 2 2 0 9 ,4 4 4 9 0 S te p = $ 5 ,0 0 0 Gr oup 1 Ps y c h iatry 150,232 159,448 162,000 161,202 171,300 172,350 184,827 79 5 Ge n e ral IM 142,084 150,046 153,786 153,939 165,375 172,565 178,005 76 2 Fa mily M e d icine 139,725 147,025 155,050 154,018 166,105 172,157 175,080 75 0 Pe d s 136,906 142,056 146,310 145,351 158,250 164,631 173,338 74 0 In t e rnal M e dicine - Bra n c h 137,859 143,513 152,933 157,718 153,561 162,732 168,344 72 -3 Pe d s -A d o l - Bra n c h 135,800 138,000 144,643 144,436 150,112 154,000 163,917 70 -4 Me dian - Gr oup 1 1 3 8 ,7 9 2 1 4 5 ,2 6 9 1 5 3 ,3 6 0 1 5 3 ,9 7 9 1 6 1 ,8 1 3 1 6 8 ,3 9 4 1 7 4 ,2 0 9 7 4 $ 60 $ 7 4 $ 89Ave r ag e - Gr oup 1 1 4 0 ,4 3 4 1 4 6 ,6 8 1 1 5 2 ,4 5 4 1 5 2 ,7 7 7 1 6 0 ,7 8 4 1 6 6 ,4 0 6 1 7 3 ,9 1 9 7 4 D.8 11.69 14.63 D.9 12.99 16.21 D.10 D.11 14.39 15.91 17.97 19.91 D.12 17.65 22.07 D.14 21.67 27.10 D.15 24.02 30.03 D.16 D.17 26.63 29.50 33.28 36.88 D.18 32.67 40.86 D.19 36.23 45.28 D.20 40.15 50.18 DATA ARCHITECT-ASSOC DATA ARCHITECT-STAFF DATA ARCHITECT-SR DATA ARCHITECT-CNSLT OUTCOMES ANALYST-ASSOC OUTCOMES ANALYST-STAFF N.15 OUTCOMES ANALYST-SR OUTCOMES ANALYST-CNSLT DATA MANAGER-ASSOC DATA MANAGER-STAFF DATA MANAGER-SR DATA MANAGER-CNSLT 27 Compe ns ation Rate by S pe c ialty Adminis tr ative Rates by Gr oup GRADE MIN MID MAX Neurosurg 345,250 389,644 395,305 400,942 450,006 465,000 499,992 214 380,207 415,351 438,901 441,133 440,000 474,772 455,455 195 306,000 356,001 375,000 410,250 410,250 424,992 440,004 188 276,001 304,750 325,494 375,003 380,234 412,101 432,618 185 258,000 309,255 330,603 350,000 372,000 410,000 420,000 179 D.13 19.56 24.45 29.36 Group4 MFM (Perinatology) 298,158 no data 385,917 312,238 395,809 375,005 382,414 163
- 33. © 2013 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Poll question How prepared do you feel to implement population health management and shared accountability (e.g., ACO) strategies?
- 34. Thank you