How to Establish an Evidence-Based Care Delivery Structure Like Allina Health
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Clinicians have to make difficult decisions on a regular basis. And when different clinicians within the same health system make markedly different decisions about medical treatment, significant waste and inconsistent outcomes arise. What will be discussed?: Establishing peer-reviewed and approved CPGs Prioritizing improvements Developing the CPG checklist Engaging and collaborating with clinicians Don't miss hearing firsthand how Allina established a systemwide EBDM model and realized a five percent decrease in Stage 1 lung cancer treatment variation as well as a 20 percent decrease in the number of heparin protocols.
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How to Establish an Evidence-Based Care Delivery Structure Like Allina Health
- 1. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential How to Establish an Evidence- Based Care Delivery Structure Like Allina Health Webinar, April 27, 2016 Dr. Timothy Sielaff Anna Kleckner, MPH, PhD CMO & SVP Specialty Care and Research Evidence-Based Practice Consultant
- 2. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Learning Objectives 1. Identify necessary components in a system-wide evidence-based decision-making model 2. Understand how to provide consistent, optimal care to patients regardless of treatment location 3. Leverage existing data sources to monitor adherence to clinical practice guidelines
- 3. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Jane’s Story
- 4. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Screen Dx mammo+ 1/2 day work Bx+ full day work PET Lung Bx & Ptx+ (1 HD) Pos margin lumpectomy Re-excision Oncotype Dx Chemotherapy Jane’s Story
- 5. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential a) Yes – 7% b) No – 45% c) Both – 41% d) Neither – 6% Poll Question Did Jane get great care? 82 respondents
- 6. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential 6 90+ clinics 13 Hospitals 16 Pharmacies Allina Health
- 7. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Allina Health plus … 11 regional health systems 2,900 physicians over 60 practices 24 specialties 13 EMRs non-exclusive to Allina Health Allina Integrated Medical Network
- 8. 8
- 9. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential One promise Shared clinical imperatives Best practices Variation in care
- 10. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Clinical Service Lines (CSLs) – Program Committees Onc Neurosci CV Breast, Lung, GI (Colo., Upper, HPB), Gyn Onc Heart Failure, Structural, Prevention Epilepsy, NeuroVasc (stroke, IR, telestroke), NeuroOnc + 8
- 11. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Uncertainty and Variation in Healthcare difficult decisions & uncertainty variation & waste1,2 11 1. Han PK, Klein WM and Arora NK. Varieties of uncertainty in health care: a conceptual taxonomy. Med Decision Making November/December 2011 31: 828-838. 2. Delaune J and Everett W. Waste and Uncertainty in the U.S. Health Care System. New England Healthcare Institute. 2008. Available at: http://www.nehi.net/writable/publication_files/file/waste_clinical_care_report_final.pdf
- 12. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Capturing Opportunities 12 Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press, 2013. doi:10.17226/13444.
- 13. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Clinical practice guidelines (CPGs) Incorporating Evidence into Care • Best available evidence • Decision making • Care delivery 13 Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press, 2013. doi:10.17226/13444.
- 14. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential 14 “Systematic, evidence-based process improvement methods applied in various sectors to achieve often striking results in safety, quality, reliability, and value can be similarly transformative for health care.” Institute of Medicine. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: The National Academies Press, 2013. doi:10.17226/13444.
- 15. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Evidence-Based Decision Making (EBDM) Best available evidence Clinician's expertise Patient's values & preferences Shared decision making 15 Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM (2nd edition). Edinburgh & New York: Churchill Livingstone, 2000. Emily Oshima Lee, M.A., and Ezekiel J. Emanuel, M.D., Ph.D. Shared Decision Making to Improve Care and Reduce Costs. N Engl J Med 2013; 368:6-8.
- 16. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential EBDM Challenges at Allina • Variation in processes for developing CPGs • No standard framework • Providers are busy • No system-wide policy or infrastructure 16
- 17. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Poll Question Does your organization have standard process for development of system-wide best practices? 90 respondents A) None or not sure – 16% B) Just getting started – 24% C) Half-way there – 30% D) Well-established (I should be giving this webinar) – 3% E) Not applicable – 27% 17
- 18. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential How Allina Built the EBDM Infrastructure 1. Implemented a System-Wide EBDM Policy 2. Established EBDM Governance 3. Tested Feasibility & Utility Stage I Lung Cancer IV Heparin 4. Prioritization Criteria 5. Culture of Collaboration 18
- 19. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential 1. Implement a System-Wide EBDM Policy Language Terminology EBDM Framework Checklist 19
- 20. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Language Purpose Statement • Improve care delivery and patient satisfaction • To reduce variation in standards of practice across the system • To standardize operational processes in guideline development • Reduce costs 20
- 21. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Language Policy Statements A. “Allina Health will follow a standard process for the development, approval, revision, and implementation of Allina Health clinical guidelines for specific clinical circumstances. B. …ensure compliance with the processes and procedures within the Allina Health Model for Evidence-Based Decision Making …” 21
- 22. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Language Expectations for Physicians • Follow approved guidelines • “Deviations” expected • Documentation of deviations expected 22
- 23. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Terminology Policy A comprehensive statement developed to assure appropriate action or work is performed and is in compliance with applicable regulation or law. In general, policies define “what we do” and remain fairly constant over time. A policy: ● communicates what must be done and the desired outcome of that action ● provides principles to guide decision making 23
- 24. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential24 Terminology Clinical Guideline • Systematically developed statements designed to support the decision-making processes in patient care • Intended to optimize patient care and are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options • Identify and evaluate the most current information about prevention, diagnosis, prognosis, therapy, risk/benefit and cost effectiveness 24 Allina Health Clinical Guidelines have been, or are being, submitted for approval through the Allina Health Quality Council, and may include adoption of existing national clinical guidelines, or expert-driven statements that meet the definition of System-Wide Clinical Guidelines. • Different from policies, guidelines define and guide not what we do, but why and how we do it. • Expected to change along with evidence, and should be reviewed on a regular basis.
- 25. EBDM Framework Allina Health Model for EBDM Variation/ Gaps/ Inequities/QI opportunity Synthesize Knowledge Formalize Knowledge Localize Knowledge Implementation & Evaluation Process Development Process Stakeholder Review Process (Policy, Procedure, Guideline, Other) Measureable Impact Allina Information • Data Analytics • Critical Events • PICO(TS) Framework • Content Review • Experts, Literature, Patients • Library Services • EBP Methodologist • Project Management • Stakeholder Review • Strategic Alignment • Quality Review • CDS, Excellian • Education • Compliance • Diffusion • Analytics • Research Allina Health Resources
- 26. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential26 Checklist 26
- 27. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential 2. EBDM Governance • Endorsement body (monthly) Policy experts endorse processes & format • Peer review & approval body (monthly) Quality experts (medical & executive) • Tracking system 3-year (max) review cycle • EBDM Core Team (quarterly) Diverse group, customer voice 27
- 28. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Stage I Lung Cancer IV Heparin 3. Proof of Feasibility & Utility 28
- 29. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Stage I Lung Cancer Opportunities 29 • Establish consensus • Allina Health “best practice” • NCCN, ACCP guideline • High risk definition • Monitoring & feedback Site A B C Treatment Surgery (%) RT (%) Surgery (%) RT (%) Surgery (%) RT (%) Pre (N = 324) 69 31 81 19 96 4 Post (N = 100) 85 15 63 37 85 15 Difference by Site +16 -16 -18 +18 -11 +11 Variation in treatment was 27% (surgery: 96% - 69%, RT: 31% - 4%) Variation in treatment was 22% (surgery: 85% -63%, RT: 37% - 15%) 5% reduction in variation across the system
- 30. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Stage I Lung Cancer: EBDM Model 30 Variation/ Gaps/ Inequities/QI opportunity Synthesize Knowledge Formalize Knowledge Localize Knowledge Implementation & Evaluation Process Development Process Stakeholder Review Process (Policy, Procedure, Guideline, Other) Measureable Impact Allina Information • Data Analytics • Critical Events • PICO(TS) Framework • Content Review • Experts, Literature, Patients • Library Services • EBP Methodologist • Project Management • Stakeholder Review • Strategic Alignment • Quality Review • CDS, Excellian • Education • Compliance • Diffusion • Analytics • Research Allina Health Resources • PICO Lit Search • PICO Lit Review • Analytics • Newsletters, Intranet • Analytics • NCCN abstract/poster • Charter • Adopt Guidelines • Committee Approval • Quality Council approval
- 31. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential IV Heparin Opportunities • Standardization of IV Heparin • Improve patient safety and patient experience • Reduce costs: • Use APTT instead of anti-Xa • Adverse events, especially bleeding • Improve safety monitoring of anticoagulation meds (Joint Commission National Patient Safety Goals) Pre: 20+ site-based documents (policies, protocols, etc.) Post: 1 system-wide guideline, 4 system-wide protocols 31
- 32. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential IV Heparin: EBDM Model Variation/ Gaps/ Inequities/QI opportunity Synthesize Knowledge Formalize Knowledge Localize Knowledge Implementation & Evaluation Process Development Process Stakeholder Review Process (Policy, Procedure, Guideline, Other) Measureable Impact Allina Information • Data Analytics • Critical Events • PICO(TS) Framework • Content Review • Experts, Literature, Patients • Library Services • EBP Methodologist • Project Management • Stakeholder Review • Strategic Alignment • Quality Review • CDS, Excellian • Education • Compliance • Diffusion • Analytics • Research Allina Health Resources • PICO Lit Search • PICO Lit Review • Formulation of Work Groups • Charter/Aim Statement • Recommend aPTT • 1 guideline, 4 protocols • Screening tool • Benchmarking • Onsite visits • Excellian • Dashboard
- 33. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Anticoagulation Safety Dashboard 33
- 34. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Poll Question How effective is your organization at implementing a new system- wide best practice? 72 respondents A) Not effective at all – 10% B) Some better than others, depends – 44% C) Effective, with some room to grow – 18% D) Very effective (we should be doing a webinar) – 3% E) Don’t know or Not applicable – 26% 34
- 35. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Development Implementation & Diffusion 4. Prioritizing EBDM Initiatives Identified variation Volume Readiness Alignment Motivation Champion Impact a commonly performed process Implementation capacity Operations support Clinical leadership support obtained Champion 35
- 36. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential 5. Culture of Collaboration • Collaborative vs. Punitive Offering a service vs. requirement • Clinical Service Line / Program Structure • Start with low-hanging fruit Gained momentum Reduced skepticism • Dedicated resource (1 FTE) 36
- 37. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential What’s Next? • Expand policy and EBDM model to additional clinical areas and conditions - 20 approved guidelines in 1 year • Upstream implementation consult - Resource identification • Implementation, measurement & communication of guideline initiatives - Evidence-Based Care Delivery Dashboard 37
- 38. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential The Cost of Jane’s Story Screen Dx mammo+ 1/2 day work Bx+ full day work PET Lung Bx & Ptx+ (1 Hosp d) Pos margin lumpectomy Re-excision Oncotype Dx Chemotherapy $500 $1000 $2,500 $4,500 $3,500 $5,000 $3,000 $3,000 $12,500 $37,000 Lost job …
- 39. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Waste Screen Dx mammo Bx PET Lung Bx & Ptx+ (1 Hosp d) Pos margin lumpectomy Re-excision Oncotype Dx Chemotherapy $500 $750 + $250 ½ day work $2,000 + $500 full day work $4,500 $3,000 + $500 + (1 Hosp day) $5,000 $5,000 $3,000 $12,500 $8,500
- 41. © 2015 Health Catalyst www.healthcatalyst.com Proprietary and Confidential Q & A
Editor's Notes
- Expectations for physicians and practitioners: • Physicians and practitioners are expected to attend to and follow relevant approved clinical guidelines for evidence-based clinical decision making. • Physicians and practitioners may deviate from the guidelines when, in the exercise of their clinical judgment, the deviation is indicated. • Physicians and practitioners are expected to document their reasons for deviating from the guideline in the patient’s medical record. • Deviations from the approved guidelines will be reviewed and may be subject to possible improvement strategies and/or local peer review if indicated. Indications for local peer review may include (but are not limited to) tripped quality indicators, physician/staff reports, patient complaints, and/or payer inquiries that point to unsubstantiated deviations from the approved guideline.