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January 16, 2014 – David A. Burton, MD
Advanced Efforts to Identify and Reduce Waste in Healthcare Delivery
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1. Constructs for understanding healthcare waste
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Clinical Integration Construct 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
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Clinical Integration Construct Clinical Support Services – workflow and defects
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
Clin
ical
Sup
port
Ser
vice
s (D
eliv
ery
of C
are)
Diagnostic Clinical Support Service (work flow models) (e.g., Pathology and Laboratory Medicine, Diagnostic Radiology)
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])
Therapeutic Clinical Support Service (work flow models) (e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy)
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Organization of teams Clinical and technical
Provides steady state domain governance and oversight
GUIDANCE TEAM
Refines Work Group output and leads implementation
CLINICAL IMPLEMENTATION
TEAM
Provides l forum to develop and/or refine clinical content and analytics feedback
WORK GROUP
Supports development of clinical content and
analytics feedback
CONTENT AND ANALYTICS
TEAM
Provides overall governance and prioritization of initiatives SENIOR EXECUTIVE
LEADERSHIP TEAM
Chief Knowledge Officer
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Technical support personnel
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=
Organization of clinical teams
Women & Newborn’s Clinical Program Guidance Team
Pregnancy SAM
Pregnancy MD Lead RN SME
Knowledge Manager
Data Architect
Application Administrator
RN, Clinical Ops Director
Guidance Team MD lead (e.g., Pregnancy MD Lead)
= Subject Matter Expert = Data Capture
= Data Provisioning & Visualization
= Data Analysis
Normal Newborn SAM
NL Newborn MD Lead RN SME
Gynecology SAM
Gyn MD Lead RN SME
• Permanent teams
• Integrated clinical and technical members
• Technical personnel support multiple packets
AbNL NB 3-A SAM
AbNL NB MD Lead RN SME
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Repeatable system for deployment Kickoff AIM Statement Implementa3on
Design Launch Approval Results Review
• Mission • Cohort Discover • Data Analysis and Review
• BMJ Best Prac9ces • Building Mul9ple Poten9al AIM statements
• Supplement BMJ content
• Refine Cohort • Refine Metrics • Develop DraA Visualiza9ons
• Develop Recommended AIM statement #1
• Cluster Reps Obtain Front Line Input
• Finalize Cohort • Develop Addi9onal metrics based on feedback
• Develop Addi9onal Visualiza9ons to support
• PDSA cycle
• Cluster Reps Obtain Front Line Input
• Improvement Plan • Implementa9on Plan • Develop cluster rep assignments, and deliverables
• Collect cluster rep feedback
• Prepare Ini9al Results from AIM statement #1
• Summarized report for historical review
• Refine, recommend AIM statement #2
Monthly Tasks and Checkpoints
7 Steps (Work Streams) 1. Gather knowledge assets
2. Define cohort
3. Select Aim Statement
4. Select, build & refine metrics
5. Develop implementa3on plan
6. Implement plan
7. Measure progress
Select Ini9al Metric Build and Refine Build and Refine Build and Refine
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Population Health Management construct
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Population Health Management Medicare fee-for-service payments by venue - 2011
Outpatient Clinic Care Inpatient SNF Home Health Hospice
$ 31.7 Billion 11.8%
77.6 Billion 28.8%
90.6 Billion 33.7%
$ 29.7 Billion 11.0%
$ 18.4 Billion 6.8%
$ 10.1 Billion 3.7%
Clinic Care Outpa3ent Inpa3ent SNF LTCH/IRF Home Health Hospice
$ 11.1 Billion 4.1%
LTCH/IRF
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Home (Patient Portal)
* To Invasive Care Processes
Clinic Care Non-recurrent
Clinic Care Chronic
Acute Medical IP Med-Surg
Acute Medical IP ICU
Invasive Medical
Invasive Surgical
Diagnostic Work-up
Bedside care
Triage to Treatment Venue
Substance Preparation
Invasive* Subspecialist
Chronic Disease
Subspecialist
Screening & Preventive Symptoms
Population Health Management Anatomy of Healthcare Delivery
Diagnostic algorithms
Indications for Referral
Indications for Intervention
Triage Criteria
Diagnostic Algorithms, Triage Criteria, Referral & Intervention Indications
Utilization Management
Knowledge Assets
Substance Selection
Substance Selection
Clinical Supply Chain Management
Procedure Treatment and
Monitoring Algorithms
Admission Order Sets Admission Order Sets
Supplementary Order Sets
Pre-Procedure Order Sets
Post-procedure Order Sets
Discharge
Bedside care practice guidelines, risk assessment and patient injury prevention protocols, bedside care procedures, transfer and discharge protocols
Treatment and Monitoring Algorithms
Health Maintenance and Preventive Guidelines
Standardized Follow-up
Post-acute care order sets IP (SNF, IRF) Home health Hospice
Management of Preventive, Ambulatory, Acute Medical, Invasive & PAC Modules
Prevention and Treatment Knowledge
Assets
Clinical ops procedure guidelines and patient injury prevention
Post-procedure Care
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Waste construct
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Utilization management waste and prevention and treatment waste
Utilization Management
Waste Per capita management (population focus)
Per encounter and per case management
(individual patient focus)
Prevention and Treatment
Waste
Sample Metrics Admits/1000 members IP days/1000 members OP visits/1000 members Procedures/1000 members ED visits/1000 members Readmissions/1000 members
Sample Metrics Cost/visit Cost/case OR minutes L&D hours LOS # of comorbidities
Population Health Management
Per Capita Waste
Per Encounter or Per Case
Waste
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Ordering Waste Workflow Waste Defect Waste
Ordering tests, care, substances and
supplies that do not add value
Variation in efficiency of delivering tests, care
and procedures ordered
Patient injuries incurred in delivering tests, care and procedures ordered
14
Three forms of waste
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Ordering Waste Workflow Waste Defect Waste
Ordering of tests that are neither diagnostic nor
contributory
Variation in efficiency of delivering tests, care
and procedures ordered
Patient injuries incurred in delivering tests, care and procedures ordered
Ordering Waste
Ordering tests, care, substances and
supplies that do not add value
15
Ordering waste
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Clinical Integration Construct 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
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Ordering of care Improvement initiative process
Mapping of admin codes to HC
clinical hierarchy
Basic cohorts –admin rules
Per Case Key Process Analyses
Advanced cohorts - admin
and clinical rules
Care Process Models for KPA
Care Process list
AIM statement starter sets
Prevention, treatment, & UM
starter sets
Process and outcome metrics & visualizations
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Wasteful
Cardiac ventriculography to measure ejection fraction
Contributory
Two-view chest X-ray Arterial blood gases
Diagnostic
Cardiac echo to measure ejection fraction
Brain natriuretic peptide (BNP)
Ordering waste example
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Ordering Waste Workflow Waste Defect Waste
Ordering tests, care, substances and
supplies that do not add value
Variation in OR room turnover (cycle time) or
Emergency Care wait time
Patient injuries incurred in delivering tests, care and procedures ordered
Workflow Waste
Variation in efficiency of delivering tests, care
and procedures ordered
19
Workflow waste
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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
Clin
ical
Sup
port
Ser
vice
s (D
eliv
ery
of C
are)
Diagnostic Clinical Support Services (work flow models) (e.g., Pathology and Laboratory Medicine, Diagnostic Radiology)
Ambulatory Clinic Clinical Support Services (work flow models) (e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics))
Acute Medical Clinical Support Services (work flow models) (e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg)
Invasive Clinical Support Services (work flow models) (Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])
Therapeutic Clinical Support Services (work flow models) (e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy)
Clinical Integration construct Clinical Support Services – delivery of care
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Mapping of client data to HC
clinical hierarchy
Triage of client data into care unit & ancillary depts
Clinical department value
stream maps
Intra- & inter- departmental
VSMs, A3s, & AIM statements
Pareto and opportunity
analyses
Workflow (delivery of care) Improvement initiative process
Process and outcome metrics & visualizations
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Workflow waste – surgical services
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Workflow waste – surgical services
reduce room turnover time
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Ordering Waste Workflow Waste Defect Waste
Ordering tests, care, substances and
supplies that do not add value
Variation in efficiency of delivering tests, care
and procedures ordered
ADEs, transfusion reactions, pressure ulcers,
HAIs, VTE, falls, wrong surgery
Defect Waste
Patient injuries incurred in delivering tests, care and procedures ordered
24
Defect waste (patient injury)
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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
Clin
ical
Sup
port
Ser
vice
s (D
eliv
ery
of C
are)
Diagnostic Clinical Support Services (work flow models) (e.g., Pathology and Laboratory Medicine, Diagnostic Radiology)
Ambulatory Clinic Clinical Support Services (work flow models) (e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics))
Acute Medical Clinical Support Services (work flow models) (e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg)
Invasive Clinical Support Services (work flow models) (Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])
Therapeutic Clinical Support Services (work flow models) (e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy)
Clinical Integration construct Clinical Support Services – delivery of care
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Hospital-Acquired Condition (HAC)
cohorts
Analysis of frequency, costs, potential savings
Patient injury Improvement initiative process
Define criteria for PIPP intervention
Define care units to which PIPPs
apply
PIPP surveillance process,
outcome metrics & visualizations
AIM statement starter sets
PIPP intervention protocol starter
sets
Patient Injury Prevention
Process (PIPP) starter set maps
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Defect waste – CLABSI prevention
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2. Prioritization – Sample healthcare industry analyses
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29
Utilization versus prevention and treatment waste
Utilization Management
Waste Per capita management (population focus)
Per encounter and per case management
(individual patient focus)
Prevention and Treatment
Waste
Sample Metrics Admits/1000 members IP days/1000 members OP visits/1000 members Procedures/1000 members ED visits/1000 members Readmissions/1000 members
Sample Metrics Cost/visit Cost/case OR minutes L&D hours LOS # of comorbidities
To be included in future waste analyses
(at such time as claims data are available)
Population Health Management
Included in today’s analysis (a subset of the total waste in the healthcare system)
Per Capita Waste
Per Encounter or Per Case
Waste
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Clinical Programs Key Process Analysis (KPA)
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Inpatient per case KPA
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
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Inpatient per case KPA
Clinic Care Outpa3ent Inpa3ent SNF LTCH/IRF Home Health Hospice
$ 31.7 Billion 11.8%
77.6 Billion 28.8%
90.6 Billion 33.7%
$ 29.7 Billion 11.0%
$ 18.4 Billion 6.8%
$ 10.1 Billion 3.7%
$ 11.1 Billion 4.1%
Outpatient Clinic Care Inpatient SNF Home Health Hospice LTCH/IRF
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Inpatient per case KPA
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Top 10 Care Process Families account for
over 40% of the opportunity
Top 32 Care Process Families account for
80% of the opportunity
X-Axis = Care Process Families by resources consumed (High to Low)
Cumulative Care Process Family % of total resources
Individual Care Process Family % of total resources
Y-A
xis
= Pe
rcen
t of t
otal
reso
urce
s co
nsum
ed
Inpatient per case KPA
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35
Y-‐ Axis =
Internal Varia9o
n in Resou
rces Con
sumed
Bubble Size = Case Count Bubble Color = Clinical Domain X Axis = 2012-‐2013 Variable Direct Cost
1
2
3
4
Inpatient per case KPA
PCI
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~ $20,000 difference in Average Direct Costs between “highest cost” provider and “lowest cost” provider for patients with identical intermediate level severity scores
Gro
uped
by
AP
R D
RG
– S
ever
ity S
core
Bubble Size = Case Count for provider
Bubble Color = APRDRG - Severity Score
X Axis = Average Variable Cost per Case for provider
Inpatient per case KPA
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Dr. J. 15 Cases $60,000 Avg. Cost Per Case
Mean Cost per Case = $20,000
$40,000 x 15 cases = $600,000 opportunity
Total Opportunity = $600,000
Total Opportunity = $1,475,000
$35,000 x 25 cases = $875,000 opportunity
Total Opportunity = $2,360,000
Total Opportunity = $3,960,000
Cost Per Case, Vascular Procedures
Inpatient per case opportunity analysis
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Gro
uped
by
AP
R D
RG
– S
ever
ity S
core
Bubble Size = Case Count for provider
Bubble Color = APRDRG - Severity Score
X Axis = Average Variable Cost per Case for provider
Inpatient per case opportunity
Waste reduction opportunity is calculated based on bringing the cases in each severity level of each APR-DRG down to the mean of the severity level
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Inpatient per case opportunity* Physician variation perspective
* This $97 MM is based on the impact of variation in MD practice across all types of relevant inpatient care units
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IP per case ordering waste Opportunity analysis
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IP per case ordering waste
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
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IP per case ordering waste Sources of ordering variation within a case
• Diagnostics • Laboratory tests • Diagnostic imaging studies
• Therapeutics • Therapies (e.g., respiratory, physical, et al) • Substances (e.g., antibiotics, blood products)
• Clinical supply chain (e.g., prosthetics, stents, synthetic bypass grafts, heart rhythm devices)
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Home (Patient Portal)
* To Invasive Care Processes
Clinic Care Non-recurrent
Clinic Care Chronic
Acute Medical IP Med-Surg
Acute Medical IP ICU
Invasive Medical
Invasive Surgical
Diagnostic Work-up
Bedside care
Triage to Treatment Venue
Substance Preparation
Invasive* Subspecialist
Chronic Disease
Subspecialist
Screening & Preventive Symptoms
Sources of per case ordering waste
Diagnostic algorithms
Indications for Referral
Indications for Intervention
Triage Criteria
Diagnostic Algorithms, Triage Criteria, Referral & Intervention Indications
Utilization Management
Knowledge Assets
Substance Selection
Substance Selection
Clinical Supply Chain Management
Procedure Treatment and
Monitoring Algorithms
Admission Order Sets Admission Order Sets
Supplementary Order Sets
Pre-Procedure Order Sets
Post-procedure Order Sets
Discharge
Bedside care practice guidelines, risk assessment and patient injury prevention protocols, bedside care procedures, transfer and discharge protocols
Treatment and Monitoring Algorithms
Health Maintenance and Preventive Guidelines
Standardized Follow-up
Post-acute care order sets IP (SNF, IRF) Home health Hospice
Management of Preventive, Ambulatory, Acute Medical, Invasive & PAC Modules
Prevention and Treatment Knowledge
Assets
Clinical ops procedure guidelines and patient injury prevention
Post-procedure Care
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IP per case ordering waste opportunity Care Process Family Total Variable
CostTotal Variable Cost
Opportunity%
OpportunityArthritis $4,495,738 $1,262,468 28.08%Pregnancy $3,386,142 $964,935 28.50%Lower GI disorders $9,223,075 $2,887,678 31.31%Pulmonary disorders $13,301,079 $4,112,305 30.92%Ischemic heart disease $16,422,491 $3,830,609 23.33%Heart failure $10,521,631 $3,151,318 29.95%Spine disorders $3,667,804 $868,486 23.68%Abdominal transplant $5,646,849 $1,150,355 20.37%Sepsis $11,766,105 $4,302,385 36.57%Infectious disease $9,757,995 $3,359,184 34.42%Abnormal newborn -‐ 3A $3,633,453 $1,078,333 29.68%Vascular disorders $10,090,688 $2,978,748 29.52%GU disorders $5,743,735 $1,790,536 31.17%Abnormal newborn -‐ 3B $5,504,113 $2,170,518 39.43%Other gastrointestinal disorders $6,150,878 $2,109,424 34.29%Heart rhythm disorders $7,745,049 $1,629,037 21.03%Trauma $5,481,067 $1,784,045 32.55%Intracranial disorders $4,655,176 $1,479,753 31.79%Sports medicine disorders $2,212,528 $616,926 27.88%Upper GI disorders $4,144,179 $1,239,599 29.91%Bone marrow procedures $6,001,248 $1,662,039 27.69%Chest procedures $2,943,145 $987,669 33.56%Heart and lung transplants $2,367,759 $654,981 27.66%TIA, stroke and paralysis $3,917,114 $1,311,687 33.49%Normal newborn $934,586 $97,998 10.49%Renal disorders $3,578,289 $1,306,072 36.50%Cancer therapeutic procedures $4,966,106 $2,057,475 41.43%Hematology $4,435,866 $1,839,409 41.47%Obstructive lung disease $3,598,005 $956,058 26.57%Biliary tract disorders $3,005,292 $849,573 28.27%Other cardiovascular disorders $3,084,102 $920,290 29.84%Liver disorders $3,662,416 $1,256,790 34.32%Pareto Total $186,043,705 $56,666,685 30.46%
Ordering Waste
* The $57 MM is based on the impact of variation in ordering of tests and services from ancillary (non-patient-care) departments (e.g., lab, imaging, pharmacy, therapies, supply chain, central services) adjusted by APR-DRG severity level
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Reducing per case ordering waste
• Order sets. Evidence-based order sets for the Care Processes in the Pareto list to reduce variation in the ordering of simple diagnostic tests (lab, imaging)
• Indications. Evidence-based indications and cost information to standardize utilization
• Imaging tests (e.g., MRI, CT, US, nuclear scans)
• Substances (e.g., utilization criteria for blood, antibiotics, total parenteral nutrition)
• Major clinical supplies (e.g., joint prosthetics, cardiac and vascular stents, synthetic bypass grafts, heart rhythm devices, neurostimulators)
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Reducing per case ordering waste • Health Catalyst advanced applications.
• High-level Care Process map laying out the scientific flow
• Aim Packet with 2-5 Aim statements
• Cohort definition to support the Aim Packet
• Common metrics plus additional outcome, process and balance metrics to support the Aim Packet
• Starter visualizations such as dashboards, scorecards, and/or interactive drill down reports
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Workflow waste Opportunity analysis
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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
Clin
ical
Sup
port
Ser
vice
s (D
eliv
ery
of C
are)
Diagnostic Clinical Support Services (work flow models) (e.g., Pathology and Laboratory Medicine, Diagnostic Radiology)
Ambulatory Clinic Clinical Support Services (work flow models) (e.g., Primary Care Clinics, Chronic Disease Specialty Clinics, Sub-specialty Clinics))
Acute Medical Clinical Support Services (work flow models) (e.g., Emergency Care, ICU/CCU/NICU/PICU, General Med-Surg)
Invasive Clinical Support Services (work flow models) (Interventional Medical [e.g., cath lab, interventional radiology, GI lab, L&D, rad onc] and Surgical [e.g., amb, IP])
Therapeutic Clinical Support Services (work flow models) (e.g., Pharmacy, Transfusion Medicine, Respiratory Therapy, Physical, Occupational, Speech Therapy)
Per case workflow waste opportunity Clinical Support Services
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Source: CA Office of State-wide Health Planning and Development (OSHPD) Annual financial reports for 2011 351 hospitals Exclusions: Kaiser State hospitals Small psych H’s
Clinical Support Service Clinical DepartmentExpenses by Clinical Department
% of Total Cum %
Acute Medical Med-‐Surg Acute Care 8,661,146,370 19.2% 19.2%Therapeutic Substance Preparation 4,662,386,338 10.3% 29.6%Therapeutic Clinical Equipment, Supplies & Services* 4,477,744,993 9.9% 39.5%Acute Medical Med-‐Surg Intensive Care 3,995,060,038 8.9% 48.3%Invasive Inpatient Surgery 3,788,458,767 8.4% 56.8%Diagnostic Laboratory 2,808,517,363 6.2% 63.0%Diagnostic Diagnostic Imaging 2,730,552,915 6.1% 69.0%Acute Medical Emergency Care 2,559,406,510 5.7% 74.7%Ambulatory Clinic Care 2,247,089,922 5.0% 79.7%Invasive Interventional Medical 1,495,321,329 3.3% 83.0%Invasive Labor & Delivery 1,159,880,048 2.6% 85.6%Therapeutic Respiratory Services 1,150,072,297 2.6% 88.1%Acute Medical Med-‐Surg Subacute Care 986,656,683 2.2% 90.3%Therapeutic Rehabilitation Services 912,246,803 2.0% 92.4%Therapeutic Dietary 616,656,823 1.4% 93.7%Ambulatory Research 413,491,699 0.9% 94.6%Therapeutic Other Ancillary Services 410,550,042 0.9% 95.6%Ambulatory Home Health Care Services 388,565,601 0.9% 96.4%Therapeutic Renal Dialysis 316,846,172 0.7% 97.1%Acute Medical Cardiology Services 314,448,422 0.7% 97.8%Acute Medical Social Services 285,775,151 0.6% 98.4%Invasive Outpatient Surgery 296,517,893 0.7% 99.1%Acute Medical Nursery 252,110,537 0.6% 99.7%Acute Medical Medical Transport 58,853,840 0.1% 99.8%Acute Medical Neurology Services 55,618,598 0.1% 99.9%Ambulatory Other Ambulatory 36,537,764 0.1% 100.0%
45,080,512,918 100.0%* Med supplies sold to pts, DME, central services
Per case workflow KPA - OSHPD
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CA OSHPD Data
Per case workflow KPA - OSHPD
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Per case workflow KPA
Care Process Family Total Variable Cost
Total Variable Cost Opportunity
% Opportunity
Arthritis $34,257,013 $4,315,132 12.60%Pregnancy $34,604,134 $3,652,085 10.55%Lower GI disorders $26,006,611 $5,598,156 21.53%Pulmonary disorders $21,083,792 $4,592,859 21.78%Ischemic heart disease $16,680,163 $3,241,204 19.43%Heart failure $21,605,230 $4,914,260 22.75%Spine disorders $28,559,591 $5,332,532 18.67%Abdominal transplant $24,209,074 $1,835,063 7.58%Sepsis $16,822,816 $4,909,676 29.18%Infectious disease $17,688,735 $4,145,960 23.44%Abnormal newborn -‐ 3A $22,057,913 $4,283,595 19.42%Vascular disorders $13,975,364 $3,505,618 25.08%GU disorders $17,328,064 $2,730,267 15.76%Abnormal newborn -‐ 3B $14,361,738 $4,060,365 28.27%Other gastrointestinal disorders $12,900,700 $2,909,332 22.55%Heart rhythm disorders $10,963,720 $2,061,714 18.80%Trauma $12,895,138 $3,498,346 27.13%Intracranial disorders $13,429,232 $3,017,544 22.47%Sports medicine disorders $11,905,026 $2,764,691 23.22%Upper GI disorders $9,088,177 $1,808,059 19.89%Bone marrow procedures $6,160,908 $862,841 14.01%Chest procedures $7,842,200 $1,586,223 20.23%Heart and lung transplants $8,075,094 $1,083,284 13.42%TIA, stroke and paralysis $6,193,324 $1,373,756 22.18%Normal newborn $8,898,584 $1,125,381 12.65%Renal disorders $6,264,978 $1,685,801 26.91%Cancer therapeutic procedures $4,194,787 $1,187,025 28.30%Hematology $4,592,082 $1,021,023 22.23%Obstructive lung disease $5,228,844 $1,220,267 23.34%Biliary tract disorders $5,775,453 $947,907 16.41%Other cardiovascular disorders $5,368,812 $1,126,570 20.98%Liver disorders $4,517,543 $1,097,365 24.29%Pareto Total $453,534,839 $87,493,901 19.29%
Workflow Waste
* The $87 MM is based on variation in efficiency of care delivery for inpatient care units (e.g., ICU, general med-surg acute care, sub-acute care, observation) adjusted by APR-DRG severity level
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Reducing per case workflow waste
• Value Stream Maps (VSMs). VSMs for the clinical departments in the Pareto list
• Improved capture of time stamps. • Today’s Lean/TPS improvement systems are highly
manual – automation is essential to ability to scale • Timely and complete capture of time stamps is key to
automation of workflow improvement systems • Success in wringing out workflow waste will depend on
improved focus on completeness and timeliness of time stamp capture in the EMR
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Reducing per case workflow waste
• Health Catalyst advanced applications. • Value Stream Map laying out the workflow to be improved
(Health Catalyst has about 70 starter set VSMs)
• Aim Packet with 2-5 Aim statements
• Cohort definition to support the Aim Packet
• Common metrics plus additional outcome, process and balance metrics to support the Aim Packet
• Starter visualizations such as dashboards, scorecards, and/or interactive drill down reports
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Defect (patient injury) waste Opportunity analysis
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HAC cohorts/registries
• Ventilator-associated pneumonia (VAP)
• Adverse drug events (ADEs)
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California Data
2,358
1,278 758 739
424 251 212 122 111 13 6 -
1,000
2,000
3,000
4,000
5,000
6,000
7,000
Hospital Acquired Conditions 2011 California Hospitals
All Payers
Total count 6,272
* Added in 2011
5,921
4,555 3,918
2,735
1,785
555 320 284 34 11 -
1,000
2,000
3,000
4,000
5,000
6,000
7,000
Hospital Acquired Conditions 2010 Medicare US Hospitals
Total count 20,118
Medicare Data C
ount
Cou
nt
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Condition Estimated cost% of Total Cum % Cases Cost/Case
Vascular Cath-‐Assoc Infection 405,299,703$ 51.9% 51.9% 2318 174,849$ Pressure Ulcers Stages III and IV 96,917,626$ 12.4% 64.3% 402 241,089$ Iatrogenic Pneumothorax 89,402,081$ 11.4% 75.8% 747 119,682$ Falls and Trauma 67,772,069$ 8.7% 84.4% 1134 59,764$ Cath-‐Assoc Urinary Tract Infection 59,991,394$ 7.7% 92.1% 720 83,321$ Surgical Site Infection 37,792,448$ 4.8% 97.0% 233 162,199$ Venous thromboembolism (VTE) 8,544,237$ 1.1% 98.1% 204 41,884$ Manifestions of Poor Glycemic Control 6,561,973$ 0.8% 98.9% 119 55,143$ Foreign Object Retained After Surgery 6,347,387$ 0.8% 99.7% 110 57,704$ Air Embolism 1,395,845$ 0.2% 99.9% 13 107,373$ Blood Incompatability 849,397$ 0.1% 100.0% 6 141,566$
780,874,160$ 6,006 130,016$ Cost estimated from gross charges based on cost to charge ratio = 0.254); Savings calculated from cost of DRG with HAC subtracted from average cost of DRG (for MS-DRGs and HAC with at least 5 cases). Estimated cost per case for all cases in California = $12,700 (3.7 million cases). Michael Dietzel analysis.
Estimated cost of defects 2011 OSHPD data
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Estimated potential savings Patient injury (defect) waste
Analytic methodology
For each MS-DRG and Hospital Acquired Condition (HAC) with at least five cases:
• Define the average total cost for each case which includes a Hospital Acquired Condition (defect)
• Define the average cost of the base MS-DRG case (without complication or comorbidity)
• Estimated potential savings (if HAC patient injury were eliminated) = cost of HAC case minus cost of base case
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-
100,000,000
200,000,000
300,000,000
400,000,000
Hospital Acquired Conditions Estimated Total Cost of Injury Cases 2011 California Hospitals All Payers
Total count of patients 6,006 without duplicates
*New HAC added in 2011
-
100,000,000
200,000,000
300,000,000
400,000,000
Hospital Acquired Conditions Estimated Savings of Injury Cases
2011 California Hospitals All Payers Total count of patients 6,006 without duplicates
Patient injury waste opportunity
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Focus on workflow/defect waste
CMS’s establishment of penalties weighted by measurement domain creates an incentive to choose CLABSI and CAUTI improvement initiatives (65% of total)
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Reducing per case defect waste • Define for each type of defect a Patient Injury
Prevention Process (PIPP). • Screening cohort of patients who may be at risk
• Screening criteria/tool (e.g., Braden Scale) to define patients who are at risk
• Clinical operations protocol to be implemented with at-risk patients to prevent injury
• Tracking system to detect injuries and near misses
• Treat patient injury as a “process failure” to be subjected to root-cause analysis rather than an “incident” to be reported
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Reducing per case defect waste
• Health Catalyst advanced applications. • Patient Injury Prevention Process map (combination of
workflow VSM and scientific flow; e.g., Health Catalyst maps for CLABSI, CAUTI, pressure ulcers)
• Aim Packet with 2-5 Aim statements
• Cohort definitions to support the Aim Packet
• Common metrics plus additional outcome, process and balance metrics to support the Aim Packet
• Starter visualizations such as dashboards, scorecards, and/or interactive drill down reports
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Why focus on workflow and defect waste?
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IP per case waste reduction opportunity Facility perspective Per case ordering waste
Per case workflow waste
Per case defect waste
64
$144 MM ~ 23%
Total IP per case waste
$57 MM* ~ 9 %
(~ 40% of total of 23%)
$87 MM* ~ 14 %
(~ 60% of total of 23%)
In Progress < 1* %
* Preliminary Findings Work in Progress
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Focus on workflow and defect waste
• Size of the opportunity (14%) and aura of safety
• Payment structure schizophrenia (see next slide) • Reduction in workflow waste benefits the system under all
forms of payment
• Reduction in defect waste benefits the system for all Medicare patients
• CMS penalties – helps system reduce or eliminate penalties under readmission reduction and HAC
• Clinical teams are clinical operations-centric rather than physician-centric (organizational readiness)
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= Negative Impact = Positive or Negative = Positive Impact
Care Process Family Knowledge Asset
Discounted FFS Per Diem
Per Case Bundled Per Case Condition Capitation
Full Capitation
CMS Commercial CMS Commercial
Workflow
Diagnostic Variation
Standing Orders
Medication Selection
Triage
Patient Safety
Ambulatory Treatment and Monitoring
Indications for Referral
Indications for Intervention
Payment structure considerations
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CMS penalty considerations
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