best practices in implementing population health

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Population Health ManagementDavid A. Burton, MD

http://www.healthcatalyst.com/
















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Confidential

Emphasis on the Continuum of CareOutpatient Inpatient

Skilled Nursing Facility

Population Health Management

Home

Home Health Care

Clinic Care

Hospice Cemetery


















Confidential

Population Health ManagementParadigm Shift

AcuteCare-CentricManagement

Inpatient Outpatient

Skilled Nursing Facility

Home

Home Health Care

Clinic Care

Hospice Cemetery

Inpatient

Population-Centric Management


















Confidential

Poll questionOutpatient

Inpatient1

2

Outpatient Inpatient HospiceHome Health

3

Outpatient Inpatient HospiceHome Health Clinic Care

4

SNF

5

Outpatient Inpatient HospiceHome Health Clinic Care

Other combination

















Population Health ManagementAnatomy of Healthcare Delivery

Symptoms


Confidential


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)

CardiacRehab

Hospice

Coronary Atherosclerosis


















Confidential7

Population Health ManagementClinical Integration hierarchy - Care Process Families

Home Clinic Care Outpatient Inpatient SNF Home HealthHospice

Hyperlipidemia

Acute Myocardial Infarction

(AMI)

Percutaneous Intervention

(PCI)

Coronary Artery Bypass Graft (CABG)

CardiacRehab

Ischemic Heart Disease Care Process Family

Coronary Atherosclerosis


















Confidential


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

















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Clinical Integration hierarchyClinical Programs – ordering of care

Primary Care

Care Process Families

e.g., Diabetes

CV


e.g., Heart Failure

W&C


e.g., Pregnancy

GI


e.g., Lower GI Disorders

Resp-iratory


e.g., Obstructive Lung

Disorders

Neuro Sciences


e.g., Spine

Disorders

Musculo- skeletal


e.g., Joint

Replace- ment

Surgery


e.g., Urologic

Disorders

General Med


e.g., Infectious Disease

Oncology


e.g., Breast Cancer

Peds Spec


e.g., Peds

CV Surg

Mental Health


e.g., Depression

















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Clinical Integration hierarchy

Care

CareProcessFamilies

e.g.,Diabetes


e.g., Heart Failure


e.g., Pregnancy


e.g., Lower GI Disorders


e.g., Obstructive Lung

Disorders


e.g., Spine

Disorders


e.g., Joint

Replace- ment

Surgery


e.g., Urologic

Disorders


e.g., Infectious Disease

Oncology


e.g., Breast Cancer

Peds Spec


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


e.g., Depression

Cli

nic

al S

up

po

rt S

ervi

ces

(Del

iver

y o

f C

are)

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])

















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Heart Rhythm

Disorders

Vascular Disorders

Ischemic Heart

Disease

Heart Failure

CARDIOVASCULAR

Care ProcessFamilies

ClinicalProgram

ICD9 Volumes I-II 17,674

Diagnosis Codes

ICD-9 Volume III3,903

Procedure Codes

2013 CPT®

Code Set9706 Codes

CPT-4Code Groupings

ICD9 ProcedureCode Groupings

ICD9 DiagnosisCode Groupings

CABGPCIAMIACSCareProcesses


















Confidential


12

Medicare 2011 fee-for-service payments by venue

Clinic Care Outpatient Inpatient SNF Home HealthHospice

$ 31.7 Billion12.3%

77.6 Billion 30.1%

90.6 Billion 35.1%

$ 29.7 Billion11.5%

$ 18.4 Billion7.1%

$ 10.1 Billion3.9%

Clinic Care Outpatient Inpatient SNF Home Health Hospice


















Confidential

Poll questionHow does your organization prioritize improvementprojects

• Respond to desires of highest volume physicians with loudest voices

• Respond to regulatory and accreditation imperatives

• Based on pre-defined strategic criteria (includingobjective and subjective factors)

• Other


















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Our Philosophy: Be Systematic

17

Late-Binding™Data Warehouse Platform

Data Warehouse, Architecture, Metadata Management, Security, and Auditing

Analytic ApplicationsKey Process Analysis,

Dashboards, Advanced Analytics

ServicesInstallation Services,

Critical Improvement Services

Integrate Data and Measure

Apply Evidence and Standardize

Change Processand Behavior


















Less TransformationMore Transformation

Catalyst’s Adaptive Data Model

Metadata: EDW Atlas Security and AuditingCommon, Linkable Vocabulary

Financial Source Marts

Administrative Source Marts

Departmental Source Marts

Patient Source Marts

EMRSource Marts

HRSource 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 TimeTracking)

EMR Source(e.g., Epic, Cerner)


















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Catalyst approach

19

1Metadata-drivenplatform

2Content-driven applications

3 Application families FoundationalApplications

DiscoveryApplications

AdvancedApplications

Late

-Bin

ding

™ D

ata

War

ehou

se P

latf

orm

Data AcquisitionEngine and Storage

Metadata Engine

Late-Binding™ Data Bus


















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Cluster = Hub Hospital/Region, Medical Group, Health Plan, Section/Division

Clinical Integration Leadership Team (CILT)

20

Administration Vice-Chair

CNOVice-Chair

ClusterCMO

ClusterCNO

ClusterAdministrator

CMOChair Chief Information

Officer Chief Knowledge Officer

Cluster #1 Cluster #2 Cluster #3 Cluster # … Cluster #N

ClusterCMO

ClusterCNO


ClusterCMO

ClusterCNO


ClusterCMO

ClusterCNO


ClusterCMO

ClusterCNO



















Confidential

CV Clinical Program Guidance Team

21

Nurse DirectorVice-Chair

CV PhysicianChair*

CVMD Lead

CVNurse Lead

CVAdministrator

Cluster #1 Cluster #2

CVMD Lead

CVNurse Lead

CVAdministrator

Cluster #3

CVMD Lead

CVNurse Lead

CVAdministrator

Cluster #4

CVMD Lead

CVNurse Lead

CVAdministrator

Ischemic*MD Chair

Heart FailureMD Chair

Rhythm DisordersMD Chair

Vascular DisordersMD Chair

* One of the Clinical Implementation Team chairs also serves as the Guidance Team chair (Ischemic MD Chair in this example)


















Confidential

Clinical Implementation Team (CIT)Heart Failure Care Process Family

22

Heart Failure MD Chair

Cardiologist

CV RNDirector

Vice-Chair

Heart Failure MD Lead

CVNurse Lead

Facility #1 Facility #2


CVNurse Lead

Facility #3


CVNurse Lead

Facility #4


CVNurse Lead


















Confidential

CIT Work Group

23

CIT Chair (MD)Scientific SME

Clinical OperationsDirector

Front Line Clinical OpsWorkflow SME

Provider/PatientEducation 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 ArchitectKnowledgeManager

Subject Matter ExpertData

Capture Workflo

w Analysis

DataProvisioning

DataAnalysis


















Workgroup Roles

DATA CAPTURE

• Acquire key data elements• Assure data quality• Integrate data capture into

operationalworkflow

DATA ANALYSIS

• 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 ExpertData

Capture Workflo

w Analysis

Data Provisioning

DataAnalysis


















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 supportclinical improvement teams


















Implementation flow diagram

















Kickoff

• Mission• Cohort

Discover

• Data Analysis and Review

• BMJ BestPractices

• Building Multiple Potential AIM statements

AIM Statement

• Supplement BMJ content

• Refine Cohort

• Refine Metrics

• Develop DraftVisualizations

• Develop Recommended AIM statement#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

• ImplementationPlan

• Develop cluster rep assignments, and deliverables

ResultsReview

• 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)Gather Knowledge Assets

Define Cohort

Select AIM Statement

Select, Build, Refine MetricsDevelop

5 Implementation Plan

for Process Improvement

6 ImplementationMeasure Progress

1

2

3

4

7

Select Initial Metric Build and Refine Build and Refine Build and Refine


Pregnancy


















Surgical Services


















Discharge from hospital topost-hospital service


















Pressure injury prevention

















Slide Decks

Handbooks

Standard organizational workMD Contract Templates

Team Charters

Job Descriptions

Job Family Grids

Deployment Process Outlines

Compensation Grids

Meeting Agendas

Project Status Reports

L a r g e C l i n i c M e di a n Co m pe n s a ti o n Da ta $ / ho u r D i ff fr o m M i n M i d M a x

Gr o u p 5 2 0 0 0 Da ta 2 0 0 1 Da ta 2 0 0 2 Da ta 2 0 0 3 Da ta 2 0 0 4 Da ta 2 0 0 5 Da ta 2 0 0 6 Da ta a t 4 5 / wk m e di a n 0 .8 0 1 .0 0 1 .2 0

17.55 C V S u rg8

19.47 R a d io lo g y (in t e rv e n t io n a l)

2

C a rd io lo g y - C a t h -2

21.56 R a d io lo g y ( n o n - in t e r v e n t io n a l) -7

O rt h o 3 06 ,4 03 3 49 ,6 97 3 51 ,2 21 3 66 ,7 32 3 89 ,9 97 4 02 ,0 03 4 12 ,0 04 1 76 -1 0

23.89 M e di a n - Gr o u p 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

$ 1 49 $ 1 8 6 $ 2 24M e a n - Gr o u p 5

26.46 S te p =

$ 2 9 ,5 0 0

1 6

32.52 C a rd io lo g y - Ge n e ra l 2 61 ,0 00 2 79 ,4 70 3 04 ,9 94 3 20 ,0 00 3 12 ,0 10 3 50 ,0 00 3 59 ,0 04 1 53 6

Va s c u la r 2 81 ,1 43 2 89 ,9 18 3 10 ,4 01 3 20 ,2 10 3 36 ,8 20 3 21 ,1 31 3 55 ,0 00 1 52 536.03 U ro lo g y 2 64 ,1 75 2 85 ,5 00 3 10 ,9 64 3 19 ,0 00 3 22 ,0 00 3 43 ,7 69 3 46 ,6 33 1 48

2 51 ,0 83 2 82 ,5 01 3 07 ,5 00 3 14 ,4 95 3 30 ,0 08 3 38 ,2 56 3 44 ,9 60 1 47

1

039.94 A n e s t h e s io lo g y

P la s t ic s 2 73 ,2 61 2 94 ,0 39 2 97 ,2 50 3 00 ,0 00 3 40 ,8 80 3 43 ,4 97 3 42 ,9 01 1 47 0

44.24 Ga s t ro e n t e ro lo g y 2 40 ,0 00 2 46 ,5 00 2 71 ,5 03 3 00 ,0 00 3 04 ,9 94 3 14 ,4 95 3 40 ,0 10 1 45 -2

Ge n e ra l S u rg e ry 2 50 ,2 51 2 73 ,9 56 2 94 ,9 25 2 87 ,9 15 3 09 ,0 21 3 20 ,6 89 3 36 ,6 94 1 44 -349.04 EN T 2 50 ,0 00 2 68 ,4 03 2 79 ,9 85 2 93 ,0 00 3 08 ,3 63 3 20 ,9 58 3 20 ,8 90 1 37 -1 0

54.34 O p h t h 2 35 ,0 33 2 45 ,6 15 2 59 ,5 85 2 78 ,0 23 2 12 ,7 46 2 86 ,4 34 3 09 ,2 81 1 32 -1 5

M e di a n - Gr o u p 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 $ 1 7660.24 M e a n - Gr o u p 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 o u p 3

D.14 C lin ic a l P a t h o lo g y 2 17 ,5 00 2 33 ,6 77 2 32 ,9 84 2 51 ,2 27 2 25 ,0 00 2 63 ,7 50 2 87 ,9 27 1 23 1 0

H e ma t o lo g y & M e d . O n c o lo g y 1 89 ,0 00 2 05 ,0 00 2 23 ,4 70 2 31 ,7 94 2 51 ,2 41 2 61 ,5 01 2 80 ,0 01 1 20 6

D.17 D e rma t o lo g y 1 85 ,3 39 2 04 ,2 83 2 17 ,2 94 2 28 ,2 70 2 41 ,4 98 2 55 ,5 68 2 79 ,0 00 119 6

O B -Gy n - B ra n c h 2 17 ,4 26 2 29 ,2 38 2 33 ,2 95 2 45 ,5 68 2 49 ,2 56 2 56 ,9 97 2 69 ,1 47 115 2

D.19 O B -Gy n 2 29 ,6 99 2 43 ,4 34 2 54 ,5 63 2 52 ,4 00 2 60 ,7 76 2 63 ,8 16 2 62 ,0 00 112 -2

D.20 C r it ic a l C a r e M e d ic in e 2 07 ,2 50 2 18 ,0 00 2 23 ,5 00 2 28 ,7 40 2 28 ,7 40 2 34 ,5 03 2 49 ,9 96 1 07 -7

Eme rg e n c y C a re 1 89 ,2 86 2 02 ,6 90 2 11,0 00 2 21 ,9 27 2 32 ,7 49 2 38 ,5 23 2 48 ,2 27 1 06 -7

N e o n a t o lo g y 2 06 ,0 03 2 03 ,9 71 2 18 ,7 03 2 13 ,1 39 2 36 ,3 78 2 49 ,4 09 2 47 ,8 29 1 06 -8

M e di a n - Gr o u p 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 $ 9 1 $ 1 1 3 $ 1 36N.13 M e a n - Gr o u p 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 o u p 2

N.17 P u lmo n a ry D is e a s e 1 88 ,2 50 2 01 ,7 14 2 00 ,0 00 2 05 ,7 64 2 18 ,0 00 2 23 ,2 73 2 34 ,8 85 1 00 1 2

N e p h ro lo g y 1 87 ,0 00 1 91 ,6 61 1 96 ,7 52 2 04 ,6 17 2 14 ,7 51 2 17 ,7 57 2 25 ,5 04 9 6 8

N.19 A lle rg y / A s t h ma1 75 ,3 63 1 91 ,3 85 1 94 ,5 00 1 98 ,3 76 2 01 ,2 41 21 0 ,97 0 22 1 ,83 3 9 5 7

P h y s ia t ry 1 76 ,6 17 1 80 ,9 53 1 87 ,2 52 1 83 ,3 37 2 01 ,9 93 2 07 ,0 04 2 19 ,9 92 9 4 6

N e u ro lo g y 1 82 ,6 00 1 88 ,4 31 1 91 ,4 96 1 95 ,0 00 2 01 ,2 41 2 10 ,5 00 2 11,6 64 9 0 2

D.13 E n d o c r in o lo g y 1 65 ,0 00 1 82 ,6 58 1 80 ,3 54 1 88 ,9 92 1 85 ,0 00 1 85 ,2 50 2 00 ,5 29 8 6 -2

In fe c t io u s Di s e a s e 1 61 ,4 47 1 64 ,8 94 1 79 ,4 73 1 86 ,8 96 1 78 ,6 27 1 89 ,6 15 1 97 ,9 96 8 5 -3

D.15 U rg e n t C a re1 42 ,9 06 1 57 ,3 68 1 61 ,7 85 1 65 ,5 59 1 68 ,1 43 1 87 ,0 00 1 97 ,8 20 8 5 -4

D.17 O c c M e d

1 72 ,4 14 1 78 ,2 24 1 86 ,2 50 1 81 ,4 59 1 86 ,4 02 1 94 ,2 47 1 94 ,2 13 8 3 -5

R h e u ma t o lo g y 1 58 ,5 06 1 75 ,117 1 76 ,8 05 1 79 ,7 00 1 81 ,0 16 1 85 ,0 00 1 90 ,0 00 8 1 -7

D.19 M e di a n - G r o u p 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 $ 7 0 $ 8 8 $ 1 06M e a n - Gr o u p 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 o u p 1

P s y c h ia t ry 1 50 ,2 32 1 59 ,4 48 1 62 ,0 00 1 61 ,2 02 1 71 ,3 00 1 72 ,3 50 1 84 ,8 27 7 9 5

Ge n e ra l IM 1 42 ,0 84 1 50 ,0 46 1 53 ,7 86 1 53 ,9 39 1 65 ,3 75 1 72 ,5 65 1 78 ,0 05 7 6 2

F a mily M e d ic in e 1 39 ,7 25 1 47 ,0 25 1 55 ,0 50 1 54 ,0 18 1 66 ,1 05 1 72 ,1 57 1 75 ,0 80 7 5 0

P e d s 1 36 ,9 06 1 42 ,0 56 1 46 ,3 10 1 45 ,3 51 1 58 ,2 50 1 64 ,6 31 1 73 ,3 38 7 4 0

In t e rn a l M e d ic in e - B ra n c h 1 37 ,8 59 1 43 ,5 13 1 52 ,9 33 1 57 ,7 18 1 53 ,5 61 1 62 ,7 32 1 68 ,3 44 7 2 -3

P e d s -A d o l - B ra n c h 1 35 ,8 00 1 38 ,0 00 1 44 ,6 43 1 44 ,4 36 1 50 ,112 1 54 ,0 00 1 63 ,9 17 7 0 -4

M e di a n - Gr o u p 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 $ 6 0 $ 7 4 $ 8 9A ve r a g e - Gr o u p 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-STAFFDATA ARCHITECT-SR

DATA ARCHITECT-CNSLT

OUTCOMES ANALYST-ASSOCOUTCOMES ANALYST-STAFF N.15

OUTCOMES ANALYST-SROUTCOMES ANALYST-CNSLT

DATA MANAGER-ASSOC

DATA MANAGER-STAFF

DATA MANAGER-SR

DATA MANAGER-CNSLT

2 7

Co m pe n s a ti o n Ra te by S pe c i a l ty A dm i n i s tr a ti ve Ra tes by Gr o u pGRADE 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 Group 4

MFM (Perinatology)

298,158 no data 385,917 312,238 395,809 375,005 382,414 163


Confidential

Poll question

How prepared do you feel to implement population health management and shared accountability (e.g., ACO) strategies?

















Thank you

best practices in implementing population health

Health & Medicine

diabetes care process

emergency care

primary care clinics

confidential emphasis

gi lab

procedure codes

codes cpt

cpt code set