© 2013 health catalyst proprietary and confidential © 2013 health catalyst proprietary and...

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Population Health ManagementDavid A. Burton, MD


Outpatient

Population Health ManagementEmphasis on the Continuum of Care

Home

Clinic Care

Hospice Cemetery

Skilled Nursing Facility

Inpatient

Home HealthCare


Population Health ManagementParadigm Shift

AcuteCare-Centric Management

Inpatient Outpatient

Home

Clinic Care

Hospice Cemetery

Skilled Nursing Facility

Inpatient

Home HealthCare

Population-Centric Management


Poll questionOutpatient 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

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Home(Patient Portal)

* To Invasive Care Processes

AmbulatoryNon-recurrent

Ambulatory Recurrent

Acute MedicalIP Med-Surg

Acute Medical IP ICU

Invasive Medical

Invasive Surgical

Diagnostic Work-up

Bedside careProcedure

Triage to Treatment Venue

Substance Preparation

Post-procedure Care

Substance Selection

Invasive* Subspecialist

Chronic Disease

Subspecialist

Substance Selection

Screening & Preventive Symptoms

Population Health ManagementAnatomy of Healthcare Delivery

Treatment and Monitoring Algorithms

Admission Order SetsAdmission Order Sets

Supplementary Order Sets Pre-Procedure Order SetsClinical Supply Chain Management

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 setsIP (SNF, IRF)Home healthHospice

Management of Preventive, Ambulatory, Acute Medical, Invasive & PAC Modules

Module-Focused Knowledge

Assets

Diagnostic algorithms

Indications for Referral

Indications for Intervention

Triage Criteria

Diagnostic Algorithms, Triage Criteria, Referral & Intervention Indications

Population-Focused Knowledge Assets

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Population Health ManagementClinical Integration hierarchy - Care Processes

Hyperlipidemia

Acute Myocardial Infarction

(AMI)

Percutaneous Intervention

(PCI)

Coronary Artery Bypass Graft (CABG)

Cardiac Rehab

Care Processes

Home OutpatientClinic Care Inpatient SNF Home Health Hospice

CoronaryAtherosclerosis


Population Health ManagementClinical Integration hierarchy - Care Process Families

Hyperlipidemia

Acute Myocardial Infarction

(AMI)

Percutaneous Intervention

(PCI)

Coronary Artery Bypass Graft (CABG)

Cardiac Rehab

Ischemic Heart DiseaseCare Process Family


CoronaryAtherosclerosis


Population Health ManagementClinical Integration hierarchy - Clinical Programs

Vascular Disorders Care Process Family

Heart Rhythm Disorders Care Process Family

Heart FailureCare Process Family

Ischemic Heart DiseaseCare Process Family

Cardiovascular Clinical Program



Clinical Integration hierarchyClinical Programs – ordering of care

Primary Care

CareProcessFamilies

e.g.,Diabetes

CV

CareProcessFamilies

e.g.,Heart

Failure

W&C

CareProcessFamilies

e.g., Pregnancy

GI

CareProcessFamilies

e.g., Lower GIDisorders

Resp-iratory

CareProcessFamilies

e.g., Obstructive Lung

Disorders

Neuro Sciences

CareProcessFamilies

e.g.,Spine

Disorders

Musculo-skeletal

CareProcessFamilies

e.g., Joint

Replace-ment

Surgery

CareProcessFamilies

e.g.,Urologic

Disorders

GeneralMed

CareProcessFamilies

e.g.,Infectious Disease

Oncology

CareProcessFamilies

e.g., BreastCancer

Peds Spec

CareProcessFamilies

e.g.,Peds

CV Surg

Mental Health

CareProcessFamilies

e.g., Depressio

n


Clinical Integration hierarchyClinical Support Services – delivery of care ordered

Primary Care

CareProcessFamilies

e.g.,Diabetes

CV

CareProcessFamilies

e.g.,Heart

Failure

W&C

CareProcessFamilies

e.g., Pregnancy

GI

CareProcessFamilies

e.g., Lower GIDisorders

Resp-iratory

CareProcessFamilies

e.g., Obstructive Lung

Disorders

Neuro Sciences

CareProcessFamilies

e.g.,Spine

Disorders

Musculo-skeletal

CareProcessFamilies

e.g., Joint

Replace-ment

Surgery

CareProcessFamilies

e.g.,Urologic

Disorders

GeneralMed

CareProcessFamilies

e.g.,Infectious Disease

Oncology

CareProcessFamilies

e.g., BreastCancer

Peds Spec

CareProcessFamilies

e.g.,Peds

CV Surg

Mental Health

CareProcessFamilies

e.g., Depressio

n

12 Clinical Programs (“Ordering of Care”)

Clin

ical

Su

pp

ort

Ser

vice

s (D

eliv

ery

of

Car

e)

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)


Heart Rhythm

Disorders

VascularDisorders

Ischemic Heart

Disease

HeartFailure

CARDIOVASCULAR

Care Process Families

ClinicalProgram

ICD9 Volumes I-II17,674

Diagnosis Codes

ICD-9 Volume III 3,903

Procedure Codes

2013 CPT® Code Set

9706 Codes

CPT-4 Code Groupings

ICD9 ProcedureCode Groupings

ICD9 Diagnosis Code Groupings

CABGPCIAMIACSCare Processes


Population Health ManagementMedicare 2011 fee-for-service payments by venue

OutpatientClinic Care Inpatient SNF Home Health Hospice

$ 31.7 Billion12.3%

77.6 Billion30.1%

90.6 Billion35.1%

$ 29.7 Billion11.5%

$ 18.4 Billion7.1%

$ 10.1 Billion3.9%

Clinic Care Outpatient Inpatient SNF Home Health Hospice


c


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


Our Philosophy: Be Systematic

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

SystematicallyIntegrate Data and Measure

SystematicallyApply Evidence and Standardize

SystematicallyChange Process and Behavior


Metadata: EDW Atlas Security and Auditing

Common, Linkable Vocabulary

FinancialSource Marts

AdministrativeSource Marts

DepartmentalSource Marts

PatientSource Marts

EMR Source Marts

HRSource Mart

Diabetes

Sepsis

Readmissions

Less TransformationMore Transformation

Catalyst Adaptive Data WarehouseCatalyst’s Adaptive Data Model

DepartmentalSources

(e.g., Apollo)

Patient SatisfactionSources

(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)


Catalyst approach

19

1 Metadata-driven platform

2 Content-driven applications

3 Application families Foundational Applications

Discovery Applications

Advanced Applications

Late

-Bin

ding

™ D

ata

War

ehou

se P

latfo

rm

Data Acquisition Engine and Storage

Metadata Engine

Late-Binding™ Data Bus


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

Clinical Integration Leadership Team (CILT)

AdministrationVice-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



CV Clinical Program Guidance Team

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)


Clinical Implementation Team (CIT)Heart Failure Care Process Family

CV RN DirectorVice-Chair


Cardiologist

Heart FailureMD Lead

CVNurse Lead

Facility #1 Facility #2


CVNurse Lead

Facility #3


CVNurse Lead

Facility #4


CVNurse Lead


CIT Work Group

CIT Chair (MD)Scientific SME

Clinical OperationsDirector

Front Line Clinical OpsWorkflow SME

Provider/PatientEducation Team

ClinicalApplication

Steward

AdministrativeApplication

Steward

* CMIO, CQO, Chief Patient Safety Officer, or Chief Analytics Officer provided individual has requisite qualifications and skills

Data ArchitectKnowledgeManager

Subject MatterExpert

Data CaptureWorkflow Analysis

Data Provisioning

Data Analysis


Workgroup Roles

DATA CAPTURE

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

workflow

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 MatterExpert

Data CaptureWorkflow Analysis

Data Provisioning

Data Analysis


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


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 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

• 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

MonthlyTasks andCheckpoints

7 Steps(Work Streams)

Gather Knowledge Assets

Define Cohort

Select AIM Statement

Select, Build, Refine Metrics

Develop Implementation Plan for Process Improvement

Implementation

Measure Progress

1

2

3

4

5

6

7

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


Pregnancy


Surgical Services


Discharge from hospital to post-hospital service


Pressure injury prevention

32

Slide Decks

Handbooks

Standard organizational work

MD Contract Templates

Team Charters

Job Descriptions

Job Family Grids

Meeting Agendas

Project Status Reports

Deployment Process Outlines

Compensation GridsLarge Clinic Median Compensation Data $/hour Diff from Min Mid MaxGroup 5 2000 Data 2001 Data 2002 Data 2003 Data 2004 Data 2005 Data 2006 Data at 45/wk median 0.80 1.00 1.20 Neurosurg 345,250 389,644 395,305 400,942 450,006 465,000 499,992 214 27CV Surg 380,207 415,351 438,901 441,133 440,000 474,772 455,455 195 8Radiology (interventional) 306,000 356,001 375,000 410,250 410,250 424,992 440,004 188 2Cardiology - Cath 276,001 304,750 325,494 375,003 380,234 412,101 432,618 185 -2Radiology (non-interventional) 258,000 309,255 330,603 350,000 372,000 410,000 420,000 179 -7Ortho 306,403 349,697 351,221 366,732 389,997 402,003 412,004 176 -10Median - Group 5 306,202 352,849 363,111 387,973 400,124 418,547 436,311 186 149$ 186$ 224$ Mean - Group 5 311,977 354,116 369,421 390,677 407,081 431,478 443,346 189

Step = $29,500Group 4MFM (Perinatology) 298,158 no data 385,917 312,238 395,809 375,005 382,414 163 16Cardiology - General 261,000 279,470 304,994 320,000 312,010 350,000 359,004 153 6Vascular 281,143 289,918 310,401 320,210 336,820 321,131 355,000 152 5Urology 264,175 285,500 310,964 319,000 322,000 343,769 346,633 148 1Anesthesiology 251,083 282,501 307,500 314,495 330,008 338,256 344,960 147 0Plastics 273,261 294,039 297,250 300,000 340,880 343,497 342,901 147 0Gastroenterology 240,000 246,500 271,503 300,000 304,994 314,495 340,010 145 -2General Surgery 250,251 273,956 294,925 287,915 309,021 320,689 336,694 144 -3ENT 250,000 268,403 279,985 293,000 308,363 320,958 320,890 137 -10Ophth 235,033 245,615 259,585 278,023 212,746 286,434 309,281 132 -15Median - Group 4 256,042 279,470 301,122 306,119 317,005 329,694 343,931 147 118$ 147$ 176$ Mean - Group 4 260,410 273,989 302,302 304,488 317,265 331,423 343,779 147

Step = $21,000Group 3Clinical Pathology 217,500 233,677 232,984 251,227 225,000 263,750 287,927 123 10Hematology & Med. Oncology 189,000 205,000 223,470 231,794 251,241 261,501 280,001 120 6Dermatology 185,339 204,283 217,294 228,270 241,498 255,568 279,000 119 6OB-Gyn - Branch 217,426 229,238 233,295 245,568 249,256 256,997 269,147 115 2OB-Gyn 229,699 243,434 254,563 252,400 260,776 263,816 262,000 112 -2Critical Care Medicine 207,250 218,000 223,500 228,740 228,740 234,503 249,996 107 -7Emergency Care 189,286 202,690 211,000 221,927 232,749 238,523 248,227 106 -7Neonatology 206,003 203,971 218,703 213,139 236,378 249,409 247,829 106 -8Median - Group 3 206,627 211,500 223,485 230,267 238,938 256,283 265,574 113 91$ 113$ 136$ Mean - Group 3 205,188 217,536 226,851 234,133 240,705 253,008 265,516 113

Step = $13,000Group 2Pulmonary Disease 188,250 201,714 200,000 205,764 218,000 223,273 234,885 100 12Nephrology 187,000 191,661 196,752 204,617 214,751 217,757 225,504 96 8Allergy/Asthma 175,363 191,385 194,500 198,376 201,241 210,970 221,833 95 7Physiatry 176,617 180,953 187,252 183,337 201,993 207,004 219,992 94 6Neurology 182,600 188,431 191,496 195,000 201,241 210,500 211,664 90 2Endocrinology 165,000 182,658 180,354 188,992 185,000 185,250 200,529 86 -2Infectious Disease 161,447 164,894 179,473 186,896 178,627 189,615 197,996 85 -3Urgent Care 142,906 157,368 161,785 165,559 168,143 187,000 197,820 85 -4Occ Med 172,414 178,224 186,250 181,459 186,402 194,247 194,213 83 -5Rheumatology 158,506 175,117 176,805 179,700 181,016 185,000 190,000 81 -7Median - Group 2 173,889 181,806 186,751 187,944 193,822 200,626 206,097 88 70$ 88$ 106$ Mean - Group 2 171,010 181,240 185,467 188,970 193,641 201,062 209,444 90

Step = $5,000Group 1Psychiatry 150,232 159,448 162,000 161,202 171,300 172,350 184,827 79 5General IM 142,084 150,046 153,786 153,939 165,375 172,565 178,005 76 2Family Medicine 139,725 147,025 155,050 154,018 166,105 172,157 175,080 75 0Peds 136,906 142,056 146,310 145,351 158,250 164,631 173,338 74 0Internal Medicine - Branch 137,859 143,513 152,933 157,718 153,561 162,732 168,344 72 -3Peds-Adol - Branch 135,800 138,000 144,643 144,436 150,112 154,000 163,917 70 -4Median - Group 1 138,792 145,269 153,360 153,979 161,813 168,394 174,209 74 60$ 74$ 89$ Average - Group 1 140,434 146,681 152,454 152,777 160,784 166,406 173,919 74

Compensation Rate by Specialty Administrative Rates by GroupGRADE MIN MID MAX

D.8 11.69 14.63 17.55

D.9 12.99 16.21 19.47

D.10 14.39 17.97 21.56

D.11 15.91 19.91 23.89

D.12 17.65 22.07 26.46

D.13 19.56 24.45 29.36

D.14 21.67 27.10 32.52

D.15 24.02 30.03 36.03

D.16 26.63 33.28 39.94

D.17 29.50 36.88 44.24

D.18 32.67 40.86 49.04

D.19 36.23 45.28 54.34

D.20 40.15 50.18 60.24

DATA ARCHITECT-ASSOC D.14DATA ARCHITECT-STAFF D.17

DATA ARCHITECT-SR D.19

DATA ARCHITECT-CNSLT D.20

OUTCOMES ANALYST-ASSOC N.13OUTCOMES ANALYST-STAFF N.15OUTCOMES ANALYST-SR N.17OUTCOMES ANALYST-CNSLT N.19

DATA MANAGER-ASSOC D.13DATA MANAGER-STAFF D.15

DATA MANAGER-SR D.17

DATA MANAGER-CNSLT D.19


Poll question

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

34

Thank you

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