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Predictive Analytics: 'A Means to Harnessing the Power to Drive Healthcare Value‘

Wolf H. Stapelfeldt, MDChairman, Department of General 

Anesthesiology

Cleveland Clinic

• Vice Chairman, Surgical Operations,       Medical Operations Division

• Vice Chairman, Information Systems & Technologies, Anesthesiology Institute

• Faculty, Samson Global Leadership Academy for Healthcare Executives

Learning Objectives• Review the key elements of Clinical and Business Intelligence (C&BI) 

• Recognize the rationale for enlisting C&BI as part of organizational strategy

• Appreciate an example of the value of C&BI in affecting meaningful clinical and business outcomes

QualityCostValue =

QualityCostValue =

via the services that are being provided …

QualityCostValue =

via the services that are being provided …and by leveraging technology…

QualityCostValue =

via the services that are being provided …and by leveraging technology…

QualityCostValue =

via the services that are being provided …and by leveraging technology…

(Clinical & Business Intelligence)

Meaningful Outcomes

• In‐Hospital Mortality• Length of Stay (LOS)• Hospital Charges• Re‐admission Rate• 30‐Day Mortality

Clinical Challenge(Patients, Populations)

Actions/Interventions

Clinical Challenge(Patients, Populations)

Clinical & BusinessProcesses

Actions/Interventions

Clinical Challenge(Patients, Populations)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Clinical Challenge(Patients, Populations)

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Knowledge/Experience Actionable Information(Decision Support)

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Knowledge/Experience Actionable Information(Decision Support)

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

C&BI

Outcomes

Knowledge/Experience Actionable Information(Decision Support)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

C&BI

Outcomes

Knowledge/Experience Actionable Information(Decision Support)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

C&BI

Outcomes

Knowledge/Experience Actionable Information(Decision Support)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

C&BI

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

C&BI

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Device Integration

ETL Processes

C&BI

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Device Integration

ETL Processes

C&BI

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Device Integration

ETL Processes Analytics

C&BI

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Device Integration

ETL Processes Analytics

C&BI

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Device Integration

ETL Processes Analytics

Real-Time Processing

C&BI

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Device Integration

ETL Processes Analytics

Real-Time Processing

C&BI

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Clinical Challenge(Patients, Populations)

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

Outcomes

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

Clinical Challenge(Patients, Populations)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

1. Current Status of Perioperative Care

1. Current Status of Perioperative Carea. Handwritten Anesthesia Record

1. Current Status of Perioperative Carea. Handwritten Anesthesia Record

1. Current Status of Perioperative Carea. Handwritten Anesthesia Record

Problems

1. Difficult to read (often not legible)2. Not updated in real time3. Not accessible electronically

1. Current Status of Perioperative Carea. Handwritten Anesthesia Record

Problems

1. Difficult to read (often not legible)2. Not updated in real time3. Not accessible electronically

1. Current Status of Perioperative Carea. Handwritten Anesthesia Record

Problems

1. Difficult to read (often not legible)2. Not updated in real time3. Not accessible electronically

1. Current Status of Perioperative Carea. Handwritten Anesthesia Record

Problems

1. Difficult to read (often not legible)2. Not updated in real time3. Not accessible electronically

1. Current Status of Perioperative Carea. Handwritten Anesthesia Record

Problems

1. Difficult to read (often not legible)2. Not updated in real time3. Not accessible electronically

1. Current Status of Perioperative Carea. Handwritten Anesthesia Record

Problems

1. Difficult to read (often not legible)2. Not updated in real time3. Not accessible electronically

1. Current Status of Perioperative Carea. Handwritten Anesthesia Record

1. Current Status of Perioperative Carea. Handwritten Anesthesia Recordb. Automatically-generated Record

1. Current Status of Perioperative Carea. Handwritten Anesthesia Recordb. Automatically-generated Record

ARKS

1. Current Status of Perioperative Carea. Handwritten Anesthesia Recordb. Automatically-generated Record

ARKS

1. Current Status of Perioperative Care

ARKS

Advantages

1. Legible2. Accurate3. Queryable

1. Current Status of Perioperative CareWhat constitutes hypotension severe enough to worry about?

ARKS

1. Current Status of Perioperative CareWhat constitutes hypotension severe enough to worry about?

ARKS

1. Current Status of Perioperative CareWhat constitutes hypotension severe enough to worry about?

ARKS

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

Hypotension

Hypotension

MAP < 70 ?

< 60 ?

< 50 ?

< some other discrete value (such as 20% below baseline) ?

< 60 !

Hypotension

MAP < 70 ?

< 60 ?

< 50 ?

< some other discrete value (such as 20% below baseline) ?

< 60 !

Hypotension

MAP < 70 ?

< 60 ?

< 50 ?

< some other discrete value (such as 20% below baseline) ?

< 60 !

Hypotension

MAP < 70 ?

< 60 ?

< 50 ?

< some other discrete value (such as 20% below baseline) ?

< 60 !

Hypotension

MAP < 70 ?

< 60 ?

< 50 ?

< some other discrete value (such as 20% below baseline) ?

When does hypotension become significant?

When does hypotension become significant?

… after 2 minutes?   …5 minutes?     …15 minutes?

When does hypotension become significant?

… after 2 minutes?   …5 minutes?     …15 minutes?

When does hypotension become significant?

… after 2 minutes?   …5 minutes?     …15 minutes?

MAP

MAP

MAP

MAP

MAP

MAP

MAP

Hypotensive Case 1 Case 2Threshold [cum min] [cum min]

55 10 074 20 16073 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP

Hypotensive Case 1 Case 2Threshold [cum min] [cum min]

55 10 074 20 16073 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP

Hypotensive Case 1 Case 2Threshold [cum min] [cum min]

55 10 060 10 14573 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP

Hypotensive Case 1 Case 2Threshold [cum min] [cum min]

55 10 060 10 14573 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP

Hypotensive Case 1 Case 2Threshold [cum min] [cum min]

55 10 060 10 14573 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP

Hypotensive Case 1 Case 2Threshold [cum min] [cum min]

75 20 16074 20 16073 20 16072 20 15571 20 15570 20 15569 20 15568 20 15567 20 15566 15 15565 15 15064 15 15063 15 15062 10 14561 10 14560 10 14559 10 12558 10 9557 10 6056 10 055 10 054 5 053 0 052 0 051 0 050 0 049 0 048 0 047 0 046 0 045 0 0

MAP

HypotensiveThreshold

75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

N=35904

at a MAP below

Average CumulativeTime Spent

Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive

Thresholds Ranging From 75 To 45

Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45

HypotensiveThreshold

75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

N=35904

at a MAP below

Average CumulativeTime Spent

Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive

Thresholds Ranging From 75 To 45

Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45

HypotensiveThreshold

75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

N=35904

at a MAP below

100%

50%

0%

Incidence

Average CumulativeTime Spent

Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive

Thresholds Ranging From 75 To 45

Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45

HypotensiveThreshold

75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

N=35904

at a MAP below

100%

50%

0%

Incidence

Average CumulativeTime Spent

Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive

Thresholds Ranging From 75 To 45

Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45

HypotensiveThreshold

75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

6%5%4%3%2%1%

N=35904

at a MAP below

100%

50%

0%

Incidence

30-dayMortalityAverage

CumulativeTime Spent

Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive

Thresholds Ranging From 75 To 45

Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45

HypotensiveThreshold

75 70 65 60 55 50 45

120100

80604020

4550

5560

6570

75

6%5%4%3%2%1%

N=35904

at a MAP below

100%

50%

0%

Incidence

30-dayMortalityAverage

CumulativeTime Spent

Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive

Thresholds Ranging From 75 To 45

Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45 and in 30-day mortality

10%

20%

30%

40%

50%

1020

3040

5060

75 70 65 60 55 50 45Spent at an MAP Below

CumulativeMinutes

normotensive (n= 21485, 60%)% Increase In Odds Ratio(30‐day     

Mortality)                

Percent Increase in the Odds Ratio for 30‐day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds 

10%

20%

30%

40%

50%

1020

3040

5060

75 70 65 60 55 50 45Spent at an MAP Below

CumulativeMinutes

normotensive (n= 21485, 60%)% Increase In Odds Ratio(30‐day     

Mortality)                

Percent Increase in the Odds Ratio for 30‐day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds 

10%

20%

30%

40%

50%

1020

3040

5060

75 70 65 60 55 50 45Spent at an MAP Below

CumulativeMinutes

normotensive (n= 21485, 60%)% Increase In Odds Ratio(30‐day     

Mortality)                

hypertensive (n= 14419, 40%)

Percent Increase in the Odds Ratio for 30‐day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds 

10%

20%

30%

40%

50%

1020

3040

5060

75 70 65 60 55 50 45Spent at an MAP Below

CumulativeMinutes

normotensive (n= 21485, 60%)% Increase In Odds Ratio(30‐day     

Mortality)                

hypertensive (n= 14419, 40%)

Percent Increase in the Odds Ratio for 30‐day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds 

10%

20%

30%

40%

50%

1020

3040

5060

75 70 65 60 55 50 45Spent at an MAP Below

CumulativeMinutes

% Increase In Odds Ratio(30‐day     

Mortality)                

hypertensive (n= 14419, 40%)

Percent Increase in the Odds Ratio for 30‐day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds 

20%

10%

20%

30%

40%

50%

1020

3040

5060

75 70 65 60 55 50 45Spent at an MAP Below

CumulativeMinutes

% Increase In Odds Ratio(30‐day     

Mortality)                

hypertensive (n= 14419, 40%)

Percent Increase in the Odds Ratio for 30‐day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds 

The line in red represents the same (20%) impact on the Odds Ratio for 30‐day Mortality

20%

10%

20%

30%

40%

50%

1020

3040

5060

75 70 65 60 55 50 45Spent at an MAP Below

CumulativeMinutes

normotensive (n= 21485, 60%)% Increase In Odds Ratio(30‐day     

Mortality)                

hypertensive (n= 14419, 40%)

Percent Increase in the Odds Ratio for 30‐day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds 

The line in red represents the same (20%) impact on the Odds Ratio for 30‐day Mortality

20%

10%

20%

30%

40%

50%

1020

3040

5060

75 70 65 60 55 50 45Spent at an MAP Below

CumulativeMinutes

normotensive (n= 21485, 60%)

5 311

2137

Minutes

% Increase In Odds Ratio(30‐day     

Mortality)                

hypertensive (n= 14419, 40%)

Percent Increase in the Odds Ratio for 30‐day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds 

The line in red represents the same (20%) impact on the Odds Ratio for 30‐day Mortality

CumulativeTime SpentBelow

an MAP Threshold of

AssociatedIncrease inOdds RatioFor 30‐DayMortality

CumulativeTime SpentBelow

an MAP Threshold of

AssociatedIncrease inOdds RatioFor 30‐DayMortality

CumulativeTime SpentBelow

an MAP Threshold of

AssociatedIncrease inOdds RatioFor 30‐DayMortality

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Patients Carrying a PreoperativeDiagnosis of Hypertension

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Patients Carrying a PreoperativeDiagnosis of Hypertension

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

Cumulative Time Spent

Below                

an MAP Threshold of

Associated withan Increase in 

30‐day Mortality Odds Ratio of 

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

In‐Hospital Mortality                                               Median LOS*                                            90th Percentile LOS*

Hospital Charges                                               Readmission Rate                                         30‐Day Mortality

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

 Lim

itsPe

rcen

t Patients E

xceeding

 Lim

its

A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits

# Limits Exceeded   15  14  13  12   12   12  12  11  11   11                                                  15   14   13   12 12   12    12   11   11    11                                      15    14   13   12   12   12    12   11   11    11        

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) .   Below limits  Exceeding Limits

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

In‐Hospital Mortality                                               Median LOS*                                            90th Percentile LOS*

Hospital Charges                                               Readmission Rate                                         30‐Day Mortality

N=27,436

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

 Lim

itsPe

rcen

t Patients E

xceeding

 Lim

its

A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits

# Limits Exceeded   15   14    13   12     12   12    12   11   11    11                                     15    14    13   12 12   12    12   11   11    11                                    15    14   13   12   12   12    12   11   11    11        

# Limits Exceeded   15  14  13  12   12   12  12  11  11   11                                                  15   14   13   12 12   12    12   11   11    11                                      15    14   13   12   12   12    12   11   11    11        

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) .   Below limits  Exceeding Limits

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

In‐Hospital Mortality                                               Median LOS*                                            90th Percentile LOS*

Hospital Charges                                               Readmission Rate                                         30‐Day Mortality

N=27,436

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

 Lim

itsPe

rcen

t Patients E

xceeding

 Lim

its

A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits

# Limits Exceeded   15   14    13   12     12   12    12   11   11    11                                     15    14    13   12 12   12    12   11   11    11                                    15    14   13   12   12   12    12   11   11    11        

# Limits Exceeded   15  14  13  12   12   12  12  11  11   11                                                  15   14   13   12 12   12    12   11   11    11                                      15    14   13   12   12   12    12   11   11    11        

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) .   Below limits  Exceeding Limits

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

In‐Hospital Mortality                                               Median LOS*                                            90th Percentile LOS*

Hospital Charges                                               Readmission Rate                                         30‐Day Mortality

N=27,436

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

 Lim

itsPe

rcen

t Patients E

xceeding

 Lim

its

A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits

# Limits Exceeded   15   14    13   12     12   12    12   11   11    11                                     15    14    13   12 12   12    12   11   11    11                                    15    14   13   12   12   12    12   11   11    11        

# Limits Exceeded   15  14  13  12   12   12  12  11  11   11                                                  15   14   13   12 12   12    12   11   11    11                                      15    14   13   12   12   12    12   11   11    11        

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) .   Below limits  Exceeding Limits

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

In‐Hospital Mortality                                               Median LOS*                                            90th Percentile LOS*

Hospital Charges                                               Readmission Rate                                         30‐Day Mortality

N=27,436

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

 Lim

itsPe

rcen

t Patients E

xceeding

 Lim

its

A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits

# Limits Exceeded   15   14    13   12     12   12    12   11   11    11                                     15    14    13   12 12   12    12   11   11    11                                    15    14   13   12   12   12    12   11   11    11        

# Limits Exceeded   15  14  13  12   12   12  12  11  11   11                                                  15   14   13   12 12   12    12   11   11    11                                      15    14   13   12   12   12    12   11   11    11        

* Live discharges

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) .   Below limits  Exceeding Limits

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

In‐Hospital Mortality                                               Median LOS*                                            90th Percentile LOS*

Hospital Charges                                               Readmission Rate                                         30‐Day Mortality

N=27,436

* Live discharges

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

 Lim

itsPe

rcen

t Patients E

xceeding

 Lim

its

A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits

# Limits Exceeded   15   14    13   12     12   12    12   11   11    11                                     15    14    13   12 12   12    12   11   11    11                                    15    14   13   12   12   12    12   11   11    11        

# Limits Exceeded   15  14  13  12   12   12  12  11  11   11                                                  15   14   13   12 12   12    12   11   11    11                                      15    14   13   12   12   12    12   11   11    11        

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) .   Below limits  Exceeding Limits

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

In‐Hospital Mortality                                               Median LOS*                                            90th Percentile LOS*

Hospital Charges                                               Readmission Rate                                         30‐Day Mortality

N=27,436

* Live discharges

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

 Lim

itsPe

rcen

t Patients E

xceeding

 Lim

its

A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits

# Limits Exceeded   15   14    13   12     12   12    12   11   11    11                                     15    14    13   12 12   12    12   11   11    11                                    15    14   13   12   12   12    12   11   11    11        

# Limits Exceeded   15  14  13  12   12   12  12  11  11   11                                                  15   14   13   12 12   12    12   11   11    11                                      15    14   13   12   12   12    12   11   11    11        

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) .   Below limits  Exceeding Limits

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

In‐Hospital Mortality                                               Median LOS*                                            90th Percentile LOS*

Hospital Charges                                               Readmission Rate                                         30‐Day Mortality

N=27,436

* Live discharges

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

 Lim

itsPe

rcen

t Patients E

xceeding

 Lim

its

A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits

# Limits Exceeded   15   14    13   12     12   12    12   11   11    11                                     15    14    13   12 12   12    12   11   11    11                                    15    14   13   12   12   12    12   11   11    11        

# Limits Exceeded   15  14  13  12   12   12  12  11  11   11                                                  15   14   13   12 12   12    12   11   11    11                                      15    14   13   12   12   12    12   11   11    11        

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) .   Below limits  Exceeding Limits

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

1

2

3

4

5

6

7

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500

5

10

15

20

25

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

0%

1%

2%

3%

4%

5%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 500%

5%

10%

15%

20%

0%10%20%30%40%50%60%70%80%

5 10 15 20 25 30 35 40 45 50

In‐Hospital Mortality                                               Median LOS*                                            90th Percentile LOS*

Hospital Charges                                               Readmission Rate                                         30‐Day Mortality

N=27,436

* Live discharges

N=27,436 N=27,436

N=26,940 N=26,940

N=26,940

Percen

t Patients E

xceeding

 Lim

itsPe

rcen

t Patients E

xceeding

 Lim

its

A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits

# Limits Exceeded   15   14    13   12     12   12    12   11   11    11                                     15    14    13   12 12   12    12   11   11    11                                    15    14   13   12   12   12    12   11   11    11        

# Limits Exceeded   15  14  13  12   12   12  12  11  11   11                                                  15   14   13   12 12   12    12   11   11    11                                      15    14   13   12   12   12    12   11   11    11        

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) .   Below limits  Exceeding Limits

In‐Hospital Mortality                              Average LOS*                          Readmission Rate*(N=27,436 )                                                                                 (N=26,940)                        (N=26,940)

0%1%2%3%4%5%6%7%8%9%

10%

1 2 3 4 5 6 7 8 9 100.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

1 2 3 4 5 6 7 8 9 100%

1%

2%

3%

4%

5%

1 2 3 4 5 6 7 8 9 105   10   15  20  25  30   35  40  45  50                                5   10   15  20  25  30   35  40  45  50              5   10   15  20  25  30   35  40  45  50            

* Live discharges

Hypotensive Exposure, Unadjusted        (95% Confidence Interval)

Hypotensive Exposure, AHRQ Adjusted (95% Confidence Interval)

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) 

Percent Increase in Risk (Odds Ratio) per Exposure Limit Exceeded (DSS Alert)Portended by a Novel Risk Index for Adverse Postoperative Outcome 

Based on the Number of Intraoperative Hypotensive Exposure Limits Exceeded(with and without adjustment for a set of 30 co‐morbidities identified by AHRQ)

In‐Hospital Mortality                              Average LOS*                          Readmission Rate*(N=27,436 )                                                                                 (N=26,940)                        (N=26,940)

0%1%2%3%4%5%6%7%8%9%

10%

1 2 3 4 5 6 7 8 9 100.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

1 2 3 4 5 6 7 8 9 100%

1%

2%

3%

4%

5%

1 2 3 4 5 6 7 8 9 105   10   15  20  25  30   35  40  45  50                                5   10   15  20  25  30   35  40  45  50              5   10   15  20  25  30   35  40  45  50            

* Live discharges

Hypotensive Exposure, Unadjusted        (95% Confidence Interval)

Hypotensive Exposure, AHRQ Adjusted (95% Confidence Interval)

Exposure Limit Risk Sets, as previously found to be associated with increased 30‐day mortality (Stapelfeldt at al., 2012) 

Percent Increase in Risk (Odds Ratio) per Exposure Limit Exceeded (DSS Alert)Portended by a Novel Risk Index for Adverse Postoperative Outcome 

Based on the Number of Intraoperative Hypotensive Exposure Limits Exceeded(with and without adjustment for a set of 30 co‐morbidities identified by AHRQ)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

1. Current Status of Perioperative Care

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR KnowledgeBase

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR KnowledgeBase

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation (the right informationat the right time to make the right decision)

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation (the right informationat the right time to make the right decision)

± History of hypertensionRisk factors for hypotension(ex: hypertrophic obstructive CM)

Association between hypotensive exposure & outcome

(“Diving Charts”)

Increased risk for adverse outcome portended by progressive hypotensive exposure

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation

Web-Based Secure (electronically, physical)Compliant with Standards (HL7, SNOMED ontology)Platform-IndependentScalableUniversally Applicable

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation

Web-Based Secure (electronically, physical)Compliant with Standards (HL7, SNOMED ontology)Platform-IndependentScalableUniversally Applicable

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation

Web-Based Secure (electronically, physical)Compliant with Standards (HL7, SNOMED ontology)Platform-IndependentScalableUniversally Applicable

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation

Web-Based Secure (electronically, physical)Compliant with Standards (HL7, SNOMED ontology)Platform-IndependentScalableUniversally Applicable

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation

Web-Based Secure (electronically, physical)Compliant with Standards (HL7, SNOMED ontology)Platform-IndependentScalableUniversally Applicable

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation

Web-Based Secure (electronically, physical)Compliant with Standards (HL7, SNOMED ontology)Platform-IndependentScalableUniversally Applicable

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation

Web-Based Secure (electronically, physical)Compliant with Standards (HL7, SNOMED ontology)Platform-IndependentScalableUniversally Applicable

1. Current Status of Perioperative Care2. Concept of Decision Support (DSS)

ARKS

EMR

DSS

KnowledgeBase

Pertinent,Patient-SpecificInformation

Web-Based Secure (electronically, physical)Compliant with Standards (HL7, SNOMED ontology)Platform-IndependentScalableUniversally Applicable

OR

SupervisingPhysician

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

Allows adverse physiologic developmentsto be addressed before they become crises

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

Allows adverse physiologic developmentsto be addressed before they become crises

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

Allows adverse physiologic developmentsto be addressed before they become crises

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

Allows adverse physiologic developmentsto be addressed before they become crises

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

Allows adverse physiologic developmentsto be addressed before they become crises

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

Allows adverse physiologic developmentsto be addressed before they become crises

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

Allows adverse physiologic developmentsto be addressed before they become crises

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

ARKS

EMRDSS

KnowledgeBase

OR

Allows adverse physiologic developmentsto be addressed before they become crises

Update the effective MAP Matrixto include the most recent minute of the case

Update the cumulative number of minutes spent below each of the MAP 

thresholds  (75 to 45 mm Hg)

Compare with the set of time thresholdsfor the selected level of risk (risk set)  

Count the number of thresholds exceededfor the current minute

Count greater than the previous minute’s count?

Alert

executed every minutein near real time

Each alert portends a 5.1% increase in the projected odds ratio for death within 30 days (20% risk set) 

5

4

3

2

1

Odds of Mortality

1

2

3

4

5

12:00:00 13:12:00 14:24:00 15:36:00 16:48:00

5

4

3

2

1

Odds of Mortality

Odds of Mortality

1

2

3

4

5

12:00:00 13:12:00 14:24:00 15:36:00 16:48:00

5

4

3

2

1

Odds of Mortality

1

2

3

4

5

12:00:00 13:12:00 14:24:00 15:36:00 16:48:00

5

4

3

2

1

to be evaluated in a prospective randomized clinical effectiveness trial…

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

Decision Support Toolbox (CPOE, Alerts, etc.)

C&BI

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

C&BI

Hypotensive ExposuresNumber of Limits ExceededAlerts

in real time (every one minute),for every patient

MAP Matrix

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

Minute‐to‐Minute MAP DataMedical History (Hypertension)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

C&BI

Hypotensive ExposuresNumber of Limits ExceededAlerts

in real time (every one minute),for every patient

MAP Matrix

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

BP

Minute‐to‐Minute MAP DataMedical History (Hypertension)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

C&BI

Hypotensive ExposuresNumber of Limits ExceededAlerts

in real time (every one minute),for every patient

MAP Matrix

Targeted

Postop. Care

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

BP

Minute‐to‐Minute MAP DataMedical History (Hypertension)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

C&BI

Hypotensive ExposuresNumber of Limits ExceededAlerts

in real time (every one minute),for every patient

MAP Matrix

Targeted

Postop. Care

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

BP

Minute‐to‐Minute MAP DataMedical History (Hypertension)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

C&BI

Hypotensive ExposuresNumber of Limits ExceededAlerts

in real time (every one minute),for every patient

MAP Matrix

Targeted

Postop. Care

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

Hypotensive exposuresare difficult to detect…

…and impossible to avoid…

BP

Minute‐to‐Minute MAP DataMedical History (Hypertension)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

C&BI

Hypotensive ExposuresNumber of Limits ExceededAlerts

in real time (every one minute),for every patient

MAP Matrix

Targeted

Postop. Care

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

Hypotensive exposuresare difficult to detect…

…and impossible to avoid…

BP

Minute‐to‐Minute MAP DataMedical History (Hypertension)

Clinical & BusinessProcesses

Actions/Interventions

Results Data

Knowledge/Experience Actionable Information(Decision Support)

Learning/Understanding Information

Intraoperative Hemodynamics

Device Integration

ETL Processes Analytics

Real-Time Processing

C&BI

Hypotensive ExposuresNumber of Limits Exceeded

in real time (every one minute),for every patient

MAP MatrixBP

Targeted

Postop. Care

In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality

Hypotensive exposuresare difficult to detect…

…and impossible to avoid…

Minute‐to‐Minute MAP DataMedical History (Hypertension)

Alerts

References• Implementing Business Intelligence in Your Healthcare Organization. Cynthia 

McKinney, MBA, FHIMSS, PMP, Ray Hess, MSA, RRT, FHIMSS, and Michael Whitecar, MIS, LCDR (ret.), MSC, USN. http://marketplace.himss.org/OnlineStore/ProductDetail.aspx?ProductId=3329

• Risk‐Based Decision Support Thresholds for Hypotension in Adult Patients Undergoing Non‐Cardiac Surgery. Wolf H. Stapelfeldt, M.D., Jarrod Dalton, Ph.D., Pamela Bromley, M.B.A., George Takla, Ph.D., Jacek Cywinski, M.D., Marc Reynolds, M.S., Bhaswati Ghosh, M.S. http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=9B5E43B933F1D63ABAED7E20D57A44D1?year=2012&index=14&absnum=4351

• Prolonged hypotension in surgery linked to poor outcomes. Michael Vlessides. Anesthesiology News 38  (12), December 2012. http://issuu.com/mcmahongroup/docs/mman0012_2012_tab/1?zoomed=&zoomPercent=&zoomX=&zoomY=&noteText=&noteX=&noteY=&viewMode=magazine

• Starter Question #1Where to begin with C&BI?

The opportunity for C&BI begins with a solid foundation of electronic acquisition of data that capture the essential clinical and business processes as well as indicators of their outcomes through device integration and ETL processes by interfacing with relevant data sources such as patient monitors, EMRs, patient registries etc.

• Starter Question #2What outcomes to focus on when it comes to C&BI?

These could be key reportable patient outcome measures such as mortality, quality indicators, process measures or parameters such as cost per case. It is important to choose the most relevant ones and keep these in constant focus while realizing that it is resulting informed actions and interventions which affect these, not C&BI per se. 

• Starter Question #3What types of data parameters are most suitable to be concentrating on when applying predictive analytics?

While predictive analytics needs to account for any input parameters deemed relevant it is those that might be altered through intervention (“actionable information”) that would be most relevant. Example: hemodynamic management (alterable) versus certain pre‐existing co‐morbidities (very important, but not typically alterable).

• Starter Question #4How can predictive analytics be leveraged to affect relevant outcomes?

There are essentially two important requirements: both, the analysis of clinical and business data for “actionable information” as well as provider notification to this information must occur within a sufficient time frame to allow any necessary actions/interventions to still be instituted and take effect in order to influence outcomes. 

• Starter Question #5What is the ROI of instituting C&BI?

It is the determined by the value attributed to the percent improvement in meaningful outcome(s) one can expect to attain as a result of the implementation of C&BI relative to the cost of instituting the latter. This is one reason why it is important, at the outset, to choose the highest impact outcomes to be affected (example: number of lives saved;incremental operating margin through reduction in LOS).

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