Collaboration Is Key To Increasing Surgical Value
David Skarda, MDJeannette Prochazka, MSNKatie Liljestrand, RN, MBAWendy Gort, MBA
Intermountain has partnered with Empiric Health to commercialize ProComp
Disclosure
Objectives
Identify key components of a successful multi-disciplinary team
Discuss how data cohorts are created and maintained to make meaningful and comparable data to reduce variation in practice
Give examples of how collaboration with teams has reduced cost and improved surgical outcomes
Healthcare in 2017- Fitting a square peg in a round hole…
Financial Distress
Since 1975• 22 hospitals• 2,784 licensed beds
Since 1983• Health plans• 700,000+ members
Since 1994• 1,200 employed physicians• 558 advanced practice clinicians
Since 1997• 10 key service lines
A Highly-Integrated Health System
Hospitals
SelectHealth
Medical Group
Clinical Programs
System-wide physician, and clinical administrativeoperations leaders needed to implement best practice
Development teams identified and established
Clinical Management Infrastructure
Measurement System Implementation Support
Staff support personnel and systems necessary to measure clinical, financialand satisfactionoutcomes for key clinical processes
Staff and systemsnecessary to develop, disseminate, support and maintain the clinicalknowledge basenecessary to implement best practice
INFORMATION TECHNOLOGY
CLINICAL PROGRAM INFRASTRUCTURECollaboration BEGINS here
Information Management Infrastructure
Clinical Programs and ServicesWorking Together
Ne
uro
scien
ces
NursingImaging
RespiratoryPharmacy
RehabNutrition
Laboratory
Be
havio
ral He
alth
On
colo
gy
Prim
ary Care
Mu
sculo
skeletal
Card
iovascu
lar
Wo
me
n &
Ne
wb
orn
s
Surgical Se
rvices
Inte
nsive
Me
dicin
e
Pe
diatrics
Supply Chain
Development Team Structure
• Elements of a strong physician leader Who to pick & who to avoid
• What motivates this leader?
• Good data makes all of the difference!
Development Team Structure
Physician Lead(s)
Physician Representatives
Administration
Project Manager
ProCompNurse
SelectHealth
Supply Chain Pharmacy OR DirectorsClinical
Program Directors
Compliance/ Quality
Data Analysts
Development Teams: Key to Physician Engagement
AnesthesiaBariatric Surgery
Blood Management
EndoscopyGeneral Surgery
Geriatric Hip Fracture
Gyn Surgery ENT Plastics Robotics
Spine Total Joints Urology Vascular/CV
Multiple Clinical Program Collaboration
Houston….We have a problem…..Intermountain…We have a goal…
Variation in clinical practice and supply utilization
Incomparable cost and outcome data
Working in silos
Disengaged physicians and clinicians
Lack of transparency in cost and outcomes data
ProComp: a technology & services platform to encourage evidence-based clinical practice
Create a culture of
evidence-based
clinical practice
REDUCEunnecessary
clinical variation &
cost
Reach consensus
on best practice
ENGAGEclinicians with
personalized insight
Identify
procedural
variation and
waste
COMPARE procedures &
workflows
ProComp is the center of the
solution ProComp
Surgeons
Supply Chain Organization
Development Teams
Surgical Services Clinical
Program
Operating Room Staff
Central Processing
Empiric Health formed.
Empiric launched at HIMSS
History of Intermountain ProComp development
specialties 6
cohorts 15
savings $15M
specialties 8
cohorts 40
exhorts 10
savings $58M
specialties 12
cohorts 127
exhorts 39
savings $80M
2013 2014 2015 2016 2017
specialties 13
cohorts 236
exhorts 128
savings $92M
Intermountain launches
ProComp to reduce variation in
surgical services
Intermountain
cohort and savings
metrics
Delivering comparable and meaningful data
Identify procedural
variation and waste
COMPARE procedures & workflows
Creating Refined, Comparable, and Transparent Data
“I would rather look at a lower volume of cases knowing those cases were all alike versus looking at all of the encounters knowing that some of those cases didn’t really fit in.”
~Dr. Jay Bishoff, Urology
Co-developed
with physicians
Intermountain cohorts present truly comparable encountersTraditional Procedural Data Intermountain Cohorts
Procedures with the same primary
procedure code often have
additional secondary procedures
Cohorts define comparable
procedures exactly the way
physicians want to look at them
Currently
251 Cohorts,
131 Exhorts
All definitions
available for review
with physicians
Ability to create
new or refine
existing definitions
Lifecycle of a Cohort
Cohort TypesStandard Cohorts
• Primary Procedure (ICD or CPT)
• List of secondary ‘May Have’ or ‘May Not Have’ procedures
• May also use age, supplies, trauma levels, MSDRGs, etc.
• 72 distinct rules
• Currently 169 Standard Cohorts
Examples:
Lap Cholecystectomy Inpatient (>=15yrs)
Total Hip Arthroplasty
Total Knee Arthroplasty
Tonsillectomy and Adenoidectomy
Cohort Extractor - When a basic cohort just isn’t enough
Key terms are tagged in records and encounters can be included or excluded appropriately.
Examples include: prostatectomy, hysterectomy, bariatric, robotic, and spine procedures.
Cohort TypesCohort Extractor (Tagged) Cohorts
• Each case reviewed and tagged by an Outcomes nurse
• Primary procedure (posterior lumbar fusion)
• Approach (laparoscopic, robotic)
• Qualifiers (anterior, posterior, revision)
• Additional Details (complications, surgical technique)
• 14 distinct rules
• Currently 82 Tagged Cohorts
Examples:
Prostatectomy, Robotic Simple (CE) Levels
Total Laparoscopic Hysterectomy
Total Laparoscopic Hysterectomy with Lymphadenectomy
Cohort TypesExhorts
• Most cohorts contains a partner exhort
• Same primary definition as cohort, but falls into exhort due to additional procedures (ex. appendectomy and cholecystectomy in same case)
• Eliminates known variation
• Able to account for all cases for a primary procedure for analysis on volumes, SSI, etc.
• Currently 131 Exhorts
Cohort TypesProcedure Groups
• When there isn’t a cohort defined for a primary procedure, the case falls into a procedure group
• Able to account for all surgical services cases for analysis on savings, OR utilization, etc.
• Also used to determine potential defined cohorts
Examples:
15820 Blepharoplasty, lower eyelid
15824 Rhytidectomy
00500ZZ Destruction of Brain, Open Approach
00590ZZ Destruction of Thalamus, Open Approach
Reach consensus on
best practice
ENGAGEclinicians with
personalized insight
Collaborating across the system to engage caregivers
Engaging clinicians through Development Teams
“What matters to you and your patients….”
Identify best practice based on evidence
Standardize best practice throughout Intermountain
Look for variation in cost and outcomes
Align with Intermountain goals
Spine Development Team
Low attendance by surgeons
Data that was not meaningful
Cost reduction goal (without outcome data)
Engaging physician lead
Creation of clinically relevant data
Problems
Solution
Billing data (ICD and CPT) combines multiple fusion levels. This data is not comparable.
Spine Development Team Improvements
Created dynamic dashboard (unblinded data)
Encouraged input on meaningful data metrics
Increase in attendance by surgeons
Discussion of cost reduction- Reduction of implant suppliers led to $4.2 million savings
Participation in national registry for outcome data
Dashboard Component Examples
Outcome
Solution
Spine Development TeamCohort Extractor (Tagged) Cohorts
Facilities
Surgeons
Spine Development TeamCohort Extractor (Tagged)
Facilities
Surgeons
Consistent practice through standardized order sets
General Surgery Development Team:
Evidence-based practice
Physician decisions
Pharmacy and ID expertise
Operationalizing-standardized order sets
Dashboard development and tracking orders
General Surgery Development TeamStandard Cohorts (Lap Appendectomy and Lap Cholecystectomy)
Facilities
Surgeons
General Surgery Development TeamStandard Cohorts (Lap Appendectomy and Lap Cholecystectomy)
Some cohorts further defined during reporting by searching for
key terms on operative report
ex. ruptured (perforated, ruptured, gangrenous)
Facilities
Surgeons
Anesthesia Development TeamQuality Measure Variation Reduction
PSI-11 Post operative Respiratory Failure
Anesthesia Development Team- Identify root cause
Collaboration with Clinical Documentation Specialists, Respiratory Services
Education to: Intensivists, Surgeons, Resident Physicians
Continued ADT review of PSI 11 Failures
• Identification of high risk patients (OSA, multi-modal pain management)
3.30%
2.60%
1.40%
Quarter 1 Quarter 2 Quarter 3
PSI-11 Failure Rate (per 1000 discharges)
Engaging with the Individual Physician
• One physician was using a product 234% > any other physician.
• Product = $170/case
Opportunity Identified
• Nurse presented data on cost/case variation and related outcomes.
ProComp• Physician decreased
utilization over a few months and now rarely uses the product.
• Savings in one year = $36,000
Decreased Utilization
Create a culture of
evidence-based clinical
practice
REDUCEunnecessary clinical
variation & costIdentification of variation and
operationalization of best practice
T & A surgery within Intermountain
High volume, high variability in cost and complicationso 4,007 T & A surgeries (Cohort), 751 T & A surgeries (Exhort)
oHospital Mean Cost per Case- $1000-$2400
Meaningful Data Influences Physicians Behavior
Parent-reported study shows more expensive cautery does not improve outcomes.
Personalized data sent to ENT surgeons quarterly
T&A Cohort- over 4 year period
T&A Cohort- Over 3 year period
Results: Change in behavior and reduction of cost per case
One Appendectomy
Appendicitis is Common
• Most common surgical emergency in children
• Surgical technique is variable
• Outcomes are consistently good
• Cost to treat per child with non-ruptured appendicitis in USo $5,000 to $10,000
• Cost to treat per child with ruptured appendicitis in USo $10,000 to $30,000
• Ideal target to improve value
Less Expensive Alternatives Exist
Port
• Items available but not used
were over 81% less than what
was being used
Loops instead of staplers
• Loops are over 86% less than
Staplers
Endocatch bag • Use the bag $• No use $0
Disposable fascia closure device • Use the device $• No use $0
Heat source• Harmonic scalpel $• Ligasure $• Hook cautery $0
All Patients with Appendicitis
Historical Controls
N=346
Standardized Procedure
N=362 P Value
Mean
(95% CI) Mean
(95% CI)
Appendectomy Device Cost
$844.11 (838.65-849.56)
$305.32 (302.05-308.60)
<0.001
Skin to Skin OR Time (min)
34.8 (33.3-36.3)
37.0 (35.6-38.4)
0.006
Roll-in Roll-out OR time (min)
59.3 (57.6-61.1)
61.7 (60.0-63.3)
0.016
$195,041.98/year
No difference in Outcomes
3 Years Later—Cost Per Case Per Surgeon
Surgeons
Intermountain Healthcare Pediatric Sedation/Anesthesia/Procedural Care Policy
A “Principled Compromise” Solution
The Problem:
• There are well-defined “high-risk” populations• Premature babies
• Babies 0-12 months old
• Children ASA 3+
• 7 “high-risk” specific clinical scenarios
• System variability in “who can do what where”
• We had an event
• Mandate. . . “stop the bleeding. . . and make a policy”
Process:
• Created and met with a Stakeholder group
NORTH REGIONMatt Pollard Mike BroadbentDavid Harker Pat Watkins
Michael Cragun Larry HawsMarcie Sherner
CENTRAL REGIONNate Kofford Ruth ZimmerBill Hamilton Shannon PhillipsSabrina Cole Carolyn ReynoldsKelly Davis Pramod Sharma
Nancy Nelson Deanna WelchMark Ott
SOUTH REGIONJonathan Meyers Craig Grose
Darren Obray Becky DavisSteve Bigler Will ShakespeareGary Beck
SOUTHWEST REGIONTodd Plumb Steve Van NormanTyler Nelson
PRIMARY CHILDREN’S REGIONJeremy Meier Jeff Schunk
Douglas Barnhart Sheldon FurstChristopher Maloney
Process:
• Created and met with a Stakeholder group
• Analyzed external and internal data and guidelines
• Evaluated a number of potential options
• Came to a potential deadlock
• Generated a “principled compromise” solution
• Policy approved by IH clinical leadership
Spectrum of Pediatric Policy
No Policy• Everyone does what they want• Facility or Regional Control• Prior to Aug 1
Strong Regulation• System standards• Facility limitations• Central Control
“Principled Compromise” Proposal
Sweet Spot
Region-based AdministrationRegion-based Monitoring System-wide Adoption of UCR Policy
Criteria-based access to “high-risk” groups
You don’t have to “Pass It” to know what is “In It”
• Treats all facilities and all providers equally
• All facilities and providers can treat healthy children (7 months old and older, ASA 1-2)
• Defines “high-risk” populations and who can treat them
• Creates an ongoing pediatric SAP outcome monitoring process
Facilities
Surgeons
Facilities
Surgeons
Report Metrics
• Volumes• PACU Duration• Return to OR• Readmission• Mortality
PRBC Utilization
We Had a Problem• Intermountain used a lot of PRBCs
• 2009 cross matched PRBC Units transfused – 39,567
• Total of PRBC discarded products – 3,128
• Total Transfusion reactions – 222
• PRBCs are expensive. . . $1800-$2800/unit transfused
• PRBCs can cause problems
System PRBC transfusion Indications
PRBC Transfusion Reduction Project
Educate clinicians• Indications
• One unit at a time unless MTP
Monitor leading and lagging measures
Provide clinicians with feedback
Monthly Letter to clinicians that transfuse PRBC’sDear Esteemed Colleague:You are receiving this email because you ordered a PRBC transfusion in an Intermountain facility during the month of January. Intermountain Healthcare has a continued focus on reducing the number of unnecessary PRBC transfusions in the population. Thank you for your participation to decrease PRBC transfusions and I invite you to click on this link, Physician Blood Utilization Report, from a computer inside the Intermountain Healthcare firewall and using your standard Intermountain user ID/password, so you can view your transfusion data.Intermountain Ongoing Blood Utilization Goals:1. Minimize the frequency of two-unit transfusions2. Minimize the frequency of transfusion for Hematocrit > 22.9% Most patients do not need an elective blood transfusion for hematocrits above 21%. When a blood transfusion is appropriate, one unit instead of two units is usually the appropriate volume. Please consider giving your patient one unit of blood and then reevaluating the patient before routinely giving them the second unit of blood. We know that this is different from what you may have learned in medical school and residency, but is well supported by the best evidence based guidelines below.Please compare your personal blood transfusion practice to these best evidence based guidelines for transfusion indications based on hematocrit level and medical history:
Blood Utilization
Blood Utilization
Blood Utilization Cost Savings
> $4,000,000
Summary- How to fit a square peg in a round hole…
• Strong physician leader
• Multi-disciplinary team- expert opinions/insight
• Involve physicians in data refinement process
• Comparable and meaningful data
• Standardization of processes in large system is possible!