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Population Health Management David A. Burton, MD Proprietary and Confidential Proprietary and Confidential © 2013 Health Catalyst www.healthcatalyst.com © 2013 Health Catalyst www.healthcatalyst.com Population Health Management Emphasis on the Continuum of Care Outpatient Inpatient Skilled Nursing Facility Home Home Health Care Hospice Cemetery Clinic Care Proprietary and Confidential © 2013 Health Catalyst www.healthcatalyst.com Population Health Management Paradigm Shift Inpatient Outpatient Inpatient Skilled Nursing Facility Home Home Health Care Hospice Cemetery Clinic Care Acute Care-Centric Management Population-Centric Management Proprietary and Confidential © 2013 Health Catalyst www.healthcatalyst.com Poll question Outpatient Inpatient Outpatient Inpatient Home Health Hospice Outpatient Inpatient Home Health Hospice 1 2 Clinic Care 3 Outpatient Inpatient Home Health Hospice Clinic Care SNF 4 5 Other combination Proprietary and Confidential © 2013 Health Catalyst www.healthcatalyst.com Population Health Management Anatomy of Healthcare Delivery Symptoms Screening & Preventive Health Maintenance and Preventive Guidelines Management of Preventive, Ambulatory, Acute Medical, Invasive & PAC Modules Population-Focused Knowledge Assets Diagnostic Algorithms, Triage Criteria, Referral & Intervention Indications Diagnostic Work-up Diagnostic algorithms Home (Patient Portal) Module-Focused Knowledge Assets Triage to Treatment Venue Triage Criteria Admission Order Sets Ambulatory Non-recurrent Ambulatory Recurrent Acute Medical IP Med-Surg Admission Order Sets Invasive Medical Acute Medical IP ICU Treatment and Monitoring Algorithms Standardized Follow-up Indications for Referral Indications for Intervention Substance Selection Substance Selection Supplementary Order Sets Invasive* Subspecialist * To Invasive Care Processes Post-acute care order sets IP (SNF, IRF) Home health Hospice Invasive Surgical Substance Preparation Chronic Disease Subspecialist Pre-Procedure Order Sets Clinical Supply Chain Management Procedure Bedside care Postprocedure Order Sets Treatment and Monitoring Algorithms Bedside care practice guidelines, risk assessment and patient injury prevention protocols, bedside care procedures, transfer and discharge protocols Proprietary and5Confidential Post-procedure Care Discharge © 2013 Health Catalyst www.healthcatalyst.com Population Health Management Clinical Integration hierarchy - Care Processes Home Clinic Care Outpatient Inpatient Hyperlipidemia Acute Myocardial Infarction (AMI) Coronary Atherosclerosis Percutaneous Intervention (PCI) Coronary Artery Bypass Graft (CABG) Proprietary and Confidential SNF Home Health Hospice Cardiac Rehab Care Processes 6 © 2013 Health Catalyst www.healthcatalyst.com Population Health Management Clinical Integration hierarchy - Care Process Families Home Clinic Care Outpatient Inpatient Hyperlipidemia Acute Myocardial Infarction (AMI) Coronary Atherosclerosis Percutaneous Intervention (PCI) Coronary Artery Bypass Graft (CABG) Proprietary and Confidential SNF Home Health Hospice Cardiac Rehab Ischemic Heart Disease Care Process Family 7 © 2013 Health Catalyst www.healthcatalyst.com Population Health Management Clinical Integration hierarchy - Clinical Programs Home Clinic Care Outpatient Inpatient SNF Home Health Hospice Cardiovascular Clinical Program Ischemic Heart Disease Care Process Family Heart Failure Care Process Family Heart Rhythm Disorders Care Process Family Proprietary and Confidential Vascular Disorders Care Process Family © 2013 Health Catalyst www.healthcatalyst.com Clinical Integration hierarchy Clinical Programs – ordering of care Primary Care CV W&C GI Respiratory Neuro Sciences Musculoskeletal Surgery General Med Oncology Peds Spec Mental Health Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families 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 Replacement e.g., Urologic Disorders e.g., Infectious Disease e.g., Breast Cancer e.g., Peds CV Surg e.g., Depression Proprietary and9Confidential © 2013 Health Catalyst www.healthcatalyst.com Clinical Integration hierarchy Clinical Support Services – delivery of care ordered Clinical Support Services (Delivery of Care) 12 Clinical Programs (“Ordering of Care”) Primary Care CV W&C GI Respiratory Neuro Sciences Musculoskeletal Surgery General Med Oncology Peds Spec Mental Health Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families Care Process Families 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 Replacement e.g., Urologic Disorders e.g., Infectious Disease e.g., Breast Cancer e.g., Peds CV Surg e.g., Depression 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]) 10Confidential Proprietary and © 2013 Health Catalyst www.healthcatalyst.com Clinical Program Care Process Families Care Processes CARDIOVASCULAR Heart Rhythm Disorders Vascular Disorders Ischemic Heart Disease Heart Failure ACS AMI PCI CABG ICD9 Diagnosis Code Groupings ICD9 Procedure Code Groupings CPT-4 Code Groupings ICD9 Volumes I-II 17,674 Diagnosis Codes ICD-9 Volume III 3,903 Procedure Codes 2013 CPT® Code Set 9706 Codes Proprietary and Confidential © 2013 Health Catalyst www.healthcatalyst.com Population Health Management Medicare 2011 fee-for-service payments by venue Clinic Care Outpatient Inpatient SNF Home Health Hospice $ 31.7 Billion 12.3% 77.6 Billion 30.1% 90.6 Billion 35.1% $ 29.7 Billion 11.5% $ 18.4 Billion 7.1% $ 10.1 Billion 3.9% Inpatient SNF Home Health Clinic Care Outpatient Proprietary and Confidential Hospice 12 © 2013 Health Catalyst www.healthcatalyst.com c Proprietary and Confidential © 2013 Health Catalyst www.healthcatalyst.com c Proprietary and Confidential © 2013 Health Catalyst www.healthcatalyst.com c Proprietary and Confidential © 2013 Health Catalyst www.healthcatalyst.com 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 Proprietary and Confidential © 2013 Health Catalyst www.healthcatalyst.com Our Philosophy: Be Systematic Change Process and Behavior Apply Evidence and Standardize Services Installation Services, Critical Improvement Services Analytic Applications Key Process Analysis, Dashboards, Advanced Analytics Late-Binding™ Integrate Data and Measure Data Warehouse Platform Data Warehouse, Architecture, Metadata Management, Security, and Auditing Proprietary and Confidential 17 © 2013 Health Catalyst www.healthcatalyst.com Catalyst Adaptive Data Warehouse Catalyst’s Adaptive Data Model Metadata: EDW Atlas Security and Auditing Common, Linkable Vocabulary Financial Sources (e.g., EPSi, Peoplesoft, Lawson) Financial Source Marts Departmental Sources (e.g., Apollo) Departmental Source Marts Readmissions Administrative Sources (e.g., API Time Tracking) Administrative Source Marts Diabetes Patient Source Marts Patient Satisfaction Sources (e.g., NRC Picker, Press Ganey) Sepsis EMR Source Marts HR Source Mart EMR Source Human Resources (e.g., PeopleSoft) (e.g., Epic, Cerner) 18Confidential Proprietary and More Transformation Less Transformation © 2013 Health Catalyst www.healthcatalyst.com Catalyst approach Application families 2 Content-driven applications 1 Metadata-driven platform Foundational Applications Late-Binding™ Data Warehouse Platform 3 Proprietary and Confidential Discovery Applications Advanced Applications Late-Binding™ Data Bus Data Acquisition Engine and Storage Metadata Engine 19 © 2013 Health Catalyst www.healthcatalyst.com Clinical Integration Leadership Team (CILT) Administration Vice-Chair CMO Chair CNO Vice-Chair Chief Information Officer Chief Knowledge Officer Cluster #1 Cluster #2 Cluster #3 Cluster # … Cluster #N Cluster CMO Cluster CMO Cluster CMO Cluster CMO Cluster CMO Cluster CNO Cluster CNO Cluster CNO Cluster CNO Cluster CNO Cluster Administrator Cluster Administrator Cluster Administrator Cluster Administrator Cluster Administrator Cluster = Hub Hospital/Region, Medical Group, Health Plan, Section/Division Proprietary and Confidential 20 © 2013 Health Catalyst www.healthcatalyst.com CV Clinical Program Guidance Team CV Physician Chair* Nurse Director Vice-Chair Cluster #1 Cluster #2 Cluster #3 Cluster #4 CV MD Lead CV MD Lead CV MD Lead CV MD Lead CV Nurse Lead CV Nurse Lead CV Nurse Lead CV Nurse Lead CV Administrator CV Administrator CV Administrator CV Administrator Heart Failure MD Chair Rhythm Disorders MD Chair Vascular Disorders MD Chair Ischemic* MD Chair * One of the Clinical Implementation Team chairs also serves as the Guidance Team chair (Ischemic MD Chair in this example) Proprietary and Confidential 21 © 2013 Health Catalyst www.healthcatalyst.com Clinical Implementation Team (CIT) Heart Failure Care Process Family Heart Failure MD Chair Cardiologist CV RN Director Vice-Chair Facility #1 Facility #2 Facility #3 Facility #4 Heart Failure MD Lead Heart Failure MD Chair Heart Failure MD Chair Heart Failure MD Chair CV Nurse Lead CV Nurse Lead CV Nurse Lead CV Nurse Lead Proprietary and Confidential 22 © 2013 Health Catalyst www.healthcatalyst.com CIT Work Group Subject Matter Expert Clinical Operations Director Data Capture Workflow Analysis Data Provisioning CIT Chair (MD) Scientific SME Provider/Patient Education Team Data Analysis Front Line Clinical Ops Workflow SME Data Architect Knowledge Manager Administrative Application Steward Clinical Application Steward * CMIO, CQO, Chief Patient Safety Officer, or Chief Analytics Officer provided individual has requisite qualifications and skills Proprietary and Confidential 23 © 2013 Health Catalyst www.healthcatalyst.com Workgroup Roles Subject Matter Expert DATA CAPTURE Knowledge Managers Data Capture Workflow Analysis Data Provisioning • Acquire key data elements • Assure data quality • Integrate data capture into operational workflow Application Administrators (e.g., EMR Administrators, Financial System Administrators) Data Analysis DATA ANALYSIS DATA PROVISIONING • Interpret data • Discover new information in the data (data mining) • Evaluate data quality Knowledge Managers • Move data from transactional systems into the EDW • Build visualization for use by clinicians Data Architects (Analysis) Data Architects (infrastructure) 24Confidential Proprietary and Data Architects (Visualization) © 2013 Health Catalyst www.healthcatalyst.com 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 Proprietary and Confidential © 2013 Health Catalyst www.healthcatalyst.com Implementation flow diagram Proprietary and Confidential © 2013 Health Catalyst www.healthcatalyst.com Standard “organizational” work Monthly Tasks and Checkpoints 7 Steps (Work Streams) 1 Gather Knowledge Assets 2 Define Cohort 3 Select AIM Statement 4 Select, Build, Refine Metrics 5 Develop Implementation Plan for Process Improvement 6 Implementation 7 Measure Progress Implementation Design Launch Approval Results Review • Supplement BMJ content • Refine Cohort • Refine Metrics • Develop Draft Visualizations • Develop Recommended AIM statement #1 • Cluster Reps Obtain Front Line Input • Finalize Cohort • Develop Additional metrics based on feedback • Develop Additional Visualizations to support • PDSA cycle • Cluster Reps Obtain Front Line Input • Improvement Plan • Implementation Plan • Develop cluster rep assignments, and deliverables • Collect cluster rep feedback • Prepare Initial Results from AIM statement #1 • Summarized report for historical review • Refine, recommend AIM statement #2 Build and Refine Build and Refine Build and Refine Kickoff AIM Statement • Mission • Cohort Discover • Data Analysis and Review • BMJ Best Practices • Building Multiple Potential AIM statements Select Initial Metric 27 Pregnancy 28Confidential Proprietary and © 2013 Health Catalyst www.healthcatalyst.com Surgical Services 29Confidential Proprietary and © 2013 Health Catalyst www.healthcatalyst.com Discharge from hospital to post-hospital service 30Confidential Proprietary and © 2013 Health Catalyst www.healthcatalyst.com Pressure injury prevention 31Confidential Proprietary and © 2013 Health Catalyst www.healthcatalyst.com Standard organizational work Slide Decks MD Contract Templates Team Charters Meeting Agendas Handbooks Job Descriptions Project Status Reports Job Family Grids Deployment Process Outlines Compensation Grids GRADE 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 D.20 40.15 50.18 54.34 60.24 DATA ARCHITECT-ASSOC DATA ARCHITECT-STAFF DATA ARCHITECT-SR DATA ARCHITECT-CNSLT D.14 D.17 D.19 D.20 OUTCOMES ANALYST-ASSOC OUTCOMES ANALYST-STAFF OUTCOMES ANALYST-SR OUTCOMES ANALYST-CNSLT N.13 N.15 N.17 N.19 DATA MANAGER-ASSOC DATA MANAGER-STAFF DATA MANAGER-SR DATA MANAGER-CNSLT D.13 D.15 D.17 D.19 Compensation Rate by Specialty Administrative Rates by Group Large Clinic Median Compensation Data $/hour Diff from Min Mid Max Group 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 27 CV Surg 380,207 415,351 438,901 441,133 440,000 474,772 455,455 195 8 Radiology (interventional) 306,000 356,001 375,000 410,250 410,250 424,992 440,004 188 2 Cardiology - Cath 276,001 304,750 325,494 375,003 380,234 412,101 432,618 185 -2 Radiology (non-interventional) 258,000 309,255 330,603 350,000 372,000 410,000 420,000 179 -7 Ortho 306,403 349,697 351,221 366,732 389,997 402,003 412,004 176 -10 Median - 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 = $29,500 Group 4 MFM (Perinatology) 298,158 no data 385,917 312,238 395,809 375,005 382,414 163 16 Cardiology - General 261,000 279,470 304,994 320,000 312,010 350,000 359,004 153 6 Vascular 281,143 289,918 310,401 320,210 336,820 321,131 355,000 152 5 Urology 264,175 285,500 310,964 319,000 322,000 343,769 346,633 148 1 Anesthesiology 251,083 282,501 307,500 314,495 330,008 338,256 344,960 147 0 Plastics 273,261 294,039 297,250 300,000 340,880 343,497 342,901 147 0 Gastroenterology 240,000 246,500 271,503 300,000 304,994 314,495 340,010 145 -2 General Surgery 250,251 273,956 294,925 287,915 309,021 320,689 336,694 144 -3 ENT 250,000 268,403 279,985 293,000 308,363 320,958 320,890 137 -10 Ophth 235,033 245,615 259,585 278,023 212,746 286,434 309,281 132 -15 Median - 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 = $21,000 Group 3 Clinical Pathology 217,500 233,677 232,984 251,227 225,000 263,750 287,927 123 10 Hematology & Med. Oncology 189,000 205,000 223,470 231,794 251,241 261,501 280,001 120 6 Dermatology 185,339 204,283 217,294 228,270 241,498 255,568 279,000 119 6 OB-Gyn - Branch 217,426 229,238 233,295 245,568 249,256 256,997 269,147 115 2 OB-Gyn 229,699 243,434 254,563 252,400 260,776 263,816 262,000 112 -2 Critical Care Medicine 207,250 218,000 223,500 228,740 228,740 234,503 249,996 107 -7 Emergency Care 189,286 202,690 211,000 221,927 232,749 238,523 248,227 106 -7 Neonatology 206,003 203,971 218,703 213,139 236,378 249,409 247,829 106 -8 Median - 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 = $13,000 Group 2 Pulmonary Disease 188,250 201,714 200,000 205,764 218,000 223,273 234,885 100 12 Nephrology 187,000 191,661 196,752 204,617 214,751 217,757 225,504 96 8 Allergy/Asthma 175,363 191,385 194,500 198,376 201,241 210,970 221,833 95 7 Physiatry 176,617 180,953 187,252 183,337 201,993 207,004 219,992 94 6 Neurology 182,600 188,431 191,496 195,000 201,241 210,500 211,664 90 2 Endocrinology 165,000 182,658 180,354 188,992 185,000 185,250 200,529 86 -2 Infectious Disease 161,447 164,894 179,473 186,896 178,627 189,615 197,996 85 -3 Urgent Care 142,906 157,368 161,785 165,559 168,143 187,000 197,820 85 -4 Occ Med 172,414 178,224 186,250 181,459 186,402 194,247 194,213 83 -5 Rheumatology 158,506 175,117 176,805 179,700 181,016 185,000 190,000 81 -7 Median - 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 = $5,000 Group 1 Psychiatry 150,232 159,448 162,000 161,202 171,300 172,350 184,827 79 5 General IM 142,084 150,046 153,786 153,939 165,375 172,565 178,005 76 2 Family Medicine 139,725 147,025 155,050 154,018 166,105 172,157 175,080 75 0 Peds 136,906 142,056 146,310 145,351 158,250 164,631 173,338 74 0 Internal Medicine - Branch 137,859 143,513 152,933 157,718 153,561 162,732 168,344 72 -3 Peds-Adol - Branch 135,800 138,000 144,643 144,436 150,112 154,000 163,917 70 -4 Median - 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 32 Poll question How prepared do you feel to implement population health management and shared accountability (e.g., ACO) strategies? 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