A Guide to Successful Outcomes Using Population Health Analytics

articulates the knowledge that should be applied to improve outcomes and shortens the time from when new medical knowledge is discovered to when it becomes the everyday practice of frontline clinicians.

Map of the Process: Care Continuum Map

To start considering what should be happening to provide the best care, a health system needs to look carefully at the entire continuum of care using a care improvement map.

Figure 4 is a care improvement map for sepsis showing the major processes included in delivering safe care for sepsis patients. Also identified are potential problem areas (storm clouds) and the metrics that are important to understand for a particular step in the process. The care improvement map shows components across the continuum of care that will be important to understand for clinical improvement. It also shows places where a clinical team and a technical team can collaborate.

Care map sepsis and septic shockFigure 4: Care Improvement Map for Sepsis and Septic Shock (click to enlarge)

Identify Common Problems and Potential Improvements

Organizational leaders can use the map to identify which of those problem areas (or storm clouds) will be most important to work on first. They can look to historical data for variation as an indication of opportunity for improvement. Having a list of common problems that are often not fully effective saves time and allows the team to come to a consensus around what to work on first.

For example, with heart failure, having a list of potential process aim statements can help expedite discussion on choosing an area to focus
on first. If a team considers heart failure readmissions as the primary improvement area, the team could look at three aim statements: 1. Improve medication reconciliation; 2. Improve follow-up visit scheduling; and 3. Improve follow-up phone call within 48 hours of discharge. The team will come up with specific percentage improvements and target dates based on their own data, but these starter sets can really help accelerate the discussion. As an organization writes—and achieves—aim statement after aim statement, it will see an effect on the outcome improvement goal. The specific numbers will be determined by the team, but these are sample aim statements to help the team get started.

To paraphrase W. Edwards Deming, PhD, the great process improvement consultant, “aim defines a system.” Deciding what part of the care to improve is a critical step.

Scope the Problem and Define Precise Patient Registries

Next, an organization needs to scope the problem and define the precise patient registry for a given aim statement. The process can start with a standard registry from administrative codes, but quickly will need to move beyond that. This will mean specific clinical inclusion and exclusion criteria for the sub-cohort of patients.

For example, a children’s hospital decided to focus on improving care for an asthma patient population, and it wanted to define “acute exacerbation of asthma in the inpatient setting.” It started by finding patients with the ICD9 code for asthma, 493.xx who had two steroids or beta-agonists administered within eight hours of admission and found about 29,000 patients. To create a precise registry, the hospital looked beyond the ICD9 code to patient problem lists and found an additional 22,955 patients. Next, the organization pulled supplemental ICD9 codes listed on patient encounters (such as 786.07 for wheezing and two steroids or beta-agonists administered within eight hours of admission)
and identified 38,250 patients. Finally, it looked at medication lists for associated prescriptions such as albuterol and gathered 72,581 patients. All of these elements and many others were evaluated, which expanded the final cohort in some ways and condensed it substantially in other ways. In the end, the hospital had a precise asthma patient population registry to focus on for its improvement efforts that comprised around 8,000 patients.

Precise Asthma Patient RegistryFigure 5: An Example of Creating a Precise Asthma Patient Registry

Adopt Standardization Aids

Then, the health system needs to adopt standardization aids. These can include checklists, order sets, or protocols. Sometimes these aids are called knowledge assets. These will make it easy for clinicians to choose the best action.

There are three major types of standardization aids (shown in figure 6):

Three types of assetsFigure 6: The Three Types of Assets, including Questions to Ask, Examples, and Possible Measures for Each

  • Utilization knowledge assets, which describes which patients should receive care. This would include triage criteria indicating if a patient should be admitted to the hospital or cared for by his primary care physician. It also includes intervention criteria such as specifying if a patient should get an invasive procedure versus physical therapy. Referral criteria is another example of a utilization knowledge asset; showing whether a patient should be referred to a specialist or stay with her primary care physician for care. Typically, decisions such as these are not standardized and are often based on the treating physician’s prior experience and training, which may not always be the latest evidence or medical knowledge.
  • Order sets come into play after a provider decides that a patient should receive care. Order sets dictate what should be included in that care. This includes admission order sets, pre-procedure order sets, and supplementary order sets. It also includes guidelines for which medications or substances should be selected and what supply chain components will be a part of this patient’s care.
  • Workflow standardization aids help deliver the care in the most efficient way. These include checklists (transfer checklists, discharge checklists, etc.), risk assessments, standard work, and actions performed by providers and support staff, over and over again.

Anatomy of Healthcare delivery corresponding types of assetsFigure 7: The Anatomy of Healthcare Delivery, colors correspond with figure 6, the Three Types of Assets. Orange denotes a utilization asset, blue is an order set asset, and green indicates a workflow asset (Click to enlarge)

When organizations consider these three standardization aids, metrics can be used to fully understand the use of these aids in the care delivery process and how to manage each one effectively throughout the continuum of care. For example, when looking at utilization knowledge assets, a hospital can consider metrics such as: Admits/1000 members, IP days/1000 members, Readmissions/1000 members, etc. For order sets, a health system can use cost per case/procedure or Operating Room minutes as metrics. And for workflow metrics, a hospital can measure nursing hours by unit or cost per ancillary test.

In figure 7, the anatomy of healthcare delivery is shown, which places the different types of knowledge assets in their logical location within the continuum of care delivery. Different standardization aids are used in the clinic and the ambulatory setting, for example, than in the acute medical unit or the invasive setting.

Payment Structure Considerations

As shown in figure 8, payment structures can really impact improvement work. Sometimes doing the right thing for the patient can have a negative financial impact on the care delivery organization as a whole. For example, a hospital in a discounted fee-for-service payment arrangement that makes a change to an intervention indication, resulting in fewer patients receiving a particular intervention, can see negative impacts in its bottom line. Whereas, if that hospital were in a full capitation or a condition capitation arrangement, the bottom-line impact would be positive.

Payment structure considerationsFigure 8: Payment Structure Considerations Based on Standardization Types; the colors in the “Knowledge Asset Type” column correspond with the colors in figure 6, the Three Types of Assets, and figure 7, the Anatomy of Healthcare Delivery. Orange denotes a utilization asset, blue is an order set asset, and green indicates a workflow asset.

The implications, of course, are that care delivery systems should consider the type of standardization change (seen as knowledge asset types in the right hand column of figure 8) in relation to its payment arrangements and consider approaching payers with a full capitation or condition capitation model. This way, hospitals, clinics, payers, and the patient community can all benefit from improving outcomes through utilizing the system appropriately, including the right components as the care is ordered, and decreasing waste and wait times through efficiency improvements.

Produce Actionable Visualizations

The final component of best practices is actionable visualizations. It is just not enough for a health system to know that, on the whole, it’s managing its diabetic patients or heart failure patients in a good manner. The organization needs to know exactly what actions or steps should be taken with specific patients.

A good example of this type of actionable visualization is shown in figure 9. Here, recently discharged heart failure patients are listed by whether or not there is a follow-up visit scheduled. The list is sorted by risk of readmission. So, care managers could make phone calls to schedule follow-up visits with those patients who have the highest risk scores (the highest on this example is 81) and move down the list. Since follow-up visits are part of best practice protocol for heart failure patients, ensuring high-risk patients are prioritized for follow-ups should help decrease readmission rates.

Heart failure patients needing phone callFigure 9: An Example of an Actionable Visualization: Heart Failure Patients Needing Follow-up Phone Calls Prioritized by Risk

Patient Flight Path

Another example of an actionable visualization is the Health Catalyst Patient Flight Path (shown in figure 10). With this tool, a physician could sit down with an individual patient and talk about changes or actions the patient should take in his day-to-day life, whether it be trying to get his BMI to a better place or reducing LDL. The physician can actually create…

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