Associate Chief Quality OfficerPartners HealthCare, Center for Population Health

Neil W. Wagle, MD, MBA

Ambulatory Quality:Returning to the Essence of Our Work

Medical Director, Clinical AnalyticsPartners HealthCare, Center for Population Health

Lara Terry, MD, MPH

Session #7

Learning Objectives

• Assess current barriers to successful quality improvement.

• Describe the key ingredients required to achieve successful improvement.

• Explain how to construct analytics tools to identify areas for improvement that will have a high impact.

Poll Question #1

How far along is your organization in pursuing data-driven quality improvement?

1) Not yet started2) Getting our feet wet3) Growth phase4) Robust deployment5) Unsure or not applicable

Partners HealthCare System

Partners HealthCare is an integrated system consisting of:• Two large academic medical centers (Massachusetts

General Hospital and Brigham and Women’s Hospital).• Six community hospitals.• Five community health centers.• Five major multispecialty ambulatory sites.• Inpatient and outpatient psychiatric and rehabilitation

specialty services.• Homecare.• More than 6,000 physicians.

Denominator

The Taxonomy of “Stupid”

• Trendable: Rolling 12.• Real-time feedback.• Context (trend + comparison).

Stupid

• Claims + EHR.• Problems list.• Medications.

• Accurate.• Comprehensive and

nuanced.• Up-to-date.• Allows for judgment.

• Attribution.• Inclusion.

Numerator Data Sources Operations

The “Streetlight Effect”

The “4th Quarter Push” for Quality Metric Reporting

(Bad) Measure Proliferation Is Increasingly Well-Recognized

“Evidence mount[s] that even superb and motivated professionals [have] come to believe that the boatloads of measures, and the incentives to “look good,” [have] led them to turn away from the essence of their work.”

– Robert M. Wachter, Interim Chairman, UCSF Dept. of Medicine

New York TimesMost Emailed Article (1/17/2016)

Don Berwick: “Current Measurement Era Isn’t Going to Work”

Steps to Move to “Era 3”

1. Fewer measures.2. Simplify incentives.3. Decrease focus on $ (incentives).4. Avoid doctor as “Lord.”5. Employ improvement science.6. Embrace transparency.7. Protect civility.8. Listen.9. Reject greed (as an industry).

Institute for HealthCare Improvement Keynote, December 2015

Era 1(until late 1900s)

Era 2(current)

Era 3(Future?)

“Moral Era.”Measurement, carrots, and sticks.

Professional dominance.

Physician burnout has become a crisis.

Denominator

The Taxonomy of “Stupid”

• Trendable: Rolling 12.• Real-time feedback.• Context (trend + comparison).

Stupid

• Claims + EHR.• Problems list.• Medications.

• Accurate.• Comprehensive and

nuanced.• Up-to-date.• Allows for judgment.

• Attribution.• Inclusion.

Numerator Data Sources Operations

Better Hypertension Measure Definition

Denominator: • All primary care patients who have

hypertension as defined by multiple clinical and billing sources.

Numerator: • ≤140/90; if age > 60 ≤150/90. • Credit if DBP≤70.• Use better of last blood pressure (BP) or

the average of last 3 BPs over 18 months. • Credit if on 3 anti-hypertensive agents.

Persell, S. D., Kho, A. N., Thompson, J. A., & Baker, D. W., (2009). Improving hypertension quality measurement using electronic health records. Medical Care, 47(4), 388-394.

Exceptions Preserve Autonomy

• Terminally ill. • Adverse reaction to medication.• Anatomically not applicable.• Competing comorbidity. • Patient declined.• Patient cannot afford.

• Deceased. • Not a patient of this PCP. • Not a patient of this clinic.• Misdiagnosis.

Numerator Denominator

The Tool

The Team

Clinicians must believe they are important.

“Registry”: a tool to close gaps in care.

People to use the tool (hopefully not frontline docs).

The Measures1

2

3

4

5

Ingredients for Success

Behavior Change = Feedback + Motivation

The Tool

The Team

The Data

Motivation

Clinicians must believe they are important.

“Registry”: a tool to close gaps in care.

People to use the tool (hopefully not frontline docs).

Near-real time measurement, run-charts, and comparison.

Social pressure, Transparency, Financial, Shared purpose

The Measures1

2

3

4

5

Ingredients for Success

Clinical Registries and the Quality Insights AnalyticsChange the way we measure.

1. Measurement That Reflects Reality

Clinical Registry-Based Measures

More clinically relevant

measures.

Increased buy-in from clinicians.

Increased investment in

tools and effort.

Improve on clinically relevant

measures.Better care.

2. Real-time, Actionable Data

3. Easy to Access and Use

Delineate and Define Roles and ResponsibilitiesExecutive sponsor.

1

2

3

4

5

6

Business owner.

Subject matter experts.

Data architect.

Project manager.

Data analyst.

Engage Your Stakeholders Early in the ProcessRole for Stakeholder Group

Inform development team of stakeholder needs. • Who is the audience?• How do they use the data?

• What do they need to see?• What do they want to see?

• What is their level of analytical sophistication? How to best display this?• What is the existing workflow and how do they anticipate it being integrated?

Local champions when application is released.

Identify Sources for Data Elements Hard/structured data

elements from electronic health

record (EHR).

Soft/unstructured data elements from EHR as available and needed.

Claims for risk populations only

(commercial at-risk, ACO, Neighborhood

Health Plan, Medicaid).

Manually added elements

as available and needed.

Metrics = calculations based on the data

elements.

Visits, bills, labs, vitals, health maintenance, immunizations, specialized flowsheets, PROMs.

Findings from radiology, pathology, imaging findings.

SmartForms, bar code scanners.

Registry Primer: Types of “Registries”

“Internal Registry”• For clinical care and internal quality

improvement purposes—measuring performance, identifying variability, focusing on improvement.

• Underlying data elements and “inclusion rules” which determines measure denominators.

• Data could be used for research retrospectively with Internal Review Board approval.

“External Registry”• For submission to national or

research registry.

Identify Numerator and Denominator for Measure

Numerator = Patients for whom measurement is expected.

Exclusions:• Terminally ill.• Adverse reaction to medication.• Anatomically not applicable.• Competing comorbidity. • Patient declined.• Patient cannot afford.

Denominator = Patients who meet inclusion.• e.g., all diabetics.

Exclusions:• Deceased. • Not a patient of this PCP. • Not a patient of this clinic.• Misdiagnosis.

What Is the Target For the Measure?

Is there an industry target to be met?

Is there a benchmark?Local? National? Other?

How do the providers compare with their peers in similar settings?

Data Validation: Ensuring Accurate Data Is KEY to Provider Engagement

Registry denominator accuracy.Errors of inclusion and inadvertent exclusion (type 1 and type 2 errors).

Validate data throughout the process.

Numerator accuracy.Were exclusion criteria correctly applied?

Calculation.Is the math right?

Provider Attribution.Did the patient get linked to the right provider?

Embed It in the Existing Workflow• Reduce the number of clicks to get to

the data.• Ideally, the data should be actionable

from the same site that it’s viewed by the same person who views it.• Find a gap.• Implement improvement at same time

in same place.

For Clinical Care in EHR• Patient-level detail.• Run as user or clinic.• Sort/Filter.• Real-time.• Close gaps in care.

Embed It in the Existing Workflow

Use analytics applications based on data sources within the EDW for:

• Quality improvement.• Aggregate data.• Compare clinics/RSOs.• Weekly updates.• Identify variability.• Discover best practices.

Poll Question #2

How effective is your organization at identifying and using impactful quality measures using your own data?

1) Not effective2) Somewhat effective3) Moderately effective4) Very effective5) Unsure or not applicable

Success Story

71%72%73%74%75%76%77%78%

HTN - BP Control

60%62%64%66%68%70%72%74%

CVD - Lipid Control

74%75%76%77%78%79%80%81%82%83%

DM - BP Control

64%66%68%70%72%74%76%78%

DM - Lipid Control

72%73%74%75%76%77%78%79%80%81%82%

CA - Breast Cancer Screening

60%62%64%66%68%70%72%74%

CA - Cervical Cancer Screening

62%

64%

66%

68%

70%

72%

74%

CA - Colorectal Cancer Screening

+3%on ~100,000 HTN Pts

In the last year …

+8%on ~28,000 Diabetics

+3%on ~28,000 Diabetics

+8%on ~25,000 CVD Patients

+7.5%on 140,000 people

+5%on ~78,000 women

+7.5%on ~150,000 Women

Are Exceptions Driving Performance?

36

74.2% 77.2%

0.0%0.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

September 2016 September 2017

Breakdown of Gains in Hypertension Control

Clinical passing Exception passing

74.2% 77.2%

100,158 patients 97,381 patients

64.8%69.9%

0.1%4.2%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

September 2016 September 2017

Breakdown of Gains in CVD Lipid Control

Clinical passing Exception passing

74.1%64.9%

24,969 patients 24,911 patients

Measure NNT / NNSPatients Newly

Passing

Lives Saved or Stroke / MI

prevented

Hypertension BP Control1:125 (death)1:67 (stroke)1:100 (MI)

2,816 ~93

CVE Lipid Control 1:27 (composite death, MI, stroke) 1,973 ~73

Diabetes Lipid Control 1:28 (composite death, MI, stroke 2,354 ~87

Diabetes BP Control1:125 (death)1:67 (stroke)1:100 (MI)

895 ~29

Colorectal Cancer Screening 1:107 (death from colon cancer) 10,559 ~99

Cervical Cancer Screening 1:1000 (death from cervical cancer) 10,975 ~11

Breast Cancer Screening 1:368 (death from breast cancer) 4,084 ~11

Total: 403

Measure in Lives

Providers and Managers Happier

Physician Survey:“Overall, what impact did these activitieshave on the care provided to your panel ofpatients?”

Positive Impact: 85%(Large or Small = 102/120)

Doctor: “That [population health manager] is worth her weight in pure Spanish saffron!”

Staff: “This is life-changing. I did in minutes what it used to take me weeks to do.”

Lessons Learned and Key Takeaways

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2

3

4

Not all measures are created equal.

Engage stakeholders early in the process.

High quality, accurate data is required to engage stakeholders.

Measures must be embedded in existing workflow.

Thank You