iHT2 Health IT Summit Atlanta 2013 – John Doulis, MD , CIO, MedCare Investment Funds, Former Assistant Vice Chancellor – Health Affairs Chief Operations Officer – Informatics, Vanderbilt University - Case Study: "The Chaos in Health Care Today and
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iHT2 Health IT Summit Atlanta 2013 – John Doulis, MD , CIO, MedCare Investment Funds, Former Assistant Vice Chancellor – Health Affairs Chief Operations Officer – Informatics, Vanderbilt University - Case Study: "The Chaos in Health Care Today and the Need for an Analytics Platform"
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iHT2 Health IT Summit Atlanta 2013 – John Doulis, MD , CIO, MedCare Investment Funds, Former Assistant Vice Chancellor – Health Affairs Chief Operations Officer – Informatics, Vanderbilt University - Case Study: "The Chaos in Health Care Today and
- 1. iHT2 Health IT Summit Atlanta, GA April 24, 2013 John Doulis, M.D. CIO MedCare Investment Funds The Chaos in Healthcare Today and the Need for an Analytic Platform
- 2. The problem The science Examples of the science at work Road Map
- 3. Clarion Call
- 4. Do the Right Thing 69.1% (1999)1984Cholesterol Screening 75.5% (2001)1982Mammography 48.1% (2000)1981Diabetic Eye Exam 53% (2000)1977Pneumococcal Vaccine 64% (2000)1968Flu Vaccine Current rate of use Landmark TrialClinical Procedure Balas EA, Boren SA., Managing Clinical Knowledge for Health Care Improvement. Yearbook of Medical Informatics 2000.
- 5. Do the Right Thing Quality of Pneumonia Treatment for Elderly, 2002 63.1 67.9 81 29.6 0 10 20 30 40 50 60 70 80 90 100 Received 1st dose of antibiotic within 4 hours of hospital arrival Received recommended antibiotics consistent with current guidelines Have blood cultures collected before antibiotics are administered Received all recommended treatment regimens Measure Percentageofpatients Source: Centers for Medicare & Medicaid Services, Quality Improvement Organization Program, 2002. • 81% of Medicare pneumonia patients get blood cultures before antibiotics • 68% get the right antibiotics • 63% get their first antibiotic in a timely manner • Yet, only 30% get all of three recommended interventions
- 6. Healthcare & Biomedical IT is HARD Individuals are highly variable biological systems. Clinical measurements rarely have precise meaning. Diagnoses lack clinical detail. Clinical work is a chaotic, opaque ecosystem. Perspectives vary by role.
- 7. Biomedical Informatics Definition: Science that deals with information, its structure, acquisition and use Cornerstones: Techniques to structure, discover, visualize & reason with information content Approaches to link people, process & technology together as a system Methods to evaluate systems and their technology components Processes to facilitate change
- 8. Automation Connectivity Decision Support Data Mining Mismatch between Computational Technique & Scale of Problem
- 9. Data Mining Automation Connectivit y Decision Support Aggregate EHR Disease managemen t dashboards Work lists Evidence- based advisors Match Computational Approach to Complexity of Data Stead WW. Electronic Health Records. In: Rouse WB, Cortese DA, eds. Engineering the system of healthcare delivery. Tennenbaum Institute Series on Enterprise Systems, Vol. 3. Amsterdam: IOS Press; 2009.
- 10. Managing Chaotic Events and Complexity Work at multiple scales Triangulate multiple signals for robustness Satellite Doppler Radar Rain Gauge
- 11. R E P O S I T O R I E S •transaction processing •event life cycle Holistic Informatics •modeling & simulation Plan •optimization algorithms •surveillance •visualization of status Activation Task Management Informatics Foundation for Systems Approach to Care •Signal capture •edits •robotics Task Performance Analysis Granular Automation
- 13. EDW REPOSITORIES CLINICAL DOCUMENTATION CPOE SCHEDULING & THROUGHPUTS ELIGIBILITY & REGISTRATION SUPPLY CHAIN MATERIALS MGMT PHARMACY RADIOLOGY LAB HR FINANCIAL GIE • Tagging • Logging • Protocol Conversion • One to Many Communication PATIENT SUMMARY SERVICE HIGH AVAILABILITY CACHE RULES ENGINE ALERTS ENGINE SOAWEBSERVICES COMMUNICATION SUBSYSTEMTRANSACTION PROCESSING SYNCHRONOUSASYNCHRONOUS GENERAL EXTERNALIZED TABLES ROLES ORDERABLES LABS CDR DEIDENTIFIED IDENTIFIED
- 14. EDW REPOSITORIES CLINICAL DOCUMENTATION CPOE SCHEDULING & THROUGHPUTS ELIGIBILITY & REGISTRATION SUPPLY CHAIN MATERIALS MGMT PHARMACY RADIOLOGY LAB HR FINANCIAL GIE • Tagging • Logging • Protocol Conversion • One to Many Communication PATIENT SUMMARY SERVICE HIGH AVAILABILITY CACHE RULES ENGINE ALERTS ENGINE SOAWEBSERVICES COMMUNICATION SUBSYSTEMTRANSACTION PROCESSING SYNCHRONOUSASYNCHRONOUS GENERAL EXTERNALIZED TABLES ROLES ORDERABLES LABS CDR DEIDENTIFIED IDENTIFIED Role Specific Views
- 15. EDW REPOSITORIES CLINICAL DOCUMENTATION CPOE SCHEDULING & THROUGHPUTS ELIGIBILITY & REGISTRATION SUPPLY CHAIN MATERIALS MGMT PHARMACY RADIOLOGY LAB HR FINANCIAL GIE • Tagging • Logging • Protocol Conversion • One to Many Communication PATIENT SUMMARY SERVICE HIGH AVAILABILITY CACHE RULES ENGINE ALERTS ENGINE SOAWEBSERVICES COMMUNICATION SUBSYSTEMTRANSACTION PROCESSING SYNCHRONOUSASYNCHRONOUS GENERAL EXTERNALIZED TABLES ROLES ORDERABLES LABS CDR DEIDENTIFIED IDENTIFIED Research
- 16. EDW REPOSITORIES CLINICAL DOCUMENTATION CPOE SCHEDULING & THROUGHPUTS ELIGIBILITY & REGISTRATION SUPPLY CHAIN MATERIALS MGMT PHARMACY RADIOLOGY LAB HR FINANCIAL GIE • Tagging • Logging • Protocol Conversion • One to Many Communication PATIENT SUMMARY SERVICE HIGH AVAILABILITY CACHE RULES ENGINE ALERTS ENGINE SOAWEBSERVICES COMMUNICATION SUBSYSTEMTRANSACTION PROCESSING SYNCHRONOUSASYNCHRONOUS GENERAL EXTERNALIZED TABLES ROLES ORDERABLES LABS CDR DEIDENTIFIED IDENTIFIED Dashboards & Business Intelligence
- 17. EDW REPOSITORIES CLINICAL DOCUMENTATION CPOE SCHEDULING & THROUGHPUTS ELIGIBILITY & REGISTRATION SUPPLY CHAIN MATERIALS MGMT PHARMACY RADIOLOGY LAB HR FINANCIAL GIE • Tagging • Logging • Protocol Conversion • One to Many Communication PATIENT SUMMARY SERVICE HIGH AVAILABILITY CACHE RULES ENGINE ALERTS ENGINE SOAWEBSERVICES COMMUNICATION SUBSYSTEMTRANSACTION PROCESSING SYNCHRONOUSASYNCHRONOUS GENERAL EXTERNALIZED TABLES ROLES ORDERABLES LABS CDR DEIDENTIFIED IDENTIFIED WORKFLOW INTEGRATION Role Specific Views Research & Education PATIENT MANAGEMENT POPULATION MANAGEMENT z100 REPORTS OPERATIONS PLANNING & FORECASTING Dashboards & Business Intelligence
- 18. #1 Data Aggregation, Information Extraction & Curation Examples of Informatics at Work
- 19. Systems (ADT, Lab, Rad…) Dictation/Transcription Note Capture Tools Sources Image (PACS, EKG…) Fax/Scan Text Reports Externalize Content as Documents Report Header plus Pointer to Image Index each Word or Number for Cross- Patient Queries Electronic Patient Chart Assemble “Documents” By Patient “Tag” Clinical Concepts for Curation and Decision Support Clinical Data Repository
- 20. Current Documentation Document Oral Care Here Document HOB Here
- 21. Examples of Informatics at Work #2 Closed loop quality control
- 22. Evidence-Based Contributions to Ventilator Management Ventilator weaning protocol reduces vent time (Ely; NEJM 1996 Dec 19;335(25):1864-9 ) Consistent use of low tidal volume and low airway pressures reduces mortality by 25% (ARDS Network: NEJM 342: 1301- 8, 2000) Activated protein C for Sepsis reduces mortality by 20% (Bernard; NEJM 2001 Mar 8;344(10):699-709) No need to normalize PCO2, drastic reduction in use of arterial blood gases (ARDS Network: NEJM 342: 1301- 8, 2000) PA Catheters not beneficial, 90% reduction in use (ARDS Network: NEJM 2006;354:2213-24) Consistent conservative use of fluids shortens ventilator time by 3 days (ARDS Network: N Engl J Med 2006;354:2564-75) Wake up and breath; sedation holiday improves survival. (VU Delirium Group: Lancet 2008 Jan 12;371(9607):126-34)
- 23. Evidence-based Medicine Consistent Process Visualization of Results vs. Plan Iterative Improvement Outcomes Systems Approach to Care
- 25. Improvement Opportunities (Z=100%) TOTAL COMPLIANCE
- 26. Improved Performance (single unit) November 2007 January 2008 February 2008 March 2008
- 27. Rateper1000VentDays VAP Rates – VUH: All ICUs
- 28. Tangible Results (2008 – 2011) 1 SHEA Guideline, Infect Control Hosp Epidemiol 2007; 28:1121-1133: $22,875 per VAP ($9,986-$54,503), 9.8 day additional LOS per VAP (7.4-11.5) 2 IHI 5 Million Lives Campaign: $40,000 per VAP VAPs Prevented 2008 82 2009 95 2010 140 2011 168 Total Prevented 485 $ Saved (SHEA)1 $11,091,955 $ Saved (IHI)2 $19,395,768 Hospital Days1 4752 ICU Days 1940 Deaths 73 UHC RANKING O/E LOS O/E Cost O/E Mortality >96 Hours on Vent 1 1 1 <96 Hours on Vent 2 6 3 Baseline: 18.1
- 29. Evidence-based Medicine Consistent Process Visualization of Results vs. Plan Iterative Improvement Outcomes Systems Approach in Practice
- 30. Source: UHC and Vanderbilt Data 3. Mortality for Ventilator Patients Compare to all the other Hospitals – Best in the U.S. 100 150 200 250 300 2005 2006 2007 2008 2009 1. Number of Ventilator Acquired Pneumonia (VAP) Cases/Year Fiscal Year 2009 Results c/w 2008 VAPs Prevented 108 Deaths Avoided 16 $ Saved $4.3M Hospital Days Avoided 1055 ICU Days Avoided 431 2. Impact on Results Systems Approach to Care # 1 O/E Vent Mortality O/E Length of Stay O/E Cost
- 31. Congestive Heart Failure Surveillance Algorithm Integrated Decision Support
- 32. EDW REPOSITORIES CLINICAL DOCUMENTATION CPOE SCHEDULING & THROUGHPUTS ELIGIBILITY & REGISTRATION SUPPLY CHAIN MATERIALS MGMT PHARMACY RADIOLOGY LAB HR FINANCIAL GIE • Tagging • Logging • Protocol Conversion • One to Many Communication PATIENT SUMMARY SERVICE HIGH AVAILABILITY CACHE RULES ENGINE ALERTS ENGINE SOAWEBSERVICES COMMUNICATION SUBSYSTEMTRANSACTION PROCESSING SYNCHRONOUSASYNCHRONOUS GENERAL EXTERNALIZED TABLES ROLES ORDERABLES LABS CDW DEIDENTIFIED IDENTIFIED WORKFLOW INTEGRATION Role Specific Views Research & Education BIOVU REDCAP PATIENT MANAGEMENT POPULATION MANAGEMENT z100 REPORTS OPERATIONS PLANNING & FORECASTING Dashboards & Business Intelligence
- 33. EDW REPOSITORIES PATIENT SUMMARY SERVICE HIGH AVAILABILITY CACHE RULES ENGINE ALERTS ENGINE SOAWEBSERVICES COMMUNICATION SUBSYSTEM SYNCHRONOUSASYNCHRONOUS GENERAL EXTERNALIZED TABLES ROLES ORDERABLES LABS CDW DEIDENTIFIED IDENTIFIED WORKFLOW INTEGRATION Role Specific Views Research & Education BIOVU REDCAP PATIENT MANAGEMENT POPULATION MANAGEMENT z100 REPORTS OPERATIONS PLANNING & FORECASTING Dashboards & Business Intelligence GIE • Tagging • Logging • Protocol Conversion • One to Many Communication
- 34. 1000 FactsperDecision 10 100 1990 2000 2010 2020 Human Cognitive Capacity Need for Patient-Specific Decision Support Assistance Structural Genetics: e.g. SNPs, haplotypes Functional Genetics: Gene expression profiles Proteomics and other effector molecules Decisions by clinical phenotype i.e., traditional health care
- 35. Summary Automation & connectivity get you only 60% In addition to automation and connectivity need to view and leverage clinical systems for Information Liquidity Need for dashboards and knowledge engines that sit on top of the information. Need BI/Analytics Platform that leverage the information. This architecture is scalable Managing Risk: ◦ What problems are worth solving (BI) ◦ Key interventions to reliably intervene (dashboards + automation of decision support)