1. Big Data Outcomes / Performance
Adele Allison, National Director of Gov’t Affairs
SuccessEHS, Inc.
2. Big Data and Health Care
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Perspective on Data
Federal Policy and Data
Health IT Today
Data and Performance
Data Capture for Success
Questions
www.SuccessEHS.com • 888.879.7302
3. Bits, Nibbles and Bytes
• Bit = 1 or 0 (on / off) → Binary Digit
• Nibble = 4 Bits of Data
• Byte = 8 Bits of Data
www.SuccessEHS.com • 888.879.7302
Source: doi:10.1093/bioinformatics/btn582
4. Bits, Nibbles and Bytes
Bit = 1 or 0 (on / off) → Binary Digit
Nibble = 4 Bits of Data
Byte = 8 Bits of Data
Kilobyte (KB) = 1,024 Bytes
Megabyte (MB) = 1,048,576 Bytes
or 1,024 KB
• 1 MB = 873 Pages of Plain Text (1,200
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characters)
• 800 MB = Human Genome
www.SuccessEHS.com • 888.879.7302
Source: doi:10.1093/bioinformatics/btn582
5. Gigabyte (GB)
• 1 GB = 1,024 Megabytes
• 1 GB =7 Minutes HD-TV
Video
• 2 GB = 20 Yards of Books
on a Shelf
• 4.7 GB = Standard DVD-R
www.SuccessEHS.com • 888.879.7302
Source: www.mozy.com
6. Terabyte (TB)
1 TB = 1,024 GBs
1 TB = All X-rays in large hospital
2 TB = Academic Research Library
7 TB = Amount of Tweets/Day
10 TB = All Printed Materials of U.S.
Library of Congress
• 45 TB = Data Amassed by Hubble
Telescope first 20 years
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www.SuccessEHS.com • 888.879.7302
Source: www.mozy.com
7. Petabyte (PB)
1 PB = 1,024 TB
1 PB = 20 Million, 4-drawer filing cabinets of text
1 PB = 13.3 Years of HD-TV Video
1.5 PB = Size of Facebook photos → 10 Billion
20 PB = Data processed by Google EVERY DAY!
50 PB = ALL Mankind’s written works from
Beginning of Recorded History (All Languages)
• 100 PB = Facebook data storage before IPO (2.1.2012)
• 300 PB = Facebook data today!
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www.SuccessEHS.com • 888.879.7302
Source: www.mozy.com
8. Zettabyte (ZB)
• 1 ZB = 1 Million Petabytes!
• 1 ZB = 1,000,000,000,000,000,000,000
Bytes
o That is 21 Zeros, or
o 1 Sextillion Bytes
• If 1 GB = 60 Watt Bulb, then …
• 1 ZB = 15.7 years of energy from the
Hoover Dam to power a 1 ZB Light Bulb
for 1 hour
www.SuccessEHS.com • 888.879.7302
Source: www.mozy.com
9. Who’s Using Big Data?
• Snowden → NSA receives data from
Google, Facebook, Yahoo, YouTube, Skype,
AOL and Apple
• Average Am. Stats
o Avg. 150 Facebook friends/users (teens avg. 300)
o Avg. 150 add’l email/phone contacts/person
o Total Avg. Electronic “Contacts” = 300
• PRISM → NSA’s surveillance program
300 Contacts x Their 300 Contacts
x Their 300 Contacts
= 27 Million People
www.SuccessEHS.com • 888.879.7302
10. Who’s Using Big Data?
• Facebook → Presto
• 1,000 Employees
o Run 30,000 interactive Queries
per Day
o Over 1 PB of processing
• Open Source
• Types of Queries → Trends,
Marketing, Business Intelligence
www.SuccessEHS.com • 888.879.7302
11. Perspective
• 1-40 MB = Average Size of a
Patient’s EHR record
o Excluding Images
o 80 MB at Large Hospitals
o Top Average Size, including
imaging, 3-5 GB
• 3,281 = Average Number of
Active Patients for FP*
Estimate: 12 MB x 3,200 =
38,400 MB / FP or 37.5 GB / FP
www.SuccessEHS.com • 888.879.7302
*Source: AAFP
12. Real Ambulatory Metrics
• 653 DBs totaling 59.2 TB
• Wide variance in DB size → Average 90 GB
• Smallest 3.5 GB – Largest 1.7 TB
o Average is > 50 users is 226 GB
o Pictures, Word, Scanning, etc. ↑ Size Directly
o Transactional data creates marginal increases
• Examples:
o NJ CHC 44 Providers → 2.6 TB
o CA Ped. Practice 3 Providers → 10 GB
o LA School Based 1 Provider → 3.6 GB
www.SuccessEHS.com • 888.879.7302
13. Health Care “Score”
• Financial Data creates Individual
Credit Score
o Payment History Data
o Amounts Owed
o Length of Credit History
o New Credit
o Types of Credit
www.SuccessEHS.com • 888.879.7302
14. Health Care “Score”
• Will Health Care data create
Individual Health Score?
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Lifestyle Choices (E.g., Smoking, BMI)
Worksite Wellness (E.g., Environment)
Activity Levels (E.g., Sedentary, Exercise)
Nutrition (E.g., Chips v. Broccoli)
Adherence / Compliance (E.g., Meds)
Behavioral Health (E.g., Quality of Life
Questionnaire, Sleep)
o Genomics (E.g., Genetic marker for Breast
Cancer)
www.SuccessEHS.com • 888.879.7302
16. Big Data and Health Care
• Perspective on Data
• Federal Policy and Data
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Health IT Today
Data and Performance
Data Capture for Success
Questions
www.SuccessEHS.com • 888.879.7302
17. Affordable Care Act – By the Numbers
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24 percent of federal budget goes to health care
36 times ACA mentions Patient Centeredness
15 times ACA references the Medical Home
73 times ACA mentions Accountable Care Organizations
93 times ACA references Quality Measures
29 times ACA links Quality to reporting Clinical Data
100 times ACA discusses Value-Based and Payment Modifiers
as relates to Hospital/MD Reimbursement and Measures
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12 SCOTUS Opinion mentions Broccoli
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18. Patient Centeredness and Policy
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Behavioral Economics sought → About an Engaged Patient
Federal Gov’t → Leadership role in Health Care Reform
Transition → Episodic Care to Long-Term Healing and Wellness
Patient Centered Care → Measured Quality Performance
Federal Policymaking and Patient Centered Care
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Regs CMS Meaningful Use Stage 2 – 7 Measures
Regs CMS Accountable Care Organizations (ACOs) – 7 Measures
Regs CMS Value-based Purchasing – Differential Payment
Regs CMS Public Measure Transparency – Physician Compare
www.SuccessEHS.com • 888.879.7302
19. Public Transparency
• IOM → $105 Billion Annually in Waste due to
o Lack of Competition
o Excessive Price Variation
• Obama Executive Order → CMS hospital pricing by
Top 100 DRGs (May 8, 2013)
o Charge vs. Medicare Allowable http://go.cms.gov/124pbRh
o E.g., Joint Replacement → $5,300 (Ada, OK) v. $233,000
(Monterey Park, CA)
• Medicare Data Access for Transparency and
Accountability Act (H.R. 2843, S. 1180)
www.SuccessEHS.com • 888.879.7302
20. CMS Proposed Rule – CY2014
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Physician Compare Website – CY2014
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Provider Transparency
PQRS GPRO 2012 and 2013 Performance Data
ACO Performance Data
CG-CAHPS Patient Experience Survey Data (All groups by CY2015)
www.SuccessEHS.com • 888.879.7302
22. Big Data and Health Care
• Perspective on Data
• Federal Policy and Data
• Health IT Today
• Data and Performance
• Data Capture for Success
• Questions
www.SuccessEHS.com • 888.879.7302
23. Value and Difficulty Continuum
Data Analytics
• Prescriptive
o How can we make it happen?
• Predictive
o What will happen?
• Diagnostic
o Why did it happen?
• Descriptive
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o What happened?
24. Decision-Making and Health IT
• 4 Habits of High Performing Health Care Systems (NEJM,
Dec. 2011)
1.
2.
Specification and Planning → Use data to trigger an “advanced plan”
Infrastructure Design → Workflows that:
Simplify the process
3.
4.
Deliver timely information at the right decision point
Match the proper skills, resources to process
Measurement & Oversight → Realtime, Data-driven Operations
Self-Study → Apply measurements for ongoing learning and
improvement
www.SuccessEHS.com • 888.879.7302
25. Data Impact Potential
• 5 Potential Areas of Impact → Quality, Patient Engagement,
Efficiency / Revenue, Clinical Research, Risk / Liability
• Today, Market Remains …
o Fragmented
o Transaction-based
o Acute Care / Reactive Care Delivery
• Reform Goal: Morph into agile, responsive system that is …
o Proactive with a focus on prevention
o Engaging the patient for wellness lifestyles
o Managing complex patient populations
• Industry is Young → Health IT Hype Cycle
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28. EHR Adoption Rates
•
MU launched in 2011 → Physician Adoption around 20%
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Source: Healthcare Technology Online, May, 2013
30. Big Data and Health Care
• Perspective on Data
• Federal Policy and Data
• Health IT Today
• Data and Performance
• Data Capture for Success
• Questions
www.SuccessEHS.com • 888.879.7302
31. MU Cultural Shift
• 4 V’s of Health Care Data
o Volume – Large data stores for research
o Variety – Multiple approaches
o Velocity
Info to Provider when with the Patient
Info to Patient when they can still make a
behavior change
o Value – Data that drives a cultural shift
and ongoing process improvement
www.SuccessEHS.com • 888.879.7302
32. Incremental Approach
• Incremental approach today positions for
Incredible Future
• Call to Action …
o What do market and regulatory changes mean?
o Evaluate the Must Do vs. the Must Do
o Collaborate with stakeholders
Align goals with public health, hospitals, payers,
patients, clinicians, vendors
Identify potential barriers and formulate solutions
o Primary Care Health IT Application
New approaches to managing patient populations for
prevention
Use of data for purpose-driven performance
improvement
www.SuccessEHS.com • 888.879.7302
33. CDS Workflow
• Great place to start!
• MU1 → Implement 1 CDS Intervention
and Track Adherence
• MU2 → Implement 5 CDS
Interventions, align with 4+ CQMs
• MU3 → Implement 15 CDS
Interventions
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34. Text to Code Translation
• Guidelines are Narrative → Human Readable
• AHRQ eRecommendation for Technical Specification →
Machine Readable
• Consistency in coded logic statements aligns:
o Development Costs
o Implementation Timelines
o Uniformity of data for comparative effectiveness
• AHRQ 5-Rights of CDS
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o
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o
o
Get the Right Information
To the Right Person
In the Right CDS Format
In the Right Technology Channel
At the Right time in the Patient Workflow
www.SuccessEHS.com • 888.879.7302
35. CDS Workflow
eMeasure NQF 0059; CMS CQM 122 → Hemoglobin A1c screenings
of Poorly Controlled Diabetic Patients
Report the percentage of patients age 18-75 with diabetes who had
hemoglobin A1c > 9.0% during the measurement period
The “Right”
The Answer
Redesign
1.Rule-logic pre-built?
2.Available in EHR?
• Initial assessment of
DM; target A1c value
of ≤ 7%
Get the Right
Information
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3.If pt. presents for
unrelated issue, will
system alert?
• A1c at least 2x/year
for stable patients.
• More frequently for
poorly controlled.
4.Can EHR generate list
of non-compliant pts.
for outreach based on
pt. communication
preference?
36. CDS Workflow
The “Right”
The Answer
• Monitor and treat
hyperglycemia with a
target A1c of 7%
Redesign
1.Who needs this
information during
clinic workflows?
2.Who needs this
information for noncompliance tracking
and outreach?
To the Right
Person
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37. CDS Workflow
The “Right”
The Answer
Redesign
1.What is the proper
CDS Format(s) to
manage DM A1c?
• Alerts / Reminders
• Reference Guidelines
In the Right
CDS Format
• Condition-focused
Order Sets
• Pt. Reports
• Flowsheets
• Documentation
Templates
• Other
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2.What can my EHR
provide?
3.Can alerts, order sets
and documentation
templates be
customized?
38. CDS Workflow
The “Right”
In the Right
Technology
Channel
The Answer
• Mobile Device
• Internet Patient Portal
• EHR
• PHR
• Other
Alert!
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Redesign
1.Will the alert be a popup note or will the user
have to prompt?
2.Can communication
for outreach be done
via secure email?
3.Should an alert be
sent to the Patient
Portal?
39. CDS Workflow
The “Right”
The Answer
Redesign
1.Can and should CDS
information be
provided at more than
one time of the patient
workflow?
At the Right
Time in the
Patient
Workflow
• Pt. Registration
• Assessment / Triage
• Exam Room / PE
• Treatment / Plan Dev.
• Performing Orders
• Check-out
• Remote / After Hours
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2.Can alerting be
configured (E.g.,
based upon severity)?
3.Can patient education
/ information be
customized?
40. Let Technology Work for You!
CDS Type
Patient Alerts
Patient
Reminders
EvidenceBased Clinical
Guidelines
Point-ofCare
Workflow
X
X
X
www.SuccessEHS.com • 888.879.7302
Pop.
Mgmt.
Workflow
X
X
X
EHR
Adoption
Maturity
Level
BeginnerModerate
Beginner
BeginnerModerate
Types of CDS
Technology
Solutions
Rx Interactions,
Formulary,
Delinquent
Orders and
Deferred Orders
Patient Portal,
Secured Patient
emails, Text
Messages, Form
Letters/Postcard
s, Phone Call List,
Auto-Phoning
Pre-designed
CDS rulesengine, Point-ofCare alerts,
Intelligence
Prompting,
Patient
Education
Improves Improves
Quality
Patient
Safety
of Care
X
X
X
Cautionary Notes
X
Alert Fatigue can result
in clinicians ignoring
alerts.
X
System should
automatically identify
the patient’s preferred
method of
communication under
HIPAA.
X
System needs to allow
for customizable
guidelines; variance in
recognized standards of
care
41. Let Technology Work for You!
CDS Type
Order Sets
Flow-Sheets
Dashboards
EHR
Adoption
Point-ofPop.
Maturity
Care
Mgmt.
Level
Workflow Workflow
X
X
X
www.SuccessEHS.com • 888.879.7302
X
Types of CDS
Technology
Solutions
Wellness age
65+ and
Moderate pediatric,
Chronic Disease
Management
Vitals, Lab
Moderate
results, Antepartum, growth
Advanced charts
Timely followup, Results
signed-off,
Delinquent
orders and
Advanced
deferred orders,
appt.
compliance,
protocol
compliance
Improve
Quality
of Care
Improve
Patient
Safety
X
X
System needs to allow
for customization.
X
System needs to allow
for customization and
graphing.
X
System should have
metric drill-through for
details; requires
consist workflows for
data capture.
X
X
Cautionary Notes
42. EHR
Adoption
Point-ofPop.
Maturity
Care
Mgmt.
Level
Workflow Workflow
Let Technology Work for You!
CDS Type
Structured
Knowledgebase
Documentati
on Templates
Diagnostic
Support
Workflow
Tools
X
X
X
www.SuccessEHS.com • 888.879.7302
X
X
X
Types of CDS
Technology
Solutions
Intelligent
prompting for
differential
diagnoses,
Advanced clinical element
prompting for
symptoms, PE
considerations
Intelligence
prompting for
differential
diagnoses, autoAdvanced monitoring
based upon
results (e.g. lab),
recommended
therapies
Point-of-care
alerting, waitModerate time analysis,
mobile devices,
Advanced Internet,
compliance
tracking
Improve
Quality
of Care
X
X
X
Improve
Patient
Safety
Cautionary Notes
X
While significant time
savers, pre-filled
forms/lists and autonegatives/positives
can result in “cookiecutter”
documentation.
X
Requires providers to
break out of intuitive
decision-making and
adopt analytically
decision-making.
X
Critical to CDS
adoption, successful
workflow integration
requires the clinician’s
time and involvement.
43. Do’s and Don’ts
Don’t
Practice “Cookie-Cutter” Medicine → Same Tests
to all Patients with Similar Symptoms
Efficient, but not necessarily Effective
Seek all answers from a Data Warehouse
• Big, powerful but …
• Expensive and not suitable for many day-today needs
Approach Data as a Hunter, Gatherer
• Time consuming, expensive
• Data is often not compatible
www.SuccessEHS.com • 888.879.7302
Do
Practice Evidence-Based Medicine
• Use HIE to look beyond 4-walls
• Use Standardized Vocabularies
E.g., Sys. 1→ High BP; Sys. 2 → Elev. BP; Sys. 3 →
HTN; Instead use SNOMED CT
Leverage MU2 CCDA/CCD to support patientspecific tasks
• Use coded data to standardize terminology
• Supports HIE
• Helps with predictive modeling
• Can fill-in record gaps
Domesticate Data by “Normalizing,” if possible
• Map/Document using structured vocabularies
(E.g., SNOMED, LOINC)
• Meets MU and other regs
• Strive for consistent Data Capture
44. Do’s and Don’ts
Don’t
Do
Wait to consider new ways to use your data
• Don’t wait for Big Data to knock on your
door
• You have a wealth of enterprise data
today
Aggregate data wherever you can afford to
do so
• Does your vendor have a ServiceOriented Architecture (SOA) strategy?
• Where can data come from?
E.g., Financial, Operational and Clinical
E.g., Medical devices, Labs, Questionnaires
Limit your vision to your Health Care
Organization; you will only be able to react
to the market for competitiveness
Use free Public Health Data for Strategic
Planning
www.SuccessEHS.com • 888.879.7302
E.g., Univ. of FL merged health data with
Google Maps to create “heat” sensitivity for
chronic dz. Found 3 counties underserved
for breast screening and sent mobile units.
46. Big Data and Health Care
•
•
•
•
Perspective on Data
Federal Policy and Data
Health IT Today
Data and Performance
• Data Capture for Success
• Questions
www.SuccessEHS.com • 888.879.7302
47. Here’s Your Patient
• Miss West
• Belligerent
• Some kind of Liver
Function Problem
• Paranoia
• Non-Compliant ALL the
time
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48. Patient Scenario
• Patient presents for wart removal
• Key → Must Consistently Capture Your Data
• 4 CQM / PQRS Measures:
o Influenza & Pneumonia Immunizations
o Breast & Colorectal Cancer Screenings
• What do you accomplish?
• 4
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→ 1
49. Consistent Data Capture
• Consistent Data Capture = Strong Reporting
• Data Reporting Drives Performance for VBP
• Data Reporting Provides Credit for treat the
“Miss West” Patient
• Three Ways to Capture Data
o Performed (Here or Elsewhere)
o Not Performed (Medical Reason)
o Not Performed (Patient Refusal)
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50. Patient Complexity Data
Health plans
use claims data
to build patient
complexity
profiles
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The patient
complexity profile
must be
repopulated
annually using
calendar-year
claims data
(i.e., patient
complexity starts
at baseline
every year).
Diagnosis Codes
(ICD-9 and
ICD-10) are
used to
calculate
patient
complexity.
51. The Impact of Documentation & Coding
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Source: BCBSAL, Complete Picture of Health Documentation and Coding
Improvement Initiative, Aug., 2013
52. CEUs or Copies
webinars@successehs.com
White Papers
www.SuccessEHS.com
Follow me on Twitter:
www.twitter.com/Adele_Allison
Added to The BRIEF or Questions:
adelea@successehs.com
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Notas del editor
ACA By the Numbers
23% of the Federal Budget currently goes to health care. The only line item that is higher than health care is the military – and together they represent nearly 50% of the total federal budget. 16% of the federal budget went to pay for Medicare last year; and, on average 57 cents of every Medicaid dollar is paid by the Federal gov’t.
36 times ACA talks about Patient-Centeredness. The full continuum is called to patient-centeredness. Americans are unengaged as patients. We want to smoke our cigarettes, drink our beer, sit on the couch in a sedentary lifestyle and watch football – no where more so than in the SEC! Then when things start to go wrong and break, we want to go to someone and get a quick fix. This is about a cultural shift within your practice and with the relationship you have with the American patient.
15 times ACA discusses a return to wellness, prevention and chronic disease management through the Medical Home – a model in patient centeredness for primary care.
73 times ACOs are referenced. We are seeing uptick trends in the development and establishment of ACOs. A model of value-based purchasing through the creation of a care “community” and the use of health IT.
93 times ACA talks about measuring quality – PQRS will be the vehicle for Medicare patient quality measures. Boomers are enrolling at a rate of 2.8 million/year – and will continue to do so for the next 18 years, essentially doubling the number of Medicare beneficiaries (what’s % of your payer mix does Medicare represent?). The health care industry is being called to action – this is your health care system. Data will be the barometer of your reimbursement, public comparison and comparative effectiveness. This requires the consistent capture and reporting of accurate clinical data on the patient, which is why …
29 times ACA links quality to the reporting of Clinical Data
100 times ACA talks about value-based and payment modifiers when it comes to reforming hospital and physician reimbursement.
And, as a side note, the Supreme Court of the U.S. (SCOTUS) final opinion upholding ACA references “Broccoli” 12 times. During oral argument in March of last year, counsel argued that it was a slippery slope to allow the federal gov’t the ability to require an American to purchase something under threat of penalty. If they can require an American to purchase health insurance, then can they also require them to buy a certain type of care – or broccoli, because it promotes health.