University of Utah Health Care initiated an enterprise-wide effort to improve clinical outcomes and reduce costs and built a management and data-analytic reporting tool, called Value-Driven Outcomes (VDO). VDO allows clinicians and managers to analyze actual system costs and outcomes at many levels: individual encounters, department, physician, diagnosis, and procedure. (Lee VS, et al. JAMA 2016)
The VDO tool is a modular framework that allocates care costs to individual patient encounters and integrates cost information with relevant quality and outcome measures. VDO extracts information from the enterprise data warehouse (EDW), which includes data on quality; externally-defined and physician-defined metrics; costs of care; supply, pharmacy, imaging and laboratory tests; and human resource utilization. Costs can be understood from multiple perspectives, including that of the health system, payer, patient, or society. VDO takes the health system perspective and identifies costs attributable to direct patient care.
The VDO tool was developed in 2012. Then, system-wide deployment of VDO scorecards for the Top 50 Medical Conditions (MC) was initiated. The top 50 MC were determined by the medical conditions or procedures with high volume and high costs associated with externally defined quality metrics. Providing information on quality and costs of care to physicians helps to visualize value improvement opportunities, areas of significant variations of care delivery, and care redesign ideas.
Up to date, 24 scorecards have been built and 4 more in the pipeline. Clinical care pathways were developed in 10 of the Top 50 MC.
We will summarize: 1) Key elements for measurements, 2) Care redesign examples, and 3) Lessons learned through the implementation.
Essential Elements for Measurements include the followings.
1) Physicians have to be in the driver seat to change health care delivery. A top-down approach is not as effective as physician-led bottom-up effort.
2) Building multi-disciplinary care teams with diverse and broad perspectives is critical. We must include nurses, case managers, and pharmacists, clinic directors, and others.
3) Balance between externally defined metrics and physician defined metrics is necessary.
4) Measure what matters to patients – these could be different based on MC
5) Good outcomes motivate providers - especially disease-specific outcomes of physicians’ interest
Care redesign does not have to be a major health care breakthrough. Things that may appear trivial could have the substantial downstream impact. Some examples.
• Coordination of care for joint replacement – Same day physical therapy, discharge to home
• Early diagnosis of high acuity conditions: Sepsis, Pneumonia, PE, Stroke, ACS
• Standardization of care for ACS, PE, hip fractures, pneumonia, sepsis, and diabetes
• Operating room Supply cost reduction –ORCA (See Dr. Glasgow's exhibit)
• Reduction of expensive anticoagulants: ACS and Cardiac Cath Lab
• Spinal anesthesia instead of general anesthesia for joint surgery
• Reduced lab utilization reduction by hospitalists
Lessons Learned –
While we are still in the middle of the value Journey, we have learned several lessons through the deployment of VDO Scorecards for Top 50 MC in the past few years.
1) Data analytics requires iterative refinement
2) Accuracy of data depends on accuracy of EHR documentation
3) Population definitions require broader perspectives with subgroup analysis
4) Severity adjustment must be considered : compare apple and apple
5) Clarify attribution – who is responsible for care for the entire admission?
6) Physician engagement is critical
7) Quality improvement should be recognized as a career pathway
8) Alignment with Department Chairs and School of Medicine is critical