Population Health,

Informatics and Quality

Improvement
PQCNC Learning Session
May 8, 2014
Arthur Ollendorff, MD
MAHEC OB/GYN Specialists
Asheville, North Carolina

Clinical Professor of OB/GYN
University of North Carolina SOM

Arthur.Ollendorff@mahec.net

Disclosures
! PQCNC Co-director of Maternal Projects
" 0.1 FTE
! Physician informaticist for Mission Health
" 0.1 FTE
Another Disclosure
Objectives
! To review the basics of population
health and its potential impact on new
healthcare payment models
! To discuss the benefits and limitations
of medical information systems
! To understand the role of the
informatics team in the development
and analysis of quality improvement
initiatives

We all wear many hats
! My hats include
" OB/GYN
" Medical educator
" Quality Guy
" Informaticist
A Tale of Two Pyramids
Informatics Pyramid Evidence Pyramid
Population Health
! The health outcomes of a group of
individuals, including the distribution
of such outcomes within the group
! The field of population health includes
health outcomes, patterns of health
determinants, and policies and
interventions that link these two
Kindig D and G Stoddart. American Journal of Public Health
March 2003: Vol. 93, No. 3, pp. 380-383.
An unofficial, simplistic and
pragmatic definition
! Population health uses data to
analyze the health attributes of a
population and then uses evidence-
based decision making to improve the
health of that population
What population to look at?
! An individual physicians patient panel
! An office/clinics patients
! Neighborhood
! Town/City
! State
! Region
! National
Accountable Care Organization
! Groups of doctors, hospitals, and
other health care providers, who come
together to give coordinated high
quality care to their patients
" The goal is to get the right care at the
right time, while avoiding unnecessary
duplication of services and preventing
medical errors
" Share in the savings it achieves
Adapted from http://www.cms.gov/Medicare/
Medicare-Fee-for-Service-Payment/ACO
Institute for Health Improvement
Triple Aim
! Improving the
patient experience
of care
! Improving
the health
of populations
! Reducing the per
capita cost of
health care
Essential Elements of an ACO
! Culture of Teamwork
! Primary Care
! Administrative
Capabilities
! Financial Incentives
! HIT and Data
! Best Practices
! Patient Engagement
! Patient Population
Scale
Edmiston G and D Wofford, Physician Alignment: The Right Strategy; the
Right Mindset, Healthcare Financial Management Association (December
1, 2010).
Essential Elements of an ACO
! Culture of Teamwork
! Primary Care
! Administrative
Capabilities
! Financial Incentives
! HIT and Data
! Best Practices
! Patient Engagement
! Patient Population
Scale
Edmiston G and D Wofford, Physician Alignment: The Right Strategy; the
Right Mindset, Healthcare Financial Management Association (December
1, 2010).
Health Information
Technology and Data
! How reliable is the
data we currently
use?
! How many
different data
systems are
involved?
! How easy is it to
get the reports we
need?
The Basis of Best Practice
Health and Informatics
! Informatics
" the science of information
! Health Informatics
" putting information and knowledge to
use in promoting health and improving
health care
Informatics Pyramid
Ackoff, R. L. (1989). From data to wisdom. Journal
of Applied Systems Analysis 15: 3-9.
DIKW
! Data
" the product of observations
! Information
" contained in answers to questions
! Knowledge
" Makes possible the transformation of information into
instructions. It makes control of a system possible.
! Wisdom
" ability to see the long-term consequences of any act
and evaluate them relative to the ideal of total control
" omnicompetence
Ackoff, R. L. (1989). From data to wisdom. Journal
of Applied Systems Analysis 15: 3-9.
Big Data
! A collection of data that represents a
source for ongoing discovery and
analysis
" Unstructured data
information that is not organized or easily
interpreted by traditional databases or data
models, and typically, is text-heavy
" Multi-structured data
data formats that can be derived from interactions
between people and machines
What Is Big Data. Forbes.com. 8/15/2013
The Evidence Pyramid
Two research study designs
RCTs
! Study design controls the
intervention
! Requires a lot of upfront
planning and design
! Results are
straightforward to analyze
! Pure
Cohort Studies
! The intervention is less
under control
! Does not require too
much planning and
design
! Results require more
statistical expertise to
analyze
! Real world
QI Initiatives = Cohort Study
! More work occurs in data acquisition
and analysis
! Data is analyzed from actual patient
care encounters
! The need of an expert to assist
" Cohort study Statistician
" QI project Informatics team
Is There a Quality Link to
This Story?
The New Realities*
! There will be increasing demand for
health outcomes data at our
institutions
! Some of this data will be high stakes
data that will determine payment and
resource allocation
! QI initiatives will, at times, compete for
informatics resources
*with apologies to Peter Drucker
How Is Your QI Data Gathered?
Automated Hand Counted
Technology
Limitations of Using EHR for
Quality Improvement
! EHRs are designed for clinical care
" there is a great deal of unstructured,
free text data
" nurses and providers, many who are
untrained in the quality arena, are
entering the data
! Medicine is complex and patients do
not always fit into a category
What is the Cure?
1. Throw money at the problem
2. Hope that a renewed focus on value
will make nurses/providers better at
entering data
3. Develop clinically relevant systems
that improve patient care and yield
usable data for quality review
Initial Steps
! Know the capabilities and limitations
of your EHR
! Recognize that design (data input and
workflow) are critical
! Control what is in the foreground
(what the providers see) and what is
in the background (data that can be
used but not visible)
The Ideal Informatics Team
! Knows the capacities, limitations and
potential of the data systems in use
" EHR corporate rep
! Can extract data from the system
" IT person who works in a service line
! Has clinical experience to know what
providers and nurses use in daily
practice
" Nurse and physician informatics types
Angel
Transylvania

Mission
Hospital
Blue
Ridge

McDowell
Hospital
Mission Health Hospitals Providing
OB Care
Mission Health Womens
Service Line IT Approach
! Leverage Cerner Powerchart Maternity
to provide
" JCAHO Core Perinatal Measures
" PQCNC Data
" Data we suspect might be important
Induction of labor
! Drive quality and patient safety with
usable templates for nurses and
providers that are similar across all
hospitals
Mission Healths Timeline
! June 2012
" Decision made to upgrade to Powerchart Maternity
! September 2013
" Worked with providers to develop a clinically useful
note
" Worked with nurses to develop useful charting tools
! October 2013-March 2014
" Developed and vetted six OB Powernotes and
numerous nursing iViews
! March 22, 2014
" Go Live
Mission Health Admit H&P
Mission Health Delivery Note
Summary
! There is not a roadmap to maximize
informatics at your institution
! Seek out opportunities to align your
goals with that of your institution
" ACO (value-based) outcomes
" HEN/PQCNC initiatives
! Develop a team to design a system to
improve data acquisition
Conservative
Management of
Preeclampsia
(C-MOP)
The Rest of This Afternoons
Gameplan
! 12:30 Team presentations of PDSA,
challenges, successes
! 2:50 Break
! 3:00 Teams work together to
" come up with next PDSA
" decide 'what are you gong to work on
as soon as you get back?'
" 'report back
! 4:30 Closing remarks
Aim
To provide the education and support
necessary to develop standards of care
in NC hospitals for the patient with
preeclampsia
Outcomes
! Primary
" To eliminate deliveries at less than 37
weeks gestational age for women with
preeclampsia without severe features
! Secondary
" Administration of antenatal
corticosteroids to women who deliver
< 34 weeks with preeclampsia
PDSA Cycle Presentations
! Each team will have 5 minutes to
discuss their progress, successes and
challenges of their PDSA cycle
! There will be 3 minutes for feedback
and discussion
! Teams will be chosen at random

C-MOP Participating Sites
!
!
!
!
!
!
!
!
!
!
Cape Fear Valley
Caromont
Cleveland Regional
CMC-Main
CMC-Northeast
CMC-Pineville
Columbus
Duke
Forsyth
Granville


McDowell
Mission
New Hanover
Novant-Huntersville
Presbyterian
Rex
Transylvania
UNC
Vidant
Wake Med
Womack
!
!
!
!
!
!
!
February 4, 2014
!
!
Randomly Generated
Presentation Order
1. McDowell
2. Mission
3. New Hanover
4. CMC-
Northeast
5. CMC-Pineville
6. Novant-
Huntersville
7. Cape Fear
Valley
8. Caromont
9. Presbyterian
10. CMC-Main
11. Rex
12. Wake Med
13. Vidant
14. Duke
15. Columbus
16. Cleveland
Regional
17. Forsyth
18. Transylvania
19. Womack
20. Granville
21. UNC
The Next Step
! 3:00 Teams work together to
" come up with next PDSA
" decide 'what are you gong to work on
as soon as you get back?'
! 3:45 Report Back
" Share ideas
" Use the larger group as a sounding
board