Predictive Analytics: 'A Means to Harnessing the Power to Drive Healthcare Value

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1 Predictive Analytics: 'A Means to Harnessing the Power to Drive Healthcare Value

2 Wolf H. Stapelfeldt, MD Chairman, Department of General Anesthesiology Cleveland Clinic Vice Chairman, Surgical Operations, Medical Operations Division Vice Chairman, Information Systems & Technologies, Anesthesiology Institute Faculty, Samson Global Leadership Academy for Healthcare Executives

3 Learning Objectives Review the key elements of Clinical and Business Intelligence (C&BI) Recognize the rationale for enlisting C&BI as part of organizational strategy Appreciate an example of the value of C&BI in affecting meaningful clinical and business outcomes

4 Quality Value = Cost

5 Quality Value = Cost via the services that are being provided

6 Quality Value = Cost via the services that are being provided and by leveraging technology

7 Quality Value = Cost via the services that are being provided and by leveraging technology

8 Quality Value = Cost via the services that are being provided and by leveraging technology (Clinical & Business Intelligence)

9 Meaningful Outcomes In Hospital Mortality Length of Stay (LOS) Hospital Charges Re admission Rate 30 Day Mortality

10 Clinical Challenge (Patients, Populations)

11 Actions/Interventions Clinical Challenge (Patients, Populations)

12 Clinical & Business Processes Actions/Interventions Clinical Challenge (Patients, Populations)

13 Outcomes Results Data Clinical & Business Processes Actions/Interventions Clinical Challenge (Patients, Populations)

14 Outcomes Results Data Learning/Understanding Clinical & Business Processes Actions/Interventions Information Clinical Challenge (Patients, Populations)

15 Outcomes Results Data Learning/Understanding Clinical & Business Processes Actions/Interventions Information Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations)

16 Outcomes Results Data Learning/Understanding Clinical & Business Processes Actions/Interventions Information Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations)

17 Outcomes Results Data Learning/Understanding Clinical & Business Processes Actions/Interventions C&BI Information Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations)

18 Outcomes Results Data Learning/Understanding Clinical & Business Processes Actions/Interventions C&BI Information Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations)

19 Outcomes Results Data Learning/Understanding Clinical & Business Processes Actions/Interventions C&BI Information Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations)

20 Outcomes Results Data Learning/Understanding Clinical & Business Processes Actions/Interventions C&BI Information Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations)

21 Outcomes Results Data Learning/Understanding Clinical & Business Processes Actions/Interventions C&BI Information Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations)

22 Outcomes Device Integration Results Data ETL Processes Learning/Understanding Clinical & Business Processes Actions/Interventions C&BI Information Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations)

23 Outcomes Device Integration Results Data ETL Processes Learning/Understanding Clinical & Business Processes Actions/Interventions C&BI Information Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations)

24 Outcomes Learning/Understanding Device Integration Results Data ETL Processes Clinical & Business Processes C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations)

25 Outcomes Learning/Understanding Device Integration Results Data ETL Processes Clinical & Business Processes C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations)

26 Outcomes Learning/Understanding Device Integration Results Data ETL Processes Clinical & Business Processes C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations) Real-Time Processing

27 Outcomes Learning/Understanding Device Integration Results Data ETL Processes Clinical & Business Processes C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations) Real-Time Processing

28 Outcomes Learning/Understanding Device Integration Results Data ETL Processes Clinical & Business Processes C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations) Decision Support Toolbox (CPOE, Alerts, etc.) Real-Time Processing

29 Outcomes Learning/Understanding Device Integration Results Data ETL Processes Clinical & Business Processes C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations) Decision Support Toolbox (CPOE, Alerts, etc.) Real-Time Processing

30 Outcomes Results Learning/Understanding Device Integration ETL Processes Clinical & Business Processes Data C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations) Decision Support Toolbox (CPOE, Alerts, etc.) Real-Time Processing

31 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Learning/Understanding Device Integration ETL Processes Clinical & Business Processes Data C&BI Analytics Information Actions/Interventions Decision Support Toolbox (CPOE, Alerts, etc.) Knowledge/Experience Actionable Information (Decision Support) Clinical Challenge (Patients, Populations) Real-Time Processing

32 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Learning/Understanding Device Integration ETL Processes Clinical & Business Processes Data C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Intraoperative Hemodynamics Decision Support Toolbox (CPOE, Alerts, etc.) Real-Time Processing

33 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Learning/Understanding Device Integration ETL Processes Clinical & Business Processes Data C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Intraoperative Hemodynamics Decision Support Toolbox (CPOE, Alerts, etc.) Real-Time Processing

34 1. Current Status of Perioperative Care

35 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record

36 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record

37 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record Problems 1. Difficult to read (often not legible) 2. Not updated in real time 3. Not accessible electronically

38 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record Problems 1. Difficult to read (often not legible) 2. Not updated in real time 3. Not accessible electronically

39 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record Problems 1. Difficult to read (often not legible) 2. Not updated in real time 3. Not accessible electronically

40 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record Problems 1. Difficult to read (often not legible) 2. Not updated in real time 3. Not accessible electronically

41 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record Problems 1. Difficult to read (often not legible) 2. Not updated in real time 3. Not accessible electronically

42 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record Problems 1. Difficult to read (often not legible) 2. Not updated in real time 3. Not accessible electronically

43 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record

44 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record b. Automatically-generated Record

45 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record b. Automatically-generated Record

46 1. Current Status of Perioperative Care a. Handwritten Anesthesia Record b. Automatically-generated Record ARKS

47 ARKS

48

49 1. Current Status of Perioperative Care ARKS Advantages 1. Legible 2. Accurate 3. Queryable

50 1. Current Status of Perioperative Care What constitutes hypotension severe enough to worry about? ARKS

51 1. Current Status of Perioperative Care What constitutes hypotension severe enough to worry about? ARKS

52 1. Current Status of Perioperative Care What constitutes hypotension severe enough to worry about? ARKS

53 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Learning/Understanding Device Integration ETL Processes Clinical & Business Processes Data C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Intraoperative Hemodynamics Decision Support Toolbox (CPOE, Alerts, etc.) Real-Time Processing

54 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Learning/Understanding Device Integration ETL Processes Clinical & Business Processes Data C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Intraoperative Hemodynamics Decision Support Toolbox (CPOE, Alerts, etc.) Real-Time Processing

55 Hypotension

56 Hypotension MAP < 70? < 60? < 50? < some other discrete value (such as 20% below baseline)? < 60!

57 Hypotension MAP < 70? < 60? < 50? < some other discrete value (such as 20% below baseline)? < 60!

58 Hypotension MAP < 70? < 60? < 50? < some other discrete value (such as 20% below baseline)? < 60!

59 Hypotension MAP < 70? < 60? < 50? < some other discrete value (such as 20% below baseline)? < 60!

60 Hypotension MAP < 70? < 60? < 50? < some other discrete value (such as 20% below baseline)?

61 When does hypotension become significant?

62 When does hypotension become significant? after 2 minutes? 5 minutes? 15 minutes?

63 When does hypotension become significant? after 2 minutes? 5 minutes? 15 minutes?

64 When does hypotension become significant? after 2 minutes? 5 minutes? 15 minutes?

65 MAP

66 MAP

67 MAP

68 MAP

69 MAP

70 MAP

71 MAP

72 Hypotensive Case 1 Case 2 Threshold [cum min] [cum min] MAP

73 Hypotensive Case 1 Case 2 Threshold [cum min] [cum min] MAP

74 Hypotensive Case 1 Case 2 Threshold [cum min] [cum min] MAP

75 Hypotensive Case 1 Case 2 Threshold [cum min] [cum min] MAP

76 Hypotensive Case 1 Case 2 Threshold [cum min] [cum min] MAP

77 Hypotensive Case 1 Case 2 Threshold [cum min] [cum min] MAP

78 Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive Thresholds Ranging From 75 To Average Cumulative Time Spent at a MAP below Hypotensive Threshold N=35904 Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45

79 Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive Thresholds Ranging From 75 To Average Cumulative Time Spent at a MAP below Hypotensive Threshold N=35904 Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45

80 Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive Thresholds Ranging From 75 To 45 Average Cumulative Time Spent at a MAP below 100% Incidence 50% 0% Hypotensive Threshold N=35904 Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45

81 Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive Thresholds Ranging From 75 To 45 Average Cumulative Time Spent at a MAP below 100% Incidence 50% 0% Hypotensive Threshold N=35904 Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45

82 Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive Thresholds Ranging From 75 To 45 Average Cumulative Time Spent at a MAP below 100% Incidence 50% 0% % 5% 4% 3% 2% 1% Hypotensive Threshold 30-day Mortality N=35904 Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45

83 Incidence, 30-day Mortality and Distribution of Average Cumulative Times Spent Below Various MAPs of Cases with MAPs Dropping Below Hypotensive Thresholds Ranging From 75 To 45 Average Cumulative Time Spent at a MAP below 100% Incidence 50% 0% % 5% 4% 3% 2% 1% Hypotensive Threshold 30-day Mortality N=35904 Different hypotensive thresholds are indicative not only of time spent below that threshold but of differences in the time spent at any MAP between 75 and 45 and in 30-day mortality

84 Percent Increase in the Odds Ratio for 30 day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds % Increase In Odds Ratio (30 day Mortality) normotensive (n= 21485, 60%) 50% 40% 30% 20% 10% Spent at an MAP Below Cumulative Minutes

85 Percent Increase in the Odds Ratio for 30 day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds % Increase In Odds Ratio (30 day Mortality) normotensive (n= 21485, 60%) 50% 40% 30% 20% 10% Spent at an MAP Below Cumulative Minutes

86 Percent Increase in the Odds Ratio for 30 day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds % Increase In Odds Ratio (30 day Mortality) hypertensive (n= 14419, 40%) normotensive (n= 21485, 60%) 50% 40% 30% 20% 10% Spent at an MAP Below Cumulative Minutes

87 Percent Increase in the Odds Ratio for 30 day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds % Increase In Odds Ratio (30 day Mortality) hypertensive (n= 14419, 40%) normotensive (n= 21485, 60%) 50% 40% 30% 20% 10% Spent at an MAP Below Cumulative Minutes

88 Percent Increase in the Odds Ratio for 30 day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds % Increase In Odds Ratio (30 day Mortality) hypertensive (n= 14419, 40%) 50% 40% 30% 20% 10% Spent at an MAP Below Cumulative Minutes

89 Percent Increase in the Odds Ratio for 30 day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds % Increase In Odds Ratio (30 day Mortality) hypertensive (n= 14419, 40%) 50% 40% 30% 20% 10% Spent at an MAP Below 20% Cumulative Minutes The line in red represents the same (20%) impact on the Odds Ratio for 30 day Mortality

90 Percent Increase in the Odds Ratio for 30 day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds % Increase In Odds Ratio (30 day Mortality) hypertensive (n= 14419, 40%) normotensive (n= 21485, 60%) 50% 40% 30% 20% 10% Spent at an MAP Below 20% Cumulative Minutes The line in red represents the same (20%) impact on the Odds Ratio for 30 day Mortality

91 Percent Increase in the Odds Ratio for 30 day Mortality Depending Upon the Duration of Hypotension Below Certain MAP Thresholds % Increase In Odds Ratio (30 day Mortality) hypertensive (n= 14419, 40%) normotensive (n= 21485, 60%) 50% 40% 30% 20% 10% Minutes Spent at an MAP Below % Cumulative Minutes The line in red represents the same (20%) impact on the Odds Ratio for 30 day Mortality

92 Cumulative Time Spent Below an MAP Threshold of Associated Increase in Odds Ratio For 30 Day Mortality

93 Cumulative Time Spent Below an MAP Threshold of Associated Increase in Odds Ratio For 30 Day Mortality

94 Cumulative Time Spent Below an MAP Threshold of Associated Increase in Odds Ratio For 30 Day Mortality

95 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

96 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

97 Cumulative Time Spent Below Patients Carrying a Preoperative Diagnosis of Hypertension an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

98 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

99 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

100 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

101 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

102 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

103 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

104 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

105 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

106 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

107 Cumulative Time Spent Below Patients Carrying a Preoperative Diagnosis of Hypertension an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

108 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

109 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

110 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

111 Cumulative Time Spent Below an MAP Threshold of Associated with an Increase in 30 day Mortality Odds Ratio of

112 A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits In Hospital Mortality Median LOS* 90 th Percentile LOS* Percent Patients Exceeding Limits 80% 70% 60% 50% 40% 30% 20% 10% 0% % 4% 3% 2% 1% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26, % 70% 60% 50% 40% 30% 20% 10% 0% N=26, % 70% 60% 50% 40% 30% 20% 10% 0% Hospital Charges Readmission Rate 30 Day Mortality # Limits Exceeded Percent Patients Exceeding Limits N=27, $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26, % 15% 10% 5% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% N=27, Exposure Limit Risk Sets, as previously found to be associated with increased 30 day mortality (Stapelfeldt at al., 2012). Below limits Exceeding Limits 5% 4% 3% 2% 1% 0%

113 Percent Patients Exceeding Limits Percent Patients Exceeding Limits A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits 80% 70% 60% 50% 40% 30% 20% 10% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% In Hospital Mortality Median LOS* 90 th Percentile LOS* # Limits Exceeded N=27, % 4% 3% 2% 1% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% % 70% 60% 50% 40% 30% 20% 10% 0% Hospital Charges Readmission Rate 30 Day Mortality N=27, $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26, % 15% 10% 5% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26,940 # Limits Exceeded N=26,940 N=27, Exposure Limit Risk Sets, as previously found to be associated with increased 30 day mortality (Stapelfeldt at al., 2012). Below limits Exceeding Limits % 4% 3% 2% 1% 0%

114 Percent Patients Exceeding Limits Percent Patients Exceeding Limits A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits 80% 70% 60% 50% 40% 30% 20% 10% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% In Hospital Mortality Median LOS* 90 th Percentile LOS* # Limits Exceeded N=27, % 4% 3% 2% 1% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% % 70% 60% 50% 40% 30% 20% 10% 0% Hospital Charges Readmission Rate 30 Day Mortality N=27, $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26, % 15% 10% 5% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26,940 # Limits Exceeded N=26,940 N=27, Exposure Limit Risk Sets, as previously found to be associated with increased 30 day mortality (Stapelfeldt at al., 2012). Below limits Exceeding Limits % 4% 3% 2% 1% 0%

115 Percent Patients Exceeding Limits Percent Patients Exceeding Limits A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits 80% 70% 60% 50% 40% 30% 20% 10% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% In Hospital Mortality Median LOS* 90 th Percentile LOS* # Limits Exceeded N=27, % 4% 3% 2% 1% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% % 70% 60% 50% 40% 30% 20% 10% 0% Hospital Charges Readmission Rate 30 Day Mortality N=27, $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26, % 15% 10% 5% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26,940 # Limits Exceeded N=26,940 N=27, Exposure Limit Risk Sets, as previously found to be associated with increased 30 day mortality (Stapelfeldt at al., 2012). Below limits Exceeding Limits % 4% 3% 2% 1% 0%

116 Percent Patients Exceeding Limits Percent Patients Exceeding Limits A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits 80% 70% 60% 50% 40% 30% 20% 10% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% In Hospital Mortality Median LOS* * Live discharges 90 th Percentile LOS* # Limits Exceeded N=27, % 4% 3% 2% 1% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% % 70% 60% 50% 40% 30% 20% 10% 0% Hospital Charges Readmission Rate 30 Day Mortality N=27, $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26, % 15% 10% 5% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26,940 # Limits Exceeded N=26,940 N=27, Exposure Limit Risk Sets, as previously found to be associated with increased 30 day mortality (Stapelfeldt at al., 2012). Below limits Exceeding Limits % 4% 3% 2% 1% 0%

117 Percent Patients Exceeding Limits Percent Patients Exceeding Limits A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits 80% 70% 60% 50% 40% 30% 20% 10% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% In Hospital Mortality Median LOS* * Live discharges 90 th Percentile LOS* # Limits Exceeded N=27, % 4% 3% 2% 1% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% % 70% 60% 50% 40% 30% 20% 10% 0% Hospital Charges Readmission Rate 30 Day Mortality N=27, $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26, % 15% 10% 5% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26,940 # Limits Exceeded N=26,940 N=27, Exposure Limit Risk Sets, as previously found to be associated with increased 30 day mortality (Stapelfeldt at al., 2012). Below limits Exceeding Limits % 4% 3% 2% 1% 0%

118 Percent Patients Exceeding Limits Percent Patients Exceeding Limits A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits 80% 70% 60% 50% 40% 30% 20% 10% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% In Hospital Mortality Median LOS* * Live discharges 90 th Percentile LOS* # Limits Exceeded N=27, % 4% 3% 2% 1% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% % 70% 60% 50% 40% 30% 20% 10% 0% Hospital Charges Readmission Rate 30 Day Mortality N=27, $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26, % 15% 10% 5% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26,940 # Limits Exceeded N=26,940 N=27, Exposure Limit Risk Sets, as previously found to be associated with increased 30 day mortality (Stapelfeldt at al., 2012). Below limits Exceeding Limits % 4% 3% 2% 1% 0%

119 Percent Patients Exceeding Limits Percent Patients Exceeding Limits A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits 80% 70% 60% 50% 40% 30% 20% 10% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% In Hospital Mortality Median LOS* * Live discharges 90 th Percentile LOS* # Limits Exceeded N=27, % 4% 3% 2% 1% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% % 70% 60% 50% 40% 30% 20% 10% 0% Hospital Charges Readmission Rate 30 Day Mortality N=27, $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26, % 15% 10% 5% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26,940 # Limits Exceeded N=26,940 N=27, Exposure Limit Risk Sets, as previously found to be associated with increased 30 day mortality (Stapelfeldt at al., 2012). Below limits Exceeding Limits % 4% 3% 2% 1% 0%

120 Percent Patients Exceeding Limits Percent Patients Exceeding Limits A Novel Risk Index Portending Adverse Postoperative Outcome Based on Patients Exceeding Certain Sets of Intraoperative Hypotensive Exposure Limits 80% 70% 60% 50% 40% 30% 20% 10% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% In Hospital Mortality Median LOS* * Live discharges 90 th Percentile LOS* # Limits Exceeded N=27, % 4% 3% 2% 1% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% % 70% 60% 50% 40% 30% 20% 10% 0% Hospital Charges Readmission Rate 30 Day Mortality N=27, $140,000 $120,000 $100,000 $80,000 $60,000 $40,000 $20,000 $0 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26, % 15% 10% 5% 0% 80% 70% 60% 50% 40% 30% 20% 10% 0% N=26,940 # Limits Exceeded N=26,940 N=27, Exposure Limit Risk Sets, as previously found to be associated with increased 30 day mortality (Stapelfeldt at al., 2012). Below limits Exceeding Limits % 4% 3% 2% 1% 0%

121 Percent Increase in Risk (Odds Ratio) per Exposure Limit Exceeded (DSS Alert) Portended by a Novel Risk Index for Adverse Postoperative Outcome Based on the Number of Intraoperative Hypotensive Exposure Limits Exceeded (with and without adjustment for a set of 30 co morbidities identified by AHRQ) 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% In Hospital Mortality Average LOS* Readmission Rate* (N=27,436 ) (N=26,940) 3.5% * Live discharges (N=26,940) 3.0% 4% 2.5% 2.0% 3% 1.5% 2% 1.0% 1% 0.5% 0.0% 0% % Hypotensive Exposure, Unadjusted (95% Confidence Interval) Hypotensive Exposure, AHRQ Adjusted (95% Confidence Interval) Exposure Limit Risk Sets, as previously found to be associated with increased 30 day mortality (Stapelfeldt at al., 2012)

122 Percent Increase in Risk (Odds Ratio) per Exposure Limit Exceeded (DSS Alert) Portended by a Novel Risk Index for Adverse Postoperative Outcome Based on the Number of Intraoperative Hypotensive Exposure Limits Exceeded (with and without adjustment for a set of 30 co morbidities identified by AHRQ) 10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% In Hospital Mortality Average LOS* Readmission Rate* (N=27,436 ) (N=26,940) 3.5% * Live discharges (N=26,940) 3.0% 4% 2.5% 2.0% 3% 1.5% 2% 1.0% 1% 0.5% 0.0% 0% % Hypotensive Exposure, Unadjusted (95% Confidence Interval) Hypotensive Exposure, AHRQ Adjusted (95% Confidence Interval) Exposure Limit Risk Sets, as previously found to be associated with increased 30 day mortality (Stapelfeldt at al., 2012)

123 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Learning/Understanding Device Integration ETL Processes Clinical & Business Processes Data C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Intraoperative Hemodynamics Decision Support Toolbox (CPOE, Alerts, etc.) Real-Time Processing

124 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Learning/Understanding Device Integration ETL Processes Clinical & Business Processes Data C&BI Analytics Information Actions/Interventions Knowledge/Experience Actionable Information (Decision Support) Intraoperative Hemodynamics Decision Support Toolbox (CPOE, Alerts, etc.) Real-Time Processing

125 1. Current Status of Perioperative Care

126 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS)

127 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base ARKS

128 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base ARKS

129 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS

130 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS

131 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS Pertinent, Patient-Specific Information (the right information at the right time to make the right decision)

132 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR ± History of hypertension Risk factors for hypotension (ex: hypertrophic obstructive CM) DSS Knowledge Base Association between hypotensive exposure & outcome ( Diving Charts ) ARKS Pertinent, Patient-Specific Information (the right information at the right time to make the right decision) Increased risk for adverse outcome portended by progressive hypotensive exposure

133 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS Pertinent, Patient-Specific Information

134 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS Pertinent, Patient-Specific Information Web-Based Secure (electronically, physical) Compliant with Standards (HL7, SNOMED ontology) Platform-Independent Scalable Universally Applicable

135 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS Pertinent, Patient-Specific Information Web-Based Secure (electronically, physical) Compliant with Standards (HL7, SNOMED ontology) Platform-Independent Scalable Universally Applicable

136 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS Pertinent, Patient-Specific Information Web-Based Secure (electronically, physical) Compliant with Standards (HL7, SNOMED ontology) Platform-Independent Scalable Universally Applicable

137 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS Pertinent, Patient-Specific Information Web-Based Secure (electronically, physical) Compliant with Standards (HL7, SNOMED ontology) Platform-Independent Scalable Universally Applicable

138 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS Pertinent, Patient-Specific Information Web-Based Secure (electronically, physical) Compliant with Standards (HL7, SNOMED ontology) Platform-Independent Scalable Universally Applicable

139 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS Pertinent, Patient-Specific Information Web-Based Secure (electronically, physical) Compliant with Standards (HL7, SNOMED ontology) Platform-Independent Scalable Universally Applicable

140 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS ARKS Pertinent, Patient-Specific Information Web-Based Secure (electronically, physical) Compliant with Standards (HL7, SNOMED ontology) Platform-Independent Scalable Universally Applicable

141 1. Current Status of Perioperative Care 2. Concept of Decision Support (DSS) EMR Knowledge Base DSS Supervising Physician OR ARKS Pertinent, Patient-Specific Information Web-Based Secure (electronically, physical) Compliant with Standards (HL7, SNOMED ontology) Platform-Independent Scalable Universally Applicable

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145 EMR Knowledge Base Allows adverse physiologic developments to be addressed before they become crises DSS ARKS EMR DSS Knowledge Base OR ARKS EMR Knowledge Base DSS OR ARKS OR

146 EMR Knowledge Base Allows adverse physiologic developments to be addressed before they become crises DSS ARKS EMR DSS Knowledge Base OR ARKS EMR Knowledge Base DSS OR ARKS OR

147 EMR Knowledge Base Allows adverse physiologic developments to be addressed before they become crises DSS ARKS EMR DSS Knowledge Base OR ARKS EMR Knowledge Base DSS OR ARKS OR

148 EMR Knowledge Base Allows adverse physiologic developments to be addressed before they become crises DSS ARKS EMR DSS Knowledge Base OR ARKS EMR Knowledge Base DSS OR ARKS OR

149 EMR Knowledge Base Allows adverse physiologic developments to be addressed before they become crises DSS ARKS EMR DSS Knowledge Base OR ARKS EMR Knowledge Base DSS OR ARKS OR

150 EMR Knowledge Base Allows adverse physiologic developments to be addressed before they become crises DSS ARKS EMR DSS Knowledge Base OR ARKS EMR Knowledge Base DSS OR ARKS OR

151 EMR Knowledge Base Allows adverse physiologic developments to be addressed before they become crises DSS ARKS EMR DSS Knowledge Base OR ARKS EMR Knowledge Base DSS OR ARKS OR

152 EMR Knowledge Base Allows adverse physiologic developments to be addressed before they become crises DSS ARKS EMR DSS Knowledge Base OR ARKS EMR Knowledge Base DSS OR ARKS OR

153 Each alert portends a 5.1% increase in the projected odds ratio for death within 30 days (20% risk set) Update the effective MAP Matrix to include the most recent minute of the case executed every minute in near real time Alert Update the cumulative number of minutes spent below each of the MAP thresholds (75 to 45 mm Hg) Compare with the set of time thresholds for the selected level of risk (risk set) Count the number of thresholds exceeded for the current minute Count greater than the previous minute s count?

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159 Odds of Mortality

160 12:00:00 13:12:00 14:24:00 15:36:00 16:48:00 Odds of Mortality

161 12:00:00 13:12:00 14:24:00 15:36:00 16:48:00 Odds of Mortality

162 12:00:00 13:12:00 14:24:00 15:36:00 16:48:00 Odds of Mortality 5 to be evaluated in a prospective randomized clinical effectiveness trial

163 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Learning/Understanding Clinical & Business Processes Device Integration Data ETL Processes Actions/Interventions C&BI Analytics Information Decision Support Toolbox (CPOE, Alerts, etc.) Knowledge/Experience Actionable Information (Decision Support) Real-Time Processing Intraoperative Hemodynamics

164 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Learning/Understanding Clinical & Business Processes Device Integration Data ETL Processes Actions/Interventions C&BI Analytics Information Decision Support Toolbox (CPOE, Alerts, etc.) Knowledge/Experience Actionable Information (Decision Support) Real-Time Processing Intraoperative Hemodynamics

165 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Device Integration Data ETL Processes Clinical & Business Processes Minute to Minute MAP Data Medical History (Hypertension) Analytics Learning/Understanding Actions/Interventions Information C&BI in real time (every one minute), for every patient MAP Matrix Knowledge/Experience Actionable Hypotensive Information Exposures Alerts (Decision Support) Number of Limits Exceeded Real-Time Processing Intraoperative Hemodynamics

166 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Device Integration Data ETL Processes Clinical & Business Processes Minute to Minute MAP Data Medical History (Hypertension) Analytics Learning/Understanding BP Actions/Interventions Information C&BI in real time (every one minute), for every patient MAP Matrix Knowledge/Experience Actionable Hypotensive Information Exposures Alerts (Decision Support) Number of Limits Exceeded Real-Time Processing Intraoperative Hemodynamics

167 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Targeted Postop. Care Device Integration Data ETL Processes Clinical & Business Processes Minute to Minute MAP Data Medical History (Hypertension) Analytics Learning/Understanding BP Actions/Interventions Information C&BI in real time (every one minute), for every patient MAP Matrix Knowledge/Experience Actionable Hypotensive Information Exposures Alerts (Decision Support) Number of Limits Exceeded Real-Time Processing Intraoperative Hemodynamics

168 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Targeted Postop. Care Device Integration Data ETL Processes Clinical & Business Processes Minute to Minute MAP Data Medical History (Hypertension) Analytics Learning/Understanding BP Actions/Interventions Information C&BI in real time (every one minute), for every patient MAP Matrix Knowledge/Experience Actionable Hypotensive Information Exposures Alerts (Decision Support) Number of Limits Exceeded Real-Time Processing Intraoperative Hemodynamics

169 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Targeted Postop. Care Device Integration Data ETL Processes Clinical & Business Processes Minute to Minute MAP Data Medical History (Hypertension) Analytics Learning/Understanding Hypotensive exposures are difficult to detect BP Actions/Interventions Information C&BI in real time (every one minute), for every patient MAP Matrix Knowledge/Experience Actionable Hypotensive Information Exposures Alerts and impossible to avoid (Decision Support) Number of Limits Exceeded Real-Time Processing Intraoperative Hemodynamics

170 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Targeted Postop. Care Device Integration Data ETL Processes Clinical & Business Processes Minute to Minute MAP Data Medical History (Hypertension) Analytics Learning/Understanding Hypotensive exposures are difficult to detect BP Actions/Interventions Information C&BI in real time (every one minute), for every patient MAP Matrix Knowledge/Experience Actionable Hypotensive Information Exposures Alerts and impossible to avoid (Decision Support) Number of Limits Exceeded Real-Time Processing Intraoperative Hemodynamics

171 In-Hospital Mortality; Length of Stay Readmission Rate; 30-day Mortality Results Targeted Postop. Care Device Integration Data ETL Processes Clinical & Business Processes Minute to Minute MAP Data Medical History (Hypertension) Analytics Learning/Understanding Hypotensive exposures are difficult to detect BP Actions/Interventions Information C&BI in real time (every one minute), for every patient MAP Matrix Knowledge/Experience Actionable Hypotensive Information Exposures Alerts and impossible to avoid (Decision Support) Number of Limits Exceeded Real-Time Processing Intraoperative Hemodynamics

172

173 References Implementing Business Intelligence in Your Healthcare Organization. Cynthia McKinney, MBA, FHIMSS, PMP, Ray Hess, MSA, RRT, FHIMSS, and Michael Whitecar, MIS, LCDR (ret.), MSC, USN. Risk Based Decision Support Thresholds for Hypotension in Adult Patients Undergoing Non Cardiac Surgery. Wolf H. Stapelfeldt, M.D., Jarrod Dalton, Ph.D., Pamela Bromley, M.B.A., George Takla, Ph.D., Jacek Cywinski, M.D., Marc Reynolds, M.S., Bhaswati Ghosh, M.S. 3B933F1D63ABAED7E20D57A44D1?year=2012&index=14&absnum=4351 Prolonged hypotension in surgery linked to poor outcomes. Michael Vlessides. Anesthesiology News 38 (12), December Percent=&zoomX=&zoomY=&noteText=&noteX=&noteY=&viewMode=magazine

174 Starter Question #1 Where to begin with C&BI? The opportunity for C&BI begins with a solid foundation of electronic acquisition of data that capture the essential clinical and business processes as well as indicators of their outcomes through device integration and ETL processes by interfacing with relevant data sources such as patient monitors, EMRs, patient registries etc.

175 Starter Question #2 What outcomes to focus on when it comes to C&BI? These could be key reportable patient outcome measures such as mortality, quality indicators, process measures or parameters such as cost per case. It is important to choose the most relevant ones and keep these in constant focus while realizing that it is resulting informed actions and interventions which affect these, not C&BI per se.

176 Starter Question #3 What types of data parameters are most suitable to be concentrating on when applying predictive analytics? While predictive analytics needs to account for any input parameters deemed relevant it is those that might be altered through intervention ( actionable information ) that would be most relevant. Example: hemodynamic management (alterable) versus certain pre existing comorbidities (very important, but not typically alterable).

177 Starter Question #4 How can predictive analytics be leveraged to affect relevant outcomes? There are essentially two important requirements: both, the analysis of clinical and business data for actionable information as well as provider notification to this information must occur within a sufficient time frame to allow any necessary actions/interventions to still be instituted and take effect in order to influence outcomes.

178 Starter Question #5 What is the ROI of instituting C&BI? It is the determined by the value attributed to the percent improvement in meaningful outcome(s) one can expect to attain as a result of the implementation of C&BI relative to the cost of instituting the latter. This is one reason why it is important, at the outset, to choose the highest impact outcomes to be affected (example: number of lives saved; incremental operating margin through reduction in LOS).

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Bringing Evidence-Based Medicine to the Bedside:

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