Predictive Analytics: 'A Means to Harnessing the Power to Drive Healthcare Value
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- Sybil Andrews
- 8 years ago
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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
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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=¬eText=¬eX=¬eY=&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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