analytics and population health management initiatives · ranges from clinical inpatient...

Dan Exley Executive Director, Data Strategy & Reporting

Memorial Care

Dr. Barbara AntunaMedical Informatics Specialist

Health Language – Wolters Kluwer

Sarah Bryan Director, Product Management

Health Language – Wolters Kluwer

Code Groups The building blocks for your big data analytics and population health management initiatives

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Dan Exley | Executive Director, Data Strategy and Reporting, MemorialCareDan Exley is the Executive Director, Data Strategy and Reporting at MemorialCare Hospital and Health Care in the Greater Los Angeles Area. He has been working in healthcare for over 20 years. Dan is responsible for reporting activities related to MemorialCare’s electronic medical record system (Epic), as well as enterprise-wide data use initiatives, such as the executive dashboard system and enterprise data warehouse. He is one of the developers of a Medical Informatics Certificate program that is currently offered at National-Louis University in Chicago, and is also the program coordinator for the ONC HIT Community College program at Orange Coast College in Costa Mesa, CA.

Dr. Barbara Antuna | Medical Informatics Specialist, Health LanguageDr. Barbara Antuna is a Medical Informatics Specialist at Health Language. She is board certified in Clinical Informatics by the American Board of Preventive Medicine (ABPM) and continues to practice emergency medicine. Her experience ranges from clinical inpatient informatics using Epic and MEDITECH, to involvement in data normalization efforts and synonym development for Provider Friendly Terminology (PFT) at Health Language.

Sarah Bryan | Director of Product Management, Health LanguageSarah Bryan is Director of Product Management for Terminology Product Solutions, for Health Language, a part of Wolters Kluwer Health. In her eight years with Health Language, Sarah has been responsible for delivering terminology management solutions to providers, payers, HIEs, and health IT vendors, to enable interoperability through effective utilization of standard terminologies.

Speakers

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Polling Question One

What are you doing now to manage your code groups/value sets/clinical definitions?

a. Spreadsheets

b. Proprietary Systems

c. Vendor Supplied Software

d. List them in the Application Code

e. Other

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Presentation Overview

1. MemorialCare – customer use cases

2. Code Groups – the clinical perspective

3. Challenges with code groups

4. Benefits of a code management solution

Dan Exley, MMI, FABC

Executive Director, Data Strategy

Code Groups:The Building Blocks

for Analytic Initiatives

Six Nationally-Recognized Hospitals

Orange Coast Memorial Saddleback Memorial

San Clemente

Saddleback Memorial

Laguna Hills

Long Beach Memorial Miller Children’s & Women’s

Hospital Long Beach

Community Hospital

Long Beach

Two Award-Winning Physician Groups

More than

200 care sites

from the South Bay

to San Clemente

Care Sites

Total Assets: 3,059,000,000

Total Annual Revenue: 1,999,000,000

Patient Discharges: 68,841

Patient Days: 309,839

ED Visits: 198,647

Babies Delivered: 10,262

Just the Facts FY-2014

Affiliated Physicians: 2,600

Surgeries: 34,480

Employees: 11,192

Commercial/Medi-Cal lives: 123,907

Senior lives: 54,914

Some Key FY’ 16 Initiatives

Advance our

Population

Health roadmap

Participate in

CMS Bundled

Payment

initiatives

Leverage and

Optimize

Research

capabilities

Continue

readiness for

population-

based

payment

Pursuing a Common Playbook

Challenges with

Master Data ManagementAn Enterprise Code

Group Pre-requisite?

Historical

Inter-departmental and Intra-

Organization Silos

Acknowledging the vital role of

professional terminologists

• EMR (Epic and Other)

• Transactional System Reports

• Decision Support System

Reports

Grouping Things Together

• Enterprise Data Warehouse(s)

• External Reference

Terminology

• Local/De-facto terminology

• Externally defined measure definitions

• Reference sets different by program, payor, etc.

• Some measures calculated by 3rd party software

• Some measures calculated by in-house

(audited) development

Pay for (Provider) Performance

$

Sample of One External Measure Program Set

• Development of reports for different PI activities in support of Physician Best Practice Teams and Enterprise-wide Service Line Committees

• Customers often go to many different supporting groups for information about their initiatives - $ Decision Support, Epic Reporting, Enterprise Data Warehouse, 3p Vendor

• Challenges aligning definitions for different use cases and audiences

Performance Improvement Informatics

+

SQL_SEP_PreMetric_IV_Antibiotics:

MEDNAME.THERA_CLASS_C IN (10, 11, 41) OR MIX_MEDICATION.THERA_CLASS_C IN (10, 11, 41)

SQL_SEP_PreMetric_IV_Bolus:

SIMPLE_MIX.SIMPLE_MED_ID IN (79032) OR (MEDID.SIMPLE_MED_ID IN (79032)

SQL_SEP_PreMetric_Vassopressors:

SIMPLE_MIX.SIMPLE_MED_ID IN (77117, 77110, 77111, 77131, 77509) OR MEDID.SIMPLE_MED_ID IN (77117, 77110, 77111, 77131, 77509)

SQL_SEP_PreMetric_IV_Fluids:

FLOMEAS.FLO_MEAS_ID IN ('12106', '102106', '102105', '22106','32106','32105','42106','42105','52106','52105','62106','62105','72106','72105','82106',

'82105','92106','92105','3343','12105','22105','5050','12102','52','55','12500685','12500694','12500686','12500687','12500688','12500689','12500690','12500691',

'12500692','12500693','12500684','112106','112105','12500683','122106','122105','12850324','12850323')

Limited Transparency

Glossaries

• Provide support for prospective analysis, study feasibility, and active, IRB-Approved research

• Study sponsors and/or Principle Investigators not always clear on specific criteria (inclusion or exclusion) for the study guidelines

• ICD10 throws a particular wrench in here, with few exceptions

Research

Sample Research Group

Diagnoses That Drive Report Filtering to Meet

“Minimum Necessary” Policy

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Polling Question Two

Are you using clinical data (i.e. SNOMED, LOINC) or unstructured data in your data repository?

a. Yes

b. No

c. Not currently, but we plan to in the future

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Presentation Overview

1. MemorialCare – customer use cases

2. Code Groups – the clinical perspective

3. Challenges with code groups

4. Benefits of a code management solution

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Terminology Barriers Are Pervasive

My doctor said it was heart failure

SNOMED CT code: 42343007-Congestive

heart failure

ICD-9-CM: 428-Congestive heart failure,

unspecified

ICD-10-CM: 150.9 –Heart failure, unspecified

LOINC 30934-4 B – Type natriuretic

peptideRxNorm: 3407 -

Digoxin

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The Importance of Code Groups

How do code groups relate to business rules and use cases?Code groups or value sets are critical building blocks for todays business rules which in turn are used as tools to solve larger Health IT initiatives. Simply put, they can be thought of as ‘bags of codes’ that represent clinical concepts.

Accountable Care Organizations, quality improvement, health information exchange, analytics, and population health management initiatives all create a need to manage code groups (aka value sets) to support a variety of activities:

Quality Measures – Attesting for Meaningful Use, PQRS, HEDIS, Stars

Population Identification – Care Management, Population Health and Analytics

Sensitivity codes

Decision Support

Benefit Policies

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Code Groups & Business Rules

How do code groups relate to business rules and use cases?Code groups or value sets are critical building blocks for todays business rules which in turn are used as tools to solve larger Health IT initiatives. Simply put, they can be thought of as ‘bags of codes’ that represent clinical concepts.

Results Supports CGM Use Cases:

• Claim costs and utilization patterns

• Reports (e.g. quality metrics, care management cohorts)

• Cohort with co-morbidities• Other (Application Pick Lists,

Sensitivity codes, Medical Benefit Policies)

Code GroupsExecutable

RuleManage

TerminologiesRules

AuthoringEvaluate

Rule

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Code Groups within Population Cohorts

Code groups can also be used to create a rule that identifies a cohort, or population, to be evaluated in a care management program or a research study. For example, a care management program may want to monitor a population of patients that meet specific criteria.

Heart Failure (diagnoses)

Ejection Fraction

(test results)OR < 40%][ AND

BNP(lab tests)

> 300 pg/ml

] ] -ARB/ACEI Exclusions (diagnoses)

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24,500 patients

Population of Diabetes – Different Ways to Define Them

Richesson RL, Rusincovitch SA, Wixted D, et al. J Am Med Inform Assoc 2013; 20:e319-e326

Many Faces of Diabetes

ICD-9-CM 250.xx Codes CMS CCW NYC A1C Registry SUPREME-DM

Diabetes-associated medications DDC phenotype eMERGE

2924,500 patients identified by criteria from any of the three terminology domains

Many Faces of Diabetes

Variability With Different Terminology Domains

MEDS LABS

DIAGNOSES

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Many Faces of Diabetes

24,500 patients identified by criteria from any of the three terminology domains

DIAGNOSES

LABSMEDS

22% of Your Population

Variability With Different Terminology Domains

MEDS LABS

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• Increase in claim costs and utilization

• Lack of adherence to treatment plans

• Lower payments in P4P programs

Many Faces of Diabetes

Impact of Inaccurate Code Groups?

MEDS LABS

DIAGNOSES

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MEMBERS WITHDEPRESSION

HIV+MEMBERS

MEMBERS WITHDEPRESSION

HIV+MEMBERS

Code Groups and Sensitivity Codes

Create a cohort of all HIV+ members with a co-morbid of depression

Depression is a major barrier to HIV

treatment outcomes

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Polling Question Three

What does your organization use code groups for? a. Defining population cohorts for care management

b. Defining population cohorts for research and analysis

c. Defining sensitive codes to ensure compliance

d. All of the above

e. None of the above

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Presentation Overview

1. MemorialCare – customer use cases

2. Code Groups – the clinical perspective

3. Challenges with code groups

4. Benefits of a code management solution

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The Importance of Code Groups in Analytics

Forward-thinking initiatives such as: Accountable Care, Quality Improvement, Health Information Exchange, Analytics, and Population Health Management all create a need to manage code groups (aka value sets) to support a variety of activities:

Quality Measures Attesting for

Meaningful Use, PQRS, HEDIS, Stars

Population Identification

Care Management, Population Health

and Analytics

Decision Support

Sensitivity Codes

Benefit Policies

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Code Group Pain Points

Conflicts regarding terminology intake, management, and distribution are inevitable without an enterprise terminology management strategy.

Hard-Coded Business

Rules

Multiple IT Systems

The Spreadsheet

Chaos

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Benefits of a Code Management System

Single Source of Terminology TruthIncrease accuracy for your code groups through the creation of a single, integrated and trusted source of truth for all local and standard code groups across your organization.

Terminology GovernanceReduce operational overhead by aligning terminology and code group definitions, intended use, and versioning across business domains and all your clinical applications.

Always Up To DateStay current with content updates from the world’s leading terminology standard bodies.

Systems IntegrationIntegrate seamlessly within your current environment

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Our Enterprise Terminology Platform

1. CONTENT200+ standard and

enhanced terminologies,

mappings, code groups,

and synonym libraries

2. SOFTWAREto view, manage, export,

and standardize all

clinical content on a

single platform

3. TOOLSto map, model, search,

remediate, customize,

and group terminologies

4. SERVICESIncluding custom

mapping and modeling,

terminology consulting,

claims analysis,

and more

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Q&A

Thank You