health systems as research platforms · health systems as research platforms serving patients’...

1MAYO CLINIC | ©2010 MFMER

Health SystemsHealth Systemsas Research Platformsas Research Platforms

Sherine E. Gabriel, MD, MSc Sherine E. Gabriel, MD, MSc William J. and Charles H. Mayo Professor William J. and Charles H. Mayo Professor ProfessorProfessor of Medicine and Epidemiologyof Medicine and EpidemiologyCoCo--PI, Mayo Clinic Center for Translational Science ActivitiesPI, Mayo Clinic Center for Translational Science ActivitiesMedical Director, Office for Strategic AlliancesMedical Director, Office for Strategic Alliances

Institute of MedicineInstitute of MedicineApril 1, 2010April 1, 2010

Enhancing Science, Value and InnovationEnhancing Science, Value and Innovation


Mayo Clinic provides inpatient, outpatient Mayo Clinic provides inpatient, outpatient and communityand community--based health carebased health care

3 locations3 locations•• 526,000 unique patients*526,000 unique patients*•• 132,000 hospital admissions132,000 hospital admissions

7070--communitycommunityhealth systemhealth system

*Individuals counted once annually*Individuals counted once annuallySource: 2008 Mayo Clinic Annual ReportSource: 2008 Mayo Clinic Annual Report

Rochester, MNRochester, MN

Jacksonville, FLJacksonville, FL

Scottsdale andScottsdale andPhoenix, AZPhoenix, AZ


MAYO CLINIC AND CLINICAL RESEARCHMAYO CLINIC AND CLINICAL RESEARCHAn Outgrowth of Patient CareAn Outgrowth of Patient Care

•• Part of our heritage and culturePart of our heritage and culture


William Worrall Mayo, MDWilliam Worrall Mayo, MD

“Left open for further thoughtand research”

“Left open for further thoughtand research”


MAYO CLINIC AND CLINICAL RESEARCHMAYO CLINIC AND CLINICAL RESEARCHAn Outgrowth of Patient CareAn Outgrowth of Patient Care

•• Part of our heritage and culturePart of our heritage and culture•• Singular focusSingular focus……

The needs of patientsThe needs of patients•• Strong emphasis on valueStrong emphasis on value

•• Individual patientsIndividual patients•• Broader health care systemBroader health care system

•• Translation ofTranslation of……


Health SystemsHealth Systemsas Research Platformsas Research Platforms

Serving patientsServing patients’’ needs todayneeds todayand preparing to serve the needsand preparing to serve the needsof patients tomorrowof patients tomorrow1.1. Rochester Epidemiology Project Rochester Epidemiology Project ––

population basedpopulation based2.2. Total Joint Registry Total Joint Registry –– clinical practice clinical practice

basedbased3.3. Anticoagulation optimizationAnticoagulation optimization4.4. High Value Health Care InitiativeHigh Value Health Care Initiative5.5. Enterprise Data TrustEnterprise Data Trust


RochesterRochesterEpidemiology ProjectEpidemiology Project

•• Collaboration among health careCollaboration among health careproviders in Olmsted County, MNproviders in Olmsted County, MN•• Share medical records for researchShare medical records for research•• Research health and illnesses of peopleResearch health and illnesses of people

living in this communityliving in this community•• Improve health/health care in the entire countryImprove health/health care in the entire country

•• Unique resourceUnique resource•• One of few places for populationOne of few places for population --based research based research •• NIH funded since 1966NIH funded since 1966•• Supports ~ 40 individual NIH grants Supports ~ 40 individual NIH grants •• Cumulative publications to date = 2,042Cumulative publications to date = 2,042


Impact on Patient CareImpact on Patient Care

Selected examplesSelected examples•• Occurrence of GuillainOccurrence of Guillain--BarrBarréé syndromesyndrome

after swine flu vaccine only slightly increasedafter swine flu vaccine only slightly increased(Beghi et al, 1985)(Beghi et al, 1985)

•• Putative adverse sequelae of silicone breast Putative adverse sequelae of silicone breast implant not confirmedimplant not confirmed (Gabriel et al, 1994)(Gabriel et al, 1994)

•• Putative increased risk of autism after Putative increased risk of autism after immunizations not confirmedimmunizations not confirmed ((BarbaresiBarbaresi et al, 2005)et al, 2005)

•• Increased mortality and increased riskIncreased mortality and increased riskof neurological disorders after prophylactic of neurological disorders after prophylactic oophorectomyoophorectomy ((RoccaRocca et al, 2006, 2007, 2008)et al, 2006, 2007, 2008)


Mayo ClinicMayo ClinicTotal Joint RegistryTotal Joint Registry

•• Data on 97,500 arthroplasties since 1969Data on 97,500 arthroplasties since 1969(i.e., world(i.e., world’’s most comprehensive joint s most comprehensive joint replacement registry)replacement registry)

•• Structured, standardized information Structured, standardized information gathered before, during and at scheduled gathered before, during and at scheduled intervals after surgery, for the lifetimeintervals after surgery, for the lifetimeof the patient and implantof the patient and implant

•• Allows comparisons of surgical technique, Allows comparisons of surgical technique, implant types, patient demographics, implant types, patient demographics, conditions and outcomesconditions and outcomes

•• Identifies most effective surgical practices Identifies most effective surgical practices and implant modelsand implant models


Total Hip ArthroplastyTotal Hip ArthroplastyAge/Sex Adjusted Survival Free of RevisionAge/Sex Adjusted Survival Free of Revision

7,989 patients, 9,584 hips7,989 patients, 9,584 hips


00 55 1010 1515 2020Years since THAYears since THA

% fr

ee o

f rev

isio

n%

free

of r

evis

ion

00

2020

4040

6060

8080

100100

00 22 44 66 1010Years since THAYears since THA

00

2020

4040

6060

8080

100100

88

Longitudinal comparative analysis of cup designsLongitudinal comparative analysis of cup designsallowed Mayo to change practice employing only thoseallowed Mayo to change practice employing only those

designs that significantly improved time to revisiondesigns that significantly improved time to revision

Types of cups usedBEFORE study

Types of cups usedAFTER study


Anticoagulation OptimizationAnticoagulation OptimizationWarfarin ProjectWarfarin Project

DefinitionDefinitionAny inpatient receiving Any inpatient receiving Warfarin is unsafeWarfarin is unsafeif any subsequent if any subsequent inpatient INR is >5.0 inpatient INR is >5.0

Baseline defect rateBaseline defect rateMC 3.5%MC 3.5%

Primary goalPrimary goalReduce the proportionReduce the proportionof unsafe Warfarin of unsafe Warfarin Inpatients to <1.5%Inpatients to <1.5%

2005 Baseline2005 Baseline18,700 Annual Warfarin Patients18,700 Annual Warfarin Patients

96.5%

INR within safe rangeHazardous INR >5

3.5%3.5%



StandardizationStandardization

1.1. Standardized rulesStandardized rules--based, robust algorithm based, robust algorithm launched by prescriber launched by prescriber order, thenorder, then

2.2. Run by pharmacist Run by pharmacist

3.3. System and algorithm System and algorithm improved dozens of improved dozens of times (PDSA cycles) times (PDSA cycles) based on surveillance, based on surveillance, performance data and performance data and user feedbackuser feedback

Starting in 2009Starting in 200918,700 Annual Warfarin Patients18,700 Annual Warfarin Patients

Countermeasure: No increase in proportion of patients with INR <1.7 after 3 doses

98.5%

INR within safe rangeHazardous INR >5

<1.5%<1.5%


Improving Value of CareImproving Value of CareThe Mayo Clinic Value EquationThe Mayo Clinic Value Equation

Pay for results, outcomes, value,Pay for results, outcomes, value,not process compliancenot process compliance

Goal: Quality care with decreased Goal: Quality care with decreased unexpected variation and lowerunexpected variation and loweruse of resourcesuse of resources

(outcomes, safety, service)(outcomes, safety, service)Value =Value =

Cost over timeCost over time

QualityQuality


Improving Value of Care Improving Value of Care The High Value Health Care InitiativeThe High Value Health Care Initiative•• Characterize the quality and cost of best Characterize the quality and cost of best

practices over time practices over time •• Phase I: The distribution of costs of best practices compared Phase I: The distribution of costs of best practices compared

to costs for risk matched patientsto costs for risk matched patients•• Implement evidence based best practiceImplement evidence based best practice

and shared decision making and shared decision making •• Study new reimbursement models that support Study new reimbursement models that support

high value carehigh value care•• Improve the value of care for our patientsImprove the value of care for our patientsCollaborative effort betweenCollaborative effort between•• The Mayo Clinic The Mayo Clinic •• The Dartmouth Institute The Dartmouth Institute •• Intermountain Health CareIntermountain Health Care•• GeisingerGeisinger Health SystemHealth System


InstitutionalInstitutionalReview BoardReview Board

FDAFDACLINICALCLINICAL RESEARCHRESEARCH

ANALYTICSANALYTICS

EXPERIMENTALEXPERIMENTAL

REG

ULA

TOR

YR

EGU

LATO

RY

BAPBiospecimens

PhysicianPhysician

PatientPatient

BiospecimensBiospecimens

Clinical NotesClinical Notes

TherapeuticsTherapeutics

BiomarkersBiomarkers

Bio

info

rmat

ics

Bio

stat

istic

s

Lab TestLab TestResultsResults

CORE LabsGene expression

GenotypesProteomics

Clinical,Clinical,Translational &Translational &Basic ScienceBasic Science• Epidemiology• Pharmacology• Oncology• Pathology• etc


Generating Knowledge in Daily Clinical SettingsGenerating Knowledge in Daily Clinical Settings

CureWellnessQualityof lifeValue

OutcomesOutcomesPatientPatientData Data

ClinicalClinical•• LabLab•• ImagingImaging•• EMREMR•• Dept. Dept.

systemssystems

BiologicalBiological((BiobankingBiobanking))

SecuritySecurity

Meta Data, Standards Meta Data, Standards and Ontologies (informatics)and Ontologies (informatics)

Data GovernanceData Governance

Integrated Integrated Database Database (Controls and (Controls and

disease states)disease states)

Data SynthesisData Synthesis

EnterpriseEnterpriseDataDataTrustTrust(EDT)(EDT)

Analytics/Analytics/ComputationComputation

PatientPatientData Data

Genetic Genetic epidemiologyepidemiology

EtiologyEtiologyProgressionProgression

Risk analysis/ Risk analysis/ preventionprevention

DiagnosisDiagnosis

TreatmentTreatmentPrognosisPrognosis

StratificationStratification& Rx planning& Rx planning

PublicPublic

ProfessionProfession

Clinical Clinical practicepractice

DLMP, MML, DLMP, MML, MVSSMVSS

Research Research grantsgrants

LicensingLicensing

ObjectivesObjectives

Dec

isio

n Su

ppor

tD

ecis

ion

Supp

ort

ResearchResearch

ClinicalClinical

EducationalEducational

BusinessBusiness


The KnowledgeThe Knowledge--Driven Health Care Driven Health Care Delivery System of the FutureDelivery System of the Future

•• PatientPatient--centered care centered care –– focus on qualityfocus on quality(best results) and coordination of care(best results) and coordination of care

•• Real time data and feedback for providersReal time data and feedback for providersat pointat point--ofof--care (horizon scanning)care (horizon scanning)

•• Culture of collaboration, innovation and Culture of collaboration, innovation and translation of scientific knowledge into translation of scientific knowledge into improved health for patients and communitiesimproved health for patients and communities

•• Health information technology (HIT) systems Health information technology (HIT) systems –– integration, standardization, interoperabilityintegration, standardization, interoperability

•• Delivery of highDelivery of high--value health care in an value health care in an informationinformation--enabled single practiceenabled single practice


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health systems as research platforms · health systems as research platforms serving patients’...

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