Decision Support & Business Intelligence. The Next Generation. Derek Morkel, CEO GAFFEY Healthcare

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1 Decision Support & Business Intelligence The Next Generation Derek Morkel, CEO GAFFEY Healthcare Measurement is the core of any process "An acre of performance is worth a whole world of promise." - William Dean Howells "Don't rate potential over performance." -Jim Fassel "Goal setting has traditionally been based on past performance. This practice has tended to perpetuate the sins of the past." -Joseph M. Juran "If you can't describe what you are doing as a process, you don't know what you are doing. - W. Edwards Deming "In God we trust, all others bring data." -W. Edwards Deming 1

2 Establishing a culture of measurement 1. What is Business Intelligence? Business Intelligence is the process of transforming all of the raw data that companies (hospitals) collect from their various operations into actionable information. 3 Why the current state has to change CMS Projections for National Healthcare Spending (Amount in Billions) CY $5, % $4,500 $4,353 $4,000 $3,500 $3,000 $2,500 $2,000 $4,062 National Health Expenditures (billions) $3, % 19.8% $3,541 National Health Expenditures as a Percent of Gross Domestic Product $3, % $3,111 $2, % $2, % $2,624 $2, % 18.0% $2,379 $2, % 17.7% $2,113 $1,981 $1,855 $1, % 20.0% 19.0% 18.0% $1, % 17.0% 16.2% $1, % 15.9% 15.9% 16.0% 16.0% $500 $ % Source: Centers for Medicaid & Medicare Services - NHE Projections , Forecast Summary and Selected Tables 2

3 The growth in healthcare spending, combined with healthcare drivers will continue to have major impacts IBM presentation Healthcare 2015 Drivers Globalization Impacts Continued shift from employer-based insurance Consumerism Changing demographics and lifestyles Diseases that are expensive to treat New technologies and treatments Increasing focus on value Increase in consumer responsibility New approaches to promoting health and delivering care Growing resource challenges Data & Reimbursement Landscape Old/Current $ $ 4 Community Dataflow stops at Point 2 $ $

4 Data/Reimbursement Landscape Future Physician Community Hospital $ s & data shared in closed loop Nursing Home Tertiary Care Hospital 7 Current State Data - Fragmented Lab System OR System ED System Pharmacy System Registration System Hard Copy Medical Records Micro Results Hematology Chemistry Results Peri Op Documentation OR Med Admin Time ED Admit Time ED DC Time Medication Name Dispense Order MRN Name ICD 9/10 4

5 Examples Healthcare Data Sources EMR Clinical Data Patient Accounting Physician Practice Management Risk Management Insurance Plan Data Home Health ACO participation PCMH Patient Generated Data Cost Accounting 9 Current Decision Support Model Hospital focused Product Line/DRG/Physician alignment Profitability core calculation Stand alone system & database Complex costing models Monthly calculation Standard reporting packages LESS THAN 50% HOSPITALS DOING THIS 10 5

6 Why New Model Necessary Need to know costs for all aspects of care continuum Without detailed & on demand cost information facilities disadvantage to others Focus on patient away from Facility/PL/DRG Data models allow hospitals function with same capability as insurance company Close the information gap Ability/Flexibility to track & model probability Multitude of data requests/interactions One Month, One Week or even One Day too late 11 New Decision Support Model Patient Focused Focused on cost & clinical efficiency managing high risk patients Equal or better access to data vs. your partners Must include all areas continuum that responsibility for or is included in risk sharing models Real time data critical All activities costed hospital, physician, PCMNH Control own data build/maintain Data Warehouse 12 6

7 Relational Database Basics A relational database is a databasethat has a collection of tablesof data items, all of which is formally described and organized according to the relational model. Data in a single table represents a relation, from which the name of the database type comes. In typical solutions, tables may have additionally defined relationships with each other. In the relational model, each table schemamust identify a column or group of columns, called the primary key, to uniquely identify each row. A relationship can then be established between each row in the table and a row in another table by creating a foreign key, a column or group of columns in one table that points to the primary keyof another table. The relational model offers various levels of refinement of table organization and reorganization called database normalization. (See Normalizationbelow.) The database management system(dbms) of a relational database is called an RDBMS, and is the software of a relational database. 13 Relational Database Basics Primary Key = Unique Identifier Patient ID # Medical Record # SSN# Physician ID Any data store that contains one or more of these elements can be tied to any other data with same elements 14 7

8 The Future of Decision Support Provide Access Transform Data to Information Administrators Developers & Executives CLINICAL IMPROVEMENT Quality Quality Real Time Compliance Compliance Quality Reporting Chronic Medication Chronic Medication Disease Safety Patient Disease High Cost Safety Monitoring Adherence Management Patients Monitoring Dashboard Physicians & Patient Clinicians OPERATIONS EFFICIENCY Electronic Electronic Claims Disease Claims Attachments Registries Attachments (Diabetes) Real-time Real-time Claims Claims Operations Adjudication Adjudication KPI Dashboard Consumer Consumer On Line On Payments Patient Line and Payments and Scheduling Throughput Analytics Aggregate and Integrate Data Enterprise Data Warehouse Generate and Acquire Data Inpatient EMR Pharmacy Med Mgmt Diagnostic Imaging Lab Revenue Cycle Emergency Clinical and Business Transactional Systems Ambulatory Surgery Mgmt Optimize Infrastructure Infrastructure and IT Processes Example What is economic impact of slips & falls? Data Sources Risk management/incident reporting system Patient Accounting data Charges, Payments, Adjustments, Net Revenue Demographics Age, Payor, LOS etc. Cost Accounting Direct Costing by Patient PA Data Demographic Data Cost Accounting Direct Margin RM System DW - Patient ID, Unique ID Output Comparison DM with & w/o falls 16 8

9 Simple Query Example Knee Replacement 2012 ICD-9-CM Diagnosis Code V43.65 Knee joint replacement Short description: Joint replaced knee. ICD-9-CM V43.65 is a billable medical code that can be used to specify a diagnosis on a reimbursement claim. Query Any Variation in Data = Error [Either Charge or Procedure] DESCRIPTI ON Pat ID DOS ICD 9 Proc. Description Rev Code Implant Est Charge Actual Chg S /1/2014 V43.65 Knee Joint Replacement 278 $ 9, $ 9, SOURCE CHG/DEMO CHG/DEMO PROCEDURE/DIAGNOSIS PROCEDURE/DIAGNOSIS CHG DETAIL CUSTOM CALC. CHG DETAIL [COST* MARKUP] 17 Simple Query Example ER Levels 9

10 Simple Query Example AR Analysis Report What are my next steps? What do you want/need to measure Top 5/10 daily priorities Map out data needs for each priority Where data located What is status of Data Warehouse Analytical Tools Owner/Executive Sponsor 20 10