SURVIVAL TACTICS IN A SEA OF SALTY DATA
Data, data, every where,
Lest tumor boards should shrink;
Data, data, every where,
No time to stop to think.
—with apologies to Winslow Homer and Samuel Taylor Coleridge
Case studiesVermont Project• State-sponsored single payor initiative• Large & diverse partner group
White paper: Bloomberg Highlights Vermont Cancer Pilot; PCD Partners Plays Key HIT Role• Unique care delivery environment
White paper:Perverse Incentives, Clumsy Laws, and the Value/Volume & RVU Conundrum in Medical Quality
Tennessee Project• Large, diverse metropolitan environment• Competitive business landscape
White paper: Decreasing Complexity, Improving Care Quality, and Reducing Cost in Oncology
ContextBoth projects have similar characteristics:
– Large-scale care integration– Payment reform– Clinical improvement & innovation
And similar system requirements:– Data-driven– Process controlled– Continuous improvement
A lot to do and a lot to learn—and quickly
Tools of Industry
ISO-9001
Lean
Six-Sigma
Process maps
Value stream maps
Swim lanes
Kaizen
Ohno circle
Quality
CAPA
ISO-13485
ISO-14972
QMSClinical pathways
Rapid learning system
SOPs
Quality Clinical Care
Process and outcome metrics
Our Approach: QMS Rapid Learning
Tools of Industry Quality Clinical Care
Six-SigmaSOPsLeanOhno circleKaizenSwim lanes
Clinical pathwaysProcess andoutcome metricsCAPAQMSQualityProcess mapsValue stream maps
Rapid learning systemISO-14972ISO-13485ISO-9001Outcome metrics
Process control& efficiency
Data becomes information
RapidLearning
Our Approach: QMS Rapid Learning
Tools of Industry Quality Clinical Care
Six-SigmaSOPsLeanOhno circleKaizenSwim lanes
Clinical pathwaysProcess andoutcome metricsCAPAQMSQualityProcess mapsValue stream maps
Rapid learning systemISO-14972ISO-13485ISO-9001Outcome metrics
Process control& efficiency
Data becomes information
RapidLearningQuality Management
in Complex Systems
White paper: Medical Quality Systems: The Elusive Goal of Quality in Complex Systems
Our Approach: QMS Rapid Learning
Metrics/Quality & Process Change
Process Metrics:• Measure compliance;
almost all metrics are process metrics
Outcomes Metrics• Only viable in context of uniform processes
Who provides these? See A Taxonomy of Leading Oncology Organizations and Patient-Reported Outcomes: Choosing Appropriate Metrics From a Still-Evolving Toolset
CMS
AHRQ, NQF
ASCO, ACS CoC, ACCC, ASTRO, NCCN
Other oncology organizations
Compliance, e.g. multi-modality care planEfficiency, e.g. radiographic imaging incidence, chemotherapy protocol adherenceProcess, e.g. queuing issues, overtime
Drowning in a sea of data: necessary and sufficient?
Cheap to gather.
Large corpus.Matters to Payors and used in ranking.Doesn’t measure anything but itself.Necessary, but not sufficient for improvement.
Small corpus.Valuable only internally and in DTP marketing.
Expensive to gather.
Registries, QOPI, NCCN, Press Ganey, HCHAPS
Does it change cost? Improve process? Change outcomes?
Process/efficiency dataBest practice data
The Trick/Secret Sauce
Integrate documents and data into a single systemNovel functionality of a cloud-based relational database:
• Integrated process definition (ISO) and monitoring with flexible and defined data feeds.
• Yields ISO control and auditability in a data-driven environment; easy to show effectiveness.
• Data model exactly mimics the real world; connects the components of the SOP to the way things truly work.
E.g.: The Problem of Two WorldsRegistries & Best Practice Data Document Management & SOPs
PROs: Meets regulatory requirementsMay improve paymentAffords some comparison within industryEpidemiologically importantFits EMR data fields
CONs:Significant auditing problemsDefinitional variabilityNot process-directedLittle or no impact on outcomes
PROs: Meets regulatory requirementsMay improve paymentAffords some comparison within industryRequired for clinical trials
CONs:Significant auditing problemsDefinitional variabilityNot data-directedFeels like a straight-jacketSits alone, ignored and unloved
Are Green Lights enough?
Process A
Process B
Process C
S T A T U SP R O C E S S
Looks good!
0
20
40
60
80
100
Process A
0
20
40
60
80
100
Process A
0
20
40
60
80
100
Process A
Are problems being addressed? Improvements made?
0
50
100
Process
0
50
100
Outcomes
0
50
100
Outcomes
PROCESS CHANGE
NO CHANGE CHANGE EFFECTIVE
Data-defined process =
Auditable outcome
DASHBOARDS
ProcessData Entry
!
REPORTS
ALERTS
EMR
ProcessDef. & Target
AUDIT REPORTS
rQMS
CARE PLANCollaborative
RLS/QMS = Process Control & ImprovementRequired to make it work:
1. Define the processes & train for competent operation
2. Collect data to monitor process performance & fix issues
3. Audit processes for compliance and improvement needs
4. Improve processes as needed
5. Review the entire system and align with strategy
RLS/QMS in Action
PROCESS
A
CMO OncologyHospital Partner
Management Review
Definition: SOP
T R A I N I N G
D A T A
PROCESS
B
. . .
Monitoring
Audit
Definition: SOP
Monitoring
Audit
repeat
CMA Audit
P C D
QMS
RLS
CMO Oncology
Rapid Learning
PROCESS
A
Definition: SOP . . .
Monitoring
Audit
repeat
Management ReviewStrategic change
Improvement
Fix
M E D I C A L C A R E P A T I E N TC A P A s
P. R.O.
Framing the ProblemHistorical Care / Payment ArrangementsIncentives for More Process StepsTreatment Patterns: Fee for Service
Med Onc
Surg Onc
Rad Onc
$ $ $ $$ $ $ $$ $ $ $
Variable end pointsUncoordinated careUndocumented outcomes
System-optimized for $size and frequency Palliation
Data: chargemaster onlyRCM-optimized
Primary Care $
$
Single planIntegrated care deliveryBest-practice driven
Patient objectivesintegrated
Framing the SolutionChanges in Care Management
Patient
$ $ $Care Plan
PCPPalliationMed OncSurg OncRad OncHospice
System integrates ISO / Lean Six SigmaClinical data confirms protocol compliance
Plan Updates
$
Framing the SolutionISO-style RLS/QMS controls compliance and CAPAs
ISO-STYLE RLS/QMScontrols compliance and CAPAs
CLINICAL PATHWAYSspecify care plan
LEAN & SIX SIGMA optimize care delivery
D A
T A
S T
R E
A M
S
ReportingControl
Spec & Planning
Optimization
Outcomes
ED Off-ramp
PLANNED & EXECUTED CARE DELIVERYPatient-specific
Med Onc, Surg Onc, Rad Onc, Palliation, PCP, Other
Patient
Behind the curtain: the RLS/QMS
Rapid Learning Systemcloud-mandatory
cloud-optional
D A T A S T R E A M S
ExternalData Feeds
EMR& Chargemaster
DataWarehouse
Patient-reported Outcomes
Lean / Six Sigma
ISO-style
PathwaysRules Engine
Care PlanDesign & Implementation