Integrated Medical Analytics. Matt Modleski & Brad Brimhall Orchard Software Corporation June 22-23, 2016

Transcription

1 Integrated Medical Analytics Matt Modleski & Brad Brimhall Orchard Software Corporation June 22-23, 2016

2 Learning Objectives Explain advantages of integrating external sources of data Identify knowledge and skills required for successful analytics teams Cite examples of employing analytical skills and knowledge to add value to healthcare organizations

3 Integrating Data/Knowledge/Skills

4 Analyzing a Test

5 Integrating Tests

6 Integrating Laboratory Sections

7 Integrating Outside the Laboratory

8 Translating Outside the Laboratory

9 Database & Laboratory Operations Laboratory Test Data Middleware HTML Operational & Medical Report Data Warehouse Hospital Administrative Data Direct SQL Query Document Statistical Analysis Research & Trend Analysis Reports

10 Laboratory Data Warehouse

11 Laboratory Data Warehouse Realized Cost Savings (2005)* Annual savings $746,200 Pct of total laboratory costs 4.5% Profitability (actual figures )* Payback period (actual) 1.47 y NPV $2,968,639 MIRR 59.4% Still being used today! Phil Boyer, MD, PhD (3/14) *Brimhall BB, Hall TE, & Walczak S. AMIA Annu Symp Proc 2006:865

12 Improving Pathology Reviews

13 Patient Example: CBC WBC 7.0 [ K/mL] RBC 4.61 [ M/mL] HGB 10.2 L [ g/dl] HCT 31.9 L [ %] RDW 17.9 H [ %] PLT 496 H [ K/mL]

14 Patient Example: Peripheral Smear

15 Patient Example: CBC WBC 7.0 [ K/mL] RBC 4.61 [ M/mL] HGB 10.2 L [ g/dl] HCT 31.9 L [ %] RDW 17.9 H [ %] PLT 496 H [ K/mL] MCV 69.2 L [ fl] MCH 22.1 L [ pg] MCHC 32.0 [ g/dl] Vitamin B [ pg/ml] Serum folate 12.2 [>6.0 ng/ml]

16 Simple Anemia Flowchart Anemia MCV Low Microcytic Iron studies Hemoglobin EP (if iron studies are normal) Normal Normocytic Reticulocyte Count High Macrocytic Serum vitamin B12 Serum folate RBC folate

17 Cost of Unnecessary Anemia Tests Tests Concurrent with CBC Having Low MCV (± Anemia) Test Volume Vbl Cost + Labor Total Cost Vitamin B $938 $2,070 $3,121 Serum folate 426 $677 $1,572 $2,381 RBC folate 70 $143 $290 $426 TOTAL 1,035 $1,758 $3,932 $5,928 Tests Concurrent with CBC Having High MCV (± Anemia) Test Volume Vbl Cost + Labor Total Cost Ferritin 1,112 $1,835 $4,170 $6,338 Iron Saturation 1,286 $1,340 $5,843 $9,735 Hgb A2 200 $798 $5,838 $6,322 TOTAL 2,598 $3,973 $15,851 $22,395

18 Approving a New Purchase

19 Current Approach Fast, inexpensive, limited Slow, expensive, accurate

20 MALDI Project Version 1 MALDI-TOF / Vitek profitability analysis Year Item t = Total Cost of Instrument ($312,387) $0 $0 $0 $0 $0 ($312,387) Service contract $0 $0 ($19,178) ($19,178) ($19,178) ($19,178) ($76,710) Cost savings from reagents $0 $33,408 $33,408 $33,408 $33,408 $33,408 $167,040 Sum of cash flows ($312,387) $33,408 $14,230 $14,230 $14,230 $14,230 ($222,058) PV Cash Flows ($312,387) $33,408 $13,553 $12,907 $12,293 $11,707 ($228,519) FV Reinvested +ve Cash Flows $36,162 $14,382 $13,429 $12,539 $11,707 $88,219 Payback period Payback period (years) Payback period (months) Payback period (weeks) 1, Modified internal rate of return Discount rate 5% Reinvestment rate 2% MIRR % Net present value Discount rate 5% Project NPV ($228,519)

21 Medical Literature Reduced Time to Bacterial Identification Mean reduction = 34.3 hours Lagace-Wiens PRS, Adam HJ, & Karlowski JA, et al. J Clin Microbiol 2012;50: [University of Manitoba, Winnipeg, MB] Mean reduction = 1.45 days (34.8 hours) Tan KE, Ellis B, & Lee R, et al. J Clin Microbiol 2012;50: [Johns Hopkins University, Baltimore, MD] Mean reduction = 28.8 hours Vlek ALM, Bonten MJM, & Boel CHE. PLoS ONE 2012;7:e32589 [Univ. Medical Center, Utrecht, NL] Implications for Patient Care Reduced time to appropriate therapy: 28.8% of patients (treating physician), 44.6% of patients (stewardship team) Tamma PD, Tan K, & Nussenblatt VR, et al. Infect Control Hosp Epidemiol 2013;34: [Johns Hopkins University, Baltimore, MD] Increase in proportion of patients receiving appropriate treatment at 24 hours: 11.3% Vlek ALM, Bonten MJM, & Boel CHE. PLoS ONE 2012;7:e32589 [Univ. Medical Center, Utrecht, NL] Percent with modification of empirical therapy: 35.1% Clerc O, Prod hom G, & Vogne C, et al. Clin Infect Dis 2013;56: [Univ. of Lausanne, Lausanne, CH]

22 Downstream Financial Analysis MSDRG Interpretation 870 Septicemia w/ MV (96+ h) 871 Septicemia w/o MV (96+ h) w/ MCC 872 Septicemia w/o MV (96+ h) w/o MCC Annual Admissions Patients LOS>=2d 710 Mean LOS (d) 7.49 Inpatient Costs for Sepsis Patients Variable Cost Total Cost Total $7,826,845 $10,784,850 Per Hospitalization $11,024 $15,190 Per Hospital Day $1,472 $2,028

23 MALDI Project Version 2 MALDI-TOF / Vitek profitability analysis Year Item t = Total Cost of Instrument ($312,387) $0 $0 $0 $0 $0 ($312,387) Service contract $0 $0 ($19,178) ($19,178) ($19,178) ($19,178) ($76,710) Cost savings from reagents $0 $33,408 $33,408 $33,408 $33,408 $33,408 $167,040 *Cost savings from early d/c $0 $1,253,967 $1,253,967 $1,253,967 $1,253,967 $1,253,967 $6,269,836 Sum of cash flows ($312,387) $1,287,375 $1,268,198 $1,268,198 $1,268,198 $1,268,198 $6,047,778 PV Cash Flows ($312,387) $1,287,375 $1,207,807 $1,150,293 $1,095,517 $1,043,349 $5,471,954 FV Reinvested +ve Cash Flows $1,393,496 $1,281,735 $1,196,764 $1,117,427 $1,043,349 $6,032,772 Payback period Payback period (years) 0.24 Payback period (months) 2.91 Payback period (weeks) Modified internal rate of return Discount rate 5% Reinvestment rate 2% MIRR 80.79% Net present value Discount rate 5% Project NPV $5,471,954

24 MALDI Project Sensitivity Analysis Project Payback Period (y) hours to get payback of 2 years Decrease in Mean LOS (h)

25 Saving the Blood Donor Center

26 Donor Center: Blood Products RBC FFP SDPLT TOTAL Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

27 Donor Center: Net Savings $70, $60, $50, $40, $30, $20, $10, $0.00 ($10,000.00) Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

28 Saving the Blood Donor Center Contribution Analysis: Summary (Calendar Year 2014) Whole Blood Platelet Total Percent Outside Cost $1,690,775 $678,780 $2,369, % Less Consumables $233,244 $233,808 $467, % Less Testing $333,188 $43,593 $376, % Less Supplies $8,554 $1,119 $9, % Less Incentives $93,390 $12,219 $105, % Contribution to Labor $1,022,399 $388,041 $1,410, % Less Labor $352,642 $62,231 $414, % Less Recruiting $92,604 $16,342 $108, % Contribution to Local Fx $577,153 $309,468 $886, % Regulatory Costs $3,698 $653 $4, % Common Supplies $5,863 $1,035 $6, % Equipment Costs $229,311 $40,466 $269, % Contribution to Overhead $338,280 $267,315 $605, %

29 Saving the Blood Donor Center Contribution Analysis: Summary (Sept Aug 2015) Whole Blood Platelet Total Percent Outside Cost $1,579,425 $579,960 $2,159, % Less Consumables $218,632 $199,769 $418, % Less Testing $312,380 $37,246 $349, % Less Supplies $8,020 $956 $8, % Less Incentives $87,557 $10,440 $97, % Contribution to Labor $952,835 $331,549 $1,284, % Less Labor $352,642 $62,231 $414, % Less Recruiting $92,604 $16,342 $108, % Contribution to Local Fx $507,589 $252,976 $760, % Regulatory Costs $3,698 $653 $4, % Common Supplies $5,863 $1,035 $6, % Equipment Costs $229,311 $40,466 $269, % Contribution to Overhead $268,716 $210,822 $479, %

30 Blood Donor Center: New Growth

31 Donor Center: Blood Products RBC FFP SDPLT TOTAL Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

32 Donor Center: Net Savings 2 $80, $70, $60, $50, $40, $30, $20, $10, $0.00 ($10,000.00) ($20,000.00) Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

33 Granulocyte Transfusions

34 Initial Questions Why is our hospital using >330 times more granulocyte transfusions than a comparable tertiary care hospital in Boston? Why is our hospital using more than 95% of all granulocytes in the city? Granulocytes = $1,575 per unit (local blood center)

35 Literature Review Transfusion, Blood N = 33,262 Granulocyte* N = 13,292 N = 606 N = 427 Limit to Human N = 100 Additional Searching 1. Other permutations of search parameters 2. Apply search to other data bases 3. Pull references from articles (reverse searching) 4. Forward searching in Web of Science 5. Other terms (e.g., neutrophils, aspergillus, etc.) Fungal Infection N = 8,322

36 Systematic Review Schiffer et al. (1979) Mannoni et al. (1979) Strauss et al. (1981) Sutton et al. (1982) Ford et al. (1982) Gomez-Vilagran et al. (1978) Clift et al. (1978) Winston et al. (1982) ln (OR of infection after tx) Similar limitations in study by Klein, Strauss, and Schiffer (1996). Vamvakas & Pineda. J Clin Apheresis 1997;12:74-81

37 Next Steps Restrict granulocyte transfusions to neonates with resistant fungal infections until better evidence is provided Annual savings to hospital: $261,450

38 Heparin-induced Thrombocytopenia (HIT)

39 Expensive Anticoagulant Use HIT Test Ordered Heparin Other Anticoagulant

40 Pre-test Probability: 4T s Score Category 2 Points 1 Point 0 Points Thrombocytopenia Plt fall >50% AND plt nadir 20K/uL Plt fall 30%-50% AND plt nadir 10K-20K/uL Plt fall <30% AND plt nadir 10K/uL Timing of platelet count fall Clear onset fall 5-10 d OR plt fall 1 day IF heparin exposure within previous 30d Consistent with fall 5-10d but not clear (e.g., missing data) OR onset after 10d OR fall 1d (previous heparin exposure prior d) Platelet fall <5d without recent heparin exposure Thrombosis or other sequelae New thrombosis (confirmed) OR skin necrosis at heparin injection sites OR acute systemic reaction after heparin bolus Progressive or recurrent thrombosis OR non-necrotizing skin lesions OR suspected thrombosis (not proven) None Other causes of thrombocytopenia None apparent Possible Definite Adapted from: Cuker A. Semin Thromb Hemost 2014;40:

41 EMR Alert to Calculate 4T s Score

42 Changes Over Time Change HIT Tests Test Vbl Cost $26,320 $7,872 ($18,448) Drug Vbl Cost $313,964 $93,909 ($220,055)

43 Improving Radiology Workflow

44 Primary Data Sources Combined Data

45 Post Hoc Project Analysis POCT Launch 6/17/13 Before: 12/1/12-5/31/13 After: 7/1/13-12/31/13

46 Results Decreased wait times for patients: cut down on our wait time to almost no wait for labs on ER and outpatients. [Chief MRI Technologist] Fewer canceled studies after patient arrival (Pre = 17.7/month, post = 2.6/month)

47 Chief of Medical Staff Just now thinning down my pile of to do stuff; sorry it has taken a few days to get back with you. Needless to say, I was very impressed with what [the lab has] been able to accomplish as it relates to data analytics, especially since the message I ve been receiving is that we can t do anything like this because the data is a mess.

48 Where did we learn these skills?

49 Orchard School of Medical Analytics Covers key subjects to help laboratory leaders more effectively lead teams in the laboratory and outside the laboratory to benefit healthcare organizations and patient populations. Prepare laboratory leaders to pounce on opportunities to demonstrate value, starting in the laboratory and expanding from there. Enable laboratory leaders to more effectively communicate and work with others in the healthcare system having different skill sets.

50 Analytics in My Lab? Can my lab also start developing and deploying analytical work? Dr. Thomas Novicki will speak tomorrow about findings and new projects at the Marshfield Clinic.

51 Questions? Thank you!