What does it look like to leverage data and IT at a very deep level and help to rework core clinical processes in order to improve clinical performance and patient outcomes and rethink costs? The leaders at Allina Health know, because they’re doing it. And they’re doing it particularly intensively in the cardiovascular services arena, where they have made groundbreaking progress in a number of areas, with documented results to show for it. For their pioneering work, the editors of Healthcare Informatics have named the Allina Health team the first place-winning team in our Innovator Awards Program this year.
At the highest level, says Penny Wheeler, M.D., the president and CEO of the 13-hospital, 61-clinic integrated health network in Minneapolis, “We at Allina are very much focused on how we create value for the individuals and the community we serve—which means the best outcomes in terms of quality, access, and experience, over dollars spent. That’s what value means. And when that’s your goal, you start to think about what kind of infrastructure you need to support it,” says Wheeler, who spent 22 years as a practicing obstetrician/gynecologist. Speaking of the data and IT infrastructure at Allina, as well as of the clinical leadership situation prior to the launching of the organization’s current initiatives, she says, “What we didn’t have was the right latticework to support certain things. Yes, we had Epic, and could connect that way, but couldn’t pull in all the information needed, nor did we have the clinical expertise next to that data, and the authority needed to drive us forward. So we built the right infrastructure to support this, and we had the right physician leadership to drive this, and we gave them the right authority to get it done.”
What “it” is, is a complex set of innovations focused initially on the cardiovascular services area (and which is now spreading to other areas in the organization). And it began when Allina leaders established the Minneapolis Heart Institute Center for Healthcare Delivery Innovation (MHI-HDI), to leverage existing data and analytics resources within the organization, including an enterprise data warehouse (EDW), developed by Salt Lake City-based Health Catalyst, with those resources being applied to cardiovascular care delivery under the aegis of the MHI-HDI.
A large number of initiatives are evolving forward under that umbrella. Among those that have documented dramatic improvements in outcomes of all kinds has been around the procedure known as percutaneous coronary intervention, or PCI, also commonly known as coronary angioplasty, a procedure used to open up blocked or narrowed arteries, during which a cardiologist feeds a deflated balloon or other device on a catheter from the inguinal femoral artery or radial artery up through blood vessels until they reach the site of blockage in the heart. There was a set of issues around PCI that Allina clinician leaders wanted to look at, to improve outcomes and also examine costs. That team was led by Craig Strauss, M.D., M.P.H., cardiologist and the medical director of the MHI-HDI, and Pam Rush, R.N., M.S., clinical program director of the Allina Health cardiovascular service line.
As Dr. Strauss notes, “The first step in improving outcomes is getting reliable data from across the system, and that was a big first step.” The next step, he continues, is “sharing that data, and bringing it together in an effective way, through our data warehouse.” And then following up on that step, the team found that it needed to create “the ability to develop condition-specific dashboards," he adds. “So we linked all of our cost and clinical record data, and our registry data—we have national registry data on PCI cases, because every PCI case is submitted to a national registry—and we put all that into a dashboard in our EDW, to allow us to look at and risk-stratify patients.” Indeed, data already existed in the cardiovascular literature suggesting that it was possible to risk-stratify patients coming into the cardiac cath lab, by three levels of risk—high, medium, or low. So Strauss, Rush, and their colleagues set about developing a questionnaire for each interventional cardiologist to complete about each patient about to receive PCI. As Strauss recounts it, “We brought all the interventional cardiologists together to develop a consensus approach to managing PCI complications, especially around bleeding.” And Rush adds, “Filling out the questionnaire requires the participation of the entire staff. When you implement a scoring tool like this and you’re counting on nurses to enter the data, it requires the whole team.”
Specifically, the clinicians looked at the use of what is called a closure device, which, as Strauss explains, “closes the hole made by the catheter when it goes into the femoral artery in the leg. We looked retrospectively to see for high, medium, and low risk patients, where the benefit was. And with closure devices, we found that the outcomes around bleeding complications did not different significantly among patients identified as being at low or medium risk for complications, in terms of whether the cardiologists used the closure device in their procedure or not; but for those determined to be high risk according to the scoring tool, there was a significant difference. Among the high-risk patients, bleeding within 72 hours occurred at a rate of 8 percent for those with no closure device, but only 3 percent if a closure device was used. What’s more, the red blood cell transfusion rate averaged 12.6 for those high-risk patients who had gone through the procedure without the use of a closure device, but only 5.9 for those whose cardiologists had used the device.”
Yet when Strauss, Rush, and their colleagues analyzed the data for the use of the device, they found that there was no correlation between frequency of use of the device in PCI by cardiologists and levels of risk of the patients undergoing the procedure; in other words, physicians were approaching the question on an individual and unexamined basis. “Leveraging the EDW and the dashboard,” Strauss says, “we showed them a graph documenting the variation across all the interventional cardiologists. One was using closure devices for 70 percent of his high-risk cases, while others were at 3 or 5 percent, with the average use at about 29 percent. So we showed them the data and the value of the use of the device for high-risk patients versus for patients at low or medium levels of risk, and got them to use the calculator to risk-stratify everybody, and to agree to use the closure devices more for high and less for low and medium. And now the use of closure devices among high-risk patients has reached 80 percent for high-risk patients—which is what we wanted to have happen.”
Strauss and Rush agree that this PCI case study demonstrates that, when presented with data that is evidence- and/or consensus-based, and that they feel they can trust, physicians will do the right thing for their patients, which in this case has had the result both of improving outcomes and lowering costs per case, which is something that these leaders agree is so often the case. What’s more, Rush says, “The other thing about this is keeping the data constantly in front of them and in front of the team. When we first rolled this out, we were sending them weekly data on how often they were using closure devices, and they could graph their usage of the calculator.” Once they received the data on a very regular basis, she notes, the interventional cardiologists changed their practice patterns to conform to the evidence-based guideline.
Above all, Strauss and Rush agree that it is essential to go through continuous cycles of concepting the gathering of data, gathering the data, analyzing the data, sharing it with physicians and nurses, supporting clinicians in changing their practice patterns, and then cycling back into analyzing the data that comes out of changes in practice, in order to achieve improvements. That, they agree, really is at the heart of the ongoing process of clinical transformation in care delivery. Importantly, Rush says, “It sounds very simple to explain what’s been done” in the PCI case. “But when you come to the point of operationalizing it, the devil really is in the details. For example, where were they going to document the bleeding risk score? So we had to create a field for them to add that data; then we had to create a place for that data in the EDW, and figure out a way to easily collect the data and analyze and report that information back out. And all of those are steps.” She and Strauss agree that what might be called a “high-tech, high-touch” approach—with great collaboration between and among clinician leaders, front-line clinicians and clinician champions, clinical informaticists, and IT managers—is absolutely essential to the success of these kinds of clinical transformation efforts.
“I would say that, to be successful, you need to have three components,” Strauss summarizes. “You need to have accurate data and access to the data; you need physician leadership to identify and drive opportunities for change; and you need broad participation from the entire practice and from the entire care team—in the cath lab, it’s everybody participating in the care of the patient—to be able to operationalize the changes.”
What will happen in the next two years, with regard to these programs? “As we move to models that put us more on the hook for the outcomes of the people and communities we serve, these programs will continue to expand, on a very solid foundation,” CEO Wheeler says. “We’d like to tap Craig Strauss and Pam Rush times 15,” she adds. “So we’ll just keep building; we’ve got 42 [clinical transformation] programs across different service lines, so we’ll just continue that expansion. And we hope to get more rewards for it,” from area payers.
