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Solving the Physician Attribution Puzzle for Length of Stay

Session 61, March 6, 2018Ingrid Carlson Wurpts, PhD, Dignity HealthAngelica Chanco, MD, Dignity Health

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Ingrid C. Wurpts, PhD andAngelica Chanco, MD

Have no real or apparent conflicts of interest to report.

Conflict of Interest

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Agenda• Why is provider attribution important in improving certain hospital

metrics?• How was the Substitutable Medical Approaches and Reusable

Technology (SMART) Provider Attribution Algorithm developed?• How was SMART Provider Attribution (SPA) extended to other use

cases?• How is SPA being used in a dashboard to improve clinical

outcomes?

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Learning Objectives• List the potential problems with using the attending physician as the

attributable physician for length of stay and HCAHPS physician communication questions

• Compare attending versus the SMART provider attribution method for attributing HCAHPS physician communication and length of stay

• Explain how a visual analytics dashboard can be used to monitor and improve patient outcomes such as length of stay

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Dignity Health: Who Are We?

682kPatient days

licensed beds

38Hospitals

5th LARGESTNon-Profit Health Care System in the nation

8.3k

Ingrid C. Wurpts, PhDData Scientist

Angelica Chanco, MDClinical Analyst

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Provider Attribution1. Link between encounter-level healthcare

metric and responsible provider2. Necessary for targeted interventions to

improve physician communication, etc.3. Previous approach: Attribution given to

attending at discharge physician4. Challenge: The attending at discharge

may not have had any significant involvement in the patient’s care

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Why Address Provider Attribution at Dignity?

• Goal: Improve HCHAPS physician communication scores across the enterprise

• Previous interventions targeted attending physicians– “I barely saw that patient!”

• How could we use data to improve attribution?• Critical Success Factor: Collaborative effort between Medical

Informatics and Data Science team and Care Management team

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SMART Provider Attribution Algorithm1. We developed a statistical algorithm that uses clinical

documentation to determine provider attribution more accurately than using attending physician

2. All physicians on a patient’s chart receive an attribution rank

3. Attribution can include non-physician providers (PA, NP, CNM) if desired

4. Algorithm has been validated for two use cases:

• HCAHPS physician communication

• Length of Stay (LOS)

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SPA Algorithm Development• Algorithm development

• Gold standard data set: clinical abstractors rated which provider(s) were most responsible for communication with the patient across 100 encounters

• Data mining techniques used to determine which clinical engagement variables (e.g., med orders, surgery notes) in the patient’s chart could predict the abstractor’s top rated provider(s) most closely

• Final algorithm• SPA is a weighted sum of specific data fields from each patient’s chart.• Each provider is given a score, and provider with top score within each

patient’s chart is given attribution.

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SPA vs. Attending Comparison• Attending at discharge physician:

• PPV* = 65/100 = 65% is the probability that attending at discharge physicians were identified as primarily responsible for communication by the abstractors. 95% CI [55%, 74%]

• SMART Provider Attribution Algorithm:

• PPV = 89/100 = 89% is the probability that physicians identified as primary by SPA were identified as primarily responsible for communication by the abstractors. 95% CI [82%, 95%]

*Positive Predictive Value (PPV)

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SPA vs. Attending Comparison• Med cases only:Algorithm PPV = 60/68 = 90% [80%, 96%]Attending PPV = 44/68 = 65% [52%, 76%]

• OB cases only:Algorithm PPV = 20/22 = 91% [71%, 99%]Attending PPV = 11/22 = 50% [28%, 72%]

• Surgical cases only:Algorithm PPV = 9/10 = 90% [56%, 100%]Attending PPV = 10/10 = 100%

• Originally interested in medical service line.

• Extended to OB and surgical to have continuity across our adult service lines

• SPA provides more accurate attribution than attending especially for medical and OB patients.

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Extending SPA to Another Use Case• SPA was implemented into our data ecosystem• Care management leaders receive a monthly report of average

physician communication scores, attributed by our SPA algorithm• Data consumers were interested in using SPA for other encounter-

level metrics, like length of stay (LOS)• Is the provider primarily responsible for communication also

primarily responsible for LOS?• Collected gold standard data on LOS attribution

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Using SPA for Length of Stay• Attending at discharge physician:

• PPV = 27/48 = 56% is the probability that attending at discharge physicians were identified as primarily responsible for communication by the abstractors. 95% CI [41%, 71%]

• SMART Provider Attribution Algorithm:

• PPV = 37/48 = 77% is the probability that physicians identified as primary by SPA were identified as primarily responsible for communication by the abstractors. 95% CI [62%, 88%]

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Why is it important for Dignity Health?

682kPatient days

licensed beds

38Hospitals

5th LARGESTNon-Profit Health Care System in the nation

8.3k

Even a 1% reduction in unnecessary LOS days can

yield big results:

$17.5MCost savings

$2,571 = an average estimate of expenses incurred by the hospital to provide a day of inpatient care in CA, NV, AZ hospitals

1999 - 2015 AHA Annual Survey, Copyright 2016 by Health Forum, LLC, an affiliate of the American Hospital Association.

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SMART Provider Attribution Dashboard

SPA Algorithm Refresh Rate: Daily

Admission / Discharge / Transfer systems

Electronic Medical Records Financial Analytics & Dignity Health tables

CMS tables

Hadoop

Dashboard

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Dashboard data• Focus on opportunity

– Days variance to GMLOS by Payor

– Top 10 providers over GMLOS (days and patients)

– Top 10 MS-DRGs over GMLOS (days and patients)

– Top 10 Service Lines over GMLOS (days and patients)

• Encounter level information displayed

– Patient demographics, payer and provider information

* GMLOS – Geometric Mean Length of Stay

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Dashboard data (continued)• Trending

– Days over GMLOS by facility– Provider days and patients above GMLOS

• User customizable cohorts for data discovery– Filter, sort, export data within dashboard– Save searches

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App Prototype

Testing

Feb 2017

PilotJune 2017

Enterprise Rollout

July 2017

Completion of Rollout

Feb 2018

SPA Dashboard Development & Rollout

• Rapid development• In-house development team

• Rapid rollout• 1 region every 2-3 weeks (except holidays)

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35 Facilities completed

220kEncounters

SPA Dashboard Development and Rollout (continued)

USERS:• Hospital Administration• Care Coordination• Hospitalist Groups Leaders• Analysts

• Encounters with days over GMLOS • Data from 10/2015 onwards

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Action Opportunities• Clinical Practice Optimization• Length of Stay Committees• Hospitalist Groups• Physician Outlier meetings

– Utilization Management– Sepsis Initiative

• Data for monitoring and trending– Trend LOS for Implemented Initiatives

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Sample Cases• Case 1

– Dr. Smith: high % of patients over LOS– Workflow review reveals improvement opportunities upon coordination with care

team• Case 2

– Sepsis (DRG 871) major contributor to LOS opportunity days– Initiative to improve sepsis bundle compliance

• Case 3– Consistently excellent performance in Joint Replacement (DRG 470) Ortho

service lines– Best practices dissemination to other service areas

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SPA AppSPA App User

Launch

Measure

Maintain

Launch

Iterative SPA & Targeted Intervention Improvement Model

Discover Design Develop Deliver

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Implementation Takeaways

Challenge Solution

Dirty source data• Work with source systems• “Data in, data out”; internal cleansing

Increasing adoption of SPA application

• Ensure facility sponsors are engaged• Education and training

Applying information gleaned from SPA

• Cultivate system best practices

Refining algorithm • Collecting data; scheduled for refinement 2018

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SummarySPA helps solve the physician attribution puzzle• Identified limitations of using the attending physician as the attributable

physician for length of stay and HCAHPS physician communication questions

• Shared Dignity Health experience on how this insight led to actionable initiatives:

– Compared attending versus the SMART provider attribution method for attributing HCAHPS physician communication and length of stay

– Developed a visual analytics dashboard currently used to monitor and improve patient outcomes such as length of stay

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Summary (continued)• Provider attribution is necessary for targeted improvement of

patient-level outcomes, but previous attribution methods were insufficient

• We used data mining to develop a new attribution method (SPA)• SPA performed better than the previous method for both physician

communication and LOS use cases• Rapid paper-to-production deployment is possible with dedicated

resources, a clear directive, and user base support• Improvement is an iterative process – it is important to measure and

monitor, then design and implement changes

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Questions• Ingrid.Wurpts@dignityhealth.org• Mel.Chanco@dignityhealth.org

• We welcome feedback! Please complete the online session evaluation