Using PHIS to Prioritize and Evaluate Performance to Drive Improvement Rustin Morse, MD, MMM; Children s Health System of Texas Matt Hall, PhD; Children s Hospital Association Wednesday, March 22, 2017; 9:30 am 10:30 am
Learning Objectives Develop an understanding of PHIS and its capabilities for QI Learn examples of how PHIS can be used to help drive improvement
Checking In Who are you? Physician Hospital executive Quality Department leader or staff Current PHIS experience? Never logged in and run a report Write your own reports within PHIS Receive PHIS data from someone else What is PHIS??
Agenda What is PHIS? Identifying improvement opportunities with standard reports Going beyond standard reports
What is PHIS?
What Data are in PHIS? PHIS By The Numbers (Since 2004) Participating Hospitals: 49 Inpatient Cases: 6.4 million Inpatient Days: 39.2 million ED encounters: 27.1 million Total Charges: $423.3 billion Total ICD-Codes: 129.9 million INPATIENT EMERGENCY DEPT. Medical Record System PHIS AMBULATORY SURGERY OBSERVATION STATUS Billing System Over 125 data items submitted by hospitals for each patient. No manual data entry!
PHIS Participating Hospitals Akron - Children s Hospital Medical Center of Akron Ann Arbor C.S. Mott Children s Hospital Atlanta - Children s Healthcare of Atlanta Austin Dell Children s Medical Center of Central Texas Birmingham - Children s of Alabama Boston Boston Children s Hospital Buffalo - Children s Hospital of Buffalo Chicago Lurie Children s Hospital of Chicago Cincinnati - Children s Hospital Medical Center Cleveland UH Rainbow Babies & Children s Hospital Columbus - Children s Hospital Corpus Christi - Driscoll Children s Hospital Dallas - Children s Health Children s Medical Center of Dallas Denver - The Children s Hospital Fresno / Madera Valley Children s Hospital Ft. Worth - Cook Children s Medical Center Hartford - Connecticut Children s Medical Center Houston - Texas Children s Hospital Houston - Children's Memorial Hermann Hospital Indianapolis - Riley Hospital for Children at Indiana University Health Kansas City - Children s Mercy Hospitals & Clinics Knoxville - East Tennessee Children s Hospital Little Rock - Arkansas Children s Hospital Long Beach Miller Children s and Women s Hospital Long Beach Los Angeles - Children s Hospital Los Angeles Louisville Kosair Children s Hospital Memphis - Le Bonheur Children s Medical Center Miami - Miami Children s Hospital Milwaukee - Children s Hospital of Wisconsin Minneapolis - Children s Hospitals and Clinics Nashville - Vanderbilt Children s Hospital New Haven - Yale New Haven Children s Hospital New Orleans - Children s Hospital New York - New York Presbyterian-Morgan Stanley Children s Hospital Norfolk - Children s Hospital of The King s Daughters Oakland - UCSF Benioff Children s Hospital Oakland Omaha - Children s Hospital and Medical Center Orange - Children s Hospital of Orange County Palo Alto - Lucile Packard Children s Hospitals Philadelphia - The Children s Hospital of Philadelphia Phoenix - Phoenix Children s Hospital Pittsburgh - Children s Hospital of Pittsburgh Salt Lake City - Primary Children s Hospital San Antonio Children s Hospital of San Antonio San Diego - Children s Hospital and Health Center Seattle Seattle Children s Hospital St. Petersburg - All Children s Hospital Johns Hopkins Medicine St. Louis - St. Louis Children s Hospital Washington D.C. - Children s National Medical Center
What s Collected on Each Patient Encounter Patient Abstract Billed Transaction/ Utilization Data Patient Abstract Pharmacy Imaging / Radiology Diagnoses (ICD-9/10) Procedures (ICD-9/10) PATIENT ENCOUNTER Lab Supplies Clinical Other - Room/Nursing - Surgical Svcs - Other Misc. Hospital ID Patient ID Dates/LOS Age, Bw, Gest Age Principal Diagnosis Principal Procedure Disposition APR-DRG MS-DRG Key Physicians Payer
Patient Abstract Data (Level 1) Patient Abstract We will follow one patient visit through different sections of PHIS Value: Define comparable cohorts Compare LOS Readmission/ED return rates (using MRN)
Diagnosis Codes Diagnoses (ICD-9/10) Value: Go beyond the principal dx Specific patient inclusion / exclusion
Procedure Codes Procedures (ICD-9/10) Value: Go beyond the principal px Pre vs. Post-Op LOS Analysis by surgeon
How billing data is made comparable Hospital A Hospital B 35309888 Vancomycin 125 mg CTC Code 124133.1011552 6561447 Tablet 125 mg Vancomycin 12 Anti-infectives (Drug Class = 12) 124 Misc antibiotics (Therapeutic Cat = 124) 124133 Vancomycin (Generic Drug=124133) 12413310 oral (Route of Administration=10) 1241331011 tablet (Dosage Form=11) 124133101155 55 (Strength=125) 1241331011552 mg (Unit of Measure=2)
Pharmacy Data Pharmacy Value: Compare drug utilization by drug, class, and/ or category Compare when drugs were given (by day) Compare route of administration (IV, PO, etc.)
Imaging Imaging / Radiology Value: Compare number of tests per patient Identify potential over utilization
Room / Nursing Room / Nursing Value: Compare LOS by type of room (med/surg vs. ICU) Measure Return to ICU/Direct Admit to ICU Analyze resource utilization by room type (eg. drugs while in NICU)
Benefits of using PHIS Benchmark against peer hospitals Un-blinded comparisons Line item daily utilization Inpt, Obs, ED, Amb Surg
Identifying improvement opportunities with standard reports
Agenda Overview of standard reports Example Starting with executive insight report series And drilling down using other select reports
Types of PHIS Users Viewers Ability to view and run existing reports o Standard Reports or reports created by a PHIS Reporter Reporters Ability to create and modify reports Training required Power Users Wide range of users Note: A PHIS Direct Access Agreement is required for both levels of access.
Categories of Standard Reports (Clinical) Category Number Description Avoidable Days/Excess Days 4 Identify LOS improvement opportunities Pharmacy Profile 11 Identify opportunities to reduce pharmacy costs and/or identify variation in pharmacy utilization Readmissions 31 Identify and analyze readmission rate improvement opportunities Report Cards 9 Key measures for : Appendicitis, Asthma, Bronchiolitis, Choosing Wisely, DKA, ED, Hospital Acquired Conditions (HAC), and AHRQ PDIs Resource Utilization/ Stat Reports 3 (36 detail) Identify resource utilization improvement opportunities Utilization Management 1 Overall hospital utilization management measures
Categories of Standard Reports (Global) Category Number Description Coding Opportunity 7 Identify coding/documentation improvement opportunities Comparative Analysis 6 High-level comparisons for top patient populations Complex Chronic Care 1 Show changes in the chronic population Data Quality Reports 3 Show the current data quality measures incorporated in the database and which hospitals have issues with those measures by year and quarter. Executive Insight Report Series Key Performance Indicators 11 Key hospital metrics for the purpose of monitoring overall performance 16 Unblinded hospital comparisons for key hospital measures Physician Profiling 8 Helps with OPPE needs and identifying variation. Templates/Special Reports 2 Used when creating an ad hoc report and user-submitted reports; also includes user-created reports and PHIS reporting tool utilization reports U.S. News Survey 9 Data-driven 2016 US News survey questions.
Going beyond standard reports
Prioritization outside standard reports Standardized Cost Report PHIS Opportunity Report
Standardized Cost In PHIS, costs are estimated from charges using hospital specific cost-to-charge ratios High variation in unit costs across hospitals creates excess noise in analysis Standardized Cost: For every billable item in PHIS, the median unit cost across hospitals was determined Every bill was the re-calculated using these costs
Standardized Cost For every APR-DRG, we can determine the observed and the expected (based on the severity mix of cases) standardized cost O/E Std Cost APR-DRG N Cases Total Pharm Lab Imaging Other Bronchiolitis & RSV pneumonia 739 1.22 1.56 2.34 3.79 1.26 Pulmonary edema & respiratory failure 701 1.43 1.54 1.91 2.97 1.53 Chemotherapy 679 0.87 0.40 1.48 10.83 1.22 Seizure 631 1.42 2.48 5.42 15.37 1.39 Diabetes 547 0.96 0.33 1.75 9.03 0.96 Total standardized cost at the hospital for bronchiolitis is 22% higher than at other hospitals
PHIS Opportunity Report Hospital specific data compared to peers Delivered twice a year
Content Comparative hospital descriptive information Key Performance Indicator Hospital P25 Median P75 Pediatric CMI 1.8 1.5 1.8 1.9 Total Inpatient Discharges 14,958 8,697 11,544 15,792 Total Unique Patients 12,647 7,312 8,887 12,708 Average Length of Stay (ALOS) 2.4 2.2 2.3 2.5 Overall Observed to Expected LOS Ratio 1.3 1.3 1.4 1.5 Total Excess Days 15,365 10,643 14,541 17,767 % of Discharges with any Complex Chronic Condition (CCC) 31 30 33 38 Overall Observed to Expected Cost Ratio 1.0 1.01 1.02 1.04 Adjusted 7-day Readmission Rate 2.2 1.6 1.9 2.2 Adjusted 14-day Readmission Rate 2.8 2.4 2.7 3.1 Adjusted 30-day Readmission Rate 4.1 3.6 4.3 4.9
Content Prioritization metrics by service line Risk adjusted 14 and 30 day readmission rate Observed to expected LOS Excess days (observed expected) Observed to expected standardized cost Service Line # Cases O/E Ratio (Lower is Better) Rank Neuroscience Service - Medical 1,031 1.67 8 of 49 Cancer Care - Oncology 675 1.59 12 of 49 Endocrinology - Medical 578 1.57 12 of 49 Digestive Disease - Medical 1,638 1.54 6 of 49 Infectious Disease - Medical 1,129 1.41 22 of 49
Key Principles for Using PHIS PHIS is best used as a learning tool, not as a judgment tool PHIS doesn t tell you if you are right or wrong but will demonstrate variation from peer hospitals PHIS will help you make informed decisions but won t tell you what decision to make
Thank you! Presentations: www.childrenshospitals.org Rustin Morse; Children s Health System of Texas rustin.morse@childrens.com Matt Hall; Children s Hospital Association matt.hall@childrenshospitals.org