Cleveland Clinic's Physician Portal: Managing Physicians to Success with Business Intelligence

1. Cleveland Clinic's Physician Portal: Managing Physicians to Success with Business Intelligence Brian Harte MD, President Hillcrest Hospital Brett Young, Director Business Intelligence Michael Mann, EBI Analyst Business Intelligence

2. Disclosures None of the Presenters Have Any Conflicts of Interest to Disclose

3. Learning Objectives • Understand the current environment of physician-level reporting • Discuss a framework for addressing the challenges in monitoring physician performance • Describe a data-driven, physician performance review process • Become familiar with the role of data warehousing in developing a performance management system

4. Agenda • Introduction to Cleveland Clinic • Business Intelligence: Concepts and Implementation • The Changing Environment of Physician-Level Measurement • Initial Attempts at Physician Management • Realizing a Performance Directed Culture • Putting it All Together: the Physician Portal

5. Agenda Introduction to Cleveland Clinic Business Intelligence: Concepts and Implementation The Changing Environment of Physician-Level Measurement Initial Attempts at Physician Management Realizing a Performance Directed Culture Putting it All Together: the Physician Portal

7. Cleveland Clinic • Multi-specialty group practice founded in 1921 • Based on WW I Team • “To Act as a Unit”

8. Cleveland Clinic • AMC + 9 Hospitals in Ohio & 18 Family Health Centers • Facilities in Florida, Las Vegas, Abu Dhabi • >4 million Patient Visits • 41,000 Employees • > 3,000 Physicians & Scientists

9. Ashtabula County Medical Center Ashtabula County Medical Center ClevelandClinic Toronto Euclid Hospital Euclid Hospital Willoughby HillsFamily Health Center H H H H H H H H H H H H H H H H Hillcrest Hospital Hillcrest Hospital ClevelandClinic Lakewood Hospital CCCHR FHC FHC FHC FHC FHC FHC FHC FHC FHC FHC FHC FHC FHC FHC FHC Beachwood FamilyHealth and Surgery Center South PointeHospital ClevelandClinicFlorida Elyria FamilyHealth Center Avon FamilyHealth Center Lutheran Hospital Westlake FamilyHealth Center LakewoodFamily HealthCenter Marymount Hospital MedinaHospital MedinaHospital Solon FamilyHealth Center Lorain Family Health And Surgery Center Lou Ruvo Centerfor Brain Health Las Vegas, Nevada Fairview Hospital Fairview Hospital Independence FamilyHealth Center Chagrin Falls FamilyHealth Center Strongsville Family Health and Surgery Center Brunswick FamilyHealth Center Wooster FamilyHealth Center Care Delivery System

10. Group Practice Model • Physician-led not for profit enterprise • Staff physicians employed & salaried • Annual professional reviews/ reappointments • No volume incentives • Expectation of excellence • Physician alignment

11. Agenda • Introduction to Cleveland Clinic • Business Intelligence: Concepts and Implementation • The Changing Environment of Physician-Level Measurement • Initial Attempts at Physician Management • Realizing a Performance Directed Culture • Putting it All Together: the Physician Portal

12. Business Intelligence • Business Intelligence is the use of informationto enable organizations to best decide, measure, manage, and optimize performance. • BI is an umbrella term to describe a set of concepts and methods to improve business decision-making by using fact-based support systems.

13. How EBI is used in Healthcare • Align departmental goals with strategic priorities • Improve quality of care through monitoring & trending • “If you can’t measure it, you can’t manage it” – Peter Drucker

14. Information Delivery Environment Before EBI Heavy reliance on packaged technology solutions with limited integration Data stores developed and owned by independent departments – duplicative and expensive Disjointed approach to information access & display (reports, online tools, Excel, Crystal, etc.) Multiple representations of data with inconsistent definitions – no single source of truth DSS Billing ODS ORIS Crystal Excel GL SC CIS Data “Stores” / Applications Information Access / Display Data Sources

15. Current Information Delivery Environment Coordinated approach to data storage, visualization and reporting Efficient and timely delivery of information Coordinated representations of data with consistent definitions – moving towards a single source of truth Billing ORIS GL SC DSS CIS Medops Others Others Others Distributed Enterprise Data Warehouse Consistent Information Access / Display Data Sources

16. Dashboard Architecture Finance & Statistics Quality Patient Access Operational Dashboards Operational Dashboards • Summary • P&L by entity • Financial metrics • Key statistics • Reports • Service line • Summary • Core measures • Patient experience • Hand hygiene • Outpatient access • Days wait • Appt when wanted • Physicians • Institute chair • Department • Nursing • Clinical operations • Patient support services • Finance • Statistics • Patient Access • Quality • Patient Experience • High Level • Indicator Driven • Visual & Intuitive • Focused • Flexible Executive Dashboard

17. Business Intelligence Tools at Cleveland Clinic • Dashboards & scorecards • Physician-level reports • Self-service data marts • Web applications • Predictive analytics • Ad hoc reports

18. Dresner’s Performance Culture Maturity Model TM Source: Profiles in Performance, Howard Dresner, 2009

19. Cleveland Clinic’s Culture Maturity ‘00 ‘00 ‘00 ‘00 ‘00 ‘00 Source: Profiles in Performance, Howard Dresner, 2009

20. Cleveland Clinic’s Culture Maturity ‘09 ’09 ’08 ’07/09 ’07/09 ‘07/09 Source: Profiles in Performance, Howard Dresner, 2009

21. Agenda • Introduction to Cleveland Clinic • Business Intelligence: Concepts and Implementation • The Changing Environment of Physician-Level Measurement • Initial Attempts at Physician Management • Realizing a Performance Directed Culture • Putting it All Together: the Physician Portal

22. Managing Physicians in the Group Practice Model • Physicians practice on a 1-year contract • Annual Performance Review (APR) • Ongoing Professional Practice Evaluations (OPPE) occur twice yearly

23. Physician Performance: The Management Imperative CMS Quality Agenda: Transforming Medicare from a passive payer to an active purchaser of higher quality, more efficient health care Payment based on quality/value

24. Hospital Value-based Purchasing (HVBP) Value-based Purchasing • Hospital Medicare reimbursement is tied to performance on measures of clinical process, patient experience and outcomes

25. FY 2014 Domain Weighting (Discharges from October 1, 2013 to September 30, 2014)

26. Example Incentive Payment Calculation

27. Other Penalty Programs Impacting Hospitals and Hospitalists Reducing Readmission Rates: • Beginning FY 2013, imposes financial penalties on hospitals for so-called “excess” readmission rates • Performance based on the 30-day readmission measures for heart attack, heart failure and pneumonia (2015: COPD and total joint replacement) • Reductions to hospitals are expected to amount to $7.1 billion over 10 years.

28. Other Penalty Programs Impacting Hospitals and Hospitalists Hospital-Acquired Conditions: • Beginning in FY 2015, adds a 1% penalty to hospitals in the top quartile of rates of HACs, resulting in reductions of $1.5 billion over 10 years.

29. Hospital VBP • Millions of dollars at-risk for hospitals • Improving clinical performance demands • Durable physician partnership • Focus on process improvement • Just culture • Data – even though physician level data is notoriously challenging

30. CMS Physician VBP Plan FFS

31. Physician Value Based Purchasing What is the Value-Based Payment Modifier? • The Affordable Care Act requires that Medicare phase in a value-based payment modifier (VM) that would apply to Medicare Fee for Service Payments starting in 2015, phase-in complete by 2017 • The Value Modifier assesses both quality of care furnished and the cost of that care

33. Value Modifier and the Physician Quality Reporting System (PQRS) - 2015 §301

34. Applying the 2015 Modifier Quality Tiering

35. Physician Quality Reporting System (PQRS) Bonus payment as percentage of Total Allowable Medicare Charges: 2011 - 1% 2012 - 0.5% 2013 - 0.5% 2014 - 0.5% 2015 - negative 1.5% payment adjustment 2016 - negative 2% payment adjustment

36. PQRSBonus Calculation Example

37. Physician Value-Based Purchasing Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) Sec 131(c): “The Secretary shall establish a Physician Feedback Program under which the Secretary shall use claims data to provide confidential reports to physicians that measure the resources involved in furnishing care. The Secretary may include information on the quality of care furnished by the physician (or group of physicians) in such reports.” Reports on per capita physician resource use and quality of care measures Reports to 1,600 physicians in 12 markets so far

38. Physician Quality and Resource Use Report ACA Section 3003: Continues and expands the Physician Feedback Program until every applicable Medicare physician receives a report Provide Physician Feedback Reports that quantify and compare patterns of resource use of individual physicians to other physicians

39. Examples of Physician Quality and Resource Use Physician-level performance measures (PQRS) Total per capita Medicare Part A and Part B costs (average annual costs per patient) Per capita costs by type of service (e.g. in-patient) Total per capita costs for patients stratified by specific chronic conditions: HF, COPD, CAD, diabetes, and prostate cancer Hospital and ED admissions

40. Physician Compare Website ACA Section 10331: Requires public reporting of physician performance to include: PQRS results Patient health outcomes and functional status Assessment of continuity and coordination of care and care transitions Efficiency measures Assessment of patient experience and patient and family engagement Assessment of safety, effectiveness and timeliness of care

41. Physician Compare Website

42. Accountable Care Organizations

43. Managing Physicians in a VBP World • Millions of dollars at-risk for group practices and health systems • Improving clinical performance demands • Sense of Urgency • Timely, accurate, physician data • Strong Partnerships to help manage the environment: ICD-10, MU etc

44. Agenda • Introduction to Cleveland Clinic • Business Intelligence: Concepts and Implementation • The Changing Environment of Physician-Level Measurement • Initial Attempts at Physician Management • Realizing a Performance Directed Culture • Putting it All Together: the Physician Portal

45. Physician Reporting: A Failed Experiment (2006) Objectives: 1 Develop a physician management reporting tool 2 Adoption by physicians and leadership

47. Physician Reporting: A Failed Experiment (2006) Objectives: 1 Develop a physician management reporting tool 2 Adoption by physicians and leadership A Metrics not specific to individual physician practice B Lack of integration into performance review C Culture of managing through data not established D Displayed on physicians’ screen EVERY MORNING

49. What We Learned • Physician leadership endorsement is crucial • Communication & education strategy • No clear link to improvement strategy • The “in your face” approach is not effective • Climate not ripe

50. Agenda • Introduction to Cleveland Clinic • Business Intelligence: Concepts and Implementation • The Changing Environment of Physician-Level Measurement • Initial Attempts at Physician Management • Realizing a Performance Directed Culture • Putting it All Together: the Physician Portal