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Allina’s Pioneering Move Forward on Population Health Risk Stratification and Management

August 20, 2012
by Mark Hagland
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How a multidisciplinary team helped the Minnesota integrated system create a groundbreaking dashboard for assessing readmissions risk for inpatients—before they’re discharged

The Healthcare Informatics Innovator Awards Program reaped a cornucopia of outstanding submissions in 2012. Indeed, the editors at HCI concluded that every semi-finalist entry was worth coverage, given the very high level of quality of the entries in this successful program, whose goal has been to highlight team-based achievements in informatics work in patient care organizations nationwide.

One of the semi-finalist teams this year was the Patient Census Dashboard Team at the Minneapolis-based Allina Health. The 11-hospital, 90-plus-clinic, 24,000-employee, 5,000-physician Allina organization is already nationally known for its innovations in many areas of patient care delivery and operations.

With regard to the organization’s Innovator Awards program submission, in 2011, staff from Allina’s Performance Resources department convened an interdisciplinary team from 10 hospitals to understand the barriers to coordinating care for patients with complex needs. The team learned of a desperate need to assist clinicians in the identification of patients at higher risk for readmission.

As it turns out, clinicians were spending hours finding these patients, who require an interdisciplinary approach in order to achieve a successful transition from the hospital to the post-acute setting. The team began work on designing a case-finding tool to quickly identify these patients and assist in convening the care team to create a transition plan. What was needed, the leaders of the team decided, was a tool that could quickly identify these patients while still in the hospital and could provide instant access to real-time clinical information and summarized key healthcare resource utilization measures for each patient, including indicators such as how frequently a patient has visited a hospital in the past 30 days, a count of total emergency department visits in the prior year, and how many different medications a patient might be taking.

After months of work on this project, the ultimate result was the Patient Census Dashboard, a business intelligence application developed internally at Allina using QlikView business intelligence technology, and providing users with an intuitive, interactive environment in which to explore these types of data points. The tool leverages established and prior investments in the organization’s electronic health record (EHR), enterprise data warehouse (EDW), and business intelligence tools. Given those advantages, the Allina team members were able to produce the tool with nominal effort and no cost in additional hardware, software, or professional services. This tool is now being used widely by Allina clinicians.

HCI Editor-in-Chief Mark Hagland recently interviewed members of the team that developed the Patient Census Dashboard. Present at the interview were the following Allina leaders: Michael J. Doyle, manager of the Enterprise Data Warehouse; Penny Wheeler, M.D., chief clinical officer; Susan Heichert, R.N., vice president, health information systems and CIO; Karen Tomes, R.N., director of quality improvement and care management; and Jason Haupt, Ph.D., senior statistician. Below are excerpts from that interview.

What was the strategic impulse behind this initiative?

Penny Wheeler, M.D.: We are very much on the path of, and feel that it’s our civic duty to, transform healthcare for our community. So all of this is about getting away from the traditional revenue generation, providing the most care to the most people, and getting towards quality-based care delivery. It’s really about pushing that Queen Mary of healthcare into a more positive direction, to demonstrate that we can deliver superb outcomes to our community. For example, we’re a pioneer ACO [accountable care organization, as part of the federal Medicare Shared Savings Program] organization. And data is really something that needs to be aggregated to help us do the right thing; and we’re really on the forefront of using some of those tools to accomplish those things.

Susan Heichert, R.N.: We’ve made significant investments not only in our EHR, but also in data warehouses and other tools, and our goal is to use those tools to improve care delivery and outcomes.

Karen Tomes. R.N.: The exciting outcome of this project is that the clinicians designed it, and also gave us feedback into what needs to happen in the current state, to help them succeed in terms of care transitions. So the exciting part of this project was listening to clinicians, including physicians, nurses, pharmacists, case managers, and social workers.

Michael J. Doyle: The investment that Susan talked about that Allina has made in infrastructure for performance measurement has really made this possible in a way that wouldn’t have happened otherwise. Second, it was an extremely gratifying project; we worked very closely with our clinicians, and it helped the front-line clinicians understand that we’re not too far removed from their concerns. It was really neat; it was very much not a “request a dashboard and we’ll build it” kind of situation; it was a collaboration.

Wheeler: We’ve got a ways to go, like everyone else. But when people visit and see these tools, their jaws drop; and we’ve got something very precious here that we’re using on behalf of our community.

What have been the revelations and learnings so far around the leveraging of IT?