Managing clinical variation continues to be a significant challenge facing most hospitals and health systems today as unwarranted clinical variation often results in higher costs without improvements to patient experience or outcomes.
Like many other hospitals and health systems, Flagler Hospital, a 335-bed community hospital in St. Augustine, Florida, had a board-level mandate to address its unwarranted clinical variation with the goal of improving outcomes and lowering costs, says Michael Sanders, M.D., Flagler Hospital’s chief medical information officer (CMIO).
“Every hospital has been struggling with this for decades, managing clinical variation,” he says, noting that traditional methods of addressing clinical variation management have been inefficient, as developing care pathways, which involves identifying best practices for high-cost procedures, often takes up to six months or even years to develop and implement. “By the time you finish, it’s out of date,” Sanders says. “There wasn’t a good way of doing this, other than picking your spots periodically, doing analysis and trying to make sense of the data.”
What’s more, available analytics software is incapable of correlating all the variables within the clinical, billing, analytics and electronic health record (EHR) databases, he notes.
Another limitation is that care pathways are vulnerable to the biases of the clinicians involved, Sanders says. “In medicine, what we typically do is we’ll have an idea of what we want to study, design a protocol, and then run the trial and collect the data that we think is important and then we try to disprove or prove our hypothesis,” he says.
Sanders says he was intrigued by advances in machine learning tools and artificial intelligence (AI) platforms capable of applying advanced analytics to identify hidden patterns in data.
Working with Palo Alto, Calif.-based machine intelligence software company Ayasdi, Flagler Hospital initiated a pilot project to use Ayasdi’s clinical variation management application to develop care pathways for both acute and non-acute conditions and then measure adherence to those pathways.
Michael Sanders, M.D.
Flagler targeted their treatment protocols for pneumonia as an initial care process model. “We kicked around the idea of doing sepsis first, because it’s a huge problem throughout the country. We decided to use pneumonia first to get our feet wet and figure out how to use the tool correctly,” he says.
The AI tools from Ayasdi revealed new, improved care pathways for pneumonia after analyzing thousands of patient records from the hospital and identifying the commonalities between those with the best outcomes. The application uses unsupervised machine learning and supervised prediction to optimally align the sequence and timing of care with the goal of optimizing for patient outcomes, cost, readmissions, mortality rate, provider adherence, and other variables.
The hospital quickly implemented the new pneumonia pathway by changing the order set in its Allscripts EHR system. As a result, for the pneumonia care path, Flagler Hospital saved $1,350 per patient and reduced the length of stay (LOS) for these patients by two days, on average. What’s more, the hospital reduced readmission by 7 times—the readmission rate dropped from 2.9 percent to 0.4 percent, hospital officials report. The initial work saved nearly $850,000 in unnecessary costs—the costs were trimmed by eliminating labs, X-rays and other processes that did not add value or resulted in a reduction in the lengths of stay or readmissions.
“Those results are pretty amazing,” Sanders says. “It’s taking our data and showing us what we need to pursue. That’s powerful.”
With the success of the pneumonia care pathway, Flagler Hospital leaders also deployed a new sepsis pathway. The hospital has expanded its plans for using Ayasdi to develop new care pathways, from the original plan of tackling 12 conditions over three years, to now tackling one condition per month. Future plans are to tackle heart failure, total hip replacement, chronic obstructive pulmonary disease (COPD), coronary artery bypass grafting (CABG), hysterectomy and diabetes, among other conditions. Flagler Hospital expects to save at least $20 million from this program in the next three years, according to officials.
Finding the “Goldilocks” group
Strong collaboration between IT and physician teams has been a critical factor in deploying the AI tool and to continue to successfully implement new care pathways, Sanders notes.
The effort to create the first pathway began with the IT staff writing structured query language (SQL) code to extract the necessary data from the hospital’s Allscripts EHR, enterprise data warehouse, surgical, financial and corporate performance systems. This data was brought into the clinical variation management application using the FHIR (Fast Healthcare Interoperability Resources) standard.
“That was a major effort, but some of us had been data scientists before we were physicians, and so we parameterized all these calls. The first pneumonia care path was completed in about nine weeks. We’ve turned around and did a second care path, for sepsis, which is much harder, and we’ve done that in two weeks. We’ve finished sepsis and have moved on to total hip and total knee replacements. We have about 18 or 19 care paths that we’re going to be doing over the next 18 months,” he says.
After being fed data of past pneumonia treatments, the software automatically created cohorts of patients who had similar outcomes accompanied by the treatments they received at particular times and in what sequence. The program also calculated the direct variable costs, average lengths of stay, readmission and mortality rates for each of those cohorts, along with the statistical significance of its conclusions. Each group had different comorbidities, such as diabetes, COPD and heart failure, which was factored into the application's calculations. At the push of a button, the application created a care path based on the treatment given to the patients in each cohort.
The findings were then reviewed with the physician IT group, or what Sanders calls the PIT crew, to select what they refer to as the “Goldilocks” cohort. “This is a group of patients that had the combination of low cost, short length of stay, low readmissions and almost zero mortality rate. We then can publish the care path and then monitor adherence to that care path across our physicians,” Sanders says.
The AI application uncovered relationships and patterns that physicians either would not have identified or would have taken much longer to identify, Sanders says. For instance, the analysis revealed that for patients with pneumonia and COPD, beginning nebulizer treatments early in their hospital stays improved outcomes tremendously, hospital leaders report.
The optimal events, sequence, and timing of care were presented to the physician team using an intuitive interface that allowed them to understand exactly why each step, and the timing of the action, was recommended. Upon approval, the team operationalized the new care path by revising the emergency-department and inpatient order sets in the hospital EHR.
Sanders says having the data generated by the AI software is critical to getting physicians on board with the project. “When we deployed the tool for the pneumonia care pathway, our physicians were saying, ‘Oh no, not another tool’,” Sanders says. “I brought in a PIT Crew (physician IT crew) and we went through our data with them. I had physicians in the group going through the analysis and they saw that the data was real. We went into the EMR to make sure the data was in fact valid, and after they realized that, then they began to look at the outcomes, the length of stay, the drop in readmissions and how the costs dropped, and they were on board right away.”
The majority of Flagler physicians are adhering to the new care path, according to reports generated by the AI software's adherence application. The care paths effectively sourced the best practices from the hospital’s best doctors using the hospital’s own patient groups, and that is key, Sanders notes.
“When we had conversations with physicians about the data, some would say, ‘My patient is sicker than yours,’ or ‘I have a different patient population.’ However, we can drill down to the physician’s patients and show the physician where things are. It’s not based on an ivory tower analysis, it’s based on our own data. And, yes, our patients, and our community, are unique—a little older than most, and we have a lot of Europeans here visiting. We have some challenges, but this tool is taking our data and showing us what we need to pursue. That’s pretty powerful.”
He adds, “It’s been amazing to see physicians rally around this. We just never had the tool before that could do this.”
While Flagler Hospital is a small community hospital with fewer resources than academic medical centers or larger health systems—for example, the hospital doesn’t have a dedicated data scientist but rather uses its in-house informatics staff for this project—the hospital is progressive in its use of advanced analytics, according to Sanders.
“We’ve been able to do a lot of querying ourselves, and we have some sepsis predictive models that we’ve created and put into place. We do a lot of real-time monitoring for sepsis and central line-associated bloodstream infections,” he says. “Central line-associated bloodstream infections are a bane for all hospitals. In the past year and a half, since we’ve put in our predictive model, we’ve had zero bloodstream infections, and that’s just unheard of.”
Sanders and his team plan to continue to use the AI tool to analyze new data and adjust the care paths according to new discoveries. As the algorithms find more effective and efficient ways to deliver care that result in better outcomes, Flagler will continue to improve its care paths and measure the adherence of its providers.
There continues to be growing interest, and also some hype, around AI tools, but Sanders notes that AI and machine learning are simply another tool. “Historically, what we’ve done is that we had an idea of what we wanted to do, conducted a clinical trial and then proved or disproved the hypothesis, based on the data that we collected. We have a tool with AI which can basically show us relationships that we didn’t know even existed and answer questions that we didn’t know to ask. I think it’s going to open up a tremendous pathway in medicine for us to both reduce cost, improve care and really take better care of our patients,” he says, adding, “When you can say that to physicians, they are on board. They respond to the data.”