Analytics are the way of the future in healthcare and spine surgery is just beginning to jump on board.
Jonathan Slotkin, MD, is the Director of Spinal Surgery at the Geisinger Health System Neurosciences Institute and Director of Spinal Cord Injury Research for Geisinger Health System. Dr. Slotkin serves as the Co-Chairman of the Operations Committee for the National Neurosurgery Quality and Outcomes Database (N2QOD). Matthew McGirt, MD, is a practicing spinal neurosurgeon at Carolina Neurosurgery & Spine Associates and is Associate Research Professor at University of North Carolina. Dr. McGirt serves as the Vice-director of N2QOD and serves on the North American Spine Society Registry Committee.
They share their thoughts on the most important benchmarking initiatives in spine care and how data will impact care delivery in the future.
Question: What is the importance of data in spine care — both clinical and economic data? Why should spine surgeons collect and pay attention to their numbers?
Dr. Jonathan Slotkin: A combination of forces has encouraged many nationally to really scrutinize their data. When we start to think about value-driven, patient-centered outcomes and care delivery, spine surgery nationwide is one of the furthest behind and has more catching up to do. The area of analytics — some people call "Spine Moneyball" — is now available to us.
Historically, a lot of spine surgeons nationwide have been very good at clinical intelligence, and we as a field have been getting better at business intelligence. I think over the next five to 10 years we will need to master predictive intelligence and analytics. The challenge used to be a paucity of data. As EMR becomes required, everyone will begin to have access to the same data, or at least good data. The question for the next five to 10 years is what do we want to do with that data — how do we utilize it intelligently.
Dr. Matthew McGirt: Medical and surgical spine care is first and foremost designed to help improve patients' health status and quality of life. Evolving our understanding of what works and what doesn't in each setting for each individual patient is how we can begin evolve using intelligent analytics of outcomes data. We want to identify the right treatment, in the right patient, at the right time to optimize outcomes and reduce healthcare waste.
The evidence paradigm has traditionally been randomized trials in controlled settings, which are largely artificially constrained and include only a certain subset of the most motivated "research consenting" patients. This is an important group, but not one that can be generalized to populations or individuals in everyday real world care. We need to understand data as it exists within a wide variety of surgeons, healthcare setting, and patient populations. That's real world effectiveness. There is a huge variation of disease and patient sub-types, as well as provider/physician quality, which creates a huge spectrum of variation in effectiveness and value of care. Integrating outcomes data solutions into standard of care in the real-world setting allows a much better and more granular understanding of valuable and wasteful care in each unique spine care practice setting.
Q: How can spine surgeons translate their data collection and understanding into useful information that will help them provide better care and improve their practice?
McG: At its essence, analytics in real time will measure care as it happens, like in a baseball game. We are able to gather information and learn from the variety of treatment outcomes about the best patient, best treatment, best setting and best timing. Feeding this data back to patients, physicians, and hospital decision makers enables practice based learning and allows hospitals to trim the fat (waste) in real time.
A recently coined term "Science of Practice" — an article published in the January 2013 issue of Neurosurgery Focus — provides a technical framework to the process of systematic collection of care delivery data as a part of standard of care. All spine care providers generate data on what works and what doesn't in the surgeon's own hands in their particular healthcare setting and patient population. It's just a matter of collecting this data as its generated every day.
This is no different from baseball players generating individual statistics to their play. The Science of Practice, or systematic collection of outcomes data and integrated analytics, will allow the current healthcare reform paradigm to move away from paternalistic payer, policy maker, or hospital administrator dictated care parameters, and move towards smart evidence based tools to help surgeons and their patients achieve the same desired outcomes and eliminate waste.
JS: We have to be data literate and also translate those numbers into action. My colleagues and I have spent the last year home growing spine dashboards that draw from four to five distinct data streams within Geisinger. These are discrete data streams from electronic operative, outpatient, billing, patient demographic and quality outcomes data. Our IT team members have created impressive fuzzy logic algorithms to merge these distinct data sources. Right now, we are using these tools for business and clinical intelligence purposes and to increase the value in our care delivery. These efforts have been collaborative efforts involving neurosurgery, orthopedics, medicine, and several other segments of the provider environment.
What we are rapidly moving toward is using those tools for predictive intelligence — to ask questions as to what variables most predict superior outcomes.
Q: Many spine surgeons around the country work in smaller groups of 10 or 15 surgeons. Is there an opportunity for them to participate in "Spine Moneyball" as well?
JS: We are aware that [the Geisinger projects] are demonstration projects and they won't apply in their entirety everywhere, but there are components that smaller groups can deploy at their institutions. The most important thing is for providers to become involved in data collection and analytics and not just respond passively to data being collected and analyzed by others. I would recommend they design their best practices and obtain local expert consensus using this data before moving forward with new initiatives.
There are off the shelf dashboard software programs that can interface with your EHR and help your perform these types of analytics. Partner with hospitals that already have access to dashboards to understand and control the data streams and to improve best practices and outcomes.
McG: Our group is an independent group of neurosurgeons and we have integrated data collection into our everyday care with standardized patient reported outcomes measurements. We utilize a call center to track one-year outcomes via phone interview and are now investing in mobile health technologies that automate this process. We have a web-based portal that allows connectivity to our patients throughout a one-year episode of spine care. We measure the variety and timing of patient treatment paradigms as it happens to see what works best in whom. Outcomes are measured as standard of care, and reported only by the patients receiving care. It keeps our neurosurgical care patient-centered, and allows transparency and accountability of quality care at both the surgeon level and the group level.
We can also now generate reports for any stakeholder who purchases care or refers care to out center. If you are a self insured employer, a third-party payer, or a referring physician, we can demonstrate what our quality of care looks like based on the hundreds or previous patients treated in your health plan or whom you have referred. This includes surgical complication rates, return-to-work status, along with patient reported pain, disability, satisfaction and quality of life before and after treatment. This accountability and transparency of quality helps position our practice group to compete in the emerging value-based healthcare market. Practices and hospitals aiming to become regional destination spine care centers will need to report not only their safety of care, but also their effectiveness and durability of their treatments.
Q: Where do you see data collection in the spine field headed over the next five years?
McG: There is a big gap in longitudinal patient reported outcomes data collection. The low hanging fruit has been process measures and basic safety data obtainable from claims data; were antibiotics given, was a surgical checklist utilized, was best evidence followed, was the patient re-admitted within 30-days of hospital discharge? This has remained the state of the art this past decade. As more centers begin longitudinal outcomes data collection (improvement in pain, disability, quality of life, return to work), which are the metrics patients seek care for, centers will be able to measure the effectiveness of care along with their cost of care, and assess the relative value (effectiveness/cost) of various and competing treatment options.
As measurement of the numerator (effectiveness of care) in the value equation evolves, intelligent value based reform will be enabled. Then spine care providers and stakeholders will be able to institute value-based purchasing, individualized treatment paradigms, and sliding scale capitated payment and bundled payment models for risk stratified patients. All of this will be powered by the science of practice and maximized to achieve its goal.
JS: Over the next five years we will be focused on using data smartly. I would urge providers to begin to construct or participate in integrated practice units. IPUs have been described by many, but the best description was published in a Harvard Business Review in an article by Dr. Tom Lee and Michael Porter called "The Strategy That Will Fix Health Care." IPUs are designed to base care delivery models on patient need and to strive for the best patient outcomes at the lowest possible costs.
Their article discusses advancing the value agenda, but doing so with a good eye towards competitive strategy and operational effectiveness. They recommend physicians become involved and organize IPUs, measure outcomes and costs for patients, make movements toward bundled payments for care delivery cycles, integrate care delivery across facilities, and then expand their excellent care geographically.
Virginia Mason and others have done a great job on this. If I could tell spine surgeons one thing, it would be to study and analyze maximizing the value of the care delivery so that it provides excellent care at the appropriate cost, and consider doing it through the physician-driven formation of IPUs.
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