Analyze what area of the organizations strategic goal is supported by analytics as discussed by Davenport (2014). Is it clinical, marketing, or business?BestPracticesinHealthcareAnalytics

10/2/22, 9:25 PM Print

https://content.uagc.edu/print/McNeill.2947.17.1?sections=ch18,ch19,ch20,ch21,ch22&content=all&clientToken=91e0f5df-a186-e33f-c66b-58e2e5a9… 1/18

18 Partners HealthCare System

Thomas H. Davenport

Partners HealthCare System (Partners) is the single largest provider of healthcare in the Boston area. It consists of 12 hospitals, with more than 7,000 affiliated physicians. It has 4 million outpatient visits and 160,000 inpatient admissions a year. Partners is a nonprofit organization with almost $8 billion in revenues, and it spends more than $1 billion per year on biomedical research. It is a major teaching affiliate of Harvard Medical School.

Partners is known as a “system,” but it maintains substantial autonomy at each of its member hospitals. While some information systems (the electronic medical record, for example) are standardized across Partners, other systems and data, such as patient scheduling, are specific to particular hospitals. Analytical activities also take place both at the centralized Partners level and at individual hospitals such as Massachusetts General Hospital (MGH) and Brigham and Women’s Hospital (usually described as “the Brigham”). In this chapter, both centralized and hospital-specific analytical resources are described. The focus for hospital-specific analytics is the two major teaching hospitals of Partners—MGH and the Brigham—although other Partners hospitals also have their own analytical capabilities and systems.

Centralized Data and Systems at Partners The basis of any hospital’s clinical information systems is the clinical data repository, which contains information on all patients, their conditions, and the treatments they have received. The inpatient clinical data repository for Partners was initially implemented at the Brigham during the 1980s. Richard Nesson, the Brigham and Women’s CEO, and John Glaser, the hospital’s chief information officer, initiated an outpatient electronic medical

record (EMR) at the Brigham in 1989.1 (http://content.thuzelearning.com/books/McNeill.2947.17.1/sections/ch18#ch18end01) This EMR contributed outpatient data to the clinical data repository. The hospital was one of the first to embark on an EMR, though MGH had begun to develop one of the first full-function EMRs as early as 1976.

A clinical data repository provides the basic data about patients. Glaser and Nesson came to agree that in addition to a repository and an outpatient EMR, the Brigham—and Partners after 1994, when Glaser became its first CIO—needed facilities for doctors to input online orders for drugs, tests, and other treatments. Online ordering (called CPOE, or Computerized Provider Order Entry) would not only solve the time-honored problem of interpreting poor physician handwriting, but could also, if endowed with a bit of intelligence, check whether a particular order made sense or not for a particular patient. Did a prescribed drug comply with best-known medical practice, and did the patient have any adverse reactions in the past to it? Had the same test been prescribed six times before with no apparent benefit? Was the specialist to whom a patient was being referred covered by his or her health plan? With this type of medical and administrative knowledge built into the system, dangerous and time-consuming errors could be prevented. The Brigham embarked on its CPOE system in 1989.

Nesson and Glaser knew that there were other approaches to reducing medical error than CPOE. Some provider institutions, such as Intermountain Healthcare in Utah, were focused on close adherence by physicians to well-established medical protocols. Others, like Kaiser Permanente in California and the Cleveland Clinic, combined insurance and medical practices in ways that incented all providers to work jointly on behalf of patients. Nesson and Glaser admired those approaches, but felt that their impact would be less in an academic medical center such as Partners, where physicians were somewhat autonomous, and individual departments prided themselves on their separate reputations for research and practice innovations. Common, intelligent systems seemed like the best way to improve patient care at Partners.

In 1994, when the Brigham and Mass General combined as Partners HealthCare System, there was still considerable autonomy for individual hospitals in the combined organization. However, from the onset of the merger, the two hospitals agreed to use a common outpatient EMR called the longitudinal medical record (LMR) and a CPOE system, both of which were developed at the Brigham. This was powerful testimony in favor of the LMR and CPOE systems, since there was considerable rivalry between the two hospitals, and Mass General had its own EMR.

Perhaps the greatest challenge was in getting the extended network of Partners-affiliated physicians up on the LMR and CPOE. The physician network of more than 6,000 practicing generalist and specialist physician groups was scattered around the Boston metropolitan area, and often operated out of their own private offices. Many lacked the IT or telecom infrastructures to implement the systems on their own, and implementation of an outpatient EMR cost about $25,000 per physician. Yet full use of the system across Partners-affiliated providers was critical to a seamless patient experience across the organization.

Glaser and the Partners information systems (IS) organization worked diligently to spread the LMR and CPOE to the growing number of Partners hospitals and to Partners-affiliated physicians and medical practices. To assist in bringing physicians outside the hospitals on board, Partners negotiated payment schedules with insurance companies that rewarded physicians for supplying the kind of information available from the LMR and CPOE. By 2007, 90% of Partners-affiliated physicians were using the systems, and by 2009, 100% were. By 2009, more than 1,000 orders per hour were being entered through the CPOE system across Partners.

The combination of the LMR and the CPOE proved to be a powerful one in helping to avoid medical error. Adverse drug events, or the use of the wrong drug for the condition or one that caused an allergic reaction in the patient, typically were encountered by about 14 of every 1,000 inpatients. At the Brigham before LMR and CPOE, the number was about 11. After the widespread implementation of these systems at Brigham and Women’s, there were just above five adverse drug events per 1,000 inpatients—a 55% reduction.

Managing Clinical Informatics and Knowledge at Partners The Clinical Informatics Research & Development (CIRD) group, headed by Blackford Middleton, is one of the key centralized resources for healthcare analytics at Partners. Many of CIRD’s staff, like Middleton, have multiple advanced degrees; Middleton has an MD, a Master of Public Health degree, and a Master of Science in Health Services Research.

The mission of CIRD is

10/2/22, 9:25 PM Print

https://content.uagc.edu/print/McNeill.2947.17.1?sections=ch18,ch19,ch20,ch21,ch22&content=all&clientToken=91e0f5df-a186-e33f-c66b-58e2e5a9… 2/18

to improve the quality and efficiency of care for patients at Partners HealthCare System by assuring that the most advanced current

knowledge about medical informatics (clinical computing) is incorporated into clinical information systems at Partners HealthCare.2

(http://content.thuzelearning.com/books/McNeill.2947.17.1/sections/ch18#ch18end02)

CIRD is part of the Partners IS organization. It was CIRD’s role to help create the strategy for how Partners used information systems in patient care, and to develop both production systems capabilities and pilot projects that employ informatics and analytics. CIRD’s work had played a substantial role in making Partners a worldwide leader in the use of data, analysis, and computerized knowledge to improve patient care. CIRD also has had several projects funded by U.S. government health agencies to adapt some of the same tools and approaches it developed for Partners to the broader healthcare system.

One key function of CIRD was to manage clinical knowledge, and translate healthcare research findings into daily medical practice at Partners. In addition to facilitating adoption of the LMR and CPOE, Partners faced a major challenge in getting control of the clinical knowledge that was made available to care providers through these and other systems. The “intelligent CPOE” strategy demanded that knowledge be online, accessible, and easily updated so that it could be referenced by and presented to care providers in real-time interactions with patients. There were, of course, a variety of other online knowledge tools, such as medical literature searching, available to Partners personnel; in total they were referred to as the “Partners Handbook.” At one point after use of the CPOE had become widespread at Brigham and Women’s, a comparison was made between online usage of the Handbook and usage of the knowledge base from order entry. There were more than 13,000 daily accesses through the CPOE system at the Brigham alone, and only 3,000 daily accesses of the Handbook by all Partners personnel at all hospitals. Therefore, there was an ongoing effort to ensure that as much high-quality knowledge as possible made it into the CPOE.

The problem with knowledge at Partners was not that there wasn’t enough of it; indeed, the various hospitals, labs, departments, and individuals were overflowing with knowledge. The problem was how to manage it. At one point, Tonya Hongsermeier, a physician with an MBA degree who was charged with managing knowledge at Partners, counted the number of places around Partners where there was some form of rule-based knowledge about clinical practice that was not centrally managed. She found about 23,000 of them. The knowledge was contained in a variety of formats: paper documents, computer “screen shots,” process flow diagrams, references, and data or reports on clinical outcomes—all in a variety of locations, and only rarely shared.

Hongsermeier set out to create a “knowledge engineering and management” factory that would capture the knowledge at Partners, put it in a common format and central repository, and make it available for CPOE and other online systems. This required not only a new computer system for holding the thousands of rules that constituted the knowledge, but an extensive human system for gathering, certifying, and maintaining the knowledge. It consisted of the following roles and organizations:

• A set of committees of senior physicians who oversaw clinical practice in various areas, such as the Partners Drug Therapy Committee, which reviewed and sanctioned the knowledge as correct or best known practice

• A group of subject matter experts who, using online collaboration systems, debated and refined knowledge such as the best drug for treating high cholesterol under various conditions, or the best treatment protocol for diabetes patients

• A cadre of “knowledge editors” who took the approved knowledge from these groups and put it into a rule-based form that would be accepted by the online knowledge repository

High Performance Medicine at Partners Glaser and Partners IS had always had the support of senior Partners executives, but for the most part their involvement in the activities designed to build Partners’ informatics and analytics capabilities was limited to some of the hospitals and those physician practices that wanted to be on the leading edge. Then Jim Mongan moved from being president of MGH (a role he had occupied since 1996, shortly after the creation of Partners) to being CEO of Partners overall in January 2003. Not since Dick Nesson had Glaser had such a strong partner in the executive suite.

Mongan had come to appreciate the value of the LMR and CPOE, and other clinical systems, while he headed Mass General. But when he came into the Partners CEO role, with responsibility over a variety of diverse and autonomous institutions, he began to view it differently. Mongan said:

So when I was preparing to make the move to Partners, I began to think about what makes a health system. One of the keys that would unite us was the electronic record. I saw it as the connective tissue, the thing we had in common, that could help us get a handle on utilization, quality, and other issues.

Together Mongan and Glaser agreed that while Partners already had strong clinical systems and knowledge management compared to other institutions, a number of weaknesses still needed to be addressed (most importantly that the systems were not universally used across Partners care settings), and steps needed to be taken to get to the next level of capability. Working with other clinical leaders at Partners, they began to flesh out the vision for what came to be known as the High Performance Medicine (HPM) initiative, which took place between 2003 and 2009.

Glaser commented on the process the team followed to specify the details of the HPM initiative:

Shortly after he took the reins at Partners, however, Jim had a clear idea on where he wanted this to go. To help refine that vision, several of us went on a road trip, to learn from other highly integrated health systems such as Kaiser, Intermountain Healthcare, and the Veterans Administration about ways we might bring the components of our system closer together.

Mongan concluded:

We also were working with a core team of 15-20 clinical leaders and eventually came up with a list of seven or eight initiatives, which then needed to be prioritized. We did a “Survivor”-style voting process, to determine which initiatives to “kick off the island.” That narrowed down the list to five Signature Initiatives.

The five initiatives consisted of the following specific programs, each of which was addressed by its own team:

10/2/22, 9:25 PM Print

https://content.uagc.edu/print/McNeill.2947.17.1?sections=ch18,ch19,ch20,ch21,ch22&content=all&clientToken=91e0f5df-a186-e33f-c66b-58e2e5a9… 3/18

• Creating an IT infrastructure—Much of the initial work of this program had already been done; it consisted of the LMR and the CPOE, which was extended to the other hospitals and physician practices in the Partners network and maintained. This project also addressed patient data quality reporting, further enhancement of knowledge management processes, and a patient data portal to give patients access to their own health information.

• Enhancing patient safety—The team addressing patient safety issues focused on four specific projects: 1) providing decision support about what medications to administer in several key areas, including renal and geriatric dosing; 2) communicating “clinically significant test results,” particularly to physicians after their patients have left the hospital; 3) ensuring effective flow of information during patient care transitions and handoffs in hospitals and after discharge; 4) providing better decision support, patient education, and best practices and metrics for anticoagulation management.

• Uniform high quality—This team addressed quality improvement in the specific domains of hospital-based cardiac care, pneumonia, diabetes care, and smoking cessation; it employed both registries and decision support tools to do so.

• Chronic disease management—The team addressing disease management focused on prevention of hospital admission by identifying Partners patients who were at highest risk for hospitalization, and then developed health coaching programs to address patients with high levels of need, for example, heart failure patients; the team also pulled together a new database of information about patient wishes about end- of-life decisions.

• Clinical resource management—At Jim Mongan’s suggestion, this team focused on how to lower the usage of high-cost drugs and high-cost imaging services; it employed both “low-tech” methods (e.g., chart reviews) and “high-tech” approaches (e.g., a data warehouse making transparent physicians’ imaging behaviors relative to peers) to begin to make use of scarce resources more efficiently.

Overall, Partners spent about $100 million on HPM and related clinical systems initiatives, most of which were ultimately paid for by the Partners hospitals and physician practices that used them. To track progress, a Partners-wide report, called the HPM Close, was developed that shows current and trend performance on the achievement of quality, efficiency, and structural goals. The report was published quarterly to ensure timely feedback for measuring performance and supporting accountability across Partners.

New Analytical Challenges for Partners Partners had made substantial progress on many of the basic approaches to clinical analytics, but there were many other areas at the intersection of health and analytics that it could still address. One was the area of personalized genetic medicine—the idea that patients would someday receive specific therapies based on their genomic, proteomic, and metabolic information. Partners had created the i2b2 (Informatics for Integrating Biology and the Bedside), a National Center for Biomedical Computing that was funded by the National Institutes of Health. John Glaser was co-director of i2b2 and developed the IT infrastructure for the Partners Center for Personalized Genetic Medicine. One of the many issues these efforts addressed in personalized genetic medicine was how relevant genetic information would be included in the LMR.

Partners was also attempting to use clinical information for postmarket surveillance—the identification of problems with drugs and medical devices in patients after they have been released to the market. Some Partners researchers had identified dangerous side effects from certain drugs through analysis of LMR data. Specifically, research scientist John Brownstein’s analyses suggested that the level of patients with heart attack admissions to Mass General and the Brigham had increased 18% beginning in 2001 and returned to its baseline level in 2004, which coincided with the timeframe for the beginning and end of Vioxx prescriptions. Thus far the identification of problems had taken place only after researchers from other institutions had identified them, but Partners executives believed it had the ability to identify them at an earlier stage. The institution was collaborating with the Food and Drug Administration and the Department of Defense to accelerate the surveillance process. John Glaser noted:

I don’t know that we’ll get as much specificity as might be needed to really challenge whether a drug ought to be in a market, but I also think it’s fairly clear that you can be much faster and involve much fewer funds, frankly, to do what we would call the “canary in the mine”

approach.3 (http://content.thuzelearning.com/books/McNeill.2947.17.1/sections/ch18#ch18end03)

Partners was also focused on the use of communications technologies to improve patient care. Its Center for Connected Health, headed by Dr. Joe Kvedar, developed one of the first physician-to-physician online consultation services in an academic medical setting. The Center was also exploring combinations of remote monitoring technologies, sensors (for example, pill boxes that know whether today’s dosage has been taken), and online communications and intelligence to improve patient adherence to medication regimes, engagement in personal health, and clinical outcomes.

In the clinical knowledge management area, Partners had done an impressive job of organizing and maintaining the many rules and knowledge bases that informed its “intelligent” CPOE system. However, it was apparent to Glaser, Blackford Middleton, and Tonya Hongsermeier—and her successor as head of knowledge management, Roberto Rocha—that it made little sense for each medical institution to develop its own knowledge base. Therefore, Partners was actively engaged in helping other institutions with the management of clinical knowledge. Middleton (the principal investigator), Hongsermeier, Rocha, and at least 13 other Partners employees were involved in a major Clinical Decision Support Consortium project funded by the U.S. Agency for Healthcare Research and Quality. The consortium involved a variety of other research institutions and healthcare companies, and was primarily focused on finding ways to make clinical knowledge widely available to healthcare providers through EMR and CPOE systems furnished by leading vendors.

Despite all these advances, not all Partners executives and physicians had fully bought into the vision of using smart information systems to improve patient care. Some found, for example, the LMR and CPOE to be invasive in the relationship of doctor and patient. A senior cardiologist at Brigham and Women’s, for example, argued in an interview [with the author] that:

I have a problem with the algorithmic approach to medicine. People end up making rote decisions that don’t fit the patient, and it can also be medically quite wasteful. I don’t have any choice here if I want to write prescriptions—virtually all of them are done online. But I must say that I am getting alert fatigue. Every time I write a prescription for nitroglycerine, I am given an alert that asks me to ensure that my patient isn’t on Viagra. Don’t you think I know that at this point? As for online treatment guidelines, I believe in them up to a point. But once something is in computerized guidelines it’s sacrosanct, whether or not the data are legitimate. Recommendations should be given with notification of how certain we are about them…. Maybe these things are more useful to some doctors than others. If you’re in a subspecialty

10/2/22, 9:25 PM Print

https://content.uagc.edu/print/McNeill.2947.17.1?sections=ch18,ch19,ch20,ch21,ch22&content=all&clientToken=91e0f5df-a186-e33f-c66b-58e2e5a9… 4/18

like cardiology you know it very well. But if you are an internist, you may have shallow knowledge, because you have to cover a wide variety of medical issues.

Many of the people involved in developing computer systems for patient care at Partners regarded these as valid concerns. “Alert fatigue,” for example, had been recognized as a problem within Blackford Middleton’s group for several years. They had tried to eliminate the more obvious alerts, and to make changes in the system to allow physicians to modify the types of alerts they received. There was a difficult line to draw, however, between saving physician attention and saving lives.

Centralized Business Analytics at Partners While much of the centralized analytical activity at Partners has been on the clinical side, the organization is also making progress on business analytics. The primary focus of these efforts is on financial reporting and analysis.

For several years, for example, Partners has employed an external “software as a service” tool to provide reporting on the organization’s revenue cycle. It has also developed several customized analytics applications in the areas of cash management, underpayments, bad debt reserves, and charge capture. These activities primarily took place in the Partners Revenue Finance function.

The Partners Information Systems organization is also increasing its focus on administrative and financial analytics. It is putting in place Compass, a common billing and administrative system, at all Partners hospitals. At the same time, Partners has created a set of standard processes for collecting, defining, and modifying financial and administrative data. Further, as one article put it:

At Partners, John Stone, corporate director for financial and administrative systems, is developing a corporate center of business analytics and business intelligence. Some 12 to 14 financial executives will oversee the center, define Partners’ strategy for data management, and determine data-related budget priorities. “Our analysts spend the majority of their time gathering, cleaning, and scrubbing administrative data and less time providing value-added analytics and insight into what the data is saying,” says Stone. “We want to flip that equation so our

analysts are spending more time producing a story that goes along with the data.”4

(http://content.thuzelearning.com/books/McNeill.2947.17.1/sections/ch18#ch18end04)

Hospital-Specific Analytical Activities—Massachusetts General Hospital MGH, because it was a highly research-driven institution, had long focused primarily on clinical research and the resulting clinical informatics and analytics. In addition to the LMR and CPOE systems used by Partners overall, MGH researchers and staff have developed a number of IT tools to analyze and search clinical data, one of which was a tool that searched across multiple enterprise clinical systems, including the LMR.

While historically, the research, clinical, information systems, and the analytically focused business arms of MGH tended to operate in stove pipes, the challenges of an evolving healthcare landscape have forced a change in that paradigm. For instance, a strong current focus within MGH is on how to achieve federal “meaningful use” reimbursement for the organization’s expenditures on EMR. Because achieving meaningful use objectives is predicated on a high level of coordination among information systems, the physicians, and business intelligence, people like David Y. Ting, the associate medical director for Information Systems for MGH and Massachusetts General Physicians Organization, and Chris Hutchins, the director of Finance Systems and deputy CIO, are beginning to collaborate extensively.

The HITECH/ARRA criteria for Stage 1 EMR meaningful use prescribe 25 specific objectives to incentivize providers to adopt and use electronic health

records.5 (http://content.thuzelearning.com/books/McNeill.2947.17.1/sections/ch18#ch18end05)

To raise the level of EMR use by all its providers, as well as to provide resources for the work needed to achieve that level, MGH has arrived at a novel funds distribution model. They determined that the physicians organization will reserve a portion of the pool of $44,000 per physician toward IT and analytics infrastructure, then distribute the remaining incentive payment across all providers, proportional to the amount of data a particular physician is charged with entering. An internal quality incentive program would serve as the distribution mechanism. So, for example, if you recorded demographics, vital signs, and smoking status for the requisite number of patients, you would receive 30% of the per-physician payment from the pool. If you fulfilled all ten quality measures, you would receive 100% of the payment from the pool. This encourages all physicians to contribute to the meaningful use program, but it also means that no physicians will receive the full amount of $44,000. The incentive from the federal government is up to $44,000 for each eligible provider who fulfills the meaningful use criteria. MGH has examined the objectives and broken them down into ten major pieces of patient data that physicians need to record in the EMR. However, many are not relevant for all of its physicians. For example, a primary care physician would logically enter such data as demographics, vital signs, and smoking status, but these would be less relevant for certain specialists to enter.

Clearly, such a complex quality incentive model requires an unprecedented level of analytics. Currently, Ting, Hutchins, and others at MGH are working to map the myriad clinical and finance data sources that are scattered among individual departments, exist at a hospital site level, or exist at the Partners enterprise level. Simultaneously, they must negotiate data governance agreements even among other Partners entities, to ensure that the requisite data feeds from sources within Partners and pertaining to MGH, but stored outside MGH’s physical data warehouses, are available for MGH analytics purposes.

MGH has some experience with reimbursement metrics based on physician behaviors, having used them in Partners Community HealthCare, Inc. (PCHI), its physician network in the Boston area. Physician incentives have been provided through PCHI on the basis of admission rates, cost-effective use of pharmacy and imaging services, and screening for particular diseases and conditions, such as diabetes. This was also the mechanism used to encourage the adoption of the LMR and CPOE systems by physicians. But MGH, like other providers, struggles with developing clear and transparent metrics across the institution that can help to drive awareness and new behaviors. If MGH could create broadly accessible metrics on individual physicians’ frequency of prescribing generic drugs, for example, it would undoubtedly drive MGH’s competitive physicians to excel in the rankings.

10/2/22, 9:25 PM Print

https://content.uagc.edu/print/McNeill.2947.17.1?sections=ch18,ch19,ch20,ch21,ch22&content=all&clientToken=91e0f5df

Collepals.com Plagiarism Free Papers

Are you looking for custom essay writing service or even dissertation writing services? Just request for our write my paper service, and we'll match you with the best essay writer in your subject! With an exceptional team of professional academic experts in a wide range of subjects, we can guarantee you an unrivaled quality of custom-written papers.

Get ZERO PLAGIARISM, HUMAN WRITTEN ESSAYS

Why Hire Collepals.com writers to do your paper?

Quality- We are experienced and have access to ample research materials.

We write plagiarism Free Content

Confidential- We never share or sell your personal information to third parties.

Support-Chat with us today! We are always waiting to answer all your questions.