**Transcript of Cyberseminar**

**HERC Health Economics Seminar**

**Overview of the Office of Analytics and Business Intelligence**

**Presenter: Stephan Fihn**

**September 19, 2012**

**Overview of the Office of Analytics and Business Intelligence**

**September 19, 2012**

Paul Barnett:Well, it is my great pleasure to introduce Stephan Fihn, who is well known to us in HSR&D, indeed a very productive researcher over the year. More than two hundred and fifty published papers. For eighteen years he headed the Center of Excellence in Seattle and during that time he spent some time commuting from Washington to Washington to be the chief research and development officer and is now taking the position as head of the office of Analytics and Business Intelligence. He is also a professor at Madison at University of Washington, and where for seventeen years he was head of the division of General Internal Medicine. I guess he spends a lot of time on the airplane these days. Steve, looking forward to your presentation.

Steve Fihn:Hey, thanks Paul, can everyone hear me? 

Paul Barnett:Yes, we can. 

Steve Fihn:Great, now let me back up my slides here. I apologize if there are some other people who have seen this or heard this before. Some of this is older material that we have presented in the past about the office, but there may be some new material as well. My plan is to provide a relatively comprehensive but quick overview of the Office of Analytics and Business Intelligence, which we affectionately call ABI and then leave some time for questions and comments. I believe in this lecture mode, you need to go through the old presentation and then the questions. 

Great and it is wonderful to talk to you all. I still consider myself to be in the research pool, so we obviously collaborate with many people in HSR&D on a regular basis. Again, our office was created as part of the realignment, which happened in VHA about eighteen or nineteen months ago. The Office of Informatics and Analytics was established and the overall purpose was to enhance the analytical tasking within VHA, to begin standardizing some of the approaches to how we gather data, analyze it and report; improve efficiencies by consolidating some of the programs and offices that were engaged in that activity; and working to improve data quality. Our mantra really is providing the right information to the right person at the right time. It is a bit trite, but I think it actually does describe accurately what our overarching goal is. 

The Office of Informatics and Analytics has three components, of which ABI is one. The other two are Health Information Governance and many of you interact with them on a regular basis with issues related to data access, data quality, coding, et cetera; and Health Informatics which also through VINCI and many others has a very close relationship to the research community. We all work closely together. Gail Graham is the assistant deputy undersecretary for informatics and analytics, and my other partners who, Marsha Insley is in charge of Health Information Governance, and Terry Cullen who many of you may not have met, she’s been in VA only a few months, previously the CIO from the Indian Health Service, is the director of Health Informatics. 

As you can see, the multiple programs in all these groups, I will not go through this slide in detail, but you can review it at your leisure. In terms of the ABI, we have three component organizations. One is Operational Analytics and Reporting, the director of which is Peter Almenoff, who many of you know from his previous work as a VISN director and as director of IPEC and then as previously the assistant deputy undersecretary for quality and safety. Within OAR there are three programs for... including field analytics... but business analytics, which is primarily [inaudible] and people know that group from Bedford; business reporting, Scott Dingman, who was previously in BSSC; operations and management support, Jill Powers; and then the field analytics program, which I will talk to you about. 

I am going to run through quickly some of the programs that all of these groups are responsible for. Our second division is Clinical Analytics and Reporting, which is directed by Joe Francis who I’m sure everybody knows very well. Actually, I realize this is a little bit out of date because although  Betsy Lancaster is the acting director of Clinical Program Support and Ron Freyburg is actually no longer the head of clinical metrics, he’s moved to field analytics, and that is mainly the IPEC program, which I know you all know. Then performance evaluation, which is headed by Steve Wright, the component of the... What was formerly OQP... that was responsible performance measurements, SHEP and the EPRP program. 

By the way, the third group, which is the smaller part of our program, which is clinical data integration, has several pieces, which includes web solutions, which is headed by Kathy Frisbee, largely doing mobile applications. The CART program, which I think many of you know which is jointly managed between patient care services and ABI, which is directed by John Rumsfeld. Predictive analytics program, which is in development, directed by Chris Nielson; and then what we call analytic support, which includes a variety of other programs, but primarily the National PACT evaluation. There are lots of people; this is only a few of them. There are over two hundred people in ABI and they are scattered widely around the country. It is really a virtual organization. We have a few clusters in Cincinnati and a few other places, but largely it is an entirely virtual organization. 

Again, I’ll go through this as programs, but I like to think about us in terms of our product line, so for management, we produce information-related products which help them make decisions. These include all sorts of ProClarity cubes and dashboards and reports that are used for decision making, process improvement, we have an analytics training program which I’ll describe, and developing tools for collaboration. We also develop... it is for clinicians, again in the realm of... beginning with decisions for population management, real-time data collection. For leadership we are continually putting together reports, both small and large, of issues and programs within VHA. As I mentioned, we are in the process of developing web-based and mobile applications for patients; and for research, working closely, as I’ll mention, with providing relevant data and analytics tools. 

Unidentified Female:Steve, can I interrupt you, I am sorry just for a second. We have gotten a couple of comments, if you could, I don’t know, pull your microphone a little closer, or speak a little bit louder. We are just having some people not able to hear. 

Steve Fihn:I am using the headset.

Unidentified Female:I know, thank you. 

Steve Fihn:Let me see if I can do this... I am showing... so, are people... Is that any better? Can you tell me Heidi... in fact, Mike is telling me it is too loud? 

Unidentified Female:I... it is tough for me. I can hear you really well using the headset, but from people using... just using their computer speakers, the audio quality is not always as great. I... Not better yet, just the feedback I am getting. 

Steve Fihn:Okay, well I... I will talk louder; I will try... again... um please email Heidi... if that still does not work, but I am using my headset here... so and for other healthcare partners, we do benchmarking, leading measures and we are responsible for a lot of the transparency initiatives within VHA. 

I am just going to run through a bunch of products that we do. This is going to be quick... I’m not going into any detail. Really, my purpose here is to give you sort of an idea of the depth and breadth of the products our office produces. So... homelessness as you well know is the secretary’s highest priority and we provide a lot of the data support for that, so I’ll walk through a few of the applications, there’s a homeless services queue, which is used to manage both the program and understand how we are doing. It is used by homeless coordinators at the highest program levels to see how the program is doing. There is a registry of homeless veterans and those at risk. Then there is an application which is used by the homeless program coordinators that allows them to manage that and to track patients down to the patient level. Other projects are mentioned here, but again there is data sharing with HUD as part of the HUD-VASH program. There are dashboards which are constantly being upgraded and we support the office that deals with the homeless folks, Vince Kane and that group who were honored in Washington, DC last week with a [inaudible] award and this is excellent work. 

In terms of mental health, another one of the pie areas, we provide a lot of products. The mental health summary reports, which are used to track national and local mental health programs. The uniformed services handbook, which looks to see how well individual programs are meeting the requirements laid out in that handbook; then an overall mental health information system, which provides metrics for program leadership. 

Many of you are familiar with our primary care products as well, the primary care almanac, which is available from the CPRS tools menu to all primary care providers that looks at panel assignments, metrics, labs, cohorts, et cetera and many, I think primary care providers, find this very useful in managing their panels. There is a newer product called the CANSCORE, which is a predictive model which I will mention a bit more. It provides for all enrolled primary care patients within VA, a weekly updated score based on a complex statistic model that predicts the likelihood of death or hospitalization within ninety days or one year and it mentions that is for all patients enrolled in primary care. Then there is the PACT Compass, which provides metrics related to implementation of PACT at the panel level. There is also the provider cube, which is used to manage panel sizes and we are currently in the process of updating the model to adjust panel sizes. Again, there is also staffing and room application that look at how long clinics are making the necessary allocations of staffing and rooms to implement PACT. There’s also a dual assignment application, and interestingly we just got a request from Congress late last week for updates on numbers of dual assigned veterans so that gets used as well. Finally, there is a primary care mental health integration for the dashboard that looks to track how well we are doing in terms of integrating primary care and mental health, which I think I already mentioned. I apologize. 

Many other projects, we are in the process of re-hosting PCMM in the corporate data warehouse and that the folks from HP, as I understand it, have been tracking that and are moving forward. That’s actually done through Rich Stark in the office of primary care operations but we support that activity and I’ve been working also with them with the PACT team recognition and metric studies to understand a variety of PACT metrics. 

Again, there’s a whole host of other products that we produce on a regular basis. Last estimate, there were probably close to a thousand products which are maintained and they vary widely, so not just clinical products like I’ve shown you, but capital assets, EEO alternatives, dispute resolutions. There is a sexual assault database, which we developed over the last year in response to reports from GAO on this problem. There is data that are collected regularly on the CLCs and a variety of other products that includes looking at enrollment eligibility and revenue, I’ll say a little bit more about that. Consults... and that is a very big deal right now. The NLC, which has met the last two days, spent a lot of time looking at consults and [inaudible] for consults and that has become a very hot topic. We are working with 10N to develop a way to aggregate issue briefs. Many of you know that the facilities send in dozens of these a month up to 10N and there has to this time not been a good way to aggregate them and understand trends in issues that are being dealt with at the facility level. There is a report on rehabilitation services tracking the use of secure messaging and just a variety of others that deal with OEF/OIF, palliative care, women veterans, the nursing dashboard, I mentioned PACT teams, the executive career field plan, which is the performance plans for the network directors and facility directors, et cetera. So that’s just, again, a variety of reports that we put out. Many of them you can find on the VSSC web site. If there are questions specifically about them, you can talk to them. 

I did mention also that OPES, the Office of Productivity, Efficiency and Staffing is in ABI. They do a ton of reports that have to do with productivity and staffing. Also, some very high profile, over the last couple of months, IG did a report which suggested that VA might be potentially overstaffed, particularly in some specialties and we are working through our reports to understand the productivity and staffing issues. Dr. Almenoff with the group there has developed the [inaudible] computer analysis and looked at the efficiency groups which many of the facilities and network directors use to identify areas to improve efficiency. We produce a lot of supporting tools related to operations and transparency as well. On this slide in the upper left here is the Aspire web site, which is both a public and internal web site which lays out performance goals which are aspirational beyond our normal targets. Our Secretary felt that it would be useful to have some very ambitious targets laid out and you can see we put those there and those are available publicly. Recently we have been developing a VA version of the Thompson Reuters reports that sort of pulls together a variety of in-patient and out-patient and operational metrics and then lists facilities in terms of how they do on each of those on a one to five scale. You get sort of a one shot view of overall facility performance and some of the facilities have found these very useful in sort of painting a big picture view of areas in which they might be able to identify areas for improvement. 

Many of you are familiar with the IPEC reports, which have been produced for a long time, which looks at in-patients and ICUs, mortality and length of stay and infection rates and a variety of clinical metrics. I mentioned [inaudible] analysis which looks at these funnel plots as well in terms of facility efficiency, et cetera. 

As I mentioned earlier, we are developing new operational reports, Comp and Pen, non-VA care is a big one. As you know, VA services now contract close to five billion dollars a year in outside care. There hasn’t been a great way to track these and to ensure that they’re being done in a very efficient way. Working through our field analytics program, we are developing a couple of new reports. One links together the fee basis and claims and the payments; the ordering services, so that facilities can start to manage the fee basis. Then an integrated billing and revenue report that can help the facilities track billing for these services. We just recently put out a beta version for an emergency department information system that has a variety of metrics that are available through that. 

Then, one of the big pushes we have been doing over the last year is to start moving as many of these applications. Most of them have functioned previously on just the shadow systems. We are now moving them into the corporate data warehouse to the extent the data are available there, so this is just a list of the reports, which currently are pulling data from the corporate data warehouse as part of the routine reporting functions. Another area in which we are moving forward is the development of web applications. Our first one is something called PCAS, or the Patient Care Assessment System, this effort is being led by Tammy Bach in Denver and essentially it’s a web application that is designed to be used primarily by nurse care managers on the PACT team. It uses the CAN score which I mentioned earlier, to identify high-risk patients and the goal here, this is just one screen save, from as you can see a very full featured application with lots of screens. Basically that lets the nurse care managers do one-stop shopping and pull data from a variety of sources to look at high risk patients, coordinate their care, see what care they are receiving and set task lists and care goals over time to manage complex patients in primary care. It allows them to set a lot of identified patients as high risk on the basis of a number of criteria. 

We are getting ready to roll out a one-stop shop for a lot of these data. As I showed you, with many products, one of the recurring complaints is people just cannot find the data; they do not know whether it exists; and if they do, they do not know where to find it. We are working on having a Google-type front end, in which you simply go in, and type in what you are looking for as opposed to having to hunt through a variety of various web reports. I’m sympathetic, I find myself spending a lot of time doing just that myself and I’m supposed to know all these web applications. 

Many of you are very familiar with the performance measurement system that includes HEDIS and a variety of other performance support that we do as part of the EPRP. Other programs, the SHEP program you are also familiar with; SHEP has undergone some changes in its current year, beginning in the spring, we started with a fifty percent sample replacing the out-patient CAPS module with a new CAPS module that is specifically related to the patient centered medical home. We’re running these in parallel. We will switch over once we’ve done all the validity testing and the necessary correlations so that we can do a shift. I suspect most of you are familiar with SHEP, which is the survey of over six hundred thousand veterans annually. We do, as I mentioned earlier, our external reporting, ASPIRE, I described to you... I showed you the old ASPIRE website, the new ASPIRE website, which will be coming out shortly looks much like Hospital Compare in which you can identify a hospital and then a particular position or result to see how that hospital compares on a variety of domains. We also do report VA hospitals on Hospital Compare but we also have other metrics in addition, so we have a VA hospital compare site. 

I mentioned the CAN score. The CAN score is really our first effort in complex and predictive analytics but as I mentioned Chris Nielson working again with the folks from HSR&D, including Michael Matheny at Vanderbilt, are helping to develop a much more broad-based and robust program of predictive analytics. We mentioned we now have models that are near ready for prime time to identify patients at risk for acute kidney injury, MRSA, C. diff and actually other areas such as suicide. Again, trying to learn both how to efficiently and accurately develop these models. Almost all these models have c-statistics in excess of point eight [inaudible] have become our lower limit now for acceptable models. Many of them are very complicated, the CANSCORE for example pulls about a hundred and fifty variables out and we have been working with various other partners to develop more sophisticated predictive methodologies, and this report, as I mentioned, is available to all primary care providers through the almanac. 

Many of you also are familiar with CART. CART’s been around now for eight or nine years. It’s a point of care program in all cath labs within VA that allows performance benchmarking, national peer review. We have a joint MOU with the FDA for device safety surveillance, and this is one of their sentinel sites and more recently we have been working with the implementation of the RTLS system, the real time locater system, as the first clinical application to use this, and also working with DoD since we now have CART operational in a couple of our DoD partner medical centers. We are developing GIS sophisticated geospatial mapping. This is a map of the CAN scores. We have some dynamic viewers that we are now putting out and much of our reporting in the future will be using the geospatial maps. 

I did also mention the field analytics training program. This is a program, which, in addition to producing, I think, higher quality analytic information; we also help people understand it better and apply it in their work. For the past year, we have had a pilot program in twelve VA medical centers. We are now finishing that pilot, compiling the reports, and getting ready to expand to additional sites in the next several months. Many of you are also familiar with much of the risk adjusted outcomes and metrics and I’ve mentioned those; including particular ones that are produced by IPEC. I also, as many of you know, mentioned that we are responsible for the national evaluation of PACT and oversee the demonstration labs and we will have reports exiting from that... initial reports from that evaluation, shortly. 

I also mentioned Cathy Frisbee’s work leading the mobile applications. These will be for patients as well as for providers and caregivers. Ultimately, they have developed a suite of applications to run on iPads and are now going to be field testing what’s known as clinic in hand, an application for caregivers for disabled veterans. Again, this has only been a, I know it’s a whirlwind, to give you an idea of the kinds of things the office does. I have already touched on some of the products and not nearly described them all, but we are undergoing what seems to be near constant integration in this budget era, it is becoming increasingly crucial for us to achieve efficiencies. We are collaborating with multiple offices and with VBA. For example, we have developed an Aspire web site for them. I think one of the themes here is that traditionally we have gone from retrospective reporting with dashboards and cubes using performance measures for decision-making. Increasingly I think we want to move to real time reporting and prediction and enhance our analytic capacity. One thing I didn’t put on the slides which I think is, to me, one of the most exciting aspects which we’ve been working closely with Jonathan Nebeker, Seth Eisen, and others to develop joint leadership for the VINCI program, which will become... I think, will continue to be a very valuable resource for the research community, but also a high value program for the operational side as well. 

So, let me stop there and I think that gives us a half an hour for questions. So, Paul or  Todd, let us know how to proceed. 

Speaker:One of the, I am not sure if he... if we lost him, but hopefully he will get back on. One of the first questions was just... and maybe you will take the next one Todd, we will just tag team here... was about how to access data that your office may have created. The question was specifically about the homeless registry, but I guess it is kind of a broader question and is does it make sense for researchers to recreate stuff that you have done, but obviously, they need to go through the proper procedures. Where would one start? 

Steve Fihn:We are trying to streamline the procedures. Actually, there has been a committee working on this for several months and there will be a new report out that I’m anxiously anticipating, about the data access and improving and simplifying data access. In many cases, I hope, eliminating the need for DUAs. But we have to wait for a new policy. Again, most of the policies under which the research groups operate as you all well know, are set forth in research handbooks. We work with many people who routinely get data from our office and make data requests through the usual processes and procedures, obviously it varies by office. We are trying to standardize them, but in general, we always strive to provide data when requested, but it obviously has to go through approval and many of those have to go through John Quinn’s office and be reviewed in that way. Our office actually does not handle, usually, the processing of the permission, however once they are in order, we do our best to provide data. I agree, I do not see a lot of reasons to recreate data. One of our goals in working in VINCI is actually to develop a common site where data can be accessible so they do not have to be recreated. I do not know if that answers... that is a pretty general and vague answer without... you know there are so many situations as you know, I cannot really say... 

Speaker:So the specific steps you would go is go to the national data systems web site.

Steve Fihn:Exactly.

Speaker:And they... it may require for some of these operations data set, a specific data use agreement with the operations partner who created the data set. 

Steve Fihn:Right, and we are trying... I think... I am hoping we can eliminate the need for some of those DUAs. We have gotten a general decision from General Counsel, within, say, data that stay within VHA may not in many cases require DUA, but I think we will have to look and see when that new handbook is issued, so specifically the circumstances in which DUAs are no longer required. 

Speaker:Sounds great, so because I think, Steve, you presented such a breadth of material, I think the questions reflect that. We have some very specific questions that I am trying to answer some probably off line, but I will... I apologize if some of these are very specific. Feel free to punt them if you want to. Have you had any involvement in the problem of staffing the homeless or suicide hotline call centers and helping them use querying theory to analyze their staffing problems? 

Steve Fihn:Oh, you mean queuing theory. No, I think that would fall more in the realm of the VERCs. We do... I actually do not know. You would have to drill down the detail. I do not know if we do those staffing models, so I have to plead ignorance on that. I would suggest that you just get in touch with the program owners for that. That would be Vince Kane’s group, I think.

Speaker:Then there was a question about the OPES web site. Evidently, in the past they had a restriction that only seven or eight individuals per medical center could use the web site, get permission to use the OPES web site and they are wondering if that’s still true and... 

Steve Fihn:I do not know the answer to that one either. Sometimes there are license restrictions based on the software that they use. They do use some proprietary software like ACG. We are actually now in the process of trying to... DCG excuse me... we are now in the process of doing an evaluation to see if we’ll continue to use DCGs. My guess is some of that might actually be restrictions based on enterprise licenses for the software. Again, I think you can contact Eileen Moran [PH] directly and the folks at OPES to get clarification about that. 

Speaker:Okay, that sounds great. With respect to the CAN score and predictive analytics, is there any documentation that we can access in the models utilized for these analytics? 

Steve Fihn:Yes. We have actually published the first article, which is heart failure. That just came out I think... I can look it up as the... the... that model is described in detail in that article. Actually, we have an article under revision and if I can find my way quickly, I will get that back to the journal in the next couple of days. It describes the CAN model in detail. But in the interim, we are happy to provide [inaudible] if people want to [inaudible] for their own personal use. 

Speaker:And my understanding, Steve, is the CAN model was developed on a heart failure sample to look at readmissions and mortality? 

Steve Fihn:No, no it was, originally, I think if you can see on your screen, here is the American Journal of Cardiology that we started with a heart study and model just because it was a little more practical. It is a smaller number of patients. There were only about three hundred thousand patients in that group and there is some fairly extensive literature, so we had some benchmarks that we could talk about. No, the current CAN model was developed on all primary care patients and it’s run on about six million patients. But the models are actually... you know again... the models are similar... They are obviously not identical and the coefficients for some of the terms changed, but if, for example, you look at the CMS mortality models for AMI, pneumonia, and heart failure, you notice there are much more alike than they are different, in fact the AMI and CHF models are exactly the same in terms of the variables. Again, when you are dealing with a very chronically ill population, predicting these major outcomes, it makes sense that many of the same variables are entered into all of the models. Generally, the CAN model is based on all primary care patients. 

Speaker:So there are a couple of questions about the field analytics training. People are wondering if there is an opportunity to participate, but I think there is probably a larger question about how we learn more. 

Steve Fihn:There is a field analytics web site and I would encourage people to go here. Here is the web site... maybe after the call you can send out the link. Largely, this has several components, the field analytics program. First, there is an educational component. We do a lot of onsite training as well as there’s actually a certificate program through the University of Nebraska, although we are switching institutions now. There is a four tier educational program and people can come out with a certificate. In terms of the... and that is open very widely. We have also supplemented that with some online training through Bellevue Community College that is just outside Seattle. I think a thousand people have done that analytics certificate program. 

We are working with the twelve... actually now eleven pilot sites in which our teams go in there, they identify problems that they want to work on. We try to work with them on how they use data and develop analytic resources, and then track that over time because one of the goals here, and Dr. Petzel has felt very strongly about this, that every institution ought to have a whole coterie of individuals who are really facile with using data. Knowing where to find it, how to apply it, and working with their system re-design teams in order to make process improvements based on analytics, so, again, that’s been defined as a huge need within the organization. It was interesting to me that when we opened up that online distance-learning program at Bellevue Community College that a thousand people ended up on the waiting list after two hours. That it was so quickly subscribed, I think, is a reflection of the perceived need for analytics training within the organization. I hope that answers the question. 

Speaker:I think the answer will be we will send the URL to this web page out. 

Unidentified Male:Steve, if I could get you to think big, and if you were to throw down the gauntlet to the seat of researchers, and say over the next two to five years, this is what operations really needs researchers to think about and to really push VA forward. What would you say are the top three things? 

Steve Fihn:First, I think in the general area of analytic metrics, I mean the CAN report is still using what I consider to be old school methods for those complex statistics models. There are far more sophisticated predictive analytic models out. We’re exploring all kinds of multi-stage models, Bayesian models; we not only need to know which perform better, but there are performance issues as well too... computing, overhead, bandwidth requirements. As you look ahead, the EHR of the future is going to be a highly customized web-based program, which is going to look different for every user, it’s going to be available to program people, provider-facing, patient-facing and there will be opportunities I think for real time decision support. Can we run every week, there’s data in the corporate data warehouse, some of this data in the model are only refreshed weekly, so that’s as often as we can run the model. But in reality, what you’d really like is a button to click in the EHR that would return the results to you instantaneously. As we develop increasing numbers of predictive models, then we have to figure out how do you pick the targets, how do you optimize the models?

We are facing lots of questions as we develop sorts of suites of these models. What are the most efficient ways to create the models? How do we update them? The model performance degrades over time, so we need to develop monitoring tools for these models as well as... There’s a whole host of issues related to predictive modeling and I think the era where someone does a model and puts it out in a paper and says here’s the model we developed and it doesn’t get used by anybody and it is not necessarily replicable in other health groups, you know I really think that era has passed.  Every system is going to have to customize these models for their particular patient population, the intricacies of their data, so that’s a huge area, I think, in which I have not seen much research in HSR&D happening and I do know that we have actually been working with IBM Watson folks. We have been working with, hoping to work closely with DoD for example on using a lot of other data sources. 

I don’t know if this is another thing Todd, but the latest, the whole area of  how do we use NLP and VINCI has a huge research... not a huge but a very robust research program in there. I think there is a lot of research that needs to be done about where that fits into the larger area of data and use of data for improving, for doing both research and improving patient care. My focus these days, given my position, is more on the operational and the process improvement side. I think the NLP holds great promise, and then another large area, I think, has to do with the area of data combinations. Again, combining and synthesizing analytic data so we have developed a thousand data products, only a small proportion of people actually are probably expert users of those products. 

I think the ProClarity cubes, the dashboards, people are overwhelmed by that and we really need to understand ways in which these data can be meaningfully condensed and synthesized. The final common pathway for a lot of the data will be decision support systems, both for managers, for clinicians. Right now our decision support systems, I think, are rudimentary and crude at best. The clinical reminder system basically is a hammer. It does not use nearly... it uses only a very small fraction of the relevant information that exists within our system. There is no context sensitivity, so you give the same reminder to medical students that we give to experienced clinicians, or we do not look at priorities. People get overwhelmed with data and they tend to turn them all off. We know from our system who the user is, we know who the patient is, we know past history, we could be designing these guides in all sorts of very smart kinds of clinical decision support, and we should get rid of the term “reminder”, in fact.

Then thinking about how you deliver those. I think there is a whole set of research related to the behavioral, psychological aspects of data presentation, how people use these data, how they are going to get them, how they are effectively transmitted. That’s similar to [inaudible]. I don’t know if that was two things or ten things, but a whole list of sort of areas in which in my daily work I have questions almost every day about how to do that. Another whole area in the economics realm that is going to be huge are questions of how do we measure value? We have got all these data, we have got these performance data, we have got these outcome data, and we have got shrinking, shrinking budgets and everyone is asking the same question. How do we tell where we should devote our resources; and not just in terms of traditional cost/benefit analyses, but coming up with some sort of estimates of value and particularly how to do return on investment. 

One of the things we are doing in the PACT evaluation is trying to understand how you could value what the investment in PACT is. It is a simple question it seems. On top, it is obviously quite difficult, particularly in an area where many things are happening simultaneously. Lots of co-interventions, lots of contamination and also very large secular trends in things like hospital admissions, ED visits, primary care utilization. How do we bring all those data together in a meaningful way, because Congress, the public, the Secretary’s office, is asking the question, you know we are spending a billion dollars on this? What did we get? That is a good question. To me there are just so many questions. As I look at the research agenda, I can think of dozens of areas in which... the kinds of things we are dealing with on a daily basis raise questions. We would love to know in order to be able to work better. 

Speaker:Thank you Steve. Somebody actually typed in a comment that says, when you mention the fewer dashboards, this person said, “I believe the VA needs fewer dashboard reports and more directly actionable support for clinicians and their teams so that actionable key items may be transmitted to the appropriate member of the clinical teams.” I think people definitely resonate with those comments you were suggesting. 

Steve Fihn:Yeah, we have a long way to go organizationally. And again, for the anthropologists, how do you get an organizational culture to change? A culture that was really focused on [inaudible] performance measures to just sort of get to what it takes to try and get those data down low in the organizations, empower people to use those data. Part of that is sort of the goal of the field analytics program, but I think, organizationally, lots of things have to happen, so I would agree with that. 

Speaker:Are there organizations that are doing it right in your estimation? Just to pick on two in your neck of the woods, Virginia Mason, and Group Health often come up. But if people were to do cross-system comparisons; are there systems that we should be thinking more about? 

Steve Fihn:We are looking at them. I know Group Health and Virginia Mason quite well. I am actually looking out my window at both of them right now and the weather here in Seattle is gorgeous, seventy-five, sunny, not a cloud in the sky. I think they have their strengths. Virginia Mason has really adopted LEAN and I think they have really become experts in the process improvement, particularly in clinical micro systems and I think we could learn a lot from them and many VA people have been to Mason. Group Health has been implementing the patient-centered medical home and we communicate with them a great deal. In fact, they are adopting a CAN model as we speak. They’ve started to use it in their system. I think they have their strengths. You know, we also visited recently, I’m in the process of working with the [inaudible] folks up in Anchorage. They have a very interesting system in the way they use data and their culture, so we are definitely looking at other systems. My own view is there is no system that’s sort of hit a home run in this area yet and I’d love to see VA be the one that does sort of  hit it out of the park here, but I know it’s going to take a lot of work to get there. 

Todd Wagner:Thanks Steve, any other comments or questions coming in Paul? I don’t see anything else. 

Paul Barnett:I do not see anything else. There are some that we may have skipped that were pretty specific though. I was just wondering if you think there is any great accomplishments, any home runs, if you will, that have been hit by the analytics folks in VA that might be a model for other things that we do. 

Steve Fihn:I think we beat ourselves up a lot about not meeting our own standards. If I look at the private sector, you know, VA, in terms of the ability to collect data and deliver it back is remarkable and when people from other systems come and look at our system, they are actually awestruck by what we are able to do. In my mind the big one... I would not call it a home run yet, but I think it is what’s going to allow us to do that, is the corporate data warehouse is going to be an enormous asset for us. It gets us out of the retrospective view we have had with enough data sets and allows us to do things in real time, looking forward. I think that is going to be a paradigm change for how health services researchers are able to do their work. The problem with when we are in this paradigm, and you’ve got two years to get a grant application and three years to finish your grant and another year to write it up; it doesn’t work because of the time-frame in which we are currently working. I mean start to finish on the CAN program, was under a year from when we started the project to when it was actually implemented in the system. The papers are getting done now, later, but in the PACT evaluation, thing are... we measure our progress in weeks. 

Todd Wagner:Did we lose Steve? 

Paul Barnett:It sounds like we lost Steve’s audio there. We have just some fuzzy noise. Well, if you can hear us Steve, maybe you need to reconnect, we will see. 

Moderator:Yeah, he just went to an off line status, so I’m guessing that something happened at their local facility causing an internet outage or something like that and since he was using the VOIP audio, we lost that. 

Todd Wagner:It is that beautiful weather in Seattle, it only happens rarely and so, they cut the internet so people can get outside. 

Paul Barnett:I was talking to someone in the other Washington last night; they said oh, there are tornadoes out my window, so I think he is in the right Washington today. 

Todd Wagner:So we should probably wrap up. I just wanted to thank Steve for speaking today about OABI, so it is an amazing system that they have set up and hopefully we can get more information, learn more about it, and get a chance to work with them. Do you have any closing comments Paul? 

Paul:Well, just that we have promised to make available to people that information about the field analytics, how you get more training in this. And I guess, Heidi, is that something you would distribute, or you count on us to do it? I am not... 

Heidi:No, I will take care of that. We always send that archive notice out to the audience after the session and I will get in touch with Steve this afternoon and make sure I have all the links that he wants to send out and I’ll include all of that with the archive notice I’m going to send out. 

Paul:Well, that is wonderful of you, thanks. 

Heidi:Not a problem. 

Paul:Then we should also announce what is next. 

Heidi:Our next session in the HERC economics session series is scheduled for October 17th and Denise Hynes will be presenting colon cancer costs and quality of care and we sent out some registration information on that yesterday and we will send out further registration information as we get closer to the session. Thank you everyone. 

Todd:Thank you Heidi and thank you Paul. 

Paul:Thanks all. 

Heidi:Thank you all for joining us today, we will see you at a future session. Thank you. 

Page 12 of 12