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Pitfalls of Analytical Product Development and How to Escape Them

Data Analytics

Our health care analysts build data-driven products (dashboards, reports, etc.), and they think through all of the technical implementation steps required to make these products successful. The next step determines the success of the product: pinpointing and avoiding the potential pitfalls that can undermine its usefulness. These pitfalls include:

  • Failure to understand what we really mean by "business intelligence"
  • Poor understanding of the users of our product and their needs
  • Poor data management

Often data sources look like a dangerous cocktail of social determinants of health coupled with genetic, environmental and clinical data with other information thrown in. Finding a meaningful way to manage these data and capitalize on the value of the information can be challenging.

Let’s look at the end user of our analytical products – the provider. The volume, variety and velocity of available information can far exceed any professional’s abilities to process and interpret. For example, our Partnership to Advance Tribal Health (PATH) participating hospitals are bombarded and confused by multiple layers of mandatory reporting and dashboards provided by local area offices, their Medicare Quality Improvement Networks, their Hospital Improvement Innovation Network organization, tribal epidemiology centers, state departments of health and many more organizations.

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Why Talking Matters

speech bubbles

Late last year I decided to tackle a topic I had been putting off for quite some time – having the dreaded end-of-life conversation with my family. No, I am not ill (thankfully), nor are my loved ones currently going through a difficult situation. However, I think it’s important to have these discussions while my family and I are in good health, without the added pressure of chronic disease or terminal illness.

I decided to start the conversation with myself and then talk with my husband, adult children, sister, mother and so on. I wanted to make some decisions about what was important to me so that others wouldn’t one day find themselves trying to figure that out for me. I love my family, but do they know what matters most to me?

I live in a house where I am the only female, so history has taught me to be at least a little skeptical that my husband and sons would be in tune with my personal wishes. I’m thinking they could use a little help in that department and would be grateful to receive it – God forbid they would need to act on it anytime soon.

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We Can’t Let Inertia Set In!

Hands in a circle

Many of you may be wondering what will happen with federal legislation to either repeal or replace the Affordable Care Act. And we’re equally curious when it will happen. Many people have told me, “Surely, by the fall we will have some legislative fix around repeal or replace.” I don’t think that’s very likely. In fact, I don’t think it’s even very likely to happen in this calendar year. There are too many special interests and not enough working across party lines to reach consensus or alignment around the core issues impacting health care. The current discussion has essentially focused only on health care coverage – which is critical, but it hasn’t even touched the areas of changing how we provide health care, how we pay for care, the supply of health care professionals, and the innovative part of health care that we need as we move into this new health care environment. We have seen lots of talk but, as of yet, no real movement over the last couple of months. So, for now the Affordable Care Act is still the law of the land.

It’s anyone’s guess as to whether the gridlock in Washington will be resolved any time in the near future. For this reason, we must not allow inertia to set in. We have a broken health care system and we can’t expect that any one federal or state policy will fix it. There is so much uncertainty in all sectors of health care that you can almost sense the inertia beginning. We can’t let that happen: we need to continue to push and innovate transparency in the system around quality and cost; we need to continue to support and fund innovation; we need to continue to pilot and experiment with different payment models; and ultimately, we need to continue to push for the new health care system of the 21st century.

It’s hard work, but those of us in the trenches must roll up our sleeves and identify new partners to align with in order to drive toward a new agenda for health care. We must support our colleagues and providers on the ground in their day-to-day efforts to create a higher quality, more efficient system and walk hand-in-hand with them in a spirit of experimentation. We can’t go backward: we need to continue to look forward in our vision of how health care can and should look. We’re the torch bearers and we must continue to carry the torch forward.

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The Path of Totality—Did You See It?

Solar Eclipse

A young man, transported from 20th century Connecticut to King Arthur’s court, finds himself in a pickle, and tied to a stake for performing acts of sorcery. He happened to have an almanac with him and knew that a solar eclipse was about to occur. He warns the king that he will make the sun disappear, and on cue, the sky darkens and the sun sinks into a black hole. The king pleads with him and the young man agrees to make the sun reappear in return for his freedom.

Whenever I hear about a solar eclipse, I can’t help but think about Bing Crosby in the 1949 movie, “A Connecticut Yankee in King Arthur’s Court,” an updated version of Mark Twain’s 1889 novel. That particular scene portrays a historical representation of omens and superstition that have accompanied solar and lunar eclipses for centuries.

Today, we know that a total solar eclipse occurs when the new moon passes between the earth and the sun at a distance where the moon and the sun appear to be the same size. If in the path of totality, you would see the sun disappear for a short while, followed by images that are described as truly magnificent. The hype leading to the 2017 eclipse led millions of people to flock to the path of totality to observe what could be a once in a lifetime experience.

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Working Upstream

Granddad and granddaughter fishing

Summertime in the Pacific Northwest is a great time to catch a glimpse of salmon making the life and death journey swimming upstream back to the place of their birth.

We often talk about working “upstream” with patients with kidney failure and how critically important, yet difficult, this work can be. One out of seven Americans (30 million!) has chronic kidney disease (CKD), often referred to as the “silent killer,” due to symptoms that are undetectable until it is too late. Not only is CKD a growing public health threat, but the health care costs associated with CKD and end stage renal disease (ESRD) represent more than a quarter of all Centers for Medicare & Medicaid Services (CMS) claims.

Nephrologists who care for kidney patients have increasingly expressed their concern for the lack of care for patients in the early stages of ESRD (stage 1-4) before kidney failure (stage 5). Dr. Louis Cotterell, a nephrologist and member of the ESRD Network board of directors, relayed the importance of working “upstream”, he said:

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Medicare Payment Reform Ramps Up: How Are We Doing?

It’s been five years since the first Pioneer Medicare Accountable Care Organizations (ACOs) formed, marking the beginning of Medicare payment reform and now one year of the Quality Payment Program (QPP) is up. So, how are we doing? And what can we still learn as it rolls out? The QPP was created to implement Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and if we’ve learned anything in the first year, it is that practices need support to make the changes needed to be successful. I want to highlight three recent articles that have given me pause and can give us direction for our efforts on the path from volume to value.

In the past quarter, a few interesting reports on MACRA and QPP have been published, framing the current status of provider participation, understanding, and potential impact of payment reform. Two reports take a pulse of American physicians. First, the American Academy of Family Physicians (AAFP) self-report Annual Member Survey of 2017 looked at member family physicians and found that 83 percent of reporters take Medicare patients, a record high in the last decade for family docs, yet only 50 percent consider themselves “somewhat-to-very-aware” of QPP/MACRA. And earlier this year, 45 percent reported being “undecided” on their plan to participate in MIPS or APMS.

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Medicare, Up Close and Personal

Senior Couple Gardening

Several months ago, I began receiving a flood of letters and phone messages from health plans, insurance brokers and others, reminding me—as if I needed reminding—that I was about to turn 65. “It’s almost time!” they said. “Congrats in advance!”

They were concerned about my future health coverage and wanted me to get the most out of life. They understood my confusion and were there to help. Some even offered me a free meal.

“You have a limited window of time to enroll,” they warned. “You have options, we have answers. Give yourself the coverage you need. You owe it to yourself…”

Not getting enough love from strangers? Join the Medicare marketing cohort!

Joking aside, Medicare is about to get up close and personal for me. Until lately, I thought of it as a nebulous bureaucratic system I would need to engage with “one of these days.” Even as a communicator for a Medicare contractor, I sometimes found it hard to relate to the quality-of-care issues our organization grapples with every day. Now the program and its future have my full attention.

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Health Cost Reform – Whose Ox Gets Gored?

Healthcare costs

There has been much ado in the news about health care reform, health coverage reform, health payment reform and clinical practice reform. All are tangential references to the real elephant in the room — health cost reform.

Why has the elephant grown so large? Is there a combination of diet and exercise that can help our elephant become slim and trim?

Your perspective on the reasons and solutions depends on the part of the elephant closest to you. If near the poor, unhealthy, uninsured patient part of the elephant, mandatory affordable health insurance for all is the ticket. If near the insurer part of the elephant, your focus is reducing the discretionary price-gouging, cost-shifting and wasteful choices of consumers and providers. If near the employer and plan sponsor part, you may wonder whether replacing employees with robots may be the better way to avoid health costs. Those near the care and treatment part fuss about the onerous rules, processes and habits that interfere with engaging patients in achieving and maintaining better health. Those near the social and mental health part of the elephant see a need for allocating more resources to prevention and education than to rescue.

Everybody sees that the big elephant is crowding out other important things desired for the room, such as wage increases, job protection, life choices, equitable access and security.

All parts of the elephant need to shrink to a more normal size. The March 2013 Time Magazine article by Steven Brill - Bitter Pill, Why Medical Bills Are Killing Us describes many wasteful practices that perhaps could be curtailed. But where do we start? Whose ox gets gored?

We Americans tend to prefer "nudges" to affect sustained change rather than voting for more government mandates typical in other lower-cost countries. Therefore, perhaps we should leverage all available resources to favorably influence the choices of health care users and providers to affordably improve our health.

We need to seek first to understand and prioritize what is most important.

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Auditor, Audit Thyself

MW Blog 7 14 2017 Sandia Crest The Needle sm

Numbers. Numbers can tell us many things, including how good or bad something is. When the numbers are low in my bank account, that’s bad. When the numbers are high, that’s good. As a member of the External Quality Review (EQR) team, numbers are part of my daily routine. As a nurse and an auditor, I’m trained to interpret different numbers. In quality review, numbers tell us about the effectiveness of an organization's objectives. In our personal lives, numbers tell us if we are meeting our own objectives or if we’re headed in the wrong direction.


Last year, when our staff underwent biometric screening, I had my blood drawn, just like many of my co-workers. Unlike many others, my numbers were bad. As a nurse, I know about lab results and what patients should do when the results are bad. When I saw how high my hemoglobin A1C was, I paid attention. I knew what this number meant – if I didn’t do something soon, I would soon be diabetic and need insulin, just like my parents. I needed to figure out how to do the improvement.

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Behavior Change and Duct Tape – the Stickier, the Better!

Couple walking

Adopting a new behavior, even one that is good for us, can be difficult. I belong to a gym, and I've come to observe each January with interest. That's when the resolutionists, as I affectionately call them, flood the gym for the first several weeks of the new year after making some sort of fitness resolution. The parking lot becomes crowded and exercise machines are busier than ever. (They really like the treadmills for some reason). While I hope a few new faces will stick with it and become familiar over the coming months, most of the crowd has dispersed by the early part of February and continues to taper over the following months until we're largely back to our usual routine. As I looked around the gym recently, I wondered – what would it take to retain a greater percentage of the resolutionists?

We know that individual behaviors are substantial contributors to our health outcomes, representing about 30-50 percent according to a Health Affairs Policy Brief. But how can we effectively take charge of our own health by implementing and retaining more healthy behaviors?

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As Payment Moves to Value, the Circle of Root Causes Expands

Group in conference room

Over the past 20 years at HealthInsight, I've had the opportunity to work with health care providers and organizations on root cause analysis to learn from sentinel events, patient harms and other negative, unwanted and unexpected events. Seeking to prevent future harms, we've learned that the most important answers to the question "why did this happen?" – the root causes – are often far removed in time and space from the events that occasioned the review.

Cause and effect analysis is a technique employed in root cause analysis that pushes you to consider all possible causes of a problem, rather than just the ones that are proximal and obvious. Forms of cause and effect analysis include the "5 Whys" and causal tree analysis. Analyses using these techniques produce cause-effect chains, with each identified cause itself becoming the effect of preceding causes. When learning and applying either of these analysis techniques, it's not always clear when the analysis stops, because one can always propose a preceding cause – even if you have to go back to the "big bang."

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Toward a Multistakeholder Approach to Payment Reform


MACRA. QPP. MIPS. Value-based payment. If you feel lost in the sea of acronyms, reporting requirements and systems-level change, you aren't alone. Years of ongoing effort to transform the health care delivery system are now aligning with Medicare's commitment to paying for high-value care, and the change process seems dizzying at times.

Almost everyone agrees that the cost of health care is unsustainable and we must change the way we pay for care. Yet providers, health plans and other stakeholders face significant barriers as they strive to implement and sustain new payment models. System changes come with innumerable intricacies and nuances, including concerns about who wins and who loses. A major challenge is how to obtain and share reliable data to inform and test new models, and to reassure providers who are asked to accept accountability for improving quality while reducing cost. In the midst of these swirling changes, practices have to keep working hard to ensure high-quality care that satisfies their patients.

As I've worked in system change initiatives with multiple stakeholder groups over the years, I've noted all too often that stakeholders tend to work on addressing challenges within their individual spheres—be it a clinical practice, an organization or a network—even though adjustments in one part of the system have an impact on all others. Sustainable change depends on making all adjustments mesh effectively for all stakeholders.

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What is Return on Investment for the QIO Program?

2016 QIO Program Progress Report

Thoughts from a fiscally conservative taxpayer

I have been working for HealthInsight since 1995 and most of that time has been spent operationalizing the Medicare Quality Improvement Organization (QIO) contracts over the years. During this journey, there have been numerous times when the QIO program has been assessed by various entities to determine whether it produces value for Medicare beneficiaries, health care providers and ultimately the U.S. taxpayer who funds the program.

In the effort of being transparent, I believe any taxpayer funded program should be thoroughly reviewed to determine value to the ultimate funder. After all, the U.S. has a national debt approaching $20 trillion or about $60,000 per citizen, so all dollars need to be cherished. If the QIO program is funded in the $1 - $3 billion range—an educated guess—for this contract cycle, what is the estimated return on that investment? What impact, if any, does the QIO program have in driving change?

Being part of the QIO program for over two decades, I have sometimes struggled with my own internal debates and have been defensive when it appears the QIO program has received criticism from various entities for failing to "transform" the health care system or failing to be a cost effective program. I argue of course the QIO program is producing change and transformation. I pull out pre and post measures and data over time to show localized impact as well as community engagement levels. On the other hand, I ponder: is the QIO really a primary lever in any observed changes? Would any of these observed and measured improvements have happened without the QIO program?

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A National Epidemic; Local Experience


Katie has been my dental hygienist for the past 20 years. At my most recent "clean and check" visit, she told me about an encounter she had with the health care system.

She said that after experiencing a headache for a couple of days, she started to notice an odd crackly sound in her ear. She decided to have it checked out at the local quick care clinic. The quick care doctor told Katie she had an ear infection that would require antibiotics.

"What is your antibiotic of choice?" he asked her. "A Z-Pac, antibiotic A or antibiotic B. What do you prefer?"

Stunned, she said she just wanted what would be best to treat the infection. When she got to the pharmacy to pick up the antibiotic, the pharmacist began with an apology.

"I'm sorry," he said, "but we don't have enough hydrocodone to fill the doctor's prescription."

Now confused, Katie asked the pharmacist what he was talking about. He told her that the doctor had ordered 50 hydrocodone to treat her headache. She told the pharmacist not to worry about it, because although she mentioned to the doctor she had a headache, she had not sought treatment for it.

Lying in the dental chair with my head below her hands and a metal tool in my wide-open mouth, she asked, "Does this sound odd to you?"

Where to start?

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HealthInsight: A Top Workplace in New Mexico

Albuquerque Journal Top Work Place

Each year the Albuquerque Journal offers the opportunity for businesses to be considered for inclusion among the state's "Top Workplaces." This opportunity is offered throughout the country and HealthInsight Utah has been recognized before as well. This year and previously in 2013, HealthInsight New Mexico was named a Top Workplace.

Our journey began with an employee first nominating the organization to be considered, which was gratifying in itself. Following the nomination, management has to agree to support the nomination by allowing employees to participate in a survey. Employee responses are what determine an organization's success in the process.

The survey focuses on characteristics of an organization that are related to organizational health and employee engagement.

Among the strengths that emerged from our survey data were that employees believe they are part of something meaningful and that they feel enabled to work to their full potential. Those are powerful statements.

When I'm asked about what's important to me about where I work, the first thing I talk about is that the organization is mission driven. It's heavily focused on improving health status and health care in the locations we serve. New Mexico probably faces some of the greatest challenges, and every day I see staff dedicated to that mission because they feel they are part of something important.

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Finding New Vistas in Health Care


A couple of weeks ago, I was talking with a neighbor who had just completed a 100-mile race across the Bonneville Salt Flats in Utah. He is an adventurer who loves river running, skiing and most any outdoor activity. I enjoy hiking, so we often talk about different trails in Utah. I've lived in Salt Lake City most of my life and feel I'm pretty knowledgeable about local treks, until he told me about the Heughs Canyon waterfall. I had never heard of this waterfall and was intrigued since the trailhead was less than 10 minutes away from my neighborhood.

My wife and I hiked to this beautiful waterfall last weekend and were surprised to find a cave, lean-to and fun bridges on the trail. As I was returning from the hike, I was reminded of the knowledge (and adventures) right under our noses that we often overlook because we don't know where to find them. I was grateful for a friend who pushes beyond the status quo and finds new adventures in the outdoors.

In health care, we are constantly pushing beyond the limits and looking for transformation and innovation to propel our health care system to heights never seen before. Currently, payment reform is big focus. Medicare is taking a leading role with bipartisan support behind the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) legislation and is beginning to roll out the Quality Payment Program (QPP). There is a lot of information and resources about payment reform and QPP that clinicians may not know are available.

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Inspiring Leaders in an Environment of Change

Young Adults

Rapid organizational change can be both exciting and unsettling at the same time. HealthInsight has experienced its share of this kind of rapid change in the past few years—so much so that exciting and unsettling seems to describe just about every day around here. We've seen:

  • Significant corporate growth, most recently by expanding our programs into Oregon and into End-Stage Renal Disease work.
  • Challenging new initiatives on top of our already large portfolio of work for the Medicare program—including but not limited to helping improve the quality of care in Indian Health Service hospitals across the nation, integrating behavioral health screening into primary care and preparing Medicare providers for value-based payment.
  • Regionalization of several of our programs, requiring new ways of engaging stakeholders and coordinating regional activities while maintaining essential local focus.
  • Persistent and pervasive uncertainty and change in the health care environment we seek to influence.

This rapid change in our organization and in the world is very likely to continue into the future as well. But the pace and intensity of efforts to keep up and reinvent our organization has led at times to "change fatigue," similar to the burnout that many of our stakeholders have reported experiencing as they implement multiple, simultaneous and sometime overlapping quality improvement activities.

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United to Save Lives

Man and woman looking at meds

A few weeks ago, I was privileged to join 2,250 other attendees at the 2017 National Rx Drug Abuse & Heroin Summit in Atlanta, put on by Operation UNITE. Billed as "the largest annual conference addressing the opioid crisis," this event brings together professionals from across the nation to discuss how to respond to the epidemic of opioid abuse, misuse and overdose.

Attendees of this summit are acutely aware of the grim statistics. The Centers for Disease Control and Prevention reported more than 33,000 deaths in 2015 from prescription opioids and heroin. That's an average of more than 90 deaths a day of Americans from all parts of the country, all walks of life and all age groups.

As a non-health care professional, I listened for three days as advocates, researchers, providers, clinicians, law enforcement and government officials—including my HealthInsight Oregon colleagues—described efforts to reverse the current trends and save lives. I heard about many initiatives, ranging from prevention of opioid abuse and misuse to addiction services and diversion tools. Several focus areas emerged for me.

  • Reduce unneeded opioid prescribing. Prescription Drug Monitoring Programs are electronic databases that provide a complete history of controlled prescription medications given to a patient. Almost all states have implemented these programs to help physicians and pharmacists detect worrisome prescribing patterns and reduce harmful drug interactions and overprescribing.
  • Consider alternative methods to treat and manage pain. Non-pharmaceutical treatments and non-opioid medications are preferred over opioids for most painful conditions. There is good evidence that non-pharmaceutical treatments are beneficial, with low cost and minimal side effects. These treatments include physical and occupational therapy, acupuncture, chiropractic and massage therapy as well as cognitive behavioral therapy and guided meditation to redirect painful symptoms. Physicians are seeing the value of these kinds of treatments and insurers have begun paying for them. When opioids are needed to treat serious painful conditions, providers and pharmacists play an essential role in educating patients and their families about the risk of opioids and how to safely use, store and dispose of them.
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New ATOP Director Talks Project Progress and Perspective


I fully embraced the opportunity to join HealthInsight Nevada as the director of the Admissions and Transitions Optimization Program (ATOP) in October 2016 and take the reins of the Phase 2 project. It has been an extraordinary six months of learning and leading for me with invaluable professional and personal growth. ATOP began in 2012 with Phase 1 targeting 24 nursing facilities in Nevada to receive supplemental clinical resources by making RNs and APRNs available to improve the health care outcomes of long-term residents and reduce health care costs without restricting access to care or choice of provider. ATOP nurses focused on the training and education of facility staff (CNAs, LPNs, RNs) as well as providing direct care (in a teaching manner) to facility residents. This project was driven by a Centers for Medicare & Medicaid Services (CMS) measurement showing that a staggering 45 percent of hospital transfers for this population are deemed potentially avoidable.

Phase 1 concluded in September 2016 with impressive results. The ATOP project in Nevada reported that total spending dropped 21.7 percent per resident on average and potentially avoidable hospitalization occurrences declined by 25.5 percent.

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Medication Management: No Simple Task

Closeup pills

$320 billion – this is how much money was spent in 2015 on prescription medications, according to the Centers for Medicare & Medicaid Services' Office of the Actuary National Health Statistics.

10 percent – this is the percentage of people who are taking at least five medications a month, according to the Centers for Disease Control and Prevention's National Center for Health Statistics.

We know that older adults are likely to be on more medications to manage their chronic conditions, and we also know that four out of every 1,000 patients visit the emergency room for adverse events related to their medications. Patients see many different providers. New drugs are coming into the market that may interact with others. Transport to the pharmacy may be an issue. Older patients may not be able to hear the prompts to refill a prescription. And, of course, costs continue to rise. How do patients and their care givers keep on top of all of this?

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