1. VA Decision Support System (DSS) Paul G. Barnett PhD Wei Yu, PhD Samuel King, MS Ciaran Phibbs, PhD July 20, 2005

2. Outline of DSS Presentation 1.DSS Production Data 2.DSS National Data Extracts (NDE) 3.Comparison of DSS to VA Utilization Databases 4.Reports and Documentation

3. 1.DSS Production Data Workload, clinical, and financial data from VA electronic medical record Veterans Health Information Systems and Technology Architecture (VistA)/Computerized Patient Record System (CPRS) Allocation data and schedule of relative values (unique to DSS) DSS finds the cost of: –VA health care products –VA health care stays and visits

4. DSS Production System Proprietary software and databases Located at Austin Automation Center Each medical center a separate database Medical centers grouped into data regions by network (VISN)

5. Where do DSS data come from? VISTA workload, clinical, & financial data Extracts of DSS- SAS Files at Austin Time allocation Relative values DSS VISN Level Production Databases (at Austin but limited access)

6. DSS Production System Program Modules Account Level Budgeter (ALB) Department Cost Manager (DCM) Daily Cost & Resource Profiler (DCR)

7. Account Level Budgeter (ALB) Labor and supply costs are assigned to ALB cost centers

8. Costs assigned to cost centers Cost allocation to ALBCC Salary and supply cost (PAID, FMS) Activity allocation Dropped Account Level Budgeter Dead-end Cost Centers (no workload) Indirect Cost Centers Direct Cost Centers Costs allocated to cost centers by activity reports and assignment of supply, equipment, other costs

9. Department Cost Manager (DCM) Overhead is distributed to patient care departments Workload is tabulated in units of relative value Cost per relative value is found Unit cost of each product is found

10. DCM distributes overhead to direct care departments Account Level Budgeter Indirect Cost Centers Administration Teaching Research Engineering etc. Direct Cost Centers Inpatient Medicine Ward Inpatient Psychiatric Ward Long-Term Care Unit Primary Care Clinic Cardiology Clinic etc. Department Cost Manager Inpatient Medicine Ward Inpatient Psychiatric Ward Long-Term Care Unit Primary Care Clinic Cardiology Clinic etc. “Step down” allocation

11. Workload is tabulated in units of relative value Workload Count of units of each intermediate product produced in department Schedule of Relative Value Units (RVUs) Relative resources needed for each intermediate product Total RVUs produced in department X = 

12. Cost per unit of relative value is found Total RVUs produced in department Department Cost Cost per RVU in this department  =

13. Unit cost of each product is found Cost per RVU in this department Relative Value Units to produce this intermediate product = Unit cost of this intermediate product X

14. Complexities Indirect cost distributed in “large step- down” There are 5 types of variable cost –Each has its own RVU schedule –Each contributes to unit cost

15. Daily Cost & Resource Profiler (DCR) Intermediate products are bundled into encounters –(outpatient visit or inpatient stay) Costs are assigned to each encounter

16. Costs assigned to encounters Daily Cost & Resource Profiler (DCR) Unit cost of each intermediate product Workload Count of each intermediate product used in encounter Total cost of encounter (Visit or stay) = X 

17. Financial data in DSS Production System Production unit cost and workload –Variance from budgeted cost & workload Intermediate product cost Encounter (bundle of intermediate products) –Inpatient stay –Outpatient encounter Analytical tools allow aggregation of encounters– e.g., episodes, cohorts

18. Clinical data in DSS Production System Diagnoses and procedures Detailed utilization data from radiology, laboratory surgery, pharmacy, other VISTA packages –Prescriptions –Results of 59 laboratory tests

19. Accessibility of production system Very difficult to obtain access permission –must be obtained from each medical center or VISN –Only uses real Social Security Numbers - privacy issues –Scarce computational power –Costs accrue to facility owning data Even with permission, data can be extracted only with DSS report software, one network at a time

20. Outline of DSS Presentation 1.DSS Production Data 2.DSS National Data Extracts (NDE) 3.Comparison of DSS to VA Utilization Databases 4.Reports and Documentation

21. 2. DSS National Data Extracts (NDE) Encounter level files –Inpatient files –Outpatient files –Intermediate Product Department files Department level financial files Clinical NDEs

22. Accessibility of national extract Stored as SAS files at Austin Web based report generator –VISN Support Service Center web site (klfmenu) Easy access for users of VA Austin Automation Center (see HERC manual)

23. DSS Encounter Level NDE Inpatient files –Treating specialty file –Discharge file Outpatient Files –4 pharmacy files –4 files of all other care files

24. Cost data in all DSS NDE encounter files Total cost of encounter Cost by department group –Nursing, Lab, Pharmacy, Radiology, Surgery, Other Each type of cost divided into fixed direct, variable direct, and indirect Units of service No intermediate product detail

25. Inpatient discharge file Care of patients discharged in fiscal year Record represents one discharge (even if stay involves multiple bed sections) Includes cost incurred in prior fiscal years May exclude stays that began before DSS implementation

26. DSS NDE data only in discharge file Admit Day Discharge Day Days of Stay Discharge treating specialty (bed section)

27. DSS inpatient treating specialty file The terms “treating specialty” and “bedsection” mean the same thing File includes: –Care provided during fiscal year –Stays not yet over –One record per bed section (treating specialty) per month

28. Comparison of Record Structure ADMITDAY 3/15/04 TRTIN 3/22/04 TRTOUT 4/12/04 FP 6 ADMITDAY 3/15/04 TRTIN 3/22/04 TRTOUT 4/12/04 FP 7 March Rehabilitation April Rehabilitation ADMITDAY 3/15/04 DISDAY 4/12/04 March General Medicine ADMITDAY 3/15/04 TRTIN 3/15/04 TRTOUT 3/22/04 FP 6 Treating Specialty- 3 records Discharge– 1 record

29. DSS NDE data only in treating specialty file Treating Specialty Census indicator (patient in hospital at end of fiscal year) Date of entry and exit from treating specialty –Not number of days in treating specialty Stay admission date –Neither discharge date, nor length of stay

30. Comparison of Record Structure (Overlapping fiscal year) September General Medicine October General Medicine ADMITDAY 9/22/03 DISDAY 10/8/03 In FY04 file ADMITDAY 9/22/03 TRTIN 9/22/03 TRTOUT 9/30/03 FP 12 CENSUS=Y In FY03 File ADMITDAY 9/22/03 TRTIN 9/22/03 TRTOUT 10/8/03 FP 1 CENSUS=N In FY04 File Treating Specialty- 2 records Discharge– 1 record

31. DSS NDE data in both inpatient files Admitting DRG Principal Diagnosis, Admitting Diagnosis Physician (VL4) and contract labor (VL5) cost sub-totals –Surgery, radiology, all other

32. Outpatient files Record represents all services provided to patient on a given day in a given clinic stop ~100 million records per year total Data divided into files by four groups of regional networks –4 pharmacy files –4 files for all other visits

33. DSS NDE data only in outpatient files Date of encounter DSS identifier (clinic stop) –DSS uses “pseudo stop” to characterize utilization of laboratory, pharmacy etc. Flag variables identifying data source –National Patient Care Database –Pharmacy, Laboratory, Prosthetics, other

34. DSS Outpatient Records and Costs by Category Flag (Non-Pharmacy records) FY2003 Flag% of total records% of total cost NPCD81.479.0 CLI-records not in NPCD2.01.9 PROS-prosthetics3.55.0 DDC-Denver Distribution Center 0.80.9 NOSHOW6.52.3 UTIL-no link to encounter2.7 NOFLAG-ASI tests, etc.2.57.2 MULTIPLE0.70.9

35. Contract Long-term Care in DSS Outpatient File FY2004 Cost (millions) 650Community Nursing Homes290.5 651State Nursing Home331.6 653State Hospital44.3 654Non-VA Residential12.0 655Community non-VA18.5

36. Intermediate Product Department Detail Both inpatient and outpatient files One record with costs incurred in each intermediate product department in stay/visit Not yet documented

37. DSS Department-Level NDE Account Level Budget Cost Center (ALBCC) –Cost and Hours –Cost Center (VA Service) –Budget Object Code (e.g. type of personnel) –ALB Cost Center –Production Unit –DCM Department Useful to find labor costs and hours rates by clinical area E.g., hourly labor cost of RN in psychiatry clinics Not yet documented, but see: klfmenu

38. DSS Department-Level NDE (cont.) Monthly Program Cost Report –Cost by Cost Distribution Account –Intended to replace CDR –Does not allocate national costs, depreciation, unfunded pensions

39. Clinical DSS National Data Files Laboratory Tests –All tests, inpatient and outpatient Radiology –Cost of Each Procedure Prescriptions –Cost of Each Prescription Laboratory Results –59 laboratory tests

40. Outline of DSS Presentation 1.DSS Production Data 2.DSS National Data Extracts (NDE) 3.Comparison of DSS to VA Utilization Databases 4.Reports and Documentation

41. Concerns about DSS accuracy Inpatient medical procedures not captured at all sites Uncertain quality of relative value units Uncertain accuracy of labor cost estimates Rare “million dollar” intermediate products

42. Validation Studies of DSS HERC annual evaluation of extracts HERC validation of DSS Estimates of the Cost of VA Stays for Acute Myocardial Infarction Additional studies underway: –ESRD Patients by Murphy et al at VIREC –CBOC costs by Maciejewski, et al –Stroke patient costs by Reker et al

43. Reason to Compare DSS and VA Utilization Data To check data validity To merge clinical data with cost files –NPCD files (PTF, OPC) have clinical data not in DSS diagnoses and procedure codes, length of stay, demographics, etc. –DSS has cost data

44. HERC Comparisons between DSS and NPCD Utilization Files DSS NDENPCD Discharge FilePTF MainTreating SpecialtyPTF Bed SectionOutpatientNPCD Outpatient Events File

45. Design Differences Between DSS Discharge and PTF Main DSS treats observation care as outpatient care PTF puts observation care in a separate hospital stay file (PMO) DSS does not have stays that began before date of DSS implementation Integration of facilities sometimes implemented on different dates in different databases

46. PTF Main 633,116 Records DSS Discharge vs. PTF Main FY2003 After adjusting for design differences DSS NDE Discharge 632,421 Records PTF only 757 DSS only 62 In both 632,359

47. Design Differences Between DSS Treating Specialty and PTF Bed Section DSS Treating Specialty file –divides bed section stays into separate records for each month –includes stays not yet over at end of fiscal year –excludes days provided in prior fiscal years –excludes observation care –does not count a day that is less than 24 hours when a patient is transferred to another bedsection

48. PTF Bed Section 812,248 Records Comparison of DSS Treating Specialty File with PTF Bed Section Files FY2003 After adjusting for design differences DSS Treating Specialty 819,148 Stay Segments PTF only 4,877 DSS only 11,294 In both ~807,500

49. Differences between DSS Treating Specialty and PTF Bed Section Most of poor matches due to differences in dates –Differences in date of admission to bedsection –Differences in date of transfer/discharge from bedsection –Differences (of one day) in admission or discharge dates

50. Design Differences between DSS Treating Specialty File and Discharge File Discharge file has days provided before beginning of fiscal year (excluded from Treating Specialty) Treating Specialty file has stays that aren’t over by end of fiscal year (excluded from Discharge) Treating specialty divides a stay into separate records for each bedsection, for each month

51. Comparison of DSS Treating Specialty File and DSS Discharge FY2003 DSS Discharge 606,950 Stays DSS Treating Specialty 611,893 Stays After adjusting for design differences Discharge only 221 stays Treating specialty only 5,619 stays In both 606,274 stays

52. Comparison of DSS Treating Specialty and Discharge File FY2002FY2003 > $1002032,367 >$1,0001211,392 >$5,00050440 Number of stays by amount of cost difference

53. Design Differences Between DSS and NPCD Outpatient Files DSS outpatient file puts all of a day’s activities for a clinic stop in one record NPCD can have 2 or more records with same clinic stop on same day

54. Design Differences Between DSS and NPCD Outpatient Files (cont.) DSS has utilization not recorded in NPCD –Prosthetics –Pharmacy –No show (These are being phased out) –Ancillary services NPCD has utilization not in DSS –Telephone care (but some is being added) –Clinic visits by domiciliary and residential inpatients

55. Comparison of DSS and NPCD Outpatient Files FY2003 10% Sample, after adjusting for design differences NPCD Outpatient 6,177,171 Visit Days DSS Outpatient 5,601,790 Records NPCD only 390,151 DSS only 2,301 In both 5,599,489

56. Cost outliers in DSS Outpatient Files (Cost greater than $100,000) FY2002FY2003 Pharmacy Number19586 Total cost$43,034,998$23,623,266 Maximum$1,249,454$812,737 Clinics Number98123 Total cost$22,180,695$27,671,254 Maximum$758,844$1,400,710

57. Summary DSS represents a great improvement in VA cost data DSS cost data are accessible in NDEs Data quality is improving DSS NDEs can be combined with utilization data bases to obtain demographics, procedures, & diagnoses

58. Summary (cont). Merger must consider differences in definition of record, what utilization is included –DSS discharge files easily matched to PTF main –DSS treating specialty difficult to merge to PTF bed section files –Outpatient NPCD has data only on DSS visits with NPCD flag May be multiple NPCD records for each DSS record

59. Summary (cont.) Many sites have cost data that are consistent with variance and cost of non-VA sector, even in areas where DSS has weaknesses There are still problems with some DSS data Users should modify costs estimates that are unexpectedly high given characteristics of care

60. Outline of DSS Presentation 1.DSS Production Data 2.DSS National Data Extracts (NDE) 3.Comparison of DSS to VA Utilization Databases 4.Reports and Documentation

61. DSS National Data Extract Documentation See Publications on HERC web site –http://www.herc.research.med.va.govhttp://www.herc.research.med.va.gov –Research Guide to Decision Support System National Cost Extracts 1998 - 2000 –Soon to be updated! Describes steps to gain access to DSS national extracts “Non-Disclosure statement” is no longer needed

62. DSS system DSS web site KLF menu

63. HERC Technical Reports Reconciliation of DSS NDE to VA utilization databases –#4: Reconciliation for FY2001 –#9: Reconciliation for FY2001-2002 –Next release: FY2003-2004 reconciliation

64. HERC Technical Reports (cont.) Comparisons of HERC and DSS Cost Data –#10: Inpatient Cost Comparisons –#13: Person-Level Aggregate Costs –Next release: Outpatient Cost

65. DSS Clinical NDE Documentation VIReC Research User Guide: DSS Clinical National Data Extracts FY2001-FY2003 http://www.virec.research.med.va.gov/References/R UG/RUG-DSS01-03.pdf