Predictive Analytics: It's The Intervention That Matters

Predictive Analytics:
It’s The Intervention That Matters

David Crockett
Dale Sanders, Sep 2013
© 2013 Health Catalyst
ww© 2013 Health Ccom
w.healthcatalyst.atalyst
www.healthcatalyst.com

An Email Yesterday
From a CMIO about today’s webinar
Dale,
“One thing that I think would be helpful, generally
speaking, is helping executives and operational
leaders get a really concrete idea of what value true
analytics brings to a healthcare organization. These
days the terms ‘predictive analytics’ and ‘big data’
are thrown around so frequently and so casually, that
for many they have become devoid of actual
meaning.”


Audience Poll

Benefits of predictive analytics to
healthcare over the next three years?


Overview
Dale Sanders
•

Human interest and color commentary
•

A selection of stories, concepts and lessons learned,
such as…

•

The parallels between “treating” terrorists and treating
patients using predictive analytics

David Crockett
•

A graduate-level crash course
•

Machine learning, algorithms, feature selection,
classification, tools, etc.


An Oddly Relevant Career Path
US Air Force CIO
•Nuclear warfare operations

TRW
•

NSA
•

Nuclear Command & Control Counter Threat Program

•

Credit risk scoring, traffic routing & optimization

•

Strategic Execution Decision Aid

5


Key Messages & Themes
1.

We are fixated on predictions and interventions of readmission
●
●

We should be predicting and intervening on ADMISSIONS
Aim higher…!

2.

Predictions without interventions are useless-- and potentially
worse than useless

3.

Correlation does not imply causation

4.

Missing data = Poor predictions
●

5.

Some of the most important predictions don’t need a computer
algorithm
●

6.

Patient outcomes, familial, genomics

Nurses and physicians can tell you

When it comes to analytics, take care of the basics, first
●

The time will come for predictive analytics

6


Most Common Causes for Readmission
Robert Wood Johnson Foundation, Feb 2013
1.

Patients have no family or other caregiver at home

2.

Patients did not receive accurate discharge instructions

3.

Patients did not understand discharge instructions

4.

Patients discharged too soon

5.

Patients referred to outpatient physicians and clinics not
affiliated with the hospital

7


Healthcare Analytics Adoption Model
Level 8

Cost per Unit of Health Payment &
Prescriptive Analytics

Contracting for & managing health. Tailoring
patient care based on population outcomes.

Level 7

Cost per Capita Payment &
Predictive Analytics

Diagnosis-based financial reimbursement &
managing risk proactively

Level 6

Cost per Case Payment
& The Triple Aim

Procedure-based financial risk and applying
“closed loop” analytics at the point of care

Level 5

Clinical Effectiveness & Accountable Care

Measuring & managing evidence based care

Level 4

Automated External Reporting

Efficient, consistent production & agility

Level 3

Automated Internal Reporting

Efficient, consistent production

Level 2

Standardized Vocabulary & Patient
Registries

Relating and organizing the core data

Level 1

Integrated, Enterprise Data Warehouse

Foundation of data and technology

Level 0

Fragmented Point Solutions

Inefficient, inconsistent versions of the truth


Healthcare Analytics Adoption Model: The Details for Organizational Self-Inspection

Level 8

Level 7

Cost per Unit of Health Payment & Prescriptive Analytics: Providers Analytic motive expands to wellness management and mass customization of
care. Physicians, hospitals, employers, payers and members/patients collaborate to share risk and reward (e.g., financial reward to patients for healthy
behavior). Analytics expands to include NLP of text, prescriptive analytics, and interventional © cision support. Prescriptive analytics are available at the
de
point of care to improve patient specific outcomes based upon population outcomes. Data content expands to include genomic and familial information.
The EDW is updated within a few minutes of changes in the source systems.
Cost per Capita Payment & Predictive Analytics: Analytic motive expands to address diagnosis-based, fixed-fee per capita reimbursement models.
Focus expands from management of cases to collaboration with clinician and payer partners to manage episodes of care, using predictive modeling,
forecasting, and risk stratification to support outreach, triage, escalation and referrals. Patients are flagged in registries who are unable or will not
participate in care protocols. Data content expands to include external pharmacy data and protocol-specific patient reported outcomes. On average, the
EDW is updated within one hour or less of source system changes.

Level 6

Cost per Case Payment & The Triple Aim: The “accountable care organization” shares in the financial risk and reward that is tied to clinical outcomes.
At least 50% of acute care cases are managed under bundled payments. Analytics are available at the point of care to support the Triple Aim of
maximizing the quality of individual patient care, population management, and the economics of care. Data content expands to include bedside devices
and detailed activity based costing. Data governance plays a major role in the accuracy of metrics supporting quality-based compensation plans for
clinicians and executives. On average, the EDW is updated within one day of source system changes. The EDW reports organizationally to a C-level
executive who is accountable for balancing cost of care and quality of care.

Level 5

Clinical Effectiveness & Accountable Care: Analytic motive is focused on measuring clinical effectiveness that maximizes quality and minimizes waste
and variability. Data governance expands to support care management teams that are focused on improving the health of patient populations.
Permanent multidisciplinary teams are in-place that continuously monitor opportunities to improve quality, and reduce risk and cost, across acute care
processes, chronic diseases, patient safety scenarios, and internal workflows. Precision of registries is improved by including data from lab, pharmacy,
and clinical observations in the definition of the patient cohorts. EDW content is organized into evidence-based, standardized data marts that combine
clinical and cost data associated with patient registries. Data content expands to include insurance claims. On average, the EDW is updated within one
week of source system changes.

Level 4

Automated External Reporting: Analytic motive is focused on consistent, efficient production of reports required for regulatory and accreditation
requirements (e.g. CMS, Joint Commission, tumor registry, communicable diseases); payer incentives (e.g. MU, PQRS, VBP, readmission reduction); and
specialty society databases (e.g. STS,NRMI, Vermont-Oxford). Adherence to industry-standard vocabularies is required. Clinical text data content is
available for simple key word searches. Centralized data governance exists for review and approval of externally released data.

Level 3

Automated Internal Reporting: Analytic motive is focused on consistent, efficient production of reports supporting basic management and operation of
the healthcare organization. Key performance indicators are easily accessible from the executive level to the front-line manager. Corporate and business
unit data analysts meet regularly to collaborate and steer the EDW . Data governance expands to raise the data literacy of the organization and develop
a data acquisition strategy for Levels 4 and above.

Level 2

Standardized Vocabulary & Patient Registries: Master vocabulary and reference data identified and standardized across disparate source system
content in the data warehouse. Naming, definition, and data types are consistent with local standards. Patient registries are defined solely on ICD
billing data. Data governance forms around the definition and evolution of patient registries and master data management.

Level 1

Integrated, Enterprise Data Warehouse: At a minimum, the following data are co-located in a single data warehouse, locally or hosted: HIMSS EMR
Stage 3 data, Revenue Cycle, Financial, Costing, Supply Chain, and Patient Experience. Searchable metadata repository is available across the
enterprise. Data content includes insurance claims, if possible. Data warehouse is updated within one month of changes in the source system. Data
governance is forming around the data quality of source systems. The EDW reports organizationally to the CIO.

Level 0

Fragmented Point Solutions: Vendor-based and internally developed applications are used to address specific analytic needs as they arise. The
fragmented Point Solutions are neither co-located in a data warehouse nor otherwise architecturally integrated with one another. Overlapping data
content leads to multiple versions of analytic truth. Reports are labor intensive and inconsistent. Data governance is non-existent.

Audience Poll

Analytics Adoption Model:
At what level does your organization consistently and
reliably function?

10


Challenge of Predicting
Anything Human

11

Sampling Rate vs. Predictability
The sampling rate and volume of data in an
experiment is directly proportional to the predictability
of the next experiment

12


Can We Learn From Nuclear Warfare
Decision Making?
“Clinical” observations
•

Satellites and radar indicate an enemy launch

Predictive “diagnosis”
•

Are we under attack or not?

Decision making timeframe
•

<4 minutes to first impact when enemy subs launch from the east
coast of the US

“Treatment” & intervention
•

Launch on warning or not?

13


Desired “Outcomes”
1.

Retain US society as described in the Constitution

2.

Retain the ability to govern & command US forces

3.

Minimize loss of US lives

4.

Minimize destruction of US infrastructure

5.

Achieve all of this as quickly as possible with minimal

expenditure of US military resources

14


Where And How Can A Computer Help?
Reduce variability in decision making & improve outcomes

15


Lessons For Healthcare
•

Humans didn’t trust predictive models when the decision making
timeframe was compressed and the consequences of a bad
decision were extreme
•

•

Subjective human issues were not well-modeled
•
•

•

At present in healthcare, predictive analytics are easier to apply in
slowly changing situations, e.g., chronic condition management,
elective procedures, ventilator weaning, glucose management in the
ER, antibiotic protocols

The “Rogue Commander” scenario
We need to at least try to quantify the “difficult patient”

Without outcomes data, it’s all guesswork
•
•

Thankfully, we don’t have much outcomes data related to nuclear
warfare
That shouldn’t be the case in healthcare

17


Quantifying the Atypical Patient
Not all patients can participate in a protocol
At Northwestern, we found that 30% of patients fell into
one or more of these categories
1.

Cognitive inability

2.

Economic inability

3.

Physical inability

4.

Geographic inability

5.

Religious beliefs

6.

Contraindications to the protocol

7.

Voluntarily non-compliant
18


Accounting For These Patients
30% of your patients will have to be treated and/or
reached in a unique way
•

Your predictive algorithms must be adjusted these
attributes, especially for readmission
•

These patients are a unique numerator in the overall
denominator of patients under accountable care

•

You need a data collection & governance strategy for
these patient attributes

•

You need a different interventional strategy for each of
the 7 categories

•

Your physician compensation model must be adjusted
for these patient types

19


Sortie Turnaround Times
The Goal: Predictable, fast turnaround of aircraft to a successful battle

20


Patient Fight Path Profiler
The Goal: Predictable, fast turnaround of patients to a good life

21

Healthcare As a Battle Field…??
The Order of Battle and the Order of Care Demand
forecasting: What do we need and when?

22

NSA, Terrorists, and Patients
The Odd Parallels of T
errorist Registries and Patient Registries

23


Predicting Terrorist Risk
Risk = P(A) × P(S|A) × C
•

Probability of Attack

•

Probability of Success if Attack occurs

•

Consequences of Attack (dollars, lives, national psyche, etc.)

•

What are the costs of intervention and mitigation?
•

Do they significantly outweigh the Risk?

24


Predicting Patient Risk

25


We Know the Probabilities

What are the consequences?
What are the strategies and costs to intervene?
26

Lessons For Healthcare
•

Multiple predictive models that “vote” are more accurate than single models

•

In the absence of data, and until more data is available, multiple expert opinion is
better than nothing for predicting outcomes and managing risk
“Wisdom of crowds”

•

•

Backward chaining predictive models (supervised learning) are the most accurate, but
are also inflexible and fragile
How did this person become a terrorist? What was their pre-terrorist data
profile?

•

•

Friends, family, and what you read are MAJOR predictors of terror risks
•

We don’t collect familial data in the course of care

•

If you associate with more than one terrorist group, even greater predictor
•

•

Parallels to a comorbidity

Even when we can predict accurately, the cultural willingness and ability to intervene
are incredibly difficult and can be very controversial
Armed drone “assassinations”, TSA profiling
•
•

BRCA genes and prophylactic mastectomies

27


More Reading
1. Eliciting Probabilities from Experts. Advances in

Decision Analysis. Cambridge, UK: Cambridge
University Press, 2007. Hora S. ,Edwards W, Miles R,
Jr., von Winterfeldt D (eds).
2. Estimating Terrorism Risk. RAND Center for T
errorism

Risk Management Policy, 2003. Willis H, Morral A,
Kelly T Medby J.
,
3. Probabilistic Risk Analysis and Terrorism Risk. Risk

Analysis, Vol. 30, No. 4, 2010. Barry Charles Ezell,
Steven P Bennett, Detlof von Winterfeldt, John
.
Sokolowski, and Andrew J. Collins.

28


Suggestive Analytics©
Surround the decision making environment with
suggestions, based on analytic data
●
●

Much easier than predicting
Leverages “Wisdom of Crowds” data

Worth reading
●

“Nudge: Improving Decisions About Health, Wealth, and
Happiness”


30


Closed Loop Analytics:
The Triple Aim

31

The Antibiotic Assistant
• Predicting the efficacy and costs of antibiotic
protocols for inpatients
Antibiotic
Protocol

Dosage

Route

Interval

Predicted
Efficacy

Average
Cost/Patient

Option 1

500mg

IV

Q12

98%

$7,256

Option 2

300mg

IV

Q24

96%

$1,236

Option 3

40mg

IV

Q6

90%

$1,759

Dave Claussen, Scott Evans

32


The Antibiotic Assistant Impact
Complications declined 50%
Avg # doses declined from 19 -> 5.3
The replicable and bigger story
●

Antibiotic cost per treated patient: $123 -> $52

●

By simply displaying the cost to physicians

33


Stories of Correlation vs. Causation
•

The production of butter in Bangladesh and the S&P 500
•

•

David Leinweber, UC Berkeley

TRW Credit Reporting (Experian)
•
•

•

NSA-developed predictive algorithms indicated Black (African
American) borrowers were higher risk
Sociologists on staff explained the bigger picture

Women, Hormone Replacement Therapy, and
Cardiovascular Disease
•
•

Women with HRT had lower CVD
Women with HRT were from higher income levels and could
afford to exercise

34


Audience Poll

How confident are you that your organization is
prepared to combine the technology of predictive
analytics with the processes of intervention?

35


Wrap-Up
•

Vendors are in the EXTREME hype cycle of
predictive analytics
•
•

Without outcomes data, we are largely stuck with
predicting the obvious
T
ake care of the basics of analytics, first

•

The human “mathematical model” is years away

•

Suggestive analytics is easier

•

Intervening to reduce risk is the hard part
•
•

Predicting is the easy part
Predicting without intervening is ripe for lawyers

36


Many thanks
•

Contact information
•

dale.sanders@healthcatalyst.com

•

dale.sanders@hsa.ky

•

@drsanders

•

www.linkedin.com/in/dalersanders

37


David Crockett:
The Graduate Crash Course

ww© 2013 Health Ccom t
w.healthcatalyst.atalys
38

Objectives
T
opics we’ll cover today include:

Machine
Learning
Overview

Software
Examples
(Open Source,
Commercial)

Prediction
Modeling
Demo

4 Insights to
Implementation


Machine Learning 101

A scientific discipline
concerned with algorithm
design and development
that allows computers to
learn based on data.

A major focus of machine
learning research is to
automatically learn to
recognize complex patterns
and make intelligent
decisions based on data.


Machine Learning 102
Extracting useful information from large
machine-readable data sets is a problem faced
by people in nearly every area of commerce,
manufacturing, government, academic
discipline and science

Machine learning has a wide range of applications:


Algorithms
Machine learning algorithms are organized into
a taxonomy, based on the desired outcome of
the algorithm.
Supervised Learning
Generates a function that maps
inputs to desired outputs

Reinforcement Learning
Learns how to act given an
observation of the world

Unsupervised Learning
Models a set of inputs: labeled
examples are not available

Transduction
Tries to predict new outputs
based on training inputs,
training outputs, and test inputs


The Modeling Process
Step 1
Define
Problem
Gather
Data

Step 2
Select
Model

Run/Evaluate
Models

T
est
Model

INITIAL

VALIDATION
DATASET

DATASET

Step 3
Apply Model
Run Prediction

TEST
DATASET

A Few Definitions…
INPUT

•
•
•
•
•

Features
Attributes
Variables
Class
Labels

OUTPUT

•
•
•
•

Outcome
Prediction
Forecast
Trend

FEATURE SELECTION

Selecting a subset of relevant variables (features)
for use in construction a model
CLASSIFICATION

Use an object's characteristics (features) to identify
which class (or group) it belongs to


Feature Selection

PCA
●

principal components analysis

ReliefFAttributeEval
●

recursive feature elimination

CfsSubsetEval
●

correlation-based feature subset selection

ChiSquaredAttributeEval
●

chi-squared statistic with respect to class


Know Your Data…
It is crucial to understand the data set being used


Insight #1

Don’t confuse more data
with more insight.


Specific Improves Accuracy
In our hands:
Generic Readmissions
Predictor ~ 79% PPV

Heart Failure
Readmission Predictor
~ 91% PPV


Classification

Rules
Linear (Regression)
Trees
Neural Networks
Support Vector Machine

Bayes


Classification – Rules Based

Rules
gender=male AND age>40: getting a little thin on top ~ 65%
gender=male AND age>40 AND bald grandpa OR uncle ~ 82%

Linear (Regression)
Trees
Neural Networks

Bayes


Classification – Regression

Rules

Linear (Regression)
male(1)x(41.8) + age(44)x(0.607): getting thin on top ~ 68%
male(1)x(41.8)+age(44)x(0.607)+uncle(19.2): going bald ~ 87%

Trees
Neural Networks

Bayes


Classification – Tree Based

Rules
Linear (Regression)

Trees
Neural Networks
Bayes


Insight #2

Don’t confuse
insight with value.


The Cost of Readmissions
Medicare rehospitalization within 30 days after discharge: $17.4 billion

Jencks, NEJM 2009

Prediction In Context

87%


Data Warehouse Synergy
Prediction can be more powerful “in context.”
Rothman Index, an early wellness metric.
In a data warehouse
environment…

System architecture and data flow

• Incorporate additional

site specific data
• Filter across multiple

data sources
• Available to any user

and any application
• Show when and where

needed

Evaluating Performance

true positive (TP hit)
,
true negative (TN, correct rejection)

false positive (FP false alarm, Type I error)
,
false negative (FN, miss, Type II error)

sensitivity or true positive rate
(TPR, hit rate, recall)
TPR = TP / P = TP / (TP + FN)

specificity (SPC or True Negative Rate)
SPC = TN / N = TN / (FP + TN) = 1 − FPR
positive predictive value (PPV, precision)
PPV = TP / (TP + FP)

Sensitivity measures the proportion of actual positives which are correctly identified
Specificity measures the proportion of negatives which are correctly identified


Always a trade off…
However, there is always a trade-off between sensitivity
and specificity…
For example, airport security
scanners can be set to trigger
on low-risk items like belt
buckles and keys…
(very sensitive, but not too specific)

This trade-off is often represented graphically as a
receiver operating characteristic (ROC) curve.

ROC Curves
The trade-off is between: Sensitivity vs. Specificity…

Area Under the Curve (AUC)
Machine learning often uses
this AUC statistic for model
comparison. (~ c statistic)
PPV (precision) is a common
metric that’s also used.
PPV = TP / (TP + FP)

Whiting et al. BMC Med Res Methodol. 2008 Apr 11;8:20

Insight #3

Don’t overestimate the
ability to interpret the data.


Open Source Tools
Many open source tools exist...

Waffles

http://jmlr.org/mloss/

Open Source Example
Various implementations of a given approach can be found.
For example, random forest classification (circa 2001):
Original implementation by Leo Breiman and Adele Cutler (Fortran)
ALGLIB (library, C++, C#, Pascal, Visual Basic, Python)
Orange (toolkit, C++, with Python interface)
fast-random-forest (Java)
RandomForest (Weka)
Milk (toolkit, Python)
treelearn (Python)

http://oz.berkeley.edu/users/breiman/randomforest2001.pdf

Open Source Standards
Predictive Model Markup Language (PMML), is an
industry standard used to represent numerous
predictive modeling techniques.
Such as:
• Association Rules

• Cluster Models
• Neural Networks
• Decision Trees


Commercial Tools
Many commercial tools also exist...
IBM SPSS

GE Predictivity
The Forrester W ave™: Predictive Analytics Solutions, Q1 2013

Enhancing Commercial Tools
Leveraging the enterprise warehouse…
IBM SPSS

GE Predictivity

Late-BindingTM Data Bus
Data Acquisition and Storage
Metadata Engine

Insight #4

Don’t underestimate the
challenge of implementation.


Predictive Modeling Demo
Supervised learning with a known class label (outcome)
•

Simple example: Pima Indian diabetes

Several standard ML techniques have been built into a
software "workbench" called Waikato Environment for
Knowledge Analysis (WEKA).


Weka File Explorer
1

3

2


Weka Classify – Zero Rules
1

2

3


Weka Classify – One Rule
T mode:10-fold cross-validation
est

1

=== Classifier model (full training set)
===
plas:
< 114.5 -> tested_negative
< 115.5 -> tested_positive
>= 154.5
->
tested_positive
(585/768 instances correct)
Time taken to build model: 0.05 s


Weka Classify – JRIP
1

T mode:10-fold cross-validation
est
===
JRIP rules:
===========
(plas >= 132) and (mass >= 30) =>
class=tested_positive (182.0/48.0)
(age >= 29) and (insu >= 125) and
(preg <= 3) => class=tested_positive
(19.0/4.0)
(age >= 31) and (pedi >= 0.529) and
(preg >= 8) and (mass >= 25.9) =>
class=tested_positive (22.0/5.0)
=> class=tested_negative
(545.0/102.0)
Number of Rules : 4


Weka Classify – Regression
1

Test mode:10-fold cross-validation
===
Logistic Re gression with ridge
parameter o f 1.0E-8
Odds Ratios...
Variable
tested_negative
============================
preg
0.8841
plas
0.9654
pres
1.0134
skin
0.9994
insu
1.0012
mass
0.9142
pedi
0.3886
age
0.9852


Machine Learning Models
Step 1
Define
Problem
Gather
Data

Step 2
Select
Model

Run/Evaluate
Models

T
est
Model

INITIAL

VALIDATION
DATASET

DATASET

Step 3
Apply Model
Run Prediction

TEST
DATASET

Predictive Analytics: Insights to
Implementation/Intervention
Lessons Learned:
●

Lesson #1:
Don’t confuse more data with more insight

●

Lesson #2:
Don’t confuse insight with value

●

Lesson #3:
Don’t overestimate the ability to interpret the data

●

Lesson #4:
Don’t underestimate the challenge of implementation

From David Shaywitz, Forbes.com

Thank you!

Questions and Answers


Next Webinars
Healthcare Reform: Implications for Your Health System
Brian Ahier, Healthcare Evangelist
Date: October 8, 2013 from 1:00 PM - 2:00 PM ET

Widely recognized as one of healthcare's most knowledgeable speakers on
healthcare policy Brian Ahier will provide an in-depth look at current healthcare
,
reform and more specifically the implications of President Barack Obama's 2010
legislative efforts, namely the Patient Protection and Affordable Care Act, also
referred to as 'Obamacare’.
Population Health Fundamentals
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Date: October 9, 2013 from 1:00 PM - 2:00 PM ET
Dr. Burton, former Intermountain Executive and current Executive Chairman of the
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healthcare analytics from a focus on inpatient (acute care) to a focus on the
continuum of care. The shift is being driven by the linked imperatives of Population
Health Management and Accountable Care Organizations and other shared
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Predictive Analytics: It's The Intervention That Matters

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