VA Decision Support System (DSS)

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VA Decision Support System (DSS)

• Paul G. Barnett PhD
• Wei Yu, PhD
• Samuel King, MS
• Ciaran Phibbs, PhD
• July 20, 2005

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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

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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

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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)

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Where do DSS data come from?
VISTA workload, clinical, financial data
Time allocation Relative values
Extracts of DSS- SAS Files at Austin
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DSS Production System Program Modules

• Account Level Budgeter (ALB)
• Department Cost Manager (DCM)
• Daily Cost Resource Profiler (DCR)

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Account Level Budgeter (ALB)

• Labor and supply costs are assigned to ALB cost
  centers

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Costs assigned to cost centersCost allocation to
ALBCC
Salary and supply cost (PAID, FMS)
Activity allocation
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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

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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.
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Workload is tabulated in units of relative value
Schedule of Relative Value Units (RVUs) Relative
resources needed for each intermediate product
Workload Count of units of each intermediate
product produced in department
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Cost per unit of relative value is found
Total RVUs produced in department
Department Cost
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Unit cost of each product is found
Cost per RVU in this department
Relative Value Units to produce this intermediate
product
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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

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Daily Cost Resource Profiler (DCR)

• Intermediate products are bundled into encounters
• (outpatient visit or inpatient stay)
• Costs are assigned to each encounter

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Costs assigned to encounters Daily Cost
Resource Profiler (DCR)
Unit cost of each intermediate product
Workload Count of each intermediate product used
in encounter
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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

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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

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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

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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

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2. DSS National Data Extracts (NDE)

• Encounter level files
• Inpatient files
• Outpatient files
• Intermediate Product Department files
• Department level financial files
• Clinical NDEs

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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)

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DSS Encounter Level NDE

• Inpatient files
• Treating specialty file
• Discharge file
• Outpatient Files
• 4 pharmacy files
• 4 files of all other care files

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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

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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

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DSS NDE data only in discharge file

• Admit Day
• Discharge Day
• Days of Stay
• Discharge treating specialty (bed section)

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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

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Comparison of Record Structure
Discharge 1 record
Treating Specialty- 3 records
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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

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

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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

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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

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DSS Outpatient Records and Costs by Category Flag
(Non-Pharmacy records) FY2003
Flag of total records of total cost
NPCD 81.4 79.0
CLI-records not in NPCD 2.0 1.9
PROS-prosthetics 3.5 5.0
DDC-Denver Distribution Center 0.8 0.9
NOSHOW 6.5 2.3
UTIL-no link to encounter 2.7 2.7
NOFLAG-ASI tests, etc. 2.5 7.2
MULTIPLE 0.7 0.9
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Contract Long-term Care in DSS Outpatient File
FY2004
Cost (millions)
650 Community Nursing Homes 290.5
651 State Nursing Home 331.6
653 State Hospital 44.3
654 Non-VA Residential 12.0
655 Community non-VA 18.5
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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

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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

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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

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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

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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

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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

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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

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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

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HERC Comparisons between DSS and NPCD Utilization
Files
DSS NDE
NPCD
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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

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DSS Discharge vs. PTF Main FY2003

• After adjusting for design differences

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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

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Comparison of DSS Treating Specialty File with
PTF Bed Section Files FY2003

• After adjusting for design differences

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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

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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 arent
  over by end of fiscal year (excluded from
  Discharge)
• Treating specialty divides a stay into separate
  records for each bedsection, for each month

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Comparison of DSS Treating Specialty File and DSS
Discharge FY2003

• After adjusting for design differences

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Comparison of DSS Treating Specialty and
Discharge File
Number of stays by amount of cost difference
FY2002 FY2003
gt 100 203 2,367
gt1,000 121 1,392
gt5,000 50 440
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Design Differences Between DSS and NPCD
Outpatient Files

• DSS outpatient file puts all of a days
  activities for a clinic stop in one record
• NPCD can have 2 or more records with same clinic
  stop on same day

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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

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Comparison of DSS and NPCD Outpatient Files FY2003

• 10 Sample, after adjusting for design differences

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Cost outliers in DSS Outpatient Files (Cost
greater than 100,000)
FY2002 FY2003
Pharmacy Number 195 86
Pharmacy Total cost 43,034,998 23,623,266
Pharmacy Maximum 1,249,454 812,737
Clinics Number 98 123
Clinics Total cost 22,180,695 27,671,254
Clinics Maximum 758,844 1,400,710
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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

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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

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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

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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

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DSS National Data Extract Documentation

• See Publications on HERC web site
• http//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

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DSS system

• DSS web site
• KLF menu

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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

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HERC Technical Reports (cont.)

• Comparisons of HERC and DSS Cost Data
• 10 Inpatient Cost Comparisons
• 13 Person-Level Aggregate Costs
• Next release Outpatient Cost

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DSS Clinical NDE Documentation

• VIReC Research User Guide DSS Clinical National
  Data Extracts FY2001-FY2003
• http//www.virec.research.med.va.gov/References/RU
  G/RUG-DSS01-03.pdf