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Healthcare Leaders Embrace Reform
17th Annual Scottsdale Institute Spring Conference April 14-16, 2010
Camelback InnScottsdale, AZ
Essentials of Healthcare Informatics for the C-Suite Scottsdale Institute, Spring 2010
Jeffrey S. Rose, MDVP, Clinical Excellence Informatics
Ascension Health
People need to be reminded more often
than they need to be
instructed.
Samuel Johnson
A 3 Pointer
How informatics can help actualize high reliability, elevate human performance and improve clinical outcomes, thereby enhancing healthcare as a system
Focus in upon he key clinical information tools that can have the greatest impact on quality (what you should expect to accomplish with informatics)
Provide an high level methodology to address in cultural challenges in executing information strategy
Ascension Health is the largest Catholic health system, the largest private nonprofit system and the third largest system (based on revenues) in the United States, operating in 19 states and the District of Columbia
Facilities and Staff Locations
500+ Acute Care Hospitals 67Long-term Acute Care Hospitals 2Rehabilitation Hospitals 3Psychiatric Hospitals 4Available Beds 17,928Associates
113,000Physicians
20,000
Care of Persons Who Are Poor and Community Benefit $868 Million
Financial Information (FY09)Total Assets $16.5 BillionOperating Revenue $14.3 BillionOperating Income $371 MillionNet Income ($710 Million)Investment (Loss) ($980 Million)
• Discharges 696,206• Available beds 17,928• Number of births 76,268• Total surgical visits 544,400• Home health visits 554,664• Clinic visits 1,748,421• Emergency visits 2,317,004• Physician office visits 5,112,392• Total outpatient visits 17,702,630
The dilemma:
Cost, resource limitation, reform
Workforce shortages; staffing/hours mandates, inefficiency
External regulation and reporting regulation and reporting (medicine by proxy)
Advancing science, information and ‘evidence’Advancing science, information and ‘evidence’
Quality, safetyQuality, safety, risk, privacy, ethics, service
Aging, expectations, ethnic disparities
Access, mission
Unprecedented transparency with inadequate dataUnprecedented transparency with inadequate data
‘‘Meaningful Use’, ARRAMeaningful Use’, ARRA
Health Information Technology
Congressional Budget Office Estimates
of Cost of Healthcare Reform
Informatics
Collect & consolidate information,analyze and transform information into knowledge, and support a learning organization with evolving
best practices from the learning
• Health informatics is the intersection of information science, computer science, and health care.
• It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine.
• Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems also applied to the areas of nursing, clinical care, dentistry, pharmacy, public health and (bio)medical research.
The Informatics Journey
QUALITY =
Safety (HRH) +
Value +
Appropriateness
Why do we need a different approach?
Despite attention over the past 30 years to care quality adults today (overall) receive about half the care widely accepted as recommended by the medical community; ‘the gap between what we know works and what is actually done is substantial’…….
McGlynn et. al. NEJM June 26, 2000
Same in pediatrics
The Quality of Ambulatory Care Delivered to Children in the United States Mangione-
Smith R, De Cristofar Setodji CM, Keesey J, Klein DJ, Adams JL, Schuster MA, McGlynn EA, NEJM, Oct. 11, 2007
Cottage Industry to Postindustrial Care —The Revolution in Health Care Delivery Posted by NEJM January 20th, 2010 http://healthcarereform.nejm.org/?p=2836&query=home#printpreview#printpreview Stephen J. Swensen, M.D., M.M.M., Gregg S. Meyer, M.D., Eugene C. Nelson, D.Sc., M.P.H., Gordon C. Hunt, Jr., M.D., M.B.A., David B. Pryor, M.D., Jed I. Weissberg, M.D., Gary S. Kaplan, M.D., Jennifer Daley, M.D., Gary R. Yates, M.D., Mark R. Chassin, M.D., M.P.P., M.P.H., Brent C. James, M.D., M.Stat., and Donald M. Berwick, M.D., M.P.P.
Key points Current health care system is a cottage
industry of nonintegrated, dedicated artisans who eschew standardization
Even those who work in larger groups create individualized care plans that cannot be integrated with care in neighboring “out-of-network” facilities; cannot treat and track patients over space and time
Today’s system pays for volume rather than value: more tests, exams, surgeries, and appointments
“Good doctors” are celebrated for their unwavering dedication to doing whatever it takes, (rescue imperative) often swimming upstream against the system, rather than relying confidently on it
Three key steps — wise standardization, meaningful measurement, and respectful reporting — have transformed other industries, and we believe they can help health care as well
Guidelines must be tended over time. Advancing knowledge may render even the best guidelines outdated
The evolution of scientific knowledge is not grounds for eschewing guidelines; it is a reason to modify and improve them continually
Allowing physicians to make thoughtful exceptions to guidelines but asking them to report why their practice varies can support loops of continuous learning
Modern physicians should welcome guidelines covering the basics of evidence-based care, which can free them to focus on the complex issues that require their training and expertise.
Effective standard practice will also require interdisciplinary care. An invaluable consequence of fostering interdependence is better teamwork that should lead to safer care (e.g., comfort in speaking up when something seems wrong, as well as better handoffs and communication)
Reliability
Reliability: The probability that a system, structure, component,
process, person will successfully provide the intended function(s)
Just as high reliability is a vital part of the solution to our
dilemma, as is informatics, neither is sufficient alone to get
us where we need to be
Both are necessary but not sufficient
High Reliability Organizations
Nuclear power plants
High speed trains
Automobile and other industrial production
Commercial airlines
But not healthcare
Why No High Reliability Healthcare?
There are no best practices, just best doctors. It’s not an industry, it’s a collection of industrious folks…..they’re isolated practitioners. Medicine is not vertically integrated or horizontally integrated--it’s is not integrated at all! Kessler, A., The End of Medicine, 2006
Informaciation
Inadequate patient information Inadequate current knowledge to
guide diagnostic and treatment choices to maximize effectiveness
We practice with incomplete information about the people and disorders we are treating almost all the time
Wood, NEJM, 1972; Covell, Ann Int Med, 1985 Gorman, Med Info, 2001; Fries, Med. Care, 1975
Tang, Proc Annu Symp Comput App Med Care, 1994
‘Medical knowledge is scattered to the wind---little bits of it in lots of individuals. There is no product---you and I are the product. Medicine consumes us.’
A. Kessler, The End of Medicine, 2006
Preoccupation with failure (regarding minor errors that are potential symptoms of
something more serious)Reluctance to simplify interpretations
Embracing diversity, experience and perspectiveSensitivity to operations
Know what is occurring at the front line
Commitment to resilience Detect, correct and rebound from events
Deference to expertise Encouraging decision making by those with the
most knowledge and expertise
Weick,KE and Sutcliffe, KM: Managing the Unexpected; Jossey-Bass, San Francisco, 2007
David Gaba, Anesthesia Patient Safety Newsletter, 2003
Characteristics of an HRO: Collaboration
HARM
Human Performance
Initial experience
Failure mode:
Keeping Current?
Finish medical school and residency knowing everything…read and retain 2 articles every single night…at the end of 1 year you’re only 1,225 years behind.
W Stead. JAMIA 2005;12:113-20Alper BS, Hand JA, Elliott SG, et al. J
Med Lib Assoc 2004;92:429-37
• Clinical Knowledge Management
• 20,000 biomedical journals• 500,000 indexed in PubMed annually*• >150,000 articles per month• 6,000 articles a day• 2,618 active performance measures• 231 active P4P measures• 100,000 genetic tests over next few years**• More data over the last 3 years than
previous 40,000 years combined”***
*Medical References Services Quarterly 2007;26:1-19**A Roadmap for National Action on Clinical Decision Support
June 13, 2006***UC Berkeley, School of Information Management and Systems,
Deloitte Consulting Report
Reaching our High Reliability Goals Requires:
Appropriate standardization of content Redundancy functions (rules/alerts) Process redesign: mindfulness, potential failure
remediation and culture management– Evidence informed foundation content
– Doing the right thing becomes the easiest thing to do in a single ubiquitous multipurpose tool
– Technology introduction approach as a new way of doing things, not the old way with new tools
– Collaboration and convergence as expected norms
Behavior and Process Behavior and Process StandardsStandards
Clinical Content StandardsClinical Content Standards
Lexical and Data Architecture Lexical and Data Architecture StandardsStandards
Communication and Display Communication and Display StandardsStandards
Technical Technical
Engineering Engineering StandardsStandards
Behavior and Process Behavior and Process StandardsStandards
Clinical Content StandardsClinical Content Standards
Lexical and Data Architecture Lexical and Data Architecture StandardsStandards
Communication and Display Communication and Display StandardsStandards
Technical Technical
Engineering Engineering StandardsStandards
Standards
EHR Infrastructure Essential for High Reliability Healthcare
Omnipresent clinical information for all providers Reduction of documentation duplication, hunting-gathering Clinical Decision Support (CDS): insure safe practices,
current knowledge, safety-nets, reminders at point of care, and appropriateness
Proved flexibility, innovation and measured results of such Automated reporting, reimbursement, and regulatory
compliance Public Health information sharing, community health
information model development and HIE Improved medical-legal risk mitigation, privacy, ethical
decision enhancement
IT’s Not How Much You Spend, It’s About How You Use ITPaul Strassman, The Squandered Computer, 1997
EHRs and Clinical Decision Support
“Taken alone, clinical information technologies like bar-coding, smart pumps, nursing documentation, pharmacy and physician order entry systems don’t sufficiently improve clinical practice to justify these (CIS) investments. The systems must be supplemented by embedding intelligence into the clinical workflow. Decision support is the key to driving high quality and fail safe care.”
True North “Hardwiring The Evidence” The Advisory Board
EHRs Do NOT innately contain (rules and alerts)• Do not automatically revise HRH required process changes• Cannot get you to High Reliability Healthcare without associated
culture and operations change
“As implemented, EHRs were not associated with better quality ambulatory care. In selecting an EHR, physician practices should carefully consider the inclusion of clinical decision support to facilitate quality care…” Arch Intern Med 2007 (Ambulatory EHRs, 2003, 2004 17 ambulatory quality indicators EHRs 18%, 1.8 billion ambulatory visits)
Why Use Care Sets?
Almost everything in our hospitals begins with a physician order; influencing the way physicians order, can influence everything:
Care-sets can incorporate evidence informed practice, drive most of the direct value and quality of coordinated care
They are key elements to diminish unnecessary variation, improve currency and automated compliance with quality core (and other) measurements of process and outcomes
They are a primary point of influencing clinician decision making and serve the needs of many ‘customers’
They can facilitate the ordering and delivery processes
– 37% reduction in time spent entering orders (vs. CPOE without order sets)
– They can provide safety nets and and are vital parts of safe closed-loop medication delivery systems and other procedure practices
They can be updated and disseminated as evidence, practice habits, formulary, regulatory and accrediting agency requirements change
They can allow more efficient overall workflow if done well and introduced gracefully and in an appropriate sequence
Meaningful Use Summary Objectives from HIT Policy Committee Meeting
Goals 2011 2013 2015
Improve quality, safety, efficiency
– Provide access to comprehensive patient health data for patient’s health care team
– Use CPOE (for hospitals, 10% of all orders – any type – entered through CPOE)
– Implement drug-drug, drug-allergy, drug-formulary checks
– Maintain an up-to-date problem list of current and active diagnoses
– Generate and transmit permissible prescriptions electronically
– Maintain active med and allergy lists; record demographics, vital signs, etc.
– Incorporate lab-test results into EHR as structured data
– Implement at least one clinical decision rule relevant to specialty or high clinical priority
– Check insurance eligibility and submit claims electronically
– Use CPOE for all order types– Use evidence-based order sets (for hospitals,
record clinical documentation in EHR, e-prescribe)
– Manage chronic conditions using patient lists and decision support
– Provide clinical decision support at the point of care
– Specialists report to relevant external disease or device registries as approved by CMS
– Achieve minimum levels for quality, safety and efficiency measures
– Implement clinical decision support for national high priority conditions
– Medical device interoperability– Multimedia support (e.g., x-rays)
Engage patients and families
– Provide electronic copy of- or electronic access to clinical information for patients
– Patient-specific educational resources– Clinical summaries for each patient
encounter
– Access for all patients to PHR populated real time with health data
– Offer patient-provider secure messaging capability
– Provide access to patient-specific educational resources in primary language
– Record patient preferences – Documentation of family medical history– Upload data from home monitoring device
– Patients have access to self-management tools
– Electronic reporting on experience of care
• Use CPOE (for hospitals, 10% of all orders – any type – entered through CPOE); 80% for EP’s!
• Use CPOE (for hospitals, 10% of all orders – any type – entered through CPOE); 80% for EP’s!
• Use CPOE for all order types• Use evidence-based order sets (for
hospitals, record clinical documentation in EHR, e-prescribe)
• Use CPOE for all order types• Use evidence-based order sets (for
hospitals, record clinical documentation in EHR, e-prescribe)
The Care CollaborativeA partnership of faith based organizations
Started with Foundation Evidence informed Foundation sets, collaborated upon by 114 community-based hospitals
Subject matter expertise in expert-based and evidence-based order set development, deployment, and knowledge management.
Library of 1,100 ‘out of the box’ order sets and modular protocols including: Condition based Procedure based Convenience Specialty specific
40% of the Care Collaborative content is unique to ZynxOrder content - remaining 60% is based on ZynxOrder content with modifications made by clinicians using the content
The CollaborativeA partnership of faith based organizations
Evidence-Based PowerPlans™ (2009) Per Discharge
CPOE
While technology plays a role, CPOE and care-set coordination is really about how well a facility handles change.
CPOE represents a tremendous opportunity to improve patient safety, operational outcomes and gain new efficiencies – but they don’t happen by accident. Ultimately it’s the data
– Severity-adjusted with tests of statistical significance
– Quarterly outcome data
• Reported to each facility
• Aggregate data for corporate system view
Improvements in elements of quality using order and care sets can long proceed CPOE; separate the content delivery from computer use
Standards of Clinical Decision Support (CDS)
Reduced inefficient decision-making Reduced costs (e.g., via more appropriate testing) Reduced medical errors Reduced liability insurance premiums Increased revenue (e.g., P4P and NP4NP) Increased market share Improved staff retention/utilization Enhanced leverage to improve outcomes Enhanced quality of healthcare professional education Improved health services research
Improving Outcomes with Clinical Decision Support: An Implementer’s Guide
Jerome A. Osheroff, MD, FACP, FACMI et al
•Upperman, J, fetal. , et. al. The Introduction of Computerized Physician Order Entry and Change Management in a Tertiary Pediatric Hospital, Pediatrics November 2005
•Shimlyian, et. al., Health Services Research, 6/26; HealthDay,; University of Minnesota release, University of Minnesota School of Public Health, 2007
•Ash, JS, PHD, MLS, et. al. A Consensus Statement on Considerations for a Successful CPOE Implementation, JAMIA, 2003•NCQHC, CEO Survival Guide to Electronic Health Record Systems, 2005
•Kashual, et. al. Return on Investment for a CPOE System, JAMIA, 2006•Frisse, M, Comments on Return on Investment for a CPOE System, Editorial JAMIA, 2006
•Kuperman, G and Gibson R, Computerized Physician Order Entry: Cost, Benefits and Issues, Annals of Internal Medicine 2003•Bates, et. al, Reducing Medical Errors in Medicine Using Information Technology, JAMIA, 2001
•Shortell, Stephen M PhD, MBA, MPH Improving Patient Care by Linking Evidence-Based Medicine and Evidence-Based Management JAMA. 2007
Lexical Uniformity: Tools and Content and Knowledge Production
“If you cannot name it you cannot teach it, research it, practice it, finance it, or put it into public policy”
Norma Lang, 1992, Dean of Nursing, University of Pennsylvania
Nor can computer-data systems truly interoperate
Clinical notes
“Multi-modal” data entry
EMR
Human Readable forNuance and flexibility
Machine Readable for analysis and CDS launch
Patient
Possible Patterns:•Referral Process•Discharge Summary•Rx Distribution•HRH•CPOE•…
Coding
We lack effective means of recording, collecting-communicating in a form that is both human readable and machine process-able
Without Lexical Standards
• Healthcare data is non-comparable
• Health systems cannot interchange data
• Secondary data analysis (Research, QA) is slow, arduous and arguable
• Linkage to Decision Support Resources (synchronous and asynchronous) is NOT easily or evolutionarily possible
• Maintenance, system swaps, terminology and code set updates are inordinately complex and expensive
Clin
ical &
Op
era
tion
al D
ata
Dic
tion
ary
(L
exic
on
)Clinical Operations
Ministry Intelligence CenterEHR/Clinical Content/Coding
Symphony
Financial NormalizationStandardized financial reporting/analysis
HR NormalizationComparison of hours per patient day/turnover rates/etc.
Supply Chain NormalizationStandardized Reporting
Improved quality and value, use
Enhanced real-time clinical analytics
Automated Decision Support (CDS)
Clinical regulatory requirements
Healt
hcare
Th
at
Work
s,
Is S
afe
, &
Leaves N
o O
ne
Beh
indOperational regulatory
requirements
Link clinical quality to care processes and supplies
Link operational costs to care processes and supplies
Rapidly recall defective supplies
Link workman’s comp to care processes and supplies
En
terp
rise-w
ide d
ata
rep
osit
ory
The Power of Integrated Data
MIC High Level Architecture
High Reliability Healthcare Defined
A dependable system of intersecting human and technical interactions with the purpose of maintaining or restoring individual and population wellness
Based on principles of measurement: events, outcomes, error sources, potential errors and benchmarked processes
Using current and evolving best evidence about individuals and their health
Leveraging information technology to
Decreasing reliance on memory
» Enhancing focus on appropriate best practices (including spiritual and experience) and scientific evidence
» Ensuring optimal quality: value, safety and appropriateness
Using mindful coordination of information/processes/ just culture
» Positive preoccupation and resilience around error
» Deference to expertise
» climate of collaboration
Aiming at continual discovery, learning and improvement of individual and system performance
Dominant shared values Stable, highly resistant to change
– ‘Commonly’ defines what is right or wrong, good or bad, correct or incorrect
– Justified by moral standards, reasoning or tradition
Expressed in:– Language– Norms of behavior– Commonly understood roles,
responsibilities, beliefs and customs Local: ‘it’s the way we do things around here’ The success of a culture depends on what
the organization wants to accomplish [in this case HRH
Broom, L. and Selznick, P. Sociology: A Text with Adapted Readings. 3rd edition, 1963
Culture warning:
STRATEGY
CULTURE
• Information technology in healthcare is the means to transformation, not the end goal
• ‘The moment an
organization forgets this, it places in jeopardy the change it needs to survive’
Robbins, H and Finley, M Why Change Doesn’t Work, Petersons’s Press, NJ, 1996.
• Assumed:• At 90% adoption, potential HIT-enabled
savings high (~$77B/yr health care efficiency savings)
• Found via computer modeling:
• Costs are modest relative to savings (~$10B/yr)
• Potential safety (~ $4 B/yr) and health benefits also large and could double the savings
• Health benefits include (~ $81 B/yr):
• Better delivery of preventive care
• Better management of chronic diseases
• Total annual savings from use of EMRS = $162 billion
“Theoretical knowledge is not the same as hands on knowledge.”
Dietrich Dorner, The Logic of Failure, 1996
COORDINATION Is about: Infrastructure; Process identification;
Standards
COLLABORATIONIs about:Mindfulness;Working together;Agreements;Involvement;Teams;High Reliability Assurance
COMPREHENSION Is about:Cognitive understanding; Gaining and conferringguilt-free understanding; How knowledge is sharedNot a NEW problem for us
The 5C’s of Culture Change
COMPASSIONIs about: Caring;Mission;Worth;Values;Dedication;Commitment; ‘What’s in it for me’
CONVERGENCEIs about:Leadership;Style;Timing
CULTURETRANSFORMATION
Questions
Did these points come acrossDid these points come acrossThe role of informatics in a high reliability healthcare The role of informatics in a high reliability healthcare
organizationorganization
The importance of clinical decision support in a high The importance of clinical decision support in a high reliability organizationreliability organization
Awareness and a method to address cultural Awareness and a method to address cultural challenges to using information systems to achieve challenges to using information systems to achieve high reliabilityhigh reliability