Make the Complex Simple…

The Healthcare Knowledge Map…and Break Down the Silo’s

David Shiple,Practice Leader, Advisory Services

» Healthcare professionals often work and think “in silo’s”, but increasingly need to solve enterprise-wide problems

» Seasoned hospital professionals with a comprehensive understanding of hospital processes typically acquired this knowledge after decades of hospital experience

» New professionals coming into the field must quickly gain the same understanding as industry veterans in a period of hyper-change, and

› Knowledge of only a single hospital “silo” is no longer an option› Knowledge and credibility in clinical areas is a critical success factor› Every process change can have an unintended cascading effect

within a health system

Solving The Healthcare Knowledge Gap

The Problem

» How do we quickly help healthcare service professionals get their arms around the complex flow of a health system?

» It would be nice if the major health system processes could be put into one, visually compelling map

» It would be nice… and it’s been done.

Solving The Healthcare Knowledge Gap

The Solution

People Learn Best by Seeing …

We use large graphical models for rapid understanding … and to get everyone on the same page (i.e. confirming the “current state”)

“… if I can get everything onto one page, I can get mental control over it..” - Workshop Participant

Understanding Correlations Among WorkflowsOnce people can get the whole problem on a “workbench”, correlating workflows and planning enterprise-wide changes can begin

“ .. For the first time, managers from each discipline felt their colleagues had a good understanding of their business models, workflow, and issues…”- Workshop Participant

Sample Knowledge Map SectionsDetailed is carefully balanced: enough detail to make information meaningful, but not too much information that would make the model unusable

The data points are color-coded to highlight key workflow steps, technology enablers, and commentary on current issues of adoption, ROI, etc.

How is the Knowledge Map Organized?

Workflow Step Technology Enabler Commentary

Example from the physician’s workflow:

Workflow Step

Technology Enabler Commentary

Pictures, metrics tables, and reference material is embedded into the map to further drive accelerated understanding of the health system.

How is the Knowledge Map Organized? (cont’d)

30 minArrival to First MD Encounter

< 1%% of time on Diversion

3-5 minRegistration Start to Registration End

< 20 minRegistration End to Placed in Treatment Room

10 minArrival to First RN Encounter

< 10 minTriage End to Registration Start

60 – 75 minFirst MD Encounter to Disposition Order Written

15 min (discharged pt)

30 min (admitted pt)

Disposition Order Written to time Patient Left the ED

5-7 minTriage Start to Triage End

1% AMA

< 1%Left Without Being Seen

240 minLOS for Admitted Patients

90 minLOS for Treat & Release

BenchmarkPerformance Indicators

30 minArrival to First MD Encounter

< 1%% of time on Diversion

3-5 minRegistration Start to Registration End

< 20 minRegistration End to Placed in Treatment Room

10 minArrival to First RN Encounter

< 10 minTriage End to Registration Start

60 – 75 minFirst MD Encounter to Disposition Order Written

15 min (discharged pt)

30 min (admitted pt)

Disposition Order Written to time Patient Left the ED

5-7 minTriage Start to Triage End

1% AMA

< 1%Left Without Being Seen

240 minLOS for Admitted Patients

90 minLOS for Treat & Release

BenchmarkPerformance Indicators

The HIMSS 8-Stage EMR Maturity Model

Stage 7 - Medical records are fully electronic; hospital is able to contribute continuity of care document as byproduct of EMR; data warehousing in use

Stage 6 – Physician documentation in structured templates; full clinical decision support system in use; full radiologic and PACS in use

Stage 5 – Closed loop medication administration that addresses every step of medication use process

Stage 4 – Computerized physician order entry system in use; clinical decision support system in use for clinical protocols

Stage 3 – Clinical documentation, clinical decision support system in use for error checking, PACS in use outside of radiology

Stage 2 – Clinical data repository, controlled medical vocabulary, clinical decision support system; may have document imaging

Stage 1 – Ancillaries (lab, radiology, pharmacy) are installed

Stage 0 – None of the ancillaries are installed

Images help students to develop a rich “mental map” of the health system; the one on the left is from the O.R. workflow

Metrics help professionals understand how a given workflow is measured and what is seen as important - the table above is from the E.R. workflow

The reference section of the model contains commonly used statistics, best practices criteria, and other Knowledge information which is commonly accessed by users of the model

Acute Care Hospital

How is the Knowledge Map Organized? (cont’d)

Nurse

Physician

Physician Office

Med/ Surg ICU

Reve

nue

Cycl

e

Emer

genc

y D

ept.

Ope

ratin

g Ro

om

Phar

mac

y

Radi

olog

y

Lab

Nurse/ PhysicianInteraction

Knowledge Material

Meaningful Use Criteria

EMR 8-Stage Model

CMS Core Measures

Health System KPIs

36”

48”

• The model prints as a 36” x 48” color poster• The model contains roughly 200 workflow points• Other workflow modules are available that can be

“swapped in”: Supply Chain, Cardiology, Oncology, etc.

The patient experience underlies the entire model

Health system IT professionals

IT vendor professionals

Board Members

Quality/ Safety Directors

Marketing Professionals

First year MHA & MPH students

Lean Sigma Practitioners

Ancillary Managers

Nurse Managers

CMIO’s

Admitting Dept. Managers

Revenue Cycle Managers

Facilities Managers

Performance Improvement Professionals

Who Needs the Big Picture?

I need to solve my problem

- OR -

Let’s solve our problems

Silo

Health System

» Part of on-boarding or level-setting process for people new to the industry or new to an enterprise-wide project

» Low-cost, 4-hour course to give participants an operational/ technology overview of a typical healthcare system using the Knowledge Map

» Each student receives a full-sized Knowledge Map to own, and to use during instruction

» Short competency exam is given at conclusion of the course

» “Introduction to Hospital Operations” certification is given to each passing student

» Students are encouraged to display the Knowledge Map in their office or hallway and internalize it over time

Used for Rapid Knowledge Infusion

“ Our managers have dubbed the program, ‘death to the silos’…”- HR Director

» Provides a compelling “one-stop-shopping” visual for illustrating the current and future states of enterprise improvements, e.g.

» Reducing average length of stay» Increasing patient throughput» Establishing EHR meaningful use

» Provides a “workbench” for process change teams to brainstorm, form cross-silo correlations, and form a high-level future map

» Maps are easily modified and are inexpensive

Used as a Performance Improvement Tool

“ .. People ask what the future state will look like…I say, ‘stop by my office – it’s hanging on my wall’ ”- Lean Sigma Project Manager

» Substitutes for 100’s of pages of text or slides (that never gets read and does not lend itself to building an integrated mental map)

» Provides a map that can be gradually internalized on the wall of an office or cube

» Helps bridges the communication gap between the various actors in the operation of a hospital – in days or weeks, not months and years

» Gives all players in the healthcare system an appreciation for the complexity of care delivery and challenges facing each player

» Visually compelling - people are drawn to large diagrams describing their line of work

The Value

» A Knowledge Map that includes the full workflow scope of the acute care hospital and physician office setting has not existed until now

» Legions of people work in the “ecosystem” of healthcare – can we afford each to have only a piecemeal understanding?

» The Knowledge Map can be easily customized for:» A specific hospital or health system» A set of technologies specific to a vendor» Emphasis on particular workflows (e.g. revenue cycle and supply

chain) » The Knowledge Map is a powerful tool used during on-

boarding, weekend workshops, certification programs, retreats, and performance improvement projects

Making a Difference in Healthcare

» Filter slide control gradually move user from high-level to detailed views

» Zoom in and out of model for greater/ lesser detail» Workflows can be added/ changed easily» Workflow widgets (IT enablers, actors, illustrations) can be

picked from palettes» Mouse-over workflow item to display IT enablers, metrics,

issues, etc» Healthcare Knowledge Map 2.0 is planned for early 2012

Healthcare Knowledge Map 2.0DIVURGENT has begun integrating the knowledge content into a leading workflow tool to create a “living model”

Hospital just a platform for care for community docs?

Pharmacy

Radiology

Acute Care Hospital

ICU

Physician Office

Nurse

Physician

Review test results from night before B

egin developing next steps/

Write orders if appropriate

Ask nurse for obser- vations

Begin Rounding S

tart w/ pending disch first

Save new admissions (take the most time) for last

Review chart/ take notes

Get census

Computerized Physician Order Entry (CPOE)• Physicians enters own orders

• Electronic ordersets used to order protocol based orders

• System flags conflicts between meds, allergies, DX’s ,etc

• Many docs perceive CPOE as too time-consuming

• Zynx - popular orderset content tool - contains >50,000 ordersets

• Journal references available online

• CPOE seen to require electronic physician documentation, CDSS, and access to EMR

Physician/ Nurse communication part of

many patient sat surveys

Physician: page me if/ when…”

Nurse: brief physician on patient

statusTruly part of

multi- disciplinary

team?

“Nurse most knowledgeable about patient”

Physician calls in order

• Hospitalists• Interventionists• House Staff• Specialists• Community Physicians

Physician documentation system Tem

plate driven

Medical vocabulary required for discreet data capture

Do checkboxes can dumb down notes?

“Boxes checked… but doesn’t convey clinicians rationale, thinking, context of their observations”

When templates used – do all notes start looking the same?

Discharge summaries

- Cannot bill until disch summary complete and signed

• Nurse/ Patient Ratio• Patient satisfaction• Want fewer agency nurses• Magnet status• Nurse shortage• Walking 3 miles a day• Can’t recruit nurses without

good IT (they want a safe place – fewest mistakes as possible)

Charting-Assessments-Vitals-I&O-HT/ Weight-Treatments-Pt education

Draw blood for lab tests NP – write

scripts

Write Orders

Perform Consults

Participate in physician

rounding

Get signature on patient consent

forms

Admission/ On-going

Assessments

Administer Medications

“The 5 Rights”

MAR update

Report ADEsIs patient Comfortable?

Family Interaction

Verify Physician Orders

Nursing Orders

Care Plan

- Care goals

Patient Call Button

Infection Control

Process transfers

24x7 Care

All clinicians: wash hands before/ after each patient

• ICU for patients that need to be watched constantly

• Goal is stabilize and step-down to med/ surg floor

• Typical patient: elderly, sedated, Medicare

• 1 – 3 patients/ nurse

• 100 – 160 procedures/ day

• Advance directives in use

Key to patient satisfaction, patient knows:• Who is leading coordination

of my care• Who is in the room, and

what their roles are• What is happening and why• What is going to happen

next

30 CMS core measures now, expected to be 125 by 2012

“Effective communication amongst multitude of caregivers an on-going challenge”

“Huge information asymmetry between clinicians & patients”

“The Checklist” from Hopkins reduced ICU infections by 60%

CBC, electrolytes, chest x-ray the most common procedures

Rapid Response Teams – preventative measure – should be called for patient in trouble to prevent coding

Discharge planner - everything lined up for patient so can leave as soon as disch order given

Case Mgr - throughput focused- doctor, anything you can do to expedite...?

70% of all inpatient admits come thru ED

Increasing patient thruput is only as good as having beds available

“60% of ED protocols can be started without Physician approval – but only 5% are”

Some ED’s aim to be profitable; some not

'“Golden hour" - the hour after accident in which most likely to survive

Accountability: meds administered = physicial amounts in cabinets

"Take and return" buttons to account for meds

Adjust alert catalog - remove annoying alerts

Educate patient on meds at D/C

Distribute meds throughout hospital S

atellite pharmacies

Dispensing carts

Meds packaged into unit-doses

Meds are bar-coded

Pharmacist verifies each order

Pharmacist addresses physician alert overrides

Pharmacist consults with Attendings E

sp. in ER

Pharmacist rounds on patent floors

Develop formulary

Limit number of “like” meds

Negotiate/ order from drug wholesalers

Meet with drug reps

Ask Tech for new/ different image if needed S

ometimes, a “wet read” first, then more specific test

If patient not prepped W

hat contrast to drink/ what not to eat

Lab tests to be done prior

If problem, appt canceled; time wasted

Patients transported to Radiology F

rom ICU’s (very onerous)

From Floors

From ED

Walk-in’s

Nurse reviews next day’s studies

Do all orders match medical necessity?

Patients scheduled

Common modalities show below

ICU, ED, and “Pending Discharge

Automatically ordered STAT

Attending Physician writes order

• ~ 60% of ED patients get imaging

• What Phy is ordering and why?

• Attending consults Radiologist if needed

• Consults very common in ED

Eligibility

Pre-Admit

Reporting

Write-off

Deferred Collections

Collections

AR & Contractual Write-offs

Medical Necessity (Dx doesn’t match procedure)Pre-Authorizations

Admission

ABN (Advanced Beneficiary

Notice)

Charge capture for

misc.

Not paid for never events

Claim can’t be submitted w/o

signed discharge

Coding/ Abstracting

-- Determine actual coded diagnosis from

medical record

Claims Generation

Claims Editing

Claims Submission

Round at local hospital

Check-in

See Patients

Exam (avg. 7 minutes/ patient, 30-35 patients/ day)

Dictate/ write notes

Orders

Medical SpecialtiesAllergy & ImmunologyAnesthesiaCardiovascular Disease(CardiologyDermatologyEmergency MedicineEndocrinology and MetabolismFamily PracticeGastroenterologyGeneral PracticeGeriatric MedicineGynecologyGynecologic OncologyHematologyInfectious DiseasesInternal MedicineNeonatologyNephrologyNeurologyNeurological SurgeryObstetrics and GynecologyOncology, MedicalOphthalmologyOrthopedic SurgeryOtorhinolaryngology(Ear, Nose & Throat)PathologyPediatricsPhysical Medicine and RehabilitationPlastic SurgeryPodiatric Medicine(Podiatry)Preventative MedicinePsychiatryPulmonary DiseaseRadiology, DiagnosticRadiology, NuclearRadiation OncologyRheumatologySports MedicineSurgery, GeneralSurgery, HandSurgery, ThoracicSurgery, VascularSurgery, Colon and RectalSurgery, Urology

Nothing happens till Doc writes an order

Almost all patients need image(s)

Maximize reimbursement

Dispensing cabinets delivered to floors

RadiologyNeurologyCardiologyOther Specialists

Operate/ transfer to PACU, then the to floor Admit Patient

Self Pay Write-offs

Is patient safe?

Register

Write prescriptions- -

Paper

- - Fax

- - Electronic

15-20% EMR adoption – expected to rise quickly with ARRA – worth $44k per doc

80% of money made (and patient care delivered) office – not hospital

Many single-practice docs, but no one to replace them when retire

Will docs and payers drive “medical home” concept?

Shortage of primary docs, $120k - $150k/ year

“Give me meds, problem lists, and 20 minutes to ask questions & I’ll get to right dx”

“If docs thought EMR would make them more efficient, they would have bought them long ago”

Hospital disaggregation trends: Imaging Chemo/

Radiation

Dialysis (Renal)

Day Surgery

Endoscopies

Heart procedures

Anyone doc can invest in ACS, but only docs doing procedures can refer to it

Take patient calls• Need appointment• “Not getting any

better”• Script refill• Got a letter – told to

call for f/u• Etc

RAC - Recovery Audit Contractors

Bundled payments

Medical Home – PCP’s paid extra for coordinating care

ICD-10 – 10x the number of codes of ICD – 9 (290 codes for diabetes); used in Europe; like Y2K conversion, biggest IT risks

• claims scrubbing, coding rules, and charge edits.

Bundled payments – Claims for an episode of care – to multiple providers – under a captivated arrangement; in pilot stages only

Emerging technologies

• Alarms, lab abnormals, etc messaged to nurses wireless phone - escalates to nurse manager in 3 minutes;

• Robots to transport supplies, etc;

• ER-like tracking board with to-do's, labs awaiting, P, C or other to denote core measure related diseases,

• RTLS giving pt location when out of unit, RFID to find supplies, equip – prevent hoarding - stop s equip trying to leave area

• Auto calls for routine blankets, missing meals, etc

Check-out to next doc

Workflow interruptions- Patient

call button- Question

from doc- Question

from pharmacy, lab, etc

- Question from another nurse

- Patient coding, falling, etc.

- Family upset

- Case manager

POC payments

Centralized Scheduling

Combined billing office

Pre-auth, pre-verification, collections, counseling 3 days prior to service

More high deductible plans mean more bad debt

Pre-Verification

Financial Counseling

Smart Cards

Online pre-registration

Kiosks

Not paid for hosp acquired condition

not POA

- eg, Surgery infection

Discharge Order• Doc - “discharge

if labs ok”• Sometimes

incentives to discharge by 5pm

“Docs don’t look at nursing notes”

Automated phone reminders for appointments

Computer getting smart enough to read images?

PACS becoming ubiquitous

PACS: storage & backup is risky & expensive

Imaging devices innovating very quickly

3D imaging – a next step

Voice recognition for notes very popular

Internet allows “anywhere” interpret -tations

Chief Complaint

History of Present Illness

Past Medical History

Family History

Social History

Review of Systems

Physical Exam

Evaluation & Management

Floor Nurse

Nurse Manager

Attending

Specialists

Consulting Physicians

Resident

Therapists: Respiratory, Physical, Occupational

Phlebotomist

Social Worker

Transport

Unit Secretaries/ Coordinators

Nutritionist

Chaplain

Housekeeping

Case Manager

Discharge Planner

Hourly (flowsheet) documentation of:• Vitals

• Pain

• Drips

• Respiratory Therapy

• Intake/ output

• IV Infusions

• Sedations

On the Floors/Contact with Patient

Sometimes diagnostic testing hours limited in evenings / weekends - effects LOS

Bed assignment

LabsMedsRadiologyRT, PT, OTConsultsTransferDischargeEtc, etc

Medication reconciliation• Meds to

continue• Meds to stop• New Meds

5 Rights- -

Right patient

-- Right time-- Right medication-- Right dose-- Right route

Sometimes a single nurse dedicated to only administering meds

Team Meeting

- Usually involves end-of-life

Take Report

Discharge goals, e.g.• Home• LTC• Hospice• Home Health

Half of all surgeries are now minimally evasive

Robotic surgeries (with dramatic outcomes – small incisions, little blood loss, surgeon can see every fiber, etc) becoming the norm

60%/ 40% day surgeries vs. inpatient surgeries is typical

30a – 5p OR use is typical

Online/ Virtual Visit (eg, RelayHealth)

Nursing interventions – eg, assist patient TCDB (turn, cough, deep breathe)

Examples of Common Order SetsAbdominal Aortic Aneurysm RepairAcute Myocardial Infarction/STEMI Acute Renal FailureAlcohol WithdrawalAppendicitis/Appendectomy – AdultAppendicitis/Appendectomy – PediatricAsthma – AdultAsthma – PediatricAtrial FibrillationBariatric SurgeryBrain InjuryCardiac Surgery – PediatricCarotid EndarterectomyCesarean DeliveryChest Pain – AcuteChest Pain – Low RiskCholecystectomyChronic Kidney DiseaseChronic Obstructive Pulmonary DiseaseColectomyCoronary Artery Bypass Graft Surgery….…..……

Key Medical Record ContentsIdentification SheetProblem ListMedication RecordHistoryPhysicalProgress NotesConsultationsPhysicians’ OrdersImaging and X-ray resultsLab resultsImmunization RecordOperative ReportPathology ReportDischarge SummaryDiagnoses CodesProcedure Codes

30 minArrival to First MD Encounter

< 1%% of time on Diversion

3-5 minRegistration Start to Registration End

< 20 minRegistration End to Placed in Treatment Room

10 minArrival to First RN Encounter

< 10 minTriage End to Registration Start

60 – 75 minFirst MD Encounter to Disposition Order Written

15 min (discharged pt)

30 min (admitted pt)

Disposition Order Written to time Patient Left the ED

5-7 minTriage Start to Triage End

1% AMA

< 1%Left Without Being Seen

240 minLOS for Admitted Patients

90 minLOS for Treat & Release

BenchmarkPerformance Indicators

30 minArrival to First MD Encounter

< 1%% of time on Diversion

3-5 minRegistration Start to Registration End

< 20 minRegistration End to Placed in Treatment Room

10 minArrival to First RN Encounter

< 10 minTriage End to Registration Start

60 – 75 minFirst MD Encounter to Disposition Order Written

15 min (discharged pt)

30 min (admitted pt)

Disposition Order Written to time Patient Left the ED

5-7 minTriage Start to Triage End

1% AMA

< 1%Left Without Being Seen

240 minLOS for Admitted Patients

90 minLOS for Treat & Release

BenchmarkPerformance Indicators

Review medical records

Nursing assignments

Reference

Care Delivery Map

Typical Activities:• Turn patient

• Change dressings

• Daily chemistry's & CBC's

• Head to toe exam every 4 hours

• Fluoroscopy & ultrasounds

• Feeding tubes

• Central lines

• Family observations

• Stomach sounds (digesting?)

• Monitor ventilator

Revenue Cycle

Operating Room

EmergencyRoom

In office, review yesterday’s correspondence• Diagnostic

results

• ER/ Hospital discharges

• Consults

• Refils

• Patient phone call

• Physician calls

• Drug rep visit today

• Etc

Do next steps or delegate

• Call patient

• Refer to specialist

• Sign script refill

• Suggest further tests

• Send letter to patient with test result

• Test patient to come in for F/U

Per office protocol, perform procedure per patient disease, e.g.• Glucose for

diabetes patient

• EKG for cardio post MI patient

• Take BP with patient standing up

• Etc.Before physician arrives

Page physician with results of all STAT orders

Successful care teams: communicate, communicate, communicate…

Review chart before entering or with

patient

Refer to specialist- If time, dictate letter describing

patient's story

Schedule Patient. ideally• Schedule openings

favor profitable procedures

• Schedules booked at 110%

• “Like patients” are scheduled together

Record vitals• Weight• Temp\• Blood

pressure• Pulse

Escort patient to room

Some offices, NPs and PAs do 90% of what physician can do, eg,• Stitch a

wound

Some cases (eg elderly with severe pneumonia), send to hospital If

family member to drive, call admitting

If not, call 911

Significant number of ER visits come from Physician offices

Write orders

See drug reps

Call back other physicians

End-of-day paperwork

Patient schedules follow-

up

Complete P4P reporting

Start claims process

Deal with business relationships Hospital contracts Market to other

physicians Billing company

performance Office staff

performance issues

Office lease New physicians

for the practice

Post exam activities• Draw blood

for lab tests• Give

injections• Provide

patient information

Metric Volume Cases/ Room revenue First case on time Contribution margin by Doc

Block Utilization rate Infection reate Turnover time < 20 Minutes

Worklists created for Radiologists Worklist

worked among of a pool of Rad’s

Workload balanced among Rad’s and facilities

Order worked at discretion of Rad’

“Nighthawk” service for remote reading Generally for

11pm – 7am shift

Technicians conduct imaging A “time out”

before test begins

Qualification includes 2-year degree

No latitude to interpret and take extra images

Tech records body measurements

Clear imaging specifications from Radiologists

Each procedure generates 2 charges Hospital

charge Physician

charge

Bedside Radiology in ICUs Ultrasound Mobile X-Ray

Ordering physician can view PACS Generally

Orthopedics and Surgeons

RFID tracking against floor plan; where are?: The other

caregivers?

My patient?

The medical equipment I need?

Time stamp of location move or significant activity

Monitor tracking board for number of patients In waiting

room waiting for exam bed

Waiting to be seen by physician

Seen by physician, but awaiting nursing tasks

Awaiting diagnostic test

Divert ambulances if hit capacity

Take calls from referring docs

Assign Physician(s) & Nurse(s) to patient

Triage patient Use 1-5

scale – (see below)

Patient prioritized

Greet patient

Monitor tracking board P

atient is ready for next activity by you

Where is my patient?

Who has been waiting too long?

All orders are automatically STAT

Order diagnostic tests

Clinicians alerted to completed tests

Additional tests ordered as needed

Complete nursing Documentation

Complete physician documentation C

hief complaint, meds, allergies, PMH, SOC, FH

Annotated anatomical drawings

Write discharge instruction(Eg, based on Ohio ACEP set)

Post charges & supplies

Follow-up calls/ call-backs

Work/ school release

Nurse & Admin

Make a Doc happy; review

Physician notes before paging the

Doc

Make a Nurse happy; return pages asap so Nurse can take action

Timeout- N

urse outlines entire case

- All have to listen

- All have to verbally concurs

Phy marks/ initials site

Moved to OR, slid onto table

OR prepped per phy’s preference list- 1 per

surgeon/ procedure

- Instruments, sit/ stand, glove size, meds, etc

IV inserted- Hydration- Access

for anesth., emerg. meds

Possible delay/ cancellation- Patient has eaten

Holding area- Patient on stretcher- See nurse- See

surgeon- Document

alternatives discussed, risks, doing self-care post-op

- See Anesthesiologist

- -Sign informed consents

Arrival- Change

into johnny- Final

assessment

- Armband put on

- Ready for OR

Pre-Reg- Insurance, etc- Consent- Schedule a

bed- Instruct

not eat/ drink on surgery day

Pre-admission testing- Standing orders- Orders from surgeon- Eg, if certain meds, get CBC or CHEM-7

Patient scheduled into surgeon’s time “block”

Antibiotics w/in 1 hour of incision

Anesthetist – -

Secure airway

- Admin anesthesia

- Monitor vitals

Scrub nurse – hands instruments & responsible for sterile field

OR RN’s – assist with suturing, retract tissue, position patient, tilt table, etc.

Circulating nurse-

Patient advocate

- Watch everyone’s moves

- Runs the show

- Document care

- Can stop surgery if needed

OR documentation-

Legal record

- All surgical procedures

- What safety devices used

- How protected from infection, etc

Surgery performed

All items counted going in; counted afterward- I

n counts don’t match, an automatic x-ray

Regain consciousness

Reflexes back (can cough)

PACU – look for respiration, can move limbs, pain, respond to verbals

Transfer - on floor, patient needs to communicate, hit call button, etc

Surgeons round

Floors specialized by surgery type

CSF’s: manage pain, move around, no infections

Robotics w/ camera w/ depth perception & magnific-tion

Perioperative systems for complete documentation. alerts, safety, and data transfer to floors

Analytics and reporting to optimize expensive real estate

Category Nrise Time Examples Level I(Brief) 0-15 min No medication, no testing

i.e. cold, insect bites Level II (Intermediate)

15-30 min Min. treatments, simple testing i.e. minor laceration, suturing

Level III (Extended) 30-60 min Moderate treatments, IV fluids i.e. Pneumonia, simple stroke

Level IV(Intensive) 60-120 min Extensive treatments i.e. COPD, Obtunded Stroke

Level V(Comprehensive)

> 120 min Life threatening disorders, Greater than one nurse required

Drug Purchases 25th %'tile

Purchases / Inpatient Day $88

Purchases / Occupied Bed $35,529

Purchases / Admission $419

Purchases / APD $90

SDC – Supplies, Drugs & Consumables (excluding purchased ser vices

Metric Benchmark

SDC as % of operating expense 21% SDC Exp per Adj. patient day $350 SDC Exp per Adj. discharge $2,300 SDC as % of net revenue 20.0%

The HIMSS 8-Stage EMR Maturity Model

Stage 7 - Medical records are fully electronic; hospital is able to contribute continuity of care document as byproduct of EMR; data warehousing in use

Stage 6 – Physician documentation in structured templates; full clinical decision support system in use; full radiologic and PACS in use

Stage 5 – Closed loop medication administration that addresses every step of medication use process

Stage 4 – Computerized physician order entry system in use; clinical decision support system in use for clinical protocols

Stage 3 – Clinical documentation, clinical decision support system in use for error checking, PACS in use outside of radiology

Stage 2 – Clinical data repository, controlled medical vocabulary, clinical decision support system; may have document imaging

Stage 1 – Ancillaries (lab, radiology, pharmacy) are installed

Stage 0 – None of the ancillaries are installed

Act on next pathway step, e.g. D

ay 1 - Do X

Day 2 – Do Y

Metric 25th %'tile

Turn-around time

Volume

Revenue/ profitability

Procedure mix

Metric Best Practice

Days in A/R < 50 Days

Denial Rate 3 – 8 %

Bad Debt % < 3%

CDM Turnaround Time <12 Days

Days to Bill Drop

Contract Utilization

Payer Mix 40%/ 20%/ 40%

MCare/Mcaid/Comm

Rebills

Modality Sample Uses

Nuclear Radiology Full body scan, use of contrasts, full motion video

CAT Scan Head trauma, abdominal pain

MRI Head, ligaments

Mammogram Breast cancer

Chest X-ray Pneumonia

Ultrasound Fetal development, gall stalls

Hospital contracting to outside Radiologist group is common

Over 400 Radiology tests available

Enter progress note after each

patient

Enter progress note after each patient-Handwritten?-Dictated?-Template driven e-physician documentation?

Med/ Surg

• Patient floors generally align with specialties

• Nurses care for patient; physicians make all treatment decisions; many nurses deeply involved in clinical decision making

• 24x7 care; typically 3 shifts: 7a-3p, 3p-11p, 11p-7a

• Get tests started ASAP, which drives meds & other therapeutics; then can learn and make adjustments

• Start ruling things out; adjust diagnosis

• Patient gets better on their own, responds to therapy, or cannot be helped any further

• If patient not “acute”, should be in another care setting

Establish rapport

Review events to date

Get patient’s observations

Describe next steps/ ask for patient concurrence

• US adoption rate ~ 20%

• Adoption expected to increase significantly under ARRA

• CPOE shown to significantly decrease errors, e.g., No misreading hand-writing, phy receives contraindication alerts

• Many docs perceive CPOE as too time-consuming

• CPOE = “Evidenced based medicine” to many

• Standardized order sets can educe variation, instill best practices, and lower utilization

• Ordersets typically takes 6-9 months to be developed/ approved

Large screens showing real-time status, tracking, and metrics information

Status screens using icons and color coding for reference on status of all patients

RFID tracking showing movement of patients, providers, and equipment

System automatically pages providers when they’re next to see patient

Extensive decision support, auto checking for conflicts: med-med, med-allergy, Med-DX, Dosage-BMI

Meds unit-dosed/ bar-coded with robotics

Robotics for IV compound mixing

Robotics auto fill med cabinets

Patient to Nurse - can you translate what doctor said?

By far, the most common intervention in hospital care

Focus on Rx - high costs and center of IOM medical error report

Robotics allowing pharmacists to spend time on high-value activities – i.e., available on floors for advice

Robotics eliminate human handling of hazardous drugs

Performance Indicator Metric

% Formulary Compliance %

ADE’s x

STAT Order Cycle Time x

Accountability: meds administered = physicial amounts in cabinets

Taking from cabinets automatically charges patients and decrements inventory

Non-repudative and confidential reporting system for ADEs

"Take and return" buttons to account for meds

Adjust alert catalog - remove annoying alerts

Educate patient on meds at D/C

Distribute meds throughout hospital S

atellite pharmacies

Dispensing carts

Meds packaged into unit-doses

Meds are bar-coded

Pharmacist verifies each order

Pharmacist addresses physician alert overrides

Pharmacist consults with Attendings E

sp. in ER

Pharmacist rounds on patent floors

Develop formulary

Limit number of “like” meds

Negotiate/ order from drug wholesalers

EMR value proposition is to ensure all activities completed during patient visit:

Patient record and recent tests viewed online

System prompts with reminders

Clinical note templates populated as exam takes place

Provider enters orders and e-prescribes meds

System captures/ suggests E&M, ICD9, CPT, and other coding to complete billing

Deliver care in the exam room

Inpatient Outpatient

2011 HOSPITAL MEANINGFUL USEOBJECTIVESImprove quality, safety, efficiency, and reduce health disparityUse of computerized physician order entry with 10% of all orders by an authorized provider Implement drug-drug, drug-allergy, drug-formulary checks Up to date problem list of current and active diagnoses using SNOMED or ICD9 Maintain active medication listing Maintain active medication allergy listing Record demographics of preferred language, ethnicity, race, gender and insurance type Record advanced directives Record vital signs height weight blood pressure, calculate and display: BMI Record smoking status Have lab results in the clinical repository Generate listing of patient specific conditions Report hospital quality measures to CMS Implement one clinical decision rule relevant to high priority hospital condition Electronically check insurance eligibility. Submit claims electronically to payers. Engage patients and familiesProvide patients with an electronic copy of their health information (lab results, problem list, medication lists, allergies, discharge summaries, procedures) upon request Provide patient with an electronic copy of their discharge instructions and procedures at the time of discharge upon request. Provide access to patient-specific education resources Improve care coordinationCapability to exchange key clinical information (discharge summary, procedures, problem list, medication list, allergies, test results) among providers of care and patient authorized entities electronically (to be specified by HIE Work Group of HIT Policy Committee) Perform medication reconciliation at relevant encounters and each transition of care Improve population and public healthCapability to submit electronic data to immunization registries and actual submission where required and accepted Capability to provide electronic submission of reportable lab results to public health agencies and actual submission where it can be received. Capability to provide electronic syndromic surveillance data to public health agencies and actual transmission according to applicable law and practice. Ensure adequate privacy and security protections for personal health informationCompliance with HIPAA Privacy and Security Rules Compliance with fair data sharing practices set forth in the Nationwide Privacy and Security Framework.

MEASURESImprove quality, safety, efficiency, and reduce health disparityReport quality measures to CMS including:

% of smokers offered smoking cessation counseling % eligible surgical patients who receive VTE prophylaxis % of orders (for medications, lab tests, procedures, radiology, and referrals) entered directly by physicians through CPOE Use of high-risk medications (Re: Beers criteria) in the elderly % lab results incorporated into EHR in coded format Stratify reports by gender, insurance type, primary language, race ethnicity % of all medications, entered into EHR as generic, when generic options exist in the relevant drug class % of orders for high-cost imaging services with specific structured indications recorded [EP,IP] % claims submitted electronically to all payers % patient encounters with insurance eligibility confirmed Engage patients and families% of all patients with access to personal health information electronically % of all patients with access to patient-specific educational resources % of encounters for which clinical summaries were provided Improve care coordinationReport 30-day readmission rate % of encounters where med reconciliation was performed Implemented ability to exchange health information with external clinical entity (specifically labs, care summary and medication lists) % of transitions in care for which summary care record is shared (e.g., electronic, paper, eFax) Improve population and public health% reportable lab results submitted electronically Ensure adequate privacy and security protections for personal health informationFull compliance with HIPAA Privacy and Security Rules Conduct or update a security risk assessment and implement security updates as necessary

HEDIS MEASURES• Colorectal Cancer Screening• Glaucoma Screening in Older Adults• Care for Older Adults *•• Use of Spirometry Testing in the

Assessment and Diagnosis of COPD• Pharmacotherapy of COPD

Exacerbation• Controlling High Blood Pressure *• Persistence of Beta Blocker Treatment

After a Heart Attack• Osteoporosis Management in Older

Women• Antidepressant Medication

Management• Follow-Up After Hospitalization for

Mental Illness• Annual Monitoring for Patients on

Persistent Medications• Potentially Harmful Drug-Disease

Interactions• Use of High Risk Medication in the

Elderly• Medication Reconciliation Post-

Discharge • Board Certification

HCAHPS * Patient Survey Sample* Hospital Consumer Assessment of Healthcare Providers & Systems • Did doctors and nurses treat you with

respect, listen carefully, and explain things?

• Was response to call button quick enough?• Were new medications explained to you?• Was room and bathroom clean?• Was it quiet at night?• Did you get help getting to the bathroom as

quickly as you wanted?• Was pain managed as well as could be?• Did staff talk to about whether you could

take care of yourself after leaving? And what symptoms/ problems to be on look out for?

• How would rate hospital overall?• Would you recommend hospital to your

friends/family?• How’s your health? What’s your education

level? ethnicity?

CMS Core MeasuresHeart Attack• Aspirin at arrival• Aspirin at discharge• ACE inhibitor for left ventricular

systolic dysfunction• Beta-blocker at arrival• Beta-blocker at discharge• Thrombolytic within 30 minutes of

arrival• Percutaneous coronary intervention

within 120 minutes of arrival• Smoking cessation counselingHeart Failure• Assess left ventricular function• ACE inhibitor for left ventricular

systolic dysfunction• Discharge instructions• Smoking cessation counselingPneumonia• Oxygenation assessment• Initial antibiotic timing• Pneumococcal vaccination• Blood culture before first antibiotic• Smoking cessation counseling• Right first antibioticSurgical Infection Prevention• Antibiotic within 1 hour before incision• Discontinued antibiotic within 24 hours

after surgery