adding value to the emr: a clinical perspective

Adding Value to the EMR: A Clinical Perspec9ve

Texas Children’s Hospital Charles G. Macias M.D., M.P.H.

Poll Ques9on #1

What is your primary area of focus? q Physician/clinical care provider q Quality q  Informa9on systems q Finance q Administra9ve execu9ve q Other

2

Objec9ves •  Describe the power of pairing an EDW with an EMR to realize care improvement, subsequent waste reduc9on and cost savings.

•  Understand early results of TCH’s cultural shi: to focus on value and the link between quality and cost.

•  Discuss how TCH’s focus on linking clinical science and payment models and opera9on science have driven financial stewardship and early successes in popula9on health management.

The Healthcare Value Equa9on

•  In an environment where cost is marginally increasing, healthcare must markedly improve quality.

•  Adop9on of EMRs and clinical systems should help push the quality agenda but alone may not be enough to deliver data intelligence.

Quality Cost Value =

Quality?

Access to Care and Care CoordinaBon

Best Prac9ces Do Exist Best Care at Lower Cost, IOM 2013 Report • The best examples come from communiBes not policymakers, and they inevitably involve pa9ents, doctors, nurses and other providers working together.

–  Donald Berwick, former administrator of the Centers for Medicare and Medicaid Services during the session en9tled, “Controlling health care costs while improving quality.”

–  Healthcare project in Alaska, where team-‐based care has resulted in 50 percent fewer hospital bed days, 53 percent fewer emergency department admissions and 65 percent fewer specialty visits.

• By one es9mate, roughly 75,000 deaths might have been averted in 2005 if every state had delivered care at the quality level of the best performing state.

• While some hospitals in southwestern Pennsylvania were paid an average of $18,000 to perform heart bypass surgery, others were paid as much as $35,000 for the same procedure. Similarly, payments for heart valve surgery ranged from a low of $24,000 to a high of $54,000.

–  Moreover, the lowest priced hospitals had lower mortality and readmission rates (i.e., beber quality) than the highest-‐priced hospitals

Poll Ques9on #2

•  How concerned are you about realizing ROI on your EMR investment? A – Very concerned B – Somewhat concerned C – Neutral D – Slightly concerned E – Not concerned

ROI on EHRs Proves Difficult

In Second Look, Few Savings from Digital Health Records New York Times: January 10, 2013 2005 RAND report forecasts $81 billion annual U.S. savings. “Seven years later the empirical data on the technology’s impact on health care efficiency and safety are mixed, and annual health care expenditures in the United States have grown by $800 billion.” In our view, the disappoin9ng performance of health IT to date can be largely abributed to several factors: • Sluggish adopBon of health IT systems, coupled with the choice of systems that are neither interoperable nor easy to use; • The failure of health care providers and ins9tu9ons to reengineer care processes to reap the full benefits of health IT.

EHRs, Red Tape Eroding Physician Job SaBsfacBon Most physicians, however, expressed deep frustra9on with costly and overly complicated EHRs that have fallen far short of their promise to improve prac9ce efficiency. Twenty percent want to return to paper.

-‐A tension between figh9ng to improve the EMR and spending late nights catching up on data entry

About Texas Children’s Hospital

So how does the paBent relate to healthcare expenditures?

•  Houston-‐based and na9onally renowned for providing top-‐notch pediatric and women’s care

•  Provides a full con9nuum of services

•  Commibed to developing clinical effec9veness guidelines to deliver the highest quality care possible

Sta9s9cs Number of Beds 469

Annual Inpa9ent Admissions

21,744

Annual Outpa9ent Visits

1.44 million

Emergency Room Visits

82,049

Inpa9ent Surgeries 8,655

Outpa9ent Surgeries

14,439

Pareto 80/20 Principle in Healthcare

Asthma

Affects ~7M children in the US,

~80,000 in Houston (most-common chronic

disease of children)

Acute asthma accounted for approximately

~3,000 ED visits and ~800 hospital

admissions in 2011 at TCH

National asthma practice guidelines have

been available since 1991 (updated 2007),

yet hospitalizations and ED visits have not

decreased

Severity Adjusted Varia9on

Correla9on Between Costs and High Quality Care Is Low

•  Describing varia9on in care in three pediatric diseases: gastroenteri9s, asthma, simple febrile seizure –  Pediatric Health Informa9on System database (for data from 21

member hospitals) –  Two quality-‐of-‐care metrics measured for each disease process –  Wide varia9ons in prac9ce –  Increased costs were NOT associated with lower admission rates or 3-‐

day ED revisit rates •  Implica9ons?

–  Op9mal care may be delivered at a lower cost than today’s care!

Kharbanda AB, Hall M, Shah SS, Freedman SB, Mistry RD, Macias CG, Bonsu B, Dayan PS, Alessandrini EA, Neuman MI. Varia9on in resource u9liza9on across a na9onal sample of pediatric emergency departments. J Pediatr. 2013

Higher Quality Is Ooen Lower Cost

•  A Modern Healthcare analysis found that in seven of 12 ci9es examined, the hospital with the lower average cost for inpa9ent and outpa9ent Percutaneous Coronary Interven9on procedures also had a lower readmission rate for PCI pa9ents.

hbp://www.modernhealthcare.com/ar9cle/20131026/MAGAZINE/310269941#

Consumer Care/Cost Uncertainty

•  Consumers: –  Trust their physicians –  Hope for the best –  Struggle to understand cost and care

–  Don’t ooen know what they are geqng

–  Don’t always get great outcomes

•  Value is what they want

Challenge of Healthcare

Image Source: hbp://www.hopkinschildrens.org/pediatric-‐residency.aspx

•  Physicians are: –  Driven by science and key values

–  Overwhelmed with medical literature

–  Not well trained to turn that experience into high quality pa9ent outcomes

•  Transparency of local data is part of the solu9on!

Poll Ques9on #3

•  For non-‐clinical abendees or non-‐prac9cing physicians in abendance, during what percentage of pa9ent visits are your physicians talking about cost and care tradeoffs? A – 80-‐100% B – 60-‐79% C – 40-‐59% D – 20-‐39% E – 00-‐19%

Poll Ques9on #4

•  For prac9cing physicians in abendance, during what percentage of pa9ent visits are physicians in your organiza9on talking about cost and care tradeoffs? A – 80-‐100% B – 60-‐79% C – 40-‐59% D – 20-‐39% E – 00-‐19%

Evidence to expertise

Clinical Decision

Source: SAEM. Evidence Based Medicine Online Course 2005

Physicians and Care Cost

Resource issues

Physician preferences

Evidence

Patient values and preferences

Clinical Expertise

Once taboo, physicians should take cost into consideraBon: Without money . . . there is no mission. there is no expansion. there is no innova9on. there is no healthcare.

And so providers must . . . understand what creates improvements understand the story that their data tells.

The New Healthcare

Data linked to systems of care can drive quality iniBaBves!

TCH’s Clinical Integra9on Strategy •  Build a comprehensive, integrated and evidence-‐based quality and safety

program resul9ng in measurable improvements in processes and quality care.

•  Collect and meaningfully use data that provides informa9on about clinical outcomes and opera9onal processes.

•  Implement an enterprise-‐wide data-‐management infrastructure that will leverage the clinical systems; star9ng with Epic and financial informa9on in order to provide easy-‐to-‐access, meaningful and relevant data to assist in accelera9ng improvements in clinical and opera9onal processes.

Metadata: EDW Atlas Security and Auditing

Common, Linkable Vocabulary

Financial Source Marts

Administrative Source Marts

Departmental Source Marts

Patient Source Marts

EMR Source Marts

HR Source Mart

Less Transformation More Transformation

FINANCIAL SOURCES (e.g. EPSi,)

ADMINISTRATIVE SOURCES (e.g. API Time Tracking)

EMR SOURCE (e.g. Epic)

DEPARTMENTAL SOURCES (e.g. Sunquest Labs)

PATIENT SATISFACTION SOURCES

(e.g. NRC Picker,

Human Resources (e.g. PeopleSoo)

TCH’s EDW Architecture Copyright © HealthCatalyst 2013

Operations •  Labor produc9vity

•  Radiology •  Prac9ce Mgmt •  Financials •  Pa9ent Sa9sfac9on

•  + others

Clinical •  Asthma •  Appendectomy •  Deliveries •  Pneumonia •  Diabetes •  Surgery •  + others

How TCH Defines Quality 1.  Ins9tute of Medicine domains:

•  Safe •  Effec9ve •  Efficient •  Timely •  Pa9ent centered •  Equitable

2.  Importance of minimizing unintended varia9on in health care delivery

3.  The degree to which health services for individuals and popula9ons increase the likelihood of desired health outcomes and are consistent with current professional knowledge. – Lohr, K.N., & Schroeder, S.A. (1990). A strategy for quality assurance in Medicare. New England Journal of Medicine, 322 (10):707-‐712.

4.  Systema9c infusion of evidence into a system that integrates opera9onal improvement and data transforma9on

Approach to Improving Processes of Care

•  Organizing permanent, integrated workgroup teams consis9ng of physicians, nurses, IT, quality and pa9ent safety, quality improvement, clinicians, and business analysts that are responsible for a clinical program or clinical services over the long-‐term.

•  Integra9ng cri9cal elements of evidence-‐based pracBces

into the delivery of care. •  Establishing baseline measures, AIM statements with

measurable goals and on-‐going review of results versus targets. Outcome and balance metrics are included.

Clinical Program

Knowledge Manager

Data Architect (Analysis)

Data Architect (Visualization and Infrastructure)

Application Service Owner

Clinical Director

Domain MD Lead

Copyright © HealthCatalyst 2013

#5 Care Process

MD Lead

RN Lead

#4 Care Process

MD Lead

RN Lead

#3 Care Process

MD Lead

RN Lead

#2 Care Process

MD Lead

RN Lead

#1 Care Process

MD Lead

RN Lead

= Subject Matter Expert = Data Capture = Data Provisioning = Data Analysis

Operations Director

Quality & Clinical Evidence-‐Based Team

DATA DRIVES WASTE REDUCTION

Option 1: Focus on Outliers – the prescriptive approach

Strategy Identify extreme cases with the potential for high costs from bad outcomes and eliminate the unfavorable tail of the curve (“executive dashboard” approach)

Result If the outlier trim point is set at 1.96 standard deviations, only 2.5% of cases fall under the adverse outcome tail, so the impact is minimal

# of Cases

Excellent Outcomes Poor Outcomes

1.96 std

# of Cases

Mean


1 box = 100 cases in a year

Alterna9ve Approaches to Waste Reduc9on

27


# of Cases

Mean

1 box = 100 cases in a year

Excellent Outcomes

# of Cases

Poor Outcomes

Option 2: Focus On Inliers – improving quality outcomes across the majority

Strategy Identify best practices through research and analytics and develop guidelines and protocols to reduce inlier variation

Result Shifting the cases that lie above the mean toward the excellent end of the spectrum produces a much more significant impact

Alterna9ve Approaches to Waste Reduc9on

28

Improving Cost Structure Through Waste Reduc9on

Ordering Waste Workflow Waste Defect Waste

Ordering of tests that are neither diagnostic nor

contributory

Variation in Emergency Care wait time

ADEs, transfusion reactions, pressure ulcers,

HAIs, VTE, falls, wrong surgery

Ordering Waste


contributory

29

Evidence against

CXR utilization in patients with known asthma, steroids in

bronchiolitis

Evidence equivocal

Hypertonic saline and bronchodilators in select patients with bronchiolitis

Evidence Supports

Quicker steroid delivery for status asthmaticus, goal

directed therapy for septic shock

Use Cases and Business Drivers Care Redesign Care Redesign Methodology

30

Cost Per Case and Case Volumes

31

51%

35%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Oct

. 201

0

Nov

. 201

0

Dec

. 201

0

Jan.

201

1

Feb.

201

1

Mar

. 201

1

Apr

. 201

1

May

. 201

1

Jun.

201

1

Jul.

2011

Aug

. 201

1

Sep.

201

1

Oct

. 201

1

Nov

. 201

1

Dec

. 201

1

Jan.

201

2

Feb.

201

2

Mar

. 201

2

Apr

. 201

2

May

. 201

2

Jun.

201

2

Jul.

2012

Aug

. 201

2

Sep.

201

2

Oct

. 201

2

Nov

. 201

2

Dec

. 201

2

Jan.

201

3

Feb.

201

3

Mar

. 201

3

Apr

. 201

3

Perc

enta

ge

Month year

Asthma: Care Process Team Cohort, Percentage of Chest X-rays Ordered* (Oct. 2010 - Apr. 2013)

Feedback of rates to hospitalists and Emergency Center clinicians

Order set revisions

* Inpatient, Emergency Center (EC) and observation patients (Care Process Team cohort), P-Chart based upon EDW data extraction of 5/14/2013 (M& W).

51%

35%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Oct

. 10

Nov

. 10

Dec

. 10

Jan.

11

Feb.

11

Mar

. 11

Apr

. 11

May

. 11

Jun.

11

Jul.

11

Aug

. 11

Sep.

11

Oct

. 11

Nov

. 11

Dec

. 11

Jan.

12

Feb.

12

Mar

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Apr

. 12

May

. 12

Jun.

12

Jul.

12

Aug

. 12

Sep.

12

Oct

. 12

Nov

. 12

Dec

. 12

Jan.

13

Feb.

13

Mar

. 13

Apr

. 13

Perc

enta

ge

Month year


Feedback of rates to hospitalists and Emergency Center clinicians

Order set revisions


51%

35%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Oct

. 10

Nov

. 10

Dec

. 10

Jan.

11

Feb.

11

Mar

. 11

Apr

. 11

May

. 11

Jun.

11

Jul.

11

Aug

. 11

Sep.

11

Oct

. 11

Nov

. 11

Dec

. 11

Jan.

12

Feb.

12

Mar

. 12

Apr

. 12

May

. 12

Jun.

12

Jul.

12

Aug

. 12

Sep.

12

Oct

. 12

Nov

. 12

Dec

. 12

Jan.

13

Feb.

13

Mar

. 13

Apr

. 13

Perc

enta

ge

Month year


Feedback of rates to hospitalists and Emergency Center clinicians Order set

revisions





contributory

Variation in OR room turnover (cycle time) or

Emergency Care wait time



Workflow Waste


33

Patient presents to Emergency Dept (ED).

Patient registers

Patient waiting

Patient evaluated by triage nurse

Does patient have vomiting &/

or diarrhea

Triage nurse does the following:·∙ Vitals

What is the patient’s level of

dehydration?

Severe dehydration

Mild or Moderate

dehydration

Put patient in ED room

Triage nurse does the following:·∙ Give Zofran·∙ Provide gatorade/pedialyte

Is the patient vomiting?

Evaluate per clinical symptoms

Follow TCH AGE clinical algorithm

Triage nurse does the following:·∙ Nothing or give patient gatorade/

pedialyte

BEGIN

Patient waiting

Patient put in ED room

Patient evaluated by

nurse


Medical student

Patient evaluated by ED resident


ED fellow

Patient evaluated by ED attending

Is the patient ok for discharge?

Decision to admit patient

MD does admission

orders

ED secretary requests bed

Bed approved

Nurse-Nurse checkout occurs

Decision to discharge

patient

MD does discharge

orders

PCA checks vital signs

Nurse discharges

patient


Fellow/Attending does pre-

transfer check

Patient discharged home1

Patient transferred to inpatient bed2

Key:___ solid arrow indicates “yes”_ _ broken arrow indicates “no”

1 Outcome: Time in ED2 Outcome: Time to inpatient bed3 Outcome: Length of stay (LOS)4 Outcome: Revisit from ED discharge4 Outcome: Revisit from inpatient discharge

Flow chart of a patient with acute gastroenteritis through the TCH Emergency Department: Existing process

34

Modified: 7/21/2009Process map before EBG

Patient presents to Emergency Dept (ED).

Patient registers

Patient waiting

Patient evaluated by triage nurse

Does patient have vomiting &/

or diarrhea

Triage nurse does the following:·∙ Vitals·∙ Assess dehydration (Gorelick score)**

What is the patient’s level of

dehydration?

Severe dehydration

Mild or Moderate

dehydration

Put patient in ED room

Triage nurse does the following:·∙ Give Zofran·∙ Provide patient education on ORT·∙ Initiate ORT·∙ Give ORT tracking sheet**

Is the patient vomiting?

Evaluate per clinical symptoms

Follow TCH AGE clinical algorithm

Triage nurse does the following:·∙ Provide patient education on ORT·∙ Initiate ORT·∙ Give ORT tracking sheet**

BEGIN

Patient waiting

Patient put in ED room


nurse


Medical student

Patient evaluated by ED resident


ED fellow

Patient evaluated by ED attending

Bedside nurse does the following:·∙ Assesses dehydration (Gorelick score)**·∙ Monitors progress on ORT tracking sheet**·∙ Reemphasizes patient education on ORT

ED Fellow does the following:·∙ Assesses dehydration (Gorelick score)**·∙ Monitors progress on ORT tracking sheet**·∙ Reemphasizes patient education on ORT·∙ Determines patient disposition

Is the patient ok for discharge?

Decision to admit patient

MD does admission

orders

ED secretary requests bed

Bed approved

Nurse-Nurse checkout occurs

Decision to discharge

patient

MD does discharge

orders


Nurse discharges

patient


Fellow/Attending does pre-

transfer check

Patient discharged home1

Patient transferred to inpatient bed2

Key:___ solid arrow indicates “yes”_ _ broken arrow indicates “no”

** New process1 Outcome: Time in ED2 Outcome: Time to inpatient bed3 Outcome: Length of stay (LOS)4 Outcome: Revisit from ED discharge4 Outcome: Revisit from inpatient discharge

Flow chart of a patient with acute gastroenteritis through the TCH Emergency Deparment

34

Collect ORT tracking sheet

Modified: 5/9/2009 Process map after EBG




contributory




Defect Waste



36

SStreamlining and Improving Processes and Operations to Minimize Errors

CClinical Decision Support to Minimize Errors

*used by permission of BMJ Group

37

Shioing Quality Improvement Culture to Effec9veness and Efficiency

•  Stewardship responsibility •  TCH financial APR-‐DRG calculator

–  Capitated model of care –  Cash value of waste

Registry Financial Score Card

Examples Demonstra9ng ROI

•  Improved clinical care – Decreases in LOS – Decrease in readmission rates – Decreased unnecessary chest x-‐ray u9liza9on – Millions in savings across several disease processes

•  Reducing waste by systemi9zing repor9ng – EDW reports cost 70% less to build

•  Labor produc9vity tools allow global views for increased opera9onal efficiency

Popula9on Management

Popula9on: Women and Children

Texas Children’s Prac9ces & Clinics

Health Plan

Pediatric Hospital/ Sub-‐Specialty Clinics

Women’s Pavilion

enterprise-‐wide data management infrastructure

Claims data Clinic systems Epic Pharmacy/Lab

Goal: Drive value across a system resul9ng in a healthier popula9on

The Healthcare Value Equa9on

•  Recognizing the investment in the EMR and opportuni9es for linkages to decision support

•  Using the EDW to link science, opera9ons and data management to drive/accelerate rapid cycle process improvement

•  Understanding and driving the importance of financial stewardship

•  Driving value through higher quality of care delivery

Quality Cost

Value =

Ques9ons and Answers

Speaker Contact Info Charles G. Macias MD, MPH [email protected] 832-‐824-‐5416

Next Webinar: Changing Healthcare Using Data North Memorial CMO Nov. 13, 2013 1-‐2 pm ET

45

adding value to the emr: a clinical perspective

Health & Medicine

solid arrow

triage nurse

inpatient

diarrhea patient

improving

discharge

edw data extraction

admission