university of michigancio.umich.edu/sites/default/files/patient-care-strategy-vision... ·...

University of Michigan

US National

Health/HealthCare Informatics/IT

1

32

4

UMHS• Hospitals and Clinics• Medical School• Nursing School

UHS

School of Dentistry &  Dental Clinics

SPH

Non HIPPA Covered Entity

Institute for Human  Adjustment

• Psychology clinic (East hall)

School of Social Work• Family Assessment clinic

UM Athletics

CAPS; Counseling and  Psychological Services

Hospitals & Clinics• 7 hospitals & Surgery Centers;

UH, Mott, VV women’s, CVC, Kellogg Eye, EAA Surgery Center, Livonia Surgery Center• 4 Specialty Centers;

Comprehensive Cancer, Diabetes, Depression, Geriatrics• 120 + Clinics (40 Health Centers)-

MI & OH

Facts;• 22,000 Faculty & Staff• 885 hospital beds expanding to 1035 (new Mott/VV)• 45,000 inpatient admissions• 80,000 Emergency Visits• 1.8 million outpatient visits/surgeries• $2.1 B Operating Revenue vs $2.02 B expenses.

Medical School• 1600 Faculty (188 Endowed Professorships)• 1850 enrolled students• $436 Million Research Funding ($366M + NIH funding)• 80 facilities, 4.6 million Gross ft2• $1.3 B total Revenue

Nursing School118 Faculty1844 enrolled students

M-net; Referring Physician Communication Network• 12,000 physicians• >2000 items sent/day• +600 physicians direct

access to Careweb

UHS• 150 Employees (25 clinicians; 10

care &

Specialties• 80,000 visits (70% student, 30% Fac/staff)• $18million operating budget ($5M fee for

service)

School of Dentistry• 410 Faculty (110 full, 300 part time)• 650 Students (444 DDS, 104 hygiene, 81 Grad)• 145,000 visits

Wide Range of Patient Ages & Services.

Large and diverse Student PopulationPopulation care, Etoh & drug, STDs, Psych/Social, Injury(prevention), Lifestyle/health-education

International Students (and Foreign travel)

Skin Cancer/Melanoma 

Multidisciplinary Aortic 

Congenital Heart Disease

Head & Neck Cancer Cranial Base 

Multidisciplinary Adrenal 

Cancer/Endocrine Oncology 

Multidisciplinary Liver Cancer 

Multidisciplinary Pancreatic CA

Bladder Cancer 

Center for Stem Cell Transplantation 

Fetal Diagnosis and Treatment Center 

Heart Rhythm Center 

Michigan Sensitized Candidate 

Program (MISCAP) 

Multidisciplinary Cerebrovascular 

Disorders 

Multidisciplinary Craniofacial 

Anomalies 

Multidisciplinary Interstitial (Fibrotic) 

Lung Disease Sarcoma 

Thoracic Insufficiency Respiratory 

Syndrome 

University of Michigan Esophageal 

Cancer Program

Total number of persons age 65 or older, by age group, 1900 to 2050, in millions

Tot

al n

umbe

r of

per

sons

in m

illio

ns

0

20

40

60

80

100

65 or Older

85 or Older

20501900 1950 2000Projected

Mortality

Angus, CCM,2001

Angus, CCM,2001

1) 750,000 Hosp. Admits

2) 215,000 deaths

3) $16.7 billion (1995 dollars)

4) A top ten consumer US hospital Costs.

AsthmaCongestive Heart FailureDiabetesHypertensionCoronary Artery DiseaseCOPDChronic Kidney DiseaseStrokeDementia/Alzheimer’s

1.

Affect more than 130 million Americans

1.

Account for 70% of all deaths in the US.

1.

Costs of care account for more than 75% of the nation’s $2 trillion medical care costs.

5 million Patients with CHF in 

US

1% of population over 65 

years old

>400,000 new cases/yr.

160% increase in 

hospitalizations over past 10 

years.

~ 50% mort. in 3 years• < half of 4200 patients on Tx

list will 

receive a heart Tx.

Total number of persons age 65 or older, by age group, 1900 to 2050, in millions

Tot

al n

umbe

r of

per

sons

in m

illio

ns0

20

40

60

80

100

65 or Older

85 or Older

20501900 1950 2000Projected

Cooper, Circ 2000

OECD, 2009

©2010 California HealthCare Foundation

Health spending exceeded $2.3 Trillion in ‘08, expected to exceed $2.5 trillion in ‘10.

©2010 California HealthCare Foundation

35% health spending in elderly is private dollars.

©2010 California HealthCare Foundation

©2010 California HealthCare Foundation

Medicine used to be simple, ineffective, and relatively safe. 

Now it is complex, effective, and potentially dangerous.

“The mystical authority of the doctor used to be essential for  practice, now we need to be open and work in partnership 

with our colleagues in health care and with our patients. We  must recognize and encourage our patients’

right to make 

fully informed decisions about available treatments and  provide care and support, not just technically advanced  interventions.”

Chantler, 1999.

Value (quality/cost) vs

Control Costs

Safety

Accountable Care OrganizationsPatient Centered Medical Homes

Personalized Medicine (Genomics)

Meaningful Use {of EMRs}

Deloitte

Monitored, coordinated and integrated care using electronic medical records and personal health records

Information technology is used to appropriately support optimal patient care, performance measurement, patient education, and enhanced communication

Innovation such as …cyber-visits, …self-monitoring devices are available….

The ability to measure and Report on the Quality of Care-the goal is not just reduce costs, but to do so while maintaining or improving quality of care= ValueRequires the ACO to accept accountability for the total costs of care and population-level quality outcomes. Miller, Harold

“I am fain to sum up with an urgent appeal for adopting …some uniform system of publishing the statistical records ofhospitals. There is a growing conviction that in all hospitals,even in those which are best conducted, there is a great andunnecessary waste of life …

In attempting to arrive at the

truth, I have applied everywhere for information, but inscarcely an instance have I been able to obtain hospitalrecords fit for any purposes of comparison …

If wisely used,

these improved statistics would tell p us more of the relative value of particular operations and modes of treatment than we have means of ascertaining at present.”

Florence Nightingale

Notes on Hospitals, London. 1863

1.5% = comprehensive EMR8% = basic system17% = CPOE11% to 23% = CDS

45% have “NO Plans” for CPOE or CDS.

Population(s)

Meaningful Use

Hersh, OHSU

ARRA= American Recovery and Reinvestment Act 2009• HITECH=Health Information Technology for Economic

and Clinical Health Act$27B incentives for EHR adoption by:

Eligible providersHospitals

$2B direct grants by Fed agencies; training, pilots, etc.• ONC= Office of the National Coordinator (Final rule July,28th, 2010)

EHR Standards Implementation specificationsCertification criteria

• CMS;

Ties incentive payments/penalties to MU specificationsMedicaid; CMSMedicare; States.

ONC= Office of the National Coordinator• HITECH technology interventions map to 5 goals

for US Healthcare System;Improving quality, safety & efficiencyEngaging patients in their careIncreasing coordination of careImproving the health status of the US populationEnsuring privacy and security of patient data

• Requires use of certified EHR technology;1.In a meaningful manner. (CDS, CPOE)2.For electronic exchange of health information to improve

quality of health care. (HIE)3.To submit clinical quality and other measures selected by

the Secretary for HHS.

Deloitte, 2011

10-1-2012

7-1-2013

Functional Requirements1. Computerized Physician Order Entry (CPOE) 2. Drug-drug, Drug-Allergy Checking3. Generate and Transmit Electronic Prescriptions (eRX); EP only4. Maintain up-to-date Problem/Diagnosis List5. Maintain Active Medication List6. Maintain Active Medication Allergy List7. Record Vital Signs8. Record Demographics9. Record Smoking Status10.Report Quality Measures to CMS and the States11. Implement Clinical Decision Support

Health Information Exchange (HIE) Requirements12. Provide Patients with Clinical Summary of Office Visits13. Provide Patient with Electronic Copies of Health Information14. Implement Capability to Exchange Key Clinical Information

HITECH Privacy And Security15. Implement Systems to Protect Patient Data

51

Architecture funded by State HIE Cooperative Agreement

51

11/30/2011 52UMHS HIE Strategy

Data Center Migration (completed)

E-Prescribe

Exchange Server & MS Outlook

Coded Diagnoses

C&W Activation & Unified Communications

Lab System Cerner to SCC

Radiology IS Upgrade

CPOE System upgrade

ICD-10 conversion; Oct, 1st, 2013

Window’s 7 migration

Health Information Exchange (HIE)

Education for Clinical IT• Implementation• Advanced Training• Updates

Operational Management(Historical. e.g. quality, 

billing, reporting etc.)

Biomedical 

Research

Trials

Quality 

Reports

Clinical Data 

Warehouse

Comparative 

Effectiveness 

Research

Population 

Research

‘Omics

Repository

Administration 

Systems

Patient Care(Electronic Health 

Record)

Multiple Clinical 

Systems

Research 

WarehouseClinical Data 

Repository 

External 

OrganizationsExternal 

Organizations

‐De‐Identification‐Consents

‐Identity Management‐Vocabulary Mapping

J. G. DeWitt, 2010

58

Population 

Research

Marts

Operational 

Management

Biomedical Research

Cancer 

Research 

Virtual Network 

Tools

Vocabulary/Ontology 

Mapping

UMHS Biomedical and Clinical Data Flow

External 

OrganizationsExternal 

Organizations

Trial 

Analysis

Virtual 

Trials

Federation 

Collaboration

Cohort 

Identification

Claims

Comparative 

Effectiveness 

Research

PHI

Quality

Reporting

EMPI

Clinical Data 

Warehouse

Patient 

Recruitment

Translational Research 

Informatics 

Framework

CTMS

Research 

Warehouse

Consent

Trial EDC

Tissue 

ConsentClinical LIS

Tissue 

BankHigh Throughput 

‘Omics

LIS

De‐identification

eIRB/ProtocolsIdentity 

Management

Clinical Data 

Repository 

Patient 

Scheduling

Foreign Documents 

Import

Registration/

ADT

Billing

Electronic 

Health Record

Historical 

Patient Data

Document 

Image 

Repository

Internal 

Recipients

‘Omics

Repository

Departmental 

Applications

Transcription

EMPI

Patient CareHIPAA/IRB Wall

I.

Review of Epic Modules

Primary Vendor Model – 3 Year View (Stage 1) = 

60

I.

Review of Epic Modules

Primary Vendor Model – 5 Year View (Stage 2) = 

61

I.

Review of Epic Modules

Primary Vendor Model – 10 Year View (Stage 3) = 

62

Q1 Q3Q2 Q42010

Q5 Q7Q6 Q8 Q9 Q11Q10 Q12 Q13 Q15Q14 Q162011 2012 2013

University of Michigan Health SystemStages 1 & 2 Implementation Sequence and Capital vs . Operating View 

Pre‐

Cont

ract P

lann

ing, D

evelop Sta

tem

ent o

f Wor

kCon

trac

t Si

gned‐J

une 20

10

Stage 1

Pro

ject K

icko

ff‐A

ugus

t 201

0

Q17 Q19Q18 Q202014

ICD‐10 Deadline

“Month 1”

Q22Q21 Q23 Q242015

C&W  Hospital & Clinics Move

Stage 2

Proj

ect Pl

anni

ng, P

roje

ct Tea

m T

rainin

g @ Epi

c/Ce

rtifi

cation

and In

itial Int

erfa

ce and W

orkf

low A

nalysis

Wor

kflo

w V

alidat

ion

Sta

biliz

e

Resolute Professional Billing, Research Integration

ADT & Prelude Registration

Resolute Hospital Billing inc . Coding & Abstracting

EpicCare Ambulatory EMR, MyChart Shared Patient Record & Care Everywhere , including Temporary Interfaces of Clinical Data with CareWeb ‐Research Integration

Temporary Interfaces: ADT/Registration to Eclipsys & CareWeb, charges from Eclipsys, charges from Worx, New interfaces: ADT downstream, DMS, plus more 

Pro

ject K

icko

ff‐A

ugus

t 201

0

Cadence Enterprise Scheduling  & Welcome Kiosk(+)

ASAP Emergency Department & Ambulatory Care Pilots ,HIM, Research Integration

Opt

imize

Capital Expense Operating Expense

Production Support & Maintenance

Cadence Scheduling, ADT & Prelude Registration, Resolute PB, Resolute HB, Coding and Abstracting, Research Integration

Sta

biliz

e

Opt

imize

Capital ExpenseSta

biliz

e

Opt

imize

Operating Expense

Production Support & MaintenanceED, Ambulatory Care Pilots, HIM, Research Integration

Production Support & MaintenanceAmbulatory Care, Research Integration

Stage 3 Startup

Stage 2a Planning & Implementation (HODs, Kaleidoscope/Ophthy, Therapies, Nurse Triage , Welcome, etc. )

Capital Expense Operating Expense

Capital Expense

Capital Expense

12,000 Active users

1,500 Order sets

11,000 Individual order items

>400 Active maintenance/enhancements

>150 New configuration requests/month

19 Million Orders to date• 500,000 orders/month

Turnaround Time for Stat and Now Orders

Metrics on Clinical ImprovementTi

me

(Min

utes

)

Mott

UH/CVC

UM-CareLink VTE Assessment Orders vs Reminder Alert

322 278 279 211 227

1368

2256 21782433

13314

2102323023

25514

0

500

1000

1500

2000

2500

3000

May June July

Augus

tSep

tembe

r

Octobe

rNove

mber

Decembe

r

Janu

ary

Month (May 2008 - January 2009)

Num

ber o

f Ord

ers

0

5000

10000

15000

20000

25000

30000

Num

ber o

f Ale

rts

VTE Assessment OrdersVTE Assessment Reminder Alerts

UMHS Policy in place re VTE Assessment

VTE Reminder Assessment Alert in Production on 10/22/2008

84 Years

International

High Level Conceptual Diagram‐‐

Future State: 

Research Interface with the Clinical Record

Genomics data 

workbench(es)

UMHS Data Warehouse 

Population‐

Risks

Assay‐

Specific

Disease‐

Specific

Qual/Outcomes

Organ 

Systems

Demographics

eThority

(billing)

ClickCommer

ce

(IRB)

Research Administration

Systems

Terminology 

Resources(ICD‐10, 

caDSR, 

SNOMED, 

etc.)

External 

Resources 

(PubMed, 

GenBank, 

KEGG, GO, 

etc.)

I2B2 Cohort 

Discovery & 

Data Mining

CDR

Clinical  & Business  Systems

Data Sharing 

with External 

Collaborators

I2b2SHRINE

CTSAscaBIGTCGA

Nursing Docs

Radiology

Pathology

Pharmacy

CareLink/Eclipsys

MiChart/Epic & Legacy

Biorepositories

Proteomics

Metabolomics

ChIP‐Seq

Next‐Gen 

Sequencing

Health 

Sciences 

Library 

Resources

ResearchData

Managemen

tSystems

Quality, Population Mngt

& 

Research QualityMetrics Data Marts

ResearchCore

Facilities/‘Omics’

HIEPt PortalProvider 

PortalPati

ent.

ResearchAdministration

Systems

I.

Revenue CycleFinance/BillingRegistrationScheduling

II. Clinical systems1.

ED

Legacy;2.

UHS

Carelink3.

Ambulatory Care

Careweb4.

Opthalmology

Centricity5.

Stage III & IV.

Others……

CAD

Clarity

Terminology mapping systems

Common Specimen Identifier Services

Messaging Bus & ETL Services

Honest Broker & Security Infrastructure

Quality, 

Outcomes 

and CPI

BC/BSCMS

JHACO

i2b2SPORES

Industry:Pharma/Biotech

Research Systems

BiomedicalEngineering

HistoricalData

Research Data

Management 

Systems

Registries

OpenClinica

Velos

BioDBX

RedCAP

Research Data Warehouse

Messaging Bus, ETL & External Collaboration Services (SOA, caGRID, SHRINE, ...)Vocabulary & Terminology Mapping Services (ICD-9/10 SNOMED, IMO, caDSR, ...)

Research Administration

Systems

Common Identifier Services (Patient, Provider, Research, Specimens, External Mappings)

HIPAA/IRB Services (Honest Broker, De‐ID Consent Management, …)   

Epic Clarity

Patient Care Systems

Centricity

Documentation

Radiology

Pathology

Pharmacy

CareLink/Eclipsys

Others…

Scheduling

Revenue Cycle

Emergency Med.

Ambulatory

Research CoreFacilities/‘Omics’

InternationalData Sharing 

with External 

Collaborators

CTSAscaBIGTCGA

Epic EHRLegacy +

ULAM

TissueBiorepositories

Metabolomics

Proteomics

Bioinformatics

Next‐Gen 

Sequencing

Bioinformatics and Systems 

Biology Workbenches

Collexis

eThority

(billing)

ClickCommerce

(IRB)

Research Pre, 

Post‐

Award

Industry:Pharma/BiotechI2b2/

SHRINE

Others …

Demographics

Diseases

Individuals

Populations

Portals / Providers, Payers, P. Health D

atabases / HIEs

/ NHIN

Campu

s System

s

IT Security

HSDW

i2b2

High PerformanceCloud Computing

&Data Storage

IT Security

• Reporting• Visualization• Analysis &• Data Mining

IT Security

Research & 

Quality Metrics 

Data Marts

Brian Athey

& ECRIT 1/11/11

Health 

Sciences 

Library 

Resources

NIH-Specific &External Data Resources

(PubMed, GenBank, 

KEGG, GO, etc.)

SPORES

Others

CIDSSAnalytics

& ReportingTools

QualityMetrics

Reporting &Peer Review

Education

CADCDREducation 

KnowledgeRepository

Research 

AdministrationData Warehouse

Others…

M‐Pathways

CTools/Sakai 3

Curriculum Evaluation System

Clinical Scheduling

ComprehensiveClinical Assessment

Exam

Admissions

UMHS Data Architecture Future State:  Unifying the Three  Missions‐‐

Education, Research, & Patient Care