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

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Op

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Dic

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(L

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)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

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Th

at

Work

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Leaves N

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Beh

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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

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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