Lisa GulkerDirector, Clinical Transformation

The Detroit Medical Center

The Chief Clinical Information Officer:Leading Innovation and Delivering Excellence

The Detroit Medical Center• Part of Vanguard Health

Systems• 8 hospitals in Detroit area

(29 hospitals in 5 states)• Large network of

ambulatory services• Pioneer Accountable Care

Organization (ACO)• Diverse mix of

organizational cultures• One Cerner Millennium

database, RHO client• Taking 2012 Code

Upgrade in 12/2012

DMC Holds HIMSS Level 6 Adoption Rating

Stage 2

Stage 3

Stage 4

Stage 5

Stage 6

Stage 7

Stage 1

Stage 0

CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging; HIE capable

Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology

CPOE, Clinical Decision Support (clinical protocols)

Closed loop medication administration

Physician documentation (structured templates), full CDSS (variance & compliance), full R-PACS

Complete EMR; CCD transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP

Ancillaries – Lab, Rad, Pharmacy – All Installed

All Three Ancillaries Not Installed

1.0%

3.2%

4.5%

10.5%

49%

14.6%

7.1%

10.1%

1.0%

3.5%

5.9%

10.7%

48.4%

14.1%

6.7%

9.6%

Eight Hospitals = Eight Cultures

• Each hospital site presented a unique leadership, clinical practice, financial, and operational environment.– Academic, urban,

community, large and small hospitals

– Private physicians– Hospital-employed– Mid-level providers– Rehab, Pediatric, and

other specialty hospitals/service lines

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Why is the CCIO role is so critical?

• Ownership• Engagement

• Empathy

Clinical Transformation & Medical Informatics

2004-2005: Dire Financial Reality and Creating a Competitive Edge

• Detroit Medical Center– Primarily landlocked in city of Detroit– Declining market share– Worsening payer mix– Old infrastructure– Limited capital resources

• Board-level decision to use QUALITY OF CARE as differentiator in marketplace– Leverage EMR as driver of improved quality

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Scope of Cerner EMR Launch (4/06-5/07)

– Patient access & patient flow– Communication and work

assignment– Orders management – CPOE

house-wide– Clinical documentation –

Nursing, Respiratory, Therapies

– Pharmacy workflow– Medication Administration –

BCMA and electronic MAR

• 8 Hospitals in 13 Months• Big Bang at each site• Components implemented – Clinical Leaders

decided on the scope – Ownership from the very beginning – Patient Discharge

– FirstNet (Emergency Department/A&E) expanded functionality

– PharmNet (Pharmacy System)– Discharge Prescriptions– Downtime solution – local

access on unit computer device

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Success Factors: Clear Vision For Everyone• Significant CEO and Board Support

– Committed 67% of capital budget to this one project– Committed to success (Paper is not an option)

• Only the best and brightest clinicians were picked to lead the project, everyone needed to know how important success was to our survival

• Clinically-driven project– IT supports, but does not lead (not an IT project)– Point of Service Ownership of process workflow– Not an initiative that will increase speed or

increase efficiency

• One standard of care system-wide– Evidence Based, multidisciplinary approach– Seamless care not bound by geography– Patient safety, quality, value, care reliability drive change– Alignment of quality and financial data points

OPERATIONS

EMR Steering

STRATEGY

LeadershipSteering

SINGLESTANDARD

ClinicalTechnical Comm

CLINICALOVERSIGHT

PharmacyTherapeutics

WORKFLOWDESIGN

DECISIONS

Clinical Councils

KEY COMPONENTS:Governance infrastructure

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EMR Success Factors• Use ethical imperatives of excellence, patient

safety to enable clinicians to tolerate the churn of change AND create ownership

• Never underestimate how difficult and stressful that change will be

• Driven by need for discriminating difference for the health system in a very competitive environment– Implementation had to be rapid, thorough and deep

• Vendor as partner; deep experience in clinical transformation and technology over many clients.– The vendor was not accountable to lead the project,

however

Uphill Leadership: Why it isn’t easy• Nature of the End User’s definition of success

– Varies by experience, by the minute, by session– Utility: “Can I use this easily?” “If I can’t, it isn’t good”– Points of View: Informatics and Clinical Transformation

• Informaticist– Does it work? How many clicks?– Is it friction-free to the end user?– Is it slick? Is it 100% dependable?

• Clinical Transformation– Does it present information to the clinician when

information is needed? (wisdom…)– Does it tell the story?– Can any clinician who needs the information see

it?– Does it ENHANCE or at least support workflow?– What is the BENEFIT to the patient?– Is excellence predictable?

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CCIO = Ownership

Clinical Transformation & Medical Informatics

A leadership lens for focus –

NOTHING comes in between or in front of the patient and the clinician or clinical intervention.

Ownership:Patient Safety Trumps the Project Plan

CCIO = Innovation through Engagement

• EMR Awards• Electronic Submission of Quality Data• Daily Huddle Dashboards• Smart Rooms & Device Integration

The EMR Awards Program – Engagement Through Innovation at the Point of

Care

EMR Award Summary 2007-2012

Total number of Submissions by Clinicians = 869

• Total number selected for awards – 129• Total number completed – 112• Total number in process – 17• Average completion time approximately 6 months

Visibility on DMC Intraweb

Daily Huddle Dashboard

Daily Huddle Dashboard

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Empathy

A personal connection to meaningful work.

Acknowledging that real world experience and human connection can’t be fully represented by data and facts.

Informed intuition helps decision-makers transcend conventional wisdom in order

to serve their peer clinicians.

Clinical Transformation & Medical Informatics

“Wired to Care” – Dev Patnaik

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CCIO - Empathy

“The map is not the territory.”- The CCIO has an intuitive

understanding of the realities of clinical practice.

- Empathy is the antidote for the process map – it is the secret ingredient that brings clinical transformation.

Clinical Transformation & Medical Informatics

“Wired to Care” – Dev Patnaik

• Phases and interventions– There is a choreography to practice, believed to be whole, complete – by

a caring expert– Implementing HIT/EMR is an insult/disruption/interference to that

experience– What happens in response? = What we have always done

– Doesn’t work any more as situation is changed– Reaction to any consequence both intended and unintended– Reaction to disruption as interruption,

» consequence of both interruption, which may be either intended or unintended.

The Natural History of Breaking

BREAK

Innovator

A Robust EMR/CIS – But Has It Achieved Its Intention?• Safety and Healing

– Do our clinicians have the information they need to make wise and safe clinical decisions?

– Does the technology support healing as an intention?

• Quality– Is the information in our EMR

current, reliable, and accurate?• Value

– Does use of our EMR contribute to achieving our strategic goals as a health system?

(mass personalization)

Vital Signs Workflow

Vital Signs Acquisition After EMR but Before Device Integration

Patient

Vital Signs Measured with VSM

Worksheet in Pocket

VS Entered into EMR

VS Data to Paper Worksheet

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Unintended Consequences

Clinical Transformation & Medical Informatics

26/30 sets of vital signs were documented accurately in the EMR, resulting in a 87% accuracy rate.

The transcription error rate was 13%. The average data latency was 24.1 minutes. The process sources of transcription error were 1. from the vital

signs device to the PCA paper worksheet (50%) and 2. from the PCA worksheet to the EMR (50%).

Unintended Consequences

• Increased Number of Transcription Events

• Increased Potential for Transcription Errors

• Increased Data Latency

• Decreased Data Accuracy

• Workflow Interference• Workflow Inefficiency• In Other Words…

Less than Predictable Excellence!

Building Opportunities…

Discussion and Collaboration