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Our EHR Journey: EMRAM Stage 7 and MU Stage 2
John Jay Kenagy, PhD
CIO Forum 2014
November 18, 2014
Or…
2
Hey, Legacy Health, you were awarded Stage 7 and just attested
for Meaningful Use Stage 2, what are you going to do next?
I’m going to Disneyland
The Nixon Library!
November 18, 2014
Our Time Together
Legacy Overview: Pictures and numbers.
Our EHR Journey: Third time’s a charm.
EHR Stewardship: The role of clinical informatics.
Our EHR Accomplishments: Benchmarking success.
What’s on our radar?: Great! Now what?
> Strategic Projects
> IS Commitment and Capabilities
What keeps me up at night?
October 7, 2014 3
November 18, 2014
Legacy’s EHR History
5
Year System Functionality
1986 Cerner Laboratory Information System
1997 Cerner Radiology Information System
1999 IDX LastWord ADT, Order Communication
2000 IDX LastWord Inpatient clinical documentation
2001 Cerner Surgery Information System
2001 IDX LastWord Ambulatory Scheduling & Documentation
2003 PICIS ICU System (NICU & PICU
2004 T-System ED Information System
2005 Cerner Hospital & Ambulatory EHR (LSCMC)
November 18, 2014
Legacy’s Epic Journey
Date Planning Stages
Fall 2007 Exploration begins;
Epic demonstrations;
Leadership conversations
Jan 2008 Contract Signed
Mar – Jun
2008
Project Team formation;
Certification training
Jul 2008 Official Kick-off
Nov 2008 Initial Workflow Validation
Feb 2009 Final Workflow Validation
Sep 2009 Multi-phased Testing
Begins
Jun 2010 Data Conversions Begin
6
Date Go-Live Events
Aug 2010 Initial Clinics Go-Live (Battleground and Fisher’s Landing, WA)
Epic Ambulatory installs preceded
hospital activation by 1-2 months
Nov 2010 Salmon Creek Medical Center
Apr 2011 Emanuel Medical Center &
Randall Children’s Hospital
Jun 2011 Good Samaritan Medical
Center
Aug 2011 Meridian Park Medical Center
Sep 2011 Mount Hood Medical Center
Oct 2012 Version 2010 Upgrade
September 2007- August 2010 Plan, Design Build, Test
August 2010 – September 2011 Train, Implement
November 18, 2014
EHR Stewardship:
The Role of Clinical Informatics
November 19, 2014 8 8
Legacy Clinical Informatics Goal
Optimize patient outcomes and care delivery
through the deep integration of information
and technology into the practice of clinical care.
Primary Functions of Clinical Informatics
Develop and implement strategy for information and
clinical technology acquisition, use and integration
Guide EHR optimization and adoption
Facilitate access to meaningful data and analytics from
EHR
Conduct ongoing review of documentation and work
processes to:
> Ensure compliance with standards
> Improve user efficiency
> Provide training and support to end-users
November 19, 2014 9
November 19, 2014 10
Measures of Success
Improved performance on quality and patient safety
indicators
Patient involvement in their care through MyHealth
(access to notes and clinical results; care team
communication)
Increased clinician adoption and satisfaction with the
EHR
Meaningful use of the EHR while achieving Meaningful
Use measures
Improved compliance of patient care documentation
with regulatory standards
November 19, 2014 11 11
Clinical Informatics Governance
Current structure developed to support:
> Effective collaboration between clinical operations,
revenue cycle operations, informatics, and IS
> Ongoing clinical/operational commitment to adoption of
standardized processes
> Integration between disciplines and functions system-wide
> Oversight to ensure attention to highest priority work
Informatics Council structure
> Founded in principles of shared governance
> Developed “organically” from the Legacy “way”
> Influenced by best practices from other institutions
November 19, 2014 LEGACY HEALTH 12
Informatics Governance Structure
IS Governance
Informatics
Governance
Physician
Advisory
Council
Nursing
Advisory
Council
Rev Cycle
Advisory
Council
Pharmacy
Advisory
Council
Education
Advisory
Council
Technology
Advisory
Council
Specialty User Groups
CIO
CNO
CMO
CMIO
CNIO
Clinical Specialty User Groups
11/19/2014 LEGACY HEALTH 13
Physician
Advisory Council
(PAC)
Nursing Advisory
Council
(NAAC)
Ambulatory / HOD
Pediatrics
Surgery
Adult Inpatient
Women’s
Emergency
Imaging
Cardiopulmonary
Hospice
Anesthesia
Revenue Cycle Specialty User Groups
11/19/2014 LEGACY HEALTH 14
Revenue Cycle
Advisory Council
Hospital Billing
Professional Billing
Patient Access
HIM
Clinical Informatics Division
Dyad leadership of CMIO and
CNIO
Dotted line to CMO and CNO
Physician Informaticists (3.0 FTE
comprised of 10 individuals from
0.1 – 0.7)
Principal Trainers (14, mostly
RNs plus RT and PharmD)
EHR Clinical Experts (4 RNs)
EHR Support Center (12 RNs)
October 7, 2014 15
Benchmarking our Success
Legacy achieves EMRAM Stage 7 system-wide Based on wide-scale Epic deployment, all Legacy hospitals and ambulatory
clinics received the designation of EMRAM Stage 7 (May 30, 2013)
Notable Accomplishments included:
Governance: very strong informatics leadership; physician engagement; collaboration
Analytics: Using data to improve care and operations
Health Information Exchange: Widespread use; a “step ahead of any other State 7 site”
Enterprise standardization: Diffusion of innovation and best practices across all hospitals
Community standardization: Legacy lead in city-wide creation of common discharge summary
Medical imaging integration: Exemplary imaging accessibility from the EMR
Biomedical device integration: Connection of bedside monitors and clinical devices was the most
advanced the surveyors had ever seen
17 November 18, 2014
Meaningful Use Stage 2
From Is Meaningful Use Dead? Wells Fargo Securities. September 24, 2014
November 18, 2014 18
IS Strategic Perspective
Optimize our Electronic Health Record (EHR) • Drive excellent Clinical Quality and Patient Safety • Motivate active Patient Engagement
Transform Care Delivery and Reimbursement • Power our Clinically Integrated Network • Deliver Population Health services • Embrace Accountability for health
Empower Decision Makers through Business Intelligence (BI)
Engage the broader Health Care Ecosystem
Optimize our Enterprise Resource Planning (ERP)
Optimize our Revenue Cycle
Build our “medical-grade” infrastructure • Enable the Intelligent Hospital and Clinic • Support the Master Facility Plan and Expansion Projects • Deliver reliable, cost-effective IT Infrastructure
Protect our systems and data through Information Security
Maintain regulatory compliance • Convert successfully to ICD-10 • Achieve Meaningful Use and pass external audits
Legacy Health IS Strategic Areas of Focus
20 November 18, 2014
Strategic Projects (2015): What’s on our radar screen
Clinical Quality & Patient Safety
• Epic 2014 enhancements
• Barcode unit collect lab specimen
• Patient Safety Alerting tool
• Pyxis ES Upgrade
• Epic Willow Ambulatory Pharmacy
• Epic Phoenix Transplant
• Philips Monitor Replacement
Care Transformation Projects
• Epic Healthy Planet
• Population Health
• Clinically Integrated Network
• At-risk reimbursement support
Italics denote project at conceptualization stage
Patient Engagement
• Epic 2014 enhancements to
MyHealth/Lucy Patient Personal Health
Record/MyChart Central
• Get Well Network
• Telehealth expansion
• Patient Education materials
• MyChart Bedside
Engaging the Health Care
Ecosystem
• Community Connect (LEAP) Expansion
• Health Information Exchange
• Community Orders Process
Enhancement (online imaging orders)
• Customer Relationship Management
21 November 18, 2014
Business Intelligence Projects
• Epic Cogito Ergo Sum
• Data “Universes” and Self-Service Tools
• SharePoint Dashboard
Enterprise Resource Planning (ERP)
Projects
• Infor Upgrade: Major Release
• Infor Analytics for Healthcare: Supply Chain,
Financial Management, and Workforce Analytics
Point of Sale Solution(s)/PCI
Revenue Cycle Projects
• Positive Patient Identification (hand scans)
• SSN# account identification elimination
Italics denote project at conceptualization stage
22
Strategic Projects (2015): What’s on our radar screen
Physician Support Systems
• Enterprise MD scheduling
• Credentialing and privileging
• Medical Staff/Physician Portal
• eNotification and Secure Text Messaging
• Physician compensation process
improvement
Employee Support Systems
• MyTime (Time and Attendance)
• Enterprise Staff Scheduling
• CASE/HR Customer Service Tool
• Remedy/IS Customer Self Service
Regulatory
• Ambulatory PQRS
• ICD-10
• Meaningful Use Stage 3
November 18, 2014
Diagnostic Systems Projects
• PACS virtualization, database
centralization, vendor neutral archive
• Lab Helix
Information Security
• Secure text messaging
• Managed Security Services/Security
Information and Event Management
• Privacy monitoring
• Business continuity/disaster recovery
• Perimeter protection (Firewall)
IT Infrastructure Enhancements
• Office 365
• Desktop video conferencing
• Print management
• Wireless capacity expansion
“Intelligent Hospital” Projects
• Enhanced RTLS and nurse call
integration; Standard functionality
• Mobile Communication devices
• Remote Monitoring
Construction/Facilities Projects
• Lab building activation
• Mt Hood Ambulatory Surgery
Center/MOB 4
• GS Emergency Dept. Remodel
• EH OR/ICU Tower Design
Lifecycle Replacements
• 2,000+ end-of-life PCs
• Core phone switch and VoiceMail
• Migrating off Windows Server 2003
• Server and network Infrastructure
23
Strategic Projects (2015): What’s on our radar screen
November 18, 2014
Customer Experience
Employee Experience
Highly Engaged IS Employees Highly Satisfied IS Customers (Operational Partners)
•Tap PE processes and tools to uncover and implement improvement opportunities (eliminate waste/delay, enhance throughput and reliability, reduce cost)
•Steward our financial resources effectively
Performance Excellence
•Establish and meet customer communication standards (strategic road-mapping, proactive change and project engagement, service recovery) to improve measurable service performance
•Implement IT Service Management best practices (service catalog, user self service) in Remedy tool
Service Excellence
•Diffuse PM best practice to effect project-driven organizational change
•Implement resource management system to enhance forecasting and reporting
Project Excellence
Goals
Initiatives • 2015 Tactics
Foundation IS Competencies
Technical & Business Skills
IS Culture Values & Behaviors
IS Structure Organization & Tools
2015 Performance Plan: IS and Informatics
External Environment
Internal Environment
Our World
Our Community
Our Patients
Our People
Measure: IS Customer Survey Score Q2: I was kept informed of the status of my request Metric: Rolling 12-month “top box” (4 or 5) scores.
Target: 87.7%
Measure: Legacy Pulse Score Employee Support Index Metric: Annual survey top box scores. Target: Baseline + 5%
Legacy Mission
Legacy Vision
Legacy Values
What keeps me up at night?
Spell it right!
Okay, it’s a Petty Pet Peeve…
Epic, not EPIC
(And it’s MEDITECH, not Meditech)
26 November 18, 2014
Are our real EHR achievements
more appreciated externally
than internally?
A Series of Firsts and Early Adoption
Legacy Health’s history of advanced use:
First Health System to achieve EMRAM Stage 7 at all hospitals and
clinics (2013)
One of first 11 sites to achieve Epic Accreditation for Community
Connect (2014)
One of first 73 US hospitals to achieve MU Stage 2 (Apr-Jun 2014)
One of top 2% of CareEverywhere (Epic HIE) message volume
Early adopter/influencer of Epic clinical applications
> Cardiology
> Anesthesiology
> Home Health for hospice care and administration
> Transplant
28 November 18, 2014
Internal Marketing Barriers
General lack of understanding or appreciation for how
tough our work really is
> The “Homefront CIO” Syndrome
Tendency to avoid self-promotion; tradition of humility
Hard message to craft: Declaring victory when we’ve
just started the optimization journey
Energy and attention focused on next thing and don’t
take opportunity to pause and celebrate last win
29 November 18, 2014
Are our users delighted?
~Our Customer Service~
Advisory Board Survey of Physician Engagement: Q. This hospital is pursuing an effective EMR/EHR
strategy
0
10
20
30
40
50
60
70
80
90
100
stronglydisagree
disagree tend todisagree
tend to agree agree strongly agree
Agree / Strongly Agree Total Exceeds
AB Benchmark by 15%
November 18, 2014 31
Advisory Board Survey of Physician Engagement: Q. I have the information I need to assess my productivity
and care quality
0
10
20
30
40
50
60
70
80
90
100
strongly disagree disagree tend to disagree tend to agree agree strongly agree
November 18, 2014 32
Qualitative Input: Themes 1. Better service/support
2. Improve training: Content, specialty focus, value the provider’s time
3. Extract data from Epic
4. Decrease redundant/unnecessary work
5. Improve connectivity with other EMRs
6. Engage physicians in decision making
7. Decrease unnecessary emails
8. More computers
9. Improved access to Legacy email from outside
10. Documentation support/scribes
11. Patient safety reporting system
12. Referrals (external)
13. Fix radiology orders
14. Replace Dragon head-sets with power-mics
November 18, 2014 33
Who is going to do all the work?
Recruiting and Retaining Talent
Lean Visual Management Board: Vacancies
35 November 18, 2014
Resource Demand Graph
Capital Project Resource Needs IS Team/Resource Role
Team Size 2015-01 2015-02 2015-03 2015-04 2015-05 2015-06 2015-07 2015-08 2015-09 2015-10 2015-11 2015-12 2016-01 2016-02 2016-03
IS Ambulatory and Community - Applications Analyst 19 -3.07 -3.17 -3.26 -3.51 -5.20 -5.96 -6.15 -6.98 -7.84 -7.71 -7.66 -7.96 -7.76 -8.03 -8.13
IS Bus Intel And Data Services - Programmer Analyst 3 3.83 3.80 3.87 3.34 3.92 3.45 2.76 2.69 2.12 2.09 2.42 1.82 2.10 1.34 1.41
IS Bus Intel And Data Services - Technical and DBA 5 1.08 1.53 0.66 3.42 3.01 2.55 1.62 0.74 1.05 0.88 0.78 0.07 0.01 -0.44 -0.21
IS Bus Intel And Data Services - Collaboration Analyst 2 -0.97 -0.95 -0.95 -0.95 -1.05 -1.05 -1.05 -1.05 -1.05 -1.05 -1.05 -1.05 -1.05 -1.05 -1.05
IS Bus Intel And Data Services - Reporting Analyst 10 -1.77 -1.29 -1.96 6.00 6.08 5.21 4.88 4.36 3.61 4.21 2.89 2.52 2.52 0.65 0.49
IS Clinical Informatics - Trainer 13 10.36 9.68 10.11 9.03 -2.21 -1.05 -0.93 -1.37 0.01 0.24 1.16 0.10 0.52 0.15 0.02
IS Clinical Systems - Applications Analyst 23 7.59 5.02 6.43 -2.16 -7.78 -6.19 0.53 1.74 0.68 0.96 -3.27 -5.28 -8.51 -8.84 -8.98
IS Diagnostic Systems - Applications Analyst 10 1.21 0.93 0.88 8.40 6.41 6.03 7.29 8.63 6.72 6.33 5.74 4.19 -1.62 -2.22 -2.93
IS Diagnostic Systems - PACS Administrator 6 -0.96 -1.12 -3.55 6.98 8.20 7.25 7.26 8.35 7.25 7.35 7.51 6.85 5.96 5.05 4.78
IS End User Computing - Desktop Support Specialist 19 0.97 1.08 2.67 3.23 3.93 3.56 3.40 3.87 2.63 2.49 3.98 2.30 -10.64 -10.97 -11.42
IS Enterprise Mgmt Systems - Applications Analyst 12 0.65 0.20 0.04 8.88 11.35 11.69 12.73 12.02 11.00 11.47 11.82 10.02 0.73 -0.04 -0.47
IS Epic Infrastructure System and Services - Cache DBA 2 0.25 0.32 0.34 0.25 -0.36 -0.80 -0.80 -0.80 -0.80 -0.80 -0.80 -0.80 -0.80 -0.80 -0.80
IS Epic Infrastructure System and Services - Client Service Mgmt 3 0.07 0.35 0.40 -0.47 -1.40 -1.50 -1.50 -1.50 -1.50 -1.50 -1.50 -1.50 -1.50 -1.50 -1.50
IS Epic Infrastructure System and Services - Interfaces 4 0.27 -0.60 -0.68 1.19 1.39 1.31 3.11 3.10 1.87 1.42 0.81 0.08 12.72 -1.66 -1.69
IS Epic Infrastructure System and Services - System Integration 3 0.28 0.38 0.48 0.43 0.21 0.06 0.19 0.11 0.13 0.58 0.23 0.19 9.82 -1.40 -1.55
IS Epic Infrastructure System and Services - Unix Administrator 3 -0.84 -0.84 -0.84 -0.52 -0.66 -0.52 0.35 0.08 0.26 -0.52 -0.51 -0.54 5.16 -0.89 -0.89
IS Information Security - Info Security Analyst 4 -1.20 -1.30 -1.15 -0.12 0.70 0.22 -0.38 0.21 -0.36 -1.01 -1.14 -1.60 -3.57 -3.86 -3.86
IS Program Management Office - IS Project Manager 9 3.12 2.79 2.45 1.94 2.60 2.01 1.62 2.33 1.85 1.96 1.65 0.73 -0.09 -0.54 -0.71
IS Revenue Cycle Systems - Applications Analyst 17 4.69 3.45 5.45 8.81 5.00 3.44 3.76 2.73 0.91 1.51 1.37 1.39 -12.10 -12.32 -12.45
IS Support Center - Applications Systems Analyst 5 0.36 0.37 1.07 2.50 2.35 2.57 1.94 1.97 1.82 2.07 2.31 2.04 -2.76 -2.90 -2.99
IS Support Center - Identity and Access Management 3 0.22 0.22 0.22 0.35 0.53 0.62 0.22 0.23 0.08 0.36 0.51 0.34 -2.56 -2.45 -2.73
IS System Engineering and Data Center - Applications System Analyst 1 -0.37 -0.37 -0.37 -0.15 -0.21 -0.24 -0.50 -0.51 -0.51 -0.51 -0.51 -0.51 0.22 -0.86 -0.74
IS System Engineering and Data Center - Data Center Operations 1 -1.00 -1.00 -1.00 -1.00 -0.70 -0.66 -0.87 -0.85 -1.00 -1.00 -1.00 -1.00 -1.00 -1.00 -1.00
IS System Engineering and Data Center - Desktop Engineer 7 -0.93 -1.15 -0.88 0.64 0.44 0.21 -1.57 -1.23 -1.71 -1.27 -1.54 -1.78 7.33 -6.35 -6.56
IS System Engineering and Data Center - Server Administration 7 -1.03 -1.03 -0.68 5.67 7.34 6.66 3.78 3.03 2.03 0.21 -0.40 0.07 6.53 -5.04 -5.45
IS System Engineering and Data Center - Storage and Backup Systems 3 -1.05 -0.92 -0.91 0.73 1.40 1.14 0.62 -0.32 0.21 -0.21 -0.48 -0.03 1.79 -1.30 -1.85
IS Telecom and Networking - Network Engineer 7 0.33 1.68 1.73 6.22 6.10 5.86 3.53 2.47 3.41 2.88 2.39 0.91 -3.69 -3.88 -3.96
IS Telecom and Networking - Telecom Engineer 8 -0.94 -0.43 0.07 1.42 0.70 0.72 -0.84 -1.05 -1.27 -1.48 -1.64 -1.69 -5.24 -5.20 -5.38
36 November 18, 2014
I’ve always relied on the kindness
of strangers…
A Streetcar Named Meaningful Use
Attestation includes measures that aren’t
under the control of the EH/EP
Transitions of Care: Community adoption of
HIE technologies, direct messaging addresses
Active use of patient EHR portal
38 November 18, 2014
It’s a Nasty World Out There
Who ever heard of ransomware till now?
Information Security
Legacy performs
HIPAA/HITECH Annual risk
assessments
In Federal FY15 (Oct 2014),
Legacy received pre-payment
audit notices for 49 eligible
professionals (Stage 2 Year 1).
Audits required security risk
assessment and remediation
plans for past three years
40 November 18, 2014
Legacy Security Improvement (2012-2014)
41
HITRUST Domains 2012 2013 2014 Legend
1. Information Security Policies Not Aligned
2. Laptop & Workstation Security Partially Aligned
3. Mobile Media Security Aligned
4. Wireless Security
5. Malware Protection
6. Configuration Management
7. Vulnerability Management
8. Secure Disposal
9. External Breach Protection
10. PHI Transmission Protection
11. Password Management
12. Access Control and Monitoring
13. Remote Access & Authentication
14. Training and Awareness
15. Third-Party Security Management
16. Incident and Breach Response
17. Business Continuity Management
18. Auditing
November 18, 2014
Disaster Recovery 2014
42 November 18, 2014
My Successor’s Worry
43 November 18, 2014
©LEIDOS. ALL RIGHTS RESERVED.
44 / leidoshealth.com
Security Threats
FUTURE
We’ve just spent $100M and 3 years
building a fully integrated EHR…
But, look, shiny and new!
Integrated, Patient-Centric EHR?
The Post-EHR Era:
> BI and HIE (use it and share it)
The new sales angle?
> Population Health
> Managing risk in a pay-for-value world
> Clinically Integrated Network
October 7, 2014 46
Thank You! [email protected]