tying it all together: informatics in...
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Tying It All Together: Informatics In Action Sherri Hess, MS-IS, BSN, RN, Director of Nursing Informatics, Denver Health System
Andrew Steele, MD, MPH, CMIO, Denver Health System
Denver Health
Integrated public safety net institution 5,300 employees Closed medical staff 500 bed hospital Extensive primary care network Level I Trauma Center Public Health Department
Denver Health Over 190,000 patients 25% of Denver population Payer mix
– 45% Medicaid – 18% Uninsured – 10% Medicare – 27% Other
$4B in unsponsored care since 1992
~$400M in 2013
Clinical Technology Strategy
Patient /Family
and Provider
Dashboard Single Sign-
on Enterprise Master Patient Index
Results Repository
Clinical Decision Support
PACS/ Imaging System
CPOE
Immuni-zation
Tracking
Enterprise Document Manage-
ment
Data Warehouse
Analytics / BI
Dashboard
Medication Admini-stration Check
Clinical Documen
tation
Patient Portal
Centers for Medicare and Medicaid Services: ACO
"an organization of health care providers that agrees to be accountable for the quality, cost, and overall care…
ACO Original Core Principals
Provider-led organizations – Strong base of primary care – Accountable for quality and total per capita costs – Provide full continuum of care for a population of
patients Payments that are linked to quality improvements that also reduce overall costs Use sophisticated performance measurement
Payment Reforms Will Motivate and Reward Innovation at a Whole New Level -Todd Park, Chief Technology Officer, U.S. Department of Health and Human Services
• Shared savings; redesigned care processes for high quality, efficient delivery
Accountable Care
Organizations
• Organized outpatient care, coordination and team-based approaches
Patient Centered
Medical Homes
• Pilot program for episodes of care; incentivizes reduced costs around eight conditions
Bundled Payments
• Motivates hospitals to engage with care coordinators and better organize delivery systems
Readmission Reduction Programs
Timely Clinical Data, Decision Support Care Integration Tools Technology to Extend Physician Reach Consumer Engagement Tools/Platforms/Apps Data Mining/Analytics
IT Innovations Needed:
Denver Health Clinical Informatics History
Denver Health Clinical Informatics History
• Pre 1998- rare nurse or physician on a committee • 1998- 2002: 0.5 FTE Physician Champion • 2010-2011: slowly added Master level Informatics Manager
• 2012: –added Director of Nursing Informatics – added 7 informatics nurses –added 8 physicians (0.2) FTE each
Denver Health Informatics Team
3 Physicians 12 RN’s
RN’s - 6 Masters in Health Informatics/IS; 2 in Grad School; 1 in DNP School
2 Pharmacists PharmD Future: ~25 RN FTE’s, ~6 MD FTE’s, ~4 Pharmacy FTE’s, ~4 ancillary FTE’s
Ratio of RN Informaticists
Item Number RN Ratio
Hospital Discharges 25,000 1087
Employees 5,500 239
Outpatient Visits 600,000 26087
Oupatient Members 120,000 5217
Net Revenue $700,000,000.00 $30,434,782.61
Roles of Informaticists at Denver Health
Roles of Informaticists at Denver Health • Order Sets • Workflow/Clinical Decision Support • Analysis of enhancement or new functionality • Design • Go-live support • Testing • Day to day clinical assistance • Education • Application support & build: new or upgrades • Committee Participation
Denver Health Committees
•Provider/RN Engagement –Physician Advisory (PAC) 10
physicians –Nursing Informatics Council
(NIC) ~35 nurses –Clinical Champions,
• >100 Providers, 200 RN’s, 150 HCP/Others
Accomplishments At Denver Health
• Over hauled EHR Class • Communication: Tips and Tricks, Huddle, Doc Box
• Verbal Unsigned Orders from 3.5% to 0.1% • Point of Care Decision Support • 22 new clinical order sets • 35 Live workflows
Verbal Orders
The Joint Commission Tracers
Huddle Sheets – As Needed
Tips and Tricks – Monthly
Doc Box News
Roles of Informaticists at Denver Health
Data Warehousing: Denver Health
Data Warehouse
Pharmacy Radiology Laboratory
Demographics Financial
Pathology Encounter Pulmonary GI Lab
Ultrasound EDM Forms
Fetal Monitoring ED Med Recon OR
2009
2007
2008
1998
Orders Med Administration
Vaccinations Wait List/Referrals Scheduling Nursing Documentation
2010
Workflow
Custom Interfaces
BI at Point of Care
5/15/2014 24
How Does the Clinical Decision Support Team Help?
• With Clinical Champions, Stakeholders, and Clinical Practice Committee, design, coordinate, test, implement and evaluation Clinical Order Sets.
– Care set • Guides the care of a specific type of patient/diagnosis/symptom, or defines a certain aspect of
care
– Admission Set • Guides the care of newly admitted patients; can be specific to a unit, area, or subset of
patients.
– Perioperative Set • Guides the care in preparation for or recovery from surgery.
– Picklist • Conglomeration of orders without clinical guidance created to help providers efficiently search
for and choose certain orders.
How Does the Clinical Decision Support Team Help?
• Linking orders to improve efficiency & patient safety – TPN-Couple PCO and Pharm Order
• Places notification order for pharmacy when TPN is ordered – Respiratory-Notify RT with vent/CPAP/BIPAP changes
• Notifies RT when vent/CPAP/BIPAP, etc. are revised or discontinued – RT-Blood Gas/Blood Draw
• Notifies RT when a blood gas is ordered, discontinued, or revised – RT-RT Therapy/Med Treatment
• Notifies RT when a med with route “INH” or “NEB” is ordered, revised, or discontinued
– Behavioral Health Emeds • Automatically places and discontinues nursing notification order when EMED
meds are ordered or discontinued. – RT Mini BAL
• When respiratory culture ordered, RT notified if sample is a Mini-BAL (which is a lab collected by RT), but does NOT notify RT if the sample is selected to be “bronchoalveolar lavage” (which is a lab collected when doing a scope procedure)
How Does the Clinical Decision Support Team Help?
• Real-time quality reporting alert examples – Central Line
• Identify patients with eligible central lines and evaluate need for removal in order to assist in the reduction of central line associated blood infections.
– Urinary Catheter • Identify patients with Foley catheters and evaluate need for removal in order
to assist in the reduction of catheter-associated urinary tract infections.
– Infection Control • Alert the infection prevention team of positive infection results for infections
requiring isolation, VRE, Cdiff, MRSA.
– Rapid Response on End of Shift Report • Alert Charge Nurses and Clinical Nurse Educators of significant changes in
the patient condition and determine the need for an Adult Rapid Response at 0600 and 1800.
How Does the Clinical Decision Support Team Help?
• CMS compliance alert examples
– Heart Failure • Alert the Healthy Heart
Nurses of potential Heart Failure (HF) patients.
– AMI • Alert the Health Heart
Nurses of potential Acute Myocardial Infarction (AMI) patients >= 18 years of age.
Real Reason For Informaticists
Journey To A Career In Informaticist at Denver Health
•On the job training -> Super User •Informatics Certifications •Practicum/Internship •Degree programs
–CU Denver –Regis –University of Denver
Is It Worth It?
Denver Health Childhood Immunizations
Denver Health Hospital Survival
Clinical Informatics in Health Care
mHealth Integration
38
38
Chronic Care Management: Using a “Customer Relationship Management (CRM)” Application
References
http://www.amia.org/ https://www.ania.org/ http://www.himss.org/index.aspx McLane, S., Turley, J.P. (2011). Informaticians. The Journal of Nursing Administration, 41, 1. Jt Comm J Qual Patient Saf. 2011 Mar;37(3):99-109.