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Revolutionary Health IT: Path Innovation, Collaboration, and Transformation

1© 2009 DocsNetwork, Ltd., Barry P. Chaiken, MD, MPH, CMO, DocsNetwork, Ltd., [email protected]


Barry P. Chaiken, MD, MPH, FHIMSSChief Medical OfficerDocsNetwork, Ltd.

© 2009 DocsNetwork, Ltd. 1

Overview

Are We Receiving Value?L t’ M Fi t Let’s Measure First Clinical Information Technology Clinician Adoption Innovation and Transformation Revolutionary HITy

2© 2009 DocsNetwork, Ltd.



“” A crisis is a terrible thing to waste.”

- Paul Romer, EconomistGraduate School of Business

Stanford University


Spending as Percent of GDP

Source: California Healthcare Foundation, Snapshot Health Care Costs 101, 2009




International Comparison of Spending on Health, 1980–2005

$7,000 United StatesGermany

16

Average spending on healthper capita ($US PPP*)

Total expenditures on healthas percent of GDP

$2,000

$3,000

$4,000

$5,000

$6,000CanadaFranceAustraliaUnited Kingdom

6

8

10

12

14

United StatesGerman

$-

$1,000

$2,000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

0

2

4

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

GermanyCanadaFranceAustraliaUnited Kingdom

PPP=Purchasing Power Parity.Data: OECD Health Data 2007, Version 10/2007

5

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

© 2009 DocsNetwork, Ltd.

World’s Highest Spending per Capita

Source: California Healthcare Foundation, Snapshot Health Care Costs 101, 2009




Medical, Medication, and Lab Errors, Among Sicker Adults

34

402005 2007

Percent reporting medical mistake, medication error, or lab error in past two years

3432

1921 22

2628

30

10

20

30

0

GER NETH UK NZ CAN AUS

International ComparisonData: 2005 and 2007 Commonwealth Fund International Health Policy Survey.

United States



Duplicate Medical Tests, Among Sicker Adults

302005 2007

Percent reporting that doctor ordered test that had already been done in past two years

1820

4

89

10

1516

10

20

0

NETH CAN UK NZ AUS GER

International ComparisonData: 2005 and 2007 Commonwealth Fund International Health Policy Survey.

United States





Test Results or Medical Records Not Available at Time of Appointment, Among Sicker Adults

30

Percent reporting test results/records not available at time of appointment in past two years

2005 2007

2322

9

1214

17 1718

10

20

0

NETH GER NZ AUS UK CAN

International Comparison

United States


Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.


Not So Good

100

120

Amenable Age-Standardized Death Rates per 100,000 (0-74)

0

20

40

60

80

100


Fran

ce

Japan

Australia

Spain

Italy

Can

ada

Norw

ay

Netherlan

ds

Sweden

Greece

Austria

Germ

any

Finland

New

Zealan

d

Denmark

United Kingdom

Ireland

Portugal

United States

OECD CountriesSource: Nolte E, McKee CM. Measuring The Health of Nations: Updating an Earlier Analysis. Health Affairs Jan./Feb. 2008, P. 58-71.



Overview



Business Intelligence is Measuring

Market researchD t i i Data mining Epidemiology - healthcare BI Tools and processes similar

– Statistical analysis– Data to information– Easily understood data presentation




Don’t Measure the Untouchable

Unwanted answers are dangerousFinding what you don’t want to know– Finding what you don’t want to know• Risk of discovering the unpleasant

Measures used must be actionable– Political failure for not acting

Analysis linked to goalsResults lead to wanted change– Results lead to wanted change

– Process in place for change• Governance


Snapshots, Not Reports

Easily understood informationU f hi t id tif t d Use of graphics to identify trends Utilized for identification of needed focus Applied to monitor progress Permits focus of effort on the important




Leverage Data Sources

Identify objectives linked to goals– What do we want to accomplish– What do we want to accomplish

Inventory data sources– What data do we have?– Where is our data coming from?– How easily can we use/combine the data?

Develop actionable BI reportp p– Can it be used as a surveillance tool?

Apply process to regularly generate reports– Includes plan for distribution and use


Creativity Leads to Results

Broad thinking, not silosC ll b ti th th ti ti Collaboration rather than negotiation Experimentation

– Multiple pilot projects

Innovation– Re-inventing– Try new things




Overview



Varied HIT Applications

Physician portalP ti t t l Patient portal Electronic medical record Personal health record

– Google, Microsoft

Health record bank– Electronic, digitized

Regional health information exchange Ancillaries HIT




Physician Portal as Information Hub

Source: MedAffinity Corporation 19© 2009 DocsNetwork, Ltd.

Personal Health Records




Varied Clinical Decision Support

Guidelines, care maps, protocolsO d t ( t t d d ) Order sets (structured orders) Rules-based expert systems

– Intelligent prompting, alerts

Order checking– First Databank for medications

Field edits Relevant, up-to-date patient information Consistent and accessible


State of CDS

Only 10% of hospitals with adaptable CPOECDS i ifi tl d di l CDS significantly decreases medical errors– Less variation with increased safety

Varied benefits of medication CDS– Usual and maximum doses– Dose adjustment for co-morbidities

P di i d i b d d i h– Pediatric dosing based upon age and weight– Limiting drug dose choices– Evidence-based disease specific order sets

Source: Gross GA, Bates DW. A pragmatic approach to implementing best practices for clinical decision support systems in computerized provider order entry systems. JAMIA;2007;1:25-28.




Embedded Decision Support


Telestroke Workflow Validation Pilot

Asynchronous telemedicine platform

Image exchange in potential stroke– Image exchange in potential stroke

– First international telestroke network

Mayo Clinic, Phoenix Arizona

Southwestern Ontario hospital

Global health platform

Allowing exchange for clinical case referral– Allowing exchange for clinical case referral

• Between worldwide hospitals

Extra functionalities will be later implemented




Information Flow

1. Source Hospital (Canada)

Hospital CT Scan automatically sends Dicom Images to MIO .

Images, Videos, Data > Images, Videos, Data >


3. MEDTINGClinical case web repository. MEDTING stores and indexes uploaded images,

videos and data. MEDTING web interface allows the sender physician to invite the

receiver specialist.

Clinical Case Review/Collaboration




Challenges Facing CDS

Clinician adoption– Iteration of improvementsIteration of improvements

Standardization of clinical content Implementation issues

– Non-standard recording of allergies– Difficult to merge allergy lists

• Prior admissions and cross-institutional– Non-drug allergy recordingg gy g– Correcting allergy lists

Alerts and reminders– Too many or too few

Source: Gross GA, Bates DW. A pragmatic approach to implementing best practices for clinical decision support systems in computerized provider order entry systems. JAMIA;2007;1:25-28.


Overview





Stages of EMR Adoption – U.S.

© 2009 DocsNetwork, Ltd. 29Source: HIMSS Analytics, September, 2009.

Physicians’ Use of EMRs

9892 89

100

Percent of primary care physicians using electronic medical records

2001 2006

17

28

79

42

2325

50

75

0

NETH NZ UK AUS GER CAN

International Comparison

United States

Data: 2005 and 2007 Commonwealth Fund International Health Policy Survey.





Secure Clinician Adoption

WorkflowImpact on patient care– Impact on patient care• Quality• Cost

– Efficiency - time• Obtain information• Patient encounter

R d fi di• Record findings


Who Should Drive Adoption?

Source: Sarah W. Fraser, IHI Forum, December 2002 (Rogers, 1995)




Overview



Process Redesign Tasks

Current state value stream mapP d it b– Process and its sub-processes

– Collect baseline metrics

Future state value stream map– Detailed workflows– Role definition

l– Align committee structures– Policy/procedure definition




Lean Value Stream Mapping

Simplify processes

Identify value steps

Reduce non-value added steps

Enable efficient care flow

Unit Secretary / RN Pharmacy

RN

Case Manager Social Worker

Supplier - Physician Customer - Patient

McKesson Star

DietaryRadiologyPhysical Therapy Laboratory

Lab order can be enteredin duplicates, or

confirmed in multiple orpartially filled.

Clarification needed

Call made to MD/RN/Dept. Supvr to clarify

orders

Unit Sectary confirm whatto order

Lab Order Clarification

Laboratory ResultSystem can notify byfax, pager or cell

RN review new order.Move step to 1st step

of adminstrationENVA

RN enters order intoMcKesson StarPhysician assesses Patient

Physician accesses andcollects additional pt.

information from Patient,Family, RN

Physician makes clinicaldecision

Physician gives verbal/phoneorder to RN

Physician places chart withorder in Order Rack

RN retrieves order fromOrder Rack

Faxes order to Pharmacy

Prints order inDepartment (For Rad,Lab, PT/OT, Dietary,

Respiratory, & Consultorders)

Unit Secretary calls Rad,Lab, Resp, SS, Dietary to

fast track orders

Unit Secretary writesorder into Kardex

Unit Secretary calls Respafter 2pm for EKG

Unit Secretary placeschart in Chart Rack RN reviews Order

RN ensures order isappropriate and confirms

order is transcribedappropriately in Kardex

Transcribesorder into the

MAR

RN directs and prioritizesthe order based on need

Transcribes order onRN's own work sheet

Administersfirst dose Rx

to pt.

Call Physician re:pt. status postSTAT orderadministered

InpatientSetting

Physician writes order onchart (Routine Orders)

VAVA

STAT orders can be verbal,phone and/or written

Documents inMAR when Rx is

given

VA

VA

VA

VA

Nurse writes verbal/phoneorder on Order Sheet

NVA

NVA

NVA

NVA

NVA

ENVA

NVA

For STAT Orders

NVANVA NVA NVA NVA

ENVA

Diagnostic Testing OrdersAppropriate Treatment =

Appropriate Diagnosis =

Broad Timing =

Appropriate Treatment =

Appropriate Diagnosis =

Broad Timing =

Treatment Orders

NVA

NVA

VA NVA

InitiateTreatment for

pt.

VA

VA

VA

Document caregiven

ENVA / VA

ENVA / VA

ENVA / VA

For STAT Orders

For Rx Order

RN interprets order andchecks for completeness.Call Physician to clarify, if

necessary.

Communicates withpt. on Plan of Care

PerformDiagnosticTest for pt.

Physicianacknowledgesorder fulfillment

Communicateswith CNA onPlan of Care

Off going and ongoing RNs

review and verifynew orders and

new MAR entries

At midnightthe new 24-hour MARprints out

RN reviewsnew and old

MAR

RN sendmemo topharmacy

withcorrections

RN correctsMAR

Old MAR isplaced in

Medical Recordand new MAR in

MAR book

NVA

NVA

RN Worksheet

MAR

VA

NVA

Route of administration =

Correct Drug =

Correct Dose =

Broad Timing =

Medication Orders

Nurse writes STATverbal/phone order

on Order Sheet

NVA

Physician assesses Patient

Physician collects pt.information from Patient,

Family& RN

Physician makes clinicaldecision

InpatientSetting

VAVA VA

Physician gives verbal/phonemedication order to RN

Physician writes medicationorder on chart (Routine

Orders include RegularlyScheduled and PRNmedication orders)

STAT orders can be verbal,phone and/or written

VA

VA

VA

Nurse writes verbal/phoneorder on Order Sheet

NVA

Please see MedicationAdministration in the Inpatient

Setting of CareCurrent State Value StreamMap (cVSM) for the differentiterations of the rest of this

process

Unit Sectary enters orderinto McKesson Star

NVA

RN retrieves order fromOrder Rack

NVA

Post testsresult to

medical recordand/or

McKesson Star

RN collect home medsinformation & verify with

Physician for continuation ornot

Laboratory call Panicvalues to MD or RN

Results faxed or enter inMcKesson STAR

STATS print directly toED

Routine printed to thefloor at midnight

MD accesses andenters data

through EPIC

Decision supportprovided by EPIC

MD enters orderdirectly into EPIC

Eliminate verbalorders; MD entersorder directly into

EPIC from home, officeand/or other location

RN enters phoneorder into EPIC.

Rarely

Barcode STATmeds directly intoMAR with order in

after the fact

RN adjust medadminstration

timing.

Order may go directlyinto departmental

system or print out

EPIC generatesKardex view

Review done in EPIC

Lab results feed intoEPIC

EPIC generates CNAworklist

Enter into EPIC

Acknwledge withinEPIC

Home Med inEPIC system if theMD uses EPIC in

office -RN toverify

Home Medsautomaticalypopulate first

order

Decision supportprovided by EPIC

MD enters orderdirectly into EPIC

Eliminate verbalorders; MD entersorder directly into

EPIC from home, officeand/or other location

Barcode on STATmeds recordsorder in EPIC

EPIC to generatethe MAR View

Electronic MAR

Collection of height, weightand allegies of pt.

Entered into EPICand avaliable for

clinicians

Clinical RPhround with MD -decision support

before orderwritten

Clinical RPhround with MD -decision support

before orderwritten


Future State Admission Process Map




Path Innovation of Clinical Processes

Required subject matter expertsProcess improvement– Process improvement

– Clinical content and evidence-based medicine– IT system design

Educating experts– Exchange knowledge

C t i i Cross training Teamwork

– Formation of long-standing working groups


Clinical Transformation Needed

Utilize clinical technologiesI t li i l Impact clinical processes Enhance quality Achieve efficiencies Necessary focus

– Clinical strategy– Clinical business– Process redesign– Change management




Summarizing Clinical Transformation

“every system is perfectly designed to every system is perfectly designed to achieve exactly the results it gets”

- Don Berwick, MDInstitute of Healthcare Improvement


Overview





Market Penetration of Robust Clinical Systems

Increasing investmentCost of doing business– Cost of doing business

Government and payor incentives Increasing use of IT

– EMR, PHR, EHR, CCR– Computerized provider order entry (CPOE)

Cli i l d i i (CDSS)– Clinical decision support system (CDSS)– Physician and patient portals


New Job Descriptions

PhysiciansHigher level of work– Higher level of work

– Greater management responsibility

Nurses– Higher level of work– Delivery of physician level care

Oth h lth id Other healthcare providers– Delivery of nurse level care




Drivers of These New Roles

Health information technology– Electronic medical recordsElectronic medical records– Clinical decision support

• Alerts, reminders, guidelines, protocols, best practicesEvidence based medicineComparative effectiveness analysis

– Electronic information transfer• ePrescribing• Electronic case collaboration• Electronic case collaboration• RHIO/Health record banks

Reimbursement/business reforms– Address economic incentives


African Proverb

Every morning in Africa, a gazelle wakes up.It knows it must run faster than the fastest It knows it must run faster than the fastest lion or it will be killed.Every morning a lion wakes up.It knows it must outrun the slowest gazelle or it will starve to death.It doesn’t matter whether you are a lion or a gazelle.

When the sun comes up, you better start running.




References

Commonwealth Fund National Scorecard on U.S. Health System Performance, 2009.

Snapshot health care costs 101, 2009. California Healthcare F d ti 2009Foundation. 2009.

Nolte E, McKee CM. Measuring The Health of Nations: Updating an Earlier Analysis. Health Affairs. 2007;27(1):58-71.

Chaiken BP. Round Healthcare in a Flat World. Patient Safety and Quality Healthcare. 2006;3(3):12-13.

Friedman TL. The World is Flat. 2005. New York: Farrar, Straus and Giroux.

Chaiken BP. Path Innovation: Transcending Automation. Patient Safety and Quality Healthcare. 2005;2(3):46-47.

Chaiken BP. Revolutionary HIT: Cure for insanity. Patient Safety and Quality Healthcare 2007;4(6):10-11 Quality Healthcare. 2007;4(6):10 11.

Chaiken BP. Strategies for Success: Clinical HIT implementation. Patient Safety and Quality Healthcare. 2008:5(4):28-31.

Chaiken BP. Healthcare IT: Slogan or Solution? Patient Safety and Quality Healthcare. 2008;5(1):6.

www.logicalimages.com www.medting.com www.himss.org


References

Chaiken BP. Useable clinical evidence-based guidelines…For real. Patient Safety and Quality Healthcare. 2005;2(1):14-16.

Chaiken BP Using IT to drive teamwork and patient safety Journal Chaiken BP. Using IT to drive teamwork and patient safety. Journal of Quality Health Care, 2003;2(1):19-20.

Chaiken BP, Holmquest DL. Patient safety: Modifying processes to eliminate medical errors. Journal of Quality Health Care. 2002;1(2):20-23.

Chaiken BP. Clinical decision support: Success through smart deployment. Journal of Quality Health Care, 2002:1(4):15-16.

Chaiken BP. Technology helps eliminate medical errors. Health Care Quality Means Business: Special Supplement to Managed Care. 2003;12(1):15-17.

Chaiken BP. Choosing clinical IT tools that matter to physicians. Health Management Technology. 2002;Sept.:20-22.

Chaiken BP. Physician adoption of technology linked to providing benefits. Journal of Quality Health Care, 2002;1(2):25-27.




Barry P. Chaiken, MD, MPH, FHIMSSChief Medical OfficerDocsNetwork, Ltd.

[email protected]
