utilizing health it to lower costs and improve outcomes in a rural health system cherokee indian...

Utilizing Health IT to Lower Costs and

Improve Outcomes in a Rural Health System

Cherokee Indian Hospital

Michael Toedt, MD, FAAFP, CDR, USPHSClinical Director, Cherokee Indian Hospital

Cherokee, NC

1. Understand how to utilize health-IT to produce population statistics to inform leadership of health trends and challenges.

2. Describe a practical method to use health-IT as a part of a system of measurement and feedback to achieve desired goals and objectives.

3. Identify useful point-of-care decision-support tools.

4. Suggest ways to develop and support interconnectivity and information-sharing with local and regional partners.


Objectives:

Cherokee, North Carolina


Primary medical home for majority of the over 14,000 members of the Eastern Band of Cherokee Nation

17,000 primary care visits/yr20,000 ER visits/yr20-bed inpatient unit156,000 prescriptions filled/yrAncillary servicesSatellite clinicsSpecialty clinics



Mission

Vision

Values

Goals

Clinical

Nursing

Finance

Operations

Engineering

Human Resources

Board Purpose Ord. 410

Mission, Vision, Values

Macro Strategies or Goals

Tactical Strategy(Organizational Objectives/Performance

attributes)

Divisional and Cross-Functional goals

Departmental objectives

Employee Performance Appraisal systemIncentive system

Mission

Vision

Values

Goals

Clinical

Nursing

Finance

Operations

Engineering

Human Resources

The Mission of the Cherokee Indian Hospital

is to be the health system of choice for members of the Eastern Band

of the Cherokee Nation by providing accessible,

quality healthcare in a caring, culturally sensitive

and healing environment through responsible management

of the Tribe’s resources

Our EHR: RPMSResource Patient Management System (RPMS)

as the database for patient information.Developed in the 1970s

The Patient Care Component (PCC) and the Indian Health Service Electronic Health Record (EHR) are tools to enable the entry of patient data into the database.PCC developed in the 1980s

A number of packages have beenadded to improve the functionality of the RPMS system.


GOOD AFTERNOONWelcome to RPMS HEAL ER ADMIN


LaboratoryLaboratory

AppointmentSystem

AppointmentSystem

PatientRegistration

PatientRegistration DentalDental

EmergencyRoom

EmergencyRoom

PCCPatient

Database

PCCPatient

Database

Elder CareElder Care

Public Health Nursing

Public Health Nursing

PharmacyPharmacy

Behavioral Health System

Behavioral Health System

Women’sHealth

Women’sHealth

PCC Data EntryPCC Data Entry

RCISRCIS

ImmunizationImmunization

RadiologyRadiology

Case Management

Case Management

CHRCHR

SurgerySurgery


RPMS-EHR – Additional Systems Integration

• I-Care population management

• VISTA imaging – scanned documents

• Spectra PACS – radiology

• Quest – lab package

• NC Immunization Registry

• NC Controlled Substances Registry

• WNC Datalink – 16 WNC Hospitals

• Clinical References / Decision Support



3. Identify useful point-of-care decision-support tools.4. Suggest ways to develop and support interconnectivity

and information-sharing with local and regional partners.


Objectives:

Mission

Vision

Values

Goals

Clinical

Nursing

Finance

Operations

Engineering

Human Resources





attributes)




Cherokee Indian HospitalUses for population statistics:Define the major health issues of the population:

Diabetes, CVD complications, obesity, cancer, substance abuse and depression are our major health issues

Define and track disease trends, clinical and administrative outcomes

Strategic planning and administrative decision support

Anticipate resource needsAdvocacy


Percentage of Patients and Visits Per Age Group User Pop FY05 - FY08

[Total Patients = 11496, Total Visits = 478901

17.47

16.13 15.91

14.1613.23

10.67

7.36

3.58

1.13 0.36

9.40 9.18

11.9112.94

16.3616.03

13.18

7.92

2.18

0.90

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00

0-10 11-19 20-29 30-39 40-49 50-59 60-69 70-79 80-89 90+

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

18.00

20.00% Pts/Total

% Visits/Total


Growth in Pediatric Services

Each micro-system must have the ability to record, track, pool, and analyze its population health statistics

Recording and tracking – EMR

Data pooling must be done in a safe, searchable database

Data must be exportable for further analysis


Ability to “Mine the Data” is Essential

Diabetes Prevelence Data 1990 - 2006

0

500

1000

1500

2000

2500

693 773 841 887 991 1053 1134 1209 1308 1376 1443 1512 1587 1666 1766 1888 2040

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006


Percentage of User Pop with a Diabetes Diagnosis Per Age Group : FY06 - FY08

0.94.2

8.1

14.5

38.8

47.8

56.3

25.7

0.00

10.00

20.00

30.00

40.00

50.00

60.00

<15 15-19 20-24 25-34 35-44 45-54 55-64 >64

FY06

FY07

FY08

75

271399

463

844

0

100

200

300

400

500

600

700

800

900

19+ years 15-18 years 10-14 years 5-9 years less than 5years

Numbers of Living Patients with Diabetes (n=2052): Number of Years Since Initial Diabetes Diagnosis

Mission

Vision

Values

Goals

Clinical

Nursing

Finance

Operations

Engineering

Human Resources

Improve access to timely and efficient patient

care services

Develop an organizational culture that fosters

safe, effective, equitable, patient-centered care in a

culturally sensitive and healing environment

Prepare (grow) the organization to meet the

health care needs of the community over the next 5

years

Mission

Vision

Values

Goals

Clinical

Nursing

Finance

Operations

Engineering

Human Resources





attributes)






•Monthly/Quarterly population health reports to Hospital Governance and Tribal Leadership:

• clinical indicators• patient satisfaction• customer concerns• human resource indicators• financial indicators

Organizational Objectives Performance Measures

Access 30%

The average time to the 3rd available appt for continuity appts is less than____days

0 to 10 days 11 -20 days >20 days 0.2

Increase in the percentage of patients seen by a provider that are on the provider's panel [lbaseline 45%]

>55% between 50% and 55% between 45% and 49% 0.2

Decrease composite wait times for pharmacy and ER by the end of the 3rd - actual performance is % of target

within ____% of target within ____% of target within ____% of target 0.2

Utilization: kept appts as percentage of total available is above ____%

65-70% 70-75% >75% 0.2

Access Performance Measures

Culture 40%

Overall customer satisfaction as measured per surveys in key clinical areas: primary care in OPD, ER and the Inpatient Unit

Based on Comparison to the Jackson Group database average 97% - 100% 100% - 103% >103%

0.20

Decrease the percentage of customer concerns No increase in total number Decrease by 3% Decrease by 5%

0.10

Quality Composite Score >7 of 10 indicators met or exceeded targets >3<7of 10 indicators met or exceeded targets <3 of 10 indicators met or exceeded target 0.40

Improve Employee Satisfaction scores in the “Quality” Section of the Annual Employee Survey

>80% positive responses >75% positive responses >70%

0.20

Vacancy and Turnover Rates for Medical and Nursing Staff

CIHA 2008 Data turnover nursing = 7.04% turnover medical = 12.5% turnover dental = 5.56% vacancy nursing = 4.00% vacancy medical = 16.67% vacancy dental = 5.56%

0.10

Organizational Culture Measures

Mission

Vision

Values

Goals

Clinical

Nursing

Finance

Operations

Engineering

Human Resources

2009 Dashboard Quality Indicators

Inpt: CMS Indicators

11%

Patient Falls/Injuries

5%

Pediatric Indicators

11%

Incidents/ Med Errors

21%Facility/IC Inspections

5%

Narcotic Processes

5%

CRS 20%

ER Code Reviews

11%

NPSG/Med Reviews

11%

Growth 30%

IT Infrastructure Projects [timeline/budget] 0.30

Facility Projects [timeline/budget] 0.20

Finance Indicators 0.40

CIHA Operating Margin - 1.8% - > $2,200,000 - >561,000 - -$1,290,000 $ 444,217

Cash on Hand - 155 days - 165 days

- 175 days 209

Percentage of Indirect Cost Compared to Tribe Indirect Cost 30.6% - 29.7% - 29.07% 26.2%

Growth Performance Measures

Other sources of data to mine: FI claims reports

Contract Health Services - Regional Impact:

$15,000,000 billed specialty-care services outside of the facility, most of it spent directly in western NC



Example: Tactical strategy to offer services in-house if we can provide equal or better service at same or lower cost

FI claims reports- revealed high utilization of contracted orthopedic services

Drill down and subsequent financial analysis revealed more cost-effective alternative- Orthopedic PA

improved access to care better care coordination surgical intervention often not necessary when

patient responds to conservative measures better outcomes with attention to physical therapy

both before and after surgical interventionCherokee Indian Hospital


PT - Orthopedic Clinic RedesignExample: Osteoarthritis of the Knee

Primary Care Provider Orthopedics PA

Physical Therapy

Orthopedic Surgeon / Sub-Specialist

Arthroscopic surgeryRealignment osteotomyArthroplasty

Diagnostic testing

Range of motion/flexibility exercises

Quadriceps strengthening

Patellar taping

Joint injections of corticosteroids or hyaluronic acid injection

Activity modificationSelf-careWeight lossLow-impact aerobic fitnessAnalgesics for pain

Example: Tactical strategy to offer services in-house if we can provide equal or better service at same or lower cost

FI claims reports- revealed high utilization of contracted respiratory therapy services and respiratory DME

Drill down and subsequent financial analysis revealed more cost-effective alternative- hired Respiratory Therapist to see patients and manage DME referrals

improved access to care better care coordination $200,000 in savings realized in first two years





3. Identify useful point-of-care decision-support tools.4. Suggest ways to develop and support interconnectivity

and information-sharing with local and regional partners.


Objectives:

Mission

Vision

Values

Goals

Clinical

Nursing

Finance

Operations

Engineering

Human Resources





attributes)






•Specific targets for selected clinical indicators

•Monthly scorecards for individual providers and for provider-nurse teams

•Hold staff accountable at the individual performance management level

•iCare – provides real-time population (panel) management tool used by nurse team lead

CRS Indicators: Diabetes

31.0%

41.9%42.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

Active DMw/A1c<7

DM w/BP<130/80

DM w/LDL<100

Jan-Mar09

Apr-Jun09

Jul-Sep09

2009 Target

Mission

Vision

Values

Goals

Clinical

Nursing

Finance

Operations

Engineering

Human Resources





attributes)









Objectives:

HIT Decision Support atCherokee Indian Hospital RPMS/EHR

1. Clinical Reminders2. Medication package3. Graphing capability4. HTML links through EHR

Vista Imaging WNC Data Link NC Controlled Substance Registry

Database NC Immunization Registry Policy Tech® i-Care

What is iCare?iCare is a Population Management software tool

that helps you manage the care of your patients. The ability to create multiple panels of patients with common characteristics (e.g., age, diagnosis, community) allows you to personalize the way you view patient data.

iCare is a Windows-based, client-server graphical user interface (GUI) to the IHS Resource and Patient Management System (RPMS).

iCare retrieves important patient information from various components of the RPMS database and brings it together under a single, user-friendly interface.

Source: Indian Health Service (IHS) Webpage

RPMS/EHR Decision Support:Clinical RemindersGuideline adherence; standards for:Preventive careDisease management

RPMS/EHR Decision Support:PostingsReady visualization of and quick access to:Crisis NotesPain ContractsAllergiesWarnings

RPMS/EHR Decision Support: Medication PackageMedication selection at CIH is assisted by:Built-in pop-up allergy and interaction alerts.Setup of RPMS/EHR to display preferred

formulary meds with most commonly used doses arranged by therapeutic category and/or clinical setting.

Drill-down menus show medication-specific dosing guidelines.

RPMS/EHR Decision Support: Graphing Capability

RPMS/EHR Decision Support: HTML LinksFacilitate access to:Reference literature / standards of care /

guidelinesDisease risk calculatorsDosing calculatorsE&M calculatorsPatient education protocols and codes and

teaching materials

RPMS/EHR Decision Support: HTML Links

RPMS/EHR Decision Support: Templates with Standards of CareDiabetes Care TemplatesVTE PreventionR/O MI OrdersSubstance Abuse






Objectives:


WNC Data Link

• 16 hospitals serving western North Carolina (WNCHN founding members)

• $2.5 million in federal funds and $1 million from The Duke Endowment


WNC Health Network Founding Member Map


WNC Data Link

• Long-Term Goal: Allow every WNC resident to have a longitudinal electronic medical record that can be accessed and updated in real time by any authorized provider.

• Short-Term Goal: Allow the secure exchange of electronic patient information between WNC hospitals.

PersonalizedAccess

Firewall

Portal

Access Management

AccessPt.SoftwareIBM WebSphere Application Server

SecureConnections(VPN)

Notification

Firewall CP HomehealthFirewall

Clinical Data

Clinical DataCP Rehab

Clinical DataMission

Clinical DataPardee

Clinical DataTransylvaniaAlthough clinical information for Jane Doe is located at each of the 5 facilities, the combination of the Portal and AccessPt. presents a consolidated view, producing a virtual EMR across the enterprise.


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Cherokee Indian HospitalData Link Hits Per Month

Two Year Comparison


Cost Savings of WNC Data Link

• Estimated $1 million savings through prevention of adverse drug events

• Estimated $400,000 savings through eliminating need to retrieve and fax paper records

• Estimated $2-4 million savings through elimination of ordering of redundant tests


Quality Improvements at Cherokee Indian Hospital

2004 2007

• Domestic violence screening 1% 80%

• Tobacco use screenings 43% 80%

• BP at target control 73% 79%

• Healthy cholesterol levels 71% 75%

• Breast cancer screenings 39%49%

• Alcohol use screenings 4% 82%

Cherokee Indian Hospital2008 HIMSS Nicholas E. Davies

Award of Excellence in Public Health


1. Health-IT is a valuable tool that can be mined to produce population statistics to inform leadership of health trends and challenges.

2. It is essential as a part of a system of measurement and feedback to achieve desired goals and objectives.

3. Many useful point-of-care decision-support tools are widely available.

4. It is important to partner with local and regional cooperatives to develop and support interconnectivity and information-sharing with local and regional partners.


Summary:


For additional information:

Michael Toedt, MD, FAAFP, CDR, USPHS

Clinical Director


Cherokee, NC

[email protected]

utilizing health it to lower costs and improve outcomes in a rural health system cherokee indian...

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