2011 Healthcare Informatics IT Innovator Awards Top 12 Finalists

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Hospital:

Adventist Health System

CIO name:

John McLendon

Project:

Self-Service Approach to Billing and Registration

Timeline:

More than 4 years

Budget:

$500,000-1 million

Team:

1- 10

Departments:

1 or More Clinical Departments, Finance, Revenue Cycle Management

Overview:

Patient payments are becoming an increasingly important part of healthcare revenue streams. According to a recent Celent report, patient payments will account for 30 percent of a provider's revenue source by 2012. These out-of-pocket payments are projected to grow from $250 billion to more than $420 billion by 2015, as shown in a McKinsey Quarterly report. Despite their increasing share of total revenue, patient collections secured by hospitals range from 35 to 65 percent after insurance pays its portion, according to industry estimates. Paired with tightening margins, declining reimbursement and mounting operational costs, patient bad debt is a growing issue that hospitals and health systems must address. In 2006, Tim Reiner, vice president of revenue management at Adventist Health System (AHS) and his colleagues sought an innovative approach to reengineering collections efforts and billing communications with patients. AHS, the largest not-for-profit Protestant healthcare organization in the U.S., supports 44 campuses. Its hospitals comprise more than 7,700 licensed beds. Reiner and his team spearheaded a multi-phase deployment of self-service technology to increase and expedite collections, enhance patient satisfaction, streamline workflow for staff and eliminate costly paper-based processes. This strategy enabled AHS to put procedures in place that mimic proven retail-based self-service methods, which consumers have come to expect. Phase 1: The first part of the AHS self-service initiative included rollout of a patient portal, which enables patients to access account details, including balances, billing information and payment services. Patients can also request appointments and pre-register for visits through the portal. Phase 2: Further extending the self-service technology in 2008, AHS implemented check-in kiosks to automate patient registration. Through the registration kiosks, patients can electronically sign consent forms and enter and verify their own demographic and insurance information, resulting in reduced printing, handling and filing costs associated with paper forms. This streamlines registration processes for patients and staff alike, while minimizing wait times. Patients are also prompted to pay out-of-pocket costs and outstanding balances at the kiosks leading to improved collections. Phase 3: In 2010, AHS again addressed the challenges associated with collecting patient payments by giving patients the ability to set up flexible recurring payment arrangements on outstanding balances both online and at the point of service. As more and more of its patients expect a retail-like approach to managing their healthcare expenses, this functionality has enabled a typically younger demographic to set up payment arrangements at predefined intervals based on monetary amounts that fit their budgets. It has streamlined billing workflow for staff, enhanced convenience for patients by eliminating the hassle of mailing a check and coupon or making phone payments, and decreased the administrative costs associated with collections.

Results:

Leveraging self-service technology that has been successful in other industries, but not widely deployed in healthcare, AHS took a revolutionary approach to the problems that ail hospitals, health systems and medical groups nationwide, including: Inefficient billing operations, Uncollected patient bad debt, Paper-based processes The patient impact AHS patient-centric self-service initiative resulted in numerous benefits across all of the strategies implemented. By offering patients convenient payment options, online access to appointment scheduling and pre-registration, and streamlined registration at the point of service, AHS has increased satisfaction rates and loyalty among its patients. The self-service kiosks have also shortened registration times by four minutes per visit, increasing patient throughput and cutting wait times. Patients feel more empowered since they can manage details related to their healthcare and payments at a time and place that's convenient for them whether at an appointment or from their home or work computer. In addition, AHS can now clearly establish patient expectations regarding their financial obligations, which is imperative as individuals continue shouldering greater financial responsibility for their care. Staff efficiencies The benefits extend beyond the patient impact; hospital staff now operates more efficiently and gains time to focus on other mission-critical tasks through its use of self-service: Staff can now accommodate multiple patients at once because of the registration kiosks. For example, one AHS location saved 40 hours of staff time per week, a full FTE, in the admissions department. Billing staff has also minimized time spent responding to billing inquiries, processing verbal payments, managing paper checks and coupons, and handling data entry. About 70 transactions are made via kiosk each month, and more than 6,000 transactions are made monthly through the online payment functionality. Since completing phase 3 of its project, AHS receives more than half of its patient payments through online and kiosk self-service channels. This has enhanced the accuracy of billing information, leading to fewer errors, faster payment and a decrease in re-worked claims. The collective result? Up to a 10 percent decrease in overall billing and collection costs. A number that is harder to quantify is the savings due to minimized paper-based processes. AHS has completely eliminated paper forms where the self-service registration kiosks are in place. Patients enter all of their information on the screen, and sign electronic consent forms there as well. During the same encounter, they can swipe their credit cards at the kiosks to pay balances, copayments, deductibles and coinsurance. With these payment details captured at the kiosk, paper bills, statements and receipts no longer need to be mailed to the patient, which reduces postage costs. The online payment portal and recurring payment technology also further these savings for AHS. Hard-dollar ROI Through phase 1 and phase 2 of the project, which included the online patient portal and registration kiosks, AHS captured more than $11 million in revenue via self-service channels. In the short time since AHS rolled out the recurring payment plans, the health system has increased collections by $150,000 per month, while saving 6-10 cents on every dollar that avoids placement with an early-out agency. Just as important, this part of the initiative takes a "lights out" approach, which means patients set up payment and no longer think about it. AHS staff verifies everything once and then sees payments show up regularly without any additional work. With an average of 250 patients using monthly recurring payments, transaction costs have decreased by 20-25 cents per transaction, or about $3,000-$4,000 per month. The higher volume of credit card payments also has allowed AHS to negotiate better rates with a merchant services provider. The bottom line AHS has revolutionized its approach to patient collections through the utilization of self-service technologies that mimic retail-based methods. Not only is the technology patient-friendly, but it has simplified workflow for billing and administrative staff, all while giving the health system a significant improvement in timely patient payments.


 

Hospital:

Adventist Health System

CIO name:

John McLeondon

Project:

Computerized Physician Order Entry Implementation: 25 Hospitals in 28 Months

Timeline:

2-4 years

Budget:

$1 million-$5million

Team:

More than 50

Departments:

1 or More Clinical Departments, Quality

Overview:

In May and June 2009, Adventist Health System Information Services (AHS-IS) piloted computerized physician order entry (CPOE) at Takoma Regional Hospital and Florida Hospital Zephyrhills on the Cerner iConnect platform. Serving 25 of the current 26 AHS-IS hospitals, the Cerner iConnect system has been enhanced to support the rollout of CPOE to all hospitals by August 2011. In order to enhance the iConnect system for CPOE support, AHS has invested over two years in the development of evidence-based and expert-based content through an ambitious project lead by the Office of Clinical Effectiveness in collaboration with three other large faith-based, community hospital health systems. In parallel, the AHS-IS clinical informatics teams invested most of 2008 to retool the iConnect order catalog to support CPOE design and future plans for bar code scanning support of phlebotomy and medication administration (commonly known as positive patient identification or PPID). This effort to build it once and deploy to all hospitals has created an opportunity to document hospital operational (admission, transfer, discharge) and clinical processes (e.g. medication reconciliation) and identify where standardization will create leaner processes fully aligned and supported by AHS-IT clinical information systems. In effect, AHS-IS has created two clinical states that were deployed in early 2009: Pre-CPOE which consists of numerous redesigned processes supported by the iConnect and supplemental clinical systems; and CPOE, which will be deployed sequentially to all of the AHS-IS hospitals by August 2011. This has created a commoditization model in which a standardized system will support Pre-CPOE and CPOE during the transition to fully deployed CPOE. Therefore, the critical success factors for CPOE will be the change management efforts around the deployment. This will necessitate proper assessment of individual facility readiness and barriers to CPOE adoption, successful management of the education, training, and transition in preparation for CPOE, and the implementation support of the rollout and post-activation support. In parallel to the CPOE rollout, the clinical leadership of the AHS-IS hospitals are eager for an opportunity to enhance iConnect in the areas of clinical documentation and workflow to enhance efficiency, effectiveness, and patient safety. In addition, the burden to meet ever-growing regulatory data capture and reporting has increased the need for new resources to complete the expanding list of clinical information projects to fulfill the scope and timeline set by senior leadership. Finally, several meta analyses have demonstrated that hospitals that utilize CPOE with clinical decision support (CDS) reduce medication errors by 82-88 percent. The Adventist Health System has designed CPOE rollout as a top priority for the support of the 2010 Vision. Successful implementation of CPOE and physician documentation will help AHS achieve many elements of the 2010 Vision, including becoming a national leader in quality and patient safety. With excellent execution, it will also support physician alignment and employee retention. Several critical success factors are noted: 1. Facility leaders are committed to CPOE success and the elimination of unnecessary variance and waste, and willing to stay the course despite potential obstacles. The CPOE effort must remain aligned with ongoing optimization and redesign efforts to fully leverage all aspects of the iConnect system across AHS-IS facilities and eventually across venues, such as home health and extended care. 2. CPOE is viewed and promoted by leadership as a clinical and operational imperative rather than an IT initiative. 3. All physicians and inpatient units will follow corporate best practices and utilize the iConnect system including CPOE. 4. Each facility has a dedicated physician executive (as specified in the 2010 Vision), supported by one or more physician liaisons, and many well trained super-users. 5. Evidence-based medicine is the standard, not the option of care. 6. Each facility commits to understanding and achieving clinical and operational excellence from CPOE and the iConnect system.

Results:

In the past, physicians have traditionally hand-written or verbally communicated orders for patient care, which are then transcribed by various caregivers (such as unit clerks, nurses, and ancillary staff) before being carried out. Handwritten reports or notes, manual order entry, non-standard abbreviations and poor legibility can lead to errors and injuries to patients. In addition, electronic medication ordering, with computer- and internet-based information systems to support clinical decisions. AHS developed hundreds of Evidenced Based Care ordersets that are available both online and within the Cerner iConnect application. Prescribing errors are the largest identified source of preventable hospital medical error. CPOE/e-Prescribing systems can provide automatic dosing alerts (for example, letting the user know that the dose is too high and thus dangerous) and interaction checking. In this way, specialists in pharmacy informatics work with the medical and nursing staffs at hospitals to improve the safety and effectiveness of medication use by utilizing CPOE systems. CPOE Scope includes 100 percent Computerized Physician Order Entry for all orders within the emergency department, inpatient units (including outpatients in a bed and observation patients), pre-operative orders, post-operative (e.g. PACU, Recovery Room, and Anesthesia) orders including a defined standardized process for verbal/phone orders with direct order entry and verbal order read back by receiving nurse (as defined in the corporate CPOE Order Processes policy). This also includes online medication reconciliation upon admission, transfer and discharge; Physician documentation online using PowerNote and PowerNoteED; Concurrent Scanning, to be implemented prior to CPOE activation date; Rules and Alerts around avoiding common and significant adverse drug events (ADEs); Standardized registration processes to facilitate CPOE admission processes (e.g. direct admissions, pre-admissions, pre-op registration, pre-partum registration, Lessons Learned from AHS-IS CPOE Pilots: The CPOE pilots have helped AHS-IS team further identify lessons learned that are incorporated into planning for the rollout; 1. Multiple processes have been found that are frequently less than ideal (i.e. broken) prior to CPOE, and become magnified when CPOE is implemented. It is imperative that the sites understand the actual current state of these processes, and the gap between how they think they function, and how they will function in a CPOE future state. These investigations must involve end users and their daily reality, and not rely on management's perception of what the processes are. a. Medication reconciliation is a major example of a process that may not be functioning optimally prior to CPOE 2. The facility must invest time to understand how CPOE changes some major common processes such as: a. Direct admissions b. ED admissions c. ED holds d. Consultations e. Compliance with co-signing verbal/phone orders within 48 hours f. Admission process g. Transfer and Hand-off processes h. Chart reviews (abstractors, quality, HIM, etc) i. Chart orders review (shift review of orders by nurses) j. Discharge process k. Initial medication history 3. Proper use of iConnect clinical tools such as the PAL (Patient Access List), and the multipatient task list. 4. Importance of well trained and engaged physician liaison(s) and super users (the latter on each unit/department), for process reviews, training, activation support, and ongoing support of all users, including physicians. See appendices for adequate support estimates for CPOE support. 5. Outpatient surgery processes 6. Telephone/Verbal order processes 7. Protocol orders 8. Transition states, such as IV to PO conversions, and EndoTool IV insulin to subcutaneous injections. 9. Training and orientation of new staff and agency staff 10. Activation planning around staffing and volumes 11. Device distribution and wireless stability 12. HIM and coding processes, as well as concurrent scanning 13. Impact of PowerNotes on HIM processes. To Date, Adventist Health Systems has implemented CPOE successfully at 15 facility sites to date. We have achieved leapfrog certification for medications at 75 percent of all orders are being entered by Physicians. Recent activations were Gordon Hospital, activated April 21, 2010 -- 14 day Leapfrog - 86.5 percent. Emory-Adventist Hospital was activated May 4, 2010 - 14 day leapfrog - 96.6 percent. Park Ridge Hospital activated on May 18, 2010 - 14 day Leapfrog - 92.2 percent). Specifically, at Takoma Regional there has been an 85 percent reduction of pharmacists having to call back physicians to clarify orders since CPOE activation. There has been an 89 percent reduction in allergy prevention, 100 percent reduction in Clarification illegible writing, 94 percent decrease in clarifications, 64 reductions in Drug to Drug interactions. There has been a total of 85 percent reduction in phone calls by pharmacy.

Hospital:

Brigham and Women's Hospital (Partners Healthcare)

CIO name:

Sue Schade

Project:

Medication Linking for Chemotherapy Scheduling and Administration

Timeline:

2-4 years

Budget:

$1 million-$5million

Team:

11-20

Departments:

1 or More Clinical Departments

Overview:

Brigham and Women's Hospital (BWH) is a 777-bed tertiary academic medical center in Boston that administers 6 million medication doses a year. BWH is a member of Partners HealthCare which was founded in 1994 by Brigham and Women's Hospital and Massachusetts General Hospital. In June 2009, the Closed Loop Medication Process was deployed for all adult inpatients receiving chemotherapy medications at Brigham and Women's Hospital. Our goal was to ensure appropriate dispensing and administration scheduling for chemotherapy medications and medications that must be given before, during, and after chemotherapy The BWH identified four types of administration links required for precise chemotherapy scheduling and administration. 1) Mix Together Linking for medications that are administered to the patient at the same time and are mixed together in the same vessel. (e.g. bag, syringe) 2) Mutually Exclusive Linking for two or more medications where all are ordered by the physician, but the nurse will only administer one to the patient. 3) Time Offset Linking for medications that are administered in a predefined sequence with specific lengths of time between start of administrations. 4) Sequential Linking for medications that are administered in a specific sequence, but are ambiguous to time, often defined as give before or give after. Each link type has a set of rules associated with it to ensure the link can be interpreted by three systems. The Computerized Provider Order Entry System (CPOE) used by physicians to enter patient orders. The Pharmacy System (RX) used by pharmacists to approve, process, schedule and dispense the medications ordered by the physician. The Electronic Medication Administration Record (eMAR) used by nurses to review the medication orders, scan the barcodes on the medication and the patient wristband, to ensure the right medication, the right route, and the right dose are administered to the right patient at the right time. The linking database is the single source of truth for all linking information. Every consuming group retrieves the linking information via web services or Managed Service Provider services. The web services receive and send blocks of information via XML. There are business rules for linking that apply to Partners Healthcare as a whole, but each individual site must be able to add to or override these rules. Currently, there are enterprise rules and rules specific to Brigham and Women's Hospital pharmacy. Chemotherapy treatment plans are pre-defined in CPOE so the physician does not have to individually order each medication in the complex plans. The physician chooses a specific treatment plan and the CPOE system creates the order, does all the weight-based calculations and clones the pre-defined order links to inform Pharmacy and eMAR how these orders are related to each other as far as scheduling. If an order is discontinued or changed in CPOE then the linking services are called to update the links. Orders are linked on the order level until they are approved in the Pharmacy system. Pharmacy calculates administration times for every order based on the links and creates dose-level links. These dose-level links are passed to eMAR to ensure that the meds are administered at the correct times. Linked orders are sent into the Approval Wizard within the Pharmacy application for approval. Orders are approved one at a time and the schedule of the first order in the treatment plan will drive the schedule for the rest of the orders in the plan. When a medication is due to be administered to a patient, the nurse starts the administration process. In this user interface (known as the To-Do Screen), chemotherapy and non-chemotherapy medications are listed together in the Chemotherapy section. All linked medications are identified with the link icon. The nurse can also hover over the icon here to view the linking detail. In addition, for Sequential and Time Offset links, eMAR uses linking services to ensure that medications are given in proper order and according to schedule. If an error is detected, the nurse is alerted and eMAR will not allow the nurse to proceed until the parameters are satisfied. For Mutually Exclusive links, the nurse can only choose one of the mutually exclusive orders to administer. Once the nurse scans the medication, the other orders are automatically documented as not given. For Mix Together links, the eMAR system applies status changes (Infusion Bag hung up and running, Infusion Bag down, Infusion Stopped) to all medications in the Mix Together link. In conclusion, the design of the Linking Services had to be extendible. Though the initial implementation was only for Brigham and Women's Hospital oncology, the services had to handle the additional volume when links rolled-out to other BWH clinical services, and other Partners Healthcare institutions.

Results:

Brigham and Women's hospital has implemented a successful cutting-edge system with high clinical value that improves both patient care and hospital efficiency. The scheduling and administration of chemotherapy is complex. Precision is especially important with chemotherapy medications because they have low therapeutic windows with severe side effects. Plus, the patients are often quite ill prior to treatment. The complex treatment plans include not only chemotherapy medications, but also chemotherapy related medications including pre/post-hydration, anti-nausea, anti-anxiety, and other medications that are given before, during and after chemotherapy doses. The treatment plans specify the medications and dictate precise dosing, frequency, duration, and timing of chemotherapy and of the supporting medications that treat the side effects. To the best of our knowledge, the Brigham and Women's Hospital is the first institution to fully implement the Closed Loop Medication Process with the features to address the complex scheduling of chemotherapy treatment plans. This includes the physician orders, the pharmacy dispenses, and nurse's administrations. The Linking Database and services accommodate the different ways that physicians, pharmacists and nurses work. Physicians deal with orders. Pharmacists deal with doses. Nurses deal with administrations. These three data elements are not a one-to-one match. One physician order translates into several doses. One pharmacy dose can be dispensed as two syringes, or two tablets. The Linking database and services are scalable to whichever data elements the consumer is passing. Since this system was implemented pharmacists have reported they feel more secure that schedules are appropriately set up and enjoy the efficiency of automated scheduling based on the rules of the link. Nurses have expressed the added sense of security in knowing that important medications such as pre-hydration won't be forgotten and that alerts will appear if an attempt is made to administer chemotherapy out of sequence. Initially this system was implemented on the BWH clinical services that order chemotherapy: Oncology, Gynecology, Bone-Marrow-Transplant, and Rheumatology. Based on the wide-spread success and acceptance of linked medications among the oncology specialists, BWH is implementing linking for scheduling medications on all other adult clinical services. To date all of the implementations have benefited adult inpatients receiving chemotherapy medications at Brigham and Women's Hospital. However, it is important to note that the system is designed as a scalable solution so that these state-of-the-art features can be deployed in the future at other Partners Healthcare institutions such as Massachusetts General Hospital, and Dana-Farber Cancer Institute.


Hospital:

Children's Hospital and Medical Center

CIO name:

George Reynolds, MD, MMM

Project:

Clinical Analytics and Business Intelligence

Timeline:

1-2 years

Budget:

$100,000-250,000

Team:

1- 10

Departments:

Finance, ED, Pediatrics, Ambulatory, ICU, OR/Perioperative, Quality, Med/Surg, NICU, Supply Chain/Materials Management , Revenue Cycle Management

Overview:

The Clinical Analytics and Business Intelligence project at Children's Hospital and Medical Center in Omaha, Nebraska grew out of the organization's desire to create greater value from our IT investments. Specifically, we began by leveraging the data in our clinical systems to improve patient safety and outcomes. Almost simultaneously, we began using the same software tools and personnel to create views into our operational and financial data that could be used to enhance our efficiency and financial performance. At 145 beds, Children's Hospital and Medical Center in Omaha, Nebraska is one of the smallest freestanding Children's Hospitals in the country. Several years ago, Children's embarked on a best-of-breed approach to our hospital and ambulatory IT strategy. Consequently, we rely on 7 different software vendor products for our major clinical and business systems. This obviously created a challenge as we sought to integrate the content from these systems and allow clinicians and leaders to view the data from our EHR systems in meaningful ways that support decision-making. Utilizing a federated data warehouse model and a commercially available in-memory business intelligence (BI) tool, we were able to combine data from our 2 different core EMR systems in addition to several other clinical and financial systems in order to provide clinicians and managers with intuitive, web-based views into data. Our initial plan was to use the BI tool as a front end for our data warehouse. However, the early successes of our analytics dashboards created a flood of requests from across the organization for additional dashboards. We learned that our ability to deliver swiftly resulted in greater adoption and better outcomes. The fastest way to deliver these dashboards was to create SQL data marts using the same commercial extract-transform-load software we were using to deliver data from our various systems to our data warehouse. Thus, our federated data model was born largely out of necessity. To date, we have developed over 40 dashboards that are used daily by clinical staff and hospital leadership to make decisions about patient care and hospital/clinic operations. Both clinical and business dashboards created with the BI tool are refreshed daily providing near-real-time access to key performance data. For example, our Infection Control Dashboard allows clinicians to review the isolation status and laboratory results for all current inpatients. This assures that at-risk patients and staff are appropriately protected. Our Specialty Operations Dashboard monitors EMR use in over 45 specialty clinics and includes metrics such as patient volume by clinic and practitioner, time to visit and chart completion, and efficiency of communication back to the referring physician. Our CPOE dashboard is used to track all inpatient orders and their associated alerts and is used to optimize our clinical decision support strategy by reducing nuisance alerts and increasing the value of the alerts that do fire. Each of these dashboards has been developed in collaboration with a clinical or operational sponsor. The dashboard builder meets with the sponsor and they create the initial specifications of the dashboard together. Then, through an iterative process, the dashboard is refined and enhanced until it meets the needs of the sponsor and the leaders or clinicians he represents. The BI tool offers a number of security options so that the data is provided to the appropriate individuals or groups. There are 15 dashboards that support our pediatric specialty and general pediatric ambulatory practices with a combination of clinical and operational metrics. Another 12 are focused on our inpatient care, and the remaining tools address financial performance and system wide operational issues.

Results:

The analytics program at Children's in Omaha is based on a very simple operating philosophy: If the data is stored electronically, then we can make that data available to clinicians and leaders in flexible, intuitive formats that foster improved communication and decision making. As a direct result of this philosophy, Children's has experienced a culture shift. We have become a data-driven organization. Instead of wasting time grappling with the definition and scope of a problem, we now have real-time, comprehensive and easily understood data at hand; we can turn our attention to solving problems instead of merely defining them. All major projects have clearly stated goals with baseline and post-implementation metrics. Outcomes are published and celebrated. Increasingly, we are moving away from static paper-based reports and rely on our dashboards to identify trends and model future strategic plans. We have become a much more transparent organization over the past several years, and our employee engagement scores are in the top 2 percent of our industry. Our philosophy of ubiquitous data availability has also served to foster technology adoption especially the EHR. If the data is not stored electronically, our analytics program cannot make it easily accessible. Consequently, clinicians and leaders are eager to adopt technologies that will increase data availability. For the past several years, much of the work nationally involving EHRs has focused on system implementation and clinician adoption. Going forward, merely counting the systems that have been installed and the clinicians who use them will not be enough. The analytics program at Children's in Omaha has demonstrated that meaningful, actionable data can be derived from even a complex EHR system fairly easily and at very low cost. More importantly, the use of the data from such an analytics program can move the tools for such a system from the hands of data centers and report writers and into the hands of decision makers and front-line clinicians. The results of these efforts speak for themselves: • A 59 percent reduction in medication errors reaching the patients. • Prescribing errors associated with therapeutic heparin orders and insulin orders have been completely eliminated with new order sets for each ordering process. • Overall alerting rate for CPOE orders below 3.6 percent with allergy, pediatric dose range, duplicate checking and focused drug:drug interaction checking all enabled. • Compliance with evidence-based guidelines for the care of patients with bronchiolitis increased by over 20 percent. • ADHD follow-up rates have increased from 57 percent to 100 percent. • Autism screening rates have increased from 65 percent to 94 percent. •Annual examinations for asthma patients have increased by 12 percent and twice as many patients received detailed asthma management plans. • Compliance with guidelines for the management of pharyngitis has increased to 96 percent. • Documented screening for tobacco use has increased from 60 percent to 99 percent, and lead exposure screening increased from 59 percent to 96 percent. • Wait times in the emergency department are the shortest of any of the Children's hospitals reporting data to the Child Healthcare Corporation of America. • 95 percent reduction in transcription costs in the general pediatric practice. • 98 percent reduction in duplicate patient identifiers. •5 percent reduction in overall operating budget using targeted reductions identified using the financial and productivity-based dashboards. This is obviously only a partial list. With over 100 dashboard users (virtually our entire leadership team on both the clinical and operational side), decisions are made and differences are resolved using data. Despite the size and scope of the analytics program, only 2 employees in the data services division provide virtually all of the development and support for the program. Hardware and software costs are extremely modest, and the cost of the program represents less than 1 percent of operating revenue. This is not a multimillion dollar effort; it is a focused, practical initiative using commercially available tools that can be easily replicated by hospitals of very modest size and resources.


Hospital:

Denver Health

CIO name:

Gregg Veltri

Project:

Clinical Quality Scorecard

Timeline:

Less than a year

Budget:

$100,000-250,000

Team:

1- 10

Departments:

1 or More Clinical Departments, Ambulatory, Quality

Overview:

Denver Health has taken a very intentional and strategic approach to leveraging information and knowledge across the enterprise through Data Warehouse and Business Intelligence (BI) initiatives. Based on the Microsoft technology stack, the new, scalable enterprise data warehouse infrastructure seamlessly aggregates data from many sources. In addition, advanced scorecard and dashboard technology brings powerful performance monitoring and management functionality to the solution to facilitate faster, easier access to more patient- and business-critical information from across the enterprise. The ability to now measure and manage data is fostering a culture of continuous process improvement. Prior to the implementation of the Clinical Quality Scorecard, Denver Health's Department of Patient Safety and Quality was responsible for publishing a set of metrics quarterly. It required a time-consuming manual data collection effort that involved multiple key business users around the hospital, as well as data queries made against a clinical data repository that drew data from the institution's Siemens clinical systems. The result was a massive spreadsheet with pages full of values and charts trending specific quality or patient safety metrics. The primary goals of the new Clinical Quality Scorecard project were: • Automate, wherever possible, the creation of the existing Clinical Quality Scorecard. • Integrate data from disparate systems into a single enterprise data warehouse framework and ultimately be able to cross-correlate information generated by all clinical, financial, and operational systems across Denver Health's network. • Create additional scorecards and dashboards to improve the timeliness and availability of information for enhanced business decisions and operations, and better, faster, and more cost-efficient patient care. • Establish a system that could be relied upon to deliver a "single version of the truth". • Standardize and enhance the end user's interaction and experience with Denver Health's information assets. The first phase of the project is complete and the solution has been operational for ten months. On a nightly basis, the enterprise data warehouse automatically pulls specific components of data from various Denver Health clinical systems. Other segments may be extracted weekly, monthly, or quarterly depending on data availability. Other project efforts are underway to bring additional data sources into the enterprise data warehouse, which will eliminate the need for continued manual data entry into the scorecard and decrease the lag time for data availability. The Clinical Quality Scorecard is also refreshed nightly, so that all of the new information collected by the data warehouse will be reflected on the scorecard the next day. Key inpatient and outpatient metrics within the original scorecard have also been turned into a dashboard, which is made available to the entire enterprise. Chronic disease management registries, such as those for cancer screenings, diabetes, and hypertension, are supported by specially created dashboards, which now make it possible to quickly access information and generate reports for research, as well as for monitoring and managing care for specific conditions. Some reports, such as point-of-care patient reports, are automatically printed whenever a patient on one of these registries is seen at a Denver Health outpatient clinic. To date, the dashboard development has been primarily focused on monitoring and analysis, but the next stage will support more drill-down capabilities and use the information to generate actionable items. Nearly 100 different metrics are being rolled into new clinical dashboards which will show clinic or physician data, such as how many patients had falls or pressure ulcers during a period of time or at a particular location, so that corrective changes can be made to improve care. The ultimate goal for Denver Health's data warehouse is to support a comprehensive BI portal that enables personnel to view current or historical activity recorded in any system throughout the organization's healthcare network, which includes a 477 licensed-bed main hospital, 8 family clinics located throughout the city of Denver, 12 school-based health centers, the Denver Public Health department, and a variety of support services that include 911 medical response, a medical plan, a poison and drug center, and a "NurseLine."

Results:

At the clinical level, having access to regularly updated and aggregated information from various sources helps quickly reveal what is working—and what isn't—from medication effectiveness to the clinical approach for a chronic condition. The ability to generate reports with metrics and targets specifically related to patient care, guides better decisions about where to focus efforts or make changes for improved care and outcomes. At the physician level, care givers can more accurately and actively monitor and manage their patients' conditions when equipped with up-to-date information automatically collected from different systems. For example, uninsured patients typically get their medications through Denver Heath pharmacies so physicians can easily track when patients fill, or don't fill, their prescriptions. When a patient returns for a checkup, the physician can quickly access current and historical metrics and values within their point-of-care report and easily correlate that information to direct care. To better accommodate the diverse ethnic community that Denver Health serves, information is provided in an easily understandable format, available in various languages. Patients can view their point-of-care reports and quickly see how regularly and consistently taking their hypertension medicine, for example, can result in healthier blood pressure readings. Patients are empowered by this information to take a more active role in maintaining or improving their health. From a technology standpoint, the Clinical Quality Scorecard effort has automated processes that now enable certain components of data to be updated on a nightly, weekly, monthly, or quarterly basis depending on availability. The project has also provided a template that can be replicated to more rapidly roll out other BI-related dashboard and scorecard solutions to all areas of the organization. "Our biggest win so far is our delivery mechanism," says Kevin Kellogg, Director of Data Warehousing at Denver Health. "Whether you are a director of service or a practitioner, you can now use the Scorecard. With a couple of clicks, you can see the trend graph you need instead of scanning through a spreadsheet full of numbers. The tools we have created also give us the ability to easily see where the issues and trends are, and find the differentials between systems and processes so we can streamline processes and facilitate best practices." Considerable time was spent interviewing various members of Denver Health's diversified staff to get the facts, and learn what metrics and key performance indicators (KPIs) needed to be displayed, and how they should be defined to build the proper framework. They also needed to build in dashboard flexibility so that users could easily manipulate the data as required. The popularity of the Clinical Quality Scorecard initiative has generated a significant number of project requests. To help ensure that all work is accurately prioritized during the continued roll out, Denver Health utilizes a delta team approach with clinical, financial, and technology representation. This approach, combined with the ability to reuse templates and frameworks, enables Denver Heath to get the benefits of the enterprise data warehouse out to more parts of the institution sooner, and with greater effectiveness. While other healthcare organizations may rely on the reporting functionality supported by data warehouses tied to their core systems, Denver Health has taken it a step further. The Denver Health team didn't want to just build an enterprise data warehouse and continue to generate static reports. They wanted to build tools to enable their users to interact with the data and answer their own questions. They wanted to build a system that could give the staff comprehensive monitoring capabilities that would show them where to make changes and place their efforts for greatest positive impact. By creating a BI tool that enables users to cross-correlate and fully leverage information, Denver Health has tapped into a powerful and compelling way to better support the organization and the patients who rely on it. The integrated healthcare model at Denver Health represents a microcosm for national healthcare in that it is much more than just a single hospital, but rather an entire health system. The Clinical Quality Scorecard solution serves as yet another example of advanced technology that can be leveraged to greatly improve patient care and outcomes, while simultaneously helping to simplify administration and contain escalating costs.


Hospital:

Edward Hospital

CIO name:

Bobbie Byrne

Project:

Text Click Call

Timeline:

Less than a year

Budget:

$0/budget neutral/no dedicated budget

Team:

1- 10

Departments:

ED

Overview:

Background: Edward Hospital has two Emergency Department locations located about 12 miles apart, Naperville IL to Plainfield IL. Naperville has an Adult Emergency Department and a Pediatric Emergency Department. Plainfield is a much newer facility and only became a full Emergency Department a year ago. About 30 percent of the Edward Hospital service area lives either in between the two facilities or within a 15 drive of either facility. The wait times at both Edward facilities are typically very short, often less than 10 minutes from the arrival of the patient to being seen in a room by a clinician. The quality of the patient experience is very good in both, with very high Press Ganey patient satisfaction scores. Edward Plainfield had the highest overall score of more than 1,000 hospital ERs in the Press Ganey database for the survey conducted between January 1 and March 31, 2010. The challenge was to balance volumes and wait times between the two locations as well as indicate the expected wait time for the three sites of care: Naperville Pediatric, Naperville Adult and Plainfield ED. Patients could then choose which site to receive care and to understand the expected wait time. Project Details: Patients currently have three ways to access the ED wait times. They can text to number 41411 ERWAIT and they will receive a text message back with the current wait times. They can call 630-527-5969 and listen to a message or they can click on www.edward.org to see the wait times. Clicking to edward.org also delivers information on when to receive emergency care and the locations of urgent care facilities that might meet their needs. The ER wait times are the average time it takes for a patient to begin treatment. We refer to this as our "door to treatment" time. It is the average time from when a patient arrives and checks-in at our ER to the time when they are placed in a room and treatment begins. The times are updated every 15 minutes based on actual times from the preceding 30 minutes. Edward uses Meditech Magic in the Emergency Department. The time calculation is performed from the Magic ED Tracker Board. Both locations are tracked separately, one for Naperville ED and one for the Plainfield ED. The statistics are generated every 15 minutes for the preceding 30 minute period of time for patients who were assigned a Room during that 30 minute span. The turnaround time between the patient's arrival and patient's room assignment is captured and averaged across the number of patients in the population for that 15 minute interval. For each location, the Pediatric ED and Main ED are tracked separately, based on patient age. This is because in overflow situations they may place an adult in a pediatric bed and skew the true wait times. This data is then moved through a file transfer protocol (FTP) from Meditech to a database server. An active server page then queries the database and displays the times on Edward.org, text back and on the recorded phone. A technical specification drawing is available.

Results:

Since the capability was launched in March, 2010, patient response has been enthusiastic both in the comments received from patients and in actual usage of the information. In the first 6 months it was available, there have been 4780 text requests from 1892 phones and 732 call-ins from 532 phones. The ED wait times are posted on the front page of Edward.org which gets 57,000 visits per month. Of those visitors, 9529 individuals have clicked through on the ED wait time button for more information. For those that present for care in the Naperville EDs, average of 2 percent of patients claimed to have used the service. For the Plainfield ED, a much higher 13 percent of patients used the service. Volume has grown in the Plainfield ED over the same time period. Wait times continue to be low and patient satisfaction continues to be high. It is expected that there is some additional volume into the organization by patients who see the billboards and assume that our ED wait times are reasonable since we are advertising this capability. There is an iPhone app available for internal use with the same functionality. Application to post it on the Apple app store is pending.


Hospital:

Fletcher Allen Health Care

CIO name:

Charles Podesta

Project:

Our Journey: Stage 3 to Stage 6 to Meaningful Use and Beyond

Timeline:

1-2 years

Budget:

More than $5 million

Team:

More than 50

Departments:

1 or More Clinical Departments, Finance, ED, Pediatrics, Ambulatory, ICU, OR/Perioperative, Quality, Med/Surg, NICU, Supply Chain/Materials Management , Revenue Cycle Management

Overview:

Fletcher Allen Health Care is an academic medical center in Burlington, Vermont with 562 licensed beds (excluding nursery) (419 staffed), 2,166 births, 48,791 inpatient and hospital-outpatient admissions, 58,805 emergency department visits, Employ 450 Physicians and 250 Midlevel providers, Ambulatory: 118 departments with 80 outreach sites, annual visits 875,000, Ambulatory users: 1,250 In the summer of 2007, we received certificate of need approval from the Banking, Insurance, Securities and Health Care Administration (BISCHA) in the state of Vermont to pursue the implementation of an integrated electronic health record at Fletcher Allen Health Care in Burlington, VT. Under the leadership of our COO, we began a process of choosing a vendor with the goal of a signed contract by the end of the calendar year. We received bids from 6 EHR vendors; narrowed the pool to 4 based on specific criteria set by the senior leadership team and then invited these four to demonstrate their systems to the entire organization over the course of a two week period. More than 4000 employees participated in the review process and graded each vendor based on their ability to care for a patient across predetermined clinical scenarios. In the final analysis, we choose Epic systems out of Verona, Wisconsin. Through an internal naming contest we personalized our EHR and called it PRISM (Patient Record and Information System Management) and thus began the journey for the PRISM Project. At the time Fletcher Allen was a Stage 3 facility as measured by HIMSS EMR Adoption Methodology. During the fall of 2007, we began our process of determining clinical transformation opportunities under the leadership of the Clinical Architect as well as a large recruitment effort to hire the team members we would need for our rapid implementation. Concurrently, we initiated a Benefits Realization Team under the leadership of the VP for Quality to predetermine how we would measure the benefits of the electronic health record once it had been implemented. These measurements would also be data that we would report to BISCHA on an ongoing basis. We invested considerable planning around governance structure to support a rapid pace of implementation. Hiring for the team leads was complete by December 2007 and they then began hiring staff to begin in early 2008. The implementation team consisted of more than 40 fulltime staff with more than 50 percent of these coming from clinical areas across the organization (Nurses, Respiratory Therapists, Pharmacists, and Clinical Nutritionists). The organizational kickoff occurred in March 2008, with a planned Phase 1 Go Live for June 6, 2009. Phase 1 was a big bang plan to go live in all inpatient areas (including the ED and critical care units) with all inpatient functionality including CPOE, clinical documentation, and pharmacy as well as an enterprise clinical data repository, HIM functionality, clinical decision support, and document management system. Phase 1 was completed in 15 months and went live on June 6, 2009 as planned. Phase 2 included advanced clinical documentation and a new data warehouse. Phase 3 included all the ambulatory sites, MyChart and BEACON Oncology. In actuality, we went live with the pharmacy application in May 2009 and then the remainder of the inpatient functionality on June 6, 2009 as planned. Phase 2 completed in Nov 2009 and Phase 3 is completed as of Dec. 15, 2010. Based on our initial request to BISCHA, we completed the project ahead of schedule and within budget.

Results:

We believe we are worthy for recognition in two areas, accelerated implementation methodology and benefits achieved. First off we had the right scope, resources and timelines. History shows that most large projects fail at the beginning due to inadequacy in one or more of the three pre-requisites. Next we aligned the project with operations and not Information Services. We wanted to make sure the organization understood that this was a clinical transformation initiative not an IT project. As you can imagine this choice in and of it presents many cultural hurdles. The team made 122 clinical transformation improvements which included everything from admissions through discharge workflows. We made sure that we had a simplified governance process consisting of three working committees that reported to an executive committee. In all cases issues that came to the executive committee were dealt with in one meeting. Physician leadership and training were crucial to our success. The medical staff voted to change the bylaws to require physicians to use the EHR to be credentialed at Fletcher Allen. For go-live support we took an elbow to elbow approach. Lastly we did not let hardware or other technology decisions get in the way of success. Our goal was EHR use and adoption at the point of care. To this end we installed an overabundance of mobile computing and in-room devices along with implementing a facility-wide wireless network. Lastly, sixty days prior to go-live we reorganized the IS department structure and introduced a 7X24 Service Center to better support the transition to production support. We went into our implementation with a very clear plan of where we expected our EHR to have an impact and we have already begun to realize these benefits. Indicators are measured on a monthly basis and form the basis of our ongoing efforts to enhance and optimize PRISM for our patients and our end-users. So far we have maintain a 96 percent CPOE utilization of all orders including medications. A drop in cost per adjusted discharge and reductions in lab tests per inpatient admission and chart delinquency has been achieved. We've also seen a 60 percent decrease in near-miss medication events and a 25 percent reduction in chart pulls. This effort has resulted in our HIMSS EMR adoption ranking going from Stage 3 to Stage 6 in 24 months. We planned to apply for Stage 7 in summer of 2011 and Meaningful Use in 1st quarter of 2011. Now that PRISM is fully deployed in all our owned practices, more than 50 percent of the Vermont population now has an EHR. Our efforts in the months and years ahead will focus on optimization and efforts beyond our owned practices and other hospitals in the state of Vermont we are calling PRISM Regional. In conjunction with our state's healthcare information exchange (HIE), PRISM Regional is a venture that will allow us to make PRISM available in other Vermont hospitals and private practices. Many patients who come to Fletcher Allen Health Care from outside of Chittenden County often have their primary and non-emergency care delivered in a local community hospitals or practices. The opportunity to provide Vermonters with an EHR that is accessible across a variety of hospitals and other clinical care settings will bring tremendous clinical benefit as our patients transfer from one facility to another based on the acuity of their health care needs. The commitment and dedication our senior leadership has had on a successful PRISM implementation are remarkable. As an organization, our No. 1 goal for 2009 was to successfully go live in the inpatient arena and, for 2010, to successfully rollout in about 100 ambulatory sites. We have been unwavering in achieving our goals. As an organization, we planned for a dedicated implementation team that included strong clinical leaders from across the organization. We said this project was a clinical project Ã.?" and our structure to this day continues to send the same message to our staff. It is also noteworthy that there has been essentially no staff turnover on the project team throughout our project. We believe this speaks to the quality of our processes and PRISM leadership team. Meetings with the project team include an IV pole with a hospital gown hanging on the hook. The message is this is the patient in the room; the expectation is that each decision we make is in the best interest of the patient first; the belief is that if we always focus on the patient, everything else will follow. So far, it seems to be working really well!


Hospital:

HealthInfoNet

CIO name:

Devore Culver

Project:

Maine's Health Information Exchange

Timeline:

2-4 years

Budget:

More than $5 million

Team:

1- 10

Departments:

1 or More Clinical Departments

Overview:

Long before HITECH, the stimulus package or the health care reform law passed, HealthInfoNet was quietly building the nation's most advanced statewide health information exchange. HealthInfoNet, incorporated in 2006, is a private, independent nonprofit organization based in Portland, Maine. It operates Maine's statewide health information exchange (HIE), arguably the most comprehensive clinically based exchange in the country. HealthInfoNet is organized as a public-private partnership and funded by a mixture of foundations, healthcare providers, state government, and federal grants. HealthInfoNet was developed to promote and sustain an integrated and reliable health information exchange, dedicated to delivering rapid access to patient health information across points of care. HealthInfoNet was founded to enable healthcare organizations to: • Improve patient safety, • Enhance quality of care, • Increase clinical and administrative efficiency, • Reduce duplication of services, • Better identify threats to public health and, • Expand consumers' access to their personal healthcare information. The HealthInfoNet exchange system was built as a centralized clinical repository and provides a unified view of all healthcare information systems to authorized clinical users. The integration engine is responsible for processing messages from source systems, ensuring the format of messages are correct, standardizing clinical content across corporately unaligned provider organizations and ensuring reliable delivery of information to the exchange. HealthInfoNet's HIE includes the following information: • Patient identifiers and demographics • Encounter history • Laboratory results • Radiology reports • Patient consent management • Adverse reaction/allergies • Medication history • Diagnosis/conditions/problems • Dictated/transcribed documents HealthInfoNet decided to start with an 18-month demonstration phase to test the technical infrastructure, and equally as important, to monitor how providers were using the system in hospitals and physician offices across Maine. The organization tested implementation methodologies and confirmed the technical feasibility of delivering a statewide HIE, validated usability and integration into the clinical workflow of providers, and determined the initial impact on health delivery costs, patient safety and quality. Many of the providers who used the system provided examples where tests were avoided, time saved and patient safety enhanced. Also, the existence of a robust health information exchange put the City of Bangor and Eastern Maine Healthcare's application over the top to become one of seventeen of the Office of the National Coordinator's Beacon Communities. HealthInfoNet is now working to connect all Beacon participants to the HIE as well as build a secure messaging infrastructure for the greater Bangor medical community. And now that the HealthInfoNet project has proven its value, it is moving into statewide expansion mode. Demonstration participants already make up 50 percent of all hospital, emergency department and ambulatory visits, and in 2011 HealthInfoNet expects to partner with an additional 12 healthcare organizations including hospitals and ambulatory care sites. The organizations goal is to have as close to 100 percent of all providers in Maine connected by 2015. To date it has more than 1,000 clinical users and more than 800,000 patients' information in its repository. In addition to hospitals, HealthInfoNet links the Maine CDC's statewide public health information system with the HIE to automate the laboratory reporting requirements mandated by Maine law for disease outbreak management purposes. To include medication profiles in the HIE, HealthInfoNet connects to Dr. First which provides data from a number of different sources, most recently state Medicaid prescription information. To keep patient information private and secure, HealthInfoNet follows the highest information security standards available. Information is sent over a private network when exchanged between providers and HealthInfoNet. Only authorized health care providers with proper identification and passwords can use the system and it keeps track of everyone who views a patient's record, including what parts they look at. HealthInfoNet also believes patients should have the ability to opt-out if they choose. Consumers can opt-out online, over the phone or by mail. For the vast majority of people who choose to have their information remain in the exchange, HealthInfoNet is developing a secure consumer portal, which will provide them access to their health information online. This will also provide consumers with tools to better engage in and improve their health as well as allow them to control who sees their information in the HIE, right down to the individual provider level. If HealthInfoNet is successful in launching this next year as planned, it will be the first of its kind in the nation.

Results:

What is most worthy of recognition is the project itself. While the technology used to build the HIE is not unique, the application of that technology is. Usually the technologies employed would be set up within a single enterprise, but HealthInfoNet chose to use them to merge data from multiple sources. And unlike many of its counterparts around the country, HealthInfoNet chose to use a best of breed strategy in its technology vendor selection and infrastructure development. It would have been easy to fall in line with a single vendor solution for all HIE needs, but HealthInfoNet chose to bring together a number of vendors to develop a unique HIE model. This model provided more flexibility and gave HealthInfoNet an easy platform to expand upon. And in addition to traditional HIE services, HealthInfoNet has positioned itself to offer data analytics and tools to support implementation of medical homes and accountable care organizations. It is also standardizing the clinical data within the exchange and translating it into standard terms, something other HIEs do not currently offer their participants. In addition, there are a few more aspects of HealthInfoNet's development particularly worth mentioning. These aspects may be the primary reasons Maine now leads the nation in the development of a statewide HIE, and these reasons have nothing to do with technology at all. Maine's health information exchange has been so successful because of culture, communications and relationships. First, while in many other states, fierce competition among health care systems has hindered HIE efforts, Maine's medical community working in collaboration through HealthInfoNet, has made the pledge not to compete on patient data. Patient information in Maine is seen as a resource that follows the patient, regardless of what health care facility they use. Second, HealthInfoNet has kept in close communication with organizations and individuals like the Maine Health Access Foundation, which provided start up money to the organization, the Maine Governor's Office and Legislature, which appropriated $1.7 million in funding, and Maine's congressional delegation, who helped get funding for HIEs included in the stimulus package (Maine's two Republican Senators cast two of the deciding votes). Third, the man chosen to run the organization, Devore Culver was the CIO of Eastern Maine Health Care systems for 18 years and widely respected in state and national health IT circles. Devore brought to HealthInfoNet not only many years of experience but relationships that without which the organization would have struggled to gain credibility, trust, and funding. As it grows, HealthInfoNet will continue to serve as a model for the effective use of technologies, the value of collaboration, and the innovation required to bring meaningful and lasting transformation to our nation's healthcare system.


Hospital:

Memorial Hospital and Health System

CIO name:

Steve Huffman

Project:

Telemedicine for High Risk OB

Timeline:

1-2 years

Budget:

$100,000-250,000

Team:

11-20

Departments:

1 or More Clinical Departments, Finance

Overview:

This project began in June of 2009 as a Skunkworks endeavor with a team of 5 IT professionals. These internal thought leaders were pulled together and given a summary of the Intel Health Guide and were challenged with creating a unique use within the organization. The group was given 30 days to report back to the CIO with their findings. At the end of the 30 days, the group had done research on how telemedicine was currently being used, and came up with their own model, completely different from anything that was being done in the industry. When the Skunkworks team began discussions on this product, they had three main objectives for the deployment. The first was to find a way to use the Health Guide to improve outcomes for mother and baby. The second was to identify a way to incorporate the data that was being obtained from the use of the Health Guide and integrate it with the EMR already being used by physicians of the Health System. The third was to utilize a cost avoidance model to prevent the mothers from needing to go to the hospital as much for emergent issues while shortening the length of stay when they were admitted. This naturally led into once the baby was delivered, they would need to spend less time in NICU for being preterm. This was a vulnerable patient population that the group thought could be impacted positively by having much healthier outcomes. During the 30 day innovation period, the Skunkworks team had created a financial model, physician, patient, and IT workflows. They created an experience to the patient that was uniquely "memorialized." A presentation was made by the team to executives at Intel who were impressed that the work this team had done in a limited amount of time had far surpassed the work that other large health systems had done when they evaluated the Health Guide. The team then presented their proposal for a pilot to the Health System executive team who agreed that this was a project that should be moved forward with. A health system owned high risk obstetrics practice was approached about their interest in participating in the project. They agreed to provide the patient population, and then project was slated to begin. The University of Notre Dame was invited to participate in the project from a research perspective to validate the value telemedicine brings to high risk obstetrics. Approval was granted from the IRB and training began with the team. The head nurse at Memorial Maternal Fetal Medicine took the lead role in building clinical protocols and IT was trained on the deployment and imaging of the Health Guides. Soon after, the first device was placed with a mother who was termed a "brittle diabetic." Seventeen subsequent devices have gone out to mothers who are high risk in nature. The project continues today and is preparing to deploy in additional practices. Memorial is excited to bring such a unique experience to our patients and looks forward to continuing to improve outcomes. These goals were achieved during the course of the first pilot and the study continues with the University of Notre Dame.

Results:

Memorial approached a home monitoring pilot in a drastically different manner than other healthcare organizations. We evaluated the chronic diseases that are typically monitored but realized that a younger more technologically engaged population with a limited disease state might combine to form a better pilot. In working with a number of physicians the potential of high risk obstetrics became an interesting fit. The disease state included a population of younger women whose technology prowess was heightened and also provided a limited timeframe for the disease state. A typical high risk obstetric patient is diagnosed around 20 weeks with gestational diabetes and/or risk for pre-eclampsia. For the patient this is an unsettling diagnosis, putting her and the fetus at risk. The patient is given a logbook and asked to monitor blood pressure and blood sugar. During weekly OB visits the logbook is discussed. From our evaluation and from the interviews we conducted, patients had heightened concern during their monitoring and logging of measurements. There was also concern they were disconnected from care when questions arose about increases in blood pressure, or decreases in fetal kicks. While concerns were discussed at the weekly visit, there was not a comfort built around the process. From a physician's perspective the overabundance of additional data on a real time basis for high risk OB patients did not seem to provide a consensus for a modified treatment plan. There is little that can be done for a pre-eclamptic patient whose monitored values exceed safe limits other than immediately rush to the ER. While no significant medical intervention can be made with a pre-eclampic patient, a monitored situation can lead to lifestyle discussions that can impact potential hospitalizations. An example from our patient interviews was if a patient who is being monitored experiences a slightly increased blood pressure over the course of multiple days, a call can be placed from the nurse to inquire about lifestyle changes. In another example, a mother can be placed on immediate bed rest in advance of a weekly visit when her blood pressure indicates a slight trending which does not immediately require hospitalization. Patients enrolled in the pilot receive the device in a kit ready for take home with simplistic instructions for set up. The training is performed by the head nurse at the physician's office prior to taking the device home. The training encompasses how to use device and peripherals. The nurse then monitors the patients in the Intel application and initiates a weekly web conference to ensure that the patient is following care guidelines and answer any questions, outside of the weekly OB visit. The data that is collected is also automatically uploaded to the Memorial physician's electronic medical record (EMR). This allows the physician to review all home monitoring results at the time of the weekly visit, eliminating the need for the patient to utilize the logbook. It also increases the accuracy of the data. In a November 4th 2006 study published in the Annals of Internal Medicine that outlined the benefit of telemedicine impact on high risk OB patients it was identified that there was a $5,439 cost savings related to monitoring this patient cohort from home. In our analysis there is potential to increase the savings related to high risk OB as the cost of the device and monitoring multiple patients via a combined management tool increases efficiency compared to the 2006 survey. It is our belief that the Memorial's pilot has achieved similar results. This reduction clearly benefits a payer committee that is interested in seeing a full term delivery with minimal complications to both infant and mother. The commitment from all individuals involved in the pilot has lead to the outcome of multiple healthy mothers and babies. While we have an abundance of positive stories to share, one in particular stands out. The first mother to participate in the pilot as we mentioned earlier, was a brittle diabetic. This means her sugars hit rock bottom, particularly when she was sleeping. She was sending her data to the nurse on a daily basis, and one day no measurements crossed. The nurse was alarmed because this was unusual for the patient. She called her home, work, and finally her husband. Once speaking with the husband, he went to check on his wife only to find she needed to be rushed to the ER. Upon returning home, the patient continued to be monitored with the pilot and eventually delivered a full term baby girl and had a normal hospital stay of three days each. There is no need to mention the extent to which this outcome could have been different. In addition to alerting the father, the data received with the Health Guide allowed the physician to see trends in his patient's glucose readings and manage his patient better with the accurate data provided through the use of telemedicine.


Hospital:

Muir Medical Group IPA Inc.

CIO name:

Tina Buop

Project:

Enterprise Chart

Timeline:

2-4 years

Budget:

More than $5 million

Team:

11-20

Departments:

1 or More Clinical Departments, Finance, Ambulatory, Quality, Med/Surg

Overview:

Compliance with meaningful use requirements does not automatically occur with the implementation of an electronic health record (EHR). Rather, truly meaningful use of an EHR requires comprehensive adoption of the technology. Adoption of the technology, in turn, requires managing and organizing data in ways that meet: 1) clinical, 2) reporting, and 3) privacy objectives. In addition to assessing the EHR in terms of its functionality, Muir Medical Group IPA, Inc., (MMG) has realized the potential of the EHR to become a meaningful point-of-care tool, as well as an aid for comprehensive population health management. To that end, in October 2009, MMG implemented enterprise medical charts—creating a single patient chart accessible by MMG providers. As an IPA, however, each of MMG's San Francisco Bay-area practices is independently owned. Consequently, the record had to be structured to allow 105 physicians practicing in 18 different specialties to collaborate in the best interest of patient care, yet without compromising privacy and security needs. (Most of the practices, incidentally, converted to the enterprise chart from paper patient records.) Knowing that physician involvement in the decision-making process would be vital to the project's success, MMG turned to its physician-led Executive Committee to establish an overall strategic plan for the enterprise chart. One of the first steps toward organizing it to meet the clinical and reporting needs of each specialty practice was to perform a gap analysis. Focused initially on diabetes, MMG evaluated the disease management templates and the diabetes information already captured in the NextGen Ambulatory EHR used by all electronically connected IPA practices. While ensuring the templates remained clinically relevant and enhanced workflow, this data was then compared against diabetes measures necessary to report successfully for HEDIS, pay-for-performance programs, and Medicare's Physician Quality Reporting Initiative (PQRI). Once its diabetes measurement activities were underway, MMG used reporting tools within the EHR to identify whether its physicians were consistently using the diabetes management templates. Meetings with non-adopters yielded additional efforts needed for training and adoption of the workflows. MMG additionally evaluated the accuracy of its reports. It discovered, for instance, that a simple check-box in the EHR was not being used properly and was affecting reports regarding the care of diabetic patients. Subsequent education fixed the problem; providers can now accurately gauge their performance on diabetes care measures. Two physician committees also have become integral to MMG's configuration of templates, reports, and workflows designed to improve data collection: • Clinical Integration Executive Steering Committee—The goal of this group is to standardize care for common chronic conditions using clinical decision support tools embedded in the multiple EHRs across the health system. This effort is lead by Richard Fraioli, MD, a medical director at the John Muir Physician Network who works hard to build consensus among the various stakeholders. • EHR Physician Advisory Committee—Members of this committee propose and vote on various chart enhancements during quarterly meetings. The multi-specialty perspectives brought forth in this committee have greatly enhanced overall workflow. Furthermore, MMG brought its physicians together during an enterprise-wide user group meeting to address its privacy and security issues. They opted collectively to control privacy and security settings at the enterprise level. The IPA creates or restricts access based on user roles. By combining multiple layers of physician involvement with clinical data gap analysis, MMG has successfully brought disparate practices together onto a single, enterprise patient chart to promote higher quality, more efficient patient care.

Results:

Muir Medical Group IPA, Inc. (MMG) uses a four-staged approach to ensure that its EHR integration supports those clinical objectives most meaningful to patient outcomes: • Commit—The first stage entails commitment by all practices to EHR implementation, adoption and support efforts. • Improve—In the second stage, physician-led lead clinical objectives are defined, evidence-based practice guidelines are set and compliance is measured. Goals include creating common workflow and data points for designated disease states, and identifying common ground for measurement and compliance activities. • Measure—The third stage employs clinical measurement and adoption measurement to enable the goals of documenting the use of evidence-based guidelines, and observing changes in patient care. • Advance—Measurement and care improvement actions are used to foster movement toward e-community, clinical integration, meaningful use, patient-centered medical home (PCMH) and accountable care organization (ACO) goals. Common provider workflows, templates, and reporting efforts based on discrete data collected within a single repository all are designed to center on advancing patient care quality. This approach, together with clinical data gap analysis and thorough examination of potential workflow improvements, has helped MMG detect disparities and refine workflows for each of its independent practices. For instance, training has ensured that HgA1c levels for all diabetic patients are captured via an EHR template—even if those lab values arrive on paper forms. The consistent workflow across all MMG practices means such valuable clinical patient data will not be lost. As a result, MMG is able to generate reports showing individual patient outcomes, and proactively call patients to encourage compliance with treatment plans. One patient in the program, for example, has now reduced hemoglobin A1c levels from 10.5 to 6.8. Quarterly compliance reports on diabetic measures, as well as mammography, Pap smear, and pediatric immunization rates now arm each practice with the data needed to engage patients in preventive care. Because data is gathered within each provider's normal workflow, it takes little extra effort on the part of MMG physicians to provide better patient care. Through a combination of end-user training, reporting, and target adoption rates, MMG has begun to raise the quality care bar for its patients. In addition, the use of a single chart across all IPA practices ensures all providers have a complete, up-to-date patient record. The enterprise chart has sparked a subtle shift in the mindset of providers toward continuum-wide, accountable care. Consider the fact that most patients referred from one provider to another tend to assume that the both physicians are equally informed about their health status. While not the case at most practices, the enterprise chart allows MMG physicians to live up to their patients' expectations. The communal aspect of the enterprise chart is powerful. MMG has found that a single chart fosters more complete documentation, because physicians understand that their notes will be used by all providers—not just themselves. It helps enable truly effective communication among providers, rather than more simplistic data management.


Hospital:

Nebraska Health Information Initiative (NeHII)

CIO name:

Deborah Bass

Project:

NeHII

Timeline:

1-2 years

Budget:

$1 million-$5million

Team:

1- 10

Departments:

1 or More Clinical Departments, Finance, ED, Pediatrics, Ambulatory, ICU, OR/Perioperative, Quality, Med/Surg, NICU, Supply Chain/Materials Management , Revenue Cycle Management

Overview:

The Nebraska Health Information Initiative (NeHII) is a statewide, web-based, health information exchange sponsored by Nebraska physicians, hospitals/clinics, health insurance companies and other stakeholders who share health information for treatment, payment and public health purposes to address the requirements of meaningful use. NeHII provides electronic medical record (EMR) solutions to physicians who have not implemented EMR in their office, as well as ePrescribing functionality to meet Meaningful Use requirements. The NeHII effort began early in 2005 when several individuals representing health organizations gathered to discuss the need to create a statewide health information exchange (HIE) for the betterment of patient care in the state. The exchange would enable physicians statewide to view consolidated patient medical history at the point of care, improving safety and care delivery while reducing duplicate or redundant procedures. Initially, progress was slow. In an effort to accelerate the development of a health information exchange, the initial group contacted individuals from the entire state who represented health organizations. These individuals participated in a two day Decision Accelerator meeting, a strategic planning session that jumpstarted the endeavor to its current state of statewide implementation efforts. Since the Decision Accelerator meeting, the progress of the NeHII has outpaced other regional and state similar activities. NeHII began soliciting, evaluating, and negotiating with leading health information exchange vendors. A Request for Information (RFI) was initiated. From the list of responders, a subsequent Request for Proposal (RFP) was extended to seven selected vendors. These activities were conducted in a way to ensure that vendors met the unique requirements of the initiative. The winning vendor had to demonstrate its technology's ability to exchange clinical messaging, conduct ePrescribing and complete the activities of physician referral electronically across disparate systems. A secondary consideration was the ability of the HIE to integrate with third-party Electronic Medical Records (EMRs), as well as its ability to provide EMR functionality for physicians without this technology. Another significant factor in evaluating prospective partners was to identify one that would become a strategic partner in this initiative. This process led to the selection of an HIE partner, Axolotl, Inc. On March 28, 2009, the interim board of directors of NeHII took a major step in corporate governance, approving the Articles of Incorporation and Bylaws and forming NeHII, Inc. This major step included the election of the corporation's first permanent Board of Directors, who would lead the efforts of the collaborative toward its primary goal of improving the level of health care by implementing one of the first statewide HIEs of its kind. The next step in the process was the achievement of obtaining 501(c)(3) status in 2009, granting the Nebraska corporation tax exempt status as a non-profit organization. There are three areas that have contributed tremendously to Nebraska's success in implementing the federal health care initiatives of achieving meaningful use: • Extensive and persistent stakeholder engagement • Physician engagement • Sharing knowledge among states The Executive Director of NeHII worked closely with the NeHII team and project members to ensure key stakeholders were engaged across the state. Members of the NeHII team knocked on doors, developed educational materials and launched community-based consumer education campaigns. They spoke in cities, small towns and across rural Nebraska at Rotary Clubs, State Associations and Chamber of Commerce meetings. In short, no stone was left unturned in the efforts to engage citizens across the state. NeHII was implemented using the most current available standards, and remains committed to conforming to new standards as they are developed. The NeHII team will make every effort to pursue conversations and affirmations from NeHII participants in setting those standards to guarantee the ability of HIEs to operate with the least amount of impact to daily operations. Conversations around solutions to reverse the lack of adoption of EMR technologies by physicians revealed how difficult it is to move forward with interoperability of electronic records without fully engaged physicians. At NeHII, the effort is fortunate to have Dr. Harris Frankel, a respected Omaha practicing, board-certified neurologist, who serves as the NeHII physician visionary. In this capacity, he is able to reach deep within the physician community as a respected leader and as one of their own. On numerous occasions Dr. Frankel's broad spectrum of physician relationships allowed NeHII access to respected physicians who became champions of NeHII and therefore supported interoperability across the healthcare spectrum.

Results:

NeHII is capable of connecting with any certified electronic medical record system using HL7 data sets and provides clinical information from 15 Nebraska hospitals and health systems. Within twenty months from implementation more than 16 percent of Nebraska's primary care physicians are able to view and exchange data through NeHII (some with no Electronic Medical Record in use in their office). A common theme among physicians and health care officials alike is that NeHII is user-friendly, especially as it is available through an Internet browser with broadband connectivity, eliminating the need for complex, costly equipment or IT staff. This has been a major incentive among physicians to sign up for NeHII. NeHII can deliver healthcare technology/applications at no capital cost, other than monthly license fees, which is a major feature for hospitals and physicians in this budget-conscious environment. NeHII also acts as the universal portal and eliminates need for separate individual portals that require development and on-going maintenance and support costs for physicians and payers. This fact alone delivers critical ROI which is an attractive feature to Nebraska Medicaid representatives and CIOs from the various health systems. A key feature in the attractiveness of NeHII is the affordable service fees based on monthly license fees for the technical functionality. Physician license fees range from $20/month to $51.66 for EMR and VHR functionality.. NeHII levels the playing field for providers, regardless of size or location, while automating workflows for improved quality of care which, in turn, reduces errors. A key metric in determining NeHII success at gaining acceptance and confidence from the patient community is NeHII's very low opt-out rate in Nebraska. Opt-out rates have ranged between 1.5 to 2.5 percent since the implementation of NeHII in March 2009 and continue to hold steady at that rate. NeHII's consumer education campaign demonstrated to the public that only health care professionals are allowed to access the systems and patient data. This educational campaign gave patients piece of mind when making the decision to have their records shared across the NeHII framework. The NeHII team has made multiple efforts to make it clear that patient data is safe and personal health information will not be sold. Throughout the implementation and in conversations with patients currently, most consumers are actually frustrated their health data is not more readily accessible by all their health care providers. In fact, NeHII has found that most consumers prefer their doctors have the most current, up-to-date information possible. The NeHII team has gathered valuable lessons learned and continues to share real life success models with those in the early stages of HIE, whether they are national, state, regional and/or local stakeholders. The NeHII privacy and security policies have been shared with thirteen other states at no cost with the simple stipulation that if improvements or enhancements are made by other states, they be shared with NeHII as well. Among the key impacts NeHII has had in sharing best practices with other organizations are: • No two HIEs are alike. It is critical for HIE leaders to understand their origins and roots in health care to be successful. • HIE is not simply a technology solution, but requires a variety of business and entrepreneurial skills. A diverse group of stakeholders, sharing a common purpose to improve patient safety and care needs to be a cornerstone of any HIE plan. • It is not necessary for a project like HIE to be deployed all at once. Users of HIE may customize and scale their process and timeline and deployments can be incremental. • Good planning and experience eliminate risk. • A well defined implementation, training and support plan and approach require small teams and minimal staff time. This approach is key to limit the impact on the day-to-day operations of the physician office. The table below is an accurate record of transactions that are captured and shared weekly with NeHII team members. Number of clients: Number of clients in the Master Patient Index = 1,900,000 Number of Nebraska clients in the Master Patient Index = 1,300,000 Total Patients that have Opted Out = 45,000 Total Patients Opting back in = 3,200 Hospital information: Number of hospitals participating = 17 percent of hospitals participating = 16 Percent of hospital beds covered = 44 The impact of these statistics has resulted in the following: • Reduced cost of health information data requests • Cost of duplicating the data • Forwarding the records • Maintaining security • Reduced labor expense and liability • Data integrity, the HIE identifies corrupt data sooner.


Hospital:

Southeast Texas Medical Associates LLP

CIO name:

James L. Holly, MD, CEO

Project:

SETMA Model of Care

Timeline:

2-4 years

Budget:

$1 million-$5million

Team:

1- 10

Departments:

1 or More Clinical Departments

Overview:

Since 1998, SETMA has been involved in the transformation of healthcare delivery through an electronic health record (EHR). Early in that process, we realized that EHR was too expensive and too difficult if all we were to achieve in the process was an electronic methodology for documenting a patient encounter. As a result, in 1999, we adopted the goal of electronic patient management (EPM), which we define as the ability to leverage the power of EHR to improve healthcare processes and outcomes. SETMA has thirty healthcare providers in three clinical and seven non-clinical locations. SETMA uses the NextGen EHR platform in a totally customized version. SETMA has achieved the following official recognitions: 1. Become the first, multi-specialty affiliate of Joslin Diabetes Center which is affiliated with Harvard Medical School in Boston, Massachusetts. 2. NCQA recognition as a Tier III Patient-Centered Medical Home for each of our clinics. 3. NCQA recognition in their Diabetes Recognition Program for all three clinics. 4. Accreditation Association for Ambulatory Healthcare (AAAHC) accreditation for Ambulatory Care. 5. AAAHC accreditation for Medical Home. SETMA is currently engaged in expanding our electronic tools which will further our mission of providing coordinated, integrated, evidenced-based care to the population we serve, which is the most vulnerable in our community. We agree with the thrust of the proposal regarding the need to investigate more fully with your Center researchers how we can optimize the performance of both the EHR and patient-center care initiatives. The Future of Healthcare Efforts to reform healthcare may fail unless they employ three elements upon which SETMA depends in its transformative efforts: 1. The content and standards of healthcare delivery must be evidenced-based medicine. 2. The structure and organization of healthcare delivery must be patient-centered medical home. 3. The payment methodology of healthcare delivery must be that of "Medicare Advantage." At the core of these principles is SETMA's belief and practice that one or two quality metrics will have little impact upon the processes and outcomes of healthcare delivery. SETMA employs two definitions in this analysis: A cluster is seven or more quality metrics for a single condition, i.e., diabetes, hypertension, etc. A galaxy is multiple clusters for the same patient, i.e., diabetes, hypertension, lipids, CHF, etc. SETMA believes that Fulfilling a single or a few quality metrics does not change outcomes, but fulfilling "clusters " and" galaxies" of metrics at the point-of-care can and will change outcomes. The following illustrates the principle of a "cluster" of quality metrics. A single patient, at a single visit, for a single condition, will have eight or more quality metrics fulfilled for a condition, which WILL change the outcome of that patient's treatment. The following illustrates a "galaxy" of quality metrics. A single patient, at a single visit, may have as many as 60 or more quality metrics fulfilled in his/her care which WILL change the quality of outcomes. SETMA's model of care is based on these three principles and these concepts of "clusters" and "galaxies" of quality metrics. We are achieving significant results with them. Contrasting SETMA's "model of care" with the other organizations participating in the Center's study will allow SETMA and the Center to understand the processes of healthcare transformation more fully. The SETMA Model of Care • The tracking by each provider on each patient of their performance on preventive care, screening care and quality standards for acute and chronic care. SETMA's design is such that tracking occurs simultaneously with the performing of these services by the entire healthcare team, including the personal provider, nurse, clerk, management, etc. • The auditing of performance on the same standards either of the entire practice, of each individual clinic, and of each provider on a population, or of a panel of patients. SETMA believes that this is the piece missing from most healthcare programs. • The statistical analyzing of the above audit-performance in order to measure improvement by practice, by clinic or by provider. This includes analysis for ethnic disparities, and other discriminators such as age, gender, payer class, socio-economic groupings, education, frequency of visit, frequency of testing, etc. This allows SETMA to look for leverage points through which SETMA can improve the care we provider. • The public reporting by provider of performance on hundreds of quality measures. This places pressure on all providers to improve, and it allows patients to know what is expected of them. The disease management tool plans of care and the medical home coordination document summaries a patient's state of care and encourages them to ask their provider for any preventive or screening care which has not been provided. Any such services which are not completed are clearly identified for the patient. We believe this is the best way to overcome provider and patient "treatment inertia." • The design of Quality Assessment and Permanence Improvement (QAPI) Initiatives" this year SETMA's initiatives involve the elimination of all ethnic diversities of care in diabetes, hypertension and dyslipidemia. Also, we have designed a program for reducing preventable readmissions to the hospital. We have completed a COGNOS Report which allows us to analyze our hospital care carefully. The SETMA Model Detailed The SETMA Model Step I: Provider Performance Tracking The Physician Consortium for Performance Improvement (PCPI) is an organization created by the AMA, CMS, Institute of Medicine and others to develop measurement sets for quality assessment. The intent is to allow healthcare providers to evaluate their own performance at the time they are seeing a patient. SETMA is tracking a number of these measurement sets including: Chronic Stable Angina, Congestive Heart Failure, Diabetes, Hypertension, and Chronic Renal Disease Stages IV through ESRD, Adult Weight Management, and Care Transitions. Others will be added overtime. The details of these measurement sets and SETMA's provider performance on each can be found at www.setma.com under Public Reporting PCPI. In addition to Provider Performance Tracking tools such as those produced by PCPI, the National Quality Foundation (see www.setma.com under Public Reporting NQF), and National Committee for Quality Assurance (see www.setma.com under Public Reporting HEDIS and/or NCQA), SETMA has designed a pre-visit quality measures screening and preventive care tool. This allows a SETMA provider and a patient to quickly and easily assess whether or not the patient has received all of the appropriate preventive health care and the appropriate screening health care which national standards establish as being needed by this patient. The following is the Pre-visit Preventive Screening tool. All measures in black apply to the current patient and are fulfilled. All measures in red apply to the current patient and have not been fulfilled and all measures in grey do not apply to the current patient. If a point of care is missing, it can be fulfilled with the single click of a single button. There are similar tracking tools for all of the quality metrics which SETMA providers track each day. The following is the tool for NQA measures: The providers' compliance with these measures are color coded for quick reference. The "view" button allows the provider to quickly review the content of the metric and to review the patient's results. Passing the Baton While healthcare provider performance is important for excellent care of a patient's health, there are 8,760 hours in a year. A patient who receives an enormous amount of care in a year is in a provider's office or under the provider's direct care less than 60 hours a year. This makes it clear that the patient is responsible for the overwhelming amount of their own care which includes compliance with formal healthcare initiatives and with lifestyle choices which support their health. If responsibility for a patient's healthcare is symbolized by a baton, the healthcare provider carries the baton for .68 percent of the time. That is less than 1 percent of the time. The patient carries the baton 99.22 percent of the time. The coordination of the patient's care between healthcare providers is important but the coordination of the patient's care between the healthcare providers and the patient is imperative. (For more on this concept see: Passing the Baton: Effective Transitions in Healthcare Delivery By James L. Holly, MD Your Life Your Health The Examiner March 12, 2010 at www.setma.com). The following is a direct quote from this article. The emphasis and italics appear in the original: "Often, it is forgotten that the member of the healthcare delivery team who carries the baton for the majority of the time is the patient and/or the family member who is the principal caregiver. If the baton is not effectively transferred to the patient or caregiver, then the patient's care will suffer." The SETMA Model Step 2: Auditing of Provider Performance SETMA's COGNOS Project The creating of quality measures is a complex process. That is why it is important for agencies such as the Ambulatory Care Quality Alliance (AQA), the NCQA, the NQF, the Physician Quality Reporting Initiative (PQRI) and PCPI, among others, to identify, endorse and publish quality metrics. The provider's ability to monitor their own performance and the making of those monitoring results available to the patient is important, but it only allows the provider to know how they have performed on one patient. However, the aggregation of provider performance over his/her entire panel of patients through an auditing tool carries the process of designing the future of healthcare delivery a further and a critical step. The problem with most auditing results, such as HEDIS, is that it is presented to the provider 12 to 18 months after the fact. SETMA believes that "real time" immediate auditing and giving of the audit results to providers can change provider behavior and can overcome "treatment inertia." Auditing of provider performance allows physicians and nurse practitioners to know how they are doing in the care of all of their patients. It allows them to know how they are doing in relationship to their colleagues in their clinic or organization, and also how they are performing in relationship to similar practices and providers around the country. As a result, SETMA has designed auditing tools through the adaptation to healthcare of IBM's business intelligence software, COGNOS. Multiple articles on SETMA's COGNOS Project can be found at www.setma.com under Your Life Your Health and the icon COGNOS. Those discussions will not be repeated here but auditing is an indispensable tool for the improvement of the quality of healthcare performance and for improvement in the design of healthcare delivery. The following are a few examples of the auditing SETMA does of provider performance. Through COGNOS, SETMA is able to display outcomes trending which can show seasonal patterns of care and trending comparing one provider with another. It is also possible to look at differences between the care of patients who are treated to goal and those who are not. Patients can be compared as to socio-economic characteristics, ethnicity, frequency of evaluation by visits and by laboratory analysis, numbers of medication, payer class, cultural, financial and other barriers to care, gender and other differences. This analysis can suggest ways in which to modify care in order to get all patients to goal. Using digital dashboard technology, SETMA analysis provider and practice performance in order to find patterns which can result in improved outcomes practice wide for an entire population of patients. We analyze patient populations by: • Provider Panel • Practice Panel • Financial Class payer • Ethic Group • Socio-economic groups We are able to analyze if there are patterns to explain why one population or one patient is not to goal and others are. WE can look at: • Frequency of visits • Frequency of testing • Number of medications • Change in treatment • Education or not • Many other metrics We are able to present over-time patient results comparing: • Provider to practice • Provider to provider • Provider current to provider over time • Trending of results to see seasonal changes, etc. The SETMA Model Step 3: Analysis of Provider Performance through Statistics Raw data can be misleading. It can cause you to think you are doing a good job when in fact many of your patients are not receiving optimal care. For instance the tracking of your average performance in the treatment of diabetes may obscure the fact that a large percentage of your patients are not getting the care they need. Provider Performance at the point of service is important for the individual patient. Provider Performance over an entire population of patients is important also. However, until you analyze your performance data statistically, a provider will not know how well he or she is doing or how to change to improve the care they are providing.. Each of the statistical measurements which SETMA tracks, the mean, the median, the mode and the standard deviation, tells us something about our performance. And, each measurement helps us design quality improvement initiatives for the future. Of particular, and often, of little known importance is the standard deviation. From 2000 to 2010, SETMA has shown annual improvement in the mean (the average) and the median results for the treatment of diabetes. There has never been a year when we did not improve. Yet, our standard deviations revealed that there were still significant numbers of our patients who are not being treated successfully. Even here, however, we have improved. From 2008 to 2009, SETMA experience a 9.3 percent improvement in standard deviation. Some individual SETMA providers had an improvement of over 16 percent in their standard deviations. Our goal for 2010 is to have another annualized improvement in mean and in median, and also to improve our standard deviation. When our standard deviations are below 1 and as they approach .5, we can be increasingly confident that all of our patients with diabetes are being treated well. An example of a statistical analysis of SETMA's diabetes care in regard to the elimination of ethnic disparities of care is given in the article Eliminating Ethnic Disparities in Diabetes Care Your Life Your Life Your Health The Examiner May 13, 2010, which is posted on our website at www.setma.com. The SETMA Model Step 4: Public Reporting of Provider Performance One of the most insidious problems in healthcare delivery is reported in the medical literature as "treatment inertia." This is caused by the natural inclination of human beings to resist change. Often, when patients' care is not to goal, no change in treatment is made. As a result, one of the auditing elements in SETMA's COGNOS Project is the assessment of whether a treatment change was made when a patient was not treated to goal. Overcoming "treatment inertia" requires the creating of an increased level of discomfort in the healthcare provider and in the patient so that both are more inclined to change their performance. SETMA believes that one of the ways to do this is the pubic reporting of provider performance. That is why we are publishing provider performance by provider name at www.setma.com under Public Reporting. A more complete explanation of SETMA's philosophy and intent in "public reporting" of provider performance can be found in the following articles: • Transforming Healthcare Public Reporting of Provider Performance on Quality Measures Your Life Your Health December 3, 2009; • Patient-centered Medical Home SETMA's COGNOS Project Changing Patient and Provider Behavior Your Life Your Health October 29, 2009. • County Health Rankings Ã.?" Part II Quality of Care What Will Be Gained by Public Reporting Your Life Your Health March 4, 2010 The SETMA Model Step 5: QAPI Quality Assessment and Performance Improvement Quality Improvement Initiatives based on tracking, auditing, statistical analysis and public reporting of provider performance are critical to the transformation of healthcare both as to quality of care and as to cost of care. With the above described data in hand and with the analysis of that data, it is possible to design quality initiatives for future improvement in care. Currently SETMA is designing two major quality initiatives. One is for diabetes. It is an attempt to eliminate the last vestiges of ethnic disparity in the care of diabetes. This will require the use of additional internal resources and attention but it is our intent to do so and to permanently and totally eliminate ethnic disparities. The other is in regard to decreasing avoidable readmissions to the hospital. The details of these two initiatives can be reviewed at www.setma.com : • Designing a Quality Initiative: How? Hospital Re-admissions Your Life Your Health April 22, 2010. • Eliminating Ethnic Disparities in Diabetes Care Your Life Your Life Your Health May 13, 2010 Without a systems approach to healthcare, each of these steps are impossible; certainly, the analysis and transformation of healthcare is impossible. With a systems approach, this logical and sequential process is possible and rewarding for provider and patient. This process has set SETMA on a course for successful and excellent healthcare delivery. Our tracking, auditing, analysis, reporting and design will keep us on that course. SETMA's Model of Care has and is transforming our delivery of healthcare, allowing us to provide cost-effective, excellent care with high patient satisfaction. This Model is evolving and will certainly change over the years as will the quality metrics which are at its core. SETMA's Continuing Efforts to Leverage Electronic Patient Management Tools to Fulfill the Promise of Patient-Centered Medical Home These are too numerous to include in this brief review but four will illustrate this effort. First, SETMA is collaborating with the National Quality Forum and others to identify quality measures in order to perform and then to evaluate the "care transitions" required to maintain quality care between hospital/outpatient, emergency department/community care, clinic/home and others. The following is one example of the process and outcomes metrics in this area of patient-centered care. This is an auditing tool currently being used in the hospital when the patient is discharged. The second, third and fourth of these efforts involved "follow-up call" scheduling: • The day following discharge from the hospital Ã.?" this goes to follow-up call nursing staff in our Care Coordination Department. These calls differ from the "administrative calls' initiated by the hospital which may last for 30 seconds are less. These calls last from 12-30 minutes and involved detailed discussions of patient's needs and conditions. • At a provider-designated time following a clinic visit Ã.?" these calls, scheduled by the provider at the time of care can be for any interval of time (1-60 days or more) and define what the call is for. The result of the call is reported back to the provider. These calls last for 12-30 minutes and additional follow-up calls or visits can be scheduled as needed • A coordination of care call at a clinic visit, telephone contact with a patient, hospital or emergency department visit, etc., a referral document allows for a notice to be sent to the Director of SETMA's Department of Care Coordination when issues exist which will impact the patient's care, such as financial needs, safety issues, adherence to treatment plan, etc. The following is an illustration of these functions. This one relates to Hospital Discharge Follow-up Call. Undergirding all of this is SETMA's commitment to making certain that our patients have access to care and that they can afford that care. As a result, SETMA founded The SETMA Foundation through which care can be obtained for our patients are either uninsured or who cannot afford co-pays, medications, etc. To this end, the partners of SETMA have contributed $1,000,000 to the foundation in the past two years.

Results:

The unique and reportable aspect of our project is the deployment of EHR solutions which allow the individual provider to track his/her performance on each patient seen followed by the ability to audit treatment patterns in panel of patients or populations of patients. Following this is the analysis of that audit and the public reporting of quality metrics by provider. Finally CQI projects are designed by "tracking," "auditing," "analyzing," public reporting" and then using this data in the designing of quality improvement initiatives, SETMA has achieved remarkable provider and patient compliance and adherence to quality goals. We have a ten year history of uninterrupted improvement in the care of diabetes and achieve high marks on quality metrics published by NQA, NCQA, PCPI, PQRI and BTE. SETMA has created a model care which provides reproducible results and which utilizes the healthcare team to sustain those results. SETMA meets all "meaningful use," standards and has deployed both a secure Web portal and a health information exchange which integrates care across healthcare entities. SETMA is deploying the HIE to all medical practices in our region whether or not we have a relationship with them.