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Clinical Impact and Value of Workstation Single Sign-On

Session 30, February 12, 2019

George A. Gellert, MD, MPH, MPA and John F. Crouch, CHRISTUS Health

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George A. Gellert, MD, MPH, MPA

Has no real or apparent conflicts of interest to report.

John F. Crouch

Has no real or apparent conflicts of interest to report.

Conflict of Interest

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• Learning Objectives

• Background

• Methods

• Results

– Financial Analysis

– Other

• Conclusions

• Questions

Agenda

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• Learning Objective 1: Identify the overall clinical, operational, and

financial value proposition of workstation single sign on (SSO)

• Learning Objective 2: Recognize the nature and magnitude of the impact

of SSO on clinician login time by comparing pre-SSO to post-SSO

implementation times across 6 hospitals evaluated

• Learning Objective 3: Recognize the qualitative impact of SSO on

clinician satisfaction and how SSO is facilitating adoption of other clinical

information technology such as digital documentation

• Learning Objective 4: Evaluate the results of cost effectiveness and

return on investment analyses completed on SSO implementation

• Learning Objective 5: Analyze the methodology utilized to evaluate and

quantify the impact of SSO

Learning Objectives

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• Providers adopting EHRs must maintain the security of

protected health information and HIPAA compliance

• What makes passwords effective – complexity and

frequent change – also makes them difficult to remember

• Clinicians often must recall and regularly refresh 8-20+

passwords

Background

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How many apps do your clinicians log into during a shift?https://live.eventbase.com/polls?event=himss19&polls=5141

1)1-10

2)10-20

3)More than 20

4)Not sure

Polling Question #1

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• Time lost by clinicians entering multiple passwords and

resetting them when forgotten diverts from patient care

• Single Sign-On (SSO) facilitates clinicians’ use of EHR

technology, including CPOE and digital documentation

• SSO objectives: Provide clinicians expedited access to

EHR and clinical applications; eliminate password

confusion and time wasted in password management;

enhance HIPAA compliance via authentication

Background

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Would reduced login times increase staff satisfaction? https://live.eventbase.com/polls?event=himss19&polls=5143

1.Yes

2.No

3.Not sure

Polling Question #2

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• With SSO, once logged in, clinicians need only tap or swipe

enabled identification proximity badge on workstation card

readers (except those reserved for downtime access)

• Across hospital, proximity badge to “tap and go” enables users

to pick up exactly where they left off -- conveys rapid access to

EHR and other functionality as they change location

• When the clinician changes workstation, a tap on the badge

reader brings the most recent screen used to the new screen

Background

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• SSO automatically locks workstations when care

providers leave and re-authenticates when they return to

where they left off

• Eliminates need to manually lock sessions or use

(sometimes unreliable) inactivity timers, and prevents loss

of work

• SSO reduces repetitive, manual logins with automated

process

Background

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• Expedites authenticated access to clinical applications

used during a 12 hour shift, after which usual login must

be repeated to enable another cycle

• SSO provides support for all types of applications

including terminal, client server and cloud-based

applications

• Password administration enables automated application

password change, eliminating this task for clinicians

Background

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• Quantitative evaluation of SSO impact in 19 CHRISTUS Health

hospitals. CH is a mid-size IDN in 6 U.S. states; > 350 services,

49 hospitals, 15,000+ physicians

• EHR – MEDITECH Client Server Version 5.66

• SSO product – Imprivata OneSign Version 5.1

• Reports on clinician SSO use: # deployed users; # active

users; # logins; frequency of app access; average logins/user;

average application events/user

Methods

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• Required migration from workstation PCs to a thin client

and Cloud processing

• Migrated to a virtual desktop infrastructure (VDI) to enable

clinician roaming across service lines

• 45 clinical software applications profiled and enabled

• SSO provided to MDs, RNs, mid-levels and roaming

ancillary (RTs, PTs and dieticians)

Methods

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• 7 day observation period of SSO usage in April 2018

• Measured mean login duration to workstations pre-SSO

and compared to post-SSO implementation

• Post-SSO involved 2 logins: 1st login of day to desktop

and subsequent EHR reconnects/re-logins using card

reader/swipe technology

• Mean login durations were multiplied by total number of

initial and subsequent logins

Methods

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• Assessed total time required for clinicians to login pre-

and post-SSO and quantify benefit from decreased

clinician login times

• Utilized national median hourly pay rates to translate

hourly/shift time savings into dollar cost value of

clinician time liberated from keyboard for 3 clinical

groups (MDs, RNs and Ancillary)

• Estimated cost savings by replacing PC hard drives

($900 per unit) with thin client (WYSE) devices ($200

per unit)

Methods

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Login Parameter Frequency

Active clinical users of Single Sign-On (19 hospitals) 12,903

Total Number of Logins to EHR over 7 days 184,606

Total Number of First of Shift Logins to EHR over 7 days 24,472

Total Number of Reconnect/Re-Logins to EHR over 7 days 160,134

Results

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SSO Implementation

Phase

First of Shift Login Time

Reconnect TimeRest of Shift

Time Reduction Per Login (%

Improvement)

Pre-SSO

Implementation

34.6 seconds 29.3 seconds --

Post-SSO

Implementation

29.3 seconds 8.9 seconds First login: 5.3 seconds (15.3%)

Re-login: 20.4 seconds (69.6%)

Results

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Login Performance Parameter Frequency or TimeKeyboard Time

Reduction

Time Duration First of Shift Logins 7 days:

Pre-SSO

Post-SSO

235.2 hours

[19.6 shift equivalents*]

199.2 hours

[16.6 shifts]

36.0 hours

[3.0 shifts]

Time Duration Reconnect Logins 7 days:

Pre-SSO

Post-SSO

1303.3 hours

[108.6 shifts]

395.9

[33.0 shifts]

907.4 hours

[75.6 shifts]

Results

*[Shifts equivalents = shifts of 12 hours]

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Login Performance ParameterNumber of Facilities

Keyboard Time Reduction

Total Enterprise WEEKLY time savings

enabled by SSO

Total Per Facility WEEKLY time savings

enabled by SSO

19 hospitals

1 hospital

943.4 Hours [78.6 shifts]

49.7 hours [4.1 shifts]

Total Enterprise ANNUAL time savings

enabled by SSO

Total Per Facility ANNUAL time savings

enabled by SSO

19 hospitals

1 hospital

49,056 hours [4088.1 shifts]

2584.4 hours [215.4 shifts]

Results

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• Calculated the dollar cost savings of time for 3 clinician

categories – MDs, RNs ancillary personnel (PTs,

dieticians and RTs)

• 30% of clinical users were MDs, 57% were RNs, and 13%

ancillary

• For RNs, used national average wage of $34.50 per hour

• Collapsed PTs, dieticians and RTs into a single category

with averaged hourly wage of $32.20 per hour

Results – Financial Analysis

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• Estimating MD hourly wages is complex because income

varies considerably across specialties

• Divided MDs into 4 groups of highest EHR users issuing

greatest volume of orders thru CPOE: hospitalists;

emergency medicine physicians; general surgeons; all

other MDs collapsed

• Estimated that each group = 25% of EHR/applications

use, and thus SSO use

Results – Financial Analysis

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• Used multiple MD specialty wage estimates: U.S. Dept.

Labor, Becker’s Hospital Review 2015, Salary.com,

Medscape Physician Compensation Report 2016

• Yielded hourly mean wage of $108 for hospitalists, $144

for emergency medicine physicians and $170 for general

surgeons

• Averaging hourly wage of the 4 categories yielded a

generic physician hourly wage of $138 -- quite

conservative estimate

Results – Financial Analysis

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Results – Financial AnalysisProfessional

Category Percentage of All

SSO Users[Annual Hours Liberated 19

Facilities]

Estimated Hourly Wage

Annual Value of Liberated

Time/Cost Savings Per

Facility

Annual Value of Liberated

Time/Cost Savings 19 Facilities

Physicians

(Hospitalists, Emergency

Medicine Physicians, Surgeons

and all others)

14,717.0 hours[30%]

$138.00 $106,892 $2,030,946

Nurses 27,962.4 hours [57%] $34.50 $50,744 $964,703

Ancillary

(PTs, RTs &

Dieticians)

6,377.4 hours[13%]

$32.20 $10,808 $205,352

All Professional Categories 100% -- $168,474 $3,201,001

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• Migration to WYSE devices achieved savings in averted

new replacement PC purchases – unit cost of $200 vs.

$900 = $700 savings per device

• 2432 WYSE devices deployed = $3,404,800 savings over

next 8 fiscal years or $425,600 savings per year

Results – Financial Analysis

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• Enterprise total SSO implementation cost was $1.23

million

• Annual maintenance cost for SSO is $296,000

• With value rendered by SSO in clinician shifts at

$3,201,001 per annum, adjusting for equipment costs, the

NET TOTAL ANNUAL recurrent value is $3,330,601

across 19 facilities

• SSO delivers substantial recurrent annual ROI, value and

net cost savings to our hospital system

Results – Financial Analysis

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Expenditure Savings Financial Costs Financial Value/Return

Net implementation cost of SSO

Annual maintenance cost of SSO

$1,230,000

$296,000

--

--

Averted annual purchase of replacement desktop PCs -- $425,6000

Clinician time and shift equivalents liberated from the keyboard per

year

Total net annual savings or value rendered by SSO implementation

across 19 facilities

--

--

$3,201.001

$3,330,601**

Results – Financial Analysis

**Averted PC purchases + clinician liberated time value – annual SSO maintenance cost

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• Clinicians reported high SSO satisfaction with the

improved ease/speed of access to clinical workstations

and applications

• SSO can facilitate EHR adoption, particularly among

physicians

• Our implementation of digital documentation overlapped

with SSO, and physicians reported that SSO enabled

their adoption of digital documentation and made CPOE

use easier

Results – Other

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Would implementing SSO facilitate new technology adoption?https://live.eventbase.com/polls?event=himss19&polls=5142

1.Yes

2.No

3.Not sure

Polling Question #3

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• SSO had a significant favorable impact on clinician

efficiency and productivity in these 19 hospitals

• SSO is an effective and highly cost-effective method

to liberate clinician time from repetitive, time consuming

logins to clinical applications

• SSO can facilitate adoption of key component EHR

functionalities and applications

Conclusions

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• May need to update/upgrade other components of IT

infrastructure, such as replacing PCs with thin clients,

cloud processing and VDI

• This reduces need for costly PC replacement and

upgrades, and produces substantial hardware

expenditure savings

• SSO has been a strong “clinician satisfier” - clinicians

report SSO enabled them to focus attention on patient

care rather than EHR/IT

Conclusions

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• While not “game changing” in overall impact on clinician

time demanded by EHR/IT, SSO offers an incremental

real, meaningful liberation of clinician time and

improvement in clinical workflow

• SSO implementation is recommended in hospitals where

multidisciplinary clinician use of EHRs and related

technology is substantial, and where clinical workflow

involves substantial facility roaming

Conclusions

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• SSO can save time, improve security and increase

clinician efficiency and satisfaction in today’s complex

healthcare organizational workflows

Conclusions

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• Thanks for your attention. For further information, please

contact: ggellert33@gmail.com

• Please remember to complete the online session evaluation

Questions