Dignity Health: Implementation of an EHR Alliance Bridging Acute and Ambulatory CareRaymond Lowe
Senior Director Enterprise Clinical ImplementationsEHR AllianceOctober 24, 2012
Email: [email protected]
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• This session will provide a unique learning opportunity focusing on the Dignity Health $1.8B implementation program to meet horizon 2020 as we transform healthcare. The initiative encompassed a 42 hospital health IT implementation in the acute care setting. Review the challenges associated with governance and review lessons Learned from the project.
• Learning Objectives: Key implementation points∙ Clinical Integration with Ambulatory strategies ∙ What’s next – business intelligence∙
Objective
Who is Dignity Health
• Dignity Health, headquartered in San Francisco, Calif., provides integrated, patient and family centered care to more than six million people annually.
• We are the fifth largest health system in the nation with 10,000 physicians and 55,000 employees across Arizona, California, and Nevada.
• Dignity Health is committed to delivering compassionate, high-quality, affordable health care services with special attention to the poor and underserved.
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Who is Dignity Health
• Assets: $13.1 billion
• Net Operating Revenue: $10.6 billion
• General Acute Patient Care Days: 1.8 million
• Community Benefits and Care of the Poor: $1.4 billion
• Acute Care Beds: 8,800
• Skilled Nursing Beds: 800
• Acute Care Hospitals: 40
• Clinics/Ancillary Care Centers: 150
• Medical Foundations: 11
• Active Physicians: 10,000
• Total Employees: 55,000
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Our Vision
A vibrant, national health care system known for service, chosen for clinical excellence, standing in partnership with patients, employees and physicians to improve the health of all communities served.
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The Quality Chasm
“Between the health care we have and the care that we could have lies not just a gap, but a chasm.”
Institute of Medicine Crossing the Quality Chasm: A New Health System for the 21st Century. Janet M. Corrigan, Molly S. Donaldson, Linda T. Kohn, eds. Washington, D.C. National Academy Press. 2001
Responding to the Call
• There is compelling evidence that there are great opportunities to redefine healthcare– To reduce clinical errors
– To improve clinical and cost outcomes
– To improve reliability on delivery of best practices
• Crossing the chasm will require:– Putting advanced decision making tools in the hands of care
providers
– Treating the creation and exchange of information as an integrated system
– Standardize key processes around evidenced based best practices
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Dignity Health Has Multiple Strategic Initiatives Executing In Parallel
EHR
Meaningful Use
Revenue Cycle
Compliance
Transformational Care
ICD-10 (Various Vendors)
HIPAA 5010
Meaningful Use Stages 1-3
Revenue Cycle Standardization (Siemens & Artiva)
FY14FY13 FY15FY12Q3 Q4Q3Q2Q1 Q4Q3Q2Q1 Q3Q2Q1Q4Q1
FiscalYear Q2 Q4
FY16Q4Q3Q2Q1
Ambulatory EMR (Allscripts & Mobile MD)
Lean Process Transformation
Acute EHR (Cerner & Meditech)
Compliance Deadlines
Standardization is the process of decreasing unnecessary variation to improve quality and efficiency outcomes of care– Processes done the same way every time decrease mistakes and oversights
– Processes done the same way each time become more efficient
– Reliability increases; events or steps in a process are more predictable
Key component of clinical transformation– Facilitate the measurement of quality, safety and service outcomes– Improve operational and clinical quality outcomes – Increase the speed of a “sustainable” deployment– Decrease the cost of ongoing support– Decrease cost of care
What is Clinical Standardization and Why is it Beneficial?
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From EVIDENCE To BEST PRACTICES To OUTCOMES
Outcomes
Ace-Inhibitor on dischargeBeta-Blocker on dischargeLipid therapy compliancePlatelet inhibitor Reduction in adverse drug eventsInfluenza Vaccine compliancePneumococcal Vaccine complianceSmoking Cessation education Reductions in LOS / OIReduction in preventable fallsReduction in preventable skin
breakdown
Standards Clinical Decision SupportTherapeutic Guidance
Ace-Inhibitor ReminderBeta-Blocker ReminderHMG CoA Reductase Inhibitor ReminderPlatelet aggregation Inhibitor Reminder Admission Risk Assessment ToolShort acting Rapid-Release Nifedipine AlertInfluenza Vaccine Reminder Pneumococcal Vaccine ReminderSmoking Cessation Education ReminderDrug-Lab interactionsDrug-Drug interactionsDrug-Allergy interactionsAdverse event surveillanceDelayed discharge surveillanceFall Risk assessment - alertSkin Breakdown risk assessment - alert
Order SetsTop 80% of all Dignity HealthAdmissions (by vol and cost)
AAA Repair - Postop
Acute Renal Failure - Adult Admit
AMI ED Evaluation
Appendectomy - Postop
Asthma Adult Admit
Craniotomy - Postop
Critical Care Management
Diabetes - Inpatient care
DKA - Adult Admit
PCI -Postprocedure
PNA PCP - Adult Admit
TIA - Adult Admit
Total Hip Knee Replacement - Postop
TURP - Postop
UGIB - Adult Admit
Unstable Angina NSTEMI - Adult Admit
UTI - Adult
Vaginal Hysterectomy - Postop
Unstable Angina NSTEMI - Adult Admit
From Standardization to Better Outcomes
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6 Keys to Project Success• Effective Collaboration
– It takes everyone
– Break down the barriers (IT, Clinical, Revenue Cycle, Physicians, Vendors)
– Communicate, communicate, communicate
• Culture of Transparency
– Create an environment that supports issues reporting and escalation
– Transparency facilitates information flow─ both up and down
• Sound Structure and Governance
– Work toward a common vision
– Execute within project structure
– Fine tune as you go (always learn)
• High Standards/Value on Excellence
– Be the example that everyone else wants to follow
• Emphasis on Community and Culture
– Medical Center will continue providing care long after the days of EHR implementation have come and gone
• Focus on Process vs. Product
– In projects of this scale, individuals can’t fix every problem. But everyone can work to create pathways for healthy resolution of issues
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SUCCESS…
• The EHR Implementation will only be successful if all of us are successful doing our part.– “If you could get all the people in an organization rowing in the same
direction, you could dominate any industry, in any market, against any competition, at any time.”- Patrick Lencioni
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Communication
A solid communication plan should be built, executed and monitored with adjustments as needed
Communication needs to occur at all levels
• Communicate the shared vision
• Communicate decisions, as well as the logic behind those decisions
• Communication plans for both facility and project team
• Communicate accomplishments
• If people don’t talk it out, they will act it out
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Communication and Performance through ChangeB
usin
ess P
erfo
rman
ce
Time
Uninformed Optimism/ Uncertainty
Denial
Anger
Despair/Skepticism
PessimismTesting
Acceptance
Informed Optimism
Initiative Complete
The Performance DipOrganizational Change
Impact to your business
Governance
Strong governance and leadership is needed from the start
Governance process should support having the difficult conversations and making difficult decisions
Interdisciplinary governance committees need to exist and must include facility managers and directors
• Solid decision-making process that supports timely, sound decisions and eliminates waffling on previous decisions
• Leadership has to be onboard for the governance to be effective
• The project team and facility need to hear the vision from leadership
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9/17/2012
EHR AllianceNSSA Facility Governance Model
Management Decision Group
People
Human ResourcesOrganizational Effectiveness
Change Acceleration Process
Process
MPAG (Multidisciplinary Phyisican Advisory Group)
CPIC (Process Improvement Committees)
Transformational Care
People
Clinical InformaticistsEHR Physician Champion
Super UsersKey Department Leaders
Technology
Dignity Health Information Technology
Process
Enterprise Governance “The What” and “The How”
Transformational Care
Technology
Local IT/FSO LeadershipFacility IT Site DirectorProject Infrastructure
Resources
Implementation Project Team, EHR Physician Champion, Enterprise Physician Informaticist Implementation Program Director, Director Clinical Informatics, Executive Sponsor
Trust and Culture Best Practice InfrastructureEnterprise Guidance
Facility Accountability
Implementation Program Director, EHR Physician Champion, Director Clinical Informatics, Executive Sponsor
Facility Executive Steering Committee
Executive SponsorCEO, COO, CFO, CNE, VPMA
IT Site DirectorEHR Physician Champion
Director Clinical InformaticsCerner Engagement Leader
Implementation Program DirectorEHR Alliance Senior Directors
Escalations forEnterprise Guidance
Escalations forEnterprise Guidance
Escalations forEnterprise Guidance
Feedback
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• Project Resources: – Ensure resources have the proper skill set (project and facility)
• Project Management– Strong project team structure, including a clear chain of command and
authority should be in place
– Clearly-defined issues management and escalation process supported by all team members and leadership
• Strong document management and version control solution should be used
• Structured and consistent team meetings
Key Areas of Focus
Key Areas of Focus Testing
• Sufficient number of testing cycles and time for each cycle
• Test systems available for third-party applications
• Issues tracking, reporting and documented re-testing/regression testing
Training Set expectation on training percentage required for go live … and stick to it
Provide opportunities for practice
Develop a training domain strategy, including a fully built-out, tested environment containing enough data for successful training
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Key Areas of Focus
Go-Live Planning, Execution and Transition Begin go-live planning early in the process and conduct multidisciplinary
team review meetings until all details of the cutover are identified
– Conduct a mock-live event
– Leverage production support resources and prepare for transition
– Reach out to sister hospitals for go-live support
– Go-live command center team should be properly trained; need good issues triage and tracking processes in place
– Plan for ongoing optimization efforts well in advance of live event
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Physician
Patient
Governance
CI System
Quality Metrics & Cost Savings
Care Coordination
Shared Savings
and Risks
Sharing clinical data at the CI level, across the team, promotes an emphasis on care coordination and taking a long-term, holistic view of wellness.
Hospital
Quality Metrics– Population and disease management – Better coordination improves quality of
care– Population focus means business model
takes holistic view of wellness
Financial or Risk Sharing– Model promotes rewards for improved
quality and lower cost of patient care (risk sharing model)
Creates incentives for providers to find cost savings
Increases care coordination Reduces overall costs Shifts from encounter-focused to
patient-focused care
What is Clinical Integration (CI)?
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Key Clinical Integration Capabilities: Technical Tiers
Communications
Analytics & Reports
Data Integration
Data Acquisition
Quality Metrics Information Reporting
Data Integration, Management, & Aggregation
Workflow, Data Extraction & Collection from Multiple Clinical & Financial Systems
Key Clinical Integration Capabilities: Core IT Components
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Secure Patient – Provider
Messaging
Provider PortalPatient Portal
Secure Provider-Provider
Messaging
Clinical Decision
Support (CDS)Management PHI /
Personal Health
Record (PHR) Clinical Information Delivery
Communications
Analytics & ReportsQuality Metric Analysis & Reporting
Data Integration Match Patient’s Data
& Patient EMPI
Match Providers
& Provider EMPI
Data Integration, Conforming, Normalization, & Standardization
Extract Clinical Data
(Internal Systems)
Data Acquisition
Extract Claims Data
(Internal /External Systems)
Extract Clinical Data
External Systems (Rx, Labs, etc.)
Clinical Data Repository
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Opportunities• Evidence Based Medicine
• Improved Treatments
• Intervene earlier
Opportunities and Challenges
Challenges• Managing Data Complexity
• Ensuring patient Confidentiality
• Changing Medical Practices
• Avoiding False negatives
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• Improving outcomes and point of care decisions– Analyze the patient population
– Supporting diagnosis and research
– Active diagnosis
– Point of care Decisoning
– Create values and the potential to improve outcomes.
Transformation