Ensuring Best Outcomes

through EHR/EMR/EPR Systems:

Clinical, Cost, Efficiency and

Satisfaction Outcomes

Across the Continuum of Care

Prof. Steven H. Shaha, PhD, DBA Center for Public Policy & Administration Principal Outcomes Consultant, Allscripts

Prof. Steven H. Shaha, PhD, DBA

Professor, Center for Public Policy & Administration

Principal Outcomes Consultant, Allscripts Former Dir. KLAS Research/Performance Insights

125+ journal publications, 350+ conference presentations, 3 chapters (2015), 3 books

Advisory and consulting work for 11 govt.s in Asia, Australia, Europe and No. America

Advisory and consulting to over 50 non-healthcare organisations, among them:

Disney, Ritz-Carlton, Coca-Cola, New Line Cinema, IBM, AT&T, Time Warner

Employment history includes: Coca-Cola, RAND Corporation, UCLA Medical Center,

Intermountain HC, Gartner, KLAS Research

Education:

PhD, Research Methods & Applied Statistics

DBA, Business Administration (PhD)

MA, MEd, BS

Disclosures & Bio

Prof. Steven H. Shaha, PhD, DBA

Sample of Peer-reviewed Journals

• Advance for Health Information Executives

• Advances in Patient Safety

• Agency for Healthcare Res & Qual (AHRQ Journal)

• American Journal of Ob & Gynecology

• American Journal of Sports Medicine

• Applied Clinical Informatics

• Archives of Otolaryngology, Head & Neck Surg

• Breast Cancer Research and Treatment

• British Medical Journal of Quality & Safety

• Epidemiology and Infection

• Health Management Technology

• Healthcare Financial Management

• Healthcare Technology Management

• Intl. Journal of Medical Informatics

• Intl. Journal of Pediatric Otorhinolaryngology

• Intl. Journal for Quality in Health Care

• Journal of Arthroscopic and Related Surgery

• Journal of Clinical Ultrasound

• Journal of Emergency Nursing

• Journal of Mat, Fetal & Neonatology Med

• Journal of Neurosurgery

• Journal of Obstetrics and Gynecology

• Journal of Orthopedic Trauma

• Journal of Pediatric Emergency Care

• Journal of Perinatal Medicine

• Journal of Perinatology

• Journal of Shoulder and Elbow Surgery

• Journal of the Am Acad of Ped Ophth & Strab

• Journal of Ultrasound in Medicine

• Journal of Ultrasound in Ob & Gynecology

• Laryngoscope

• Nurse Executive Watch

• Nurse Leader

• Nursing Economics

• Pediatric Critical Care Medicine

• Pediatric Emergency Care

• Pediatrics

• RN Magazine

• Spine

• Intl. Journal of Pediatric Otorhinolaryngology

• The Journal of Bone & Joint Surgery

• Ultrasound in Obstetrics & Gynecology

Aims and Emphasis

Proven Approaches for:

• Assuring that the key challenges and opportunities are effectively managed.

• Providing great benefits for patient safety, operational efficacy and enhancing both patient and staff satisfaction.

• Emphasis on what to do, and lessons learnt to assure success in achieving outcomes objectives.

EHR / EMR systems • Balancing the challenges, risks and opportunities

• Enhancing patient safety and operational efficacy

• Facilitating and supporting integration of care:

• Individual healthcare institutions • Across the continuum of care

• Highlight the issues related to assuring safety: • For patients from unintended harm • For staff from risk to medico-legal liability

• Cost-effectiveness and secure EHR / EMR

Delicate Balance …

EHRs/EPRs/EMRs: Clinical, Cost, Efficiency and Satisfaction Outcomes Across the Continuum of Care

WINS from

the Outcomes Approach

1. Engaged stakeholders: their definitions of success

Clients predictably choose what we would have anyway

2. Aligned expectations

3. Focused implementations on critical few success factors • “Less is More”

• Avoid “mission creep”

• Avoid “boiling the ocean”

• Prioritize collectively

4. Quantified and verified outcomes

5. Client evangelists of SUCCESS

6. Proof it worked in THE CLIENT’s words and on their terms

9

Model A:

Toolkits Approach to Clinical Prioritization:

1. Assembled key Clinician stakeholders (n=40-60)

• “This is NOT an IT project – it’s a Clinical undertaking”

2. Explained Outcomes through illustrative examples

3. Established Outcomes Toolkits as “Clinical Indicators”: Relevant clinical challenges with client-proven, client-defined success strategies

4. Enabled real-time Voting AND Display capabilities

5. Voted on system-level, shared priority for EACH Outcomes

Toolkit

6. Arranged findings in Pareto chart for TOP 15 Clinical Priorities

from highest to lowest priority

7. Shared results for input throughout the stakeholder base

8. Itemized KPIs for each Outcomes Toolkits LATER

10

Voting Devices

11

Best Practice Workflows

Integrated Evidence-based Content

Automated Risk Assessments and

Alerts

Order Sets and Documentation

Templates

Monitoring, Surveillance, Reporting

and Analytics

Full List of Clinical Goals for Context

• Stroke Care

• AMI – Acute Myocardial Infarction

• HF – Heart Failure

• CAD – ARRA/MU

• CAP – Community Acquired Pneumonia

• VAP – Ventilator Acquired Pneumonia

• CRBSI – Catheter-related Blood Stream

Infections

• H1N1 – Swine Flu (Epidemics and Pandemics)

• Diabetes – Blood Glucose

• Pressure Ulcers

• Pediatric Asthma

• Pediatrics (ARRA/MU)

• Oncology: Model structure for Adverse

Events

• VTE / DVT

• Catheter Associated UTIs

• Ob / Gyn

• Inpatient Blood Glucose Management

• Blood Utilization / Transfusions

• Primary Care

• Problem List

• Falls

• Surgical Process Efficacy Metrics

• Emergency Department throughput and

Quality Measures

• Management of Potentially Infectious

Patient (MRSA, VRE, MDRO, and C-Diff)

• Hand-offs and Communication

• Pain Management

• Staphylococcus aureus Septicemia

• CPOE Certification

• Drug-Drug Interactions

• Problem List Management

• Immunization & Wellness

• Sepsis Recognition

• Exchange of Key Clinical Information

• Physician Documentation – Time Saving

• History & Physical

• Progress Note

• Consult Note

• Patient Discharge & Discharge Instructions

• Anticoagulation Management

Clinical Indicators

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Phase 1

Clinical Indicators

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Phase 1 Phase 2

Clinical Indicators

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Phase 1 Phase 2

Phase 3

Clinical Indicators

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Phase 1 Phase 2 Phase 3

Converting “Clinical Indicators” into KPIs:

#1 DVT/VTE example

Possible KPIs

• Rate for Order Set (protocols) Use

• Exception Rates within Order Set Use

• Rate for Risk Assessments

• Rate for VTE Prophylaxis

• VTE Rate

17

KPI selected for guiding and

quantifying implementation.

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• Rate of Sepsis Order Set Use

• Rate of Use of Sepsis Bundle

• Sepsis Rate

• Rate for Sepsis-related Complications and/or Mortalities due to

Unrecognized or Delayed Recognition of Sepsis

18

Converting “Clinical Indicators” into KPIs:

#2 Sepsis Recognition example

163 157 156 153 151141 141 141 139 135 133 131

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KPIs selected for guiding

and quantifying

implementation.

Model B:

Clinician Brainstorming for Prioritization

19

1. Physicians

2. Nursing & Allied Professions

Physician Brainstorming for Prioritization

1. Assemble key Clinician stakeholders (n=20-40)

• “This is NOT an IT project – it’s a Clinical undertaking”

2. Explain Outcomes through illustrative examples

3. Establish Meeting “Rules: a time limit (2 hours), etc.

• No negativity regarding any suggestion is allowed

• In the interests of time, comment only as needed for clarification

4. “Shout-out” brainstorming of priorities: What is it that, as a result of this implementation should:

• Get Better

• Not Get Worse

5. White board ALL shouted statements: • No filtering or prioritization – everything get written

• Laughing is GOOD and POSITIVE commentary is invited on EACH

6. “Which are the 5-7 KEY indicators of success?”

20

White Board notes

21

Cell photos of white-board taken for later transcription

Best Practice Workflows

Integrated Evidence-based Content

Automated Risk Assessments and

Alerts

Order Sets and Documentation

Templates

Monitoring, Surveillance, Reporting

and Analytics

White Board notes • Quality

• Readmissions

• Length of stay

• Post-discharge outcomes

• Medication-related Errors

• Physician/User Convenience and

Satisfaction • Time for completing an admission

• Productivity – ability to do more things

• Keystrokes, clicks, etc.

• Efficiency/Time • Time from Rx order to dispensed

• Time from Rx order to admin - Nursing

• Time from Lab or Rad order to results

• CPOE Adoption

• Decision Support • Alert fatigue – numbers/ nature

• Complaints

• “Nuisance alert” – response to alert might

include “never show me this again”

• Patient education

• Government reportables: • Antibiotics 1hr pre-op

• Aspirin on admission and discharge

• Cost-per-case: • Cost per admission

• Cost-per-diagnosis group / population /

disease process

• Customer expectations / Patient

satisfaction • Picker scores

• Follow-up phone calls

• Patient compliance • Re building predictive models for non-

compliance, and remedial strategies

• Productivity • Calls for order clarification (RNs, Rx)

• Hand-offs

• # Patients / # cases

• Redundant / duplicate orders

• Data entered in multiple locations

• OR efficiency

Key Priorities:

To Get Better or Not Get Worse “Which 5 or 6 metrics would be the most crucial.”

• CPOE Adoption – including percent verbal orders (should NOT go to zero)

• Length of Stay – collectively and by key patient groupings

• Medication-related Errors

• User satisfaction

• Patient satisfaction – Picker scores, and follow-up phone calls

• Alert fatigue – numbers and nature of alerts

• Clinician/Physician Productivity - # cases

23

Nursing/Allied Brainstorming for Prioritization

1. Assemble key stakeholders from Nursing and Allied Professions (n=20-40)

• “This is NOT an IT project – it’s a Clinical undertaking”

2. Explain Outcomes through illustrative, bedside relvant examples

3. Establish Meeting Rules and time limit (2 hours): • No negativity regarding any suggestion is allowed

• In the interests of time, comment only as needed for clarification

4. “Shout-out” brainstorming of priorities: What is it that, as a result of this implementation should:

• Get Better

• Not Get Worse

5. White board ALL shouted statements: • No filtering or prioritization – everything get written

• Laughing is GOOD and POSITIVE commentary is invited on EACH

6. “Which are the 5-7 KEY indicators of success?”

24

Flip Chart notes

25

Cell photos of flip charts taken for later transcription

Best Practice Workflows

Integrated Evidence-based Content

Automated Risk Assessments and

Alerts

Order Sets and Documentation

Templates

Monitoring, Surveillance, Reporting

and Analytics

Flip Chart notes • Reduce order entry for physicians

• Reduced discharge form printing

• Improved interdisciplinary

• Reduced omissions

• Reduced duplicates

• “real-time QA”

• Improved Patient Satisfaction (e.g. stds of care)

• Improved Rapid Response

• Reduced Failure to Rescue

• Reduced unforeseen mortality

• Reduced Non-ICU resuscitations

• Improved Length of Stay (e.g. coordination of care)

• Improved Falls w/Injury

• Improved Pressure Ulcers

• Improved DVTs/VTEs

• Improved Readmissions (e.g. pat educ, DC planning)

• Improved Care management (e.g. social issues)

• Maintain Magnet status

• Improved Near Misses (e.g. 5 rights, name dupl)

• Improved Medication reconciliation

• Improved CRBSI

• Improved UTI / CRUTI

• Improved Pain Management

• Documentation

• Increased pat sat

• Improved document (e.g. 1-10, pre-post)

• Improved Medication documentation (e.g. 5

rights)

• Improved Observation patients

• Improved Bariatric patients care processes

• Improved Orthopedic patients care

processes (e.g. discharge efficiency, DC to

where/disposition)

• Improved Cath Lab patients care processes

• Medical Records to Outpatient/Clinic

• Improved Blood utilization (incl. Fe)

• Improved Transfers from ED

• Anesthesia

• Improved Admissions from OR (e.g. total joints)

Key Priorities:

To Get Better or Not Get Worse “Which 5 or 6 metrics would be the most crucial.”

• Readmissions through:

• Patient education

• Discharge planning e.g. by disease process

• Near Misses (e.g. 5 rights, name dupl)

• Hospital “caused: • Falls w/Injury

• Pressure Ulcers

• CRBSI

• UTI / CRUTI

• Pain Management

• Documentation

• Increased pat sat

• Improved document (e.g. 1-10, pre-post)

27

Result of

the Outcomes Approach

1. Engaged – defining Success

2. Aligned – shared expectations • At definitional user/clinician event

• At 12 subsequent system-wide user/clinician events for explanation, input

and revision

3. Implementation Focused

4. Foundation for quantifying and verifying outcomes

5. Foundation for declaration of shared SUCCESS

6. Foundation for averting perceptions of “it didn’t work”

28

Example of Success

for Outcomes Approach

29

Statistics: • The leading cause of death in hospitals globally – 1.7 Million cases a year

• Prolonged LOS in ICU w/ CCs, complex therapies, high costs – est. £18Bn annually

Solution: • SQL query 12-month retrospective chart review

• MEWS: Perpetual, house-wide, imbedded monitoring and surveillance

30

3 2 1 0 1 2 3

Systolic BP (mmHg) < 70 71-80 81-100 101-199 >= 200

Heart rate (bpm) < 40 41-50 51-100 101-110 110-129 >= 130

Respiratory rate (bpm) < 9 9-14 15-20 21-29 >= 30

Temperature (°C) < 35 35-38.4 >= 38.5

Age (y) 65-74 75-84 >= 85

BMI (kg/m²) < 18.5 25.1-34.9 > 35

Name the disease … Sepsis: An example of infections and “avoidables”

Shaha SH ( 2014) The EMR as an Effective Tool for Boosting Medication Adherence. Invited Presentation: 2nd Annual World Congress Summit to Improve Adherence and Patient Engagement, March 10-11, 2014, Phil.

Shaha SH, Hutchinson M (2014). EPR Impacts: The Real ROI. HC 2014: The National Health IT Conf & Exh, Manchester, England, March 20, 2014.

Shaha SH, et.al. (2014). CPOE’s Predictive Impact on LOS: Three Case Studies Illustrate the Impact of High Capability EMRs. HIC 2014 Health Informatics Society of Australia, Melbourne.

Patient-specific Normalisation

LOW Acuity Patient HIGH Acuity Patient

Shaha SH ( 2014) The EMR as an Effective Tool for Boosting Medication Adherence. Invited Presentation: 2nd Annual World Congress Summit to Improve Adherence and Patient Engagement, March 10-11, 2014, Phil.

Shaha SH, Hutchinson M (2014). EPR Impacts: The Real ROI. HC 2014: The National Health IT Conf & Exh, Manchester, England, March 20, 2014.

Shaha SH, et.al. (2014). CPOE’s Predictive Impact on LOS: Three Case Studies Illustrate the Impact of High Capability EMRs. HIC 2014 Health Informatics Society of Australia, Melbourne.

Document • Vitals • Device

integration

• Key CCs

Query • Key

Indicators (Age, BMI)

Calculate • Score via

Matrix

Alert • Does score

exceed threshold? Send Alert

The Process: Identification and Remediation

Shaha SH ( 2014) The EMR as an Effective Tool for Boosting Medication Adherence. Invited Presentation: 2nd Annual World Congress Summit to Improve Adherence and Patient Engagement, March 10-11, 2014, Phil.

Shaha SH, Hutchinson M (2014). EPR Impacts: The Real ROI. HC 2014: The National Health IT Conf & Exh, Manchester, England, March 20, 2014.

Shaha SH, et.al. (2014). CPOE’s Predictive Impact on LOS: Three Case Studies Illustrate the Impact of High Capability EMRs. HIC 2014 Health Informatics Society of Australia, Melbourne.

Our first alert,

May 6, 15:38

Abx LevaQuin Ordered,

May 7, 10:33

Disaster

Averted

Vigilance only

Abx Vanc Ordered,

May 8, 8:10

Shaha SH ( 2014) The EMR as an Effective Tool for Boosting Medication Adherence. Invited Presentation: 2nd Annual World Congress Summit to Improve Adherence and Patient Engagement, March 10-11, 2014, Phil.

Shaha SH, Hutchinson M (2014). EPR Impacts: The Real ROI. HC 2014: The National Health IT Conf & Exh, Manchester, England, March 20, 2014.

Shaha SH, et.al. (2014). CPOE’s Predictive Impact on LOS: Three Case Studies Illustrate the Impact of High Capability EMRs. HIC 2014 Health Informatics Society of Australia, Melbourne.

Document • Vitals • Device

integration

• Key CCs

Query • Key

Indicators (Age, BMI)

Calculate • Score via

Matrix

Alert • Does score

exceed threshold? Send Alert

Summary Impacts: Measure Pre Post

Timeliness of Recognition1 571.2

minutes

93.7

minutes

Cardiopulmonary Arrest

Rate Outside ICU2

5.54% 3.86%

ICU Length of Stay3 3.8 days 3.3 days

Down to 51.8 min (9-11-13)

Down to 28.2 min (11-Dec-13)

p<0.001

p<0.001

p<0.01

The Process: Identification and Remediation

Shaha SH ( 2014) The EMR as an Effective Tool for Boosting Medication Adherence. Invited Presentation: 2nd Annual World Congress Summit to Improve Adherence and Patient Engagement, March 10-11, 2014, Phil.

Shaha SH, Hutchinson M (2014). EPR Impacts: The Real ROI. HC 2014: The National Health IT Conf & Exh, Manchester, England, March 20, 2014.

Shaha SH, et.al. (2014). CPOE’s Predictive Impact on LOS: Three Case Studies Illustrate the Impact of High Capability EMRs. HIC 2014 Health Informatics Society of Australia, Melbourne.

Quarterly Surveillance and Refinement

35

Daily Rounding at the Bedside Quarterly Summary and Refining

Sepsis Outside of the ICU

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2011201120112011201120112011201120112011201120112012201220122012201220122012201220122012201220122013201320132013201320132013

40.2% reduction (p<.01)

37.5% addl. reduction (p<.01)

62.5% cumulative (p<.001)

£ 8.9 Million est. Cash Release

Shaha SH ( 2014) The EMR as an Effective Tool for Boosting Medication Adherence. Invited Presentation: 2nd Annual World Congress Summit to Improve Adherence and Patient Engagement, March 10-11, 2014, Phil.

Shaha SH, Hutchinson M (2014). EPR Impacts: The Real ROI. HC 2014: The National Health IT Conf & Exh, Manchester, England, March 20, 2014.

Shaha SH, et.al. (2014). CPOE’s Predictive Impact on LOS: Three Case Studies Illustrate the Impact of High Capability EMRs. HIC 2014 Health Informatics Society of Australia, Melbourne.

$14.2 Million est. Savings

How was it made possible?

• Outcomes focused, motivated and driven

• Locally defined and implemented • Ownership

• Relevance

• Engagement

• Local programmability, adaptability, refinement

• Share single patient record • Clinical, operational, financial

• Patient-centered driven

• Analytics enabled toward shared outcomes

37

Generalisability …

PPCI added

Improved Outcomes

Improved Outcomes

Improved Outcomes

• Patients arriving sicker

• Less-sick patients – other care pathways

• Trend onerous …

• What can be done?

Analytics

and

Insights

Patient

and Consumer

Engagement

Care

Coordination and

Connectivity

Core Clinical and

Core Financial

Integrated interoperability

Improved Outcomes

• Patients arriving sicker

• Less-sick patients – other care pathways

• Trend onerous …

• What can be done?

Pre EPR Post

• Constancy of 4-per-day

• Impact assessment …

Pre EPR Post

MEWs Impact on Outcomes

Pre EPR Post

Impacts & Benefits with the EPR: • Rising severity … Improving outcome

• MEWs rising:

18.1% rise recent year-over-year (3.42-4.04)

• Arrests falling:

75.0% from highest to lowest (4 to 1)

25.2% improved year-over-year

G

£116,000 Annual Case Release 3.42 Mean to

2.56 Mean

Improved Mortality Rates with MEWs

Pre EPR Post

Ho

sp S

td M

ort

Ra

tio

Impacts & Benefits with the EPR: • Decreased negative outcome

16.7% lower pre-post year-to-year (103.7 to 86.3)

103.7 Mean to

86.3 Mean

Falls with Injury • 45.7% reduced year-over-year from Pre-baseline

• 11 fewer falls with injury

Pre EPR Post

Falls • 14.1% reduced year-over-year from Pre-baseline

• 13 fewer falls

• 50.5% reduced from Pre-baseline

Grade 2

Pre EPR Post

Avg

Gra

de

2 P

Us p

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• 78.9% reduced from Pre-baseline

Grade 3+

Pre EPR Post

Zero Grade 4 A

vg

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s p

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Lessons Learnt • Begin with OUTCOMES in Mind …

• … know WHY then HOW

• EMR/EPR cannot merely be “electronified paper”

• Programmability and Adaptability • Rigidity vs. Openness

• Local autonomy vs. dependency on vendor prioritisation

• Community Connectivity and Interoperability across Settings & “HIE”

• Local Innovation … Reflecting Broader Standardisation

• No org or facility is identical – patient pops, layout, personnel, specialties …

• Access to Clinical Data

• Ad hoc, investigational, curiosity, personal/specialty improvement and optimisation

• Test new implementations, verify impact and refinement as needed, continuous

improvement

• Routine reports formatted locally or centrally and used as needed

• Outcomes-driven – the WHY of success • Clinical

• Efficiency

• Cash Releasing and Cost Reducing

• Stakeholder satisfaction

Signal to Noise Ratio

Levels of Information: Needs and Perspectives

• Routine change

• Evolving figures - Improvement

• Operational perspective

• Fluid change / Live figures

• Real results – NOW or catastrophic

• Process perspective

• Slow change

• Stable figures

• Strategic perspective

Levels of Information: Needs and Perspectives

Happy Ending …

Lessons Learnt • Begin with OUTCOMES in Mind …

• … know WHY then HOW

• EMR/EPR cannot merely be “electronified paper”

• Programmability and Adaptability • Rigidity vs. Openness

• Local autonomy vs. dependency on vendor prioritisation

• Community Connectivity and Interoperability across Settings & “HIE”

• Local Innovation … Reflecting Broader Standardisation

• No org or facility is identical – patient pops, layout, personnel, specialties …

• Access to Clinical Data

• Ad hoc, investigational, curiosity, personal/specialty improvement and optimisation

• Test new implementations, verify impact and refinement as needed, continuous

improvement

• Routine reports formatted locally or centrally and used as needed

• Outcomes-driven – the WHY of success • Clinical

• Efficiency

• Cash Releasing and Cost Reducing

• Stakeholder satisfaction 56

Ensuring Best Outcomes

through HER/EMR Systems:

Clinical, Cost, Efficiency and Satisfaction

Outcomes

Across the Continuum of Care

Prof. Steven H. Shaha, PhD, DBA

Center for Public Policy & Administration

Principal Outcomes Consultant, Allscripts