Marinka Bulic Jyothi Golkonda Diane Hunt Aziz Lalji Emad Osman

Decreasing Medicare Readmissions

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!Executive Summary 3 .........................................................................................................................

Introduction 5 .....................................................................................................................................Background 5 ................................................................................................

Definition of the Problem and Impact 7 ...............................................................Financial Impact 9 ...................................................................................................Clinical Impact 11 ....................................................................................................Other Impact 11 ......................................................................................................

Goal 12 ...............................................................................................................................................

Proposed Solutions 13 ........................................................................................................................Metrics 13

Role of Information Technology 17 ................................................................................

Clinical workflows and operations 17 ..................................................................Improve Discharge Medications Process 18 ......................................................................Optimize Transition Planning 21 ...................................................................................Care Coordination 25 ................................................................................................

Patient education 27 .......................................................................................

Integration 28 ..............................................................................................Proposed Integrated System 28 ....................................................................................Privacy Issues 31 .....................................................................................................

Use Case Diagram 32 .......................................................................................

Cost vs. Benefits Analysis 33 .............................................................................................................

Project Plan 34 ....................................................................................................................................Introduction 34 .............................................................................................

Project Governance 35 ....................................................................................

Project Roles and Responsibilities 37 ..................................................................

Project Assumptions, Constraints and Dependences 38 ............................................Assumptions 38 .......................................................................................................Constraints / Limitations 39 .......................................................................................Dependencies 40 .....................................................................................................

Quality Management Plan 40 .............................................................................

Communications Management Plan 41 .................................................................General Guidelines 41 ...............................................................................................Key Groups 41

Risk Management Plan 42 .................................................................................

High Level Functional Requirements 43 ...............................................................

High Level Workflow Requirements 45 ................................................................

Metrics & Measurements 46 ..............................................................................

Testing 46

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Figure 1: Existing system diagram 8 .........................................................................Figure 2: Use case for current workflow 8 .................................................................Figure 3: Proposed integrated system 29 ...................................................................Figure 4: Use case for workflow in proposed integrated system 31 ....................................

!Table 1: Potential Losses 10 ..................................................................................Table 2: University Hospital current LVF Scores 13 .......................................................Table 3: University Hospital current ASA on Arrival Scores 14 ...........................................Table 4: University Hospital current Blood Culture Scores 14 ...........................................Table 5: Projected Return on Investment 32 ...............................................................Table 6: Project Roles and Responsibilities 36 .............................................................Table 7: Project Dependencies 38 ...........................................................................Table 8: Project Key Groups 40 ..............................................................................Table 9: Risk Management Plan 41 ...........................................................................Table 10: Schedule 48 .........................................................................................

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Training Plan 48 .............................................................................................

Deployment 49 ..............................................................................................

Schedule 50 ..................................................................................................

Conclusion 51 .....................................................................................................................................

References 53 .....................................................................................................................................

Appendices 55 ....................................................................................................................................Appendix A—Project Structure 55 .......................................................................

Appendix B—Project Governance 56 ...................................................................

Appendix C—Roles and Responsibilities 57 ............................................................

Appendix D — Alternate solutions for Integrated systems 69 ......................................CCDAs and Interfaces 69 ............................................................................................Remote Access to all Systems 70 ..................................................................................One System for Entire Organization 70 ...........................................................................One Centralized Data Warehouse 71 ..............................................................................

Appendix E—Annotated Bibliography 73 ...............................................................

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!1. Executive Summary

University Hospital is concerned about Medicare-insured patients with diagnoses including

acute myocardial infarction (AMI), congestive heart failure (CHF), and pneumonia, as those are

the diagnoses being targeted by the Hospital Readmissions Reduction Program (HRRP).

Without drastic improvements in these areas, the organization is set to lose close to $1 million

dollars over the next three years. University Hospital has set a goal to reduce Medicare

readmissions from 21% to 10% over the next two years; The Capstone Group has developed a

multi-faceted strategy to help University Hospital not only reach their goal, but also to improve

care provision while doing it. Pre-proposal analysis of the current system and workflows utilized

by University Hospital revealed opportunities for improvement in several areas, leading to the

following recommendations:

• Improve hospital-wide performance on clinical quality measures, particularly as

they relate to the diagnoses of AMI, CHF, and pneumonia. This will be achieved

by utilizing currently-available technology to generate reports on quality measures

on a monthly basis, and by focusing re-education efforts as a result of these

reports. By enabling clinical leaders to focus on those providers/locations that

need re-education, we can better utilize available resources to encourage

improvements.

• Streamline workflows within the hospital at transition of care points, specifically

at admission and discharge of acute care patients. This will be affected by

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improving admission and discharge medication reconciliation processes through

detailed workflow analysis, evaluating patients at acute care admission for

readmission risk utilizing a BOOST score, and through the development of a

Transitional Care team to standardize movement of patients from inpatient to

outpatient care settings with necessary resources to ensure compliance with care

plans.

• Develop improved interactive education modules to help patients demonstrate

understanding of clinical conditions and play a more informative role in their care.

This will take place primarily though development and increased utilization of the

Patient Portal.

• Standardize current follow-up care modules within the organization, with

emphasis on primary care base, and home healthcare provisions. Through the

initiation of a primary care provider incentive program, which encourages primary

care providers to see discharged patients within 72 hours of discharge, in addition

to increased information sharing between the two care environments, this

objective will be obtained. In the future, the hospital will recoup these payments

through attainment of accountable care organization (ACO) quality of care

incentives.

• Complete overhaul of currently disjointed information systems, leading to a more

robust, interactive, and available electronic health record (EHR) across the

organization. Primarily, we recommend developing interfaces to share basic

clinical information between the different electronic medical record (EMR)

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systems utilized throughout the organization as well as a robust clinical data

warehouse to enable the tabulation of quality and other reporting information from

the system as a whole.

Additionally, University Hospital will be provided with a detailed project plan. The purpose

of this project plan is to clearly outline the scope of the project, assumptions made with the

generation of this proposal, and responsibilities necessary for both parties moving forward.

This proposal will save University Hospital approximately $516,000 in Medicare re-

admissions penalties over the next two years. Estimated cost for implementing the various

recommendations within this proposal is $470,000, which provides University Hospital with a

10% return on investment over the next two years.

2. Introduction

2.1. Background

University Hospital is a 500-bed facility with an Emergency Department, Intensive Care

Unit, and Cardiac Surgery Facility. In addition, University Hospital directly employs over 30

physicians in the local community encompassing a variety of specialties; however, the majority

of these physicians are primary care providers. The Capstone Group has been approached by the

administrative leadership at University Hospital to assist the organization in developing an

outline and implementing a plan to decrease hospital readmissions. The focus of project is on

not only readmissions, but also on improving the scope of care provided within the community.

As a major member in a local ACO, University Hospital understands and is committed to

improving care for its patients across the continuum of available services; this goal is aligned

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with the hospital mission, which is “To provide quality healthcare services to our community”.

University Hospital wishes to utilize the experience and expertise of The Capstone Group to help

them meet their goals of improving the care provided to their patients in a timely and economical

manner. This proposal will outline the means by which The Capstone group will help University

Hospital meet and surpass these goals.

We wish to initiate this proposal with a review of the current state of medicine as it

relates to hospital readmissions in our country. In the United States, nearly 20% of all

hospitalized patients ages 65 and older are readmitted to an acute care facility within 30 days of

discharge (Gerhardt, 2013). Medicare attributes the costs of these readmissions to be over $17.5

billion annually, and they estimate that the gross majority of these readmissions are due to

preventable causes (Gerhardt, 2013). Given these astounding figures, which pose a great threat

not only to the stability of our healthcare system overall but also to the health of our at-risk

elderly population, the government determined that action was necessary to reduce hospital

readmissions across the country. In response, a portion of the Patient Protection and Affordable

Care Act (PPACA), which was signed into law in 2010, was dedicated to solving this particular

problem. Started on October 1, 2012, HRRP serves to essentially de-incentivize healthcare

organizations with above-average readmission rates for their Medicare patient base (Cloonan,

2013). Initially, the new rules are applicable to the following three diagnoses: AMI, CHF, and

pneumonia. Most health care professionals believe that this program will be expanded in coming

years to include more diagnoses. For 2013, the initial penalty for hospitals with higher

readmission rates than national average is 1% of total Medicare reimbursement; that will

increase to 2% in 2014 and 3% in 2015. Expected readmission rates for the country are

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calculated by the Centers for Medicare & Medicaid Services (CMS), and adjusted for patient

age, gender, and co-morbid conditions. Penalties for 2013 will be levied on hospitals after it is

determined that their actual readmission rates exceed the expected readmission rates for a

particular time period (Joynt, 2013).

2.2. Definition of the Problem and Impact

University Hospital currently has higher-than-average readmission rates for Medicare

insured patients with diagnoses of AMI, CHF, and pneumonia. The Capstone Group performed a

root-cause analysis to help determine the causative factors leading to this problem. Some of

these factors include poor quality measure performance, inappropriate methods to track quality

measure indices, inadequate workflows, inappropriate follow-up, poor patient education

practices, and an insufficient Information Technology (IT) base.

University Hospital is associated with a multi-site Accountable Care Organization

(ACO). University Hospital has adopted Centricity EHR for the past 18 years. The physicians in

the hospital use computerized physician order entry (CPOE) to electronically send prescription

orders to three different pharmacies that are part of the ACO. Pharmacies respond back to the

ordering physicians with the prescription fill data. Physicians also use CPOE to electronically

order lab tests and procedures to three different labs within the ACO. The labs with in the ACO

use different terms and different test combinations. This has been a major cause for confusion on

the receiving end and a potential patient safety issue. The labs have the capability to send test

results electronically to the ordering provider. The outpatient clinics in the ACO use Epic EMR

to electronically send and receive data from the pharmacies and the labs. Although University

Hospital can exchange data electronically with labs and pharmacies there is no electronic data

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exchange between the Hospital and the outpatient clinics in the ACO. This has a major impact on

the transition of care when a patient is discharged from the hospital. Currently there is no handoff

during discharge process. The hospital has no control on the post discharge care of the patient.

Figure 1 depicts the state of the current systems within the ACO.

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Figure 1: Existing system diagram

Figure 2 captures the use case for the current workflow in the ACO. There is no transition of care

between the inpatient and outpatient care systems.

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Figure 2: Use case for current workflow

Indicates areas of improved workflows; see future use case on page 31

!The remainder of this proposal will touch on each of these concerns, and provide

University Hospital with methods to improve them.

2.2.1. Financial Impact

By careful calculation of the admissions and readmissions data for the calendar year 2012

provided by University Hospital to The Capstone Group, we have generated a potential loss

projection for the next three years based on current regulations. We want to make sure that the

administrative leadership at University Hospital understands that any solution enacted at this

point will alleviate projected losses for 2014, but that we will not be able to recoup losses already

in place to be levied for the 2013 calendar year. In 2012, University Hospital had a total of 7,500

Medicare admissions; this accounted for 5,100 novel patients. The overall 30-day readmission

rate for 2012 was approximately 21%. Of these, 60% occurred within 10 days of initial hospital

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discharge; this information is critical to any project focusing on decreasing readmissions overall.

When analyzing admission diagnoses, The Capstone Group determined that 65% of the 30-day

readmissions were in patients with either one or a combination of AMI, CHF, and pneumonia.

When we look at comparable healthcare organizations, these figures show that University

Hospital is clearly within the Medicare penalty range for 2012 data.

The following table illustrates the projected financial burden that University Hospital will

endure, if corrective actions are not taken in a timely manner to reduce the rate of readmission

(Logue, 2013).

Table 1: Potential Losses

It is the goal of The Capstone Group to develop and implement a multi-faceted plan to

help University Hospital avoid Medicare repayment penalties of over $500,000 for 2014 and

2015 that are directly related to above-average 30-day readmission rates. University Hospital is

Year 2013 2014 2015

Penalty 1% 2% 3%

No. of Medicare admissions

7500 7500 7500

Average Medicare hospitalization rate in the service area

$13,387 $12,718 $13,119

Total Medicare payment per annum

$100,402,500 $95,382,375 $98,394,450

Medicare payment for readmissions

$21,419,200 $20,348,240 $20,990,816

Readmission payments for (AMI, CHF, and Pneumonia)

$13,922,480 $13,226,356 $13,644,030

Expected Medicare readmission penalty for the three diagnoses

$139,225 $264,527 $409,321

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already predicted to lose almost $140,000 in Medicare payments due to the new requirements in

2013.

2.2.2. Clinical Impact

The Capstone Group believes that the clinical impacts presented by poor quality measure

performance and inadequate transitional workflows are of much greater potential harm than the

financial impacts. Currently, University Hospital is failing in its mission “To provide quality

healthcare services to our community”. Patients being cared for within the service lines provided

by University Hospital and its affiliates are not receiving the same standard of care expected at a

national level. This is directly impacting not only Medicare reimbursement, but also the trust

that your patients place in you as a healthcare organization. Poor quality measures are directly

related to readmission rates, as well as mortality rates and decreased quality of life indicators.

Without drastic changes in these measures, the future of University Hospital as a viable

healthcare option in the community is at risk.

2.2.3. Other Impact

At The Capstone Group, we want to make sure that our project meets your organization’s

mission. With that in mind, we would like for the leadership at University Hospital to understand

that our approach to reducing readmissions will not only result in a generous return on

investment financially, but also in terms of quality of care provided to the patients in your

community. Given University Hospital’s current involvement in a local ACO, this project will

supply the foundation from which you can realize benefits related to ACO payment models,

PCMH initiatives, Health Information Exchange (HIE) projects, and a variety of other

requirements as they relate to population health.

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3. Goal

The goal of this project is to reduce readmissions in patients with the diagnoses of AMI,

pneumonia, and CHF; University Hospital’s stated goal is to reduce these readmission rates from

the current 21% to 10% over the next two years. This proposal will outline the multi-faceted

approach recommended by The Capstone Group to help University Hospital meet that goal. Our

proposal will outline solutions including:

• Improvement of clinical quality measures and overall provision of care, with

reflection of these improvements in patient satisfaction surveys,

• Development of standardized clinical workflows at transitions of care, with focus

on discharge process, primary care follow-up, and medication compliance,

• Implementation of new patient education processes to better ensure that patients

participate and appropriately understand their own care,

• Standardization of care coordination in the ambulatory settings, to allow for better

utilization of home health providers, and primary care physicians after discharge,

• Recommendations for overhaul of the current disjointed IT solutions in the

hospital and affiliated practices in order to better streamline the flow of

information between care locations

We believe that a multi-faceted approach, addressing the majority of the concerns revealed

by the root cause analysis will help University Hospital to not only avoid further financial

penalties as they are related to Medicare readmission rates, but also to drastically improve the

quality of care provided within the organization.

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4. Proposed Solutions

4.1. Metrics

The focus on quality measures defined by CMS is a system in place to reduce patient

readmissions within 30 days of being discharged. The CMS program, HRRP, will collect data on

quality measures involving CHF, AMI, and pneumonia (CMS, 2013). If the data show that a

hospital has a higher than expected 30-day readmission rate for these diseases, penalties will be

applied against their total Medicare payments. This financial incentive has been proven to

improve readmission rates in hospitals for those diseases.

We have identified initial measures within University Hospital for each condition with a

low score that needs to be improved. A low percentage (under 95%) of a measure score is costly

in two ways:

1. Penalties in Medicare payments hurt the overall bottom line of the hospital

2. These measures are proven to reduce readmission rates with a direct correlation between

higher score with lower readmission rates.

CHF

• In the United States, there are more than 700,000 hospitalizations due to heart failure

annually; University Hospital had 1,900 admissions due to heart failure last year (Good

Shepard, 2013).

LVF Assessment – Left Ventricular Systolic Function Assessment

“This score shows the percentage of patients who had the left side of their heart assessed during

their hospital stay at University Hospital The left side of the heart is where the main pumping

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chamber is located. By assessing it, doctors can tell how well it is pumping and what type of

treatment is needed” (Memorial Health, 2013).

University Hospital Quality Measure Score - LVF

Table 2: University Hospital current LVF Scores

AMI

• Approximately 1.1 million patients have an acute myocardial infarction in the United States

annually; there were approximately 2,000 patients with a heart attack at University Hospital last

year (Good Shepard, 2013).

• Of those patients who have an AMI, almost 2/3 do not completely recover (Good Shepard,

2013).

• Patients who do survive the initial stages of an AMI have an increased chance of co-morbid

disease and ultimately death that is 2-9 times increased over non-AMI afflicted peers (Good

Shepard, 2013).

ASA on Arrival – Aspirin on Arrival

“This score shows the percentage of heart attack patients who received aspirin within 24 hours

of arriving at Memorial University Medical Center. Aspirin can help break up blood clots and

prevent new ones from forming. It may reduce the severity of a heart attack” (Memorial Health,

2013).

University Hospital Quality Measure Score – ASA on Arrival

2010 Total 2011 Total 2012 Total YTD 2013 Total Projected 2014

75.6% 78.4% 84.9% 87.3% 96.7%

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Table 3: University Hospital current ASA on Arrival Scores

Pneumonia

• The 5th leading causes of death in the nation for patients age 65 and over are pneumonia and

influenza; they are 4th for the University Hospital patient population (Good Shepard, 2013).

• More than 90% of deaths due to pneumonia occur in patients aged 65 and older (Good Shepard,

2013).

Blood Culture

“This score shows the percentage of pneumonia patients at Memorial University Medical Center

who had a blood sample studied before receiving any medication. By analyzing the blood,

doctors can see what type of pneumonia is present and which type of antibiotic will treat

it” (Memorial Health, 2013).

University Hospital Quality Measure Score – Blood Cultures

Table 4: University Hospital current Blood Culture Scores

!In order for these CMS quality measures to be implemented with the most effectiveness, the

hospital must identify its own risks by using one of the following:

• Influenza vaccine status

2010 Total 2011 Total 2012 Total YTD 2013 Total Projected 2014

66.5% 72.5% 79.5% 83.6% 95.1%

2010 Total 2011 Total 2012 Total YTD 2013 Total Projected 2014

73.7% 81.2% 89.4% 90.4% 98.2%

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• Patient Survey: Hospital Consumer Assessment of Healthcare Providers and Systems

scores

• Core measures for CHF, AMI and pneumonia

• Readmission rates

• Utilization of resources

• Cost of care per case

A review of the above results should be performed monthly in order to adjust the system and

improve the performance of the hospital. Analyzing the quality measures and identifying lapses

in performance can help the hospital adjust and reduce its risk for readmissions

Patient Survey

The HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems)

Survey is a survey that has been standardized and used to help hospitals determine how patients

feel about the care provided to them (HCAHPS Survey, 2013). HCAPHS has provided a method

to standardize a practice employed by many hospitals across the nation, as well as a means to

determine performance compared to other organizations. This survey has three goals, according

to the originators: to produce comparable data on based on a patient perspective of care that

allow comparisons amongst peer hospitals, to publicly report results of the survey so that

consumers are aware of them and there is increased transparency, and to create incentives for

hospitals that provide improved quality of care (HCAHPS Survey, 2013). All data generated

through the use of the HCAHPS survey is provided to the public.

The following topics are addressed in the current HCAHPS patient survey, and are of

particular concern to University Hospital (HCAHPS Survey, 2013):

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• Communication About Medicines

• Discharge Information

• Overall Rating of Hospital

The improvement of patient satisfaction survey metrics in the above areas is addressed

through recommendations in this proposal. The initiation of improved workflows as they relate

to these metrics will undoubtedly lead to increased patient satisfaction. Addressing these issues

through this will lead to a decrease in University Hospital’s readmission rate as well as a

healthier bottom line.

4.1.1. Role of Information Technology

Dash boards can be used to display all the above metrics to providers and administrators

alike. Dash boards provide graphical display of the key performance indicators for readmission

rates and support drill down of the key performance indicators to lower levels to examine critical

drivers of performance. They help track and manage readmission rates by providing at a glance

display for management and department heads. The analytic reports provide details of the

performance drivers that affect readmission rates. (HIMMS, 2012)

4.2. Clinical workflows and operations

The arena of clinical workflows, in particular, presents an opportunity for standardization

across the organization. We seek to help University Hospital optimize the processes related to

post-discharge medication planning, the transition process, and care coordination. We

recommend a Lean Six Sigma approach to improve the medication reconciliation processes to

help standardize and streamline these workflows. Our black-belt certified Lean Six Sigma team

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will work directly with appropriate stakeholders within the organization to map out not only the

inadequate current processes, but also a desired future state that will ensure error-free medication

reconciliation at all transitions of care. Our team will work with your stakeholders to analyze the

entire process including clinical caregiver workflows, current EMR functionality, and caregiver

to patient communication. The final stage of this project will be implementation of the future

state within all patient care areas in the hospital, led by our Lean Six Sigma consultants.

4.2.1. Improve Discharge Medications Process

The next step in the plan to reduce hospital readmissions at University Hospital is to improve

the patient’s ability to understand and adhere with medication regimens prescribed at discharge.

Studies have repeatedly shown that patients who adhere to their prescribed medication regimens

have lower readmission rates than those patients who are noncompliant with their medications

(Stewart, 1999). At the current time, we have identified three areas of concern as they relate to

the discharge medications process at University Hospital: medication reconciliation, e-

prescribing, and compliance verification. Our plan to improve processes in these three areas will

lead to increased medication compliance in patients after discharge, and reduced readmission

rates overall.

In our initial analysis, we determined that medication reconciliation is a process that is

fragmented and poorly defined; in particular, we determined that last year over 75% of

University Hospital’s admitted patients had medication reconciliations performed incorrectly at

either admission or discharge. Additionally, The Capstone Group has identified that over half of

these mistakes occurred during the admission medication reconciliation process, which then led

to carry-over errors in the discharge medication reconciliation process.

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In addition to the concerns about medication reconciliation, The Capstone Group

determined that University Hospital’s e-prescribing rate at hospital discharge is far below the

requirement for attainment of Meaningful Use. Improvement in this particular area will not only

help University Hospital to recoup some of those Meaningful Use dollars, it will also help to

improve patient compliance with discharge medication instructions. Upon initial investigation, it

was determined that providers at University Hospital cited inconvenience as the main reason

why they were not e-prescribing discharge medications consistently. We have identified an

inadequate current state that requires providers to order prescriptions individually based on how

they should be routed (controlled substances routed to the printer, non-controlled substances to

the pharmacy); this is very inconvenient and time-consuming for your providers. The next

solution we propose is that The Capstone Group work directly with Centricity’s e-prescribing

team in conjunction with University Hospital’s appropriate stakeholders to alter the current state

so that prescriptions route automatically without physician direction. This is functionality

currently available in the Centricity EMR, so we do not anticipate any difficulties with this

project. Once this phase of the project is complete, we will work directly with your providers to

educate them about the improved process. With this project, we aim to increase provider e-

prescribing at hospital discharge to more than 80% of appropriate medications, which is the

current requirement to meet Meaningful Use Stage One.

The final piece we recommend to improve discharge medication compliance is the

development of a communication channel between outpatient pharmacies and primary care

providers, with inclusion of the patient via the Patient Portal. We believe it is this phase of the

discharge medications project that will have the greatest impact on readmissions overall. When

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we evaluated compliance with discharge medications, The Capstone Group determined that

fewer than 50% of discharged patients received all of the medications prescribed for them at

release from the hospital. We will work directly with representatives from University Hospitals’

informatics team, local pharmacy representatives, and personnel from Centricity and Epic to

develop electronic workflows to allow outpatient pharmacies to inform primary care physicians

when medications are not filled by the patient. The first step in this process is to include the

primary care physician, who was identified at the time of hospital admission, on any e-

prescriptions sent at the time of discharge. This allows the local pharmacists to determine who

the appropriate following provider is for any particular patient. The next step in this process is to

work directly with the local pharmacies to take their current “refill request” process and modify

it slightly to become a “prescriptions unfilled” notification. In projects with previous clients, we

have found local pharmacies to be very willing to work with us on this communication, because

it results in increased revenue for them through higher percentages of prescriptions filled.

Additionally, this requires very little work for them to perform. These notifications will come

into the outpatient EMR, Epic, directly through the message center, just as refill requests come to

the providers or designated staff today. Once this process is in place, our team will work to

educate the primary care physician base in the community about these notifications. In

particular, we will focus on the employed primary care physicians with education about how to

respond to these notifications and identify those patients who are noncompliant at the time of

discharge. By placing that information in the hands of the primary care providers, we believe

that we can improve the ability of these providers to help recently discharged patients better

comply with medication instructions by facilitating dialogue that should elucidate reasons why

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particular medications were not filled. Once they are aware of barriers facing an individual

patient, the primary care provider can involve necessary resources to help patients comply with

discharge orders.

4.2.2. Optimize Transition Planning

Another particularly important facet of this project proposal is the transition from not only

the inpatient to outpatient care setting, but also the transition from outpatient to inpatient. The

Capstone group will help University Hospital to streamline the processes surrounding care in

both the acute care and ambulatory settings, so that the end result will be reduced readmission

rates throughout the University Hospital organization. On initial evaluation of these processes at

University Hospital, we have determined that these processes are not standardized at all. Patients

are currently at the mercy of an extremely varied system that may or may not utilize social

workers, home healthcare resources, and primary care providers to facilitate necessary post-

discharge care.

The first step in this portion of the proposal is to look at what happens when a patient is

admitted to University Hospital. We will start by focusing on identifying patients who are

particularly at risk for readmission based on certain factors present upon admission for acute

care. While there are several disease-based scoring systems available for use in the inpatient

care realm, we recommend using a more global approach to stratifying patients according to risk

scores; in this way we are more likely to reduce readmissions for our patient base overall and not

just for those disease states identified by the measurement tools. Additionally, we simplify the

admission process for the support staff, ensuring that all patients receive the same risk

assessment, regardless of diagnosis at the time of admission. Although many risk-predictive

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models have not been proven to effectively reduce readmission rates in randomized controlled

studies to date, we feel that the benefits of improved targeted care and relatively low cost of such

measures make the practice ultimately useful (Kansagara, 2011). In evaluating options for patient

risk stratification at admission, we have determined that the BOOST Model has shown the most

initial promise in reducing readmissions in the short-term. The BOOST model will allow the

clinical staff to calculate a readmission risk score for all patients over the age of 65 at the time of

admission, and includes alterations in care based on the following (The Society of Hospital

Medicine, 2013):

• The presence of problem medications

• The presence of psychological symptoms

• The principal diagnosis at the time of admission

• The presence of polypharmacy

• Poor health literacy on the part of the patient

• The presence or absence of patient support

• Prior hospitalizations in the last six months

• Palliative care

The Capstone Group will work with University Hospital’s informatics team to develop a

form within the inpatient Centricity system that is completed by nursing staff at the time of

admission on all patients over the age of 65. This form will trigger an alert identifying a patient

as high-risk for readmission if they have the presence of risk factors in 1 or more of the above

categories. This alert will be visible to all care providers on the patient’s banner bar within the

Centricity EMR, and reminds them that appropriate care should be taken with the transition from

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acute to outpatient wherever possible. Additionally, we recommend that this alert also trigger a

task within the Centricity system that places the patient onto a list for social work and/or a

transitional care team for further resources. By effectively utilizing the BOOST tool as a clinical

decision support within the EMR, we have standardized a process to best stratify those patients

who are high-risk for readmission at the time of presentation.

Finally, The Capstone Group recommends the development of a Transitional Care Team to

help smooth the movement of high-risk patients from acute inpatient care to ambulatory care

provision. Traditional models show Transitional Care Teams led by a nurse practitioner in

conjunction with a managing medical director, with staffing provided by a combination of

nurses, home healthcare providers, and social workers. The recommended team size for

University Hospital at this time is 6. This recommendation is based on initial analysis which

showed that approximately 20% of the inpatient population at University Hospital is over the age

of 65, and that half of those patients qualify as high-risk utilizing the BOOST scoring method;

this translates to an approximate case load of 50 at any given time. The medical director should

be available on a part-time basis for consultation and organizational decisions, while the

remainder of the positions should be full-time. It is this team that will help patients move across

the gap between acute and ambulatory care; these care providers will provide the full spectrum

of care for patients as they navigate that 30 day transition. Potential services offered by this

team include follow-up in home evaluation post-discharge, arrangement of home care,

housekeeping, and financial support to help patients meet medical needs (prescriptions, durable

medical equipment, dietary changes, Meals on Wheels, etc.), facilitation of transportation,

education about diagnoses and expectations, and scheduling of appointments with follow-up

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providers after discharge. While development of this team does require additional resources at

the hospital level, we have seen that the benefits of this team far exceed the cost. The Capstone

Group has seen marked success with the transitional care model across the country to date, and

nationally, readmission rates have decreased anywhere from 2-10% for certain diagnoses thanks

to the initiation of this type of program (Stauffer, 2012). Additionally, with the implementation

of the clinical decision support-aided BOOST score, we can automatically assign patients to the

Transitional Care Team based on risk. It is the task of the Transitional Care Team to act as

facilitators to work directly with patients during the move from hospitalization to home; the

development of this team will help patients to utilize the extensive outpatient support system

offered in the community, and will help them to avoid expensive Emergency Department and

Inpatient care unless it is absolutely necessary.

Our final recommendation regarding the transition of care from inpatient to outpatient is

the involvement of the Home Healthcare providers. While the local Home Healthcare agency is

not currently affiliated with University Hospital, we believe a partnership between the two would

be greatly advantageous to both entities. Home Healthcare can play a vital role in improving

patients’ quality of life, outcomes, and unnecessary readmissions (Fleming, 2013). With the

recommendation to include Home Healthcare providers on the Transitional Care Team, we allow

for both entities to provide necessary services after the time of discharge. Additionally, because

Home Healthcare services are reimbursable, while Transitional Care Services are not, the

utilization of Home Healthcare agencies creates a symbiotic relationship for both entities as well

as for the patient. Home Healthcare intervention can start within 24-48 hours after discharge

with a visit by a registered nurse (RN) to the patient’s house. The intervention continues for up to

! 25

sixty days from the date of discharge and can continue for subsequent sixty day episodes until

the patient completely recovers. During a patient’s stay with home healthcare, additional services

such as physical, occupational and speech therapy, home health aide and social worker services

are also provided. These services are provided on a weekly basis or as needed.

Home Healthcare agencies have an incentive to provide better care to patients. Early

discharge from Home Healthcare with less than five skilled services provided to patient can

result in reduction of payment to the agency. Home Healthcare agencies can also be penalized for

re-hospitalizations and not meeting the required quality metrics. Home Healthcare provides the

following services that can help reduce unnecessary readmissions (Logue, 2013):

• Providing information and education to patients about their health conditions,

how to identify red flags and self-monitoring.

• Help create up to date medication list by doing medication reconciliation.

• Reminding patients and caregivers about physician follow-up.

• Providing plan of care for timely recovery of patients

• Assess and help patient in getting other community resources

The combination of the Transitional Care Team and the Home Healthcare providers will help to

better coordinate patient care before and after discharge. The teams together will act as a liaison

between the hospital, patient, and primary care physician and will help smooth the transition of

care as it occurs (Fleming, 2013).

4.2.3. Care Coordination

In addition to standardizing the discharge medications process and the transition of care,

the coordination of care between the acute care providers and the primary care providers is

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another critical piece of this proposal. This coordination of care is necessary to keep patients out

of the hospital. Currently, patients discharged from University Hospital have less than a 50%

chance of seeing a primary care physician within 14 days of discharge. However, we know that

patients who are not seen within 72 hours of discharge have a markedly increased risk of

readmission (Cloonan, 2013). The primary care physician base in the community must be

involved in this project, or it is doomed to fail. We believe that it is essential for University

Hospital to set up an incentive program for the employed primary care physicians, to get them

invested in the project. As the hospital’s involvement in the ACO program evolves, those

payments related to decreased readmission rates could be utilized to fund the primary care

physician incentive program. A whole re-evaluation of the current payment model for these

physicians is likely necessary, as many organizations are moving away from a production-based

incentive program and towards a quality-based incentive program. However, for the purposes of

this proposal, the recommendation at this time is to develop an incentive program for the

employed primary care physicians of the hospital. This program should reward physicians who

consistently get discharged patients into the office to be seen within 72 hours of discharge and

who meet outpatient quality metrics set by Meaningful Use requirements. Because we know that

improvements in these two areas are directly related to decreased readmission rates, this program

will pay for itself in time. Additionally, given University Hospital’s ACO involvement, this will

help reduce per-patient expenditures and lower costs overall. A program that rewards primary

care physicians for improving quality of care provided, while also reducing costs of providing

that care is critical to the financial health of University Hospital moving forward. These steps in

improving coordination of care, in addition to recommendations elsewhere in this proposal to

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streamline information flow between care providers, will help facilitate improved care for

patients within the organization overall.

4.3. Patient education

One key element in reducing the admissions of patients and increasing their satisfaction is

in them getting the proper education regarding how to take their medicine and when to make

follow-up appointments. Patients who receive education on these factors are “30 percent less

likely to be readmitted or visit the emergency department than patients who lack this

information” according to a study funded by the Agency for Healthcare Research and Quality

(Jack, 2013).

One program that has shown signs of success has been Project RED, the Re-Engineered

Hospital Discharge Program considered to be a leading project in care coordination. This

program is put into place to help “nurses to help patients arrange follow-up appointments,

confirm medication routines, and understand their diagnoses using a personalized instruction

booklet” (Jack, 2013). The next step after the nurse interaction is for a pharmacist to contact the

patient up to 4 days after being discharged from the hospital in an effort to “reinforce the

medication place and answer any follow up questions” (Krames, 2013). The preliminary results

of the testing of Project Red showed that after 30 days after their hospital discharge, the 370

patients who participated in the RED program had 30% fewer subsequent emergency visits and

early readmissions than the 368 patients who did not. 94% of the patients who participated left

the hospital with a follow-up appointment with their primary care physician, compared to 35%

for patients who did not participate. 91% of participants had their discharge information sent to

their primary care physician within 24 hours of leaving the hospital (Krames, 2013).

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We would like to emulate this program at University Hospital. We will utilize the inpatient

EMR to suggest diagnosis-specific patient education at the time of discharge, and will build out a

reporting tool for University Hospital to use to determine which nurses are not providing this

education at hospital discharge. Additionally, we recommend utilizing the Transitional Care

Team to function as the pharmacist in the Project RED scenario above, to call the patient 2-3

days post discharge to verify the patient is taking medications and following care plans as

directed.

Finally, patient portals help to drive patient engagement and support patients while they

make health-related decisions and manage their own personal health information. Patient portals

can also serve as a communication channel between the patient and the physicians (physicians

who attended the patient during hospitalization and physician responsible for the follow-up care

after discharge). The portal can be used to share patient specific educational resources. Patients

can access clinical summaries online through the portal. Physicians can also choose to use the

patient portal to post the labs results with a brief message explaining the results. We recommend

optimizing the Portal currently used by University Hospital to include this functionality, and to

enhance the workflows outlined above.

4.4. Integration

4.4.1. Proposed Integrated System

The Capstone Group recommends the following steps to integrate the hospitals, outpatient

clinics, pharmacies and labs in the ACO.

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1. University Hospital uses Centricity EHR. The outpatient clinics use Epic EMR. There is

no electronic communication between the Hospital and outpatient clinics. This is a major

hurdle for transition of care between University Hospital and the primary care physician

or the home healthcare providers. Capstone Group recommends using CCDAs to bridge

the gap between the inpatient system and the outpatient systems and allow patient data to

flow across the continuum of care.

2. University Hospital is already using CPOE to electronically send and receive data from

labs, pharmacy, and radiology. But during our investigation it was observed that the labs

use different terms and test combinations. This causes confusion on the receiving end

(both inpatient systems and outpatient systems). Capstone group recommends using the

standards recommended by CMS in all labs. Use CPT codes for procedures and LOINC

codes for lab tests. Units of measure on the reported results must follow CMS

recommendation.

3. Capstone group recommends creating a centralized data warehouse and feed data from

all clinical systems (inpatient, outpatient, lab, pharmacy, radiology, etc.), financial

systems, operational systems and human resource (HR) systems. The data warehouse

could be used to generate metrics on patient care and provide possible recommendations

to the providers. Data can also be used for retrospective analysis for continuous quality

improvement.

Figure 3 depicts the proposed integrated system. Advantages of the proposed system

• An integrated system provides access to complete patient record from anywhere

anytime.

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• Potential data loss or incomplete patient record, due to manual consolidation of

patient data is eliminated.

• Allows seamless data flow between the systems.

• Addresses patient safety issues due to lost communication

• Facilitates dashboard development to track readmission rates

• Provides the necessary infrastructure for Inpatient clinical reports, Outpatient clinical

reports, Patient experience reports and Cross functional reports

• Track patient outcome with respect to financial impact

• Track patient outcome with respect to operational and staff changes

!

! 31

Figure 3: Proposed integrated system

4.4.2. Privacy Issues

With the implementation of new workflows, CMS quality measures, and technology changes, the

personal health information (PHI) of patients cared for by providers at University Hospital is at

risk. In particular, University Hospital must be cognizant to remain compliant with the

regulations included in the Health Information Portability and Accountability Act (HIPAA).

With the addition of a data warehouse to the current information technology infrastructure at

University Hospital, an agreement must be developed between the hospital and the Health

Information Organization (HIO). While a HIO is not a covered entity, it is a business associate,

under the HIPAA rules (45 C.F.R. §§ 164.502(e), 164.504(e)) (Department of Health & Human

Services, 2009). Therefore, University Hospital will need to engage legal counsel in order to

draft and enforce appropriate business associate agreements with the HIO managing and storing

the personal health information for the organization. This is outside of the scope of the proposal

presented by The Capstone Group and must be arranged by the hospital separate to this project.

Additionally, University Hospital must be cognizant of potential weaknesses in the

network that may compromise personal health information. As data is sent between physicians

and other care providers within the organization, it becomes more likely to be compromised.

Evaluation of network security is another element not provided by The Capstone Group, but is

necessary to remain HIPAA compliant. Considerations for the organization, as recommended by

The Department of Health and Human Services include utilizing unique and secure ID’s for all

users of the network, automatic log-out protocol, encryption and decryption of data, and

emergency access procedures (Department of Health & Human Services, 2009). All of these are

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considerations for University Hospital as they work to improve their information system to

reduce readmissions.

4.5. Use Case Diagram

Figure 4 depicts the use case diagram with Capstone Group’s proposed solution. Use cases in

yellow represents modification to the existing use case (using additional tools to improve care

and changes to the care delivery and discharge process). Use cases in green represent a new use

case added as a result of the proposed solution to improve patient care across the continuum of

care and reduce readmissions.

! Figure 4: Use case for workflow in proposed integrated system

! 33

5. Cost vs. Benefits Analysis

The benefit of implementing the proposed solutions will not only reduce the overall Medicare

readmission rate from 21% to 10%, but will also help University Hospital save $516,618 or 64%

in readmission penalties.

Year 2013 2014 2015 Total for 3-

years

Penalty 1% 2% 3%

No. of Medicare admissions

7500 7500 7500

Average Medicare hospitalization rate in the service area

$13,387 $12,718 $13,119

Total Medicare payment per annum

$100,402,500 $95,382,375 $98,394,450 $294,179,325

Medicare payment for readmissions

$21,419,200 $9,538,238 $9,839,445 $40,796,883

Readmission payments for (AMI, Heart Failure and Pneumonia)

$13,922,480 $3,433,766 $2,951,834 $20,308,079

Penalties after implementation of proposed solutions

$139,225 $68,675 $88,555 $296,455

Penalties before implementation of proposed solutions

$139,225 $264,527 $409,321 $813,073

Savings in penalties due to implementation of proposed solutions

$0 $195,852 $320,766 $516,618

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Table 5: Projected Return on Investment

Before the implementation of the proposed solutions 65% of the readmissions were

patients with either one or a combination of AMI, CHF, and pneumonia. After implementation of

the proposed solutions the readmissions of patients with the three diagnoses will be 33%.

The estimated costs of implementing the proposed solutions will be $470,000. Majority

of the estimated costs will be utilized for upgrading and integrating the infrastructure, training,

consultancy and other expenses.

In the next two years, the proposed solutions will help University Hospital gain 10%

Return on Investment (ROI).

6. Project Plan 6.1. Introduction !The implementation approach proposed for the solution will take on a multi-phased approach

over the course of a (12) month timeline beginning in January 2014. Core groups of work that

will be concentrated on are as follows 1) Project Management, 2) Infrastructure, 3) Application

Solution, 4) Testing, 5) Training, 6) Operations and Communications. The work will be broken

out in the following project phases or milestones:

• Planning

Estimated cost of proposed solutions

($188,000) ($211,500) ($70,500) ($470,000)

Return on investments

($188,000) ($15,648) $250,266 $46,618

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• Design

• Build

• Testing

• Deploy and Close

Capstone consulting project plan aims to clearly manage goals, strong communications, realistic

schedules, a cost – schedule – quality equilibrium supported by detailed plans. The Project Plan

and associated work breakdown structure will become the working documents of the project and

updated throughout the life of the project.

Project success factors:

• Agreement among the project team, customer, and management on the goals of the

project.

• A plan that shows an overall path and clear responsibilities, which is also used to measure

progress during the project.

• Constant, effective communication between everyone involved in the project.

• A controlled scope.

• Management support.

6.2. Project Governance !

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Project governance is illustrated in (2) ways for the Medicare Readmission Reduction (MRR)

project. Both diagrams are submitted as addendums (A & B).

Overall Project Governance – The overall project governance reflects the organizational

governance structure w/ respect to the MRR. As illustrated in addendum A, the project itself will

run up through the Chief Operations Officer at University Health. Other key decisionmakers and

business/clinical unit representation will be a part of the MRR Oversight committee. These key

members will represent:

• Information Technology

• Physician stake holders

• Nursing Stakeholders

• Revenue Cycle / Finance

• Patient Care Services

Additionally, the responsibilities of the project leaders vary from direction on the tactical/

operational approach of the project, as well as execution, and overall organizational strategy. As

the MRR project is not just focused on technology, and financial goals, there is also clinical

representation both at execution and steering committee.

ITS Project Team Governance – An additional governance chart (addendum B) has been

supplemented to highlight the governance structure with respect to the actual project execution.

As you review you will notice the different teams that will comprise the overall project team and

their roles with:

! 37

• Design / Build / Testing

• Training Development

• Training Delivery

• Implementation / Operations

Please note that the steering committee will work in coordination with the patient care service

team, and the overall EMR leadership team with ultimate reporting up to the MRR oversight

committee as highlighted in the overall project governance chart.

6.3. Project Roles and Responsibilities !Below are the project team members that will be involved with project execution and a brief

review of their responsibility. A full review of roles by responsibilities has been submitted as

addendum C.

Role Responsibilities

Clinical Adoption Mgr.

Participate and/or lead design sessions to ensure that system design and workflows support clinical care & departmental processes

MRR Clinical Analysts

Development of business process solutions and requirements with support from application support

MRR Educators Conduct training sessions following predefined standards

MRR Oversight Resolve and/or Escalate to project concerns/issues to Executive Sponsor as needed

MRR Training Lead Lead team to design enterprise-focused learning objectives, course outlines, assessments, storyboards, instructor manuals, and participant materials

! 38

Table 6: Project Roles and Responsibilities

6.4. Project Assumptions, Constraints and Dependences

6.4.1. Assumptions • Accurate and Timely Documentation – One key design feature of the MRR project will be

its ability to mine discreet patient data that is deemed critical to identifying the high risk

patient population. To be effective, the data in the patient record will need to be wholly,

accurate and timely.

• Decision Support - Another key feature of the MRR project will be its ability to provide

clinicians with evidence based patient care instructions. For the project to be effective the

Dept. Business Owner

Oversee identification, review, modification and creation of clinical policies and procedures and discharge instructions.

Education Liaison Develop and maintain training plan and training work breakdown structure

Executive Sponsor Provide overall strategic leadership to the project

MRR Design Lead Business solutions & requirements: Lead gathering and documentation

Project Director Resolve issues escalated from Project Manager, Accountant, and Architect

Project Manager Provide project tracking for each affected system and process within the project scope

Resource Manager Work with the Project Manager to staff the project appropriately so timelines and targets can be achieved

Role Responsibilities

Clinical Adoption Mgr.

Participate and/or lead design sessions to ensure that system design and workflows support clinical care & departmental processes

! 39

care instructions developed as part of the MRR initiative will need to be reviewed and

executed accordingly.

• Scope- While the MRR project will focus on (3) core measures, the project understands

there are other core measures that can adversely affect organizational readmission

statistics. This project assumes no more than a moderate (+/-3%) deviation in the core

measures outside of the scope of this project in order to drive down the whole

organizational readmission population.

• Integration – In order to observe the benefits of fully integrated patient data across the

whole care team and both University Health EMR’s (Centricity/Epic) this project assumes

significant investment in integration and interoperability efforts between both systems

and standardization of data standards

6.4.2. Constraints / Limitations • <Data Standards>– In the current state the University Health existing architecture hosts

(2) separate EMR’s. This is identified as a limitation to this project with regards to the

lack of standardization of data across both EMR’s.

o To counter this constraint we propose significant work be invested in identifying

organizational data standards with respect to patient data being documented by

provider and exchanged from system to system

• <Data Sources>– Again, with the existing architecture and use of (2) separate EMR’s,

clinicians application workflow, data mining/reporting will be constrained.

! 40

o To counter this constraint, the project proposes significant investment and time

into the development of future state workflows and development ofclear policies

and procedures for use of both EMR’s.

6.4.3. Dependencies !Below is a list of project dependencies for the MRR project. Meaningful Use Stage 2 project

will impact the future state integration architecture and standards for University Health.

Additionally, the ICD-10 implementation will have significant impact on billing / reimbursement

as well as documentation standards in the future state.

!

Table 7: Project Dependencies

6.5. Quality Management Plan !The MRR project will utilize the following tools to monitor and control the progress, project

objectives, quality, and risk with regards to the project. Capstone consulting believes monitoring

and controlling affects all other phases of the project life cycle.

Risks / Issues – Will be documented in a Microsoft SharePoint site designed uniquely for the

project. Risks and issues documented will be communicated to the project manager as well as

the lead for the particular phase of the project (i.e. design/training, implementation) for tracking

and escalation purposes.

Description Status Owner Escalation Date

Due Date

Meaningful use stage 2 Open MU PM 1/1/2014 6/30/2014

ICD -10 Open ICD 10 PM 1/1/2014 10/1/2014

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Time Tracking –Will be documented and managed utilizing Microsoft Project Server. Time

tracking will be assessed by phase and project activity by the team member responsible for the

work. Time tracking will assist the project leadership with future phase cost and resource

planning.

Project Progress – Will be documented by the Project Manager in Microsoft Project will be

integrated to project server.

6.6. Communications Management Plan

6.6.1. General Guidelines

Capstone consulting has developed thefollowing guidelines for all project communications --

• Communicate with all affected parties.

• Every message should be audience-specific.

• Set appropriate expectations.

• Provide regular, unbiased reporting of project progress.

• Communicate with other people before they need to know the information. Provide time

to assimilate the information.

6.6.2. Key Groups

Below is a list of the key groups of people with whom the project manager and/or project team

will communicate with during the project.

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Table 8: Project Key Groups

6.7. Risk Management Plan !The following risks have been identified by Capstone consulting and are evaluated based on

• Likelihood

• Impact

• Severity

Groups Members

Project Sponsor(s) Chief Operation Officer (University Health)

Project Team • Clinical Adoption Mgr • MRR Clinical Analysts • MRR Educators • MRR Training Lead • Department Business Owners (Department Managers) • Educator Liaison • MRR Design Lead • Project Director • Project Manager

Department Stakeholders

• Ambulatory Medical Directors • Acute Care Medical Directors • ICU Managers • ED Managers • Ambulatory Clinic Managers • Cardiology Managers / Directors • Director of Pharmacy • Director of Lab Operations • Director of Radiology • Home Health Managers

ClinApps Project Management Office (PMO)

Project director / Project Manager

Resource Managers Resource Managers

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Table 9: Risk Management Plan

6.8. High Level Functional Requirements !General

• Integrates with existing Centricity and EPIC EMR architecture

Integration

• Development of additional system to system integrations with adherence to CCDA

standards

• Full integration ability with all ancillary systems

Risk Likelihood Severity Impact Mitigation

Project Resources – With so many regulatory projects in 2014 such as ICD-10 and Meaningful Use there is a risk of recruiting and retaining project resources

Highly Likely

HIGH HIGH impact to timeline

Contracting staff

Clinical Adoption – Additional Decision support functionality if improperly designed and trained can impact adoption and impede clinical workflow

Likely High Significant impact to project goals

• Training Assessment

• Post-Go Live Monitoring and assessment of log files

• Qualitiative post-production surveys by users

ICD-10 – The ICD-10 project poses significant risk to reimbursement as well as documentation standards for providers.

High High Significant • Add ICD-10 validation checkpoint as part of requirement acceptance

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o Lab

o Radiology

o Pharmacy

o Home Health

o Primary Care providers portals

Decision Support

Alert Functionality - must identify patient data with respect to the following 3 measures and alert

based on reference range violation developed as part of application design efforts (see core

measures above in section 4.1)

!• Congestive Heart Failure

• Acute Myocardial Infarction

• Pneumonia

Decision Support Functionality – Based on identification of high risk alerts and patient

identification, system will provide detailed plan of care instructions to providers with respect to:

• Discharge Summary

• Follow-Up visits

• Communication to entire patient care team

• Patient Triage

• Coordinated provider hand-off

• Tailored medication reconciliation

• STAT routing for all lab

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• Documentation of Vitals

• Tailored assessment instructions

• Tailored communication and follow up messaging thru Patient Portal

Printing

• Patient Discharge Summary out of both EMR’s in addition to patient portal

• Add new printing devices (as needed)

Workflow

• Complies with ICD-10 documentation requirements

• Complies with MU requirements

Reports

• Ability to assess increase / decrease of readmission within core measure population

Hardware

• Servers

6.9. High Level Workflow Requirements !Based on development of policies and procedures new workflow requirements will need ability

to tailor the following to high risk protocols created as part of the MRR project -

• Discharge Summary

• Follow-Up visits

• Communication to entire patient care team

• Patient Triage

• Coordinated provider hand-off

• Tailored medication reconciliation

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• STAT routing for all lab

• Documentation of Vitals

• Tailored assessment instructions

• Future Orders

6.10. Metrics & Measurements !Measurements of readmission volume will be completed every (3) months. The following teams

and responsibilities have been highlighted for providing the metrics and measuring of them –

Operations – Will provide figures on the number of readmissions broken out by 1) chief

complaint 2) primary diagnosis. Operations will also provide figures and input on qualitative

surveys completed by patients as well as users of the system for continuous process improvement

IT – Will provide data figures on the amount of alerts triggered, appropriateness and adoption of

decision support steps provided

RevenueCycle – Will provide figures on the amount of reimbursement and subsequent additional

cost of readmission

6.11. Testing !Capstone consulting will also complete a detailed testing assessment as part of the project

implementation plan. A multi-phased testing approach will be utilized.

The objectives of testing for the University Health Readmission Reduction projectare to:

• Document that the system reliably and repeatedly performs as designed.

• Ensure regulatory documentation standards are met.

• Verify business and system requirements are satisfied.

! 47

• Capture discrepancies (problems) to eliminate defects.

• Establish testing documentation that can be reused for system maintenance.

• Provide information to assess go-live readiness.

• Practice a dress rehearsal build and testing

Key testing milestones and purpose will include –

Unit Testing

Unit testing will focus on application components (i.e. a unit of functionality) as they are built.

For a specific list of units that will be tested, please refer to high level requirements section

(above). Unit testing verifies basic application components work as designed during the build

process.

Application / Functional Testing

Application Testing confirms that the component functions of the product/application perform to

meet the business and technical design requirements. Focus is on software defects. This testing

will confirm correct configuration of the infrastructure as well. The application testing will focus

on the full system requirements and how they flow together, beginning with the alert and on to

the decision support guidance and full system integration and communication to the full patient

care team.

Regression / Performance

Performance Testing validates the ability of the application to function under maximum volumes

and peak transaction loads.

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Also serves to validate the technical environment supporting the application under normal and

stressed conditions.

• Stress Testing attempts to find system defects exposed by overloading its resources in a

short span of time. An example of this method of testing is for multiple users to open a

flow sheet at the exact same time.

• Volume Testing determines the system’s general ability to handle heavy volumes of data.

This is exemplified when many users are using a variety of applications simultaneously.

Focus is on response time and system performance.

Integration Testing

Integration Testing validates the ability of the application of the MRR system, to communicate

and exchange data between BOTH EMR’s in the normal or proposed course of a clinical

encounter. It also verifies that processes between all ancillary systems to behave as expected,

whether a new anticipated process change or continuance of an existing one. Additionally,

integration testing will assess the systems ability to successfully operate thru use cases, similar to

one illustrated as part of this project proposal.

!6.12. Training Plan !Training Plan - A detailed evaluation for training will be incorporated into the projects

implementation plan. The training strategy will have two core focuses:

➢ Curriculum Development

➢ Education

! 49

The curriculum development aspect will begin by assessing the content that will be delivered, ,

all resources for content. The key exercise in curriculum development will be the stakeholder

analysis as the project will look to identify what individuals will be impacted most by the

projects solution, the level of impact. Additionally, an assessment into their existing experience

in both EMR’s as well as any prerequisite knowledge needed and preferred method of training.

Content will ultimately be driven by both the workflow and application requirements designed

by the subject matter experts from the departments and the clinical analysts designing the

system.

The education aspect will focus on the execution of training, the coordination, logistics and

methods for delivering the content. Recommended options for training are as follows:

➢ Classroom

➢ Online

➢ Self Study

➢ Job Aids

➢ Blended solution of classroom and online

6.13. Deployment !Capstone consulting recommends a big bang approach of implementing ALL functionality at

once, commonly known as a big bang approach. The deployment will have one centralized

command center that will be staffed by the project team and any additional resources. The

! 50

deployment coverage will focus on at the elbow support for the end-users as well as a team

responsible for triage of service requests, troubleshooting, testing and education needed.

6.14. Schedule !Major Milestones Target Completion

Date

Pre-Planning

• Project Approval 12/1/2013

Planning

• Project kick-off meeting 1/6/2014

• Initial Work Breakdown Structure (WBS) approval

1/13/2014

• Technical Environment Planning 1/20/2014

• Project Charter Sign-off 1/27/2014

• Project Plan Sign-off 1/27/2014

• MRR QA Checkpoint #1 - Planning 1/31/2014

Design

• Design workshops complete 4/25/2014

• Initial design review complete 5/2/2014

• MRR QA Checkpoint #2 – Design 5/9/2014

Build

• Test cases identified/scripts written 7/25/2014

• Build Complete 8/1/2014

• MRR QA Checkpoint #3 – Build 8/8/2014

Testing

• First round of integrated testing complete 8/29/2014

• Second round of integrated testing complete 9/26/2014

• MRR QA Checkpoint #4 – Testing 10/3/2014

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Table 10: Schedule

7. Conclusion

We have found that the current system has limitations, hindering the quality of care

delivered and hurting the hospital financially. The project proposal is intended to bring new

technology and processes that will reduce University Hospital’s 30-day readmission rate, but also

improve the bottom line. Upfront the cost may seem daunting, but the return on the investment is

set to be at 10%. Going forward, the benefits come not only from meeting CMS measures, but

also from the trust developed with the community. As hospital operations become more

transparent, readmission data will be a large variable that the community uses to decide what

Production Readiness

• Hardware installed and printing configuration complete

11/3/2014

• Curriculum development & training preparation complete

10/3/2014

• Training for first site complete 11//28/2014

• Go-live prep activities for first facility complete

11//28/2014

• Go No Go Decision for site #1 approved 10/3/2014

Go Live

Site 1 Implementation 12/3/2014

Project Close

• Post Implementation Review 3/31/2015

• Project Close-out Report complete 5/1/2015

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hospital to receive treatment. Having an improved system in place allows for better quality of

care provided to patients allowing for closer ties between the community and hospital. Our

proposal not only provides a plan to improve the current state of the hospitals readmissions, but

also becomes a solid foundation for future improvements. As the healthcare system transitions to

a more modernized and integrated one, University Hospital will be ready for the future of

healthcare.

!

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!8. References Centers for Medicare & Medicaid Services. (2013). Quality Measures. Retrieved November 26, 2013 from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/Hospitals-and-CAH-2014-Proposed-EHR-Incentive-Program-CQM.pdf !Cloonan, P., Wood, J., & Riley, J. B. (2013, July/August). Reducing 30-Day Readmissions [Journal]. The Journal of Nursing Administration, 43(7/8), 382-387. http://dx.doi.org/10.1097/NNA.0b013e31829d6082. Retrieved on November 04, 2013 !Department of Health and Human Services. (2009). Security 101 for Covered Entities. Retrieved December 4, 2013 from: http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/security101.pdf !Fleming, M., Haney, T. (2013). Improving patient outcomes with better care transitions: The role for home health. Cleveland Clinic Journal of Medicine, 80(e-Suppl 1), e-S2. Retrieved on October 9, 2013 from http://www.ccjm.org/content/80/e-Suppl_1/e-S2.full !Gerhardt, G., Yemane, A., Hickman, P., Oelschlaeger, A., Rollins, E., Brennan, N. (2013). Medicare Readmission Rates Showed Meaningful Decline in 2012. Medicare and Medicaid Research Review, 3(2), E1-E12. !Good Shepard Medical Center. (2013). Quality: What are Core Measures? Retrieved December 7, 2013 from: http://www.gsmc.org/quality/. !HIMMS (2012). Reducing Readmissions -Top Ways Information Technology Can Help Retrieved October 13, 2013 from: http://www.himss.org/files/HIMSSorg/content/files/ControlReadmissionsTechnology.pdf !Jack, B., Passche-Orlow, M., Mitchell, S., Forsythe, S., Martin, J. (2013). Re-Engineered Discharge (RED) Toolkit. Agency for Healthcare Research and Quality. Retrieved October 14, 2013 from: http://www.ahrq.gov/professionals/systems/hospital/toolkit/redtool1.html# !Joynt, K., Jha, A. (2013). A Path Forward on Medicare Readmissions. New England Journal of Medicine, 368(13), 1175-1177. Retrieved on October 24, 2013 from: http://www.nejm.org/doi/full/10.1056/NEJMp1300122 !Kansagara, D., Englander, H., Salanitro, A., Kagen, D., Theobald, C., Freeman, M. (2011). Risk Prediction Models for Hospital Readmission, A Systematic Review. Journal of the American Medical Association; 306(15): 1688-1698.

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!Krames Patient Education. (2013). Reducing Hospital Admissions With Enhanced Patient Education. Retrieved October 14, 2013 from: http://www.bu.edu/fammed/projectred/publications/news/krames_dec_final.pdf !Logue, M., Drago, J. (2013). Evaluation of a modified community based care transitions model to reduce costs and improve outcomes [Magazine]. BMC Geriatrics, 13(94), 1-11. http://dx.doi.org/10.1186/1471-2318-13-94. Retrieved on October 24, 2013 !Memorial Health. (2013). Quality Data. Patient Satisfaction. Retrieved November 26, 2013, from https://www.memorialhealth.com/quality-data.aspx !The Society of Hospital Medicine (2013). Risk Assessment Tool: The 8 P’s. Retrieved November 3, 2013 from: http://www.hospitalmedicine.org/ResourceRoomRedesign/RR_CareTransitions/html_CC/06Boost/03_Assessment.cfm !Stewart,S., Marley, J., Horowitz, J. (1999). Effects of a Multidisciplinary, Home-based Intervention on Planned Readmissions and Survival Among Patients with Chronic Congestive Heart Failure: A Randomized Controlled Study. Lancet; 354(9184): 1077-1083. !Stauffer, B., Fullerton, C., Fleming, N., Ogola, G., Herrin, J., Martin, S. (2011). Effectiveness and Cost of a Transitional Care Program for Heart Failure. Journal of the American Medical Association Internal Medicine; 171(14): 1238-1243. !The HCAHPS Survery. (2013). The HCAHPS Survey: Frequently Asked Questions. Retrieved December 8, 2013 from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/downloads/HospitalHCAHPSFactSheet201007.pdf !!!!!!!!!!!!!!

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!9. Appendices 9.1. Appendix A—Project Structure !

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!9.2. Appendix B—Project Governance !

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MRR Project GovernanceUniversity Health COO

MRR Oversight Commitee

MRR Operational Leadership

Team

MRR Project Mgt Team

Project Team/s

CMOs

CMIO

Clinical Adoption Mgr

- University Health CIO, Chairman- Medical Director- CNO- Revenue Cycle Director- ITS Medical Director - Director of Pharmacy Services

Organization Communication

Lead

Benefits & MetricsCoordinator

HRSupport

Strategic Governance

Project Execution

Tactical / Operations Governance

Responsibility Key

ITS Liaison /PCIS Director

Assoc Administrators

PCS

Clinical Governance

ITS Governance

Physician Lead

ITS Program Director

ITS ClinApps Project Director

MRR Clinical Advisory Team

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!9.3. Appendix C—Roles and Responsibilities !Role Responsibility

Clinical Adoption Mgr

Acceptance: Responsible for working with clinical areas on usability and acceptance testing

Clinical Adoption Mgr

Business solutions & requirements: Facilitate clinical input and documentation of requirements

Clinical Adoption Mgr

Business solutions & requirements: Manage changes to clinical processes and workflow related to implementation

Clinical Adoption Mgr

Communications: Coordinate with Project Management Office Communications Coordinator

Clinical Adoption Mgr

Communications: Develop communications content for distribution to nursing and essential service departments

Clinical Adoption Mgr

Communications: Liaison to HR regarding role changes for clinical staff

Clinical Adoption Mgr

Communications: Provide communications to corporate communications for distribution

Clinical Adoption Mgr

Communications: Serve as single point of contact for nursing and essential service department leadership to provide clinical input into the MRR project.

Clinical Adoption Mgr

Communications: Manage the communications Medical Center Leadership & Department stakeholders

Clinical Adoption Mgr

Communications: To clinical leadership on system requirements and change management

Clinical Adoption Mgr

Concerns & Issues: Escalate to Project Manager or Project Leadership Team

Clinical Adoption Mgr

Design: Lead development of workflow crosswalk documentation to support process changes

Clinical Adoption Mgr

Design: Participate and/or lead design sessions to ensure that system design and workflows support clinical care & departmental processes

Clinical Adoption Mgr

Device: Assist Device Specialist in developing the device planning

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Clinical Adoption Mgr

Education: Participate in MRR vendor led application training to gain understanding of MRR functionality and product features/capabilities as they relate to future-state workflows & system design

Clinical Adoption Mgr

Implementation plans & support: Develops with Site Managers and project leadership

Clinical Adoption Mgr

Implementation plans & support: Develop and direct EMR unit experts in performing clinical department readiness assessments for MRR

Clinical Adoption Mgr

Implementation plans & support: Working together with the EMR Site Mangers, develop a deployment plan that supports providers, nurses and other clinicians

Clinical Adoption Mgr

Leadership: Escalate critical issues to senior leadership providing recommended solutions

Clinical Adoption Mgr

Leadership: Provide monthly updates both oral and written to University Health Senior Leadership on the project’s progress especially around potential clinical impacts.

Clinical Adoption Mgr

Leadership: Represent University Health Senior Leadership in project activities

Clinical Adoption Mgr

Leadership: Together with MD Lead, co-chair MRR Leadership Team

Clinical Adoption Mgr

Leadership: Recruit & supervise assigned clinical experts (subject matter experts) during system deployment

Clinical Adoption Mgr

Membership: MRR Leadership, MRR EMR Governing, MRR Global Decisions Group

Clinical Adoption Mgr

P&P: Oversee identification, review, modification and creation of clinical policies and procedures and discharge instructions.

Clinical Adoption Mgr

Quality: Ensure system supports quality initiatives

Clinical Adoption Mgr

Quality: Lead clinical workgroups to gather input, feedback, and resolve issues

Clinical Adoption Mgr

Quality: Liaison to existing quality groups to determine benefits and metrics measurements

Clinical Adoption Mgr

Quality: Maintain an expert knowledge or JCAHO and other hospital regulations

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Clinical Adoption Mgr

Quality: Participate in deployment reviews

Clinical Adoption Mgr

Quality: Participate in project QA reviews

Clinical Adoption Mgr

Quality: Provide project feedback at regular intervals to the Project Management Office and EMR Project Manager

Clinical Adoption Mgr

Quality: Serve as the MRR liaison to existing clinical committees

Clinical Adoption Mgr

Training : Act on evaluation data as needed

Clinical Adoption Mgr

Training: Assist with development of resource estimations

Clinical Adoption Mgr

Training: Identify audience for training

Clinical Adoption Mgr

Training: Participate in creation of the EMR Training Request & MRR Project Training Plan

Clinical Adoption Mgr

Training: Participate in curriculum design sessions

Clinical Adoption Mgr

Training: Provide input and feedback on all deliverables from the EMR Education team

Clinical Adoption Mgr

Training: Work with MRR Training Lead to ensure clinical expert users & project team support staff are adequately prepared to support the MRR deployment (training & materials)

Clinical Adoption Mgr

Training: Ensure that the MRR education program supports clinical training needs

Clinical Adoption Mgr

Workflow: Manage the catalog of future state workflows for clinical departments

MRR Clinical Analysts

Business solutions & requirements: develop together with application support and other team members.

MRR Clinical Analysts

Business solutions & requirements: Responsible for documenting business process solutions and requirements

MRR Clinical Analysts

Business solutions & requirements: Work with project team members assisting in their understanding of technical, customer and business process requirements.

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MRR Clinical Analysts

Concerns & Issues: Raise issues and concerns to the project manager and project leadership team, where appropriate.

MRR Clinical Analysts

Coordinate with SMEs and application support Team throughout project

MRR Clinical Analysts

Deadlines: Work to meet project deliverable deadlines

MRR Clinical Analysts

Devices - Develop of business process solutions and requirements with support from application support

MRR Clinical Analysts

Implementation plans & support: Participates in deployment and support plan development and implementation

MRR Clinical Analysts

EMR: Completes and maintains Spec documentation (data collection tools)

MRR Clinical Analysts

PM: Assist in the development and refinement of the high-level project plans.

MRR Clinical Analysts

Status Reports: Complete status reports

MRR Clinical Analysts

Test Plans & Objectives - Assist with development

MRR Clinical Analysts

Time Tracking: Participate in time tracking activities per procedure

MRR Clinical Analysts

Workflow: Responsible for completing current and future workflow documents

MRR Clinical Analysts

Workflows: Responsible for understanding vendor solutions and how they can be best utilized in clinical workflows.

MRR Educators Time Tracking: Participate in time tracking activities per procedure

MRR Educators Training: Analyze, design, and develop, and review training outlines and materials as needed following predefined standards

MRR Educators Training: Conduct training sessions following predefined standards

MRR Educators Training: Gather evaluation data and distribute it to Site Managers and Training PM

MRR Educators Training: Provide input and updates to the Education Liaison on tasks completed or in progress

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MRR Educators Training: Provide input and updates to the Lead Educator and/or Site Education Coordinator on tasks completed or in progress

MRR Educators Training: Provide input to Lead Educator or Site Education Coordinator for status reports

MRR Educators Training: Train staff and physicians

MRR Educators Training: Curriculum and training materials development

MRR Oversight Team

Acceptance Criteria: Approve

MRR Oversight Team

Communications: To hospital clinical leadership

MRR Oversight Team

Concerns & Issues: Escalate to Executive Sponsor as needed

MRR Oversight Team

Concerns & Issues: Resolve issues escalated from the Project Leadership Team

MRR Oversight Team

Implementation plans & support: Lead the development of the implementation strategy

MRR Oversight Team

Leadership: Review & approve key project documents

MRR Oversight Team

Leadership: Review and approve requirements & design decisions

MRR Oversight Team

Leadership: Provide vision, oversight, and guidance to the Project Leadership Team

MRR Oversight Team

Membership: Member of the MRR Steering Team

MRR Oversight Team

QA: Participate and approve QA checkpoint results as appropriate

MRR Oversight Team

Training: Approve training content

MRR Oversight Team

Training: Review and sign-off on training plan

MRR Training Lead

Communications: Attend project meetings and report decisions, action items, and project elements impacting training back to the EMR Education Teams,

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MRR Training Lead

Communications: Execute communication plan as defined in the 400 EMR Training Plan document working with Communication Lead

MRR Training Lead

Communications: Provide input and updates to the Training Project Manager on tasks completed or in progress

MRR Training Lead

Coordinate: Coordinate clinicians (Nursing, Physicians, Pharmacy, etc.) to review training curriculum

MRR Training Lead

Coordinate: Coordinate efforts the EMR Educators, TEACH/TRAIN Domain Administrator, Training Ops/Scheduling Coordinator and Project Management Teams

MRR Training Lead

Coordinate: Coordinate with the MRR EMR Training Project Manager, MRR EMR Project Manager and the MRR EMR Project Management Team

MRR Training Lead

Deadlines: Work to meet project deliverable deadlines

MRR Training Lead

Deadlines: Work to meet project deliverable deadlines

MRR Training Lead

Implementation plans & Support: Participate in conversion support

MRR Training Lead

Issues & Concerns: Bring forward departmental related training issues to Project Manager/s) documenting in bugzilla.

MRR Training Lead

Lead: Monitor work of MRR Education Team

MRR Training Lead

Lead: Serve as liaison between project team and EMR Education Team/s) – to include all sites within the project scope

MRR Training Lead

Leadership: Serve as a role model for Educators, TEACH/TRAIN Domain Administrator, Training Ops/Scheduling Coordinator and expert users

MRR Training Lead

Membership: Participate in ongoing project meetings

MRR Training Lead

PM: Contribute to the development of the Implementation Management Plan

MRR Training Lead

PM: Provide input to the Training Project Manager for the training work breakdown structure (WBS)

MRR Training Lead

PM: Provide regular status reports to project manager

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MRR Training Lead

PM: Develop status update reports and submit them to the MRR EMR Project Managers

MRR Training Lead

Time Tracking: Participate in time tracking activities per procedure

MRR Training Lead

Training: Lead one or more curriculum design and development teams

MRR Training Lead

Training: Assign and monitor Educators to complete training task analysis based on delta between current and future state workflows

MRR Training Lead

Training: Assign Educators to specific functional (system oriented) or role-based (job oriented) teams

MRR Training Lead

Training: Assign Educators, TEACH/TRAIN Domain Administrator, and Training Ops/Scheduling Coordinator to specific tasks per the MRR EMR Training WBS and various teams as appropriate and provide oversight

MRR Training Lead

Training: Conduct and support the training class evaluation and feedback requirements

MRR Training Lead

Training: Develop and document training schedule requirements and resource needs with input from the Site Education Coordinators and/or Education Team Members

MRR Training Lead

Training: Lead team in identifying how to sequence training content

MRR Training Lead

Training: Lead team to design enterprise-focused learning objectives, course outlines, assessments, storyboards, instructor manuals, and participant materials

MRR Training Lead

Training: Monitor work of Education Team to achieve project tasks

MRR Training Lead

Training: Organize and facilitate tasks and schedules for expert users / subject matter experts participating in design, review, and delivery of training and education

MRR Training Lead

Training: Participate in reviews of the current and future state workflows

MRR Training Lead

Training: Participate in the gathering and documentation of the current state training materials

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MRR Training Lead

Training: Perform Quality Assurance function / review of all curriculum (learning objectives, course outlines, storyboards, instructor manuals, and participant materials) to ensure consistency and alignment with EMR Education standards

MRR Training Lead

Training: Perform Quality Assurance function on training task analysis

MRR Training Lead

Training: Perform Quality Assurance function regarding current and future state workflows

MRR Training Lead

Training: Proctor training courses

MRR Training Lead

Training: Provide content to the Clinical Applications Communication Lead and/or Site Managers for department specific communications regarding training and education as needed

MRR Training Lead

Training: Provide MRR EMR training for users in all disciplines, applying knowledge of health care environment and clinical practice as the operational training lead

MRR Training Lead

Training: Provide feedback regarding ongoing issues or concerns with curriculum design via Bugzilla

MRR Training Lead

Training: Provide input into development and refinement of the detailed training project plans

MRR Training Lead

Training: Provide Trainer/Super User training - this may include classroom and one-on-one instruction

MRR Training Lead

Training: Lead team to develop interactive training materials (includes instructor and participant materials, including competency assessments) to support the most appropriate use of clinical applications

Department Business Owners (Department Managers)

Acceptance: Responsible for working with clinical areas on usability and acceptance testing

Department Business Owners (Department Managers)

Business solutions & requirements: Facilitate clinical input and documentation of requirements

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Department Business Owners (Department Managers)

Business solutions & requirements: Manage changes to clinical processes and workflow related to implementation

Department Business Owners (Department Managers)

Communicate: To clinical leadership on system requirements and change management

Department Business Owners (Department Managers)

Concerns & Issues: Escalate to Project Manager or Project Leadership Team

Department Business Owners (Department Managers)

Membership: Member of Department Project Leadership Team and/or Steering Team

Department Business Owners (Department Managers)

P&P: Oversee identification, review, modification and creation of clinical policies and procedures and discharge instructions.

Department Business Owners (Department Managers)

Training : Act on evaluation data as needed

Department Business Owners (Department Managers)

Training: Assist with development of resource estimations

Department Business Owners (Department Managers)

Training: Identify audience for training

Department Business Owners (Department Managers)

Training: Provide input and feedback on all deliverables from the EMR Departmentucation team

Educator Liaison Member: Project Team

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Educator Liaison Time Tracking: Participate in time tracking activities per procedure

Educator Liaison Training: Develop and maintain training plan and training work breakdown structure

Educator Liaison Training: Provide communications between user-educator-build/project team.

Educator Liaison Training: Communicate status of training work back to the project team / project manager.

Educator Liaison Training: Coordinate EMR Education team members to complete tasks

Educator Liaison Training: Develop resource estimates

Educator Liaison Training: Serve as liaison between project team and EMR Education Team

Executive Sponsor

Concerns & Issues: Address issues & decisions that can not be resolved by Steering Committee

Executive Sponsor

Leadership: Provide overall strategic leadership to the project

Executive Sponsor

PM: Perform final sign-off on key project documents

MRR Design Lead

Business solutions & requirements: Lead gathering and documentation

MRR Design Lead

Communication: Provides project communication to the CA Team

MRR Design Lead

Coordinate: Creation of functional and detail design documents

MRR Design Lead

Deadlines: Work to meet project deliverable deadlines

MRR Design Lead

Design: Develop current & future state design standards and enforce their use

MRR Design Lead

Design: Develop process for documentation of current and future state

MRR Design Lead

Design: Develop with Application Build Lead standardized specification document tools

MRR Design Lead

Leadership: Direct work of Clinical Analysts monitoring progress & quality

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MRR Design Lead

Leadership: Enforce standardized documentation of issues in Bugzilla by MRR Clinical analyst Team

MRR Design Lead

Leadership: Escalate critical issues to project manager & MRR Leadership Team

MRR Design Lead

Meetings: Lead Work Status Meetings/Interviews

MRR Design Lead

Membership: MRR EMR Governing & MRR Global Decisions Group

MRR Design Lead

Membership: Represents application support on the EMR MRR Governing Team & Global Decision Team

MRR Design Lead

PM: Assist in the development and refinement of the high-level project plans.

MRR Design Lead

PM: Completes tasks as assigned in project plan

MRR Design Lead

PM: Contribute to the development of the Implementation Management Plan

MRR Design Lead

PM: Provide regular status reports to project manager

Project Director Concerns & Issues: Escalate to Program Director or MRR Steering committee.

Project Director Concerns & Issues: Resolve issues escalated from Project Manager, Accountant, and Architect.

Project Director Coordinate: Scheduling project management activities and tasks across EMR projects.

Project Director Enforce use of standards

Project Director PM: Review and approves project documentation.

Project Director Vendor Management: EMR project level management of vendor relationship across all sub-projects.

Project Director Vendor Management: Enforce compliance with terms and conditions of contract amendments and agreement letters.

Project Manager Acceptance Criteria: Develop initial high-level acceptance criteria

Project Manager Communications: Provide project plan and schedule updates to project team

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Project Manager Meetings: Lead Project Team Meetings

Project Manager PM: Provide project tracking for each affected system and process within the project scope.

Project Manager PM: Monitor domain management

Project Manager PM: Monitor time tracking

Project Manager PM: Support and monitors issue management

Project Manager PM: Support IT Production Readiness process

Project Manager PM: Ensure timely completion of project milestones

Project Manager PM: Maintain project work breakdown structure

Project Manager PM: Maintain the project plan

Project Manager PM: Produce IT Project Deliverables

Project Manager Resources: Work with the project operational owner and/or managers of the effected systems and processes to ensure resource availability

Project Manager Status Reports: Create

Project Manager Technical Requirements - Assist with development

Project Manager Training: Attend high-level staff training

Resource Managers

Concerns & Issues: Escalate resource concerns to Project Manager and Project Director

Resource Managers

Design: Participate in project change decisions from an organization perspective

Resource Managers

Resources: Re-enforce time tracking requirements and other team responsibilities with their staff

Resource Managers

Resources: Work with the Project Manager to staff the project appropriately so timelines and targets can be achieved

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!9.4. Appendix D — Alternate solutions for Integrated systems !Other possible solutions to integrate inpatient, outpatient, pharmacy, labs, radiology etc..

• Access to data from all systems through CCDAs and Interfaces

• Remote access to all systems

• One system for entire organization

• One centralized data warehouse (data flows from all information systems)

9.4.1. CCDAs and Interfaces

Build two way interfaces between the inpatient, outpatient, pharmacy, labs, radiology etc.

to receive and send patient data electronically from different systems and save the complete

patient record locally within the inpatient and outpatient systems. Similarly patient data may

also be exchanged between systems through CCDAs.

Advantages:

• Complete patient record on the local system.

• No manual consolidation of patient information and potential loss of data or

incomplete information.

• Seamless data flow between the systems.

• Addresses patient safety issues due to lost communication

Disadvantages:

• Patient data duplicated in all systems.

• New interfaces have to be built every time a new lab, pharmacy or a new practice is

added to the organization

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• IT staff to maintain all interfaces. Adds cost to maintenance.

• Rework required on interfaces during any upgrade to the existing systems. CCDAs to

some extent will avoid such rework, but might be impacted by version changes to CCDA

specifications.

9.4.2. Remote Access to all Systems

Providers must be able to remotely connect to all systems (inpatient, outpatient, lab,

pharmacy, radiology…) within the organization to access patient information.

Advantages:

• Access to all patient information at any time.

• No loss of data since data from all systems in saved in one location.

Disadvantages:

• Providers must learn to navigate in the various systems to extract relevant patient

information.

• No one location/system for complete patient information.

• Management of patient data is cumbersome.

• Chances of missing some patient data during patient evaluation and potential patient

safety issue.

9.4.3. One System for Entire Organization

Use one enterprise solution for all departments inpatient, outpatient, pharmacy, lab,

radiology.. etc. All patient data is saved in one system for easy retrieval and analysis.

Advantages:

• All data available on one system.

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• No duplication of patient data.

• One source data for data analysis and analytics.

Disadvantages:

• Cost of implementation is high to move all departments on to one system.

• Disruption to patient services is high to move all departments on to an enterprise solution.

• The user experience ranking for one enterprise solution for all departments may be lower

when compared to the usability of best of the breed product for individual departments.

• Complete dependency on one vendor for all problems. Could be advantageous or

disadvantageous depending on level of customer support from the vendor.

9.4.4. One Centralized Data Warehouse

Having one centralized data warehouse with information flowing from all clinical systems

and financial systems that includes operational and HR data. Research indicates that dashboards

and analytic reports help healthcare organizations focus, track and manage re-admission rates. A

centralized data warehouse provides the necessary infrastructure for such dashboards and reports.

Advantages:

• Dashboard to track readmission rates

• Inpatient clinical reports

• Outpatient clinical reports

• Patient experience reports

• Cross functional reports

• Track patient outcome with respect to financial impact

• Track patient outcome with respect to operational and staff changes

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Disadvantages:

• Additional overhead costs to maintain the data warehouse. Expense may be justified if

used not only to track readmission rates but also for disease management of chronic

conditions and other research purposes.

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!9.5. Appendix E—Annotated Bibliography !American Hospital Association. (2011). Examining the Drivers of Readmission and Reducing Unnecessary Readmissions for Better Patient Care. Retrieved October 7, 2013 from: http://www.aha.org/research/reports/tw/11sep-tw-readmissions.pdf !This article reviews the history of the Hospital Readmissions Reduction Program, and how it was part of the Patient Protection and Affordable Care Act (PPACA). It also outlined how the Medicare reimbursement rates will be adjusted for hospitals with higher-than-expected readmission rates for patients with the included diagnoses. It detailed how a percentage is calculated, and then the hospital is penalized based on where they lie in conjunction with national averages. It also detailed information about how these reimbursement adjustments are to be adjusted based on risks of the patient, including age, gender, history of CABG, and the concurrence of other medical conditions. !Ben-Assuli, O., Shabtai, I., & Leshno, M. (2013). The impact of EHR and HIE on reducing avoidable admissions: controlling main differential diagnoses. BMC medical informatics and decision making, 13(1), 49. Retrieved October 13, 2013 from: http:// www.biomedcentral.com/1472-6947/13/49 !This study compares the use of Electronic Health Record (EHR) Information system (IS) and HIE network by physicians for admission decisions in Emergency Department. As part of the study 281,750 emergency department (ED) referrals in seven main hospitals in Israel were analyzed. The study concluded that the number of seven day readmissions and single-day admissions for all patients were reduced when physicians used EHR IS and HIE network to view patient’s medical history while making admission decisions. !Centers for Medicare & Medicaid Services. (2013). Quality Measures. Retrieved November 26, 2013 from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityMeasures/Downloads/Hospitals-and-CAH-2014-Proposed-EHR-Incentive-Program-CQM.pdf !This is a document that provides in table format all of the initially-proposed Meaningful Use quality measures for eligible hospitals. It includes details about the measurements, for both the numerator and denominator, as well as who initiated the quality measure in the first place. !Cloonan, P., Wood, J., & Riley, J. (2013). Reducing 30-Day Readmissions [Journal]. The Journal of Nursing Administration, 43(7/8), 382-387. Retrieved from: http:// dx.doi.org/10.1097/NNA.0b013e31829d6082 !This article gives background about the 30-day re-admissions rule and how this rule

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was enacted in the Affordable Care Act of 2010. It further explains the penalties the rule imposes on providers who don’t reduce the readmission rates. !Department of Health and Human Services. (2009). Security 101 for Covered Entities. Retrieved December 4, 2013 from: http://www.hhs.gov/ocr/privacy/hipaa/administrative/securityrule/security101.pdf !This article provided a refresher on HIPAA regulations and how they may apply to network and firewall security of PHI. In particular, the section outlining BA’s and requirements for BAA’s discussed how data warehouses and health information exchanges may be affected. !Fleming, M., Haney, T. (2013). Improving patient outcomes with better care transitions: The role for home health [E-Supplement]. Cleveland Clinical Journal of Medicine. Retrieved from: http://dx.doi.org/10.3949/ccjm.80.e-s1.02 !This article explains the role home healthcare plays in reducing the 30-day readmission rates by working with hospitals to ease the transition of patients at the time of discharge from hospital to home healthcare. !Gerhardt, G., Yemane, A., Hickman, P., Oelschlaeger, A., Rollins, E., Brennan, N. (2013). Medicare Readmission Rates Showed Meaningful Decline in 2012. Medicare and Medicaid Research Review, 3(2), E1-E12. This article outlines some statistics as they relate to hospital readmissions, including countrywide readmission rates as well as the financial impact to CMS of unnecessary readmissions. It also revealed that we have seen a 0.5% drop in hospital readmissions in only a year since it was initiated. !Good Shepard Medical Center. (2013). Quality: What are Core Measures? Retrieved December 7, 2013 from: http://www.gsmc.org/quality/. !This is a hospital web page that outlines some of the statistics behind the hospital quality measures currently reviewed by CMS. It quotes compiled health outcomes statistics that are directly related to readmissions quality improvements. !Hernandez, A., Greiner, M., Fonarow, G., Hammill, B., Heidenreich, P., Yancy, C., Curtis, L. (2010). Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA: The Journal of the American Medical Association, 303(17), 1716-1722. Retrieved on October 9, 2013 from: http://jama.ama-assn.org/content/303/17/1716.full !This article highlighted a study that looked specifically at readmission rates in patients with congestive heart failure. In particular, it measured average rates of follow-up after discharge, and found that there is wide disparity between patients in terms of when their follow-up actually

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occurs. Additionally, the study found that patients with early follow-up after discharge universally did better in terms of readmission rates when compared with severity-adjusted peers who did not have early follow-up. !HIMMS (2012). Reducing Readmissions -Top Ways Information Technology Can Help Retrieved October 13, 2013 from: http://www.himss.org/files/HIMSSorg/content/files/ ControlReadmissionsTechnology.pdf. !This document released by HIMSS discusses the various ways Information technology can be used to reduce avoidable readmissions. This article identifies various IT tools to help reduce readmissions and improve patient outcomes. Strategies discussed include Case management, Communication, Analytics and modeling, Post-acute follow up, Health Information Exchange, Social Media, Cloud Technology and Mobility, Robotics and Innovation. !Hubbard, T., McNeill, N. (2012). Improving Medication Adherence and Reducing Readmissions. New England Healthcare Institute Healthcare Brief. Retrieved November 5, 2013 from: http://www.nacds.org/pdfs/pr/2012/nehi-readmissions.pdf !This article provided some of the background history to the Medicare readmission problem, and specifically numbers about readmission rates and financial indices for how this affects the healthcare system overall. It includes a discussion about the need for appropriate medication reconciliation and methods to improve medication compliance at discharge. It identified the requirement to have an accurate medication list at admission (a list of truly taken medications, not medications simply prescribed to the patient), and the need to make sure that true reconciliation occurs at the transition of care. In particular, this article noted that incorrect medication follow-up is likely one of the largest reasons for readmissions in the country. The authors noted that we need to take better advantage of the benefits provided by e-prescribing in order to help medication compliance in patients recently discharged from the hospital. !Jack, B., Passche-Orlow, M., Mitchell, S., Forsythe, S., Martin, J. (2013). Re-Engineered Discharge (RED) Toolkit. Agency for Healthcare Research and Quality. Retrieved October 14, 2013 from: http://www.ahrq.gov/professionals/systems/hospital/toolkit/redtool1.html# !This pamphlet outlines the requirements for the project RED discharge kit. In particular, it gives some history and background for the initial project, and then provides information to healthcare providers and hospitals on how they can initiate the same project in their environments. It outlines the 12 steps to initiating project RED as well as evidence to back up the efficacy of the project in reducing readmissions and improving patient care. !Jones, S., Friedberg, M., & Schneider, E. (2011). Health information exchange, Health Information Technology use, and hospital readmission rates. In AMIA Annual Symposium Proceedings (Vol. 2011, p. 644). American Medical Informatics Association. Retrieved October 13, 2013 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3243133/

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!This article discusses the results of analysis conducted on a large sample of hospitals to compare the impact on risk standardized thirty-day hospital readmission rates due to hospital participating in HIE and HIT use (for medication ordering, laboratory ordering, and clinical documentation). The study concluded that hospital participation in HIE did not impact the readmission rate, but electronic documentation was associated with modest reductions in readmission for heart failure (24.6% vs. 24.1%, P=.02) and pneumonia (18.4% vs. 17.9%,P=.003). !Joynt, K., & Jha, A. (2013). A path forward on Medicare readmissions [Magazine]. The New England Journal of Medicine, 368(13), 1175-1177. Retrieved from: http:// dx.doi.org/10.1056/NEJMp1300122 !This article describes how CMS calculates the 30-day readmission penalties for the three diagnoses of acute myocardial infarction, congestive heart failure and pneumonia. !Kansagara, D., Englander, H., Salanitro, A., Kagen, D., Theobald, C., Freeman, M. (2011). Risk Prediction Models for Hospital Readmission, A Systematic Review. Journal of the American Medical Association; 306(15): 1688-1698. !This article provided an evaluation of many of the readmission predictor tools available today. The initiation of the Medicare rule stating reduced payments for hospitals with elevated admission rates essentially spurred a wave of methods to help not only reduce readmissions, but also to identify those patients who may be more likely to present back to the hospital after discharge. This article looked at this process overall and really helped to stratify whether or not these tools impacted outcomes. Interestingly, but not surprisingly, the review determined that it is really too early in the advent of these tools to say if they are helpful in changing outcomes or not. Additionally, the reviewers noted that tools that included recommendations for transitional care interventions for patients that scored higher in terms of likelihood for readmission were more likely to be of benefit than those that did not. Finally, the reviewers pointed out the necessity of these tools to calculate risks and enact changes in the care process in real-time, not retrospectively; they asserted that evaluation after the fact occurs too late in the process to cause any improvement overall. The BOOST project was mentioned specifically as a tool that shows promise, although data does not yet fully support the use of it in all hospital admissions at this time. !Krames Patient Education. (2013). Reducing Hospital Admissions With Enhanced Patient Education. Retrieved October 14, 2013 from: http://www.bu.edu/fammed/projectred/publications/news/krames_dec_final.pdf !This is a publication put out by the Krames Company, which outlines patient-education specific endeavors healthcare providers can undertake to reduce hospital readmissions. They outline a day-specific method to ensure patients understand their disease process as well as their role in

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their healthcare provision. They stress the importance of seamless transitions and printed patient education in these initiatives. !Logue, M., Drago, J. (2013). Evaluation of a modified community based care transitions model to reduce costs and improve outcomes [Magazine]. BMC Geriatrics, 13(94), 1-11. Retrieved from: http://dx.doi.org/10.1186/1471-2318-13-94 !The article explains how financial impact of penalties for 30-day readmission rates is calculated by using readmission data for patients suffering from the three diagnoses. !Radawski, D. (1999). Continuous quality improvement: origins, concepts, problems and applications. Retrieved from http://www.paeaonline.org/ht/action/getdocument action/i/ 25258 !The article describes continuous quality management as a management philosophy and method that is widely used in different settings. This article further explains that attainment of quality in healthcare is an ongoing process. !Rudin, R., Salzberg, C., Szolovits, P., Volk, L., Simon, S., Bates, D. (2011). Care transitions as opportunities for clinicians to use data exchange services: how often do they occur? Journal of the American Medical Informatics Association, 18(6), 853-858. Retrieved on October 18, 2013 from: http://www.ncbi.nlm.nih.gov/pubmed/21531703 !This article discusses a study that was conducted to evaluate the percentage of visits that involved care transitions. The study concluded that primary care physicians had an average of 54% of visits involving care transition while specialists had an average of 79% of visits involving care transition. HIE can play a significant role to aggregate patient records during care transitions with a medical group or outside the group. !Scott, I. A. (2010). Preventing the rebound: improving care transition in hospital discharge processes. Australian Health Review, 34(4), 445-451. Retrieved November 1, 2013 from: http://www.publish.csiro.au/?paper=AH09777 !This article discusses the results of a study conducted to compare the impact of peridischarge interventions on hospital readmissions. The comparison was made between single component interventions implemented before or after discharge and integrated multi component intervention which included both pre and post discharge elements. The study concluded that the multi component intervention covering pre and post discharge workflows targeted at high risk patient populations was more effective in reducing readmissions. !Stauffer, B., Fullerton, C., Fleming, N., Ogola, G., Herrin, J., Martin, S. (2011). Effectiveness and Cost of a Transitional Care Program for Heart Failure. Journal of the American Medical Association Internal Medicine; 171(14): 1238-1243.

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!This article summarized a randomized controlled trial where a transitional care program was set up for patients with heart failure. The outcome showed a significant reduction in readmission rates in patients who were enrolled in the transitional care program as compared to heart failure patients who were not enrolled in the program. !Silow-Carroll, S., Edwards, J., Lashbrook, A. (2011). Reducing Hospital Readmissions: Lessons from Top-Performing Hospitals. The Commonwealth Fund. Retrieved October 7, 2013 from: http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/ 2011/Apr/1473_SilowCarroll_readmissions_synthesis_web_version.pdf !This article provided real-life examples of hospitals and how they worked to improve readmission rates in light of the new Medicare requirements and reimbursement model A section noting that all of the hospitals studied put forth significant resources into discharge and transition of care planning was included. Additionally, the patient education, specifically that related to making sure patients understood their medication regimens and warning signs for worsening clinical condition, seemed to provide not only improvement in care for the patients but downstream effects of reduced requirements for acute care. !The HCAHPS Survery. (2013). The HCAHPS Survey: Frequently Asked Questions. Retrieved December 8, 2013 from: http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/downloads/HospitalHCAHPSFactSheet201007.pdf !This is a publication provided by CMS addresses the HCAHPS survey, and provides information about the intent of the survey overall. Additionally, it provides the individual pieces of patient care addressed in the survey and how results are tabulated across organizations. !The Society of Hospital Medicine (2013). Risk Assessment Tool: The 8 P’s. Retrieved November 3, 2013 from: http://www.hospitalmedicine.org/ResourceRoomRedesign/ RR_CareTransitions/html_CC/06Boost/03_Assessment.cfm !The BOOST project and their Risk Assessment Tool provide a way to stratify readmission risk in patients at hospital admission. Specifically, the BOOST project’s Risk Assessment Tool relies on what they call the 8P’s. These include assessment of potential problem medications, psychological factors, principal diagnosis at the time of admission, polypharmacy, poor health literacy, patient support, prior hospitalizations, and palliative care. Based on assessment in these 8 areas, the patient is given a score that ultimately determines their need for focused transitional care at the time of discharge. Additionally, based on the patient scoring, the BOOST project recommends certain interventions at each category. !Stewart, S., Marley, J., Horowitz, J. (1999). Effects of a Multidisciplinary, Home-based Intervention on Planned Readmissions and Survival Among Patients with Chronic

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Congestive Heart Failure: A Randomized Controlled Study. Lancet; 354(9184): 1077-1083. !This article specifically looks at interventions to decrease readmissions for patients with CHF. Only those patients deemed to be “high-risk” were included in the outcomes studies. Those high-risk patients received additional education prior to discharge, thus more “transitional care” than those patients determined to be normal or low risk. Additionally, this study showed that those patients who had targeted follow-up (in the home in this case, although I suspect any targeted follow-up may have resulted in the same outcomes) had markedly reduced readmission rates, higher quality of life, and lower healthcare expenditures overall. !Tuso, P., Huynh, D., Garofalo, L., Lindsay, G., Watson, H., Lenaburg, D., Kanter, M. (2013). The Readmission Reduction Program of Kaiser Permanente Southern California—Knowledge Transfer and Performance Improvement. The Permanente Journal, 17(3), 58. Retrieved on October 8, 2013 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3783066/ !This article discusses how Kaiser Permanente Northwest Region (KPNW) and Kaiser Permanente Southern California (KPSC) implemented the “transitional care” bundle. Using risk stratification tools to identify patients who are at high risk for readmission and provide care accordingly. Using standardized discharge summary to close the gap between post discharge and visit to PCP. Medication reconciliation across continuum of care, post discharge follow up call, follow-up with primary care physician, transition phone number on discharge instructions, palliative care consult for high risk patients and complex-disease case conference to reduce readmissions to hospitals. !Williams, M. (2013). A Requirement to Reduce Readmissions Take Care of the Patient, Not Just the Disease JAMA, 309(4), 394-396. Retrieved October 9, 2013 from: http://jama.jamanetwork.com/article.aspx?articleid=1558260 !This article highlights the various studies conducted on readmissions of patients discharged after hospitalizations for heart failure, acute myocardial infarction, or pneumonia. Based on the analysis of Medicare data from 2007 to 2009 it was concluded that 24.8% of patients hospitalized for heart failure were readmitted, 19.9% patients hospitalized for myocardial infarction were readmitted, and 18.3% hospitalized for pneumonia were readmitted within 30 days of discharge. Another study funded by CMS engaged hospitals, nursing facilities, home care agencies, hospices, social service agencies, area agencies on aging, and clinicians for care coordination. The study concluded that overall hospitalization rates were reduced but did not impact rehospitalization rates. This could be due to the fact that patients who are hospitalized, have health conditions that put them at greater risk for rehospitalization. Another study showed that the average age of Medicare patients admitted with heart failure was 80 years and more than one-third of those patients had hypertension, diabetes mellitus, or chronic obstructive pulmonary disease. In conclusion there is no single solution to address all the issues related to

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rehospitalization. Patient centered approaches involving all care team members for better care coordination, and implementation of Project BOOST (Better Outcomes by Optimizing Safe Transitions) can help deliver higher quality care. ! !