Minding the Gap: Path Innovation, Collaboration and Quality

Minding the Gap: Path Innovation, Collaboration and Quality

Barry P. Chaiken, MD, MPH, FHIMSSCMO, DocsNetwork, Ltd.

© 2009 DocsNetwork, Ltd.

Overview

Costs of Healthcare eHealth Vision Quality and Errors Clinical Information Technology Clinician Adoption Innovation and Transformation Flatteners and the Triple Convergence

© 2009 DocsNetwork, Ltd. 2

- Paul Romer, EconomistGraduate School of Business

Stanford University


““ A crisis is a terrible thing to waste.”

Spending Trends in US (billions)

Source: California Healthcare Foundation, Snapshot Health Care Costs 101, 2008

4© 2009 DocsNetwork, Ltd.

Spending as Percent of GDP



Spending per Capita



World’s Highest Spending per Capita



Overview



Governing for Standards, Certification

National eHealth Collaborative– Formerly American Health Information

Community (AHIC)

Healthcare Information Technology Standards Panel (HITSP)

Certification Commission for Health Information Technology (CCHIT)

National Coordinator for Health Information Technology (ONC)


National eHealth Collaborative (NeHC)

Public-Private partnership– Includes all stakeholders– Successor to AHIC (2005) – gov’t. committee

Focus on health information network– Quality, safety, cost

Development aims– HIT systems– Infrastructure– Standards– Protections– Participation– Education


HITSP Work Critical

Broad organization participation– Varied stakeholders

Public-private partnership Harmonize standards

– Data interchange– Vocabularies

Mobilize vendors– HIT– Medical devices

Driven by use cases


CCHIT Ensures Interoperability

Mission: Accelerate adoption of HIT– Breadth of stakeholders

Certifies EHRs and their networks– Tests functionality against standards

– Ensures interoperability

– Embraces all SDOs

– Works with HITSP

Independent non-government entity


HIMSS Vision for Change

Message to Pres. Obama and U.S. Congress Utilize HIT in healthcare reform

– Improve quality, reduce cost, enhance safety– EMRs, PHRs, e-prescribing– Facilitate interoperability

Immediate challenges– Leadership– Interoperability– Privacy and security– Electronic payments– Consumer empowerment– Funding


Call to Action for New Administration

Invest $25 bil. on HIT (stimulus package)– Facilitate adoption of EMRs

• Hospitals and physicians• Government entities• Expand access

– Apply recognized standards• HITSP• CCHIT

– Permanently establish governing councils• Overarching coordinating entity

National eHealth Collaborative• HITSP and national standards harmonization body• Senior level HIT leader

– Expand Stark and Anti-kickback safe harbors


Overview

Costs of Healthcare eHealth Vision Quality and Errors Clinical Information Technology Clinician Adoption Innovation and Transformation Healthcare’s Triple Convergence


Limited Proven Care Provided


A 2003 study in the NEJM

demonstrated that American patients

receive recommended care

only 56% of the time

Source: McGlynn et. al., “The Quality of Health Care Delivered to Adults in the United States,” The New England Journal of Medicine (June 26, 2003): 2635–2645.

Recommended Care and Quality Varies


Source: McGlynn et. al., “The Quality of Health Care Delivered to Adults in the United States,” The New England Journal of Medicine (June 26, 2003): 2635–2645.

55

68 6554 49 45

0

20

40

60

80

100

Overall CAD Hypertension Asthma Hyperlipidemia Diabetes

Percent Receiving Recommended Care

Standardized Measures

AMI– ASA within 24 hours

– ASA at discharge

– ACE inhibitors

– Smoking-cessation

– Beta-blocker 24 hours

– Beta-blocker at discharge

– Thrombolytic agents

– PCI intervention

– Inpatient death

Heart Failure– Discharge instructions

– LVF assessment

– ACE inhibitors

– Smoking cessation

Pneumonia– Oxygenation assessment

– Pneumococcal screening

– Blood cultures

– Smoking cessation

– Mean time to antibiotics


Source: Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of Care in in U.S. Hospitals as Reflected by Standardized Measures, 2002 – 2004. NEJM, 2005:353;255-264.

Standardized Measures and Quality

Top-RankedAMI(%)

CHF(%)

Pnu(%)

Boston 95 Boston 89 Oklahoma City 82

Minneapolis 94 Detroit 88 Indianapolis 79

Kansas City 94 Baltimore 87 Kansas City 78

Albany, NY 93 Camden 87 Camden 78

Indianapolis 92 Cleveland 86 Knoxville 77

Bottom-Ranked

Little Rock 86 San Diego 77 Miami 63

Orlando 86 Nashville 76 Chicago 61

Miami 85 Orlando 74 San Diego 60

Memphis 84 Little Rock 69 Los Angeles 60

San Bernadino 83 Lexington 68 San Bernadino 59

© 2009 DocsNetwork, Ltd.Source: Jha AK, Li Z, Orav EJ, Epstein AM. Care in U.S. Hospitals – The Hospital Quality Alliance Program. NEJM, 2005:353;265-274.

Variation in Performance

Academic institutions– AMI and CHF higher, pneumonia lower

Profit status– Not-for-profit higher for all 3 conditions

Geographic region– Midwest and Northeast outperforming the West

and South

Number of beds– Smaller hospitals do better with pneumonia


Public Perceptions on Errors

Carelessness Incompetence Substandard providers

– Physicians

– Nurses

– Laboratory technicians


Incompetent StarAverage Incompetent StarAverage

Fearing Clinical IT Lessons

Koppel– CPOE leads to increased errors– 22 types of errors facilitated

Garg – Unknown impact of CDS on outcomes– Performance improvement

Wears – Study results biased?– Foxes measuring the hen house

Cedars-Sinai abandons CPOE effort Failed CPOE

– 10+ years of the wrong dose?


Perfectly Delivering Errors

Fragmented CPOE displays– Incomplete records

– Unintuitive display of data

Pharmacy inventory as CDSS– Delivering wrong doses

Concurrent digital and paper records– Lack of single patient data source

Inflexible ordering formats– Generate wrong orders


Source: Koppel, et. al. Role of computerized physician order entry in facilitating medical errors. JAMA, 2005;293:1197-1203.

Overview



Physician Portal as Information Hub

Source: MedAffinity Corporation 25© 2009 DocsNetwork, Ltd.

Computer Physician Order Entry

Alerts to drug interaction, allergy, overdose

Accurate, up-to-date new drug information Drug-specific information

– Eliminates confusion over similar names

Improved communication– Physicians and pharmacies


Heparin HEO Slide


08/11/2000 8:00pm

35

1

165,000

76 mcm3

08/11/2000

08/11/2000

08/11/2000

08/11/2000

Integrated guidelines and

knowledge links

Easily activated guideline-

driven orders

Relevant patient drug and lab data

Source: McKesson Corporation

Personal Health Records


CCR Offers Key Data Points

CCR identifying information– Physicians, dates, purpose of referral

Patient identifying information– Unique patient identifiers

Patient insurance/financial information– Eligibility

Advance directives– Living wills and proxies


CCR Comprehensive

Patient health status– Conditions, diagnosis, family history– Adverse reactions, allergies– Social history, risk factors, immunizations– Medications– Vita signs, lab results, procedures

Care documentation Care plan recommendations Practitioners


Overview



Stages of HIT Adoption – U.S.


Source: HIMSS Analytics, September, 2008.

Secure Clinician Adoption

Workflow– Impact on patient care

• Quality

• Cost

– Efficiency - time• Obtain information

• Patient encounter

• Record findings


Who Should Drive Adoption?


Source: Sarah W. Fraser, IHI Forum, December 2002 (Rogers, 1995)

Maximizing Value

A B C D E F


Val u

eV

al u

e

80%80%

60%60%

40%40%

20%20%

100%100%

15%15%

10%10%

Ad

op

tion

Ad

op

tion

Increasingly Complex Clinical Increasingly Complex Clinical SolutionsSolutions

Solution BenefitsSolution BenefitsPotential RiskPotential Risk

Breakeven

Overview



Clinical Transformation Needed

Utilize clinical technologies Impact clinical processes Enhance quality Achieve efficiencies Necessary focus

– Clinical strategy

– Clinical business

– Process redesign

– Change management


Risk by Increasing Complexity

© 2009 DocsNetwork, Ltd. 38Number of Links

Pro

bab

ilit

y o

f F

ailu

re

0.999

0.99

0.98

0.97

0.96

0.95

0.94

0.93

0.92

0.91

0.90

0%

20%

40%

60%

1 2 3 4 5 6 7

Process Redesign Tasks

Current state value stream map– Process and its sub-processes

– Collect baseline metrics

Future state value stream map– Detailed workflows

– Role definition

– Align committee structures

– Policy/procedure definition


Lean Value Stream Mapping

Simplify processes

Identify value steps

Reduce non-value added steps

Enable efficient care flow

© 2009 DocsNetwork, Ltd.40

RN review new order.Move step to 1st step

of adminstrationENVA

RN enters order intoMcKesson Star

Unit Secretary / RN Pharmacy

RN

Case Manager Social Worker

Physician assesses Patient

Physician accesses andcollects additional pt.

information from Patient,Family, RN

Physician makes clinicaldecision

Physician gives verbal/phoneorder to RN

Physician places chart withorder in Order Rack

RN retrieves order fromOrder Rack

Faxes order to Pharmacy

Prints order inDepartment (For Rad,Lab, PT/OT, Dietary,

Respiratory, & Consultorders)

Unit Secretary calls Rad,Lab, Resp, SS, Dietary to

fast track orders

Unit Secretary writesorder into Kardex

Unit Secretary calls Respafter 2pm for EKG

Unit Secretary placeschart in Chart Rack RN reviews Order

RN ensures order isappropriate and confirms

order is transcribedappropriately in Kardex

Transcribesorder into the

MAR

RN directs and prioritizesthe order based on need

Transcribes order onRN's own work sheet

Administersfirst dose Rx

to pt.

Call Physician re:pt. status postSTAT orderadministered

InpatientSetting

Supplier - Physician Customer - Patient

Physician writes order onchart (Routine Orders)

McKesson Star

DietaryRadiologyPhysical Therapy Laboratory

VAVA

STAT orders can be verbal,phone and/or written

Documents inMAR when Rx is

given

VA

VA

VA

VA

Nurse writes verbal/phoneorder on Order Sheet

NVA

NVA

NVA

NVA

NVA

ENVA

NVA

For STAT Orders

NVANVA NVA NVA NVA

ENVA

Diagnostic Testing OrdersAppropriate Treatment =

Appropriate Diagnosis =

Broad Timing =

Appropriate Treatment =

Appropriate Diagnosis =

Broad Timing =

Treatment Orders

NVA

NVA

VA NVA

InitiateTreatment for

pt.

VA

VA

VA

Document caregiven

ENVA / VA

ENVA / VA

ENVA / VA

For STAT Orders

For Rx Order

RN interprets order andchecks for completeness.Call Physician to clarify, if

necessary.

Communicates withpt. on Plan of Care

PerformDiagnosticTest for pt.

Physicianacknowledgesorder fulfillment

Communicateswith CNA onPlan of Care

Off going and ongoing RNs

review and verifynew orders and

new MAR entries

At midnightthe new 24-hour MARprints out

RN reviewsnew and old

MAR

RN sendmemo topharmacy

withcorrections

RN correctsMAR

Old MAR isplaced in

Medical Recordand new MAR in

MAR book

NVA

NVA

RN Worksheet

MAR

VA

NVA

Route of administration =

Correct Drug =

Correct Dose =

Broad Timing =

Medication Orders

Nurse writes STATverbal/phone order

on Order Sheet

NVA

Physician assesses Patient

Physician collects pt.information from Patient,

Family& RN

Physician makes clinicaldecision

InpatientSetting

VAVA VA

Physician gives verbal/phonemedication order to RN

Physician writes medicationorder on chart (Routine

Orders include RegularlyScheduled and PRNmedication orders)

STAT orders can be verbal,phone and/or written

VA

VA

VA

Nurse writes verbal/phoneorder on Order Sheet

NVA

Please see MedicationAdministration in the Inpatient

Setting of CareCurrent State Value StreamMap (cVSM) for the differentiterations of the rest of this

process

Unit Sectary enters orderinto McKesson Star

NVA

RN retrieves order fromOrder Rack

NVA

Post testsresult to

medical recordand/or

McKesson Star

RN collect home medsinformation & verify with

Physician for continuation ornot

Laboratory call Panicvalues to MD or RN

Results faxed or enter inMcKesson STAR

STATS print directly toED

Routine printed to thefloor at midnight

Lab order can be enteredin duplicates, or

confirmed in multiple orpartially filled.

Clarification needed

Call made to MD/RN/Dept. Supvr to clarify

orders

Unit Sectary confirm whatto order

Lab Order Clarification

Laboratory Result

MD accesses andenters data

through EPIC

Decision supportprovided by EPIC

MD enters orderdirectly into EPIC

Eliminate verbalorders; MD entersorder directly into

EPIC from home, officeand/or other location

RN enters phoneorder into EPIC.

Rarely

Barcode STATmeds directly intoMAR with order in

after the fact

RN adjust medadminstration

timing.

Order may go directlyinto departmental

system or print out

EPIC generatesKardex view

Review done in EPIC

Lab results feed intoEPIC

System can notify byfax, pager or cell

EPIC generates CNAworklist

Enter into EPIC

Acknwledge withinEPIC

Home Med inEPIC system if theMD uses EPIC in

office -RN toverify

Home Medsautomaticalypopulate first

order

Decision supportprovided by EPIC

MD enters orderdirectly into EPIC

Eliminate verbalorders; MD entersorder directly into

EPIC from home, officeand/or other location

Barcode on STATmeds recordsorder in EPIC

EPIC to generatethe MAR View

Electronic MAR

Collection of height, weightand allegies of pt.

Entered into EPICand avaliable for

clinicians

Clinical RPhround with MD -decision support

before orderwritten

Clinical RPhround with MD -decision support

before orderwritten

Future State Admission Process Map


Future State

Hospitalist Admission Workflow

Anc

illar

y/C

lerk

Phy

sici

an

Direct admit?

No

Yes

Patient seen inMD office, needs

admission

Patient needs admission ?

Home

End

No

Holding note written in office chart, H&P may dictated in office.

Orders hand written and faxed to

admissions, hand carried by patient, or

may be a phone order to unit to admit

Hospitalist involved?

Yes

Yes

Referring physician notified

Patient examined and seen in

hospital

Hospitalist involved?

No

No

Yes

Sent to ER for evaluation, admission?

Yes

Admission scheduled for

date in the future?

No

Yes

ED Patient Evaluation

Is the Office an Epic Office

No

Enter Patient Orders for Admission

Review and update History,

Allergies, Current Meds, Lab/Rad results, Problem

List

Document Admission

H&P

Hospitalist receives phone notification from

Referring MD

Referring MD arranges for room

Patient arrives in

room

Review Current patient charting including old

visits, ED, Vitals, Lab/Rad results, Nursing notes.

Examine Patient

Pre-Admission Process

CPOE at hospital?

No

Yes

Yes


Path Innovation of Clinical Processes

Required subject matter experts– Process improvement

– Clinical content and evidence-based medicine

– IT system design

Educating experts– Exchange knowledge

Cross training Teamwork

– Formation of long-standing working groups


Well Designed Systems Succeed


Requires Practice and Teamwork


Summarizing Clinical Transformation

“every system is perfectly designed to achieve exactly the results it gets”

- Don Berwick, MDInstitute of Healthcare Improvement


Overview



Friedman’s Ten Flatteners

Fall of the Berlin Wall (Soviet Union) Internet, e-mail and browsers Workflow software

– Separating tasks

Open sourcing Out-sourcing Off-shoring Supply-chaining In-sourcing In-forming The steroids


The Triple Convergence

Global Web-enabled playing field Combining new technologies with new processes Universal access to computers and Internet


Triple Convergence I

Global, Web-enabled playing field Multiple forms of collaboration

– Sharing of knowledge real-time

– Irrespective of geography

– Soon, irrespective of language


Triple Convergence II

Combining new technology with new processes– Steam engines versus electric motors

• Redesign of assembly lines

• Need for critical mass of new engineers and architects

– Snail mail versus email• PDF files, Adobe Reader

Doing things differently


Triple Convergence III

Access by billions to computers and the Web– Knowledge easily obtained

– Collaboration no longer limited by geography

– Instantaneous sharing of discoveries


Healthcare’s Triple Convergence

Increasing investment– Cost of doing business

Government and payor incentives Increasing use of IT

– EMR, PHR, HER, CCR

– Computerized provider order entry (CPOE)

– Clinical decision support system (CDSS)

– Physician and patient portals


Path Innovation of Clinical Processes

Required subject matter experts– Process improvement

– Clinical content and evidence-based medicine

– IT system design

Educating experts– Exchange knowledge

Cross training Teamwork

– Formation of long-standing working groups


Successful Use of HIT

Develop good plans– Change as needed– Include all stakeholders

Invest in governance Service the clinician

– Patient-specific data– Recognize workflows– Design easy to use reports

• Balanced scorecards Transform use of data and information

– Focus on strategic vision– Revise processes– Utilize IT to deliver to transformation

Continually monitor and improve processes Innovate


African Proverb

Every morning in Africa, a gazelle wakes up.It knows it must run faster than the fastest lion or it will be killed.Every morning a lion wakes up.It knows it must outrun the slowest gazelle or it will starve to death.It doesn’t matter whether you are a lion or a gazelle.

When the sun comes up, you better start running.


References Chaiken BP. Round healthcare in a flat world. Patient Safety and Quality

Healthcare. 2006;3(3):12-13. Chaiken BP. Path innovation: transcending automation. Patient Safety

and Quality Healthcare. 2005;2(3):46-47. Friedman TL. The World is Flat. 2005. New York: Farrar, Straus and

Giroux. Snapshot health care costs 101, 2008. California Healthcare Foundation.

2008. Chaiken BP. Useable clinical evidence-based guidelines…For real. Patient

Safety and Quality Healthcare. 2005;2(1):14-16. Chaiken BP. Using IT to drive teamwork and patient safety. Journal of

Quality Health Care, 2003;2(1):19-20. Chaiken BP. Revolutionary HIT: Cure for insanity. Patient Safety and

Quality Healthcare. 2007;4(6):10-11. Chaiken BP. Strategies for Success: Clinical HIT implementation. Patient

Safety and Quality Healthcare. 2008:5(4):28-31. Chaiken BP. Healthcare IT: Slogan or solution? Patient Safety and Quality

Healthcare. 2008;5(1):6. www.HIMSS.org www.CCHIT.org


References

Chaiken BP, Holmquest DL. Patient safety: Modifying processes to eliminate medical errors. Journal of Quality Health Care. 2002;1(2):20-23.

Chaiken BP. Clinical decision support: Success through smart deployment. Journal of Quality Health Care, 2002:1(4):15-16.

Chaiken BP. Technology helps eliminate medical errors. Health Care Quality Means Business: Special Supplement to Managed Care. 2003;12(1):15-17.

Chaiken BP. Choosing clinical IT tools that matter to physicians. Health Management Technology. 2002;Sept.:20-22.

Chaiken BP. Physician adoption of technology linked to providing benefits. Journal of Quality Health Care, 2002;1(2):25-27.

Chaiken BP. Useable clinical evidence-based guidelines…For real. Patient Safety and Quality Healthcare. 2005;2(1):14-16.

Chaiken BP. Using IT to drive teamwork and patient safety. Journal of Quality Health Care, 2003;2(1):19-20.

Chaiken BP. Mind the Gap. Health and Hospital Networks Most Wired Online, March 9, 2005.


References Williams SC, Schmaltz SP, Morton DJ, Koss RG, Loeb JM. Quality of Care in in U.S.

Hospitals as Reflected by Standardized Measures, 2002 – 2004. NEJM, 2005:353;255-264.

Health Information Technology in the United States: The Information Basis for Progress. Robert Wood Johnson Foundation, MGH Institute for Health Policy, George Washington school of Public health and Health Sciences © 2006 Robert Wood Johnson Foundation.

Koppel, et. al. Role of computerized physician order entry in facilitating medical errors. JAMA, 2005;293:1197-1203.

Garg AX, et. al. Effect of computerized clinical decision support systems on practitioner performance and patient outcomes. JAMA, 2005;293:1223-1238.

Wears RL, Berg M. Computer technology and clinical work. JAMA, 2005;293:1261-1263.

Stoll K, Jones K, Health Care: Are you better off today than you were four years ago? Families USA, September 2004.

Robinson AR, Hohmann KB, Rifkin JI, Topp D, Gilroy CM, Pickard JA, Anderson RJ. Physician and public opinions on quality of health care and the problem of medical errors. Arch Intern Med 2002;162:2186-90.


Barry P. Chaiken, MD, MPH, FHIMSSChief Medical OfficerDocsNetwork, Ltd.

[email protected]


Minding the Gap: Path Innovation, Collaboration and Quality

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Transcript of Minding the Gap: Path Innovation, Collaboration and Quality