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Our way to measure ROI: The Marina Salud–Cerner Experience
Juan Manuel Lacalle Martínez IT Development Manager
Oslo, 31st of October 2013
1. Introducing Denia’s Health Department
2. ROI study fundamentals
3. ROI samples
4. Conclusions
INDEX
• Population: More than 150,000 residents (Health department is financed mainly per capita)
• Tourism: From March to October
• Municipality: 34 towns [ Dènia: approximately 40,000 – Vall d’Alcalà: around 200 ]
• Total area : 297 square miles (759 km²) • Population density: 635 people per square mile (245 hab/km²)
• Geography: Complex orography. Numerous mountains, valleys and hilly coast
Denia’s Health Department (I) GEOGRAPHICAL SCOPE
RED ASISTENCIAL MARINA SALUD
• 1 Hospital • 2 Integrated Health Centers (Specialized care) • 32 Primary Care Centers (Managed in 11 Basic areas)
Department of Health. Dénia. OPERATIONAL SCOPE
Department of Health. Dénia. OPERATIONAL SCOPE (II)
Public Service Private Managed
Administrative concession granted for 15 years
Direct supervision via AVS commissioner
Service improvement investment
Marina Salud builds the new Hospital
Marina Salud builds a new CSI in Calpe
Marina Salud builds a new CSI in Denia
Integration of professionals
Public Health Integrated Management
Health Department’s integrated Management (both Primary Care and Specialized Care working together)
There was a previous Hospital (100 % managed by regional
government; all employees depended from AVS HR Resources
policy as civil servants and locum)
At the time Civil servants (28%) and private employees (72 %)
1. Introducing Denia’s Health Department
2. ROI study fundamentals
3. ROI samples
4. Conclusions
INDEX
1. IT Strategy
• “Simplifed” Information systems map
• Benefits-measure-oriented
2. Hospital Information System scope
• Full support for HealthCare processes (Collaboration, Guidance, Continuity of care)
• EMR & Data driven (HIMSS Level 6 and 7)
3. Clear Change management strategy
• IT organization & service rules (three levels)
4. Clear Change management workflow
• Incident Management (Call center)
• Change Management (Clinical Transformation Office)
5. Representative users engaged & committed
• Results based agreement
• Clinical adoption leadership
• Transversal vision in change management
6. Clear and public rules to manage change
• Public priorization criteria (patient, professional, company)
Example: IT structure for CERNER MILLENNIUM support (VIII) – Clinical Transformation Overview
Department of Health. Dénia. 1. IT Strategy
Department of Health. Dénia. 1. IT Strategy
Denia’s Health Department (VII) – CERNER MILLENNIUM’s implantation scope
MEDICAL
SURGICAL
HOSPITALIZATION
INTENSIVE CARE
AMBULATORY
CONSULTATION
MEDICAL DAY UNIT
AMBULATORY
HEALTHCARE
SURGICAL DAY
CENTERHOME CARE
OUTPATIENT
PHARMACY
HOSPITAL
EMERGENCIES
EMERGENCY
INPATIENT
PHARMACY
IMAGING AND
RADIOLOGY
BIOLOGICAL
DIAGNOSIS
BLOOD BANK
PRYMARY CARE
EMERGENCIES
HOME CARE
EMERGENCIES
DIAGNOSTIC
PROCEDURES AND
TREATMENTS
REHABILITATION
STERILIZATION
PREVENTIVE
MEDICINECLINICAL
DOCUMENTATION
SOCIAL WORKPRE-ADMISSION
ARRANGEMENTS &
APPOINTMENTS
URGENT
SURGERY
MAJOR
HOSPITALIZATION
SURGERY
SURGERY
MAJOR
AMBULATORY
SURGERY
MINOR
AMBULATORY
SURGERY
OBSTETRICS
ADMISSION
SECOND LEVEL CARE SERVICES (SUPPORT SERVICES - ALL SCOPES)
FIRST LEVEL CARE SERVICES BY SCOPE
2. Hospital Information System scope
Denia’s Health Department (VII) – CERNER MILLENNIUM’s implantation scope
MEDICAL
SURGICAL
HOSPITALIZATION
INTENSIVE CARE
AMBULATORY
CONSULTATION
MEDICAL DAY UNIT
AMBULATORY
HEALTHCARE
SURGICAL DAY
CENTERHOME CARE
OUTPATIENT
PHARMACY
HOSPITAL
EMERGENCIES
EMERGENCY
INPATIENT
PHARMACY
IMAGING AND
RADIOLOGY
BIOLOGICAL
DIAGNOSIS
BLOOD BANK
PRYMARY CARE
EMERGENCIES
HOME CARE
EMERGENCIES
DIAGNOSTIC
PROCEDURES AND
TREATMENTS
REHABILITATION
STERILIZATION
PREVENTIVE
MEDICINECLINICAL
DOCUMENTATION
SOCIAL WORKPRE-ADMISSION
ARRANGEMENTS &
APPOINTMENTS
URGENT
SURGERY
MAJOR
HOSPITALIZATION
SURGERY
SURGERY
MAJOR
AMBULATORY
SURGERY
MINOR
AMBULATORY
SURGERY
OBSTETRICS
ADMISSION
SECOND LEVEL CARE SERVICES (SUPPORT SERVICES - ALL SCOPES)
FIRST LEVEL CARE SERVICES BY SCOPE
Exception! (Primary Care Ambulatory Consultation)
CERNER MILLENNIUM
2. Hospital Information System scope
Incident Management vs Change Management
• All users can register incidents or queries, but not all users may request changes
• Change management requires communication between peers
Three-level-based structure:
Level 1 – Direct End User support
• Help users in the use of the system
Level 2 – System Evolution & Clinical Transformation
• Adaptation management & implementation
Level 3 – Solution provider support management (SRs)
• Specialised support management (SLAs).
High Management
Committee;
Clinical Record
Committee
Middle management
End users
Incidents
Querys
DIRECCIÓN DE SISTEMAS Y TECNOLOGÍAS DE LA INFORMACIÓN
USERS
Change
Requests
Search for known solution
Escalation
User conformity management
Problem management
Progress report
Communication
Requirement management
Analysis
Design
Implementation
System Test
User Aceptance Test
Implantation (go live)
CommunicationReception
Classification
Knowledge management
Analysis of impact
Prioritization
User Request
Management
CHANGE
MANAGEMENT
INCIDENT
MANAGEMENT
Example: IT structure for CERNER MILLENNIUM support (III) – Basics 3. Clear change management Strategy
Example: IT structure for CERNER MILLENNIUM support (V) – Operational Functioning
High Management
Committee;
Clinical Record
Committee
Middle Management
End Users
C
A
L
L
C
E
N
T
E
R
CHANGE REQUEST
INCIDETN
QUERY
CHANGE
REQUEST
2º Nivel
Level 1
Level 3
Technology Providers
DIRECCIÓN DE SISTEMAS Y TECNOLOGÍAS DE LA INFORMACIÓN
USERS
COMMUNICATION
SOLUTION GO LIVE
COMMUNICATION
SOLUTION GO LIVE
APPLICATION
DEVELOPMENT
AREA
C
T
O
CHANGE REQUEST
THIRD PARTY
ESCALATION
PCP/
PCU
SUPPORT AREA
(HELP DESK)
INCIDENT
QUERY
4. Clear change management workflow
Managed by Vicent Moncho (CIO)
Coordinated by Dra. Ms. Elisa Teodoro (Obstetrics and Gynecology)
Dr. Mr. José Chordá (Internal Medicine)
Dr. Mr. José Mut (Pediatrics)
Dr. Mr. Angel Mauri (Emergency)
Dra. Ms. María José Mulet (Primary Care)
Dr. Ms. María José Martínez (Biological Diagnosis)
Dr. Mr. Jaime Poquet (Pharmacy)
Ms. Ms. Carmen Bohigues (Nurse coordinator)
Ms. Ms. Rosario Ivars (Nurse supervisor)
Ms. Francisca Atiénzar (IT Manager)
Mr. Juan Manuel Lacalle (IT Manager)
Contract agreement signed with IT Department
CLINICAL TRANSFORMATION OFFICE
Example: IT structure for CERNER MILLENNIUM support (VII) – Clinical Transformation 5. Representative users engaged & committed
Change Request Reception Phase
• Classify
• Prioritise
• Development order fullfilment
• Reply (Feedback)
Development planning review
• Design decision support
• User acceptance test (UAT)
Go live support Phase
• Go live plan validation
• Communication validation
Example: IT structure for CERNER MILLENNIUM support (VIII) – Clinical Transformation
INCIDENT
RECEPTION
PROCESS
INCIDENT MANAGEMENT PROCESS
PROBLEM
MANAGEMENT
PROCESS
CHANGE REQUEST
RECEPTION
PROCESS
CHANGE
REQUEST
ESPECIFICATION
PROCESS
CHANGE
REQUEST
PLANNING
PROCESS
GO LIVE
PROCESS
PLANNED DEVELOPMENT
PROCESS
(65 % fte)
UNPLANNED DEVELOPMENT
PROCESS
(35% fte)
CHANGE
REQUEST
EVALUATION
PROCESS
APPLICATIONS SUPPORT. INCIDENT & CHANGE MANAGEMENT PROCESS
High Management
Committee;
Clinical Record
Committee
Middle Management
End Users
C
A
L
L
C
E
N
T
E
R
CHANGE REQUEST
INCIDETN
QUERY
CHANGE
REQUEST
2º Nivel
Level 1
Level 3
Technology Providers
DIRECCIÓN DE SISTEMAS Y TECNOLOGÍAS DE LA INFORMACIÓN
USERS
COMMUNICATION
SOLUTION GO LIVE
COMMUNICATION
SOLUTION GO LIVE
APPLICATION
DEVELOPMENT
AREA
C
T
O
CHANGE REQUEST
THIRD PARTY
ESCALATION
PCP/
PCU
SUPPORT AREA
(HELP DESK)
INCIDENT
QUERY
6. Clear and public rules to manage change
1. Introducing Denia’s Health Department
2. ROI study fundamentals
3. ROI samples
4. Conclusions
INDEX
First Sepsis algorithm implementation in Spain. – No other hospital has been able to implement such
a complex process
Nurse satisfaction 95%. – Nurses are more than 50% of the organization.
– Annual cost turnover of nurses could cost at least 1.7M
Triage time improved to 9.2 min. Medium ED LOS 6.48 hrs
37.2% of physicians modified
their CPOE thanks to Multum:
Meds Adverse Events Each MAE cost arounds 3000
euros
Preoperative blood reserve
Circuit early diagnosis of cervical cancer
Automatic shipping of discharge reports to primary care
Implementation of the rule for
early detection of infection with sepsis
Reduction of CXR applications in preoperative protocols
Facts SAMPLES
It has allowed to assimilate the increase of work without increasing the staff or reducing quality
It facilitates the incorporation of new providers
• The system itself guides the new providers
• It improves the quality and safety of care
Circle of quality: measuring is first
• 'Now we know what we do and how we do it'
• There is an apparent effect of decrease in quality: now we document more and better, and detect incidents that were not previously recorded.
Reduced variability in nursing practice
• Wound care plans: 100% of patients
• Forms: documentation
Reduction of the time dedicated to documentation and tasks of little added value
• Medications: requisitions and fills
• Diets: requisitions
FirstNet Tracking Board (ED)
• Allows to know the patient workload and severity in real time
Records related to quality
• Falls
• Pressure ulcers
• Urinary tract infections
Some pending to measure:
Benefit Contents Millennium Contribution Impact Amount Hours/year FTE Discharge report
All discharged patients have a nurse discharge report
50% of the report's content is generated automatically
5 Minutes per report
11,728 977.33 0.56
Integration Continuity of care between departments
Single database per patient
15 Minutes per discharge
11,728 2,932.00 1.69
Total 2.26
Some difficult to measure:
NURSING: EXAMPLES OF QUANTIFIABLE BENEFITS
Single database • Continuity of care for post-resuscitation patients
• Vital signs can be contextualized in the hospital, requiring less interconsultations
Requests (referrals) with structured clinical information • Demand management support
Implementation of process guides in the orders Integration of the prescription with Gaia
• Avoiding a visit to Primary Care Remote home connection for providers on-call remotely
• Minimum response time • Reduced physical presence time
Process-oriented management
• Solutions help to define them
Reduced variability in clinical practice
Facilitates coordination of care between levels
Remote visits
• Anesthesia: pre-ops
• Neurology, checks
• Cardiology,
• Endocrinology
Some pending to measure:
Benefit Contents Millennium
Contribution Impact Amount Cases Hours /year FTE
Remote visits Interconsultations and remote follow-up visits. %5 of following ones .
Structured clinical information available anywhere, at any time. Protocols integrated in the system.
10 Time per visit reduced from 15 to 5 minutes
116,562 5,828 971 0.56
Documentation Continuity of care between areas.
Single database per patient.
10 Minutes per discharge
11,728 1,955 1.13
Documentation Operating Room Integration of monitoring devices
7 Minutes per major surgery
8,608 1,004 0.58
Total 2.27
Some difficult to measure:
PHYSICIANS: EXAMPLES OF QUANTIFIABLE BENEFITS
Coding: Discharge and minor surgery
Scanning and document integration
• 100,000 documents per year
• 50% consents
• Non-integrated results, documents from other hospitals
Integral documentation control
• Batch index (ECG, Cardiotocography, Urodynamics)
Patient and third-party requests
• 4,000 per year
Some pending to measure:
Benefit Contents Millennium
Contribution Impact Amount Hours/year FTE Electronic Medical Record The medical record is not
paper-based Cerner Millennium is the EMR
4 Minutes per movement (discharges, consultations, and minor surgery)
193,718 12,914.53 7.47
Coding Availability of all electronic clinical information
Cerner Millennium is the EMR
5 Minutes per major and minor surgery
14,994 1,249.50 0.72
Discharge report Discharge report is sent automatically to the Primary Care Physician
Message Center 5 Minutes per report 6,824 568.67 0.33
Total 8.19
Requests for passive archive
• When requested, they are digitized and incorporated into Millennium
Some difficult to measure:
CLINICAL DOCUMENTATION: EXAMPLES OF QUANTIFIABLY BENEFITS
Preference cards
• Costs per process
Stock reduced by 35%
• €500,000
Financial cost reduced by 34%
• 15,000 x 5 years = €65,000
Auto verification • 24-hour pharmacist is not required
• 4 pharmacists
RIS-PACS
• Avoids physical support
• 116,872 x €2.5/study x 5 years = €1,460,900
Tx X-ray rule
• Avoids pre-operative X-rays in patients under 60
years of age without pathologies that require them
• Effect on costs
• Effect on queue management
Blood bank
• Multi-phase plan for pre-operative
• Cancellations due to lack of blood have
decreased
• Time between order and surgery has
decreased
Cervical cancer
• Alert in case of alarming result
• Reduced gynecologist visit time
• Automated sending of letters in case of
normal results
Time X-rays
avoided Cost (euros) Total (euros)
84 days 112 12.02 €1,346.24
1 year 988 12.02 €11,875.76
5 years 4,942 12.02 €59,402.84 €
MORE SAMPLES…
Availability to schedule from any part of the Department (not only the hospital)
• The patient can make an appointment from any location, avoiding travel time
Centralized request system
• High specialization is not required for scheduling appointments
• Simplifies the management of human resources: Higher efficiency due to higher versatility
Allows providers to schedule appointments
Allows establishing complex scheduling processes, making several people responsible
• Multi-phase PowerPlans
• In multi-appointments various people can schedule appointments (by area) without requiring a specialization in this type of complex appointments:
Agenda Structuring
• Spaces according to priority
• Schedule care structures, not people (i.e.: spine disease agenda, not Dr. C)
Clinical information related to the appointment
Feedback in real time allows to react quickly in the event of incidents
Saves time and travelling for users
• Versatility and flexibility when assigning personnel
Improved demand management:
• Prioritization according to clinical criteria
• Simplifies the referral request by Primary Care
Does not require 24-hour hospitalization admission
• Admission for emergency surgery by the surgeon himself.
Simplifies complex appointment scheduling
Medical transport management
Third-party referral management
Fast detection and reaction in the event of problems
• Reduced OR cancellations
AND MORE…
1. Introducing Denia’s Health Department
2. ROI study fundamentals
3. ROI samples
4. Conclusions
INDEX
Cerner Millennium’s implementation project (2007-2009)
• We are using the same MILLENNIUM version since 2009
• When we opened the hospital in 2009 many users, especially physicians, had a bad opinion about the design of the system, they weren’t confident in the tool
The Clinical Transformation Office (2010)
• When users get involved in “driving” the system with the Clinical Transformation Office they checked that the tool should be used to help them to do their job better applying a crossover vision to workflows
• When this “inflection point” was achieved, this implied from the organization perspective that some processes were improved
HIMSS Level 7 (2011-2012)
• This was not a direct target for our company, but it was achieved as a consequence of this change in our ways of working
Process improvement and ROI (2012 and so on)
• Currently is the basis for the CTO’s internal philosophy and prioritization
• We can work this way because we can measure
• We can measure because we have the tools and the criteria to do that from the patient perspective, from the professional perspective and from the company perspective
Same company, same tool, same people…, different organization, different culture, …, different results
Conclusions (our experience)
Conclusions (our experience)
“Marina Salud chose the Cerner Millennium® solutions because of their ability to provide clinicians with the information needed to improve patient care on all care venues in the healthcare network: at the hospital, at the health centres and at home. This innovative approach to healthcare services overcomes traditional limitations such as data duplicity and information inconsistencies; as well as to serve as a healthcare model to all of Spain.”
Dr. Luis Fidel Campoy Domene
Councilman Delegate
HIMSS level 7 award ceremony in Copenhagen 2012
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