Donald Crandall, MD Clinical Informatics Consultant Trinity Health Sept 2007 Achieving success with Integration of HIT in Ambulatory Care

Donald Crandall, MDClinical Informatics Consultant

Trinity Health Sept 2007

Achieving success with Integration of HIT in Ambulatory Care

Copyright © 2006 Trinity Health, Novi, Michigan

Trinity Health – Our Communities

• Fourth-largest Catholic health system in the United States

• Operating revenues of $5.7billion

• 44,950 FTEs• 7,315 physicians – 95% private

practice community hospital based

• 25 Ministry Organizations, 44 hospitals (29 owned and 15 managed), 379 outpatient clinics/facilities, numerous long-term care facilities, home health and hospice programs, and senior housing communities in seven states


The Scale of Change

• How big is Genesis?

• Project Genesis will involve:– Implementation of 20+ information systems – Across 17 Member Organizations and 23 hospitals– Redesign of 300+ business and clinical processes

Copyright © 2006 Trinity Health4

Trinity Health Genesis Clin/Rev Schedule as of June 2007

MuskegonJuly 2004

Sioux CitySept 2005

F03/05

Grand RapidsOct 2004

FY06

Mason CityJuly 2005

FY07

Battle CreekFeb 2005

CompletedIn ProcessNot Started

Key:

OaklandMarch 2007

MacombApril 2005

Port HuronMar. 2003

ClintonOct 2007

DubuqueFeb 2006

LivoniaMarch 2006

FY08 FY09

BoiseJan 2009

FY10

Ann ArborJune 2009

ColumbusTB ConfirmedLate Fall 2009

HQ UpgradeAug 2006

FresnoOct 2008

South BendApril 2008

Silver SpringJuly 2008

Domain SplitJan 2007

CTTACS & CHF

Cerner UpgradeMay 2006

MC-Network Phase I

July 2007

MC-NetworkJuly 2008

MC-NetworkSept 2008

CernerUpgrade Alpha

Sept 2007

LivoniaOrtho Tot Joint

PI Pilot

ACS/CHFPI Pilot-Oakland

Mar 2007

CernerUpgrade Main

Jan 2008

FY08 Genesis Doc MngBundle

Genesis Related Dependent Pilots:•Inet-Macomb Oct 2007 required for Silver Spring•Enterprise Sched Battle Creek Mar 2008 required for South Bend•Care Planning Dubuque required for Silver Spring•Surginet Battle Creek Mar 2008


Genesis Accomplishments

• 10 ministry organizations live on in-patient system as of 7/2007• Three ambulatory clinics live on PowerChart Office• Avg. # of physicians placing orders per day (actually doing it

themselves) is >850• Orders processed per day > 300,000• Avg. chart openings per day > 160,00• Avg. HQ-Cerner ADT transactions per day > 50,000• Avg. concurrent users per day during peak hours • (08:00-16:59) > 1200• Peak concurrent users > 1500• Simultaneous synchronization to 2 data sites


Transformation: 1 Part Technology + 2 Parts Culture & Work Process

Culture/workprocess

Technology

Transformation:


Scope: Applications Installed

• CLINICAL APPLICATIONS (Cerner/Millennium)– Power Chart - Orders and results–Clinical documentation– PharmNet - Pharmacy – FirstNet: Emergency Dept.– RadNet: Radiology Dept.– SurgiNet: Operating Room – INet: ICU– Profile - HIM application– EMPI– CPOE– Power Note 2G Physician documentation–PowerChart Office

Ambulatory Electronic Medical Record

• Patient Demographics• Current Allergies• Active Medication (Medication reconciliation)• Problems and Diagnoses

– Family history, social history, inactive problems

• Notes & Documentation– Discharge summaries, care plans, visit notes, consultations

• Test Results• Orders


Physician Office Management System

• Practice Operations– EMPI, Patient registration, patient scheduling – Charge capture

• Financial Management– EDI/Claims submission, claims management, patient billing & accounts receivable,

collection management

• Management Reporting– Standard A/R Reports. Ad Hoc reporting & queries, productivity tracking

• Additional Advanced Capabilities– Managed Care support, Web-based capabilities



Gartner Magic QuadrantPhysician Office Systems 2006

Ambulatory EMR

• Healthcare would benefit from physician office EMR’s that integrate office and hospital information

• Current systems do not yet support highly efficient physician office workflow

• 80% of office visits in practices of less than 5 docs• EMR’s of all types are relatively expensive • Vender landscape is challenging• Most health systems are not invested in supporting independent

physician offices


Ambulatory EMR- Cont.

• Change in regulatory environment creates opportunities and challenges

• Adoption rates are slow, better in larger groups• Typically less than 20% of EMR functionality is being used• Even when technology is given away, adoption issues

continue (Wellpoint and the State of Mass.)• Lack of knowledge, workflow re-design, efficiency and risk

are probably more significant barriers


Percent of office-based physicians with selected features of EMR systems

(standard error)


EMR system feature

All Physicians Fully electronic Partially electronic

Patient demographics

21.4 (1.6) 91.5 (2.7) 82.3 (3.8)

Physician clinical notes

17.7 (1.6) 82.2 (5.8) 65.4 (4.9)

Lab results 17.2 (1.6) 80.9 (5.5) 63.4 (5.0)

Nurse clinical notes

14.0 (1.5) 75.6 (6.1) 46.0 (5.7)

CPOE 13.4 (1.3) 73.5 (5.1) 40.4 (4.5)

Test orders 12.7 (1.3) 67.6 (5.2) 40.2 (5.6)

Clinical reminders 10.7 (1.1) 57.9 (5.5) 33.3 (4.3)

Public health reporting

5.4 (0.9) 34.2 (5.1) 12.1 (2.8)

Catharine W. Burt, Ed.D., U.S. Department of Health and Human Services

Adoption Challenges

• Lack of resources• EMR financial

benefits do not flow to physician

• Lack of integration• Lack of IT standards


Obstacles to implementing information technologyAmerican College of Physician Executives Technology Survey March/April 2004

Stark Law Exceptions and Safe Harbors


Health System Contribution Allowable under Safe Harbor Laws* Components

Implementation Hardware NoPC,s Scanners, Tablets, Routers, Wireless Access

Network & Data Yes Telecom / Data Charges

Software Yes

Interfaces YesADT with Hospital, Lab System, Reference Labs, Transcription

Implementation Services Yes Set-up, Training

Ongoing Support Yes

Transaction Services Yes

Automatic Appointment Calling, Electronic Statement Processing, Claim Editing

•A Maximum of 85% of cost can be contributed by health system•(Not a legal opinion )


Path to Clinical Transformation

• Utilization• Standardization• Transformation

• Challenging in the Ambulatory environment

Obstacles to Ambulatory ERM Implementation and Utilization

• Specialty specific templates

• Training requirements– 1 three hour sessions, 2 one hour follow-up sessions– This after physician has training on in-patient system

• Loss of productivity in early learning curve– Buy in from all physicians in group

• Integration with:– Back-end office management systems– Front end registration and scheduling

• Integration with in-patient system– What is the right amount and format for in-patient information

• Cost and lack of standardization



Current Stasis, Challenges, Issues

• Current Status:– Trinity is 1/3 to ½ complete with implementation of Genesis– Trinity has made limited progress with Genesis-enabled clinical transformation– PGVA recommendations - focus on clinical process transformation to obtain value from

Genesis

• Challenges:– Capturing and measuring value through improvement in clinical workflow– Front-end customization to achieve adoption has led to proliferation of order sets that do not

necessarily lead to better outcomes– Missed expectations with some Cerner components– Recognition of on-going software upgrade requirements– Limited industry experience, high resource demand for “customizations”, and personnel

“burnout”– Technical risk mitigation strategies

• Key Questions:– How do we continue implementation while significantly ramping up clinical transformation?– How do we increase value and reduce risk?

Questions?

Documents

Donald Crandall, MD Clinical Informatics Consultant Trinity Health Sept 2007 Achieving success with Integration of HIT in Ambulatory Care