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The Search for Effective and Efficient Healthcare Delivery
15th Annual Healthcare Summit Disrup5ve Forces in Healthcare
The Next Step is a Bold One Catherine Claiter-Larsen Vice President, Quality Systems and Chief Information Officer, Island Health
In the Search for Efficient and Effec2ve Healthcare Delivery…
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• We’re drowning in paper and paper-‐based processes.
– Fragmented – paper-‐based health records are created and stored by provider, in different formats, in separate loca5ons
– Inaccessible – paper is available in one loca5on at a 5me, and is oAen not accessible (or even known to exist)
– Inefficient – care providers spend a significant amount of 5me ‘searching’ for relevant informa5on
– Error-‐prone – the quality of manual documenta5on is not validated and there is no feedback provided to care givers
…errors are caused by faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.”
Ins5tute of Medicine. To Err is Human: Building a Safer Health System, November, 1999 “
• people will suffer an adverse event Hospital Admissions
• people will suffer a serious adverse drug event with the drugs received on discharge Pa2ents Discharged from Hospital
• will be unnecessary Laboratory Tests Performed
• don’t receive recommended Beta-‐blocker therapy Pa2ents Post Myocardial Infarc2on
• are not screened Women at Risk for Cervical Cancer
• had an informa5on gap iden5fied, resul5ng in an average increased stay of 1.2 hours Emergency Department Visits
In Canada, for every 10001…
75
90
150
320
400
460
As a Result, the ‘System’ is Working as Designed
3
up to
up to
up to
1 Canada Health Infoway. The Need for Electronic Health Records. 2005-‐06 Business Plan Sta5s5cs from mul5ple sources.
1. Inadequate or incorrect informa5on
2. Medica5on-‐related issues
3. Inadequate assessment
4. Inappropriate type/ level of care
5. Delayed or disrup5ve care or service
6. Incorrect applica5on of process or procedure
7. Inadequate infec5on preven5on and control
8. Miscommunica5on
9. Premature discharge
10. Failure to diagnose or delayed diagnosis
The Impact on Pa2ents and Their Experience is Significant
4
39%
Pa2ent Care Quality Office Cases
Gaps in Informa5on & Communica5on
162
113
81
79
46
43
42
36
31
27
Informa2on and Communica2on Gaps – Top Ten Categories1
1 From 2013/14 Island Health Pa5ent Care Quality Office (PCQO) cases
• EHR Access – 2,597 physicians and 10,830 non-‐physician
clinical staff have ac5ve EHR accounts – Wireless access is implemented across all
major hospital facili5es – 10,900 computer devices on Island
Health’s secure network, including 500 mobile carts
• EHR Use – > 6,680 unique daily users – Avg daily peak of 2,700 concurrent users
• EHR Volumes – Over 25,230 electronic charts opened/day – Over 69,000 transac5ons/day, including:
• 2,913 medical imaging test orders • 8,330 medica5on orders • 25,000 lab orders
– Over 4,925 new encounters/day
But Aren’t There Electronic Health Record’s in Place?
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Average Daily Peak Concurrent EHR Users 2,700
480
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Paper
Electronic
Yes, but the Majority of Care Processes are S2ll on Paper
* Chart Content Propor5ons Es5mated for Illustra5on
• Despite the significant EHR investment and use, only 30% of the acute care record has been automated
• The hybrid paper/ electronic record environment is replicated within, and across, care sekngs
• The current hybrid health record results in manual, fragmented communica5on and sub-‐op5mal care delivery
Orders Mul5disciplinary Documenta5on
Graphic Monitoring
Medica5on Records
Residen2al Care
Provincial Registries
Acute Care*
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Current State – Health Records Across the Care Con2nuum
Home Care
Specialist/ Primary Care
We’re (Way) Behind our Peers
Stage Cumula2ve Capabili2es Canada US
Stage 7 Complete electronic health record (EHR), data flows across con5nuum as byproduct of EHR 0.0% 3.4%
Stage 6 Structured physician documenta5on, full complement of electronic images 0.6% 16.5%
Stage 5 Closed loop medica5on administra5on, including posi5ve pa5ent iden5fica5on 0.6% 29.5%
Stage 4 Computerized prac55oner/physician order entry, evidence based protocols 3.4% 14.5%
Stage 3 Basic clinical documenta5on and decision support for errors (drug/drug, drug/lab, etc.) 32.1% 23.9%
Stage 2 Clinicians access results from data repository, rudimentary conflict checking 29.5% 5.3%
Stage 1 Laboratory, pharmacy and radiology systems all installed 14.6% 2.5%
Stage 0 Laboratory, pharmacy and radiology systems not installed 19.1% 4.4%
n=638 n=5,553
* Based on HIMSS Analy5cs EMR Adop5on Model Q3 2014 7
What’s Taking So Long and Why is it ‘So Hard’?
Stage Cumula2ve Capabili2es Chart Automa2on Change Impact Quality Supports
Stage 7 Health Informa5on Exchange
Stage 6 Physician Documenta5on
Stage 5 Closed Loop Medica5on Management
Stage 4 Computerized Provider Order Entry (CPOE)
Stage 3 Basic Nursing/Allied Health Documenta5on
Stage 2 Clinical Viewer
Stage 1 Lab and Radiology Results, Medica5on Profiles
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Reduce some duplica5on
Reduce some errors
Significant reduc5on in errors, varia5on
Eliminate avoidable errors
Eliminate informa5on gaps across the con5nuum
Discrete data for advanced clinical analy5cs
Improve 5meliness of results
Low
Extreme
Moderate/High
Very High
Moderate
Moderate
Moderate
The Next Step is a Bold One – (A Huge) Scope of Change
Stage Cumula2ve Capabili2es Lab/ Radiology
Pharmacy
Nursing/ Allied Health
Ordering Providers Change Summary
Stage 7 Health Informa5on Exchange All providers have access to complete health record
Stage 6 Physician Documenta5on Physician providers document real-‐5me in a structured format
Stage 5 Closed Loop Medica5on Management
Significant change in medica5on produc5on, dispensing, administra5on
Stage 4 Computerized Provider Order Entry (CPOE)
Ordering providers enter orders electronically, significant process change in ancillary departments
Stage 3 Basic Nursing/Allied Health Documenta5on
Nursing/Allied Health document real-‐5me in a structured format
Stage 2 Clinical Viewer Clinicians transi5on from paper to viewer for core clinical content
Stage 1 Lab and Radiology Results, Medica5on Profiles
Significant process change across ancillary departments
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Clinical Content
Vital Signs, Allergies
Orders
Low Moderate Moderate/High High Change Impact:
• Get to ‘the Beginning’ with a safe, base set of new EHR-‐enabled processes • Leverage new capacity and tools to con5nuously evaluate, refine and improve
• Demonstrate and harden the EHR tools and change process through a major, representa5ve ac5va5on
• Re-‐establish baseline opera5onal measures and demonstrate value • Spread and repeat
• Embed EHR configura5on into quality-‐driven prac5ce, policy and process decisions
• Create capacity and support clinicians to lead and own the change
• Validate and refine an established ‘Model System’ through a highly visual, interdisciplinary workflow review process
The Next Step is a Bold One – A (Completely) Different Approach
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Validate, Not Design
Quality-‐Driven, Clinician-‐Led
Demonstrate, Stabilize, Repeat
Con2nuously Improve
The Next Step is a Bold One – Fundamental Individual Change (x10,000)
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Personal Mo2va2on
Personal Capability
Social Mo2va2on Social Capability
Structural Mo2va2on
Structural Ability
Personal experience
Values
Web-‐based training
Classroom training
Performance Metrics
Decision-‐ making
authority
Kick-‐off Events
Clinical champions
Nursing informa5cists
Subject marer experts
Peer Mentors
Individual Change
Job aids
Ongoing supports
Backfill
Recogni5on
Metrics
Rewards
EHR Learning
Tools
Devices
Local leadership
Pa5ent stories
On-‐the-‐job learning
Personaliza5on
Coached Learning
Hands-‐on preview
Cerner coaches
Benefits
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New conversa5ons between pa5ents and providers strengthens
the pa2ent and provider experience A new understanding of performance from the individual to system level
supports a learning culture
Clinical prac5ce and the EHR are refined to incorporate learnings and new evidence, driving
con2nuous quality improvement
The Next Step, Takes Us to the Beginning of a New Journey
New discoveries are enabled with real-‐5me data, advanced
analy5cs, and research partnerships
Leadership development and the shared change experience creates
new capacity for change
THE ‘BEGINNING’
Excellence IN HEALTH AND CARE
Virtual teams collaborate and care is coordinated across the
con2nuum of care
PEOPLE AND CULTURE
PRACTICE AND PROCESS
TOOLS AND INFORMATION
