Webinar: http://www.medsphere.com/infinite/Voice: (888) 346-3950Participant code: 1302465

Clinical Transformation, Part I

February 2009 Community Call

Presenters

• Edmund Billings

• Janine Powell

• Karen Small

• George Lilly

• Fay Struble

• Jon Tai

• Hartsel Bryant

Agenda

• Clinical Transformation

• Core Measures– Primer & Workflow

– Demonstration

– Future Vision & Discussion

• Open Project Updates– CCD-CCR Project

– OpenVista/GT.M Integration

• Medsphere.org: Tip of the Month

Clinical Transformation

Edmund Billings, MD

Clinical Transformation

Using the HIT system to achieve clinical improvements:

• Eliminate “Never Events”

• Patient Safety

• Quality Improvement

• Population “Disease” Management

6

7

Legislation and Initiatives

• 10/2008 “Never Events”

– Starting 10/2008 Medicare & Major Payors will not reimburse for serious preventable events (E.g.Infections, embolisms, pneumonia)

– Being adopted by 23 States with payers planning to not reimburse and/or hospital associations planning to not charge for these events.

• 08/2008 - Mass "Healthcare Reform Act"

– Implementation of EHRs in all provider settings,

– By 2015. statewide interoperable Heath Information Exchange

– A first year funding of $25 million, projected eight year $200 million investment.

• 09/2008 - The Stark Law

– The proposed bill would direct that EMR/EHR open-source technology be developed and made available to health care providers at "a nominal cost."

http://www.msnbc.msn.com/id/26140511

Never Events States-to-Date: 23

“ …provision of an open source health information technology system that is either

new or based on an open source health information technology system, such as

VistA….”

“ By 2012 for statewide adoption of CPOE would be required for hospital

licensure.”

Clinical Transformation Initiatives & Impact

8

Insurance providers est of saved life $1,500,000

Adverse drug event ($16,000-$24,000) $20,000

Cost of a VAP $40,000

Cost of a vent days $750

Medication reconciliation to reduce ADE (15%-20%) 15%

Cost surgical infection $25,546

Cost of a pressure ulcer $10,845

Cost of a bloodstream infection $25,000

Cost savings from automating forms $1.24

Reduction in ventilator days through bundle compliance 25%

9

10

Industry Recognition

11

Why Stage 6 is Critical?

• Supports Clinical Transformation

“Stage 6 hospitals have achieved a significant advancement in their IT capabilities that positions them to successfully address many of the upcoming industry transformations we will be experiencing in the near future (e.g. HIPAA Claims Attachment, pay for performance, and government quality reporting programs)”.

• Share Data with Stakeholders

“Stage 6 hospitals are also well positioned to provide data to key stakeholders (e.g. payers, the government, physicians, consumer and employees) to support electronic health record (EHR) environments and regional health information organizations (RHIO’s).”

Stage 6 Hospitals: The Journey and the Accomplishments, Mike Davis HIMSS Analytics, 2007.

12

Transformation

Value is shared goal, now the steps:

1. Implement to assure the technology is deployed and configured to support work processes.

2. The technologies enable the people to “use” the technology effectively.

3. Now, the people can use the system to change their processes and realize value.

not just adoptionADOPTION IS NECESSARY BUT INSUFFICIENT

13

3 Transformation Steps

1. Adoption1. Departmental automation - orders management - CPOE

2. Clinical usage

3. Necessary but not sufficient

2. Operational Transformation1. System itself is closed loop and fills holes

2. Efficiencies, information access and accountabilities

3. Clinical Transformation1. Use clinical content to address specific patient safety and clinical

guidelines

2. Target specific outcomes with order sets, templates, clinical reminders

14

Provider writes a new, renews,

,modifies, or DC’s an order

Places Chart in Rack

Flag Patient Chart for Orders

Unit Secretary or Nurse faxes/tubes/

or puts in pharmacy system

Nurse Reviews orders

Drug is dispensed To patient

Reviews Current Medications

Medication Order is Dispensed to

Unit

Pharmacy Tech Fills Order

Pharamcy Verifies Order

Is medication Floor stock?

Are there Any Drug

Interactions or is this the

correct Dose

Is medication Floor stock?

Nurse Pulls Chart

No

Yes

No No

Notify Physician

Yes

Medication is on Unit

Yes

Unit Secretary Pulls Chart

Pharmacy Enters Order into System

Nurse Checks 5 Rights

Nurse Administers Medication

Medication Administration: CPOE & BCMA

BeforeAutomate11 Steps

Provider writes a

new, renews,

,modifies, or DC’s

an order

Nurse Reviews

orders

Reviews Current

Medications

Medication Order

is Dispensed to

Unit

Pharmacy Tech

Fills Order

Pharamcy Verifies

Order

Barcode

Medication

Administration

Checks 5 rights

Nurse Administers

Medication

After

15

Stage 6: Operational Transformation

Care� Decrease time from Rx order to dispensing: 15-20 minutes

� Decrease Dx report turnaround: minutes, not hours

� Decrease Rx order errors

� Shift of RN time from documentation to patient care

� Decrease length of stay

Charge Capture & Claims� Increase in charge capture

� Reduction in uncoded account days

� Improved Case mix index improvement

� Discharged-Not-Final-Billed (DNFP): Dec AR days

� Decrease coding denials

� HIPAA Attachments

Order Result

Order/Doc Claim

16

How does it support clinical transformation?

1. Establish RN and MD usage

2. Plan: prompt for standard of care – Order Set

– Template

– Clinical Reminders

3. Measure outcomes– Midland 5 million Lives

– Never Events

– Core Measures

– Safety Checklists

– Big Seven Chronic Diseases

– Oncology Regime Tracking

4. Benchmark & Scoreboard

5. Iterate

17

Central Line-Associated Primary Bloodstream Infection Rate

The Central Line-Associated Primary Bloodstream Infection (BSI) Rate per 1000 Central Line-Days

improved from a mean of 24.39 (1 of 41 Jul-Sep 2005) to 2.95 (4 of 1355 Feb 2007 – Jan 2008).

24.39

2.95

0.00

5.00

10.00

15.00

20.00

25.00

30.00

Jul-Sep 2005 Feb 2007-Jan 2008

Time Period

Per

Tho

usan

d

88% Improvementin 18 months

Central Line Primary Bloodstream Infection Rate

18

Key Transformation Components

Today• Integrated EHR

• No interoperability excuses

• CPOE

• Closed loop orders and BCMA

• Clinical documentation

• Content– Order Sets

– Templates

– Clinical reminders

• CDSS: Rx Error Checking

“Its integrated and it works”

Roadmap• Richer CDSS at Point of Care

– EBM Care Protocols

– Rules-based activity monitoring

– Interruptive alerts

– Passive recommendations

– Contextual access to references

• Clinical Dashboard– Population Management

– Benchmarking

– Scoreboarding

• Community Collaboration– Sharing content

– Sharing best practices

– Proving standards of care

“Health Improvement Technology”

Core MeasuresFay Struble

Janine Powell

Karen Small

Edmund Billings, MD

Problem

• Hospitals have to hire full time staff to monitor and manage

collection of data needed for compliance with regulatory and

billing issues.

� The Joint Commission on Accreditation of Healthcare Organizations

(JCAHO) has created Core Measures standards in order to increase

patient safety, improve the quality of care, disseminate evidence

based practices, and identify high reliability health care

organizations.

What are core measures?

• Core Measures are sets of clinical care performance guidelines that the Joint Commission has established

� From research� Past reporting� Current best practices and evidence based care

• Used for reimbursement purposes (Center of Medicare & Medicaid Services)

• Used for research activities directed to improve the quality of care

• Help identify and distinguish high reliability health care organizations

• Identify and disseminate evidence-based practices and to set national benchmarks

Overview

• For 2008, hospitals are required to collect and transmit data toThe Joint Commission for a minimum of four Core Measures sets or a combination of applicable Core Measures sets and non-Core Measures. The measure sets currently available for selection are:

� Acute Myocardial Infarction (AMI)

� Heart Failure (HF)

� Pneumonia (PN)

� Pregnancy and Related Conditions (PR)

� Hospital-based Inpatient Psychiatric Services (HBIPS) – (Beginning with October 1, 2008 discharges)

� Children's Asthma Care (CAC)

� Surgical Care Improvement Project (SCIP)

� Hospital Outpatient Measures (HOP)

Poll

Value

Medsphere, in its attempt to keep their clients compliant with these new regulatory guidelines, has created a content-driven solution utilizing Clinical Reminders, health factors, and tailored templates. Clinical Reminders provide real time point of care assistance, as well asretrospective patient reporting.

� Core Measures content is designed to provide hospitals with realtime capture and retrospective reporting on Core Measure regulatory requirements while reducing the time required to manage and monitor the initiatives increasing compliance and revenue

Core Measure Initiation Workflow

Demo

Poll

Core Measures

• Future Vision

• Discussion

Open Development Projects

George Lilly & Fay Struble

Jon Tai

Community CCR/CCD Project*

Opensource CCR and CCD supportfor VistA based systems

Project Update

February 19, 2009by

George Lillyglilly@glilly.net

* This project has been funded in part with Federal funds from the National Institutes of Health, under Contr act No. HHSN268200425212C, “Re-engineering the Clinical Res earch Enterprise".

� Definition

� Purpose

� Snapshot

� Highlight

� Contributors

Topics

Definition: The Continuity of Care Record (CCR) is a machine readable and human readable ASTM XML standa rd data set of a person's clinical status

Defintion

Poll

The CCR dataset has many intended purposes includin g the exchange of medical records, synchronization with c linical repositories, and the transformation into clinical messages

Exchange of medical records:� Between two EHR systems (VistA<->VistA and VistA<->O ther) '� With a Personal Health Record (PHR) – like Google He alth or

MS HealthVault

Synchronization with clinical repositories:� For clinical decision support � For research and clinical trials – as with the Elect ronic

Primary Care Research Network (ePCRN) '

Transformation into clinical messages� XSLT transformation into a Continuity of Care Docum ent (CCD) '

� For use the the National Health Information Network (NHIN) '� For CCHIT Certification� For HIPAA Claims Attachments

� Transformation into XML Web Service messages for eP rescribing

Purpose

CCR/CCD PROJECT SNAPSHOT 2/19/2009

Payers

Advance Directives

Support

Functional Status

Problems

Alerts/Allergies

Lab Results

Medications

Family History

Medical Equipment

Immunizations

Procedures

Encounters

Plan of Care

Recent Change

Vital Signs

Social History

Actors

Export

TestingPlanned In ProductionIn DevelopmentLegend

Import (Accessioning)�Alerts/Allergies

Medication Advisories(ePrescribing)'

OpenVista WorldVistAEHR FOIA VistA RPMS

GTM GTM

GTM

Cache

GTM

Cache

Fileman CCR Elements

MUMPS Temporary Globals

CCRTemplate

CCRProcessor

File WebService

XPath Library

Template File

Template Import

Parameters

Lab Date Limits

Meds Date Limits

Vitals Date Limits

PicklistProcessing

BatchProcessing

XML RPC Variables RPC

Checksums

CCD Transformation

ePrescription XMLSupport

FilemanMenu

Options

Fileman Parameters

ePCRNConnection

Codes

Poll

Recently, we demonstrated the transformation of our CCRs into level 2 CCDs thanks to an XSLT transformation contri buted by Ken Miller

Highlight

� HP

� KRM

� Medsphere

� Robert Morris University

� Seqeuence Managers

� University of Minnesota

� Christopher Anderson

� Nancy Anthracite

� Lee Castonguay

� Duane DeCorteau

� Emory Fry

� Sam Habiel

� Jose Lacal

� George Lilly

� John McCormack

� Ben Mehling

� Dennis Menor

� Ken Miller

� Kevin Peterson

� Chris Richardson

� Mike Schendel

� Fay Struble

� Thomas Sullivan

� Chris Uyehara

� David Whitten

� Greg Woodhouse

� JohnLeo Zimmer

Contributors

OpenVista/GT.M Integration Project

Jon Tai

Activity Numbers

� 28 bugs filed

� 51 commits in 8 branches

� 32 messages discussing 6 proposals

� Many more on Hardhats

� 6 blog posts

Last Month

� Settled on filesystem layout and Linux permissions scheme

� Wrote proof-of-concept code to create OpenVista instances, perform backups

� Identified areas in OpenVista that will require modification

� Wrote proof-of-concept code to allow M-based tools in OpenVista to start/stop TCP listeners

� Started developing test plans

� Started packaging various utilities, including GT.M itself

This Month

� Finalize design decisions

� Switching “namespaces”

� KIDS and “routine tiers”

� File more bugs

� Not just defects – includes task/feature bugs

� Having all tasks in the tracker will allow us to better track work completed and work remaining

− Makes it easier for others to get involved

� Start on implementation

Get Involved

� Code is available on Launchpad

� Not production ready; for developers only

� Bugs are in Launchpad

� You can help!

� File a bug

� Comment on a bug with suggestions

� Create a branch and fix a bug yourself

� Not sure how to get started?

� Post on Medsphere.org with your interests; we'll find something for you!

Medsphere.org Tip of the Month

Hartsel Bryant

Demo