Minding the Gap: Path Innovation, Collaboration and Quality

Overview

Costs of Healthcare

eHealth Vision

Quality and Errors

Clinical Information Technology

Clinician Adoption

Innovation and Transformation

Flatteners and the Triple Convergence

Overview

Costs of Healthcare

eHealth Vision

Quality and Errors

Clinician Adoption

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

Clinician Adoption

Healthcare’s Triple Convergence

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.

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. 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 © 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. Top-Ranked AMI (%) 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

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 Star Average Incompetent Star Average

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

Costs of Healthcare

eHealth Vision

Quality and Errors

Clinician Adoption

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

08/11/2000 8:00pm 35 1 165,000 76 mcm 3 08/11/2000 08/11/2000 08/11/2000 08/11/2000 Source: McKesson Corporation Integrated guidelines and knowledge links Easily activated guideline-driven orders Relevant patient drug and lab data

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

Costs of Healthcare

eHealth Vision

Quality and Errors

Clinician Adoption

Secure Clinician Adoption

Workflow

Impact on patient care

Quality

Cost

Efficiency - time

Obtain information

Patient encounter

Record findings

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

Overview

Costs of Healthcare

eHealth Vision

Quality and Errors

Clinician Adoption

Clinical Transformation Needed

Utilize clinical technologies

Impact clinical processes

Enhance quality

Achieve efficiencies

Necessary focus

Clinical strategy

Clinical business

Process redesign

Change management

Number of Links Probability of Failure 0% 20% 40% 60% 1 2 3 4 5 6 7 0.999 0.99 0.98 0.97 0.96 0.95 0.94 0.93 0.92 0.91 0.90

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

Future State Admission Process Map

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

Summarizing Clinical Transformation

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

- Don Berwick, MD Institute of Healthcare Improvement

Overview

Costs of Healthcare

eHealth Vision

Quality and Errors

Clinician Adoption

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.

Minding the Gap: Path Innovation, Collaboration and Quality

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