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  • 1. William W. Stead, M.D. Professor of Medicine and Biomedical Informatics Associate Vice Chancellor for Health Affairs Vanderbilt University September 28, 2006 Picking an Enterprise TargetPicking an Enterprise Target Disclosures: McKesson distributes WizOrder as Horizon Expert Orders. I am a Director of Healthstream & Netsilica.
  • 2. Road Map to the TalkRoad Map to the Talk  Framework to guide thinking about alignment of enterprise and IT strategies  Picking the purpose of IT in your business  Key trends in IT and Informatics that will bear on the art of the possible  One vision of how ready access to information might change health care in the near term  Status check
  • 3. Enterprise AlignmentEnterprise Alignment  What technical barriers stand in our way?  When will technical progress solve the problem?  Is there a work around?  Will technology enable a new entrant to disrupt our business plan?  Will technology enable us to develop a new business model?  What is the purpose of technology in our business?
  • 4.  Framework to guide thinking about alignment of enterprise and IT strategies Picking the purpose of IT in your business  Key trends in IT and Informatics that will bear on the art of the possible  One vision of how ready access to information might change health care in the near term  Status check Road Map to the TalkRoad Map to the Talk
  • 5. Supply Chain & Revenue Cycle  Efficiency – FTEs, – TimeAutomation Management Decision Support  Strategy, Execution IT Strategy/Benefit FrameworkIT Strategy/Benefit Framework Remote Operation  Access Patient Centered Care  Quality, – Errors Context Sensitive Closed Loop – Errors Communication & Documentation – Errors, – Cost, – FTEs Clinical Decision Support  Quality, – Errors, – Utilization  EfficiencyUtilization of Scarce Resources
  • 6. Time High Low INFOUTILITY Info. Value Shift Source Global AVAILABILITY I/T Value
  • 7. Problems – Solutions – Results • Correct Testing 1 – ICD9 – Imaging Advisor
  • 8. Problems – Solutions – Results • Correct Testing 2 – ICD9 – Imaging Advisor
  • 9. Problems – Solutions – Results • Correct Testing 3 – ICD9 – Imaging Advisor
  • 10. pre-CPOE post-CPOE Errorsper100Orders 2.2 1.3 30.1 0.2 6.8 0.1 0 5 10 15 20 25 30 35 Potential ADE's Medication Prescribing Errors Rule Violations Potts, A. et al. PEDIATRICS 2004;:113:59-63
  • 11. Potential ADEs Duplicate therapy Inappropriate dose Inappropriate interval Inappropriate route Wrong drug Allergy Drug interaction Wrong units MPEs Weight not available Missing Information Illegible RVs Trailing zeros Abbreviation <0.001 <.001 .69 .39 .01 .07 .49 .49 <.001 <.001 <.001 <.001 <.001 <.001 <.001 <.001 Pre-CPOE (n = 6803) Post-CPOE (n = 7025) P Value 147 4 53 24 6 6 1 1 52 2049 22 1979 48 466 55 411 Total Number 2.2 0.06 0.78 0.35 0.09 0.09 0.01 0.01 0.76 30.1 0.32 29.09 0.71 6.8 0.81 6.04 Number Per 100 Orders 88 0 59 19 0 1 0 0 9 12 0 12 0 10 10 0 Total Number 1.3 0 0.84 0.27 0 0.01 0 0 0.13 0.2 0 0.17 0 Number Per 100 Orders Medication Drug Errors
  • 12. Impact of Advanced Dosing onImpact of Advanced Dosing on Potential ADE’sPotential ADE’s 7.3 13.9 2.2* 2.5* 0 2 4 6 8 10 12 14 16 pre- post- Errorsper100Orders All orders Patients < 7 days *p value < 0.001Wright L, Gregory DF, Barr FE, Patel NR, Waitman LR. Impact of patient-specific decision support on medication errors in critically ill children. Critical Care Medicine. Society of Critical Care Medicine 35th Critical Care Congress San Francisco, CA, January 7-11, 2006. 33(12) Abstract Suppl:A12, December 2005
  • 13. Clinical Decision SupportClinical Decision Support  Costs  Hardware, software, implementation  24 hr receptionist coverage  SWAT team during training & go-live  Pharmacist to reconcile multiple systems  Iterative development of content and process  Benefits  Appropriate utilization increases quality while reducing marginal cost  Quality improvement decreases downstream cost  Reduced error decreases LOS utilization, and risk management  Quality, safety and cost effectiveness increase market share
  • 14.  Framework to guide thinking about alignment of enterprise and IT strategies  Picking the purpose of IT in your business Key trends in IT and Informatics that will bear on the art of the possible  One vision of how ready access to information might change health care in the near term  Status check Road Map to the TalkRoad Map to the Talk
  • 15. Technology TrendsTechnology Trends  Convergence of media, computing and communication technologies  More natural user interfaces (voice & 3DVR)  Embedded sensors aware to person, place, time  Just-in-time data mining and simulation  Disruption of publication channels that limit access  Global/Best of Class content creation, organization to meet a purpose, mentoring during use  Faster, smaller, less expensive hardware
  • 16. Avoiding HypeAvoiding Hype
  • 17. 0 2 4 6 8 10 12 14 16 18 Yr 1 Yr 2 Yr 3 Information Technology Software Development PERFORMANCE Technical RealityTechnical Reality
  • 18. Implications for Technical Approach User Driven  Communication  Data Mining  Visualization Programmed Workflow
  • 19. Purpose Mechanism Balance between Human & Technology Efforts Impact on Process Reproducibility Adaptability Information Technology Tool KitInformation Technology Tool Kit Information Access Work Flow Automation Aggregation Data Mining Visualization Communication Work Lists Context Sensitive Decision Aids Data Processing & Knowledge Mgmt. Open Process Control Robotics T T/T T/T/T H/T H/H/T H/H/H H/T T/T/T
  • 20.  Framework to guide thinking about alignment of enterprise and IT strategies  Picking the purpose of IT in your business  Key trends in IT and Informatics that will bear on the art of the possible One vision of how ready access to information might change health care in the near term  Status check Road Map to the TalkRoad Map to the Talk
  • 21. Work-arounds System Development The Healthcare Non-systemThe Healthcare Non-system
  • 22. System Design Practice System Design Practice Evidence Based System of CareEvidence Based System of Care Pick Population •Risk •Cost •Variability Pick Population •Risk •Cost •Variability Evidence •Research •Guidelines •Practice database Evidence •Research •Guidelines •Practice database Workflow • People – Crew Training • Process – Plans, Goals, Actions • Technology Tools – Advisors, Order Sets, Alerts Workflow • People – Crew Training • Process – Plans, Goals, Actions • Technology Tools – Advisors, Order Sets, Alerts Individualize & Act •Assess •Order •ResultsIndividualize & Act • Assess • Order • Results Feedback • Trigger/Sentinel Events • Process Outcome • Clinical Outcomes
  • 23. System Design Practice Individualize & Act • Assess • Order • Results Workflow • People – Crew Training • Process – Plans, Goals, Actions • Technology Tools – Advisors, Order Sets, Alerts Evidence •Research •Guidelines •Practice database Feedback • Trigger/Sentinel Events • Process Outcome • Clinical Outcomes Pick Population •Risk •Cost •Variability Evidence Based System of CareEvidence Based System of Care
  • 24. Vignette from a System of CareVignette from a System of Care  The clinician and patient are “on the same page,” the approach is standardized yet individualized  Complementary and alternative approaches to health improvement work in combination with scientific medicine  The patient is a full partner in tracking their progress and adapting course  The patient’s plan is updated proactively as standard of practice evolves
  • 25. Roles & Process ChangeRoles & Process Change Evidence Patient Record Synthesis & Decision Clinician
  • 26. Clinician and Patient are PartnersClinician and Patient are Partners Evidence Patient Record Provider Personalized Knowledge Base Patient
  • 27. New Skills are NeededNew Skills are Needed  Teamwork, problem solving and coaching  Guiding a data-driven system of care  Privacy, confidentiality, security  Learning at “teachable moments”  Finding, assessing and applying ‘just in time’ information  Managing change
  • 28. Infrastructure Requirements ChangeInfrastructure Requirements Change Information Islands Discipline specific information and records Task specific systems, each with its own record Each note stands on its own Common Information Aggregate information from all sources Provide views specific to experience and roles Link into role specific workflow tools
  • 29.  Framework to guide thinking about alignment of enterprise and IT strategies  Picking the purpose of IT in your business  Key trends in IT and Informatics that will bear on the art of the possible  One vision of how ready access to information might change health care in the near term Status check Road Map to the TalkRoad Map to the Talk
  • 30. State of the Art 2006State of the Art 2006  Life-Time Patient Record  Remote Operation  Continuous/Personalized Medicine  Industrial Engineering Models for Scheduling ResearchStandardof Care  Access to Medical Literature, Test Results, Transcription  Data Driven Practice Modification & Contracting  Supply Chain/JIT Inventory  Revenue Cycle Management Selective Use  Point of Care Systems  Patient Portals  Electronic Data Interchange (Direct)  Telemedicine Consultation  Clinical Trial Management
  • 31. Execution ChallengesExecution Challenges  Aligning strategy and infrastructureAligning strategy and infrastructure  Managing discontinuous changeManaging discontinuous change  Building trustBuilding trust  Focusing organizational energyFocusing organizational energy  Leveraging intersectionsLeveraging intersections  Maximizing returnMaximizing return
  • 32. Research Mission 2010 Informatics Center Process & Infrastructure Management Decision Support Education Mission Clinical Mission Direct Care Layer Support of Direct Care Layer Unit/Service/ Clinic Support Layer > > > > Informatics Center 5-Year Plan Major Project Groups Supporting Milestones > Curriculum Appropriate to a System of Care 20072005 2006 Breakthrough from Focused Interdisciplinary Research Team Medication Safety Best-of-Class Across Continuum of Care 20092008 Culture that Values Evidence Based, Individualized, Systematic Care Overview of RoadmapOverview of Roadmap
  • 33. Pt. ID Lab Specimen Plan Patient to Provider Messaging Widely Available Decision Symbols Go-Live Date Symbols Roadmap SymbolsRoadmap Symbols High Level Goals Culture that Values Evidence Based, individualized, Systematic Care
  • 34. Skills for All TimesSkills for All Times  Comfort the patient  Recognize patterns  Know what you do not know  Reflect the patient’s values  Observe the patient

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