The Healthcare Knowledge Map
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  • 1. Make the Complex Simple… The Healthcare Knowledge Map …and Break Down the Silo’sDavid Shiple,Practice Leader, Advisory Services
  • 2. Solving The Healthcare Knowledge GapThe Problem » Healthcare professionals often work and think “in silo’s”, but increasingly need to solve enterprise-wide problems » Seasoned hospital professionals with a comprehensive understanding of hospital processes typically acquired this knowledge after decades of hospital experience » New professionals coming into the field must quickly gain the same understanding as industry veterans in a period of hyper- change, and › Knowledge of only a single hospital “silo” is no longer an option › Knowledge and credibility in clinical areas is a critical success factor › Every process change can have an unintended cascading effect within a health system
  • 3. Solving The Healthcare Knowledge GapThe Solution » How do we quickly help healthcare service professionals get their arms around the complex flow of a health system? » It would be nice if the major health system processes could be put into one, visually compelling map » It would be nice… and it’s been done.
  • 4. People Learn Best by Seeing …We use large graphical models for rapid understanding … and to get everyone onthe same page (i.e. confirming the “current state”) “… if I can get everything onto one page, I can get mental control over it..” - Workshop Participant
  • 5. Understanding Correlations Among WorkflowsOnce people can get the whole problem on a “workbench”, correlating workflowsand planning enterprise-wide changes can begin “ .. For the first time, managers from each discipline felt their colleagues had a good understanding of their business models, workflow, and issues…” - Workshop Participant
  • 6. Sample Knowledge Map SectionsDetailed is carefully balanced: enough detail to make information meaningful, butnot too much information that would make the model unusable
  • 7. How is the Knowledge Map Organized?The data points are color-coded to highlight key workflow steps, technologyenablers, and commentary on current issues of adoption, ROI, etc. Workflow Step Technology Enabler CommentaryExample from the physician’s workflow: Technology Enabler Commentary Workflow Step
  • 8. How is the Knowledge Map Organized? (cont’d) Pictures, metrics tables, and reference material is embedded into the map to further drive accelerated understanding of the health system. Images help students to develop a rich “mental Performance Indicators Benchmark map” of the health system; LOS for Treat & Release 90 min the one on the left is from the O.R. workflow LOS for Admitted Patients 240 min Left Without Being Seen < 1% AMA 1% % of time on Diversion < 1% Triage Start to Triage End 5-7 min Triage End to Registration Start < 10 min The reference section of the model contains commonly used Registration Start to Registration End 3-5 min statistics, best practices criteria, and other Knowledge Registration End to Placed in Treatment Room < 20 min information which is commonly accessed by users of the Arrival to First RN Encounter 10 min model Arrival to First MD Encounter 30 min First MD Encounter to Disposition Order Written 60 – 75 minThe HIMSS 8-Stage EMR Maturity Model Disposition Order Written to time Patient Left the ED 15 min (discharged pt)Stage 7 - Medical records are fully electronic; hospital is able to contribute continuity of care document as 30 min (admitted pt)byproduct of EMR; data warehousing in useStage 6 – Physician documentation in structured templates; full clinical decision support system in use; fullradiologic and PACS in useStage 5 – Closed loop medication administration that addresses every step of medication use process Metrics help professionals understand how a givenStage 4 – Computerized physician order entry system in use; clinical decision support system in use forclinical protocols workflow is measured and what is seen as important -Stage 3 – Clinical documentation, clinical decision support system in use for error checking, PACS in use the table above is from the E.R. workflowoutside of radiologyStage 2 – Clinical data repository, controlled medical vocabulary, clinical decision support system; may havedocument imagingStage 1 – Ancillaries (lab, radiology, pharmacy) are installedStage 0 – None of the ancillaries are installed
  • 9. How is the Knowledge Map Organized? (cont’d) Physician The patient experience underlies the entire model Office Acute Care Hospital Nurse Med/ ICU Surg Nurse/ Physician Interaction Physician Knowledge Material Emergency Dept.36” Operating Room Meaningful Use EMR 8-Stage Revenue Cycle Criteria Model Pharmacy Radiology Lab CMS Core Health System Measures KPIs • The model prints as a 36” x 48” color poster • The model contains roughly 200 workflow points • Other workflow modules are available that can be 48” “swapped in”: Supply Chain, Cardiology, Oncology, etc.
  • 10. Who Needs the Big Picture? Health system IT professionals I need to solve my problem IT vendor professionals Board Members Silo Quality/ Safety Directors Marketing Professionals First year MHA & MPH students Lean Sigma Practitioners - OR - Ancillary Managers Nurse Managers Let’s solve our CMIO’s problems Admitting Dept. Managers Revenue Cycle Managers Health System Facilities Managers Performance Improvement Professionals
  • 11. Used for Rapid Knowledge Infusion » Part of on-boarding or level-setting process for people new to the industry or new to an enterprise- wide project » Low-cost, 4-hour course to give participants an operational/ technology overview of a typical “ Our managers healthcare system using the Knowledge Map have dubbed the » Each student receives a full-sized Knowledge Map program, ‘death to the silos’…” to own, and to use during instruction - HR Director » Short competency exam is given at conclusion of the course » “Introduction to Hospital Operations” certification is given to each passing student » Students are encouraged to display the Knowledge Map in their office or hallway and internalize it over time
  • 12. Used as a Performance Improvement Tool » Provides a compelling “one-stop-shopping” visual for illustrating the current and future states of enterprise improvements, e.g. “ .. People ask what the future state will » Reducing average length of stay look like…I say, ‘stop by my office – it’s » Increasing patient throughput hanging on my wall’ ” » Establishing EHR meaningful use - Lean Sigma Project Manager » Provides a “workbench” for process change teams to brainstorm, form cross-silo correlations, and form a high-level future map » Maps are easily modified and are inexpensive
  • 13. The Value » Substitutes for 100’s of pages of text or slides (that never gets read and does not lend itself to building an integrated mental map) » Provides a map that can be gradually internalized on the wall of an office or cube » Helps bridges the communication gap between the various actors in the operation of a hospital – in days or weeks, not months and years » Gives all players in the healthcare system an appreciation for the complexity of care delivery and challenges facing each player » Visually compelling - people are drawn to large diagrams describing their line of work
  • 14. Making a Difference in Healthcare » A Knowledge Map that includes the full workflow scope of the acute care hospital and physician office setting has not existed until now » Legions of people work in the “ecosystem” of healthcare – can we afford each to have only a piecemeal understanding? » The Knowledge Map can be easily customized for: » A specific hospital or health system » A set of technologies specific to a vendor » Emphasis on particular workflows (e.g. revenue cycle and supply chain) » The Knowledge Map is a powerful tool used during on- boarding, weekend workshops, certification programs, retreats, and performance improvement projects
  • 15. Healthcare Knowledge Map 2.0DIVURGENT has begun integrating the knowledge content into aleading workflow tool to create a “living model” » Filter slide control gradually move user from high-level to detailed views » Zoom in and out of model for greater/ lesser detail » Workflows can be added/ changed easily » Workflow widgets (IT enablers, actors, illustrations) can be picked from palettes » Mouse-over workflow item to display IT enablers, metrics, issues, etc » Healthcare Knowledge Map 2.0 is planned for early 2012
  • 16. Physician OfficeCare Delivery Map Record vitals • Weight Per office protocol, perform Some offices, NPs and PAs do 90% • Temp procedure per of what physician • Blood patient disease, can do, eg, pressure e.g. • Stitch a Escort • Pulse • Glucose for wound patient to room diabetes Acute Care Hospital patient • EKG for cardio post MI patient Register • Take BP with patient standing up Check-in • Etc. Before physician arrives Inpatient Outpatient Schedule Patient. ideally • Schedule openings Post exam favor profitable activities procedures • Draw blood • Schedules booked for lab tests at 110% • Give • “Like patients” are injections scheduled together • Provide Key to patient satisfaction, patient patient knows: Patient Call Page Infection Process transfers Get signature on Make a Doc Automated Take patient calls information • patient consent happy; review Discharge goals, Who is leading Button physician Control phone • Need appointment forms Physician notes e.g. coordination of my care with results reminders for • “Not getting any • Care Plan before paging the • Home Who is in the room, and of all STAT appointments better” Patient On the Floors/ Doc • LTC what their roles are - Care goals orders • Script refill schedules follow- Contact with Patient • • Hospice What is happening and • Got a letter – told to up why • Home Health Floor Nurse call for f/u • Emerging technologies • Nurse/ Patient Ratio What is going to happen • Etc • • Nurse & Nurse Manager Patient floors generally align with next ICU for patients that need to be • Patient satisfaction Workflow interruptions 5 Rights • Alarms, lab abnormals, etc messaged to Complete P4P specialties watched constantly Nursing Orders Charting • Want fewer agency nurses Attending - Patient call button -- Right patient nurses wireless phone - escalates to nurse reporting Nurse 30 CMS core measures now, • Goal is stabilize and step-down to Sometimes • Nurses care for patient; physicians - Question from doc -- Right time -Assessments manager in 3 minutes; • Magnet status expected to be 125 by 2012 med/ surg floor diagnostic testing Specialists make all treatment decisions; many Typical Activities: - Question from pharmacy, -- Right medication -Vitals • Nurse shortage • Typical patient: elderly, sedated, • Robots to transport supplies, etc; hours limited in nurses deeply involved in clinical “Effective communication • Turn patient lab, etc -- Right dose -I&O • Walking 3 miles a day Consulting Physicians evenings / Admin amongst multitude of caregivers Medicare 24x7 -HT/ Weight • Can’t recruit nurses without decision making • Change dressings - Question from another nurse -- Right route • ER-like tracking board with to-dos, labs weekends - Start claims Resident an on-going challenge” • 1 – 3 patients/ nurse Care -Treatments good IT (they want a safe place • Daily chemistrys & CBCs Verify Physician - Patient coding, falling, etc. awaiting, P, C or other to denote core effects LOS process • 24x7 care; typically 3 shifts: 7a-3p, 3p- • 100 – 160 procedures/ day -Pt education – fewest mistakes as possible) Therapists: “Huge information asymmetry • Head to toe exam every 4 Orders - Family upset Sometimes a single measure related diseases, 11p, 11p-7a • Advance directives in use Respiratory, Physical, O between clinicians & patients” hours - Case manager nurse dedicated to only • RTLS giving pt location when out of ccupational • Fluoroscopy & ultrasounds administering meds unit, RFID to find supplies, equip – prevent Nursing Phlebotomist Social Worker Med/ Surg “The Checklist” from Hopkins reduced ICU infections by 60% CBC, electrolytes, chest x-ray ICU • • • Feeding tubes Central lines Family observations Family Interaction • hoarding - stop s equip trying to leave area Auto calls for routine blankets, missing assignments • Get tests started ASAP, which drives the most common procedures Hourly (flowsheet) • Stomach sounds Nursing interventions meals, etc Take Report Nurse: brief Transport (digesting?) meds & other therapeutics; then can documentation of: – eg, assist patient physician on patient Rapid Response Teams – • Monitor ventilator Unit Secretaries/ learn and make adjustments • Vitals TCDB status preventative measure – should Coordinators • Pain (turn, cough, deep Participate “Nurse most Truly part of • Start ruling things out; adjust diagnosis be called for patient in trouble to Draw blood NP – write Nutritionist • Drips breathe) in physician knowledgeable multi- for lab tests prevent coding Is patient safe? Administer Enter progress Admission/ On- Review Bed assignment • Patient gets better on their • Respiratory Therapy MAR update rounding about patient” disciplinary scripts Chaplain own, responds to therapy, or cannot be Discharge planner - everything • Intake/ output Is patient Medications note after each going medical team? • Comfortable? Report ADEs patient Assessments records Housekeeping helped any further lined up for patient so can leave IV Infusions “The 5 Rights” as soon as disch order given • Sedations “Docs don’t Physician: Case Manager • If patient not “acute”, should be in All clinicians: wash hands before/ after each patient Successful care look at nursing page me if/ another care setting Case Mgr - throughput focused- teams: notes” when…” Discharge Planner doctor, anything you can do to Physician communicate, Make a Nurse happy; expedite...? Computerized Physician Order Entry • US adoption rate ~ 20% communicate, Round at In office, review Do next steps or See Review chart before documentation system return pages asap so Check-out to (CPOE) • Adoption expected to increase communicate… yesterday’s Patients Deliver care in the Template driven Patient to Nothing Nurse can take action next doc local delegate entering or with Radiology • Physicians enters own orders significantly under ARRA exam room Medical vocabulary Nurse - can hospital correspondence patient Perform Neurology • • CPOE shown to significantly decrease happens till • Call patient Electronic ordersets used to required for discreet you translate • Diagnostic Consults Cardiology errors, e.g., No misreading hand-writing, Doc writes order protocol based orders data capture what doctor results • Refer to Other Specialists phy receives contraindication alerts an order EMR value proposition • System flags conflicts between said? Medication • ER/ specialist meds, allergies, DX’s ,etc • Many docs perceive CPOE as too time- Do checkboxes can Physician/ Nurse Hospital is to ensure all activities Chief Complaint reconciliation Labs • consuming dumb down notes? communication part of • Sign script completed during patient Many docs perceive CPOE as • Meds to discharges History of Present Illness Meds too time-consuming • CPOE = “Evidenced based medicine” to many patient sat surveys • refill visit: Maximize Almost all patients Operate/ transfer to “Boxes checked… but continue Consults Dispensing cabinets Write Radiology • Zynx - popular orderset content many doesn’t convey • Meds to stop • Refils • Suggest Exam (avg. 7 Past Medical History • Standardized order sets can educe Patient record and minutes/ patient, reimbursement need image(s) delivered to floors PACU, then the to floor Admit Patient Orders RT, PT, OT tool - contains >50,000 ordersets variation, instill best practices, and lower clinicians rationale, • New Meds • Patient further tests recent tests viewed Family History 30-35 patients/ Consults • Journal references available thinking, context of their phone call online utilization • Send letter day) Social History Transfer online observations” • Physician Physician Discharge • CPOE seen to require electronic • Ordersets typically takes 6-9 months to calls to patient System prompts with Large screens Monitor tracking Review of Systems Pre-Verification Medical Extensive Robotics w/ Etc, etc physician documentation, be developed/ approved When templates used – Discharge Order • Drug rep with test reminders Accountability: Accountability: Timeout Antibiotics w/in 1 RFID tracking showing real- board • Doc - “discharge Necessity (Dx Ask Tech for new/ decision camera w/ CDSS, and access to EMR do all notes start result Physical Exam Computer Worklists created meds meds -Nurse outlines hour of incision time Patient is visit today Clinical note templates doesn’t match support, against floor looking the same? if labs ok” different image if getting for Radiologists administered administered entire case depth status, tracking, ready for next • Etc • Test patient populated as exam Evaluation & Management Pre-Authorizations procedure) needed auto plan; where • Hospitalists • Sometimes smart Worklist worked = physicial = physicial -All have to perception Anesthetist – are?: and metrics activity by you incentives to to come in takes place Sometimes, a enough to checking & magnific- • Interventionists for F/U among of a pool of amounts in amounts in listen - Secure airway The other information Where is my discharge by Financial Counseling “wet read” read for tion • House Staff Provider enters orders Rad’s cabinets cabinets -All have to - Admin caregivers? patient? 5pm Smart first, then more images? conflicts: • Specialists and e-prescribes meds Eligibility Workload verbally anesthesia My patient? Status screens Who has been Cards Admission specific test "Take and med-med, Taking from Enter progress • Community Physicians PACS balanced among concurs Perioperativ - Monitor vitals The medical using icons waiting too long? System captures/ return" buttons med- cabinets note after each Establish rapport Begin Rounding Online pre- becoming Rad’s and e systems equipment I and color suggests E&M, ICD9, Write POC payments If patient not to account for allergy, automatically patient Review events to date Start w/ pending Review test results Hospital just a platform for care for Discharge registration ubiquitous facilities Phy marks/ for Scrub nurse – need? coding for All orders are Act on next Team CPT, and other coding prescriptions prepped meds Med-DX, charges -Handwritten? Get patient’s disch first from night before community docs? summaries Order worked at initials site complete hands reference on automatically pathway Meeting to complete billing -- Paper Kiosks What contrast to PACS: Dosage- patients and -Dictated? observations Save new Begin developing Ask Pre-Admit ABN (Advanced discretion of Rad’ Adjust alert documentat instruments & Time stamp of status of all STAT step, e.g. - Cannot bill until -- Fax drink/ what not to storage & BMI decrements -Template driven Describe next steps/ admissions (take next steps/ Review nurse for - Usually catalog - Moved to OR, ion. alerts, responsible for location move patients Day 1 - Do X disch summary -- Electronic Beneficiary eat backup is “Nighthawk” inventory e-physician ask for patient the most time) for Write orders if chart/ take obser- involves end- Get Physician calls Notice) remove Meds unit- slid onto table safety, and sterile field or significant Order diagnostic Day 2 – Do Y in order complete and  Lab tests to be risky & service for remote documentation? concurrence last appropriate notes vations of-life census Centralized annoying dosed/ Non- data activity RFID tracking tests signed Write orders Dictate/ write notes done prior reading Scheduling expensive alerts bar-coded repudative and OR prepped transfer to OR RN’s – assist showing  If problem, appt Generally for Orders Imaging with confidential per phy’s floors with suturing, Monitor movement of Clinicians Combined canceled; time 11pm – 7am shift Educate Online/ Virtual Reporting devices robotics reporting preference list retract tissue, tracking board patients, provid alerted to billing office wasted patient on Analytics position patient, Visit (eg, Charge innovating system for -1 per surgeon/ for number of ers, and completed tests Technicians meds at D/C Robotics and RelayHealth) Reference Pre-auth, pre- capture for Patients very quickly ADEs procedure tilt table, etc. patients equipment conduct imaging for IV reporting to verification, misc. transported to - Instruments, In waiting Additional tests 3D imaging A “time out” Distribute compound "Take and optimize Refer to specialist collections, Radiology sit/ stand, glove Circulating nurse room waiting System ordered as – a next before test begins meds mixing return" buttons expensive - If time, dictate counseling 3 From ICU’s size, meds, etc - Patient advocate for exam bed automatically needed Not paid for step Qualification throughout to account for real estate CMS Core Measures 2011 HOSPITAL MEANINGFUL USE letter describing days prior to (very onerous) Robotics - Watch Waiting to be pages Write-off never events includes 2-year hospital meds Heart Attack OBJECTIVES 15-20% EMR adoption – patients story service From Floors Voice auto fill IV inserted everyone’s seen by providers when Complete degree Satellite med - Hydration moves they’re next to • Aspirin at arrival Improve quality, safety, efficiency, and reduce health disparity Medical Specialties expected to rise quickly Some cases (eg elderly From ED recognition Adjust alert physician nursing More high No latitude to pharmacies • Aspirin at discharge Use of computerized physician order entry with 10% of all orders by an Allergy & Immunology with ARRA – worth $44k with severe Not paid for hosp Walk-in’s for notes cabinets catalog - - Access for - Runs the show Seen by see patient Documentation deductible interpret and take Dispensing anesth., emerg. - Document care • ACE inhibitor for left ventricular systolic authorized provider Anesthesia per doc pneumonia), send to acquired very remove physician, but The HIMSS 8-Stage EMR Maturity Model plans mean Nurse reviews extra images carts dysfunction Implement drug-drug, drug-allergy, drug-formulary checks Cardiovascular Disease hospital condition not POA popular annoying meds - Can stop awaiting Complete 80% of money made (and more bad debt next day’s studies Tech records • Beta-blocker at arrival Up to date problem list of current and active diagnoses using SNOMED or Stage 7 - Medical records are fully electronic; hospital is able to (Cardiology If family member to Meds alerts surgery if needed nursing tasks physician patient care delivered)Deferred - eg, Surgery Do all orders Internet body Possible delay/ • Beta-blocker at discharge ICD9 contribute continuity of care document as byproduct of EMR; data Dermatology drive, call admitting measurements packaged into Educate Awaiting documentation • Thrombolytic within 30 minutes of Maintain active medication listing warehousing in use office – not hospitalCollections infection match medical allows unit-doses cancellation OR Chief Emergency Medicine If not, call 911 Clear imaging patient on diagnostic test arrival Maintain active medication allergy listing Bundled necessity? “anywhere” - Patient has documentation complaint, meds, Stage 6 – Physician documentation in structured templates; full Endocrinology and Metabolism Many single-practice Significant number of Patients interpret - specifications from Meds are bar- meds at D/C eaten - Legal record • Percutaneous coronary intervention Record demographics of preferred language, ethnicity, race, gender and Family Practice docs, but no one to replace ER visits come from payments Divert insurance type clinical decision support system in use; full radiologic and PACS in scheduled tations Radiologists coded within 120 minutes of arrival Gastroenterology them when retire Physician offices - All surgical ambulances if allergies, PMH, use Common Distribute Holding area procedures • Smoking cessation counseling Record advanced directives General Practice Each procedure Pharmacist hit capacity SOC, FH Will docs and payers drive See drug repsCollections Claim can’t be modalities show generates 2 meds - Patient on - What safety Heart Failure Record vital signs height weight blood pressure, calculate and display: BMI Stage 5 – Closed loop medication administration that addresses Geriatric Medicine verifies each throughout Annotated • Assess left ventricular function Record smoking status “medical home” concept? submitted w/o below charges stretcher devices used every step of medication use process Gynecology order Take calls from anatomical signed discharge hospital • ACE inhibitor for left ventricular systolic Have lab results in the clinical repository Gynecologic Oncology Shortage of primary ICU, ED, and Hospital charge - See nurse - How protected referring docs drawings Stage 4 – Computerized physician order entry system in use; Pharmacist Satellite dysfunction Generate listing of patient specific conditions Hematology docs, $120k - $150k/ year “Pending Physician - See surgeon from infection, etc clinical decision support system in use for clinical protocols addresses pharmacies - Document • Discharge instructions Report hospital quality measures to CMS Infectious Diseases Discharge charge Assign Write discharge “Give me meds, problem physician alert Dispensing • Smoking cessation counseling Implement one clinical decision rule relevant to high priority hospital Stage 3 – Clinical documentation, clinical decision support system Internal Medicine Call back other Automatically alternatives Surgery Physician(s) & instruction lists, and 20 minutes to ask Bedside overrides carts Pneumonia condition in use for error checking, PACS in use outside of radiology Neonatology physiciansAR & ordered STAT discussed, performed Nurse(s) to (Eg, based on questions & I’ll get to right Coding/ Abstracting Radiology in ICUs risks, doing • Oxygenation assessment Electronically check insurance eligibility. NephrologyContractual Ultrasound Pharmacist Meds patient Ohio ACEP set) Stage 2 – Clinical data repository, controlled medical vocabulary, dx” Attending self-care post- All items counted • Initial antibiotic timing Submit claims electronically to payers. NeurologyWrite-offs -- Determine actual consults with packaged into clinical decision support system; may have document imaging Physician writes Mobile X-Ray going in; counted • Pneumococcal vaccination Engage patients and families Neurological Surgery “If docs thought EMR End-of-day coded diagnosis from Attendings unit-doses op Triage patient Post order - See afterward • Blood culture before first antibiotic Provide patients with an electronic copy of their health information (lab Stage 1 – Ancillaries (lab, radiology, pharmacy) are installed Obstetrics and Gynecology would make them more paperwork medical record Ordering physician Esp. in ER Meds are bar- Use 1-5 charges & • results, problem list, medication lists, allergies, discharge summaries, •~ 60% of ED Anesthesiologi -In counts don’t Smoking cessation counseling Stage 0 – None of the ancillaries are installed Oncology, Medical efficient, they would have can view PACS coded scale – (see supplies • Right first antibiotic procedures) upon request patients get Pharmacist st match, an below) Ophthalmology bought them long ago” Deal with business Claims Editing imaging Generally rounds on automatic x-ray Follow-up calls/ Surgical Infection Prevention Provide patient with an electronic copy of their discharge instructions and Orthopedic Surgery relationships Pharmacist --Sign informed PatientSelf Pay Write-offs •What Phy is Orthopedics and patent floors consents call-backs • Antibiotic within 1 hour before incision procedures at the time of discharge upon request. Otorhinolaryngology Hospital disaggregation  Hospital contracts verifies each prioritized ordering and Surgeons Regain • Discontinued antibiotic within 24 hours Provide access to patient-specific education resources (Ear, Nose & Throat) trends:  Market to other Claims Develop order Work/ school why? Arrival consciousness after surgery Improve care coordination Pathology Imaging physicians Generation formulary Pharmacist Greet patient release Capability to exchange key clinical information (discharge summary, Chemo/ Radiation •Attending - Change into Pediatrics  Billing company consults Limit number addresses johnny Reflexes back procedures, problem list, medication list, allergies, test results) among Physical Medicine and Rehabilitation Dialysis (Renal) performance RAC - Recovery Radiologist if of “like” meds physician alert - Final (can cough) providers of care and patient authorized entities electronically (to be Plastic Surgery Day Surgery  Office staff Audit Contractors Claims 70% of all inpatient admits come thru ED needed overrides assessment specified by HIE Work Group of HIT Policy Committee) Podiatric Medicine Endoscopies performance Submission Negotiate/ •Consults very - Armband put PACU – look for Increasing patient thruput is only as good as having Perform medication reconciliation at relevant encounters and each Key Medical Record Contents (Podiatry) Heart procedures issues order from Pharmacist transition of care common in ED on respiration, can beds available Identification Sheet Preventative Medicine Anyone doc can invest in  Office lease drug consults with Improve population and public health - Ready for OR move limbs, pain, Problem List Psychiatry ACS, but only docs doing  New physicians wholesalers Attendings “60% of ED protocols can be started without Physician Capability to submit electronic data to immunization registries and actual Medication Record for the practice respond to HCAHPS * Patient Survey Sample Pulmonary Disease procedures can refer to it Esp. in ER approval – but only 5% are” submission where required and accepted History Meet with drug Pre-Reg verbals * Hospital Consumer Assessment of Radiology, Diagnostic reps Pharmacist Some ED’s aim to be profitable; some not Healthcare Providers & Systems Capability to provide electronic submission of reportable lab results to Physical Radiology, Nuclear - Insurance, etc rounds on • Did doctors and nurses treat you with public health agencies and actual submission where it can be received. Progress Notes Radiation Oncology - Consent Transfer - on “Golden hour" - the hour after accident in which most patent floors respect, listen carefully, and explain Capability to provide electronic syndromic surveillance data to public health Consultations Rheumatology -Schedule a floor, patient likely to survive bed needs to things? agencies and actual transmission according to applicable law and practice. Physicians’ Orders Sports Medicine • Was response to call button quick enough? Ensure adequate privacy and security protections for personal health Imaging and X-ray results Surgery, General - Instruct not communicate, hit • Were new medications explained to you? information Lab results Surgery, Hand eat/ drink on call button, etc Category Nrise Time Examples • Was room and bathroom clean? Compliance with HIPAA Privacy and Security Rules Immunization Record Surgery, Thoracic Develop surgery day Hospital contracting to outside Radiologist group is Level I(Brief) 0-15 min No medication, no testing • Was it quiet at night? Compliance with fair data sharing practices set forth in the Nationwide Operative Report Surgery, Vascular formulary Surgeons round i.e. cold, insect bites common • Did you get help getting to the bathroom as Privacy and Security Framework. Pathology Report Surgery, Colon and Rectal Pre-admission Level II 15-30 min Min. treatments, simple testing Limit number testing Floors (Intermediate) i.e. minor laceration, suturing quickly as you wanted? Discharge Summary Surgery, Urology Medical Home – PCP’s paid extra for coordinating Over 400 Radiology tests available MEASURES of “like” meds - Standing specialized by • Was pain managed as well as could be? Diagnoses Codes care Level III (Extended) 30-60 min Moderate treatments, IV fluids Improve quality, safety, efficiency, and reduce health disparity Procedure Codes orders surgery type i.e. Pneumonia, simple stroke • Did staff talk to about whether you could Negotiate/ Report quality measures to CMS including: ICD-10 – 10x the number of codes of ICD – 9 (290 - Orders from Level IV(Intensive) 60-120 min Extensive treatments take care of yourself after leaving? And order from codes for diabetes); used in Europe; like Y2K surgeon CSF’s: manage i.e. COPD, Obtunded Stroke what symptoms/ problems to be on look out drug Level > 120 min Life threatening disorders, % of smokers offered smoking cessation counseling conversion, biggest IT risks - Eg, if certain pain, move for? wholesalers V(Comprehensive) Greater than one nurse required % eligible surgical patients who receive VTE prophylaxis meds, get CBC around, no • How would rate hospital overall? • claims scrubbing, coding rules, and charge % of orders (for medications, lab tests, procedures, radiology, and referrals) By far, the most common intervention in hospital or CHEM-7 infections • Would you recommend hospital to your Metric Benchmark edits. Performance Indicators Benchmark entered directly by physicians through CPOE SDC as % of operating expense 21% care friends/family? Bundled payments – Claims for an episode of care Modality Sample Uses LOS for Treat & Release 90 min • How’s your health? What’s your education Use of high-risk medications (Re: Beers criteria) in the elderly Examples of Common Order Sets SDC Exp per Adj. patient day $350 Patient – to multiple providers – under a captivated Nuclear Radiology Full body scan, use of Focus on Rx - high costs and center of IOM LOS for Admitted Patients 240 min level? ethnicity? % lab results incorporated into EHR in coded format Abdominal Aortic Aneurysm Repair SDC Exp per Adj. discharge $2,300 contrasts, full motion video scheduled into arrangement; in pilot stages only medical error report Left Without Being Seen < 1% Stratify reports by gender, insurance type, primary language, race ethnicity Acute Myocardial Infarction/STEMI SDC as % of net revenue 20.0% CAT Scan Head trauma, abdominal pain surgeon’s time % of all medications, entered into EHR as generic, when generic options Acute Renal Failure MRI Head, ligaments Robotics allowing pharmacists to spend time on “block” AMA 1% exist in the relevant drug class Alcohol Withdrawal Metric Best Practice Mammogram Breast cancer high-value activities – i.e., available on floors for % of time on Diversion < 1% Days in A/R < 50 Days Chest X-ray Pneumonia Triage Start to Triage End 5-7 min % of orders for high-cost imaging services with specific structured Appendicitis/Appendectomy – Adult advice Denial Rate 3 – 8 % Ultrasound Fetal development, gall stalls Triage End to Registration Start < 10 min indications recorded [EP,IP] Appendicitis/Appendectomy – SDC – Supplies, Drugs & Consumables (excluding purchased ser vices Bad Debt % < 3% Robotics eliminate human handling of Registration Start to Registration End 3-5 min % claims submitted electronically to all payers Pediatric CDM Turnaround Time <12 Days hazardous drugs Registration End to Placed in Treatment Room < 20 min % patient encounters with insurance eligibility confirmed Asthma – Adult Days to Bill Drop Arrival to First RN Encounter 10 min Engage patients and families Asthma – Pediatric Contract Utilization 40%/ 20%/ 40% Metric 25th %tile Arrival to First MD Encounter 30 min % of all patients with access to personal health information electronically Atrial Fibrillation Payer Mix MCare/Mcaid/Comm HEDIS MEASURES % of all patients with access to patient-specific educational resources Bariatric Surgery Turn-around time 60 – 75 min Rebills Half of all surgeries are now minimally evasive First MD Encounter to Disposition Order Written • Colorectal Cancer Screening % of encounters for which clinical summaries were provided Brain Injury Volume Disposition Order Written to time Patient Left the ED 15 min (discharged pt) • Glaucoma Screening in Older Adults Robotic surgeries (with dramatic outcomes – Improve care coordination Cardiac Surgery – Pediatric Revenue 30 min (admitted pt) Revenue/ profitability small incisions, little blood loss, surgeon can see • Care for Older Adults *• Report 30-day readmission rate Carotid Endarterectomy Procedure mix every fiber, etc) becoming the norm • Use of Spirometry Testing in the % of encounters where med reconciliation was performed Cesarean Delivery Cycle Radiology Performance Indicator Metric 60%/ 40% day surgeries vs. inpatient surgeries is typical Emergency • Assessment and Diagnosis of COPD Pharmacotherapy of COPD Exacerbation Implemented ability to exchange health information with external clinical entity (specifically labs, care summary and medication lists) Chest Pain – Acute Chest Pain – Low Risk Cholecystectomy % Formulary Compliance ADE’s STAT Order Cycle Time % x x 30a – 5p OR use is typical Room • • Controlling High Blood Pressure * Persistence of Beta Blocker Treatment After a Heart Attack % of transitions in care for which summary care record is shared (e.g., electronic, paper, eFax) Improve population and public health Chronic Kidney Disease Chronic Obstructive Pulmonary % reportable lab results submitted electronically Disease Metric • Osteoporosis Management in Older Ensure adequate privacy and security protections for personal health Colectomy Volume Cases/ Room Women information Coronary Artery Bypass Graft Surgery revenue • Antidepressant Medication Full compliance with HIPAA Privacy and Security Rules …. Drug Purchases 25th %tile First case on time Management Conduct or update a security risk assessment and implement security ….. Contribution margin • Follow-Up After Hospitalization for updates as necessary …… Purchases / Inpatient Day $88 by Doc Mental Illness Purchases / Occupied Bed $35,529 Block Utilization rate • Annual Monitoring for Patients on Purchases / Admission $419 Infection reate Persistent Medications Purchases / APD $90 Turnover time < 20 Minutes • Potentially Harmful Drug-Disease Interactions • Use of High Risk Medication in the Operating Elderly Pharmacy Room • • Medication Reconciliation Post- Discharge Board Certification