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The Information-Powered Health System
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The Information-Powered Health System

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Transforming Care Delivery with Data

Transforming Care Delivery with Data

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  • 1. The Information-Powered Health System Transforming Care Delivery with Data
  • 2. Conflict of Interest Disclosure David Katz, MD, JD • Salary: Yes • Royalty: NA • Receipt of Intellectual Property Rights/Patent Holder: NA • Consulting Fees (e.g., advisory boards): NA • Fees for Non-CME Services Received Directly from a Commercial Interest or their Agents (e.g., speakers’ bureau): NA • Contracted Research:NA • Ownership Interest (stocks, stock options or other ownership interest excluding diversified mutual funds): Stock Holder • Other: NA
  • 3. Road Map for Discussion 1 Health IT Takes Center Stage 2 Transforming Care Delivery with Data • Meeting the Meaningful Use Mandate • Building the Foundation for Analytics • Delivering Information-Powered Care 3 Migrating to a New Business Model
  • 4. 1. Health IT Takes Center Stage
  • 5. Market Force #1 – The New Health IT Mandate A Massive Infusion of “Obama Bucks” Health IT Funding in Stimulus Bill Designed to Accelerate EHR Adoption Breakdown of Health IT Funding in 2009 HITECH Act1 $2 B $36 B $34 B Provider EHR Office of the National Total Incentives Coordinator for Health IT Hospital Health Information Incentives Exchange Grants Physician IT Support for Incentives Critical Access Facilities 1 Health Information Technology for Economic Source: American Reinvestment and Recovery Act, 2009; and Clinical Health Act. Innovations Center interviews and analysis.
  • 6. Market Force #2 – Payment Reform Health IT Only One Piece of the Larger Reform Agenda Timing and Impact of Health Reform Proposals Expanding Coverage Promoting Efficiency Reducing Demand Capitation Comparative Effectiveness Stimulus IT Incentives Disease Management Outcome- Medical Based Homes Penalties Impact Episode- on Based Bundled Provider Payments Payments Business At-Risk Quality Bonuses Reduced DSH Employer Payments Mandate Public Individual Plan Mandate Time Source: IT Insights interviews and analysis.
  • 7. IT Backbone Essential to Transforming Care Delivery Evolutionary Path of Payment Models Extensive Capitation/ Shared Savings Episodic Level of Bundling Clinical IT Integration Pay for Performance Minimal Hospital Care Continuum Span of Accountability Source: Innovations Center interviews and analysis.
  • 8. 2. Transforming Care Delivery with Data • Meeting the Meaningful Use Mandate • Building the Foundation for Analytics • Delivering Information-Powered Care
  • 9. The Information-Powered Health System I. Meeting the II. Building the III. Delivering Meaningful Use Foundation for Information- Mandate Analytics Powered Care Preventing Disease Elevating Care at the Bedside Synthesizing Clinical Data Exchanging Supporting Hospital Data Across the Chronic Care Performance Continuum Management Reinforcing Ensuring Upskilling the Core Clinical Data Quality Analytics Systems Team Maximizing CPOE Utilization Time Source: Innovations Center interviews and analysis.
  • 10. Meeting the Meaningful Use Mandate Unbundling the Mandates for Inpatient EHR Systems Four Key Challenges to Achieving Meaningful Use Compliance Installing the Full Suite of Inpatient Systems Looking Beyond Our Four Walls I. Clearing the Hurdle for II. Securing CPOE III. Integrating Across IV. Connecting Patients Core Clinical Systems Adoption the Continuum to Providers Source: Innovations Center interviews and analysis.
  • 11. Meaningful Use Mandate #1 Clearing the Hurdle for Core Clinical Systems Looming Penalties Accelerating Replacement of Outmoded IT Systems Common Concerns in Achieving Meaningful Use Compliance Lacking Key Components Certification in Question Insufficient Legacy Systems • Clinical system missing some • Homegrown system • Legacy systems lack or all ancillary systems functionalities insufficient to integration capabilities to meet meaningful use aggregate data for reporting • Documentation system lacking, unable to interface • Core system unable to gain • Older software lacking with existing systems CCHIT1 certification necessary functionality • Central data repository not • System architecture • Vendor no longer supports present or without incompatible with needed upgrades, is out of business interoperability functionalities components 1 Certifying Commission for Health Information Technology. Source Innovations Center interviews and analysis.
  • 12. Meaningful Use Mandate #2 Securing CPOE Adoption Few Hospitals with CPOE, Even Fewer with Strong Utilization Percentage of Hospitals Percentage of Orders Entered by with CPOE in Place Physicians in Hospitals with CPOE Third Quarter 2009 n = 199 57% 27% 11% 8% 8% 20% or Less 30% - 50% 60% - 80% 90+% Entered by Entered by Entered by Entered by Physicians Physicians Physicians Physicians Source: HIMSS Analytics EMR Adoption Model, August 2009; College of Health Information Management Executives, “Summary of CHIME Member Survey on Adoption of CPOE,” July 2009, available at www.cio-chime.org; Innovations Center interviews and analysis.
  • 13. Rethinking Traditional Staffing to Ensure Successful Adoption Hospitals Leveraging Informaticists to Ease Transition to Digital Medicine Key Components of CPOE Process Redesign Success at Hollop University Health System1 Hired Chief Medical Recruited Team Incented Physicians 1 2 3 Information Officer of Informaticists to Actively Participate Addition of physician Informaticists serve as liaison Existing program providing executive builds between clinical, IT staff compensation to clinicians who credibility with physicians ensuring system compatibility work on quality improvement and other clinical leaders with true care delivery process expanded to include contribution to designing digital care pathways Case in Brief Hollop University Health System • Eight-hospital health system located in the Midwest • Leadership identified conversion of care processes from paper to digital as a key challenge • Added new staff, provided incentives for physician participation to address problems with conversion 1 Pseudonym. Source: Innovation Center interviews and analysis.
  • 14. Meaningful Use Mandate #3 Integrating Providers Across the Continuum Two-Way Data Flow the New Standard for Hospital-Physician Connectivity “An Antiquated Approach” “The Basic Option” “The Emerging Baseline” Bi-directional Exchange Provider Portal Patient health Value records updated in Fax Transmission acute care and ambulatory settings Physicians provided with read-only Medical records, access to inpatient diagnostic results EHR faxed to providers Level of Integration Source: Innovations Center interviews and analysis.
  • 15. Building Virtual Integrated Networks Health Systems Leveraging Integration Engines to Facilitate Data Exchange Array of Provider-Led Integration Initiatives Seven-hospital Spectrum 42-hospital Catholic Health using Medicity Novo Healthcare West Three-hospital Exempla Grid solution to connect with funding multiple Healthcare linking to independent practices regional integration ambulatory EHRs using initiatives Medicity Novo Grid 20-hospital UPMC1 partnering with dbMotion to 300-bed Silver Cross integrate clinic-based EHRs Hospital installed 500-bed Hoag Mirth integration Memorial creating engine to integrate network with over lab data for physician 1,000 independent offices practices Source: Howard, AJ, “The Hospital as the Network Hub,” Health Data Management, 1 University of Pittsburgh Medical Center. August 2008; Innovations Center interviews and analysis.
  • 16. Meaningful Use Mandate #4 Connecting Patients to Providers Next-Generation PHRs Beginning to Emerge Key Features of Milliways Regional Hospital1 Personal Health Record EMR Driven Easy Portability Branding Value PHR is updated with Patient can authorize PHR is accessed via information from access to record for hospital-branded the hospital’s EMR any physician with website, building access to HealthVault greater patient loyalty Case in Brief Milliways Regional Hospital • 2,500-bed hospital located in the Southwest • Developed PHR in partnership with Microsoft HealthVault • Piloted with cardiac surgery patients, ultimately to be offered to all hospital patients 1 Pseudonym. Source: Innovations Center interviews and analysis.
  • 17. Banking on Clinical IT to Elevate Performance Maximizing Leveraging Clinical Administrative Systems Information Systems Potential Revenue Cycle Performance Management Gap Impact on Staffing Performance Productivity Supply Chain Management IT Sophistication Source: Innovations Center interviews and analysis.
  • 18. The Information-Powered Health System I. Meeting the II. Building the III. Delivering Meaningful Use Foundation for Information- Mandate Analytics Powered Care Preventing Disease Elevating Care at the Bedside Synthesizing Clinical Data Exchanging Supporting Hospital Data Across the Chronic Care Performance Continuum Management Reinforcing Ensuring Upskilling the Core Clinical Data Quality Analytics Systems Team Maximizing CPOE Utilization Time Source: Innovations Center interviews and analysis.
  • 19. Technical Hurdles Hindering Analysis Common Challenges to Developing a Robust Analytics Platform Inconsistent Data Quality Siloed Information Systems Time-Consuming Reporting “Jonathan Smith” ICU CIS1 ADT “Jon Smith” Pharm Billing Registration PENDING COMPLETE “Smith, Jon H.” Pharmacy Data not consistently Data locked in disparate Report generation technically documented, lack of systems, unable to challenging, limiting widespread standardized definitions aggregate for analysis adoption of analytics 1 Clinical information systems. Source: Innovations Center interviews and analysis.
  • 20. Establishing the Data Quality Baseline Build a Dedicated Data Management Infrastructure Committees Tackle Nettlesome Data Quality Issues Enterprise Data Steering Committee • Ensures alignment of data management efforts • Supervises data committees and workgroups Data Quality Metric Management Systems Integration Committee Committee Committee • Conducts data quality audits • Constructs data dictionary • Manages data extraction, • Evaluates structured • Defines enterprise metrics transformation, and documentation • Supervises core measure loading • Supervises data stewards workgroup • Supervises data warehouse workgroup Case in Brief Zellerbach Health System1 • 400-bed hospital located in the Northeast • Identified need for comprehensive data management strategy to improve reliability and usefulness of clinical data 1 Pseudonym. Source: Innovations Center interviews and analysis.
  • 21. Aggregating Data for Meaningful Analysis Divergent Approaches to Pooling Clinical Data Data Warehousing Strategy Data Mart Strategy Central repository to support diverse analyses Discrete solutions to analyze specific questions Ancillaries ADT CIS1 Ancillaries ADT CIS1 Enterprise Data Diabetes Pneumonia Surgery Warehouse Data Mart Data Mart Data Mart 1 Clinical information systems. Source: Innovations Center interviews and analysis.
  • 22. Significant Cost Differential Between Approaches Data Mart the Low-Cost Option, but Not Without Limitations Data Infrastructure Costs Potential Drawbacks to Data Mart Strategy Average 300-Bed Hospital Data Specificity $1.5 M Requires greater understanding of specific data elements needed for desired analysis Analytical Scope $190K - $560K Limits scope of analysis to $70K - $450 K data elements defined $295K during development Pattern Recognition Technology Labor Fails to identify dependent relationships extending beyond the scope of the mart Data Marts Data Warehouse Source: Innovations Center interviews and analysis.
  • 23. Push Analytics to the Front Line Success Dependent on Ensuring Accessible Information for Key Decision Makers Normalizing the Data Creating Effective Analytical Tools Role-Based Critical Dashboards Alerts Data Repository Source Drill-Down Pre-programmed Systems Reports Queries Expanding Data Access Technical Staff Clinical Leaders Source: Innovations Center interviews and analysis.
  • 24. No Shortage of Vendor Solutions Representative Vendor Offerings Business Objects Integrated enterprise data warehouse platform that includes query, analysis, dashboard, and predictive analytics capabilities; provides performance management tools related to financial consolidation, spend analytics, and business planning Compass Tools Web-based BI tools providing robust data collection, real-time decision support, advanced analytical capabilities, and dedicated advisor support; includes financial, operational, and clinical analytical solutions PowerInsight Enterprise data warehouse built on the Cerner Millennium data model that includes Web-based dashboards with enterprise-wide view of performance measures; includes 600 predefined performance measures across four topic areas: clinical, regulatory, operational, and financial Source: Cerner, available at http://www.cerner.com, accessed June 23, 2009; SAP, available at http://www.sap.com, accessed June 23, 2009; Innovations Center interviews and analysis.
  • 25. Organizational Hurdles Hindering Analytics Common Challenges to Staffing the Analytics Effort Widening Skills Gap Redundant Unfocused Analytical Efforts Analytical Initiatives Staff Skills     MRSA MRSA  Report Report Lack of clinical expertise or Lack of staff cooperation or Ad hoc analytical efforts background limits analytical integration results in limit impact, potential sophistication of clinical redundant, potentially misalignment with strategic data sources contradictory analyses priorities Source: Innovations Center interviews and analysis.
  • 26. Cultivating Internal Analytics Expertise Requiring More Advanced Analytical Expertise Range of Informatics Specialists Implementation- Analytics- Focused Focused Health Informaticist Medical Informaticist Bioinformaticist EBM Role Intermediary between Internal “developer” of Clinical expert who clinicians and IT team in analytic tools that improve leverages genetic data to development of clinical IT the clinical decision-making improve disease systems process detection and prevention Background • Physician • Physician • Physician • Nurse • Nurse • Biostatistician • Computer programmer • Computer programmer Training Master’s degree in clinical Master’s degree in clinical Master’s degree, PhD in informatics informatics bioinformatics Typical • Deploy EHR systems • Build decision support • DNA sequencing Projects • Develop CPOE systems tools • Genetic modeling • Develop evidence-based care systems Source: Innovations Center interviews and analysis.
  • 27. Taking Staff Competencies to the Next Level Data and Information Management Enhancement (DIME) Program Overview Walking in Their Shoes Elevating Communication Competencies • Shadow physicians, business leaders for • Participate in Toastmasters to improve eight half days to better understand communication and presentation skills clinical operations across care continuum • Train with communications coach on • Identify how users interact with systems conveying complex analyses and and analytical needs improving active listening skills to better understand, identify client needs Case in Brief Kaiser Permanente Northwest • Integrated delivery system based in Portland, Oregon • Developed robust skills training for analytical staff to foster internal development of advanced analytical talent Source: Innovations Center interviews and analysis.
  • 28. Upskilling the Analytics Team Supplementing Baseline Analytical Skills with Advanced Training Ongoing Analytics Training at Kaiser Permanente Northwest Advanced Technical Training Professional Engagement Σ n Learn advanced business Participate in professional (x1 – μ)2 intelligence tools, societies, conferences; attend n k=1 simulation modeling vendor-sponsored user summits Ongoing Development Continuing Education Attend doctoral courses in Individual Develop annual individual Development dynamic simulation modeling at Plan development plan for ongoing local university skills advancement Source: Innovations Center interviews and analysis.
  • 29. Consolidating Clinical Improvement Expertise Overcoming Organizational Silos Previous Organizational Model Reorganized Department Structure CNO CIO COO Clinical Improvement Department Provide advanced analytical services for entire system Serve as internal consultants on process improvement, Quality Clinical Performance Lean redesign Improvement Informatics Acceleration Deliver quality improvement education sessions to staff Case in Brief Haas Health1 • Five-hospital health system located in the West • Reorganized departments to reduce duplication and leverage synergies • between staff to enhance performance improvement efforts 1 Pseudonym. Source: Innovations Center interviews and analysis.
  • 30. Creating a One-Stop Clinical Improvement Shop Benefits of an Integrated Model Acting as the Single Source of Truth for Data • Consistent data collection, analysis methodology ensures data reliability, validity Clinical • Specialized informaticists ensure Informaticists high-quality analysis Increasing Impact of Analytical Initiatives Performance Quality • Adept staff able to quickly translate Acceleration Staff Improvement Staff findings into actionable improvement • Continual monitoring, refinement of process ensures sustained gains Source: Innovations Center interviews and analysis.
  • 31. The Information-Powered Health System I. Meeting the II. Building the III. Delivering Meaningful Use Foundation for Information- Mandate Analytics Powered Care Preventing Disease Treating Disease Synthesizing Clinical Data Exchanging Managing Hospital Data Across the Disease Performance Continuum Reinforcing Ensuring Upskilling the Core Clinical Data Quality Analytics Team Systems Maximizing CPOE Utilization Time Source: Innovations Center interviews and analysis.
  • 32. Treating Disease Combating Pneumonia with Analytics Vanderbilt Developing Next-Generation Treatment Algorithms Data Aggregation Automated Algorithms Staff Alerts Ms.Wu VAP Bundle EHR vs. Pulls data from nurse Identifies gaps in documented Displays overdue documentation, CPOE, care against recommended treatments in color-coded and respiratory therapy VAP1 management bundle dashboard on ICU computer systems into EHR screensaver and EHR Case in Brief Vanderbilt Medical Center • 600-bed academic medical center located in Nashville, Tennessee • Developed automated electronic dashboard to display real-time patient status for compliance with evidence-based ventilator management bundle Source: Starmer J, et al., “A Real-Time Ventilator Management Dashboard: Toward Hardwiring Compliance with Evidence-based Guidelines,” American Medical Informatics Association Annual 1 Ventilator-associated pneumonia. Symposium Proceedings Archive, 2008; Innovations Center interviews and analysis.
  • 33. Automating Best Practice Yields Impressive Results VAP Dashboard Pilot Results Next Areas of Focus at Vanderbilt October 2007 – August 2008 VAP Rate Estimated Cost Reduction Reduction Catheter Patient Falls Associated UTIs1 (41%) ($1.9 - $3.5 M) Blood Stream Pressure Ulcers Infections Source: Govern P, “ICU Teams Drastically Reduce Vent-Related Pneumonia Rates,” Reporter, February 13, 2009; 1 Urinary tract infections. Innovations Center interviews and analysis.
  • 34. Managing Disease Supporting the Front Lines of Care Health Information Exchange Supports Analytical Platform for Care Management Care Management Proactive Patient Decision Support Outreach Bowles Health • Disease registry to manage Information • Notifications to remind chronically ill population Exchange1 overdue, non-compliant • Treatment alerts to patients maximize patient visits • Patient education, self- • Quality reporting tools to management tools to identify opportunities for increase compliance PMS2 EHR Lab eRX improvement • Health coaching to reinforce care plan Case in Brief Bowles Health Information Exhange • Not-for-profit health information exchange located in the East • Leverages claims data mining software to generate customized disease dashboards for participating physicians, enhance outreach to chronically-ill patients 1 Pseudonym. 2 Practice management system. Source: Innovations Center interviews and analysis.
  • 35. Pinpointing Gaps in the Chronic Care Continuum Data Mining Tool Facilitates Tracking of Chronically Ill Patients Member Hospitals Data Mining Infrastructure Sample Reports Readmissions Report Regional Claims Master Database Patient ED Utilization Index Report Chronic Care Continuum Gap Assessment Project in Brief Dallas Fort-Worth Regional Enterprise Master Patient Index • First-of-its-kind regional patient index created by the Dallas-Fort Worth Hospital Council Education and Research Foundation using QuadraMed software • Facilitates tracking of readmissions patterns, ED utilization, and other service utilization by specific patients across 75 hospitals in the North Texas region Source: Dallas-Fort Worth Hospital Council; Innovations Center interviews and analysis.
  • 36. Next-Generation Remote Monitoring Wiring the Patient Home to Continuously Monitor Patient Health Hallway sensors monitor gait and mobility Sensors capture variations in mobility Computer kiosk assesses cognitive function Case in Brief Oregon Center for Aging and Technology (ORCATECH) • Part of the Oregon Health & Sciences University located in Portland, Oregon • Established in 2004 to provide an infrastructure for developing technologies to support independent aging • Partners with senior living communities to provide living laboratories for testing home-care technologies Source: Oregon Center for Aging and Technology (ORCATECH), available at www.orcatech.org, accessed August 11, 2009; Kaye J, “Technology and the Aging Brain: New Approaches to Understanding Change,” ORCATECH; Innovations Center interviews and analysis.
  • 37. Detecting the Subtle Signs of Cognitive Decline Collecting Data on Daily Routines Analyzing the Data to Assess Risk Indications of Normal Aging Daily Computer Early Warning Long-Term Change Mobility Use Signs Algorithm Evidence of Cognitive Decline1 Medication Sleep Adherence Patterns Study in Brief • ORCATECH research funded by National Institute on Aging and Intel Corporation2 • Leveraging longitudinal data generated by home-based seniors to detect early onset of dementia, Alzheimer's disease 1 For example, potential dementia or Alzheimer’s disease. Source: ORCATECH, “Algorithms for Long-Term Change,” 2 Research funded by National Institute on Aging grants available http://www.orcatech.org, accessed August 11, AG024978, AG024059, AG008017. 2009; Innovations Center interviews and analysis.
  • 38. Preventing Disease Unearthing Latent Risks with Predictive Modeling CMM1 Identifies At-Risk Patients in (Near) Real-Time Rad ADT Automated algorithm If proper care CMM pulls patient data to outstanding, alert sent generate list of those at to pharmacy, nursing risk for pneumonia unit to assess patient Lab Rx Patient Admission Risk Assessment System Verification Clinical Alert CMM Rx CMM validates findings Elderly patient by querying pharmacy admitted for to check if appropriate hip fracture medications dispensed Case in Brief Sutter Medical Center, Sacramento • 306-bed hospital located in Sacramento, California • Developed Core Measure Manager (CMM) to identify at-risk pneumonia patients Source: Niemi K, et al., “Implementation and Evaluation of Electronic Clinical Decision Support for Compliance with Pneumonia and Heart Failure Quality Indicators,” American Journal of Health-System Pharmacy, 2006 (66) 1 Core measure manager. 4: 389-397; Innovations Center interviews and analysis.
  • 39. Seeking to Eradicate Heart Disease Tolman Health1 Leverages EHR for Community-Wide CV Prevention Effort Generating the health profile of a community… …to improve targeting of interventions Advanced Diagnostics Calcium CT Scoring Angiography Primary/Secondary Prevention Efforts Remote Genetic Medical Weight Medication Monitoring Data Information History Management Management Classes Case in Brief Tolman Health System • Five-hospital health system located in the Midwest • Partnering with public health agency, community organizations on wide-scale cardiovascular disease prevention initiative for a local community 1 Pseudonym. Source: Innovations Center interviews and analysis.
  • 40. 3. Migrating to a New Business Model
  • 41. Shouldering the Cost, Sharing the Benefits Distribution of Ongoing IT Costs by Stakeholder Distribution of Net Benefits by Stakeholder Payers and Other 3% Stakeholders Payers and Other Stakeholders 39% 61% Health Care 97% Providers Health Care Providers Source: Walker J, “The Value of Health Care Information Exchange and Interoperability,” Health Affairs, January 19, 2005; Innovations Center interviews and analysis.
  • 42. Leveraging IT to Develop New Product Lines Striking into the Insurer’s Domain Wellness Services Distinguished by Robust Analytical Foundation Differentiating on Data-Driven Approach Continuously Refining Risk Stratification Claims Pharm Electronic care management system HRAs1 CIS2 n Σk=1 (x1 – μ)2 n Proprietary algorithms for medication management Data Data mining infrastructure, Mart predictive modeling software Case in Brief Clarian Healthy Results • Separate subsidiary within Clarian Health, an integrated delivery network based in Indianapolis, Indiana • Developed corporate employee wellness division based on the data-driven success of own internal wellness program 1 Health risk assessments. 2 Clinical information systems. Source: Innovations Center interviews and analysis.
  • 43. Delivering ROI to Employers Clarian’s Healthy Results Division Reining in Employee Health Costs Total Contracts and Covered Lives Medical Claims Expense Growth Healthy Results Contracting Success Representative Client Results 30,000 8.0% 6.1% 4,500 13 4 Total Contracts Covered Lives Pre-Contract Year One 2008 2009 Source: Innovations Center interviews and analysis.
  • 44. Pursuing Risk-Based Contracting Making the Case for a Capitated Contract Health System Highlights IT-Driven Care Management Capabilities Health IT Assets Hospitalizations per 1,000 Diabetic Patients Chronic Disease Management System 370 Remote Monitoring, 315 Telehealth Physician Performance 2005 2007 Monitoring Case in Brief Sproul Health Network1 • Three-hospital health system located in the Midwest • Demonstrated success in using health IT for population health management • Supporting system efforts to transform business model and negotiate capitated contracts 1 Pseudonym. Source: Innovations Center interviews and analysis.
  • 45. Realizing the Clinical and Strategic Value of IT Advanced Analytics Impact on Care Patient-Provider Delivery Connectivity Integrated Information Exchange Point of Care Decision Support IT Investment Source: Innovations Center interviews and analysis.

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