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 © 2009 DocsNetwork, Ltd.

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) © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

Limited Proven Care Provided © 2009 DocsNetwork, Ltd. 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.

Recommended Care and Quality Varies © 2009 DocsNetwork, Ltd. 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 © 2009 DocsNetwork, Ltd. 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 © 2009 DocsNetwork, Ltd.

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? © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd. Source: Koppel, et. al. Role of computerized physician order entry in facilitating medical errors. JAMA, 2005;293:1197-1203.

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 © 2009 DocsNetwork, Ltd.

Heparin HEO Slide © 2009 DocsNetwork, Ltd. 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 © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

Clinical Transformation Needed Utilize clinical technologies Impact clinical processes Enhance quality Achieve efficiencies Necessary focus Clinical strategy Clinical business Process redesign Change management © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

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. © 2009 DocsNetwork, Ltd.

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 © 2009 DocsNetwork, Ltd.

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. © 2009 DocsNetwork, Ltd.

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. © 2008 DocsNetwork, Ltd.

Minding the Gap: Path Innovation, Collaboration and Quality

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