The CDS/PI Collaborative Getting Better Faster – Together SM

1. The CDS/PI CollaborativeGetting Better Faster – TogetherSM Jerome A. Osheroff, MD, FACP, FACMI Principal, TMIT Consulting, LLC Adjunct Associate Professor of Medicine, U. of PA April 2012

2. Contents • Executive summary • Overview of the CDS/PI Collaborative • Overview of the CHCF-funded pilot project • Phase I, Oct 2011-Mar 2012 [complete] • Phase II, Apr 2012-Mar 2013 • The CDS configuration template • Template use, benefits, evaluation • Next steps TMIT Consulting, LLC

3. Executive Summary • Many organizations have joined a Collaborative to enhance how they use CDS to address performance improvement imperatives • A CHCF-supported pilot project ran from 10/11 thru 3/12: • 9 CDOs participated to test whether such collaboration would be valuable • Participants improved their CDS and PI efforts by using a structured form for documenting and sharing CDS strategies for 2 targets (VTE, diabetes) • All sites got benefits, recommended next steps, and plan ongoing participation • Next the Collaborative will, with further CHCF support: • Engage more providers in completing and sharing target-focused CDS configurations • Improve tools for completing and sharing templates, cover more targets • Develop and share other tools to support target-focused CDS/PI project management • Engage other stakeholders (e.g. vendors, RECs) more deeply in collaborative activities • Explore mechanisms to make the Collaborative self-sustaining TMIT Consulting, LLC

4. The CDS for Performance Improvement (PI) Imperatives Collaborative TMIT Consulting, LLC

5. Why the Collaborative Formed • Providers face strong and increasing drivers (MU, ACA, VBP, etc.) to improve specific care outcomes associated with quality, safety, costs • Effective CDS is critical for these improvements but complex, expensive, and challenging to get right • Absent widely applicable and vetted target-focused CDS strategies, providers seek collaboration to ‘Get better faster – together’ • Other stakeholders (e.g., EHR/HIT vendors, federal agencies, payers) also play critical CDS/PI roles and are likewise interested in collaboration to advance the state of the art and practice TMIT Consulting, LLC

6. Collaborative Goals • Accelerate localCDS and PI effortsby documenting, sharing, and enhancing target-focused CDS strategies • Foster development and use of tools that support this strategy sharing and local value realization  • Include many provider organizations and PI imperatives • Provide major benefits for all stakeholders; especially Care Delivery Organizations, but also EHR/HIT Vendors, Payers, Federal Agencies, and others • Leverage strategies for improving outcomes with CDS from compendia such as the HIMSS CDS Guidebook Series TMIT Consulting, LLC

7. Collaborative Underpinnings • All-time HIMSS bestseller, book of the year (2005) • Widely used by CMIOs/others • New (2/12)! >100 contributors • Guidance on successful programs and interventions • Addresses hospitals, systems, practices, vendors • Worksheets underpin template; ‘Tasks’ define CDS success path ~100 contributors Bestseller, HIT book of the year (2009) Co-sponsors include AHRQ, 3 CIS vendors 6 co-publishers TMIT Consulting, LLC

8. CDS Definition “A process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery.” Improving Outcomes with CDS. HIMSS. 2012 • Very broad: way beyond alerts, order sets • Includes many things providers are already doing (though often not optimally) TMIT Consulting, LLC

9. Framework: CDS Five ‘Rights’ To improve targeted healthcare decisions and outcomes, well developed and deployed CDS interventions must provide: • the right information (evidence-based, actionable…), • to the right people (clinicians and patients…), • in the right intervention formats (alert, order set, answers, documentation tools, data display…), • through the right channels (CIS, internet, mobile…), • at the right points in workflow (decision/action ...) Addresses: What, Who, How, Where, When TMIT Consulting, LLC

10. Collaborative Participants =Staff from: • Care delivery organizations across country • EHR suppliers (Allscripts, Cerner, Epic, GE, QuadraMed, Siemens) • Federal agencies (ONC/AHRQ/CDC) • Beacon Communities • Society partners (HIMSS, Scottsdale Institute, Society of Hospital Medicine) • CDS and analytics suppliers • Clinical transformation consulting firms TMIT Consulting, LLC

11. Collaborative Status • Over 140 participants and growing steadily (driven by word-of-mouth) • California Healthcare Foundation (CHCF)-supported pilot enabled a Project Manager to be engaged, and the feasibility and value of CDS/PI collaboration activities to be tested • The pilot size, speed, and value exceeded expectations • CHCF funded a followon one-yearCollaborative phasefocused on scaling and sustainability TMIT Consulting, LLC

12. CHCF-funded Collaborative Pilot Project TMIT Consulting, LLC

13. Pilot Project Objectives (Phase I) • Validate that Collaborative goals are feasible - and work toward them is valuable - by demonstrating that: • Provider organizations would refine and use a template for documenting and sharing target-focused CDS intervention approaches • Participating organizations could agree on specific targets for joint attention and on a common template for documenting interventions • Using the templates locally, and sharing completed versions across organizations, would add value to local CDS/PI efforts • Engage key stakeholders in following and supporting the pilot efforts, and generate ongoing participation beyond the pilot • Ultimately, drive widespread, CDS-enabled improvements in patient outcomes, especially for high priority targets TMIT Consulting, LLC

14. Pilot Overview • 9 provider organizations met weekly 10/11/11 thru 12/11/11 to refine a CDS configuration template and discuss their effort to get value from using it locally • 7 organizations chose VTE as inpatient target focus and 2 chose diabetes as outpatient target focus • Group used a private website/discussion group; https://sites.google.com/site/cdsforpiimperatives/home • Used frameworks/tools from the HIMSS CDS guidebook series to underpin work • Used full Collaborative to follow and provide input on pilot efforts and prepare for scale; conducted all-participant meeting on 11/28/11 (see Appendix) • In March 2012, formally evaluated pilot effectiveness TMIT Consulting, LLC

15. Why the Pilot Sites Joined • Commitment to PI, systematizing care processes, leveraging HIT investments • Limited CDS/PI resources but high stakes; be more efficient/effective, learn from others • Successful experiences with other PI collaboratives (get and give help) • Enhance innovation and accelerate its spread throughout their health systems • Improve patient engagement and support • Establish best practices for CDS interventions TMIT Consulting, LLC

16. Pilot Sites Inpatient (VTE Prophylaxis): • Ascension/St John Providence Health System (Cerner) • Hennepin County Med Ctr (Epic) • Lehigh Valley Health Network (GE) • MetroHealthSystem, Case Western Reserve U. (Epic) • New York Hospital, Queens (AllScripts) • Texas Health Resources (Epic) • University of Pennsylvania (Allscripts) Outpatient (Diabetes Management): • University of Pennsylvania (Epic) • Veterans’ Administration (Homegrown) Note: organizations listed in darker font participated most intensively in developing and using the template and sharing results TMIT Consulting, LLC

17. The CDS Configuration Template TMIT Consulting, LLC

18. Template Overview • Starting point was worksheets from HIMSS 2012 book, Improving Outcomes with CDS: An Implementer’s Guide • Pilot sites iteratively refined this material, based on successive efforts to use it in local CDS/PI meetings • Template has 3 parts: • Diagrammatic overview of workflow and CDS interventions • Tabular view of workflow steps, corresponding target-related activities, current/planned CDS interventions at each step • ‘CDS Five Rights’ view documenting the ‘what/who/where/how/when’ for CDS interventions focused on the target • Different sites used different combinations of these 3 components in their local work To view complete template, see online Users’ Guide TMIT Consulting, LLC

19. Diagrammatic View I. Consult requests When? F. Order handling J. Dischg or svc transfer & referrals B. History & Assess. K. Post visit/home care C. Form. care plan D. Docu-mentation H. Results/ new events A. Pre-encounter Z. Pop. mgmt. G. Execute Therapies/ Procedures Pt. educ guides; follow-up care prompts E. Orders/ Rx Alerts, monitors Structured documen-tation Pre-visit questionnaires; facesheets Pattern recogni-tion logic Knowledge delivery/ interactive ref Time-based monitors; pt. reminders How?* Order sets; error checking Error checking; alternatives FFORMULATE PLAN RECOGNIZE PATTERNS COMMUNICATE (also I) RESPOND TO EVENTS EXECUTE PLAN * Template provides sample interventions for each workflow step; i.e. the ‘How’ items in the grey boxes TMIT Consulting, LLC

20. Tabular View, Sample: New York Hospital Queens[EXCERPT Part 1] VTE Prophylaxis(draft date 12/31/11) Example: VTE Prophylaxis-related Workflow and Interventions TMIT Consulting, LLC

21. Tabular View, Sample: New York Hospital Queens[EXCERPT Part 2] VTE Prophylaxis (draft date 12/31/11) Example: VTE Prophylaxis-related Workflow and Interventions TMIT Consulting, LLC

22. CDS Five Rights View (Excerpt) * Template provides sample intervention what/how/who/where for each workflow step TMIT Consulting, LLC

23. Template Use, Benefits, Evaluation TMIT Consulting, LLC

24. Pilots’ Template Use • High-level target-focused CDS strategy review • Standard assessment/communication tool for CDS approach • Get stakeholder consensus/input, identify gaps • Understand different approaches/results across health system • Organize qualitative/quantitative intervention impact reporting • Roadmap for target-focused CDS activities • Guide decisions about PI opportunities and potential CDS interventions • Plan for best practice care and optimal CDS (which evolves) TMIT Consulting, LLC

25. Pilots’ Template Use cont. • Detailed CDS configuration planning • Consider each dimension of CDS Five Rights (e.g., all care team roles and intervention types) • Optimize use of current support tools, determine need for new tools and approaches • Link MU reportable measures (VTE) to CDS configuration TMIT Consulting, LLC

26. Template Benefits for Pilot Sites • Better local CDS stakeholder engagement/communication • With recipients; leadership; CDS, IT, and quality teams; clinicians • Stakeholders better visualize and enhance their inter-related efforts • Specifies CDS PI opportunities by making explicit current thinking and deployments focused on applying CDS to specific imperatives • Enhanced strategic planning • “The exercise of categorizing and describing our [CDS/PI] strategies has been very useful and demonstrated the importance of stepping back from ‘the weeds’ to get the big picture of where our efforts are going” • Workflow diagram provides a holistic view of CDS activities and opportunities across all care processes vs. in isolation • Better understand need/opportunities to improve patient engagement TMIT Consulting, LLC

27. Template Benefits for Pilot Sites cont. • Improved CDS execution • Explain why current CDS approaches not working well • Broaden approach to CDS toolkit, recipient and workflow support opportunities, e.g.: • Reassess VTE risk after admission • Consider diabetes CDS opportunities across care continuum • Leverage CIS & CDS capabilities better and understand/address limitations • Knowledge sharing accelerates progress • Learn from other organizations’ approaches/results TMIT Consulting, LLC

28. Pilot Evaluation Survey Results • 8* out of 9 sites reported that using the template was somewhat to significantly useful for local stakeholder engagement, CDS/PI strategic planning, and/or CDS implementation • In terms of the net effect of the project on each organization’s CDS/PI efforts, all 9 sites said it was somewhat to significantly helpful • 8 sites anticipate continued use of the template in their organization** • All 9 sites indicated that they would like to continue to participate in the Collaborative * 9th site didn’t have an active CDS project focused on the target during the pilot ** 9th site would use the template if there were a large group sharing completed templates TMIT Consulting, LLC

29. Next Steps TMIT Consulting, LLC

30. Activity Threads • Foster adoption/value from CDS strategy sharing for additional provider organizations and cover more topics • Deepen and integrate engagement of CDS stakeholders other than providers • Develop a sustainability plan for maintaining/enhancing the Collaborative TMIT Consulting, LLC

31. Thread 1: Scaling Pilot Value • Get ≥10 more providers using template • Refine Users’ Guide to enable this use and value without weekly meetings and ‘hand holding’ used to engage sites during pilot • Create electronic fill-in-the-blank version of the template that is more user-friendly • Refine and deploy next-generation online ‘shared library’ for completed templates TMIT Consulting, LLC

32. Scaling Pilot Value cont. • Cover at least 3 more PI imperatives • Establish forums such as regular target-specific teleconferences and online discussions wherein Collaborative participants can review and accelerate their respective target-focused CDS/PI work • Develop/use template for documenting and sharing target-focused CDS/PI project management tasks (e.g., stakeholder engagement) • Explore feasibility/value from organization-specific sub-communities to discuss challenges and implementation best practices among facilities in large health systems; goal is to accelerate CDS/PI innovation and spread within the system TMIT Consulting, LLC

33. Sample Improvement Imperatives For Collaborative Work • Preventable complications (Safety) • VTE • Catheter-associated infections (Blood stream, urinary) • Adverse drug events • Condition management/Core Measures (Quality) • Cardiovascular (CHF, AMI, Blood Pressure, Smoking) • Diabetes • Efficiency (Cost) • Readmissions (CHF, AMI, pneumonia) • Early sepsis detection Note: Pilot sites addressed targets in blue TMIT Consulting, LLC

34. Thread 2: Stakeholder Engagement • Create vendor-focused sub-communities to ensure vendor tools are used effectively in PI • Consider other related sub-communities • Conduct cross-stakeholder explorations into enhanced inter-related value propositions from Collaborative, including a possible CDS/PI pilot of this value involving payers, Regional Extension Centers, providers, and EHR vendors TMIT Consulting, LLC

35. Examples of Collaborative ‘Sub-Communities’ • HIT/analytics vendor supports Collaborative subgroup consisting of its clients, for CDS configuration documentation and sharing, and best practice development using a template version adapted to its specific CDS related tools; by-product is insights into how vendor can enhance its CDS tools focused on one or many PI imperatives • Payer supports Collaborative subgroup within its network to identify and disseminate successful PI practices focused on targets of particular interest to the population covered • Health-system oriented sub-community as noted earlier TMIT Consulting, LLC

36. Example Sub-Communities cont. • National clinical condition-focused initiative supports Collaborative subgroup to focus on identifying successful CDS practices focused on that target, and accelerating spread of these practices on a widespread basis • Clinical Transformation consultancy builds subgroup of its clients to identify and spread CDS/PI best practices faster • Federal agencies (e.g. ONC, CDC, AHRQ) interested in enhancing use of HIT to address population health goals create sub-communities for these purposes (e.g., define and spread successful CDS practices leveraging Beacon Communities, REC’s etc.) In Thread 2, we will explore creating these potential sub-communities and examine how they inter-relate with each other and the broader Collaborative to achieve shared goals TMIT Consulting, LLC

37. Thread 3: Sustainability Plan • Identify mechanisms to make Collaborative self-sustaining (leveraging Threads 1&2) • Make the collaboration activities self-perpetuating (e.g., via Users’ Guide and related approaches to systematize steps in the Collaborative’s value delivery process) • Create plan for ongoing funding in return for value delivered to stakeholders TMIT Consulting, LLC

38. Conclusion • The pilot validated the hypothesis that the Collaborative delivers value to providers • There is strong, multi-stakeholder interest in scaling the pilot activities • We have established Phase II funding from CHCF in order to: • Scale provider engagement and value • Cultivate cross-stakeholder value propositions • Develop a sustainability plan TMIT Consulting, LLC

39. Contact Information/Websites • Project Director: Jerry Osheroff, MD • josheroff@tmitconsulting.com • Project Manager: Lynne Schabert • Lynneschabert@cox.net • Project Website/Discussion Group (Private to Collaborative) • https://sites.google.com/site/cdsforpiimperatives/home • Informational Website on Project (Public) • Includes form to request entry into the Collaborative • https://sites.google.com/site/cdsforpiimperativespublic/home • Users Guide for Collaborative and Template (Public) • Includes: configuration template; slides about it that pilot sites used locally • https://sites.google.com/site/cdsforpiimperativespublic/cds-for-pi-imperatives-users-guide • HIMSS CDS Guidebook Series • www.himss.org/cdsguide TMIT Consulting, LLC