Healthcare Leaders Embrace Reform

1. Healthcare Leaders Embrace Reform 17th Annual Scottsdale Institute Spring Conference April 14-16, 2010 Camelback Inn Scottsdale, AZ

2. Essentials of Healthcare Informatics for the C-Suite Scottsdale Institute, Spring 2010 Jeffrey S. Rose, MDVP, Clinical Excellence InformaticsAscension Health

3. People need to be reminded more often than they need to be instructed.Samuel Johnson

4. A 3 Pointer • How informatics can help actualize high reliability, elevate human performance and improve clinical outcomes, thereby enhancing healthcare as a system • Focus in upon he key clinical information tools that can have the greatest impact on quality (what you should expect to accomplish with informatics) • Provide an high level methodology to address in cultural challenges in executing information strategy

5. Ascension Health is the largest Catholic health system, the largest private nonprofit system and the third largest system (based on revenues) in the United States, operating in 19 states and the District of Columbia Facilities and Staff Locations 500+Acute Care Hospitals 67 Long-term Acute Care Hospitals 2 Rehabilitation Hospitals 3 Psychiatric Hospitals 4 Available Beds 17,928 Associates 113,000 Physicians 20,000 Financial Information (FY09) Total Assets $16.5 Billion Operating Revenue $14.3 Billion Operating Income $371 Million Net Income ($710 Million) Investment (Loss) ($980 Million) • Discharges 696,206 • Available beds 17,928 • Number of births 76,268 • Total surgical visits 544,400 • Home health visits 554,664 • Clinic visits 1,748,421 • Emergency visits 2,317,004 • Physician office visits 5,112,392 • Total outpatient visits 17,702,630 Care of Persons Who Are Poor and Community Benefit $868 Million

6. The dilemma: Cost, resource limitation, reform Workforce shortages; staffing/hours mandates, inefficiency External regulation and reporting (medicine by proxy) Advancing science, information and ‘evidence’ Quality, safety, risk, privacy, ethics, service Aging, expectations, ethnic disparities Access, mission Unprecedented transparency with inadequate data ‘Meaningful Use’, ARRA

7. Health Information Technology Congressional Budget Office Estimates of Cost of Healthcare Reform

9. Informatics • Health informatics is the intersection of information science, computer science, and health care. • It deals with the resources, devices, and methods required to optimize the acquisition, storage, retrieval, and use of information in health and biomedicine. • Health informatics tools include not only computers but also clinical guidelines, formal medical terminologies, and information and communication systems also applied to the areas of nursing, clinical care, dentistry, pharmacy, public health and (bio)medical research. Collect & consolidate information, analyze and transform information into knowledge, and support a learning organization with evolving best practices from the learning

10. The Informatics Journey

11. QUALITY = Safety (HRH) + Value + Appropriateness

12. Why do we need a different approach? Despite attention over the past 30 years to care quality adults today (overall) receive about half the care widely accepted as recommended by the medical community; ‘the gap between what we know works and what is actually done is substantial’……. McGlynn et. al. NEJM June 26, 2000 Same in pediatrics The Quality of Ambulatory Care Delivered to Children in the United States Mangione-Smith R, De Cristofar Setodji CM, Keesey J, Klein DJ, Adams JL, Schuster MA, McGlynn EA, NEJM, Oct. 11, 2007

13. Cottage Industry to Postindustrial Care —The Revolution in Health Care DeliveryPosted by NEJM January 20th, 2010 http://healthcarereform.nejm.org/?p=2836&query=home#printpreview#printpreviewStephen J. Swensen, M.D., M.M.M., Gregg S. Meyer, M.D., Eugene C. Nelson, D.Sc., M.P.H., Gordon C. Hunt, Jr., M.D., M.B.A., David B. Pryor, M.D., Jed I. Weissberg, M.D., Gary S. Kaplan, M.D., Jennifer Daley, M.D., Gary R. Yates, M.D., Mark R. Chassin, M.D., M.P.P., M.P.H., Brent C. James, M.D., M.Stat., and Donald M. Berwick, M.D., M.P.P. Key points Guidelines must be tended over time. Advancing knowledge may render even the best guidelines outdated The evolution of scientific knowledge is not grounds for eschewing guidelines; it is a reason to modify and improve them continually Allowing physicians to make thoughtful exceptions to guidelines but asking them to report why their practice varies can support loops of continuous learning Modern physicians should welcome guidelines covering the basics of evidence-based care, which can free them to focus on the complex issues that require their training and expertise. Effective standard practice will also require interdisciplinary care. An invaluable consequence of fostering interdependence is better teamwork that should lead to safer care (e.g., comfort in speaking up when something seems wrong, as well as better handoffs and communication) • Current health care system is a cottage industry of nonintegrated, dedicated artisans who eschew standardization • Even those who work in larger groups create individualized care plans that cannot be integrated with care in neighboring “out-of-network” facilities; cannot treat and track patients over space and time • Today’s system pays for volume rather than value: more tests, exams, surgeries, and appointments • “Good doctors” are celebrated for their unwavering dedication to doing whatever it takes, (rescue imperative) often swimming upstream against the system, rather than relying confidently on it • Three key steps — wise standardization, meaningful measurement, and respectful reporting — have transformed other industries, and we believe they can help health care as well

14. Reliability Reliability: The probability that a system, structure, component, process, person will successfully provide the intended function(s) Just as high reliability is a vital part of the solution to our dilemma, as is informatics, neither is sufficient alone to get us where we need to be Both are necessary but not sufficient • High Reliability Organizations • Nuclear power plants • High speed trains • Automobile and other industrial production • Commercial airlines • But not healthcare

15. Why No High Reliability Healthcare? There are no best practices, just best doctors. It’s not an industry, it’s a collection of industrious folks…..they’re isolated practitioners. Medicine is not vertically integrated or horizontally integrated--it’s is not integrated at all!Kessler, A., The End of Medicine, 2006

16. Informaciation Inadequate patient information Inadequate current knowledge to guide diagnostic and treatment choices to maximize effectiveness We practice with incomplete information about the people and disorders we are treating almost all the time Wood, NEJM, 1972; Covell, Ann Int Med, 1985 Gorman, Med Info, 2001; Fries, Med. Care, 1975 Tang, Proc Annu Symp Comput App Med Care, 1994 ‘Medical knowledge is scattered to the wind---little bits of it in lots of individuals. There is no product---you and I are the product. Medicine consumes us.’ A. Kessler, The End of Medicine, 2006

17. Preoccupation with failure (regarding minor errors that are potential symptoms of something more serious) Reluctance to simplify interpretations Embracing diversity, experience and perspective Sensitivity to operations Know what is occurring at the front line Commitment to resilience Detect, correct and rebound from events Deference to expertise Encouraging decision making by those with the most knowledge and expertise Characteristics of an HRO: Collaboration Weick,KE and Sutcliffe, KM: Managing the Unexpected; Jossey-Bass, San Francisco, 2007 David Gaba, Anesthesia Patient Safety Newsletter, 2003

18. HARM

19. Human Performance • Skill based: auto-pilot routine nearly subconscious mode • Rule Based: learned and practiced very conscious explicit ‘if-then’ responses mode • Knowledge Based: a puzzle or mystery (yes, they are different*) requires ‘figuring something out’ mode *Gladwell, M. What the Dog Saw, and Other Adventures, Chapter: ‘Open Secrets’, Little, Brown and Co., 2009

20. Initial experience Failure mode:

21. Keeping Current? Finish medical school and residency knowing everything…read and retain 2 articles every single night…at the end of 1 year you’re only 1,225 years behind. W Stead. JAMIA 2005;12:113-20 Alper BS, Hand JA, Elliott SG, et al. J Med Lib Assoc 2004;92:429-37 • Clinical Knowledge Management • 20,000 biomedical journals • 500,000 indexed in PubMed annually* • >150,000 articles per month • 6,000 articles a day • 2,618 active performance measures • 231 active P4P measures • 100,000 genetic tests over next few years** • More data over the last 3 years than previous 40,000 years combined”*** *Medical References Services Quarterly 2007;26:1-19 **A Roadmap for National Action on Clinical Decision Support June 13, 2006 ***UC Berkeley, School of Information Management and Systems,Deloitte Consulting Report

22. Reaching our High Reliability Goals Requires: Appropriate standardization of content Redundancy functions (rules/alerts) Process redesign: mindfulness, potential failure remediation and culture management Evidence informed foundation content Doing the right thing becomes the easiest thing to do in a single ubiquitous multipurpose tool Technology introduction approach as a new way of doing things, not the old way with new tools Collaboration and convergence as expected norms

23. Behavior and Process Standards Clinical Content Standards Lexical and Data Architecture Standards Communication and Display Standards Technical Engineering Standards Standards

27. EHR Infrastructure Essential for High Reliability Healthcare Omnipresent clinical information for all providers Reduction of documentation duplication, hunting-gathering Clinical Decision Support (CDS): insure safe practices, current knowledge, safety-nets, reminders at point of care, and appropriateness Proved flexibility, innovation and measured results of such Automated reporting, reimbursement, and regulatory compliance Public Health information sharing, community health information model development and HIE Improved medical-legal risk mitigation, privacy, ethical decision enhancement

28. IT’s Not How Much You Spend, It’s About How You Use IT Paul Strassman, The Squandered Computer, 1997

29. EHRs and Clinical Decision Support “Taken alone, clinical information technologies like bar-coding, smart pumps, nursing documentation, pharmacy and physician order entry systems don’t sufficiently improve clinical practice to justify these (CIS) investments. The systems must be supplemented by embedding intelligence into the clinical workflow. Decision support is the key to driving high quality and fail safe care.” True North “Hardwiring The Evidence” The Advisory Board • EHRs Do NOT innately contain (rules and alerts) • Do not automatically revise HRH required process changes • Cannot get you to High Reliability Healthcare without associated culture and operations change • “As implemented, EHRs were not associated with better quality ambulatory care. In selecting an EHR, physician practices should carefully consider the inclusion of clinical decision support to facilitate quality care…” Arch Intern Med 2007 (Ambulatory EHRs, 2003, 2004 17 ambulatory quality indicators EHRs 18%, 1.8 billion ambulatory visits)

30. Why Use Care Sets? • Almost everything in our hospitals begins with a physician order; influencing the way physicians order, can influence everything: • Care-sets can incorporate evidence informed practice, drive most of the direct value and quality of coordinated care • They are key elements to diminish unnecessary variation, improve currency and automated compliance with quality core (and other) measurements of process and outcomes • They are a primary point of influencing clinician decision making and serve the needs of many ‘customers’ • They can facilitate the ordering and delivery processes • 37% reduction in time spent entering orders (vs. CPOE without order sets) • They can provide safety nets and and are vital parts of safe closed-loop medication delivery systems and other procedure practices • They can be updated and disseminated as evidence, practice habits, formulary, regulatory and accrediting agency requirements change • They can allow more efficient overall workflow if done well and introduced gracefully and in an appropriate sequence

31. Meaningful Use Summary Objectives from HIT Policy Committee Meeting • Use CPOE for all order types • Use evidence-based order sets (for hospitals, record clinical documentation in EHR, e-prescribe) • Use CPOE (for hospitals, 10% of all orders – any type – entered through CPOE); 80% for EP’s!

32. The Care CollaborativeA partnership of faith based organizations Started with Foundation Evidence informed Foundation sets, collaborated upon by 114 community-based hospitals • Subject matter expertise in expert-based and evidence-based order set development, deployment, and knowledge management. • Library of 1,100 ‘out of the box’ order sets and modular protocols including: • Condition based • Procedure based • Convenience • Specialty specific • 40% of the Care Collaborative content is unique to ZynxOrder content - remaining 60% is based on ZynxOrder content with modifications made by clinicians using the content

33. The CollaborativeA partnership of faith based organizations Evidence-Based PowerPlans™ (2009) Per Discharge

34. CPOE • While technology plays a role, CPOE and care-set coordination is really about how well a facility handles change. • CPOE represents a tremendous opportunity to improve patient safety, operational outcomes and gain new efficiencies – but they don’t happen by accident. • Ultimately it’s the data • Severity-adjusted with tests of statistical significance • Quarterly outcome data • Reported to each facility • Aggregate data for corporate system view • Improvements in elements of quality using order and care sets can long proceed CPOE; separate the content delivery from computer use

35. Standards of Clinical Decision Support (CDS) • Reduced inefficient decision-making • Reduced costs (e.g., via more appropriate testing) • Reduced medical errors • Reduced liability insurance premiums • Increased revenue (e.g., P4P and NP4NP) • Increased market share • Improved staff retention/utilization • Enhanced leverage to improve outcomes • Enhanced quality of healthcare professional education • Improved health services research Improving Outcomes with Clinical Decision Support: An Implementer’s Guide Jerome A. Osheroff, MD, FACP, FACMI et al • Upperman, J, fetal. , et. al. The Introduction of Computerized Physician Order Entry and Change Management in a Tertiary Pediatric Hospital, Pediatrics November 2005 • Shimlyian, et. al., Health Services Research, 6/26; HealthDay,; University of Minnesota release, University of Minnesota School of Public Health, 2007 • Ash, JS, PHD, MLS, et. al. A Consensus Statement on Considerations for a Successful CPOE Implementation, JAMIA, 2003 • NCQHC, CEO Survival Guide to Electronic Health Record Systems, 2005 • Kashual, et. al. Return on Investment for a CPOE System, JAMIA, 2006 • Frisse, M, Comments on Return on Investment for a CPOE System, Editorial JAMIA, 2006 • Kuperman, G and Gibson R, Computerized Physician Order Entry: Cost, Benefits and Issues, Annals of Internal Medicine 2003 • Bates, et. al, Reducing Medical Errors in Medicine Using Information Technology, JAMIA, 2001 • Shortell, Stephen M PhD, MBA, MPH Improving Patient Care by Linking Evidence-Based Medicine and Evidence-Based Management JAMA. 2007

36. Lexical Uniformity: Tools and Content and Knowledge Production “If you cannot name it you cannot teach it, research it, practice it, finance it, or put it into public policy” Norma Lang, 1992, Dean of Nursing, University of Pennsylvania Nor can computer-data systems truly interoperate

37. We lack effective means of recording, collecting-communicating in a form that is both human readable and machine process-able EMR Clinical notes Coding Patient “Multi-modal” data entry • Possible Patterns: • Referral Process • Discharge Summary • Rx Distribution • HRH • CPOE • … Human Readable for Nuance and flexibility Machine Readable for analysis and CDS launch

38. Without Lexical Standards • Healthcare data is non-comparable • Health systems cannot interchange data • Secondary data analysis (Research, QA) is slow, arduous and arguable • Linkage to Decision Support Resources (synchronous and asynchronous) is NOT easily or evolutionarily possible • Maintenance, system swaps, terminology and code set updates are inordinately complex and expensive

39. Enterprise-wide data repository Improved quality and value, use Clinical Operations Enhanced real-time clinical analytics Ministry Intelligence Center Automated Decision Support (CDS) EHR/Clinical Content/Coding Clinical regulatory requirements Symphony Operational regulatory requirements HR Normalization Comparison of hours per patient day/turnover rates/etc. Link clinical quality to care processes and supplies Link operational costs to care processes and supplies Financial Normalization Standardized financial reporting/analysis Rapidly recall defective supplies Supply Chain Normalization Standardized Reporting Link workman’s comp to care processes and supplies The Power of Integrated Data Healthcare That Works, Is Safe, & Leaves No One Behind Clinical & Operational Data Dictionary (Lexicon)

40. MIC High Level Architecture

41. High Reliability Healthcare Defined A dependable system of intersecting human and technical interactions with the purpose of maintaining or restoring individual and population wellness Based on principles of measurement: events, outcomes, error sources, potential errors and benchmarked processes Using current and evolving best evidence about individuals and their health Leveraging information technology to Decreasing reliance on memory Enhancing focus on appropriate best practices (including spiritual and experience) and scientific evidence Ensuring optimal quality: value, safety and appropriateness Using mindful coordination of information/processes/ just culture Positive preoccupation and resilience around error Deference to expertise climate of collaboration Aiming at continual discovery, learning and improvement of individual and system performance

42. Dominant shared values Stable, highly resistant to change ‘Commonly’ defines what is right or wrong, good or bad, correct or incorrect Justified by moral standards, reasoning or tradition Expressed in: Language Norms of behavior Commonly understood roles, responsibilities, beliefs and customs Local: ‘it’s the way we do things around here’ The success of a culture depends on what the organization wants to accomplish [in this case HRH Broom, L. and Selznick, P. Sociology: A Text with Adapted Readings. 3rd edition, 1963 Culture warning: CULTURE STRATEGY

43. Information technology in healthcare is the means to transformation, not the end goal • ‘The moment an organization forgets this, it places in jeopardy the change it needs to survive’ • Robbins, H and Finley, M • Why Change Doesn’t Work, Petersons’s Press, NJ, 1996.

44. “Theoretical knowledge is not the same as hands on knowledge.” Dietrich Dorner, The Logic of Failure, 1996 • Assumed: • At 90% adoption, potential HIT-enabled savings high (~$77B/yr health care efficiency savings) • Found via computer modeling: • Costs are modest relative to savings (~$10B/yr) • Potential safety (~ $4 B/yr) and health benefits also large and could double the savings • Health benefits include (~ $81 B/yr): • Better delivery of preventive care • Better management of chronic diseases • Total annual savings from use of EMRS = $162 billion

45. COMPASSION Is about: Caring; Mission; Worth; Values; Dedication; Commitment; ‘What’s in it for me’ COMPREHENSION Is about: Cognitive understanding; Gaining and conferring guilt-free understanding; How knowledge is shared Not a NEW problem for us COLLABORATION Is about: Mindfulness; Working together; Agreements; Involvement; Teams; High Reliability Assurance CULTURE TRANSFORMATION COORDINATION Is about: Infrastructure; Process identification; Standards CONVERGENCE Is about: Leadership; Style; Timing The 5C’s of Culture Change

46. Questions • Did these points come across The role of informatics in a high reliability healthcare organization The importance of clinical decision support in a high reliability organization Awareness and a method to address cultural challenges to using information systems to achieve high reliability