HIMSS-MN Chapter Learning Session

1. HIMSS-MN Chapter Learning Session Interfacing Ambulatory Applications September, 2003

2. AGENDA You’ll learn about HealthPartners & our: • System interfacing strategy; • Interfacing strategy evolution and future considerations; • Implementation challenges encountered and key strategies to mitigate risk; • Key success factors in ambulatory systems interfacing; • Ongoing issues and limitations of interfacing.

3. Members/Patients HealthPartners - a consumer-governed health care organization Mission - To improve the health of our members, our patients and the community. Health Plan (medical & dental functions) HP Medical Group & Clinics Hospitals: - Regions as well as: Hudson, Amery, Osceola & No. St. Paul Trans Care Center HP Dental Group & Clinics Central Minn. Group Health Institute for Medical Education Institute for Clinical Systems Improvement Research Foundation Administrative support: such as Legal, Information Services, Communications Contracted Network: -Medical -Specialty -Hospital This is a functional depiction of who we are; not an organizational chart

4. About HealthPartners Medical Group & Clinics • 550 Physicians, multi-specialty group • Key component of not-for-profit integrated care delivery & financing organization • 43 clinic sites • 250,000 HealthPartners members + 100,000 fee-for-service patients

5. About HealthPartners Medical Group & Clinics • 1.5 million visits per year • 1.5 - 2 million claims per year • Appointment scheduling: • average of 5/minute, • 7AM - 9 PM, 365x14; • peak of 10/minute;

6. About HealthPartners Dental Group & Clinics • 60 Dentists, including specialties • Key component of not-for-profit integrated care delivery & financing organization • 16 clinic sites • 215,000 HealthPartners Dental members, 100,000 use our clinics

7. Our technology trajectory Perfect Care Our work now 1998 HPMG & C Designing our care system to pursue “perfect care” Ramsey Clinical Associates 2001-2 -P2 -EpicWeb View & Extended -Scanning -Common HIT Systems - Dental EDR 2000 1999 -Access -EpicWeb in specialties Group Health Clinics -Satisfaction -1st paperless clinic - Some scanning -Prelude, Cadence -Business systems -Resolute -EMR pilot 1997

8. System Interfacing Strategy Business Drivers - • When choosing best of breed systems, interfacing is part of the package; • Home grown Patient Profile not enough; • Electronic Medical Record adoption: • Build a history and manipulate it for more effective care; • Creating a one stop shop means more efficient care delivery;

9. System Interfacing Strategy Led to a Strategy - • Standardization -- HL.7, “move away from that point-to-point interface and no one gets hurt...”; • Interfaces implemented which improve workflow; • Interfaces before rollout if possible; • and a history load too! • Interfaces that meet provider needs and wants (I.e. how do we generate buy in)

10. Our interface trajectory 1996-7 1998-9 - Reg. (‘96) - Sched. - Claims - MSR - RX and Claims RX - Trans. - Lab - Lab Billing - Regions ADT - Turned off Claims RX

11. Graphing of Lab results

12. The Pursuing Perfection Initiative • Robert Wood Johnson Foundation (RWJ) with the Institute for Healthcare Improvement (IHI) issued a call for proposal, “Pursuing Perfection: Raising the Bar for Health Care Performance” in February, 2001

13. Where did the term “pursuing perfection” originate? • “Crossing the Quality Chasm” published by IOM in early 2001 is a call for a sweeping redesign of health care

14. Our Direction… changed: HPMG & C Mission • To improve the health of our members, patients and our community HPMG & C Direction • To pursue perfect care, service and access at a cost that is affordable Care Systems Mission • To make it easy for patients and practice teams to do the right thing, right 100% of the time EMR Direction • To implement EpicCare Hyperspace in a manner that makes it easy for our practice teams to pursue perfect care at a cost that is affordable

15. I. Patient Results Setting Aims for Improvement Mission (purpose) “What we strive for” (aims for improvement) • III. Organizational Supports for Change • -Patient-centered - Financial viability -Teamwork • - Measurement - Communication - Effective use of technology • Leadership - Cultural Change - Change Model • - Systematic approach to process design • - Employee/Physician Learning, Growth and Alignment • IV. Environmental Supports for Change • - Payment methods • - Transparency • Clinical education/regulation/liability • Dissemination/external spread II. The Care Itself - Simple Rules - Design Concepts

16. We’re Implementing the Planned Care Model Continuous Healing Relationships Informed, Activated Patient Prepared Practice Team Health Information Availability

17. Prepared Practice Teams Engage the Patient in a Continuous Healing Relationship • Patient’s perception of the healer’s awareness of problems in daily activity, feelings, social activity, pain, social support, physical activity. • Healers explanation of the problem • Patient involved as much as they want in decisions Continuous healing relationship • Patients want: • 65% information • 25% comfort

18. What makes this different? • All team members know who each other are (defined group) • All team members understand the planned care model • All team members understand their role as well as others within the team (based on job title and not the individual) • All PPTs will base their care on established best practices (e.g. ICSI guidelines) • All PPTs will base their care on STEEEP principles • Teams are augmented by but not dependant on technology (you can’t wait to form a good team until you get a complete EMR)

19. Prepared Practice Teams Work Across the Continuum ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD ABCD Nursing Home Hospice Urgent Care Primary Care ER Specialty Home Care CareLine Case Management Hospital CHP Behavioral Health Trans care

20. Our Health Information Technology Vision • To create a system that makes it easy for our patients and providers to do the right thing right, and guarantees patients and providers unfettered access to the health information they need, whenever or wherever they need it, 100% of the time.

21. Interfacing Strategy Evolution • Initially, identify and deploy key interfaces before application rollout to provide valuable data at the beginning (chart history); • Ongoing, parallel interface development with application rollout or key business needs; • Recognition that reconciling interfaces must occur within workflow context; • Vision: Six Sigma Interface Quality & Care Quality

22. Interfacing Strategy Evolution • Initially, identify and deploy key interfaces before application rollout to provide valuable data at the beginning (chart history); • Easy to do the right thing at the right time; • No need to reference the paper chart or PPS; • History load makes it truly meaningful;

23. Interfacing Strategy Evolution • Ongoing, parallel interface development with application rollout or key business needs; • Recognition that reconciling interfaces must occur within workflow context;

24. Interfacing Strategy Evolution • Vision: Six Sigma Interface Quality & Care Quality

25. Six Sigma • Adopting the goals of Six Sigma quality means setting tolerance limits for defective products at such high levels that fewer than 3.4 defects occur per million visits (or opportunities).

26. Diabetes (as an example) • Diabetes affects approximately 5% of HealthPartners patients and accounts for about 15% of total health care dollars • For every 1% reduction in HbA1C’s, we estimated we could save $10 million, and more importantly, patients would benefit by having fewer complications

27. Diabetes (as an example) • Only one-third of the care systems and doctors in the U.S. provide diabetes care at the minimum standards recommended by the American Diabetes Association (ADA)

28. Six Sigma View of Diabetes • If 70% of our patients with diabetes have a HbA1C of <8, that’s 300,000 defects/million • If we fulfill the comprehensive diabetes measure for only 7% of our patients with diabetes, that’s 930,000 defects/million • And our current performance is at national benchmarks!

29. System Interfacing Strategy Thus a revised Strategy - • Standardization -- HL.7, “move away from that point-to-point interface and no one gets hurt...”; • Interfaces implemented which improve workflow and STEEEP (Safe, Timely, Effective, Efficient, Equitable, Patient Centered); • Interfaces before rollout if possible; • we still love that history load! • Vision: Six Sigma Interface Quality & Care Quality

30. Our interface trajectory 1996-7 1998-9 2000-1 2002 2003 2004 - Reg. (‘96) - Sched. - Claims - MSR - RX and Claims RX - Trans. - Lab - Lab Billing - Regions ADT - Turned off Claims RX - Scanning - Outbound Sched. & Reg. - Dictaphone - Radiology - Dental Membership - Pathology - Regions OP RX Dispensing - Turned of RX pending orders - New Dental System - Lab Orders - RX orders

31. Interface Statistics • 23 Ambulatory Interfaces in service (19 more ‘hospital-only’) : • Transcription • Scheduling/Registration • ADT/Membership • Scanning • Lab Results/Orders • Pharmacy Prescriptions • Radiology • Automated Dispensing • 4.7 million messages per week through interface engine (At Six Sigma -- still 17 errors per week);

34. Interface Reconciliation • Riddle me this... • How do we know what is going through the interfaces is the right stuff and the right quality? • When is an ordering physician not an ordering physician? • How flexible is the HL.7 standard? (hint: think yoga) • Now how complicated could a billing interface possibly be? • What’s important about interface reconciliation?

35. Interface Reconciliation Q. What’s most important about interface reconciliation? 1. The vendor’s model of your business? 2. Your model of your business? 3. HL7’s model of your business? 4. CMS’ model of your business? 5. An application user’s model of your business? A. 6. All of the above together (or the story of Ordering Physician…)

36. Interface Reconciliation • The real world is a messy place • Interfacing systems requires • Vigilence • Engineering • Systems Theory • Discipline

37. Samples of... …how interfaces can make it easier to deliver more perfect care.

40. Alternative Medications are recommended for target drugs.

41. Drug allergy interaction checking occurs when ordering in Epic.

42. Entry of Patient’s Problem List will provide continuity of care

43. SnapShot screen in Epic provides Health status items on one page..

44. Health Maintenance

45. Health Maintenance/ Disease Management

46. Some issues with and limitations of interfacing • ROI is required too -- technology is expensive; • Achieving Patient and Provider satisfaction is challenging; • Variation of people in processes;

47. Return on Investment • Reduce staffing (e.g Medical Records, Charge Entry) • Reduce Dictation/Transcription volume • Decommission/reduce Legacy systems • PPS • Dictaphone/Chartscript • Improve Pharmacy • Increase generics • Increase in-house fills • Reduce postage & materials

48. Satisfaction Survey Background • Prior to 2003, this survey was conducted with paper by hand at each of the clinics • This was conducted in March-April 2003 using an Internet-based tool. • Approximately 1600 EPIC users were E-mailed. • 452 Answered the survey (28% response Rate)

49. EMR Climate • Respondents generally feel favorable. • 84% were Satisfied or Very Satisfied with “My use of Epic has improved my ability to deliver better care to my patients.” • Substantial opportunities exist to make EPIC more useful.

50. Question: Patient’s IP or ER Information availability in EPIC • 60% were satisfied or very satisfied with Hospital or ER info available in EPIC • Specialty Care Nurses had Significantly greater satisfaction than other groups. • Providers had less satisfaction than non-providers. Spec Nurses Satisfaction