Contents Executive Summary ......................................................................................................................................................................1

1. Background Knowledge ......................................................................................................................................................2

2. Local Problem Being Addressed and Intended Improvement ............................................................................................2

3. Design and Implementation ...............................................................................................................................................2

4. How Health IT Was Utilized ................................................................................................................................................3

5. Value Derived/Outcomes....................................................................................................................................................4

6. Lessons Learned ..................................................................................................................................................................5

7. Financial Considerations .....................................................................................................................................................6

Appendix A ...................................................................................................................................................................................7

Title: Core Menu Item Clinical Value

EXECUTIVE SUMMARY The Mount Sinai Medical Center (MSMC), located in New York, New York, is an internationally recognized medical teaching, patient care, and research organization. Continually striving for clinical excellence, MSMC’s focus is on fully integrating its medical center, ambulatory healthcare information technology (IT), and processes. Computerized Physician Order Entry (CPOE) and Clinical Documentation were implemented first in the ambulatory practices and in the inpatient setting starting in 2010. Phase I of the inpatient implementation consisted of nursing and ancillary clinical documentation, computerized physician order entry, pharmacy (WILLOW), emergency department (ASAP) and obstetrics (STORK). Phase II, completed June 2012, implemented physician clinical documentation in the Mount Sinai Manhattan campus. All of the previously mentioned applications are scheduled to go live at the Mount Sinai Queens Hospital in 2013. MSMC is also implementing a wide variety of advanced clinical processes that are enabled by the Epic EHR. Quality, safety, and efficiency metrics have improved since system implementation and are apparent in Meaningful Use core and menu objective reporting along with clinical quality measures. The EHR is also serving as a strong enabler for research projects involving disciplines such as genomics and clinical predictive rules.

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1. BACKGROUND KNOWLEDGE The Mount Sinai Medical Center encompasses both The Mount Sinai Hospital and the Mount Sinai School of Medicine. The Mount Sinai Hospital, founded in 1852, is a 1,171-bed tertiary and quaternary care teaching facility and one of the nation's oldest, largest, and most respected voluntary hospitals. In 2012, U.S. News & World Report ranked The Mount Sinai Hospital 14th on its elite Honor Roll of the nation's top hospitals based on reputation, safety, and other patient care factors. Nearly 60,000 people were treated at Mount Sinai as inpatients in 2011, and approximately one million outpatient visits took place. Due to Mount Sinai’s location in the Upper East Side area of New York, New York, the hospital is located at an intersection of the wealthiest and poorest zip codes in the United States and has the responsibility of meeting the unique medical needs both of those from affluent backgrounds and of patients requiring indigent care.

2. LOCAL PROBLEM BEING ADDRESSED AND INTENDED IMPROVEMENT Prior to the Epic implementation in the ambulatory environment, fragmented paper based information existed across ambulatory care in MSMC. Charts were unavailable at least 15 percent of the time and information pertaining to prior ambulatory visits was dependent on the patient’s ability to recall information. The ability to retrieve a patient’s medical record took a significant amount of resources and sometimes the record could not be found. The integrity of the medical record was often poor and care coordination across the health system was not effective. Allergy and medication information was often incomplete or unavailable and clinicians relied on phone calls to communicate with one another, which took an inordinate amount of time. There was limited ability to track quality and other metrics in ambulatory care. This situation improved significantly in the ambulatory setting as Epic was implemented cross the clinics and faculty practice associates. However, it was not until implementation of Epic in the Emergency Department (ED) and inpatient units that continuity of care was fully improved. For example, inpatient and outpatient nursing shared the same vaccination information and could tell which patients had already received vaccinations. With this implementation, providers could see updated and current medication lists, shared problem lists, and could receive updates on their patients regardless of the setting of care. Prior to the ED and inpatient implementation, a disparate ED system meant that additional nurse staffing (ED and inpatient) was needed for ED patients in order to address dual order entry systems in different care settings. The Quality Subcommittee of the Board of Directors had been reviewing monthly quality reports which included metrics such as mortality, patient satisfaction, and core measures, and called on improvements in quality to be included in the charter for the ED and Inpatient implementation. Very little real-time surveillance of quality metrics was available in the legacy environment for the ED and inpatient settings. Finally, the inpatient SOAP note layout was seen as illogical because it was a vertical note where providers had to scroll to the bottom of the page to find pertinent information such as recommendations and assessments. The revised SOAP note layout as shown in Figure 1, Appendix A was a much more user-friendly layout with pertinent information displayed on the same screen without forcing providers to scroll through the note. The new SOAP note layout was developed within Epic’s physician documentation module. Implementing the Epic integrated EHR across the MSMC enterprise, “should improve patient safety and communications by providers across all disciplines,” according to Erin DuPree, MD, Chief Medical Officer. Epic was intended to address all of the above problems and the incorporation of several novel clinical improvements was anticipated. The EHR was intended to be the key enabler behind the MSMC Accountable Care Organization; have a profound impact on safety, quality, and efficiency; and provide both a data and a research platform for National Institute of Health and other grants.

3. DESIGN AND IMPLEMENTATION The selection and implementation of the EHR for MSMC occurred in two phases. Selection of the ambulatory system was completed in 2004, the project kick off began in September of 2005, and the first clinic went live in 2006. The second selection process focused on the ED and Inpatient system selection in 2008 and involved 40 physicians (including some from the ambulatory process) along with several nursing executives and stakeholders from across the ambulatory and inpatient settings. Selection criteria included product functionality, interoperability with existing systems, EHR vendor support, and past performance with other health systems comparable to MSMC. The effort to design the inpatient EHR was extensive due to the complexity of clinical workflows involving hospital patient care, clinical research, and academic medical training activities. During the inpatient EHR implementation, Bruce Darrow, MD, PhD, inpatient physician champion and Interim Chief Medical Information Officer, noted, “There is going to be a fundamental change in the way that we take care of patients at Mount Sinai, and everyone has a stake in it.” The change in nursing was so profound that orientation was changed to a format that

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infused protocol with information technology because nursing leadership realized the new system made these orientation topics inseparable.

4. HOW HEALTH IT WAS UTILIZED MSMC is among the nation’s leading health systems to achieve EMR Adoption Model (EMRAM) Stage 6 (application for Stage 7 is planned for 2013) and has successfully attested to Meaningful Use Stage 1. The original fragmented network of clinical systems consisted of the ED system (IBEX), inpatient ordering (TDS), medication reconciliation (eMedRec), and a handoff communications application for use between residents (SignOut). The Epic EHR replaced all of these systems with a seamless and single integrated EHR platform across the inpatient, ambulatory, and clinical research settings. “The motto ‘One Chart. One Patient’ was previously a dream, but with the enterprise rollout of the Epic EHR, it became reality,” said Joseph Kannry, MD, Lead Technical Informaticist of the Epic Clinical Transformation Group. “The EHR rollout was more about process and change management than a rollout of new hardware and software,” said Kannry. The Clinical Decision Support of the EHR functionality was fully utilized to provide predictive screening alerts relating to many areas including early identification of sepsis cases. Prior to Epic, clinicians manually accessed patients for signs of sepsis requiring them to be experts in this area. The “Triage Screening Sepsis” best practice alert (BPA) was launched in the ED with an algorithm that evaluates eight criteria of sepsis infection based on by Greater New York Hospital Association (GNYHA) criteria. The BPA fires if any three of the eight variables are present, alerting clinicians that the patient has been screened positive for a possible sepsis infection. When the BPA fires, it prompts nursing and providers to place orders to initiate early, aggressive sepsis care. The patient is then monitored in Epic every four to six hours. The EHR continues to monitor vital signs and fires additional alerts to prompt reassessment for sepsis if vital signs are abnormal. Similar functionality supports early nursing identification of potential severe sepsis on medicine inpatient units.

Prior to the Epic go-live, monitoring patient vaccinations was especially problematic because immunizations were occurring in both outpatient and inpatient settings. Without a unified database, clinicians were often forced to rely on the patient’s memory for immunization history. To solve this issue, vaccination compliance was monitored and tracked in the EHR beginning at the time of go live and ensured nursing on both the inpatient and outpatient units could access and view a patient’s vaccination history. Once the order is entered, the system reminds nursing every 24 hours to administer the vaccination until it is completed. In the event a vaccination is not administered, the discharge process cannot be completed until the vaccination is given. The EHR workflow has resulted in close to 100 percent vaccination compliance throughout MSMC as illustrated in Figure 2 and 3. In addition to concurrent monitoring and compliance reports within the EHR, real time data is now sent directly to the New York City immunization registry.

Figure 2: Vaccination Trending (Pneumonia Vaccination Data from a Single Nursing Unit)

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Figure 3: Vaccination Trending (Influenza Vaccination Data from a Single Nursing Unit)

Other predictive alerts include therapeutic recommendations (e.g., medication safety warnings), reminders for preventative health (e.g., mammograms), compliance with core measures and national standards (e.g., DVT prophylaxis, CHF-ACE Inhibitors, MI-Beta Blockers), and a range of real-time surveillance tools.

5. VALUE DERIVED/OUTCOMES The inpatient EHR implementation has yielded efficiency improvements in clinical operations, nursing and physician satisfaction with better communication, and improved patient satisfaction. In fact, Aditi Vakil, Director of Epic Inpatient Applications, said, “The seamless integration of care delivery has been one of the greatest clinical values of the new system.” Some of the quantifiable improvements included:

• Several closely watched metrics; such as core measures, mortality, readmissions, and patient satisfaction; all trended positively after the go-live. Figures 4 and 5, Appendix A illustrate the trending for core measures and patient satisfaction.

• Real-time surveillance reporting; such as compliance on protocols for sepsis, vaccinations, SCIP measures, and medication reconciliation; had an immediate and on-going effect on ensuring compliance. Figures 6 and 7, Appendix A provide sample surveillance reports for sepsis and SCIP measures. Figures 8, Appendix A shows the positive trending of sepsis deaths and Figures 2 and 3 show vaccination compliance.

• Discharge summaries completed within 30 days of discharge were at 98 percent (Q1 2012). • Inpatient orders entered by physicians for the first quarter 2012 were 95 to 100 percent and MSMC ranked first in the

nation with CPOE compliance among all Epic clients with inpatient CPOE. • Inpatient verbal orders decreased from 21 percent to 0.6 percent (Q1 2012). • Readmissions for congestive heart failure patients decreased by 60 percent (Q1 2012). • Measures of patient satisfaction with both nurses and physicians improved from 50 to 80 percent satisfaction (Q4

2011). A number of qualitative value enhancements have been realized in the ambulatory and inpatient areas directly from use of off-the-shelf capabilities of the EHR. A list of these enhancements can be found in Figure 9, Appendix A. The majority of the ambulatory EHR rollout was completed before the MSMC inpatient go-live date. Several benefits were realized by ambulatory stakeholders and included:

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• Charts available prior to the visit went from 85 percent to 100 percent. • Co-signature rates from attending physicians overseeing house staff went from approximately 80 percent to 96.8

percent, significantly improving the completeness of charts. • The EHR enabled continuity of care between outpatient practices, inpatient, and the ED (same problem, medication,

and allergy lists; as well as past medical history, past social history, and family history). o Prior to the Epic implementation, paper charts were not shared across these care settings. o Dependence on patients’ memories and errors from retyping information ceased to be an issue and patient

satisfaction increased. o Prior to the Epic ambulatory EHR, problem lists needed to be recorded in the front of the chart, in the

progress note, as encounter diagnoses for the paper-based checkout, and on lab slips for reasons why the test was being done; now diagnoses are entered only once.

• Results now automatically go to a provider’s inbox in Epic where new and historical results are easily accessed and providers communicate via secure messaging. The previous paper process was fraught with lost results, requirements for a large physical mailbox space, retesting, and paging/telephone calls to discuss patient cases.

• The EHR supported achievement of NCQA Level III Medical Home recognition at MSMC primary and specialty care practices, where outcomes for certain disease populations (e.g., diabetes) have significantly improved.

• It is now easy to alert physicians when alerts arise from government agencies (e.g., contacting all providers with patients taking Actos after the medication was found to lead to increased risk of bladder cancer).

• With the new EHR, patients are able to refill prescriptions, see upcoming appointments, receive test results, and exchange messages with the providers.

o Providers are quite happy with new efficiencies in refilling medications, receiving patient messages, and releasing test results.

Beyond the documented clinical innovations, MSMC clinicians and business leaders often speak about the intangible clinical value of the EHR. The full impact of these benefits is not yet fully known but they include:

• MSMC case managers having visibility into virtually all patient touch points (inpatient, ED, outpatient, and home health) and can intervene as needed

• Population management now being possible, with high-risk patients identified and contacted for needed physician visits, exams, and diagnostic tests

• Having the infrastructure in place to work within the new constructs of healthcare reform: o Continuum of care and population-based medicine capabilities for the MSMC Accountable Care Organization

pilot o Clinical decision support, physician documentation templates, and reporting for value-based purchasing

quality metrics

6. LESSONS LEARNED A number of lessons learned and challenges were overcome during MSMC’s implementation of the Epic EHR in the ambulatory and inpatient environments to derive maximum clinical value from its EHR investment. Key challenges included:

• Engaging the nursing union early and often to provide the flexibility of changing job roles of the nursing champions as needed. This was crucial given the degree of change to clinical workflow.

• Overcoming physician community resistance to adopting the new EHR. MSMC leadership had a focused initiative that involved executive partnering with high profile admitting physicians to secure their buy-in and adoption.

• “One Chart. One Patient” required safeguarding continuity of the application across inpatient and outpatient settings of care to confirm that data was captured and retrieved in a similar fashion. Clinical decision support had to give consistent recommendations, and charting and results review had to look the same in all care settings.

o For example, developing a methodology to make all vaccination statuses, including those done outside of MSMC, viewable to all providers

• Anticipating needs of distinct audiences such as medical students, psychiatry, and researchers early on in the project. o For example, there is a need to develop compliant and educationally sufficient documentation and ordering

access for medical students. • Overcoming the fragmented network of clinical systems was seen as the primary driver for the EHR vs. ROI. As stated

by Kristin Myers, Vice President of Information Technology, “There is one main driver here for Epic and it is the quality and safety of the care we give to our patients.”

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• Although the sepsis predictive alerting was effective, close examination of alerts after go-live indicated a problem, namely nursing could not see sepsis alerts in their workspace. Information Technology staff worked closely with the vendor to ensure nursing could see the alerts in their narrator and were able to receive notifications on their mobile phones. This ensured the alerts were visible for all nursing staff.

Lessons learned revolved around cultural and change management considerations that included:

• Funding the change management program very appropriately to guide the organization through the amount of change required

• Many providers protested the changes taking place because they felt that they were at a disadvantage due to the new EHR. MSMC took the time to listen to all stakeholder concerns and address those concerns to mitigate the impact to EHR adoption

• Being clear about the rigorous EHR selection process based on the objective to have the best EHR to support a complex academic medical center

7. FINANCIAL CONSIDERATIONS

The MSMC Epic EHR program had a total approved budget of $127.5 million spanning from 2005 to 2013. The ambulatory implementation was $23.3 million, the faculty practice associates (FPA) implementation was $21.3 million, and the inpatient EHR implementation was $82.9 million. For the inpatient applications, $68 million was capital and $14.9 million was operating expense. With the rigor and discipline put forth through governance and leadership all deadlines were met, mitigating the risk of cost escalation by staying on track with the allotted capital and operating budgets. Ensuring the organization met the Stage 1 criteria for Meaningful Use was a high priority leading to capture of over $8 million in Stage 1 incentives for the ambulatory and inpatient activities, with a total potential incentive capture of $32.7 million projected through Stage 3.

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APPENDIX A

Figure 1: Revised SOAP Layout

Figure 4: Core Measure Trending

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Figure 5: Patient Satisfaction Trending

Figure 6: Sepsis Monitoring Report

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Figure 7: SCIP Monitoring Report

Figure 8: Sepsis Trending

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Figure 9: Qualitative Value Enhancements