Dignity Health: Implementation of an EHR Alliance Bridging Acute and Ambulatory CareRaymond Lowe

Senior Director Enterprise Clinical ImplementationsEHR AllianceOctober 24, 2012

Email: Raymond.lowe@dignityhealth.org

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• This session will provide a unique learning opportunity focusing on the Dignity Health $1.8B implementation program to meet horizon 2020 as we transform healthcare. The initiative encompassed a 42 hospital health IT implementation in the acute care setting. Review the challenges associated with governance and review lessons Learned from the project.

• Learning Objectives: Key implementation points∙ Clinical Integration with Ambulatory strategies ∙ What’s next – business intelligence∙

Objective

Dignity Health

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Who is Dignity Health

• Dignity Health, headquartered in San Francisco, Calif., provides integrated, patient and family centered care to more than six million people annually.

• We are the fifth largest health system in the nation with 10,000 physicians and 55,000 employees across Arizona, California, and Nevada.

• Dignity Health is committed to delivering compassionate, high-quality, affordable health care services with special attention to the poor and underserved.

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Who is Dignity Health

• Assets: $13.1 billion

• Net Operating Revenue: $10.6 billion

• General Acute Patient Care Days: 1.8 million

• Community Benefits and Care of the Poor: $1.4 billion

• Acute Care Beds: 8,800

• Skilled Nursing Beds: 800

• Acute Care Hospitals: 40

• Clinics/Ancillary Care Centers: 150

• Medical Foundations: 11

• Active Physicians: 10,000

• Total Employees: 55,000

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Our Vision

A vibrant, national health care system known for service, chosen for clinical excellence, standing in partnership with patients, employees and physicians to improve the health of all communities served.

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The Quality Chasm

“Between the health care we have and the care that we could have lies not just a gap, but a chasm.”

Institute of Medicine Crossing the Quality Chasm: A New Health System for the 21st Century. Janet M. Corrigan, Molly S. Donaldson, Linda T. Kohn, eds. Washington, D.C. National Academy Press. 2001

Responding to the Call

• There is compelling evidence that there are great opportunities to redefine healthcare– To reduce clinical errors

– To improve clinical and cost outcomes

– To improve reliability on delivery of best practices

• Crossing the chasm will require:– Putting advanced decision making tools in the hands of care

providers

– Treating the creation and exchange of information as an integrated system

– Standardize key processes around evidenced based best practices

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A Bridge to Better Care

EHR AllianceProgram Overview

Ray LoweSenior Director, IT Acute Care Strategy

Dignity Health Has Multiple Strategic Initiatives Executing In Parallel

EHR

Meaningful Use

Revenue Cycle

Compliance

Transformational Care

ICD-10 (Various Vendors)

HIPAA 5010

Meaningful Use Stages 1-3

Revenue Cycle Standardization (Siemens & Artiva)

FY14FY13 FY15FY12Q3 Q4Q3Q2Q1 Q4Q3Q2Q1 Q3Q2Q1Q4Q1

FiscalYear Q2 Q4

FY16Q4Q3Q2Q1

Ambulatory EMR (Allscripts & Mobile MD)

Lean Process Transformation

Acute EHR (Cerner & Meditech)

Compliance Deadlines

Standardization is the process of decreasing unnecessary variation to improve quality and efficiency outcomes of care– Processes done the same way every time decrease mistakes and oversights

– Processes done the same way each time become more efficient

– Reliability increases; events or steps in a process are more predictable

Key component of clinical transformation– Facilitate the measurement of quality, safety and service outcomes– Improve operational and clinical quality outcomes – Increase the speed of a “sustainable” deployment– Decrease the cost of ongoing support– Decrease cost of care

What is Clinical Standardization and Why is it Beneficial?

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From EVIDENCE To BEST PRACTICES To OUTCOMES

Outcomes

Ace-Inhibitor on dischargeBeta-Blocker on dischargeLipid therapy compliancePlatelet inhibitor Reduction in adverse drug eventsInfluenza Vaccine compliancePneumococcal Vaccine complianceSmoking Cessation education Reductions in LOS / OIReduction in preventable fallsReduction in preventable skin

breakdown

Standards Clinical Decision SupportTherapeutic Guidance

Ace-Inhibitor ReminderBeta-Blocker ReminderHMG CoA Reductase Inhibitor ReminderPlatelet aggregation Inhibitor Reminder Admission Risk Assessment ToolShort acting Rapid-Release Nifedipine AlertInfluenza Vaccine Reminder Pneumococcal Vaccine ReminderSmoking Cessation Education ReminderDrug-Lab interactionsDrug-Drug interactionsDrug-Allergy interactionsAdverse event surveillanceDelayed discharge surveillanceFall Risk assessment - alertSkin Breakdown risk assessment - alert

Order SetsTop 80% of all Dignity HealthAdmissions (by vol and cost)

AAA Repair - Postop

Acute Renal Failure - Adult Admit

AMI ED Evaluation

Appendectomy - Postop

Asthma Adult Admit

Craniotomy - Postop

Critical Care Management

Diabetes - Inpatient care

DKA - Adult Admit

PCI -Postprocedure

PNA PCP - Adult Admit

TIA - Adult Admit

Total Hip Knee Replacement - Postop

TURP - Postop

UGIB - Adult Admit

Unstable Angina NSTEMI - Adult Admit

UTI - Adult

Vaginal Hysterectomy - Postop

Unstable Angina NSTEMI - Adult Admit

From Standardization to Better Outcomes

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Board Approved FY2013 Schedule

Lessons Learned EHR Acute Implementation

6 Keys to Project Success• Effective Collaboration

– It takes everyone

– Break down the barriers (IT, Clinical, Revenue Cycle, Physicians, Vendors)

– Communicate, communicate, communicate

• Culture of Transparency

– Create an environment that supports issues reporting and escalation

– Transparency facilitates information flow─ both up and down

• Sound Structure and Governance

– Work toward a common vision

– Execute within project structure

– Fine tune as you go (always learn)

• High Standards/Value on Excellence

– Be the example that everyone else wants to follow

• Emphasis on Community and Culture

– Medical Center will continue providing care long after the days of EHR implementation have come and gone

• Focus on Process vs. Product

– In projects of this scale, individuals can’t fix every problem. But everyone can work to create pathways for healthy resolution of issues

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SUCCESS…

• The EHR Implementation will only be successful if all of us are successful doing our part.– “If you could get all the people in an organization rowing in the same

direction, you could dominate any industry, in any market, against any competition, at any time.”- Patrick Lencioni

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Communication

A solid communication plan should be built, executed and monitored with adjustments as needed

Communication needs to occur at all levels

• Communicate the shared vision

• Communicate decisions, as well as the logic behind those decisions

• Communication plans for both facility and project team

• Communicate accomplishments

• If people don’t talk it out, they will act it out

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Communication and Performance through ChangeB

usin

ess P

erfo

rman

ce

Time

Uninformed Optimism/ Uncertainty

Denial

Anger

Despair/Skepticism

PessimismTesting

Acceptance

Informed Optimism

Initiative Complete

The Performance DipOrganizational Change

Impact to your business

Governance

Strong governance and leadership is needed from the start

Governance process should support having the difficult conversations and making difficult decisions

Interdisciplinary governance committees need to exist and must include facility managers and directors

• Solid decision-making process that supports timely, sound decisions and eliminates waffling on previous decisions

• Leadership has to be onboard for the governance to be effective

• The project team and facility need to hear the vision from leadership

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9/17/2012

EHR AllianceNSSA Facility Governance Model

Management Decision Group

People

Human ResourcesOrganizational Effectiveness

Change Acceleration Process

Process

MPAG (Multidisciplinary Phyisican Advisory Group)

CPIC (Process Improvement Committees)

Transformational Care

People

Clinical InformaticistsEHR Physician Champion

Super UsersKey Department Leaders

Technology

Dignity Health Information Technology

Process

Enterprise Governance “The What” and “The How”

Transformational Care

Technology

Local IT/FSO LeadershipFacility IT Site DirectorProject Infrastructure

Resources

Implementation Project Team, EHR Physician Champion, Enterprise Physician Informaticist Implementation Program Director, Director Clinical Informatics, Executive Sponsor

Trust and Culture Best Practice InfrastructureEnterprise Guidance

Facility Accountability

Implementation Program Director, EHR Physician Champion, Director Clinical Informatics, Executive Sponsor

Facility Executive Steering Committee

Executive SponsorCEO, COO, CFO, CNE, VPMA

IT Site DirectorEHR Physician Champion

Director Clinical InformaticsCerner Engagement Leader

Implementation Program DirectorEHR Alliance Senior Directors

Escalations forEnterprise Guidance

Escalations forEnterprise Guidance

Escalations forEnterprise Guidance

Feedback

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• Project Resources: – Ensure resources have the proper skill set (project and facility)

• Project Management– Strong project team structure, including a clear chain of command and

authority should be in place

– Clearly-defined issues management and escalation process supported by all team members and leadership

• Strong document management and version control solution should be used

• Structured and consistent team meetings

Key Areas of Focus

Key Areas of Focus Testing

• Sufficient number of testing cycles and time for each cycle

• Test systems available for third-party applications

• Issues tracking, reporting and documented re-testing/regression testing

Training Set expectation on training percentage required for go live … and stick to it

Provide opportunities for practice

Develop a training domain strategy, including a fully built-out, tested environment containing enough data for successful training

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Key Areas of Focus

Go-Live Planning, Execution and Transition Begin go-live planning early in the process and conduct multidisciplinary

team review meetings until all details of the cutover are identified

– Conduct a mock-live event

– Leverage production support resources and prepare for transition

– Reach out to sister hospitals for go-live support

– Go-live command center team should be properly trained; need good issues triage and tracking processes in place

– Plan for ongoing optimization efforts well in advance of live event

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Clinical Integration

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Physician

Patient

Governance

CI System

Quality Metrics & Cost Savings

Care Coordination

Shared Savings

and Risks

Sharing clinical data at the CI level, across the team, promotes an emphasis on care coordination and taking a long-term, holistic view of wellness.

Hospital

Quality Metrics– Population and disease management – Better coordination improves quality of

care– Population focus means business model

takes holistic view of wellness

Financial or Risk Sharing– Model promotes rewards for improved

quality and lower cost of patient care (risk sharing model)

Creates incentives for providers to find cost savings

Increases care coordination Reduces overall costs Shifts from encounter-focused to

patient-focused care

What is Clinical Integration (CI)?

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Key Clinical Integration Capabilities: Technical Tiers

Communications

Analytics & Reports

Data Integration

Data Acquisition

Quality Metrics Information Reporting

Data Integration, Management, & Aggregation

Workflow, Data Extraction & Collection from Multiple Clinical & Financial Systems

Key Clinical Integration Capabilities: Core IT Components

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Secure Patient – Provider

Messaging

Provider PortalPatient Portal

Secure Provider-Provider

Messaging

Clinical Decision

Support (CDS)Management PHI /

Personal Health

Record (PHR) Clinical Information Delivery

Communications

Analytics & ReportsQuality Metric Analysis & Reporting

Data Integration Match Patient’s Data

& Patient EMPI

Match Providers

& Provider EMPI

Data Integration, Conforming, Normalization, & Standardization

Extract Clinical Data

(Internal Systems)

Data Acquisition

Extract Claims Data

(Internal /External Systems)

Extract Clinical Data

External Systems (Rx, Labs, etc.)

Clinical Data Repository

Transforming Data with Analytics

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Opportunities• Evidence Based Medicine

• Improved Treatments

• Intervene earlier

Opportunities and Challenges

Challenges• Managing Data Complexity

• Ensuring patient Confidentiality

• Changing Medical Practices

• Avoiding False negatives

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The transformation journey

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• Improving outcomes and point of care decisions– Analyze the patient population

– Supporting diagnosis and research

– Active diagnosis

– Point of care Decisoning

– Create values and the potential to improve outcomes.

Transformation

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Example Quality Metrics Dashboard

Questions?