Data + Process: The Peanut butter cup of HIT!

Howard Landa, M.D., Chief Medical

Information OfficerAlameda Health SystemOakland, CA

DataProcess

Quoting smart people makes you seem smarter

• Data is like salt water. It can drown you in its native state, but filtered and processed it sustains life. “The goal is not to drown in data while thirsting for information”-Reid Coleman

• Using data to impact processes drives value from the data

• Dashboards are not very usefulwhen standing still

2

By any other name…

Beyond Meaningful UseMU2 : Meaningful use of

Meaningful UseWhy we all started doing this:To use technology to improve

the process of Healthcare

3

Healthcare Information Technology Truisms

1) The EHR shines a bright spotlight on all your bad procedures, processes and actors

2) Workflow is everything (Implementation)3) Computers make smart people

do stupid stuff4) Where Workflow isn’t everything,

Data is everything5) Data impacting Workflow is really everything

(Optimization)

4

Scenario #1• Situation– Well resourced Accountable Care Organization– Mature EHR implemented and optimized– Reliable data and clinical decisions support

• Goal: – Improve a specific aspect of care– One that Passes the “Champagne test”

5

• Improve ordering of Mammography– Identify

Alerting– Ease ordering

• Improve cycle time• Improve patient satisfaction with process• Earlier detection Improved outcome

Goal: Improving Mammogram Screening

Initial attempt• Provide the structure–Alerts and Reminders (Staff and Patients)–Process support• Mature ubiquitous EHR• Incentives

–Analytic data• Screening rates, Treatment benefit• Monitor alerts and orders

7

Modest improvement• Modest increased screening rates• PCP most impacted• Data on resistance of other providers– Educational issue? NO– Ineffective notification? NO– Ease of ordering issue? NO– Result workflow? BINGO!

8

Result-o-phobiaThe irrational fear of looking stupid when an otherwise competent

professional does not know how to deal with a test result. e.g.:• Pediatric urologist sees patient for a circumcision, sees

alert and orders a mammogram for his patient’s mother• Result comes back “BIRADS 3, Borderline abnormal” • Pediatric urologist develops sweating and palpations when

he realized he has to contact what has inadvertently become “his patient!”

Mitigating Reluctance of non-PCP

The cure for Result-o-phobia• Ordering provider legally must get the test result

Ordering provider gets “Courtesy” copy• APN intercepts ALL results and is accountable for negative

study communication and follow-up• Communicates with Breast team non-negative• Breast team accountable for all subsequent care• Resistance is futile!

Mitigating Reluctance of non-PCP

• Resistance is now mitigated• Kaiser Permanente Hawaii in NCQA 2009– Highest breast CA screening rate (42 – 69)

~72% 85% in 2009– EHR can alert and facilitate– Incentives and accountability– Operations to support workflow based on sequential

evaluation of analytic data

Now we’re talking

Scenario #2 •Situation– County Hospital/Inner city trauma center– Poorly resourced, Resident run– Minimal Electronic systems (ED EMR)– “The best thing about standards is that there are so

many to choose from!”•Goal: To improve the quality of care– Optimize and Standardize disparate paper order

sets, leverage evidence and facilitate workflow•Recommendation: CPOE!...when we have $$$

12

Is there a stepping stone to CPOE?• Electronic Order EntryPaper Output– Increase the number of order sets–Minimize workflow change– Resource “light” implementation– Expedite creation and maintenance of order

set content– “Test drive” order sets to support future

enterprise EHR

13

• Electronic Order Entry with Paper Output– “Electronify” starter/current paper forms– Add “low impact” Clinical Decision support– Expedite creation and maintenance of

order set content– Expand functional and conditional order sets– “Test drive” order sets– Iterate!

Stepping stones to CPOE

Immediate Clinical Content Committee:Rapid cycle content management

ICCC Design

Deploy new Content

Order use analytics

User feedback

ICCC: Pharmacy HIM Quality Safety Informatics

Care quality improvement• Improved compliance with ordering of complete

insulin coverage• DVT prophylaxis compliance has increased from 50%

to 97%• Compliance with required orders– E.g. Admit, Code status, Telemetry criteria,

Resident/Attending/Service identification• 28% reduction in time from decision to admit to

creation of inpatient orders

16

Why it worked• Workflow tools at the Point-of-Care• Clinical Decision Support– Leading and guiding vs. Interrupting

• Minimal change to manage • Ordering analytics to support rapid, iterative

improvement cycles• Make the “Right” thing to do

the “Easy” thing to do

17

Taking it to the next level• Goal: Reduce Sepsis Deaths by 15%• Challenge to get baseline data– Bad data Denial, Anger, Bargaining

3/5 Kubler-Ross

• Challenge to impact process with bad data• Change Management a major problem• Need for standardized protocol and procedure for

physicians and nurses

Overcoming Barriers

• Multidisciplinary education • Standardized Protocol and

Procedures– Physicians and nurses– Sepsis education

• Paper based pilot

Sepsis the Highland WayYoutube video

Initial results promising but limited• Data evaluation and process iteration– Lactate not coming back quickly POCT testing– Antibiotic Delivery: Involve Pharmacy

Change Management: Making resistance futile– Paper to Electronic• ED order sets in EMR• Admission in SmartOrders

• Provider and nurse focus and education

Way better!• From 2009 to 2011 56% reduction in

sepsis mortality! But…–Bundle compliance still not close to 100%– Significant paper processes remained–Data collection was still a challenge–Change is hard, maintaining change is harder

Let’s implement an EHR!

• Mid-2012 through Early-2013 we implemented ambulatory and inpatient EHR

• Better order processing• Better decision support• Lots of distraction (Quality, Clinicians, IT)• Rule #2: Workflow is everything

(during Implementation)

Let’s optimize and EHR!• Don’t drown in data while thirsting for info– Too much data, not enough information– Too much distraction and too much change– Meaningful Use <> Using Meaningfully

Rule #5: Data impacting Workflow is really everything (Optimization) Identify and track key metrics Implement process improvements and iterate! Still in early phase

24

• It is NOT just the data or just the workflow!• Use good data to drive great change• Manage the change:– Make the change feel do-able: small bites– Try to pass the Champagne test– Make the “Right” thing to do the “Easy” thing to do

• Metrics are tools, not destinations. The process of Healthcare is just that, a process.

Success factors

26