1

Improving Care and Generating ROI: A Davies StorySession 95, March 6, 2018

Anupam Goel, MD, VP Clinical Information, Advocate Health Care

Angela Diop, ND, CHCIO, VP of Information Systems, Unity Health Care

Andrew Robie, MD, Chief Medical Information Officer, Unity Health Care

Organization logo(s) may be placed on this slide

2

Anupam Goel, MD MBA

Angela Duncan Diop, ND, CHCIO

Andrew Robie, MD

Have no real or apparent conflicts of interest to report.

Conflict of Interest

3

AgendaTranscription costs (Advocate Health Care)

• Technology and behavior change

• Workflow considerations

• Results

• Next steps

Leveraging health IT to improve care of hypertensive patients (Unity Health Care)

• Change management

• How Health IT was used

• Results

• Lessons learned

4

Learning Objectives• Describe the financial and workflow considerations when migrating

from a telephone transcription to voice-to-text physician documentation model

• Apply metrics to help track expected financial savings when migrating from one physician documentation model to another

• Formulate a comprehensive approach that engages, staff and patients to significantly improve blood pressure control in a patient population

• Identify the components of a change management system that will help you repeatedly deliver meaningful and lasting organizational change to support your quality initiatives

5

Using Technology to Address Transcription Costs

6

Technology and behavior change• Facilitating factor: innovation benefits

• Limiting factors: design, technical concerns, familiarity with technology, time

Gagnon et al. Systematic Review of Factors

Influencing the Adoption of Information and

Communication Technologies by Healthcare

Professionals, J Med Sys 2012. 36:241-77.

7

Environment and context• iPhone adoption among independent provider community

• Improvements in voice recognition technology

• EMRs and clinician burnout

8

https://www.ncbi.nlm.nih.gov/pmc/articles/P

MC3889939/pdf/11606_2013_Article_2597.

pdf

9

Workflow considerations• Operative reports

• H&Ps, consults

• Progress notes

• Discharge summaries

10

11

12

Stopped progress

note telephone

transcription at most

sites

13

Results• We ended 2015 with $2.24 M transcription spend (over 50%

reduction from January’s annualized estimates)

• In August 2017, we were on track for annual spend of $1.8 M

14

Key lessons• Engage senior clinical and financial leadership early

• Identify clinical champions to create testimonials

• Work with site leaders and demonstrate the technology with opportunities for users to try it out

• Provide feedback reports regularly to target users who might benefit

• When the majority of users have made the switch, institute a hard stop to force the technology adoption

15

Next steps• Voice recognition to natural language processing

• Prompting users before document signature

– Missing data elements (compliance)

– Suggested diagnoses (clinical pathways)

– Suggested treatments (real-time decision support)

16

Federally Qualified Health Center

District of Columbia

Over 106,000 patients and 500,000

visits each year

Promoting healthier communities through compassion and

comprehensive health and human services,

regardless of ability to pay.

Unity Health Care

17

HIMSS Davies Application Team• Catherine Anderton, Associate Director for Quality Improvement and Research

• Angela Diop, VP of Information Systems

• Marcia Hinkle, Assistant Director Social Services: Behavioral Health

• Cherie Jones, Information Systems Manager

• Andrew Robie, Chief Medical Information Officer

18

Unity Sites and Services

Sites

10 Community Health Centers

10 Medical Sites in Homeless

Shelters

2 School-Based Health Centers

Homeless Outreach and

Mobile Van

Health Services in DC Jail

Services

•Primary care and specialty care

•Dental care

•Behavioral health care

•Care to people experiencing

homelessness, HIV, returning

citizens, Title X

19

Change Management

Robust system

of change

management

helps to

develop and

adopt well

thought-out

changes in an

organized

manner.

From Unity’s change management Guidelines for

Electronic Health Records ~2016

20

EHR Governance Teams

20

Stakeholders

• Approve major changes to EHR and workflows and assign resources needed for change.

Implementation Team

• Track issues and changes to resolution. Assign to teams for solution. Implement and communicate changes.

EHR Support Team

• Manage ongoing maintenance, upgrades and implementations and interface with EHR vendor.

Joint Training Team

• Develop EHR and PM training. Train staff.

Reports Team

• Develop reports.

Optimization Team

• Manage major configuration and content changes to EHR.

21

Our Approach

Develop Workflows

Modify EHR

Train Staff

Change

22

Workflow Development

Groups Developing the Workflows• QI Department• QI Working Groups• Optimization Team

In collaboration with Health Information Technology Team (HIT) and Reports Team.

23

Disseminating Change

Change is developed

Working Groups develop training

Multi-disciplinary team-based training is conducted

Measure ResultsTraining is reinforced CHANGE!

24

Hypertension Case Study

25

Chronic Hypertension Major Cause of Heart Disease

*National Vital Statistics Report – June 30, 2016

0

50

100

150

200

250

DC US

Mortality from Heart Disease/100,000 Deaths*

Heart Disease

remains the No.

1 cause of death

in the US. ~American Heart Association

26

Unity’s Patients and Hypertension

• Our number one diagnosis

• >20,000 hypertensive patients annually

• Affects >20% of our adult patients

27

Hypertension Goal

• Increase the percentage of patients with hypertension whose blood pressure is controlled

• Baseline December 2013: 54% of patients diagnosed with hypertension were considered controlled with a blood pressure reading less than 140/90

28

How Health IT Was Used

29

EHR Modifications/Set-up

• Alerts

– Reset BP alert to turn red at 140/90

– Alerts for medication-allergy and medication-medication interaction were enabled

– The EHR automates formulary checks helping providers reduce barriers to medication adherence

140/90

30

EHR Modifications/Set-up

• Clinical Decision Support for Providers

– Hypertension progress note based on JNC-8

– Structured preventive medicine documentation populates visit summary with patient education and goals

31

EHR Modification/Set-up

• Created a new visit type, “Nurse BP Follow-Up Visit”

• EHR template supports clinically comprehensive visit, nurse decision points on referral back to provider, patient education, and correct documentation, including coding

• Preventive medicine section in nurse visit documentation reiterates goal BP

32

Measuring Progress

• Reports were generated from the EHR

• Progress was reported to health center leadership at QI meetings

Increases in repeat BPs up to 60%

33

Team Training

• Staff trained in teams

– Review of HTN

– Workflows

– Proper measurement

– Documenting follow-up

• Training was recorded, placed on learning management system

• Compliance with training was tracked

34

Engaged Staff

• Healthy Competition

• Created the Heart of Gold award (HOG)

Columbia Road Health Services, first winner of

the Heart of Gold Award

35

Engaged Patients

• Follow-up patients within 30 days when BP not at goal

• Easy for them to make a Nurse Visit appointment for repeat BP check

• Automated reminder calls

• Shared goals with patients

• Preventive medicine section provided in the visit summary

• QI posters at the sites

36

Value Derived

37

Results

48%

50%

52%

54%

56%

58%

60%

62%

64%

66%

2013 2014 2015 2016

Controlled Hypertension <140/90

Blood pressure control improved by 9.3 percentage points

38

ROI

Hard ROI

• $415,000 due to increased revenue from hypertension nurse visits

Soft ROI

• Increased access because of nurse visits

• Increased provider satisfaction

• Expansion of the role of medical assistants and nurses

• Growth/expansion in team based care resulting in more efficiency

0

1000

2000

3000

4000

HTN Nurse Visits

Number of Visits

2013

2014

2015

2016

39

Lessons Learned

• We can significantly impact HTN control (improving 5-10%) by using multidisciplinary teams throughout all phases of the project

• Don’t just plan training; also plan how to reinforce it

• Think broadly about which team members will be affected by the changes. Often change impacts people on the team that seem to have nothing to do with the project

40

Questions

• Please complete online session evaluation

Contact information

Anupam Goel MD, Advocate Health

•anupam.goel@advocatehealth.com

•@anupam1623

•LinkedIn: goelanupam

Angela Duncan Diop, ND, CHICIO

• adiop@unityhealthcare.org

• @AngelaDiop

• LinkedIn: AngelaDiop

Andrew Robie, MD

• arobie@unityhealthcare.org

• LinkedIn: AndrewRobieMD

• www.unityhealthcare.org

• @UnityHealthCare

41

Thank youwww.unityhealthcare.org

@UnityHealthCare