MEASURING THE BENEFITS OF HEALTH IT SYSTEMS NOT SO EASY, BUT POSSIBLE

Juan Luis Cruz – CIO Hospital Puerta de Hierro

Madrid - Spain

jlcruz@idiphim.org

@jotaelecruz

INDEX

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1. What we have done 2. ROI: not so easy… 3. But possible! 4. Final thoughts

1. What we have done Hospital Puerta de Hierro in brief

• General public hospital since 1964: 50 anniversary

• Pioneer integrating patient care, education and investigation in Spain

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• High complexity hospital. New location, building and ICT in 2008

• EMRAM Stage 6. Working hard to achieve stage 7

1. What we have done Hospital Puerta de Hierro in brief – some ciphers

• Population: 550.000 habitants

• About 3.000 health personnel

• 165.000 m2

• 613 hospitalization beds, 22 Operating Rooms

• Activity (per year):

– 550.000 external consultations

– 150.000 emergencies

– 26.000 inpatient admissions

– 17.000 surgeries

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1. What we have done Hospital Puerta de Hierro in brief – some IT ciphers

• About 3.000 IT users • About 20.000 service desk contacts / year • + 2.000 PCs • + 110 software applications • + 90 servers • + 120 LAN switches in 36 distribution rooms • +170 WiFi 802.11n Access Points • +80 7’’ Android Tablets, +50 Ruggerized PDAs • +150 Other mobile devices (BYOD) • +500 actual mobile users

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1. What we have done many eHealth projects

Well, but… what about ROI?

2. ROI: not so easy a “simple” definition

• Return = net profit:

end value (outcomes, gain) – investment >0

• ROI: return on investment (%):

(Return / Investment) × 100 >0

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Investment = 100

Outcomes (gain) = 200

2. ROI: not so easy a “simple” definition

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ROI

2. ROI: not so easy some aspects to consider (gain)

1. Hard vs. Soft ROI.

– IT caused directly a quantifiable gain? Hard ROI

– Or is it just correlated with some kind of gain? Soft ROI

– Often we have a soft ROI: IT isn’t a lonely factor, but goes in hand with aspects like better awareness, motivation, staff training or process redesign.

– So… What part of the gain is due to our IT project?

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2. ROI: not so easy some aspects to consider (gain)

2. Economic vs. Clinical & Organizational

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Arthur L. Kellermann, Spencer S. Jones. What It Will Take To Achieve The As-Yet-Unfulfilled Promises Of Health Information Technology. Health Affairs, 2013; 32 (1): 63-68 DOI: 10.1377/hlthaff.2012.0693 Howley MJ, Chou EY, Hansen N, Dalrymple PW. The long-term financial impact of electronic health record implementation. J Am Med Inform Assoc. 2014 Aug 27. pii: amiajnl-2014-002686. doi: 10.1136/amiajnl-2014-002686. [Epub ahead of print]

http://www.nytimes.com/2013/01/11/business/electronic-records-systems-have-not-reduced-health-costs-report-says.html

The conversion to electronic health records has failed to produce the hoped-for savings

in health care costs

2. ROI: not so easy some aspects to consider (gain)

2. Economic vs. Clinical & Organizational

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http://blog.himss.org/2012/09/21/roi-in-health-it-is-more-than-just-the-pricetag/

“the traditional definition of ROI as used in other industries isn’t necessarily a good fit for the healthcare industry; successfully demonstrating ROI in healthcare involves more than simply looking at how much money is saved or earned.”

“HIMSS recommends that health providers use the following areas to evaluate ROI: • Efficiency Savings • Improved outcomes of care compared to pre-health IT implementation • Additional revenue generated as the result of an IT implementation • Non-financial gains such as, but not limited to, increased patient satisfaction

with care encounters, decreased provider time at work, and higher levels of employee satisfaction

• Increased knowledge of providers about the patient population they serve.”

2. ROI: not so easy some aspects to consider (cost)

1. What part of the investment should we consider in a

corporate development (serving many centres)?

2. Should you account all the preexistent infrastructure and common services as investment in every ROI analysis of future IT projects based on them?

3. What’s the investment time period to consider for calculating costs and gains?

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2. ROI: not so easy

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Oh my… Just another year without budget…

2. ROI: not so easy Don’t give up. A broader view on ROI

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We shouldn’t avoid talking about ROI even though we don’t have always hard economic case studies.

eHealth ROI is often a soft/non-economic ROI (and that’s ok).

Soft/non-economic ROI also demonstrates the utility of HIT projects and could be key for investment decisions.

So don’t give up and document those (success) stories!

3. But possible! Some examples

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• Next: some examples of real valuable experiences in our Hospital

• Description, IT subject, investments & outcomes

• For each example degree (subjective) of:

– Hard vs. soft ROI

– Economical vs. non-economical outcomes

• Investment, outcomes… return & ROI wherever possible

3. But possible! - Week Hospital

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Description Grouping inpatients that have diagnostics with average stay < 5 in the same hospitalization ward, so it can be closed on the weekend.

IT subjects: BI - Analytics

Investments 160 man-hours for implementing the project (6.400 €) BI platform (preexisting)

Outcomes Cost savings in nurses & assistants contracts not working in weekends. Better clinical outcomes: nurses specialization in short stay cares (expected, not yet measured).

Investments: 6.400 €

Return: 247.400 eur / year

ROI (1st year): 3766 %

Hard Soft

Discharge before weekend

€ Non €

3. But possible! - Remote consultations from PC

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Description Sharing EMR between Primary Care (PC) and Hospital and doing TLC (remote consultations without the patient) so GP can ask for advice to the specialist instead of making regular appointments.

IT subjects: HIE

Investments 120 man-hours for starting the project (4.800 €) TLC development (4.000 €) EMR platform shared btw PC-Hospital (preexisting)

Outcomes 3.200 remote consultations PC-Hospital / year. Regular consultations & Time saved for the patient

Investments: 8.800 €

Outcomes (some examples):

• Sleep apnea: 427 1st visits, 23.485 patient-days saved

• Hematology: 426 IM 1st visits, 43.026 patient-days saved

• Sciatica & v.disc prolapse: 224 TRA 1st visits, 10.976 patient-

days saved ROI: ¿? Hard Soft

€ Non €

GP H

Regularappointment

Remote TLC

3. But possible! - SMS appointment reminder

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Return (1st year): 17.424 € ROI (1st year): 50 %

Return (5 years): 138.231 €

ROI (5 years): 113 %

5,2

5,4

5,6

5,8

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6,2

6,4

6,6

6,8

7

7,2

2011 2012 2013

- 1,08%

Description Activating a SMS appointment reminder system (in late 2011) for 40% of all possible appointments.

IT subjects: mHealth

Investments 80 man-hours for starting the project (3.200 €) SMS development (9.600 €) SMS sending (20.000 €/year) Corporate SMS platform (preexisting)

Outcomes Less consultations missed (5.400 in 1st year) Doctors hours not lost (1.350 in 1st year)

% missed consultations

Hard Soft

€ Non €

3. But possible! - Radiology and Pathology alerts

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Investments: 35.200 € Outcomes (1,5 years):

• 1073 alerts generated

• 105 early appointments

• 2.765 patient-days with malignant disease saved

ROI: ¿?

Description Manual activating an alert in the EMR in case of unexpected malingnant outcomes in radiological or pathological tests, so as the referring physician can be informed and can bring forward the appointment if necessary.

IT subjects: CDSS, HIE

Investments 120 man-hours for managing the project (4.800 €) Alerts + integration corporate development (30.400 €) EMR, Radiology & Pathology systems (preexisting)

Outcomes About 10% of 1073 alerts generated so far caused an early appointment (26 days saved on average).

Hard Soft

€ Non €

3. But possible! - Alerts in ePrescribing

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Investments: 46.400 € Outcomes (1st year):

• 384 prescription changes due to alerts.

• 19 potential allergic reactions avoided

ROI: ¿?

Description Firing alerts to physicians prescribing medication related to patient allergies, interactions, duplications or maximum dosage reached.

IT subjects: CDSS

Investments 160 man-hours for defining alerts (6.400 €) Alerts corporate development (40.000 €) EMR with ePrescribing, Pharmacy systems (preexisting)

Outcomes More than 54.000 alerts/year (>500K prescriptions). 384 presciption changes due to alerts.

0

5000

10000

15000

20000

25000

30000

35000

0,00%

2,00%

4,00%

6,00%

8,00%

10,00%

12,00%

14,00%

16,00%

Maximum dosage

Allergies Active ingredient duplicity

Medication duplicity

Interactions

ePrescribing alerts performance (1st year)

% Alerts modifying prescription No. Alerts fired

Hard Soft

€ Non €

3. But possible! - Secure blood products admin.

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Investments (5 years): 121.300 Outcomes (5 years):

• 1 life saved

• 10 severe reactions avoided, 50 inpatient-days saved

ROI: ¿?

Description New blood transfusion protocol, training for 800 nurses & a mobile system for triple verification (extraction, blood bank, administration). 1/10 errors causes a death.

IT subjects: CLMA, CDSS, mHealth

Investments 220 man-hours for starting up & training (8.800 €) Cost of consumables per year (includes equipment) for 7.500 prescriptions/year (22.500 €) WiFi infrastructure (preexisting)

Outcomes 3 errors avoided in first 6 months. 6 potential administration errors avoided / year.

Hard Soft

€ Non €

4. Final thoughts

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4. Final thoughts

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ROI is a tool for investment decision support of C-suite (CEO, CFO, CIO, …).

So let us adapt ROI for what they need to decide. Their decisions are not only based on economic parameters, but on patient safety, clinical

outcomes, satisfaction of patients and professionals… or just fame and prestige.

Health IT systems often offer non-economic and soft outcomes (acting as a catalyst for the organization), but very valuable.

Interesting ROI & outcomes can be achieved with small improvements upon existing IT infrastructure.

4. Final thoughts

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When IT aims to patient safety, demonstrating a ROI becomes less critical.

ROI is important, but it’s more important to be committed to demonstrate the usefulness of Health IT.

Sometimes just knowing the outcomes is enough for demonstrating utility and taking a decision. Invest time to document it to help others.

It's not so easy ... but possible!

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14 Noviembre 2014 ¡Únete a la Comunidad!

Juan Luis Cruz CIO Hospital Puerta de Hierro juanluis.cruz@salud.madrid.org @jotaelecruz