Our way to measure ROI: The Marina Salud Cerner...

Our way to measure ROI: The Marina Salud–Cerner Experience

Juan Manuel Lacalle Martínez IT Development Manager

Oslo, 31st of October 2013

1. Introducing Denia’s Health Department

2. ROI study fundamentals

3. ROI samples

4. Conclusions

INDEX

• Population: More than 150,000 residents (Health department is financed mainly per capita)

• Tourism: From March to October

• Municipality: 34 towns [ Dènia: approximately 40,000 – Vall d’Alcalà: around 200 ]

• Total area : 297 square miles (759 km²) • Population density: 635 people per square mile (245 hab/km²)

• Geography: Complex orography. Numerous mountains, valleys and hilly coast

Denia’s Health Department (I) GEOGRAPHICAL SCOPE

RED ASISTENCIAL MARINA SALUD

• 1 Hospital • 2 Integrated Health Centers (Specialized care) • 32 Primary Care Centers (Managed in 11 Basic areas)

Department of Health. Dénia. OPERATIONAL SCOPE

Department of Health. Dénia. OPERATIONAL SCOPE (II)

Public Service Private Managed

Administrative concession granted for 15 years

Direct supervision via AVS commissioner

Service improvement investment

Marina Salud builds the new Hospital

Marina Salud builds a new CSI in Calpe

Marina Salud builds a new CSI in Denia

Integration of professionals

Public Health Integrated Management

Health Department’s integrated Management (both Primary Care and Specialized Care working together)

There was a previous Hospital (100 % managed by regional

government; all employees depended from AVS HR Resources

policy as civil servants and locum)

At the time Civil servants (28%) and private employees (72 %)



3. ROI samples

4. Conclusions

INDEX

1. IT Strategy

• “Simplifed” Information systems map

• Benefits-measure-oriented

2. Hospital Information System scope

• Full support for HealthCare processes (Collaboration, Guidance, Continuity of care)

• EMR & Data driven (HIMSS Level 6 and 7)

3. Clear Change management strategy

• IT organization & service rules (three levels)

4. Clear Change management workflow

• Incident Management (Call center)

• Change Management (Clinical Transformation Office)

5. Representative users engaged & committed

• Results based agreement

• Clinical adoption leadership

• Transversal vision in change management

6. Clear and public rules to manage change

• Public priorization criteria (patient, professional, company)

Example: IT structure for CERNER MILLENNIUM support (VIII) – Clinical Transformation Overview

Department of Health. Dénia. 1. IT Strategy

Denia’s Health Department (VII) – CERNER MILLENNIUM’s implantation scope

MEDICAL

SURGICAL

HOSPITALIZATION

INTENSIVE CARE

AMBULATORY

CONSULTATION

MEDICAL DAY UNIT

AMBULATORY

HEALTHCARE

SURGICAL DAY

CENTERHOME CARE

OUTPATIENT

PHARMACY

HOSPITAL

EMERGENCIES

EMERGENCY

INPATIENT

PHARMACY

IMAGING AND

RADIOLOGY

BIOLOGICAL

DIAGNOSIS

BLOOD BANK

PRYMARY CARE

EMERGENCIES

HOME CARE

EMERGENCIES

DIAGNOSTIC

PROCEDURES AND

TREATMENTS

REHABILITATION

STERILIZATION

PREVENTIVE

MEDICINECLINICAL

DOCUMENTATION

SOCIAL WORKPRE-ADMISSION

ARRANGEMENTS &

APPOINTMENTS

URGENT

SURGERY

MAJOR

HOSPITALIZATION

SURGERY

SURGERY

MAJOR

AMBULATORY

SURGERY

MINOR

AMBULATORY

SURGERY

OBSTETRICS

ADMISSION

SECOND LEVEL CARE SERVICES (SUPPORT SERVICES - ALL SCOPES)

FIRST LEVEL CARE SERVICES BY SCOPE


Denia’s Health Department (VII) – CERNER MILLENNIUM’s implantation scope

MEDICAL

SURGICAL

HOSPITALIZATION

INTENSIVE CARE

AMBULATORY

CONSULTATION

MEDICAL DAY UNIT

AMBULATORY

HEALTHCARE

SURGICAL DAY

CENTERHOME CARE

OUTPATIENT

PHARMACY

HOSPITAL

EMERGENCIES

EMERGENCY

INPATIENT

PHARMACY

IMAGING AND

RADIOLOGY

BIOLOGICAL

DIAGNOSIS

BLOOD BANK

PRYMARY CARE

EMERGENCIES

HOME CARE

EMERGENCIES

DIAGNOSTIC

PROCEDURES AND

TREATMENTS

REHABILITATION

STERILIZATION

PREVENTIVE

MEDICINECLINICAL

DOCUMENTATION

SOCIAL WORKPRE-ADMISSION

ARRANGEMENTS &

APPOINTMENTS

URGENT

SURGERY

MAJOR

HOSPITALIZATION

SURGERY

SURGERY

MAJOR

AMBULATORY

SURGERY

MINOR

AMBULATORY

SURGERY

OBSTETRICS

ADMISSION

SECOND LEVEL CARE SERVICES (SUPPORT SERVICES - ALL SCOPES)

FIRST LEVEL CARE SERVICES BY SCOPE

Exception! (Primary Care Ambulatory Consultation)

CERNER MILLENNIUM


Incident Management vs Change Management

• All users can register incidents or queries, but not all users may request changes

• Change management requires communication between peers

Three-level-based structure:

Level 1 – Direct End User support

• Help users in the use of the system

Level 2 – System Evolution & Clinical Transformation

• Adaptation management & implementation

Level 3 – Solution provider support management (SRs)

• Specialised support management (SLAs).

High Management

Committee;

Clinical Record

Committee

Middle management

End users

Incidents

Querys

DIRECCIÓN DE SISTEMAS Y TECNOLOGÍAS DE LA INFORMACIÓN

USERS

Change

Requests

Search for known solution

Escalation

User conformity management

Problem management

Progress report

Communication

Requirement management

Analysis

Design

Implementation

System Test

User Aceptance Test

Implantation (go live)

CommunicationReception

Classification

Knowledge management

Analysis of impact

Prioritization

User Request

Management

CHANGE

MANAGEMENT

INCIDENT

MANAGEMENT

Example: IT structure for CERNER MILLENNIUM support (III) – Basics 3. Clear change management Strategy

Example: IT structure for CERNER MILLENNIUM support (V) – Operational Functioning

High Management

Committee;

Clinical Record

Committee

Middle Management

End Users

C

A

L

L

C

E

N

T

E

R

CHANGE REQUEST

INCIDETN

QUERY

CHANGE

REQUEST

2º Nivel

Level 1

Level 3

Technology Providers


USERS

COMMUNICATION

SOLUTION GO LIVE

COMMUNICATION

SOLUTION GO LIVE

APPLICATION

DEVELOPMENT

AREA

C

T

O

CHANGE REQUEST

THIRD PARTY

ESCALATION

PCP/

PCU

SUPPORT AREA

(HELP DESK)

INCIDENT

QUERY

4. Clear change management workflow

Managed by Vicent Moncho (CIO)

Coordinated by Dra. Ms. Elisa Teodoro (Obstetrics and Gynecology)

Dr. Mr. José Chordá (Internal Medicine)

Dr. Mr. José Mut (Pediatrics)

Dr. Mr. Angel Mauri (Emergency)

Dra. Ms. María José Mulet (Primary Care)

Dr. Ms. María José Martínez (Biological Diagnosis)

Dr. Mr. Jaime Poquet (Pharmacy)

Ms. Ms. Carmen Bohigues (Nurse coordinator)

Ms. Ms. Rosario Ivars (Nurse supervisor)

Ms. Francisca Atiénzar (IT Manager)

Mr. Juan Manuel Lacalle (IT Manager)

Contract agreement signed with IT Department

CLINICAL TRANSFORMATION OFFICE

Example: IT structure for CERNER MILLENNIUM support (VII) – Clinical Transformation 5. Representative users engaged & committed

Change Request Reception Phase

• Classify

• Prioritise

• Development order fullfilment

• Reply (Feedback)

Development planning review

• Design decision support

• User acceptance test (UAT)

Go live support Phase

• Go live plan validation

• Communication validation

Example: IT structure for CERNER MILLENNIUM support (VIII) – Clinical Transformation

INCIDENT

RECEPTION

PROCESS

INCIDENT MANAGEMENT PROCESS

PROBLEM

MANAGEMENT

PROCESS

CHANGE REQUEST

RECEPTION

PROCESS

CHANGE

REQUEST

ESPECIFICATION

PROCESS

CHANGE

REQUEST

PLANNING

PROCESS

GO LIVE

PROCESS

PLANNED DEVELOPMENT

PROCESS

(65 % fte)

UNPLANNED DEVELOPMENT

PROCESS

(35% fte)

CHANGE

REQUEST

EVALUATION

PROCESS

APPLICATIONS SUPPORT. INCIDENT & CHANGE MANAGEMENT PROCESS

High Management

Committee;

Clinical Record

Committee

Middle Management

End Users

C

A

L

L

C

E

N

T

E

R

CHANGE REQUEST

INCIDETN

QUERY

CHANGE

REQUEST

2º Nivel

Level 1

Level 3

Technology Providers


USERS

COMMUNICATION

SOLUTION GO LIVE

COMMUNICATION

SOLUTION GO LIVE

APPLICATION

DEVELOPMENT

AREA

C

T

O

CHANGE REQUEST

THIRD PARTY

ESCALATION

PCP/

PCU

SUPPORT AREA

(HELP DESK)

INCIDENT

QUERY

6. Clear and public rules to manage change



3. ROI samples

4. Conclusions

INDEX

First Sepsis algorithm implementation in Spain. – No other hospital has been able to implement such

a complex process

Nurse satisfaction 95%. – Nurses are more than 50% of the organization.

– Annual cost turnover of nurses could cost at least 1.7M

Triage time improved to 9.2 min. Medium ED LOS 6.48 hrs

37.2% of physicians modified

their CPOE thanks to Multum:

Meds Adverse Events Each MAE cost arounds 3000

euros

Preoperative blood reserve

Circuit early diagnosis of cervical cancer

Automatic shipping of discharge reports to primary care

Implementation of the rule for

early detection of infection with sepsis

Reduction of CXR applications in preoperative protocols

Facts SAMPLES

It has allowed to assimilate the increase of work without increasing the staff or reducing quality

It facilitates the incorporation of new providers

• The system itself guides the new providers

• It improves the quality and safety of care

Circle of quality: measuring is first

• 'Now we know what we do and how we do it'

• There is an apparent effect of decrease in quality: now we document more and better, and detect incidents that were not previously recorded.

Reduced variability in nursing practice

• Wound care plans: 100% of patients

• Forms: documentation

Reduction of the time dedicated to documentation and tasks of little added value

• Medications: requisitions and fills

• Diets: requisitions

FirstNet Tracking Board (ED)

• Allows to know the patient workload and severity in real time

Records related to quality

• Falls

• Pressure ulcers

• Urinary tract infections

Some pending to measure:

Benefit Contents Millennium Contribution Impact Amount Hours/year FTE Discharge report

All discharged patients have a nurse discharge report

50% of the report's content is generated automatically

5 Minutes per report

11,728 977.33 0.56

Integration Continuity of care between departments

Single database per patient

15 Minutes per discharge

11,728 2,932.00 1.69

Total 2.26

Some difficult to measure:

NURSING: EXAMPLES OF QUANTIFIABLE BENEFITS

Single database • Continuity of care for post-resuscitation patients

• Vital signs can be contextualized in the hospital, requiring less interconsultations

Requests (referrals) with structured clinical information • Demand management support

Implementation of process guides in the orders Integration of the prescription with Gaia

• Avoiding a visit to Primary Care Remote home connection for providers on-call remotely

• Minimum response time • Reduced physical presence time

Process-oriented management

• Solutions help to define them

Reduced variability in clinical practice

Facilitates coordination of care between levels

Remote visits

• Anesthesia: pre-ops

• Neurology, checks

• Cardiology,

• Endocrinology


Benefit Contents Millennium

Contribution Impact Amount Cases Hours /year FTE

Remote visits Interconsultations and remote follow-up visits. %5 of following ones .

Structured clinical information available anywhere, at any time. Protocols integrated in the system.

10 Time per visit reduced from 15 to 5 minutes

116,562 5,828 971 0.56

Documentation Continuity of care between areas.

Single database per patient.

10 Minutes per discharge

11,728 1,955 1.13

Documentation Operating Room Integration of monitoring devices

7 Minutes per major surgery

8,608 1,004 0.58

Total 2.27


PHYSICIANS: EXAMPLES OF QUANTIFIABLE BENEFITS

Coding: Discharge and minor surgery

Scanning and document integration

• 100,000 documents per year

• 50% consents

• Non-integrated results, documents from other hospitals

Integral documentation control

• Batch index (ECG, Cardiotocography, Urodynamics)

Patient and third-party requests

• 4,000 per year


Benefit Contents Millennium

Contribution Impact Amount Hours/year FTE Electronic Medical Record The medical record is not

paper-based Cerner Millennium is the EMR

4 Minutes per movement (discharges, consultations, and minor surgery)

193,718 12,914.53 7.47

Coding Availability of all electronic clinical information

Cerner Millennium is the EMR

5 Minutes per major and minor surgery

14,994 1,249.50 0.72

Discharge report Discharge report is sent automatically to the Primary Care Physician

Message Center 5 Minutes per report 6,824 568.67 0.33

Total 8.19

Requests for passive archive

• When requested, they are digitized and incorporated into Millennium


CLINICAL DOCUMENTATION: EXAMPLES OF QUANTIFIABLY BENEFITS

Preference cards

• Costs per process

Stock reduced by 35%

• €500,000

Financial cost reduced by 34%

• 15,000 x 5 years = €65,000

Auto verification • 24-hour pharmacist is not required

• 4 pharmacists

RIS-PACS

• Avoids physical support

• 116,872 x €2.5/study x 5 years = €1,460,900

Tx X-ray rule

• Avoids pre-operative X-rays in patients under 60

years of age without pathologies that require them

• Effect on costs

• Effect on queue management

Blood bank

• Multi-phase plan for pre-operative

• Cancellations due to lack of blood have

decreased

• Time between order and surgery has

decreased

Cervical cancer

• Alert in case of alarming result

• Reduced gynecologist visit time

• Automated sending of letters in case of

normal results

Time X-rays

avoided Cost (euros) Total (euros)

84 days 112 12.02 €1,346.24

1 year 988 12.02 €11,875.76

5 years 4,942 12.02 €59,402.84 €

MORE SAMPLES…

Availability to schedule from any part of the Department (not only the hospital)

• The patient can make an appointment from any location, avoiding travel time

Centralized request system

• High specialization is not required for scheduling appointments

• Simplifies the management of human resources: Higher efficiency due to higher versatility

Allows providers to schedule appointments

Allows establishing complex scheduling processes, making several people responsible

• Multi-phase PowerPlans

• In multi-appointments various people can schedule appointments (by area) without requiring a specialization in this type of complex appointments:

Agenda Structuring

• Spaces according to priority

• Schedule care structures, not people (i.e.: spine disease agenda, not Dr. C)

Clinical information related to the appointment

Feedback in real time allows to react quickly in the event of incidents

Saves time and travelling for users

• Versatility and flexibility when assigning personnel

Improved demand management:

• Prioritization according to clinical criteria

• Simplifies the referral request by Primary Care

Does not require 24-hour hospitalization admission

• Admission for emergency surgery by the surgeon himself.

Simplifies complex appointment scheduling

Medical transport management

Third-party referral management

Fast detection and reaction in the event of problems

• Reduced OR cancellations

AND MORE…



3. ROI samples

4. Conclusions

INDEX

Cerner Millennium’s implementation project (2007-2009)

• We are using the same MILLENNIUM version since 2009

• When we opened the hospital in 2009 many users, especially physicians, had a bad opinion about the design of the system, they weren’t confident in the tool

The Clinical Transformation Office (2010)

• When users get involved in “driving” the system with the Clinical Transformation Office they checked that the tool should be used to help them to do their job better applying a crossover vision to workflows

• When this “inflection point” was achieved, this implied from the organization perspective that some processes were improved

HIMSS Level 7 (2011-2012)

• This was not a direct target for our company, but it was achieved as a consequence of this change in our ways of working

Process improvement and ROI (2012 and so on)

• Currently is the basis for the CTO’s internal philosophy and prioritization

• We can work this way because we can measure

• We can measure because we have the tools and the criteria to do that from the patient perspective, from the professional perspective and from the company perspective

Same company, same tool, same people…, different organization, different culture, …, different results

Conclusions (our experience)

Conclusions (our experience)

“Marina Salud chose the Cerner Millennium® solutions because of their ability to provide clinicians with the information needed to improve patient care on all care venues in the healthcare network: at the hospital, at the health centres and at home. This innovative approach to healthcare services overcomes traditional limitations such as data duplicity and information inconsistencies; as well as to serve as a healthcare model to all of Spain.”

Dr. Luis Fidel Campoy Domene

Councilman Delegate

HIMSS level 7 award ceremony in Copenhagen 2012

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