The Information-Powered Health System

The Information-Powered Health System

Transforming Care Delivery with Data

Conflict of Interest Disclosure

David Katz, MD, JD

• Salary: Yes

• Royalty: NA

• Receipt of Intellectual Property Rights/Patent Holder: NA

• Consulting Fees (e.g., advisory boards): NA

• Fees for Non-CME Services Received Directly from a Commercial Interest or their Agents (e.g., speakers’ bureau): NA

• Contracted Research:NA

• Ownership Interest (stocks, stock options or other ownership interest excluding diversified mutual funds): Stock Holder

• Other: NA

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Health IT Takes Center Stage

Transforming Care Delivery with Data

Migrating to a New Business Model

Road Map for Discussion

• Meeting the Meaningful Use Mandate

• Building the Foundation for Analytics

• Delivering Information-Powered Care

1. Health IT Takes Center Stage

A Massive Infusion of “Obama Bucks”

Health IT Funding in Stimulus Bill Designed to Accelerate EHR Adoption

Source: American Reinvestment and Recovery Act, 2009; Innovations Center interviews and analysis.

Market Force #1 – The New Health IT Mandate

$34 B$2 B $36 B

Breakdown of Health IT Funding in 2009 HITECH Act1

Provider EHR Incentives

Office of the National Coordinator for Health IT

Total

Hospital Incentives

Physician Incentives

Health Information Exchange Grants

IT Support for Critical Access Facilities

1 Health Information Technology for Economic and Clinical Health Act.

Source: IT Insights interviews and analysis.

Health IT Only One Piece of the Larger Reform Agenda

Timing and Impact of Health Reform Proposals

Expanding Coverage

Market Force #2 – Payment Reform

Promoting Efficiency Reducing Demand

Time

Impact on

Provider Business

Employer Mandate

Individual Mandate

Reduced DSH Payments

PublicPlan

Bundled Payments

At-Risk Quality

Bonuses

Outcome-Based

Penalties

Episode-Based

Payments

Stimulus IT Incentives

Medical Homes

Comparative Effectiveness

Disease Management

Capitation

Source: Innovations Center interviews and analysis.

IT Backbone Essential to Transforming Care Delivery

Evolutionary Path of Payment Models

Pay for Performance

Episodic Bundling

Capitation/Shared Savings

Level of Clinical IT

Integration

Span of Accountability

Minimal

Extensive

Hospital Care Continuum

2. Transforming Care Delivery with Data

• Meeting the Meaningful Use Mandate

• Building the Foundation for Analytics

• Delivering Information-Powered Care



Hospital Performance

Elevating Care at the

Bedside

Reinforcing Core Clinical

Systems

Maximizing CPOE

Utilization

Exchanging Data Across the

Continuum

Time

Ensuring Data Quality

Upskilling the Analytics

Team

Supporting Chronic Care Management

PreventingDisease

Synthesizing Clinical Data

I. Meeting the Meaningful Use

Mandate

II. Building the Foundation for

Analytics

III. Delivering Information-

Powered Care


Unbundling the Mandates for Inpatient EHR Systems

Four Key Challenges to Achieving Meaningful Use Compliance

Meeting the Meaningful Use Mandate

II. Securing CPOE Adoption

III. Integrating Across the Continuum

IV. Connecting Patients to Providers

Installing the Full Suite of Inpatient Systems Looking Beyond Our Four Walls

I. Clearing the Hurdle for Core Clinical Systems

1 Certifying Commission for Health Information Technology. Source Innovations Center interviews and analysis.

Clearing the Hurdle for Core Clinical Systems

Looming Penalties Accelerating Replacement of Outmoded IT Systems

Common Concerns in Achieving Meaningful Use Compliance

Meaningful Use Mandate #1

Lacking Key Components Certification in Question Insufficient Legacy Systems

• Clinical system missing some or all ancillary systems

• Documentation system lacking, unable to interface with existing systems

• Central data repository not present or without interoperability functionalities

• Homegrown system functionalities insufficient to meet meaningful use

• Core system unable to gain CCHIT1 certification

• System architecture incompatible with needed components

• Legacy systems lack integration capabilities to aggregate data for reporting

• Older software lacking necessary functionality

• Vendor no longer supports upgrades, is out of business

Source: HIMSS Analytics EMR Adoption Model, August 2009; College of Health Information Management Executives, “Summary of CHIME Member Survey on Adoption of CPOE,” July 2009, available at www.cio-chime.org; Innovations Center interviews and analysis.

Securing CPOE Adoption

Percentage of Hospitals with CPOE in Place

Third Quarter 2009


Few Hospitals with CPOE, Even Fewer with Strong Utilization

11%

57%

8% 8%

27%

20% or Less Entered by Physicians

30% - 50% Entered by Physicians

60% - 80% Entered by Physicians

90+% Entered by Physicians

Percentage of Orders Entered by Physicians in Hospitals with CPOE

n = 199

1 Pseudonym. Source: Innovation Center interviews and analysis.

Hollop University Health System

Case in Brief

• Eight-hospital health system located in the Midwest

• Leadership identified conversion of care processes from paper to digital as a key challenge

• Added new staff, provided incentives for physician participation to address problems with conversion

Rethinking Traditional Staffing to Ensure Successful Adoption

Hospitals Leveraging Informaticists to Ease Transition to Digital Medicine

Key Components of CPOE Process Redesign Success at Hollop University Health System1

Hired Chief Medical Information Officer

Addition of physician executive builds credibility with physicians and other clinical leaders

Recruited Team of Informaticists

Informaticists serve as liaison between clinical, IT staff ensuring system compatibility with true care delivery process

Incented Physiciansto Actively Participate

Existing program providing compensation to clinicians who work on quality improvement expanded to include contribution to designing digital care pathways

1 2 3


Integrating Providers Across the Continuum


Value

Level of Integration

Provider Portal

Bi-directional Exchange

Fax Transmission

Medical records, diagnostic results faxed to providers

Physicians provided with read-only access to inpatient EHR

Patient health records updated in acute care and ambulatory settings

“An Antiquated Approach” “The Basic Option” “The Emerging Baseline”

Two-Way Data Flow the New Standard for Hospital-Physician Connectivity

Source: Howard, AJ, “The Hospital as the Network Hub,” Health Data Management, August 2008; Innovations Center interviews and analysis.

Building Virtual Integrated Networks

Array of Provider-Led Integration Initiatives

Health Systems Leveraging Integration Engines to Facilitate Data Exchange

1 University of Pittsburgh Medical Center.

42-hospital Catholic Healthcare West funding multiple regional integration initiatives

500-bed Hoag Memorial creating network with over 1,000 independent practices

Three-hospital Exempla Healthcare linking to ambulatory EHRs using Medicity Novo Grid

300-bed Silver Cross Hospital installed Mirth integration engine to integrate lab data for physician offices

20-hospital UPMC1

partnering with dbMotion to integrate clinic-based EHRs

Seven-hospital Spectrum Health using Medicity Novo Grid solution to connect with independent practices

1 Pseudonym. Source: Innovations Center interviews and analysis.

Milliways Regional Hospital

Case in Brief

• 2,500-bed hospital located in the Southwest

• Developed PHR in partnership with Microsoft HealthVault

• Piloted with cardiac surgery patients, ultimately to be offered to all hospital patients

Connecting Patients to Providers

Key Features of Milliways Regional Hospital1 Personal Health Record


EMR Driven

PHR is updated with information from the hospital’s EMR

Easy Portability

Patient can authorize access to record for any physician with access to HealthVault

Branding Value

PHR is accessed via hospital-branded website, building greater patient loyalty

Next-Generation PHRs Beginning to Emerge


Banking on Clinical IT to Elevate Performance

Maximizing Administrative Systems

Leveraging Clinical Information Systems

Impact on Performance

IT Sophistication

Supply Chain Management

Revenue Cycle Management

Staffing Productivity

Potential Performance

Gap




Elevating Care at the

Bedside


Systems

Maximizing CPOE

Utilization


Continuum

Time



Team

Supporting Chronic Care Management

PreventingDisease



Mandate


Analytics


Powered Care

Technical Hurdles Hindering Analysis

1 Clinical information systems.

Data not consistently documented, lack of standardized definitions

Data locked in disparate systems, unable to aggregate for analysis

Report generation technically challenging, limiting widespread adoption of analytics

Common Challenges to Developing a Robust Analytics Platform

Inconsistent Data Quality Siloed Information Systems Time-Consuming Reporting

ADTCIS1

Pharm Billing

ICU

Registration

Pharmacy

“Jon Smith”

“Jonathan Smith”

“Smith, Jon H.”

PENDING COMPLETE



Zellerbach Health System1

Case in Brief

• 400-bed hospital located in the Northeast

• Identified need for comprehensive data management strategy to improve

reliability and usefulness of clinical data

Build a Dedicated Data Management Infrastructure

Committees Tackle Nettlesome Data Quality Issues

Establishing the Data Quality Baseline

Metric Management Committee

Data Quality Committee

Systems Integration Committee

• Constructs data dictionary

• Defines enterprise metrics

• Supervises core measure workgroup

• Manages data extraction, transformation, and loading

• Supervises data warehouse workgroup

• Conducts data quality audits

• Evaluates structured documentation

• Supervises data stewards

• Ensures alignment of data management efforts

• Supervises data committees and workgroups

Enterprise Data Steering Committee

1 Clinical information systems. Source: Innovations Center interviews and analysis.

Divergent Approaches to Pooling Clinical Data

Aggregating Data for Meaningful Analysis

Enterprise Data Warehouse

Ancillaries ADT CIS1

Data Warehousing Strategy Data Mart Strategy

Diabetes Data Mart

Surgery Data Mart

PneumoniaData Mart

Central repository to support diverse analyses Discrete solutions to analyze specific questions

Ancillaries ADT CIS1

$70K -$295K

$190K -$560K

$450 K

$1.5 M

Technology Labor

Significant Cost Differential Between Approaches

Average 300-Bed Hospital

Data Infrastructure Costs Potential Drawbacks to Data Mart Strategy

Data Marts Data Warehouse

Data Mart the Low-Cost Option, but Not Without Limitations


Limits scope of analysis to data elements defined during development

Requires greater understanding of specific data elements needed for desired analysis

Fails to identify dependent relationships extending beyond the scope of the mart

Data Specificity

Analytical Scope

Pattern Recognition


Push Analytics to the Front Line

Success Dependent on Ensuring Accessible Information for Key Decision Makers

Normalizing the Data Creating Effective Analytical Tools

Source Systems

Data Repository

Role-Based Dashboards

Critical Alerts

Drill-Down Reports

Pre-programmed Queries

Expanding Data AccessTechnical Staff Clinical Leaders

Source: Cerner, available at http://www.cerner.com, accessed June 23, 2009; SAP, available at http://www.sap.com, accessed June 23, 2009; Innovations Center interviews and analysis.

No Shortage of Vendor Solutions

Representative Vendor Offerings

PowerInsightEnterprise data warehouse built on the Cerner Millennium data model that includes Web-based dashboards with enterprise-wide view of performance measures; includes 600 predefined performance measures across four topic areas: clinical, regulatory, operational, and financial

Compass ToolsWeb-based BI tools providing robust data collection, real-time decision support, advanced analytical capabilities, and dedicated advisor support; includes financial, operational, and clinical analytical solutions

Business Objects Integrated enterprise data warehouse platform that includes query, analysis, dashboard, and predictive analytics capabilities; provides performance management tools related to financial consolidation, spend analytics, and business planning


Organizational Hurdles Hindering Analytics

Common Challenges to Staffing the Analytics Effort

Widening Skills Gap

Lack of clinical expertise or background limits analytical sophistication of clinical data sources

Redundant Analytical Efforts

Lack of staff cooperation or integration results in redundant, potentially contradictory analyses

Unfocused Analytical Initiatives

Ad hoc analytical efforts limit impact, potential misalignment with strategic priorities

Staff Skills

MRSA Report

MRSA Report


Requiring More Advanced Analytical Expertise

Cultivating Internal Analytics Expertise

Health Informaticist Medical Informaticist Bioinformaticist

Role Intermediary between clinicians and IT team in development of clinical IT systems

Internal “developer” of analytic tools that improve the clinical decision-making process

Clinical expert wholeverages genetic data to improve disease detection and prevention

Background • Physician • Nurse• Computer programmer

• Physician • Nurse• Computer programmer

• Physician • Biostatistician

Training Master’s degree in clinical informatics

Master’s degree in clinical informatics

Master’s degree, PhD in bioinformatics

TypicalProjects

• Deploy EHR systems• Develop CPOE systems

• Build decision support tools

• Develop evidence-based care systems

• DNA sequencing• Genetic modeling

EBM

Implementation-Focused

Analytics-Focused

Range of Informatics Specialists


Kaiser Permanente Northwest

Case in Brief

• Integrated delivery system based in Portland, Oregon

• Developed robust skills training for analytical staff to foster internal development of advanced analytical talent

Taking Staff Competencies to the Next Level

Data and Information Management Enhancement (DIME) Program Overview

Walking in Their Shoes Elevating Communication Competencies

• Shadow physicians, business leaders for eight half days to better understand clinical operations across care continuum

• Identify how users interact with systems and analytical needs

• Participate in Toastmasters to improve communication and presentation skills

• Train with communications coach on conveying complex analyses and improving active listening skills to better understand, identify client needs


Upskilling the Analytics Team

Supplementing Baseline Analytical Skills with Advanced Training

Ongoing Analytics Training at Kaiser Permanente Northwest

Learn advanced business intelligence tools, simulation modeling

Attend doctoral courses in dynamic simulation modeling at local university

Develop annual individual development plan for ongoing skills advancement

Participate in professional societies, conferences; attend vendor-sponsored user summits

Individual

Development

Plan

Σ(x1 – μ)2

nk=1

n

Advanced Technical Training

Continuing Education

Professional Engagement

Ongoing Development

Clinical Informatics

Quality Improvement


Haas Health1

Case in Brief

• Five-hospital health system located in the West

• Reorganized departments to reduce duplication and leverage synergies

• between staff to enhance performance improvement efforts

Overcoming Organizational Silos

Clinical Improvement Department

Consolidating Clinical Improvement Expertise

Provide advanced analytical services for entire system

Deliver quality improvement education sessions to staff

CNO CIO COO

Performance Acceleration

Previous Organizational Model Reorganized Department Structure

Serve as internal consultants on process improvement, Lean redesign


Creating a One-Stop Clinical Improvement Shop

Benefits of an Integrated Model

Performance Acceleration Staff

Clinical Informaticists

Acting as the Single Source of Truth for Data

• Consistent data collection, analysis methodology ensures data reliability, validity

• Specialized informaticists ensure high-quality analysis

Increasing Impact of Analytical Initiatives

• Adept staff able to quickly translate findings into actionable improvement

• Continual monitoring, refinement of process ensures sustained gains

Quality Improvement Staff




Treating Disease


Systems

Maximizing CPOE

Utilization


Continuum

Time



Team

Managing Disease

PreventingDisease



Mandate


Analytics


Powered Care

1 Ventilator-associated pneumonia.

Source: Starmer J, et al., “A Real-Time Ventilator Management Dashboard: Toward Hardwiring Compliance with Evidence-based Guidelines,” American Medical Informatics Association Annual Symposium Proceedings Archive, 2008; Innovations Center interviews and analysis.

Vanderbilt Medical CenterCase in Brief

• 600-bed academic medical center located in Nashville, Tennessee

• Developed automated electronic dashboard to display real-time patient status for compliance with evidence-based ventilator management bundle

Combating Pneumonia with Analytics

Vanderbilt Developing Next-Generation Treatment Algorithms

EHR

Pulls data from nurse documentation, CPOE, and respiratory therapy systems into EHR

Displays overdue treatments in color-coded dashboard on ICU computer screensaver and EHR

VAP Bundle

vs.

Identifies gaps in documented care against recommended VAP1 management bundle

Automated Algorithms Data Aggregation Staff Alerts

Ms.Wu

Treating Disease

1 Urinary tract infections.

Source: Govern P, “ICU Teams Drastically Reduce Vent-Related Pneumonia Rates,” Reporter, February 13, 2009; Innovations Center interviews and analysis.

Automating Best Practice Yields Impressive Results

October 2007 – August 2008

VAP Dashboard Pilot Results

VAP Rate Reduction

($1.9 - $3.5 M)

Estimated Cost Reduction

Next Areas of Focus at Vanderbilt

(41%)

Patient Falls

Pressure UlcersBlood Stream

Infections

Catheter Associated UTIs1

1 Pseudonym.

2 Practice management system. Source: Innovations Center interviews and analysis.

Bowles Health Information Exhange

Case in Brief

• Not-for-profit health information exchange located in the East

• Leverages claims data mining software to generate customized disease dashboards for participating physicians, enhance outreach to chronically-ill patients

Supporting the Front Lines of Care

Health Information Exchange Supports Analytical Platform for Care Management

Managing Disease

• Disease registry to manage chronically ill population

• Treatment alerts to maximize patient visits

• Quality reporting tools to identify opportunities for improvement

Proactive Patient Outreach

• Notifications to remind overdue, non-compliant patients

• Patient education, self-management tools to increase compliance

• Health coaching to reinforce care plan

Care Management Decision Support

PMS2 EHR Lab eRX

Bowles Health Information Exchange1

Source: Dallas-Fort Worth Hospital Council; Innovations Center interviews and analysis.

Dallas Fort-Worth Regional Enterprise Master Patient Index

Project in Brief

• First-of-its-kind regional patient index created by the Dallas-Fort Worth Hospital Council Education and Research Foundation using QuadraMed software

• Facilitates tracking of readmissions patterns, ED utilization, and other service utilization by specific patients across 75 hospitals in the North Texas region

Pinpointing Gaps in the Chronic Care Continuum

Data Mining Tool Facilitates Tracking of Chronically Ill Patients

Regional Master Patient Index

Member Hospitals Data Mining Infrastructure Sample Reports

ED Utilization Report

Readmissions Report

Chronic Care Continuum Gap Assessment

Claims Database

Source: Oregon Center for Aging and Technology (ORCATECH), available at www.orcatech.org, accessed August 11, 2009; Kaye J, “Technology and the Aging Brain: New Approaches to Understanding Change,” ORCATECH; Innovations Center interviews and analysis.

Oregon Center for Aging and Technology (ORCATECH)

Case in Brief

• Part of the Oregon Health & Sciences University located in Portland, Oregon

• Established in 2004 to provide an infrastructure for developing technologies to support independent aging

• Partners with senior living communities to provide living laboratories for testing home-care technologies

Next-Generation Remote Monitoring

Sensors capture variations in mobility

Hallway sensors monitor gait and mobility

Computer kiosk assesses cognitive function

Wiring the Patient Home to Continuously Monitor Patient Health

1 For example, potential dementia or Alzheimer’s disease.

2 Research funded by National Institute on Aging grants AG024978, AG024059, AG008017.

Source: ORCATECH, “Algorithms for Long-Term Change,” available http://www.orcatech.org, accessed August 11, 2009; Innovations Center interviews and analysis.

Detecting the Subtle Signs of Cognitive Decline

• ORCATECH research funded by National Institute on Aging and Intel Corporation2

• Leveraging longitudinal data generated by home-based seniors to detect early onset of dementia, Alzheimer's disease

Study in Brief

Sleep Patterns

Computer Use

Medication Adherence

Daily Mobility

Long-Term Change Algorithm

Indications of Normal Aging

Early Warning Signs

Evidence of Cognitive Decline1

Collecting Data on Daily Routines Analyzing the Data to Assess Risk

1 Core measure manager.

Source: Niemi K, et al., “Implementation and Evaluation of Electronic Clinical Decision Support for Compliance with Pneumonia and Heart Failure Quality Indicators,” American Journal of Health-System Pharmacy, 2006 (66) 4: 389-397; Innovations Center interviews and analysis.

Sutter Medical Center, Sacramento

Case in Brief

• 306-bed hospital located in Sacramento, California

• Developed Core Measure Manager (CMM) to identify at-risk pneumonia patients

Unearthing Latent Risks with Predictive Modeling

CMM1 Identifies At-Risk Patients in (Near) Real-Time

Preventing Disease

Automated algorithm pulls patient data to generate list of those at risk for pneumonia

CMM validates findings by querying pharmacy to check if appropriate medications dispensed

If proper care outstanding, alert sent to pharmacy, nursing unit to assess patient

CMMRx

CMM

ADTRad

Lab Rx

Elderly patient admitted for hip fracture

Patient Admission Risk Assessment System Verification Clinical Alert


Tolman Health System

Case in Brief

• Five-hospital health system located in the Midwest

• Partnering with public health agency, community organizations on wide-scale cardiovascular disease prevention initiative for a local community

Seeking to Eradicate Heart Disease

Tolman Health1 Leverages EHR for Community-Wide CV Prevention Effort

Primary/Secondary Prevention Efforts

Medical History

Genetic Information

Remote Monitoring Data

Generating the health profile of a community…

Weight Management Classes

CT Angiography

Advanced Diagnostics

Calcium Scoring

Medication Management

…to improve targeting of interventions

3. Migrating to a New Business Model

Shouldering the Cost, Sharing the Benefits

Source: Walker J, “The Value of Health Care Information Exchange and Interoperability,” Health Affairs, January 19, 2005; Innovations Center interviews and analysis.

Distribution of Ongoing IT Costs by Stakeholder Distribution of Net Benefits by Stakeholder

3%Payers and Other

Stakeholders

97%

39% 61%

Health Care Providers

Payers and Other Stakeholders

Health Care Providers

1 Health risk assessments.

2 Clinical information systems. Source: Innovations Center interviews and analysis.

Clarian Healthy Results

Case in Brief

• Separate subsidiary within Clarian Health, an integrated delivery network based in Indianapolis, Indiana

• Developed corporate employee wellness division based on the data-driven success of own internal wellness program

Striking into the Insurer’s Domain

Wellness Services Distinguished by Robust Analytical Foundation

Continuously Refining Risk Stratification

Claims Pharm

HRAs1 CIS2

Differentiating on Data-Driven Approach

Electronic care management system

Proprietary algorithms for medication management Σ (x1 – μ)2

n

k=1

n

Data mining infrastructure, predictive modeling software

Data Mart

Leveraging IT to Develop New Product Lines


Delivering ROI to Employers

Clarian’s Healthy Results Division Reining in Employee Health Costs

Medical Claims Expense Growth

Healthy Results Contracting Success

4

4,500

13

30,000

Total Contracts Covered Lives

2008 2009

8.0%

6.1%

Pre-Contract Year One

Total Contracts and Covered Lives

Representative Client Results


Sproul Health Network1

Case in Brief

• Three-hospital health system located in the Midwest

• Demonstrated success in using health IT for population health management

• Supporting system efforts to transform business model and negotiate capitated contracts

Making the Case for a Capitated Contract

Pursuing Risk-Based Contracting

Chronic Disease Management System

Health IT Assets Hospitalizations per 1,000Diabetic Patients

370

2005 2007

315Remote Monitoring, Telehealth

Physician Performance Monitoring

Health System Highlights IT-Driven Care Management Capabilities


Realizing the Clinical and Strategic Value of IT

Point of Care Decision Support

Integrated Information

Exchange

Advanced Analytics

Patient-Provider Connectivity

Impact on Care Delivery

IT Investment

The Information-Powered Health System

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