Urgent CareIntegrating point of care service into a longitudinal health system

Rob Rohatsch, MD, CEO, Banner Urgent Care / Occupational Health ServicesDana Kosmala-Runkle, MD, Sr. Director, Medical Informatics

William Holland, MD, VP Care Management and CMIO

Banner at a Glance

Our Mission:Making healthcare easier, so life can be better.

Our Strategy:

Local ProblemHow does Banner Health fully integrate Urgent Care into its health system to drive increased

accessibility and coordination of care delivery?

Historically, Banner has not been in the urgent care business. The landscape in the healthcare industry is changing rapidly. Over the last several years, Banner has been transforming from a hospital company to a health integration company. Banner recognizes that in order to be successful, we must have a laser focus on a consumer-centric strategy. Now more than ever, personal household economics are driving how patients make their healthcare decisions. The link between quality healthcare and cost containment has been well studied. In order to fully operationalize strategy around this concept, Banner recognizes the need for increased accessibility into the system. A robust urgent care platform addresses these two critical legs of the triple aim “chair.” The third support leg is the patient experience, an area where Banner has always placed emphasis. Well-run urgent care centers can provide care to an estimated 25-75 percent of patients seen in the emergency department. Here is the rub: They can do it for 20 percent of the cost. When those numbers are coupled with a consumer experience driven by short wait times and delivering the “wow” factor, it becomes a powerful value proposition in a competitive market.

“…cost containment…the need for increased accessibility into the system. A

robust urgent care platform addresses these two critical legs of the triple aim

“chair.” The third leg is the patient experience….”

Value Proposition of Urgent CareAccess

• Create additional

primary care access

points (leakage

prevention)

• Provide lower cost

setting for non-

emergent care

• Decant unnecessary

ED utilization

Market Share

• Grow footprint in

markets

• Lower-cost entry

point (new patient

capture)

• Brand awareness

and/or recognition

PopulationHealth

• Treat patients with

chronic health issues

to reduce ED use

• Refer patients back to

their PCP

• Capture unassigned

patients who need

episodic care

On-Demand Care

Primary Care

Specialists

Diagnostics

Outpatient

Hospitals

CLICK-IN WALK-IN CALL-IN

Email | Retail | Skype | Urgent Care centers | Real-time appts

High MarginLow Volume

Low MarginHigh Volume

Customer-first Centric Delivery Model

Banner’s Urgent Care Strategy – On Demand Medicine

• Healthcare environment changes• Volume to value-based care

• Population health

• Consumer-focused• Right level of care at the right time/place

• Patients with no primary doctor

• In-network referral

Phoenix

Colorado

Tucson / Casa Grande

BUCS Payor Mix

Design and Implementation

Best of Breed vs. Full Integration

“No one has been able to do this using a big box EHR solution—ever….ever.”

Efficiency vs. Integration

Best of Breed Integrated EHR

Benefits• Created specifically for

Urgent Care workflows• Available out of the box

• Longitudinal record• We already own it

Challenges• No integration with clinics,

EDs, hospitals • Cost

• No urgent care model• Short timeline to create• “Competing priorities”

We had to do something to stop the papercuts…Nine page paper chartTwo page demographic

form at check-inPaper discharge instructions

Efficiency vs. IntegrationDiscussions kept coming back to Efficiency vs. Integration

• But does it have to be either/or?• Could we have both Efficiency AND

Integration?

Operational Requirements/Industry Standards

• Keep total LOS under 60 minutes• Keep provider documentation to less than

two minutes• Keep it simple

Data Driven Decisions

Design Decisions• Registration—what to use and how soon?

• Tracking Board vs Ambulatory Organizer vs LaunchPoint?

• Provider Documentation: Dynamic Doc vs. PowerNote?

• Workflows?

• Cerner user positions?

• Encounter types?

• How would we handle results?

• Longitudinal record?

Could We Build an Urgent Care Model?

• Minimal vendor recommendations for Urgent Care • Short time frame to implement final product• Used engineering principles to build foundation (~80%)• Once foundation is established, take to operational and/or

clinical team for final detailed decisions• “It’s easier to edit than to create”

Provider Visit Workflows

MA / Nurse Intake to Depart Workflows

Initial “Governance”• Rapid Timeline• Full Day Design Sessions with

Stakeholders• CEO and CMO of Banner Urgent Care

Services• Operational Leaders• Informatics (Physician, Nursing, Pharmacy)• IT• Cerner consultants

• Workflow decisions, clinical content, registration, orders, documentation, radiology, lab, disposition, …

Urgent Care CCG created January 17th, 2017

ED

Pulmonary

Palliative Care

NICU/Newborn

Neurosciences

Critical Care

Behavioral Health

Anesthesia

Pediatrics

Women’s Health

Post Acute Care

Medical Imaging

Primary Care

Hospital Medicine

Cardiology

Surgery

Pharmacy & Therapeutics

Infectious Disease

CV Surgery

Oncology

Ortho

Clinical Leadership

Team

Program management

CCGs and Clinical Practice

Development

InformaticsClinical & Medical

Professionals assist with

design & build

Quality

CPAClinical

Performance Analytics

Clinical Education

Process EngineeringClinicians and

Engineers assist with Design

Purpose: Define expected clinical practices for Banner Health based on best available evidence, including practice-based evidence.

Urgent Care

“Engineering” New Models

• Research practices

• Reach consensus on requirements

Define

• Describe reliable workflow and roles

• Develop tools

Design• Communicate

and train• Address issues• Monitor

Implement

Six Month Initial Rollout39 clinics fully integrated EHR with Banner Health

• 11/01/16 Banner Urgent Care Services becomes official• 01/01/17 Banner Urgent Care Providers become Banner employees• 02/07/17 Cerner Practice Management implemented • 04/18/17 Cerner PowerChart EHR implemented in 39 UC Facilities

Support Model: 39 Urgent Cares BIG Bang• Day 1-4: Command Center

– Issue resolution – Enhancement requests– Physician Informatics– Nursing Informatics – IT– Support team

• Day 1 and 2: 1 Banner or Cerner trainer at the elbow• Day 3 and 4: 1 trainer for 2 sites• Day 5: Transition to Operations and to Service Desk

Post Go-Live: Longitudinal Record

Comprehensive patient data

– Medication history

– Procedures

– Labs and radiology, etc.

Keys to Success

• Stakeholder engagement

• Commitment to timeline and scope

• Prior process standardization

• Two days onsite at the elbow support

• Transition to call center for support

Value Derived

Length of Stay by Provider• Keep total LOS under

60 minutes

• Keep provider documentation to less than two minutes

• Keep it simple0

10

20

30

40

50

60

70

80

90

100

AVG

LOS

(MIN

)

INDIVIDUAL PROVIDERSJUNE 2018

60 minute target

Length of Stay and Patients Seen

On average for all Urgent Care providers there has been 2.54 minutes decrease in time spent in the patient’s chart

Time Savings of 19.8%

Providers in all Banner Urgent Cares saved, on average each month, 81.5 days of charting time from May 2017 to April 2018

Actual Time Per Patient

Banner Health Goal: Documentation Time per Patient under 2 minutes for all Urgent Care providers

Documentation Time Per Patient

$4.50M cost savings by reducing provider time

Other Technologies DeployedEnhanced Customer Experience

0%

5%

10%

15%

20%

25%

Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18

Utilization of Clockwise12 month Online Patient Trend

YTD Data Trend on LOS & NPS

56

51

48

4341 40

60.2%58.9%

65.5%

71.3% 70.4%73.3%

35

40

45

50

55

60

65

70

75

80

Jan Feb Mar Apr May Jun

Min

utes

NPS vs LOS for BUCS YTD

LOS (min) NPS (%)

AVERAGE NPS BY INDUSTRY LEADER

73

76

78

55

33

28

21

* - Source: Satmetrix U.S. Consumer 2017 Benchmarks at a Glance

NPS/Performers by Industry*

Left Without Treatment (LWOT) Rate2.21%

2.05%

1.51%

0.92%0.79%

0.91%0.79%

1.13%

1.31%

0

10,000

20,000

30,000

40,000

50,000

60,000

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

May June July August September October November December January

Volume % LWOT

ED Transfer Rate • Streamline transfers

– Provider to Provider communication

– Pre-arrival forms completed in Cerner

– BHTS when needed to identify specialists

– Longitudinal record supports ED communications

2.55% 2.48%2.32%

2.06%

1.62%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

September October November December January

Financial Accomplishments: Text Messaging Approach

48% of patients who paid from text messages did so on the day they got the text thru the patient portal.

Ongoing Integration: Technology and Specialty

BUCS & OHS BrainScope• 19 cases to date• EEG results• BFI results

EKG Real Time Results• EKG reads within

15 min• 4 HVN groups

Cardiology Consults• 15 Min TOT• Reduced ED

XFers• Downstream

referrals

Ortho Consults• BMG ortho• Shared PACS• Nov. 2018

Banner Urgent Care Timeline

NOV 1st

Banner Urgent Care Services is an Official Banner Health Service Line

NOV 1st

Zotec Implemented for Revenue Cycle/Billing

AUG SEP OCT NOV DEC JAN FEB MAR APR MAY2018

NOV DEC JAN FEB MAR APR MAY JUN JULOCT

JAN 17th

Urgent Care Clinical Consensus Group (CCG)

2017

JAN 1st

Urgent Care Providers are now Banner Employed Providers

MAR 9th

Real-Time Radiology Reads in Phoenix Clinics)

MAR 3rd

CPM ImplementationAPR 18th

Cerner Implementation in 39 Banner Urgent Care Clinics

JUN 20th

Clockwise MD Go-Live

AUG 1st

Casa Grande Acquirement

AUG 1st

Real-Time Radiology Reads in Tucson Clinics

NOV 17th

BrainScopeJAN 1st

Colorado Expansion

JAN 1st

Official Positions created for Provider Leaders and Site Coordinators

MAY 1st

Oncology Urgent Care Clinic

MAY 1st

Pediatric Urgent Care Clinics

Thank You