Creating One Patient, One Record, One System

Duke Medicine embarked on a historic project in September to implement a single,

fully integrated electronic health record (EHR) across the health system that will forever change the way we care for patients, conduct research, and train the next generation of medical learners. The project, named Maestro Care, will require coordinated, concerted efforts from every part of the organization to implement.

The need for the seamless Maestro Care EHR developed over many years as a result of an overwhelming number of clinical applica-tions used across the health system, the majority of which do not work together. Currently providers and other clinicians must interact with up to 135 different systems to provide care for patients.

“Maestro Care will consolidate all the information we need to care for our patients into one seamless system, truly helping Duke Medicine meet the strategically important goal of establishing ‘one patient, one record, one system,’” said Jeffrey Ferranti, M.D., M.S. chief medical information officer for Duke Medicine.

The current applications operate around an ancient infrastructure, which requires extensive work and money to keep the framework

functioning. Once Maestro Care is implemented across the entire health system, every point of care – from scheduling an appointment, to examinations, to the pharmacy, to billing – will be on one integrated system.

Whether a Duke patient is seen at a primary care practice, an urgent care center, a specialty clinic, or as an inpatient in one of Duke’s three hospitals, all the information that clinicians need and want will be there and available to them in one system.

For many physicians and providers a typical day involves seeing a full slate of patients and updating paper charts along the way. At the end of the day most providers are left with a stack of notes to be dictated.

“Remembering all the details discussed in an interview and examination is difficult at the end of the day when I am ready to dictate,” said Louis Diehl, M.D., an oncologist in hematology and clinical director for the cancer treatment center. “With Maestro Care, I am going to walk out of the exam room with my thoughts com-plete, my notes completed and in a recoverable

see CReating One Patient, One ReCORd, One SyStem, p.2

VOLUME 20 NO. 8 n inside.dukemedicine.org n October 2011

Caring for our patients, their loved ones, and each other.excellence n safety n integrity n diversity n teamwork

Why maestro Care?A well-chosen name can express the meaning of a big idea

by cutting through the complexity and getting to the heart of the matter.

Enter Maestro Care, a special name for an important part of the future of Duke Medicine.

As conductor of an orchestra, a maestro has the job of making sure the various sounds of the instruments blend harmoniously into a cohesive, effective piece of music.

In the same spirit, the name Maestro Care was selected for our electronic health record (EHR) project after careful consideration of many options and a thorough discussion of how the EHR fits into our organization’s long-term strategy.

Some of you previously may have heard the project referred to as Epic. Epic is the name of the highly regarded Verona, Wis.-based company with which Duke has part-nered to deploy our system-wide EHR.

As a tool that is being tailored to the unique Duke character, the Epic EHR deserved a name that expresses the significance of the project to our organization.

Maestro Care resonates with important concepts such as coordination, integration, collaboration, orchestration and excellence. Importantly, the name also was selected because it is in keeping with our DUHS core value – “Caring for our patients, their loved ones, and each other” – and our values of teamwork and excellence.

Each of these qualities aligns with approaches that will be foundational to the health system’s next five-year strategic plan.

In the same way that a musical maestro blends the many into the one, Maestro Care will orchestrate effective, integrated solutions to our many clinical or organizational needs, creating a single EHR with benefits beyond anything DUHS has had before.

The Maestro Care logo symbolizes the goal of produc-ing an EHR result that far exceeds the sum of individual efforts and functions, while also representing the fact that its success will require meaningful contributions from all parts of Duke Medicine.

It communicates that Maestro Care is more than a mere computer software installation, but a powerful organizational concept of greater integration and teamwork supported by a computerized tool. n

Inside Duke Medicine2 October 2011

Last month, various

communication vehicles an-nounced a set of consolidated values for the health system that define what

is important to us as an organization and will serve as a compass for organizational decision-making and behaviors.

It’s no accident that a project of the magnitude, and organizational significance, of Maestro Care is perfectly in line with the core health system value of “Caring for our patients, their loved ones, and each

other.” In fact, the health system values and the Maestro Care project together form the foundation for the implementation of several major organizational projects, and a new five-year strategic plan for the health system.

“Everything we do moving for-ward has to be aligned to optimally care for our patients and, in this case, also reflect our commitment to our supporting values of excellence, teamwork and safety,” said William J. Fulkerson, Jr., MD, executive vice president for DUHS. “It’s gratifying to see how we are beginning to make the connection between our organiza-tional direction and commitment and our values.” n

At first glance, it might seem easy to assume that creation

of a health system-wide electronic health record (EHR) system is just another upgrade from Duke Health Technology Solutions (DHTS).

Nothing could be further from the truth. The reality is that adoption of the Maestro Care platform is a strategic institutional initiative that will revolutionize Duke Medicine and tie it together like never before.

Success will require the focused energies of every employee and every part of Duke Medicine. The timeline calls for implementing Maestro Care in less than three years at three hospitals, across a primary care network of more than two dozen loca-tions in seven counties, and within all of Duke’s renowned specialty clinics, as well as in their associated patient services and business functions.

“Maestro Care is enormously important for the entire health system moving forward and will be crucial to our ability to deliver the best in patient-focused care and improve our efficiency,” said Chancellor Victor J. Dzau, M.D., president and CEO of Duke University Health System. “To successfully launch Maestro Care within the compressed deadlines we have set for ourselves will require

sustained, concerted teamwork from all of us.”

Such teamwork already is oc-curring. Nurses, physician faculty, physician assistants and the entire range of health care professionals who helped select Maestro Care are working in a system of teams – un-precedented in scope and breadth at Duke – to bring this critical tool to life across Duke Medicine.

The implementation effort doesn’t stop with those providing direct patient care. It is a priority for every-one – from employees who schedule appointments, register patients and process patient health information and billing to corporate communications, facilities management and various support services.

“This is a historic, transformative moment for Duke Medicine,” said Art Glasgow, chief information officer for Duke Medicine. “Maestro Care fits squarely into our broader IT strategy of giving our providers the tools they need to make the best decisions with the best information available. The information Maestro Care collects will allow us to learn from patients how to improve their care and to deepen our insight into the health needs of the communities we serve.”

Maestro Care is the right tool at

the right time, said Ann Lore, assistant vice president for health system innovation planning.

“It is an excellent platform and will form the foundation of many of our organizational strategies moving forward,” Lore said. “These are transformational times, not only at Duke, but in the American healthcare industry.”

Moving forward, the health system is focused on three broad strat-egies, she said: redesigning our care to improve quality and reduce costs, growing our programs of distinction and overall network, and engaging our

federal, state and commercial payers as partners in these efforts.

Successfully launching Maestro Care depends on each of us and is vitally important to all of us, Dzau said.

“Maestro Care will take us much closer to our vision of one Duke Medicine,” Dzau said. “It provides us with the necessary tool to help us shift our thinking and practices, to move from old models that placed emphasis on the volume of procedures to new models that will increasingly empha-size the value that our encounters with patients provide.” n

•   Decisions will be based on doing what is best for DUHS as a whole – not a single facility, department  or service line

•   Decisions will be made with appropriate representation of clinicians, disciplines and facilities

•   �Clinical content and data will be standardized at the organizational level; processes will be standardized

•   The design will adhere to the Epic Model System

•   The design must improve coordination and communication of patient care across the continuum

Guiding PrinciplesMaestro Care

more than just an it solution

A transformative tool to help us meet the future’s challenges

form. My workday will be complete when I see my last patient.”

Maestro Care isn’t just for physi-cians and clinicians, though. It will also meet needs for front-line staff, who struggle as well with multiple ap-plications. Currently, staff record vital signs on paper and then enter them into the computer later. With the new system they will be able to record them in the computer in real-time, reducing the risk of transcription errors.

“Having this complete picture of a patient throughout the health system will allow the nurse, the pharmacist, the surgeon, the provider and so on to access all the information they

need from the same record and allow everyone to see each other’s informa-tion,” said Paul Martin, M.D., Ph.D., chief of the Division of Pediatric Blood and Marrow Transplantation.

The system will be implemented first across all ambulatory clinics beginning in July 2012 with all Duke Primary Care sites. By July 2013, all ambulatory clinics will be live with the new EHR. Next, Maestro Care will be launched at Duke University Hospital and across the revenue cycle in July 2013. Implementation will occur at Duke Raleigh Hospital in February 2014 and Durham Regional Hospital in July 2014. n

CReating One Patient, One ReCORd, One SyStem, continued

FulkeRSOn

maestro Care Reinforces Core duHS Value

Inside Duke MedicineOctober 2011 3

The Maestro Care electronic health record (EHR) system will work its

magic by using one simple computer icon to replace scores of computer and paper systems clinicians now use to document patient visits.

But none of the many significant functions Maestro Care performs will be more important than its ability to further enhance the patient care delivered by Duke Medicine providers by putting patient information at the fingertips of physicians and other care team members.

“This is Maestro Care’s greatest benefit,” said Dean Miner, M.D., a pediatrician and physician champion for the ambulatory portion of the Maestro Care project. “Having all that information, in a preferred format, updated in almost real-time, will mean better information for clinicians at the point of care.”

Now, care team members confront the challenges presented by first learn-ing, and then choosing from, as many as 135 different computer and paper systems to document patient visits, see medical imaging, e-prescribe, bill or view a patient’s history.

The consolidation and standard-ization provided by Maestro Care will enable every provider to see – in one place – a patient’s complete medical history at Duke. For patients, it means no longer having to answer the same background questions, or undergo redundant tests, at a Duke clinic or hospital or at each Duke provider they visit.

“Having all the information on one system will definitely allow me to provide better patient care because all of the information will be avail-able to me in one place,” said Lisa Nadler, M.D., a Duke Primary Care provider and physician champion for the ambulatory project. “The triggers on the Maestro Care computer screen that we have seen in the system demonstrations will help providers ask more specific questions.”

Maestro Care also means less uncertainty, more accuracy and fewer chances for errors.

A provider will know, for ex-ample, the last blood pressure reading taken for a patient anywhere in the Duke Medicine system. A primary care physician will have access to complete records of a patient’s recent hospitalization, all viewable in the same application that stores that

physician’s own records and notes about the patient. Such continuity of information is particularly important during hand-offs, when a patient’s care is transferred from one provider to another.

Maestro Care will also support clinical decision-making by automatically displaying the most recent and relevant evidence-based care suggestions as the provider enters patient information – for example – by telling the provider which patients need flu shots or if a diabetic patient still needs a foot exam.

“It’s very hard to work in the number of systems that we have currently,” said endocrinologist Susan Spratt, M.D., who is also a physician champion for the ambulatory project. “If you don’t have access to a particular system or data because someone else has access, patient care can be compromised. I will also be able to search and see how the diabetes care I provide compares with other physi-cians in the area, allowing me to think

about population management, not just individual patient management.”

Teams of physician and nursing champions are helping providers become the driving force in the transition to Maestro Care in the

ambulatory and inpatient settings. “The deployment of Maestro Care

is being actively guided by people who are providers themselves and who understand the challenges of a busy patient schedule,” Miner said. n

3

Maestro Care

Providers will realize many care support improvements

kimberley evans, m.d., who is a physician champion for the ambulatory portion of the maestro Care project, works on a care plan with patient donnell Holman. maestro Care will integrate all parts of patient encounters in a single, seamless electronic system.

B asis for a data foundation that will support health analytics and predictive modeling

E vidence-based, context-specific decision support for providers

N ew level of efficiency in patient management and provider workflow

E ngagement of patients in their own care through secured patient portals and personal health records

F lexible documentation options (prescription, diagnosis or encounter type-specific templates; free text typing; etc.)

I ntegration of documentation, billing, e-prescribing and ordering processes, as well as integration of inpatient and ambulatory patient encounters

T ransformational advances in improving patient safety, quality of care and service-value creation through centralized data capture

S ingle-view health record that captures all patient encounters within the health system and, potentially, at entities external to Duke

Maestro Care

BeneFitS for providers

Inside Duke Medicine4 October 2011

ApplicAtion MAnAger

Craig Varney

project MAnAger

Shannon Jones

technology Director

Pete Woods

trAiners

Cathy Emens Lisa Powell, RN Larry West, RN

clinicAl liAisons

Suzanne Inskip Heather Morton

clinicAl AnAlysts

Stacey Brown Becky Casp-Cheek Dawn Cannon Natalie Combs Nicole Gardner Patti Gorgone Kim Harshberger Effie Hondos Mandy Love Karen Luse Oak Miller Tuyet Pham Cynthia Tinsley Dustin Williams

clinicAl phArMAcist

Andrea L. Long, PharmD

cAche

Manish Lall Michelle Pham

interfAce

Melanie McIndoo Shirley Rufty Judy Whitesell

DAtA AnAlyst

Jeff Saville

clArity

Mark Sminkey

systeM ADMinistrAtor

Charles Harris

AmbulAtory Team

maestro Care Ambulatory Core team

AmbulAtory PhysiCiAn ChAmPions

Carole AkerlyJanet Apter, RNJohn Anderson, M.D.Leslie BardAlex BarkerTammy BerryTammy ClayMegan Clowse, M.D. Collin CooperMichael DeCoskeDaniel Dore, PT, DPT, MPAJoey GiattinoSteve Hetey

Johnetta James, RN, MSNJane LattaElizabeth LongKathryn Lytle, RN, MSNLindsay MacdiarmadaJosef McQuainClay Musser, M.D.Mark PhillipsLori Postal, RNCErin PrattMatthew Roman, PT, OMPTChris SamplesAngie Santiago

Colleen ShannonDoug StokkeFabian StoneMarie StoneJennifer Swanson, M.D.Debbie SykesCarey UngerMary Vinson, RN-BCCecil WallaceBarbara WoolleyDiana Zambrano

maestro Care Ambulatory WorkgroupIn addition to the physician champions and core team for the ambulatory project, a large, diverse team of physicians, nurses and other healthcare professionals from DPC, PDC and HBC were recruited and are contributing their time and talent to ensure the EHR clinical content and workflows are optimally configured.

The Maestro Care Ambulatory project team has been working hard since the spring, focused on preparing for implementing the integrated electronic health record (EHR) across all ambulatory clinics at Duke Medicine. Implementations will begin in July 2012 with all Duke Primary Care sites, and will be completed in July 2013, when all ambulatory clinics will be live with the new EHR.The 30-member core team was recruited primarily from Duke University Health System and many of the members have clinical backgrounds. The team received certification from Epic Systems, the vendor from whom the EHR system was purchased, which required classroom education, indepen-dent project work and multiple certification exams.

After receiving certification, the team, along with the physician champions, engaged providers and clinicians throughout the health system to understand their current workflows. The discoveries the team is making will help them design how the EHR will work in ambulatory settings. The team also participated in a series of sessions with operational leaders, nurses, physicians and other health care professionals throughout the health system to review and select specific design choices for our EHR. That process continues, and the team will begin building the system later this month.

Kimberley Evans, M.D.

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Kelly Marcom, M.D. Dean Miner, M.D. Lisa Nadler, M.D. Susan Spratt, M.D.

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JeFF FeRRanti, m.d.

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ted PaPPaS, m.d.

The governance structure for making clear and timely decisions for the project includes an EHR steering committee composed of health system, PDC and hospital leadership, that meets regularly to vote on key decisions identified by the core clinical teams.

Meet The People Working To Bring Maestro Care To Life

John Anderson, M.D.

Janet Apter, RN

Paul Bush

Rajesh Dash, M.D.

Louis Diehl, M.D.

Bill Gable

Rick Ganotta

Chuck Hodges, M.D.

Robert Lineberger, M.D.

Paul Martin, M.D.

Cecelia Moore

Holly Muir, M.D.

Steve Olson, M.D.

Vicky Orto, RN

Tom Owens, M.D.

Lisa Pickett, M.D.

Bill Richardson, M.D.

Chris Roth, M.D.

Bimal Shah, M.D.

Debra Sudan, M.D.

Pamela Sutton-Wallace

David Zaas, M.D.

ExECutivE stEEring CommiTTee

Read more about the team members at

maestro.duke.edu

Inside Duke MedicineOctober 2011 5

project MAnAger

Jean M. Clark

cpoe teAM

Jeanette Jansen, Team Lead

IT AnalystsTres BrownScott CannonBrenda CepedaMichael FosterKimberley GadowAmy MooreIra Togo

Nursing Informatics System SpecialistsWill Bisanar, TrainerDavid Dinsmore

Clinical PharmacistEsther Grifoll, RPh, MS, Trainer

clinDoc teAM

Gwendolyn Kimbrough, Team Lead

IT AnalystsTanya Alvord, TrainerJanice BrownKaren Guthrie StroudLeann OrcuttAnne C. PriceConnie Stevenson, PTPat Wilkerson, BSN, RN-BC

Nursing Informatics System SpecialistsJohn S. Schroder, RNElizabeth J. Sink, RN, TrainerClaudia Spengler, RN

eMergency DepArtMent teAM

Christine B. Fowler, MT (ASCP), Team Lead

IT AnalystsLisa DeMarcoShelley Gillman

Nursing Informatics System SpecialistsLaura Berry-Ward, TrainerPatrick Ellerd

or/Anesthesiology teAM

Richard Elliott, Team Lead

IT AnalystsKatherine GattisBeverly Hayes Maria E. Hurley, RN, BSN Jeanellen A. Newkirk, RN, MSN, Trainer

Nursing Informatics System SpecialistsJaime Almquist, RN, BSNKim Cicio, BSN, RNTim Crittenden, RN, BSNJennifer M. Dizon, RN, BSN, MAN, TrainerSara Duffy, RN, BSN, CAPA Gregory Horn

phArMAcy teAM

Jason Jackson, PharmD, Team Lead

IT AnalystsSandra B. Lee Parul Patel

Clinical PharmacistsMary Amarante, PharmD Allison Armagan, PharmD Michael Canale, MS, RPh James Greenlee, RPh, MHA Dalia Mack, PharmD, AE-C, CDE Sally M. McCollum, PharmD Annette Murray Diane Newman-Pokorney, PharmD, BCPS

Nursing Informatics System SpecialistAllison Adler RN, MSN, OCN

rADiology teAM

Michael Land, Team Lead

IT AnalystsMark BeautzBrenda Boardwine, RTRM, TrainerChristine Carlson

Nursing Informatics System SpecialistChristie Leath, RN

maestro Care inpatient Clinical team

inPAtiEnt TeamSince DUHS board approval for the system-wide Maestro Care electronic health record (EHR) at the end of August, the Maestro Care Inpatient project team was formed and began the extensive training process at Epic in Verona, Wis.

The project’s 59-member core clinical team was strategically selected with the help of operational leadership to establish a consulting partnership to increase proficiency and assist in designing the system in more complex areas, such as surgery, anesthesia and oncology. As a result, 44 percent of the team comes from operational patient care areas throughout DUHS, including nursing, radiology, pharmacy and perioperative.

The project team is working together to implement the EHR at Duke University Hospital in July 2013, Duke Raleigh Hospital in February 2014 and Durham Regional Hospital in July 2014.

After training and certification, the next steps for the project team include beginning to work closely with clinical and operational leadership at the each of the three hospitals. To assist with this process, physician and nurse champions will be identified for the project. Together, the team will systemically examine operations, looking for opportunities to unite different service areas and best practices that can be incorporated into the way Maestro Care will function.

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Heidi COzaRt

rEvEnuE CyClE Team

The Maestro Care Revenue Cycle project team is working closely with the ambulatory and inpatient teams to implement the Maestro Care electronic health record (EHR) system across patient registration, scheduling and billing. The 43-member core team was primarily recruited from within PRMO to ensure the team had a working knowledge of our patient revenue services and processes. The

team began their work in early September after DUHS board approval for the project and began training at Epic this month. The team is focused on completing training and the certification process, which will prepare them to begin designing how the EHR will work across the revenue cycle.

The revenue cycle team is collaborating with the ICD-10 project team, as Maestro Care will help ensure the health system is prepared to meet the October 1, 2013 deadline for ICD-10 compliance. Maestro Care will be implemented across the revenue cycle at Duke Hospital and all ambulatory sites in July 2013, at Duke Raleigh Hospital in February 2014 and at Durham Regional Hospital in July 2014.

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maestro Care revenue Cycle Core team

trAining leAD

Nelda Bradley

ADt/preluDe AnD cADence teAMs

Application Manager Alison Ervin

Project ManagerDenise Farrell

ADt/preluDe (BeD MAnAgeMent/registrAtion)

Chris Kappert, AC Lead

Application AnalystsTeresa BaucomEmily DillardPaul GillJames Stewart

Principle TrainerIsaac Burns

Report WriterBob Rezzarday

cADence (scheDuling)

Erich Hodges, AC Lead

Application AnalystsBob FloodJames HolmesAmy Seaver Leale Peggy Williams

Principle TrainerMichael Palko

Report WriterManuela Martin

resolute hospitAl Billing, professionAl Billing, hiM teAMs

Application ManagerTammy Morton

resolute professionAl Billing

Michael Rogers, AC Lead

Application AnalystsCathy BeckJulie EdwardsTina Riley

Report WriterMelissa Leney

resolute hospitAl Billing

Peter Chang, AC Lead

Application AnalystsAngela CanadyElaine CherryMark Hagensicker

Principle TrainerSylvia Horner

Report WriterSusan Parisi

resolute cAsh MAnAgeMent

Stacey Kelley, AC Lead

Application AnalystAngela BucknerReport WriterLewis Caviness

resolute hiM

Jill Clayton, AC Lead

Application AnalystCheri Willard

Report WriterNeil Crenshaw

Inside Duke Medicine6 October 2011

2012

Maestro Care tiMeline

jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec 2011 2013

AMBULATORY EHR

INPATIENT EHR/REVENUE CYCLE

FIRST GO LIVEDUKE PRIMARY CARE AnD fIRst-wAvE ClInICs

The same Maestro Care technology that will drive improvements in

patient care will also provide a power-ful resource for Duke’s world-class medical researchers, giving them better ways to generate new knowledge.

The greatest advantage of the new system-wide electronic health record (EHR) to clinical researchers will be the ability to use uniform terms to learn from our own clinical practice using standardized information collected in the context of clinical care.

This improvement in standardiza-tion will serve quality improvement in the health system and exactly the same information can be used to generate new knowledge. With the planned implementation, Duke investigators will be able to do small, focused studies

more effectively, and they will have the potential to do population studies of a size and scope not practically possible with current systems.

Such studies could evaluate the health of the entire population of several million patients who get their healthcare from Duke Medicine, as well as study and track the effectiveness of various intervention strategies in the treatment for patients with spe-cific diseases such as heart disease and diabetes. In addition, the studies could

shed light on how the natural history of disease, or disease interventions, differs among people with different backgrounds, including age, sex and the neighborhood in which they live.

“The possibilities for doing wide-scale population studies based on EHR

data are enor-mous,” said Robert M. Califf, M.D., vice chancellor for clinical research. “Maestro Care population data, paired with our work in geospatial

mapping, has important potential for helping to design community disease prevention and wellness strategies.”

The capability to work with the increasing number of academic medical centers using Epic-based systems like Maestro Care increases the potential for conducting population studies of even larger size and precision.

Also, Maestro Care will collect clinical data in a way previously not possible across all of Duke University Health System – as searchable, digital information. Common information such as weights, blood pressures, drug lists, symptoms, allergies and medical history, will be entered as data instead of notes, making research more precise and dependable, while cutting the time and potentially the cost of doing studies.

“It’s what we have long wanted — standardized medical data across

Duke Medicine,” Califf said. “Our physicians provide outstanding care, but in our documentation we may sometimes use different names for the same thing — which makes it difficult to measure our quality and impossible for a researcher to know exactly what is being described.”

Standardized, digital medical care data will increase the speed at which research can be done, lowering costs and leaving more time for analysis. Today, a researcher might have to comb through perhaps 100 dictated medical records to find 15 suitable cases for a study. With Maestro Care, cases for some kinds of study types may be gathered almost instantly.

Additionally, with Maestro Care it will be much easier to discover the “why” a care decision was made, not just what was decided.

“Maestro Care data will come with standardized notes that provide the context of clinical decisions,” said Duke cardiology researcher James Tcheng, M.D. “In order to have trustworthy, complete medical research, it is as important to know why a test was done as it is to know the test result.” n

new eHR supports medical research mission

“ Maestro Care data will come with standardized notes that provide the context of clinical decisions. In order to have trustworthy, complete medical research, it is as important to know why a test was done as it is to know the test result.”

— James Tcheng, M.D., Duke cardiology researcher

tCHeng

CaliFF

Inside Duke MedicineOctober 2011 7

2014 jan feb mar apr may jun jul aug sep oct nov dec jan feb mar apr may jun jul aug sep oct nov dec

GO LIVE

GO LIVEAll AMbUlAtoRY sItEs lIvE AnD IMPlEMEntED ICD-10 IMPlEMEntAtIon

DEADlInE

2013

DUKE UnIvERsItY HosPItAl DUKE CAnCER CEntER DUKE MEDICInE PAvIlIon REvEnUE CYlCE (DUH AnD ClInICs)

GO LIVEDUKE RAlEIgH HosPItAl DUKE RAlEIgH CAnCER CEntER REvEnUE CYClE (DRAH)

GO LIVEDURHAM REgIonAl HosPItAl REvEnUE CYClE (DRH)

The medical residents who arrived this year for training at Duke

come from a generation that grew up with the Internet and expect instant, fingertip access to a world of information.

The Maestro Care electronic health record (EHR) is in synch with that data-intensive mindset, and will be a powerful new tool in educating the next generation of healthcare leaders.

“Maestro Care will allow us to do things with information that are at present too resource-intensive to do effectively or simply not possible,” said Ed Buckley, M.D., School of Medicine vice dean for education. “Maestro Care will significantly help our medical education in real-world training, providing feedback to learn-ers, and evaluating the effectiveness of our teaching efforts and curriculum.”

Health systems across the country are adopting comprehensive EHRs. And the Epic system, upon which Maestro Care will be based, is being implemented at many of our peer institutions.

“We’re more than just keeping up,” said Jeffrey Ferranti, M.D., a Duke neonatologist who has overseen the training of fellows and who is

chief medical information officer for Duke Medicine. “The revolution in translational medicine, which has changed the way medicine is practiced, is also going to change the way medical students learn. We want to train medical learners on the platforms through which care will be delivered.”

In addition to learning clinical skills, medical and physician assistant

students, as well as residents and fellows, will learn how to quickly and effectively integrate the accelerating flow of new medical knowledge into their practices. Maestro Care will help them do that in real time by providing relevant on-screen links to research information and new knowledge that they can immediately apply.

“Students taught to use Maestro

Care will effectively seek out specific information they need to take care of the patient that they are looking at right then and there,” Buckley said.

At the same time, Maestro Care will collect information on the care the medical learners provide.

“Our attending physicians do a world-class job as educators, but no single attending sees the entire work of

a particular medical leaner,” he said. “It is difficult today to get that global picture of a learner’s performance. Maestro Care will transform that, allowing our educators to precisely evaluate a learner and determine how to correct deficiencies.”

Collating learner data cannot be done quickly and effectively today, but Maestro Care should be able to

provide particularly rich data describ-ing the performance of an entire class of medical learners, Buckley said.

“With an integrated, comprehen-sive database of the care provided by medical learners, we should be able to quickly do studies that feed highly valuable information back into the curriculum,” Buckley said. “For instance, we might be able to find that

our learners are performing poorly in treating a condition like diabetes. With that knowledge, medical educa-tors can go back and identify areas in the curriculum or teaching methods that need to be improved, far more quickly than we ever could now.” n

medical education will benefit from maestro Care

“ Maestro Care will allow us to do things with information that are at

present too resource-intensive to do effectively or simply not possible.

Maestro Care will significantly help our medical education in real-world

training, providing feedback to learners, and evaluating the effectiveness

of our teaching efforts and curriculum.”

— Ed Buckley, M.D., School of Medicine vice dean for education BuCkley

Inside Duke Medicine8 October 2011

In addition to the challenge of deploying the Maestro Care elec-

tronic health record (EHR) system in the next three years, Duke Medicine also must complete a lesser-known but equally critical project in the same time frame.

It’s called the ICD-10 conversion – ICD-10 being the shorthand name for the tenth revision of the International Classification of Diseases. The federal Centers for Medicare and Medicaid Services (CMS) has mandated the conversion from the current ICD-9 diagnostic and classification codes by October 2013.

“Making a successful change to ICD-10 is critical,” said Cecelia Moore, who has worked on the ICD-10 conversion project as head of the PRMO and

will continue her involvement on the project as she transitions to become chief financial officer of the Private Diagnostic Clinic. “It is significant for us because the proper use of diagnos-tic codes is integral to safe, quality patient care and because it is through these new codes that the health system will communicate to payers the care we have provided to their members.”

The ICD-10 conversion is a major undertaking. The current 18,000 ICD-9 codes will be expanded into approximately 140,000 more precise ICD-10 procedure and diagnosis codes. In addition, the five-digit ICD-9 diagnosis and procedure codes will be replaced with seven-digit alphanu-meric codes in ICD-10.

Current codes are out-of-date and often not in clinically relevant terms. For example, ICD-9 has just a single term, intermediate coronary syndrome (coded as 411.1), that encompasses many different types of angina – heart pain. This includes relatively stable types of angina that can be evaluated in the outpatient environment to more acute forms that require hospitaliza-tion and prompt attention such as urgent cardiac catheterization. Clinical care guidelines also vary considerably

depending on the type of angina. The new ICD-10 codes allow providers to make better-informed decisions, and offer researchers the chance to learn from the outcomes of care as it will be described in clinically relevant terms.

Maestro Care brings many assets, including structured documentation templates that can already incorporate the ICD-10 coding conventions and tools that support providers in select-ing appropriate diagnosis codes.

“This is a powerful benefit of Maestro Care,” said Jeffrey Ferranti, M.D., M.S., chief medical information officer for Duke Medicine. “This means there will be lots of support to providers and staff in this coding transition that might have been extremely difficult and disruptive otherwise.”

Though CMS is mandating the change, the new level of specificity of diagnosis and procedure classification required by ICD-10 has benefits for Duke.

“The new codes could not only give us more information about specific patients, but also enable us to learn more from examination of patient populations,” said Robert M. Califf, M.D., vice chancellor for clinical research. “Sustained teamwork to implement ICD-10 will go far in making the conversion more than a mere bureaucratic exercise, but actually a great benefit for healthcare providers and researchers.”

Since ICD-10 is a more clinically relevant language, Califf said, medical researchers will be able to give most providers the satisfaction of learning from their practices because informa-tion will be collected just one time for clinical care, billing and research, rather than collecting separate data for each purpose.

Because Maestro Care implementation at Duke Raleigh and Durham Regional hospitals is scheduled to occur after the man-dated implementation of ICD-10, an intermediate ICD-10 solution is being planned. Maestro Care, however, will ultimately provide the same solution options and code selection guidance for providers at Duke Raleigh and Durham Regional hospitals. n

Support for iCd-10 code implementationMaestro Care will support providers and help smooth the transition

co-chAirs

Boyd Carlson

Cecelia Moore

project leADs

Kevin Cooper

Elizabeth Nowak

Eliana Owens

Cathy Peele

Fabian Stone

Keith Stover

Barbara Woolley

project MAnAgers

Sharon Davis

Jennifer Faulk

Michelle Gray

Lisa Hagen

Pam Lawrence

John (Jay) Wagner

iCD-10 Core Project team

Alex Barker

Leigh Bleecker

Bill Burton

Mary Ann Fuchs, RN, DNP

Bill Gable

Rick Gannotta

Jonathan Hoy

iCD-10 steering Committee

mOORe

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SOnia tRePina

Liz Long

Billy Newton

Sabrina Olsen

Ted Pappas, M.D.

Roman Perun

Mike Russell, M.D.

Colleen Shannon

Stuart Smith

Jean Shields

Mark Stacy, M.D.

Doug Stokke

Kevin Sowers, RN, MSN

Kerry Watson