why we should invest in meaningful use guidelines: patient care perspective

Ryan Kreinbring

Joanne La Grange

Melody Dungee

Presenters

Ryan Kreinbring, Chief Medical OfficerJoanne LaGrange, Director of OperationsMelody Dungee, Director of Implementations

Who Are We?

Northwestern Community Hospital located: Joliet, ILNon-Profit Organization300 beds10 ClinicsPatient population: High Medicare/MedicaidCompetitors: Provena Covenant Medical Center and Silver Cross

HospitalEHR Adoption Level

Competitive Landscape

Clinics not using the same EHRONLY Community hospital in areaCompetitors are 2 Large IDN Networked hospitals (HCA and Tenet)All Hospitals using different EHR vendorsHigh Medicare and Medicaid PopulationPhysicians are private, relationship has been strained

Our Mission

To provide safe, effective, patient-centered, timely, efficient and equitable patient care with an unparalleled passion and commitment to ensure the very best healthcare for the communities we serve.

Agenda •Overview of where we are today •Discuss the benefits of 5 key impacts of Meaningful Use

•Discuss the risks of implementing Meaningful Use

•Conclusions and recommendations

Hospitals Prepared to Meet Meaningful Use

Source: iHealthBeat January 8, 2010

We Are HERE

Meaningful Use OverviewStage 1

Key Impacts To Patient Care

CPOE > 10%...why?

NCH Plans a 2 “phase” rollout starting with ED only then moving housewide

Benefits Expected:Reduced ADEStandardization of Care Improved Efficiency of Care Delivery Eliminate Transcription Errors

SafePatient

CenteredEquitabl

eEfficient

Safe

Timely

Impacts to Stakeholders

Physicians – Bring the physician back to the front lines of the patient care decision process. Should increase the timeliness of order entry and improve TAT. Also will eliminate tedious back office steps for order signoff.

Hospital Staff – Real time order entry should make everyone's job easier and decrease TAT. Eliminate deciphering of any Physician communication, everything should be spelled out and clear. Remove time entering orders to focus on patient needs.

Patient – Increased interaction with Physicians. Assurance that orders placed are accurate and backed with decision support. Standards of care can be deployed so patients don’t fall through the cracks.

Maintain Problem & Diagnosis List

Joint effort between Nursing and Providers to update and maintain

Benefits Expected:Clear picture of patients healthBest Practice Care PlanningImproved Disease Management Reporting

Effective

Efficient Safe

Patient Centered

Effective


Physicians – Allow the Physicians to actively manage patients life long problems and diagnosis with a clear picture of the patients overall health status.

Hospital Staff – Bridge the clinical gap between Physician documentation and nursing/ancillary documentation. Provide 1 place that’s managed collaboratively.

Patient – True patient centered listing across visits that will improve disease management. When every care provider is managing patients problems treatment and outcomes are tailored to patient needs.

Maintain Active Medication & Allergy List

Nursing will gather medications and allergies list on admission, Physicians will perform medication reconciliation on discharge/admission/transfer of care.

Benefits Expected:Eliminate Drug – Allergy Interactions100% compliance with Allergy documentation Improve compliance with tracking patients home medications

and feeds medication reconciliation process

Safe

Equitable

Patient Centered


Hospital Staff & Physicians– Provide discrete data in single location that crosses clinical disciplines. Allergies and medications entered will allow EMR to check for harmful interactions that will be caught before the order is even placed. Allows checks along the process where Physicians, Pharmacy, and Nursing will have visibility to potential interactions.

Patient – True patient centered listing that should substantially eliminate adverse drug events. This will substantially increase patient safety with regards to medication administration.

Provide Patient Electronic Copy of Health Information

Upon discharge create Continuity of Care DocumentBenefits Expected:

Provide patient clear picture of healthBuild foundation for interoperabilityBetter care across patient venues Patient

Centered

Efficient

Effective


Hospital Staff & Physicians– Will provide the hospital with the foundation to explore expanded HIE opportunities.

Patient – Provide patients with clear picture of overall health picture. This should lead to better follow up care as well as empower patients to truly own their health.

Perform Medication Reconciliation

Physician owned process carried out at Discharge/Admission/Transfer of care

Benefits Expected:Provide all patients with Medication Reconciliation report

Improve compliance with Joint Commission medication reconciliation requirements

Patient Centered

Effective SafeEquitabl

e


Hospital Staff & Physicians– Physicians will perform on admission, transfer, and discharge. Will provide clear concise view at all times of patients active medication orders (as well as non active).

Patient – Provide the patient with clear guidance on to medications they should Start, Stop, Discontinue. Every visit will result in updated discharge medication reconciliation reports to every patient.

What does this really mean?

Ed Archer presents to ED with Shortness of Breath

Triage Assessment

• Past Visit Allergies Reviewed - allergy to Warfarin added•Notice Problem/Diagnosis documented of Pneumonia and High Blood Pressure•Online Nurse Protocols Initiated for Community Acquired Pneumonia – Triggered off patient history online


Physician ExamOrder Entry (CPOE) at Bedside Best Practice Orders

• Online documentation recommends orders based on Problems/Diagnosis list•Best Practice orders recommended that align with organization and national quality goals (smoking cessation, blood culture before first antibiotic, etc).•Decision support – Warafrin alert triggered off patient allergy


Orders sent immediately

• All patients provided medication reconciliation report (start/stop/continue)•New prescriptions prescribed digitally•Mr Archer’s Meds changed - prescribed beta blocker and angiotension prescription cancelled•Mr Archer is provided electronic copy of care record that is also secure sent to PCP for follow up

Orders, Medications, Problems, Allergies updated real-time

Condition Improves, Discharge, follow up

Risk 1: Visibility & Perception of NCH Quality

Balanced Scorecard: Market Performance/Customer Satisfaction Internal Operations (Competitive service, quality, efficiency) Associate Satisfaction & Ability to Adapt and Improve

1. Community aware of medical errors2. $25M ONC Campaign – educate providers/public (March 2010)

• To obtain approval of HIT adoption and MU 3. Consumer Partnership for eHealth (CPeH) consumer/employer survey results (March 2010)

• MU is voluntary – capabilities exist in technology now• Harm from rapid MU deployment? “Already being harmed every day”

4. 50 Consumer & Employer Groups - HHS/CMS letter (April 2010)• Message: Retain MU - Do not defer• Wal-Mart, SEIU

5. Empowered Patient Coalition and Consumers Union's Safe Patient Project- Web site for patient surveys about their experiences with an adverse medical event

Risk 1: Visibility & Perception of NCH Quality

What is important to our customers?Substantial improvement in safety, access, communication and care coordination

To Mitigate: 1. Approve proposed marketing budget increase2. Improve & sustain transparency to demonstrate ACTION

• Ongoing media campaign to promote NCH MU efforts• Campaigns directed to external providers• NCH Website - MU page for community• Maintain consistent themes:

o Safe, effective, timely, patient-centered, efficient, equitable

Risk 2: Automate Inefficiencies and NOT Improve Safety, Quality, Effectiveness or Coordinated Care

Balanced Scorecard: Internal Operations/Clinical & Administrative Quality Ability to Adapt and Improve Employee Satisfaction

1. MU not an implementation strategy! HIT is an enabler 2. Transformation requires workflow process redesign or we “automate inefficiencies”3. Information must be meaningful and useful to have value4. Processes to support patient-centered care is a change5. Premier on MU, “Hastily implemented workflow changes could have the unintended

consequence of adversely affecting quality of care rather than enhancing it.”

Risk 2: Automate Inefficiencies and NOT Improve Safety, Quality, Effectiveness or Coordinated Care

What is important to our customers?Six IOM aims: safe, effective, timely, patient-centered, efficient, equitable care

To Mitigate: 1. Approve budget to engage a clinical workflow redesign consultant

• Avoid costly customizations of EHR 2. Leverage Premier Healthcare Alliance HIT Collaborative

• New Meaningful Use Best-Practices Library (April 2010)• Focus is expediting EHR implementation to qualify for MU incentives• Strategies for cultural change and communication

Risk 3: CPOE May Not Be Safe

Balanced Scorecard: Internal Operations/Quality, Efficiency, Safety & Quality, Timeliness of Service, Patient Safety Index Associate Satisfaction/Ability to Adapt, Improve, Implement Changes in Timely Manner Market Performance/Market Share

1. Research:• Review of FDA reports links CPOE errors to Adverse Events• CPOE users overly confident about data accuracy & processing• Center for Patient Safety Research – analyzing CPOE factors contributing to medical errors &

will classify errors2. Message Overload - miss critical messages

• Alerts, reminders & CDS to prevent errors3. Physicians provide care at different hospitals

• Learn multiple systems - different user interfaces4. No consistent method to communicate with physicians at NCH!

Risk 3: CPOE May Not Be SafeWhat is important to our customers? Six IOM aims: safe, effective, timely, patient-centered, efficient, equitable care

To Mitigate:1. Engage CPOE consultant2. Invest in CMIO position (part-time)3. Grant appropriate authority to CPOE Physician Advisory Committee

Budget/purchase Evidenced-Based Practice Order Sets Consider mobile phone connectivity

4. Identify effective physician communication channel5. Leverage Resources:

Institute for Safe Medication Practices human factors guidelines for CPOEo Content, format, protocols for managing RX approval, revisions updates

Premier MU Best Practices library

Risk 4: To Much Too Soon? Sacrificing Safety by Rushing into MU in Year 1

Balanced Scorecard: Internal Operations/Quality, Efficiency, Availability of Services, Measure of Safety & Quality, Timeliness of Service, Patient Safety Index Market Performance & Customer Satisfaction/Associate Satisfaction, Ability to Adapt and Improve

1. AHA, Premier, other professional organization – YES2. Care Coordination among diverse healthcare providers requires:

• Standardization – coding, transmission, vocabulary, processes3. Safe sequence of HIT efforts

• Standardized coding – CDS Logic• Security – Patients with electronic copy of health information

5. Change Management – Education/Communication

Risk 5: To Much Too Soon? Sacrificing Safety by Rushing into MU in Year 1

What is important to our customers? Six IOM aims: safe, effective, timely, patient-centered, efficient, equitable care

To Mitigate1. External consultant

• Assess organizational readiness• Enterprise implementation strategy

o Evaluate and plan sequence of HITo Establish safe MU milestones

• Strategies for quality; measuring, monitoring and reporting• Assess current application and use - adoption inventories

Conclusions & RecommendationsContinued support for CPOE project and expand to other MU criteriaMove forward in pursuing meaningful use at a SAFE pace Ensure project is clinically driven, NOT IT driven Support for non-staff physicians to adopt MUApprove budget requirements

External Consulting CMIO PositionTo meet needs of our customers and grow market share - Marketing campaigns to community

and external providersBudget Requests

References

RECOVERY: Comprehensive Campaign for Communications and Education about Health Information Technology for Economic and Clinical Health (HITECH) Act. (March 24, 2010). https://www.fbo.gov/index?s=opportunity&mode=form&id=93ccf0f006ab28d8076dd69fc846f6ab&tab=core&_cview=1. Accessed April 14, 2010.

Consumers weigh in on top 10 meaningful use arguments (March 8, 2010). Health IT News. Accessed April 14, 2010). http://www.healthcareitnews.com/news/consumers-weigh-top-10-meaningful-use-arguments.

New Meaningful Use Best-Practices Library Helps Hospitals Effectively Implement HER to Improve the Health of Their Communities (April 6, 2010). Accessed April 14, 2010. http://emrdailynews.com/2010/04/06/new-meaningful-use-best-practices-library-helps-hospitals-effectively-implement-ehr-to-improve-the-health-of-their-communities.

http://geekdoctor.blogspot.com/2010/01/do-it-yourself-board-presentation-of.htmlAHRQ Report: Health IT Adoption Could Lead to Gains in Care Quality (April 15, 2010). Accessed April 16,2010.

http://www.ihealthbeat.org/articles/2010/4/15/ahrq-report-health-it-adoption-could-lead-to-gains-in-care-quality.aspxWhat Percentage of Hospitals Are Prepared To Demonstrate 'Meaningful Use' of EHRs? (January 8, 2010). Accessed April 16, 2010.

http://www.ihealthbeat.org/data-points/2010/what-percentage-of-hospitals-are-prepared-to-demonstrate-meaningful-use-of-ehrs.aspxConsumers/Employers: Keep MU Strong (April 20, 2010). Health Data Management. Accessed April 20, 2010.

http://www.healthdatamanagement.com/news/meaningful-use-comment-consumers-employers-40137-1.html?ET=healthdatamanagement:e1247:161947a:&st=email&utm_source=editorial&utm_medium=email&utm_campaign=HDM_Daily_042110.

Review of FDA Reports Links CPOE Errors to Adverse Events (April 21, 2010) ihealthbeat. Accessed April 25, 2010.http://www.ihealthbeat.org/articles/2010/4/21/review-of-fda-reports-links-cpoe-errors-to-adverse-events.aspx

ISMP Develops New Guidelines to Promote CPOE Standardization (March 15, 2010). Accesses April 25, 2010). http://www.ihealthbeat.org/articles/2010/3/15/ismp-develops-new-guidelines-to-promote-cpoe-standardization.aspx

Researchers To Look at Medical Errors Related to Use of CPOE Tools (April 26, 2010). http://www.ihealthbeat.org/articles/2010/4/26/researchers-to-look-at-medical-errors-related-to-use-of-cpoe-tools.aspx

New Web Site Invites Patients To Report on Adverse Medical Events (April 26, 2010). http://www.ihealthbeat.org/articles/2010/4/26/new-web-site-invites-patients-to-report-on-adverse-medical-events.aspx

Appendix B: HIMSS Hierarchy of EMR Adoption

why we should invest in meaningful use guidelines: patient care perspective

Documents

equitable patient care

patient needs

patient carecpoe

patient care decision

care provider

standards of care

patient increased interaction

patients dont