Sustainability: Achieving Clinical and Financial Benefits Through the Use of an EHR

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1 Sustainability: Achieving Clinical and Financial Benefits Through the Use of an EHR Bert Reese SVP and CIO of Sentara Healthcare Sentara Healthcare October 6,

2 Sentara Healthcare 126-year not-for-profit mission 12 hospitals; 2,727 beds; 3,799 physicians on staff 13 long term care/assisted living centers Extended stay hospital 5 Medical Groups (650+ Providers) 444,000 - member health plan Sentara College of Health Sciences $4.3B total operating revenues $5.9B total assets 27,000+ members of the team AA/Aa2 bond ratings Virginia North Carolina 2

3 Where Is The Industry Now? Sustained ROI is difficult to achieve Organizations achieving benefits, especially financial, are rare Common Pitfalls Urgency for Meaningful Use dollars increases pace Implement first, worry about benefits later Lack of attention to process redesign IT project versus operational ownership Not enough emphasis on Optimization 3

4 Total Cost of Ownership 10 Year Overview for first 6 Hospitals Capital $ 67 M Operating Expenses $ 170 M Hardware Maintenance $ 15 M Software Maintenance $ 50 M Disaster Recovery $ 3 M Work Redesign $ 36 M Training $ 16 M Implementation $ 22 M Ongoing Support $ 22 M Other Non-Salary Support $ 6 M Total Cost of Ownership over 10 years $ 237 M 4

5 2013 ROI Business Case Benefits Benefits for first 8 Hospitals; $51.6 M Expected ecare Benefit Category Benefit (Millions)* Reduce Length of Stay $17.06 Increased Outpatient Procedures $10.89 Increase Unit Efficiency $13.95 Reduce Transcription Costs $3.27 Reduce Paper Related Supply Costs $1.17 Reduce Medical Record FTEs $3.85 Reduce OPTIMA expenses $1.02 Reduce IT maintenance expense $4.11 Other Benefits $7.04 TOTAL BENEFIT $62.36 *2013 for 7 Hospitals, Home Health and Health Plan 5

6 ecare Process Innovations Redesigned18 major processes covering entire continuum of care Lean Six Sigma Methodology 1. Arrival Management 2. Bed Management 3. Case Management 4. Charge Capture 5. Claims Processing 6. Clinical Communications 7. Disease Management 8. Emergency Department 9. Home Health 10. MD Processes 11. Medical Records 12. Meds Management 13. Monitoring/ Recording 14. Order Sets 15. Patient Care Transformation 16. Patient/ Member Satisfaction 17. Physician Practice 18. Scheduling Define Validate Complementary Technology: Bar-coding; Document Management; Device Integration Design Measure Analyze 6

7 # 15 Patient Care Transformation Team Identify Major Processes 1. Chart management 2. Clinician communication* 3. Order entry 4. Patient care prep procedures 5. Clinical admission process 6. Shift-to-shift hand-offs 7. Bedside Positive Patient Identification (PPID) 8. Documentation 9. Patient transfer 10. Lab specimen collection and delivery *these are the primary responsibility of other teams, we own the gaps 7 7

8 # 15 Patient Care Transformation Team Identify Major Processes (cont) 11. Management of safety 12. Work planning for the Novice vs. Expert 13. Hunting and gathering information 14. Clinical patient care procedures 15. Staff assignments 16. Nursing annual mandatory requirements 17. Entry of charges 18. People to technology interface 19. Medication administration* 20. Business processes *these are the primary responsibility of other teams, we own the gaps 8 8

9 # 3 Order Entry Current Process eicu orders entered by eicu MD Order prints in ICU eicu MD calls RN to notify of new order ORDER ENTRY PROCESS MD handwrites order MD flags order or gives to AA STAT orders are communicated to nurse and/or provider Nurse finds order Nurse or AA calls department for STAT order followup Nurse/AA calls consults to appropriate offices (Only some units) Nurse gives to AA/ NCP Nurse enters orders in TDS Person entering orders signs order sheet New Medical Order prints on unit AA/NCP/Nurse/No one picks up NMO Nurse corrects hand-written order Distributes to sorting boxes Order prints in pharmacy Pharmacy enters medication orders Medication orders are faxed to pharmacy OR Yellow caron is handed to rounding pharmacist Orders for tests that don't match TDS require phone call to clarify Nurse carries out order Nurse checks NMO against handwritten order NMO Put in order section of the chart Unclear orders require a phone call to clarify Call MD to re-write the order Notify Charge RN if needed Orders are checked Q2h OR When time permits OR Before acting on new order 9 9

10 eicu orders entered by eicu MD Order prints in ICU #3 Order Entry Lean Analysis (non-value added work) eicu MD calls RN to notify of new order ORDER ENTRY PROCESS MD handwrites order MD flags order or gives to AA STAT orders are communicated to nurse and/or provider Nurse finds order Nurse or AA calls department for STAT order followup Nurse/AA calls consults to appropriate offices (Only some units) Nurse gives to AA/ NCP Nurse enters orders in TDS Person entering orders signs order sheet New Medical Order prints on unit AA/NCP/Nurse/No one picks up NMO Nurse corrects hand-written order Distributes to sorting boxes Order prints in pharmacy Pharmacy enters medication orders Medication orders are faxed to pharmacy OR Yellow carbon is handed to rounding pharmacist Orders for tests that don't match TDS require phone call to clarify Nurse carries out order Nurse checks NMO against handwritten order NMO Put in order section of the chart Unclear orders require a phone call to clarify Call MD to re-write the order Notify Charge RN if needed Orders are checked Q2h OR When time permits OR Before acting on new order 10

11 #3 Order Entry Future Process ORDER ENTRY PROCESS eicu orders entered by eicu MD MD enters order New orders are flagged for nurse and others Med orders are reviewed by a pharmacist Unclear orders require a phone call or inbasket message to clarify New order written/ order adjusted Nurse acknowledges new order Nurse carries out order 11

12 Optimization Develop a focused approach to achieve the following: 1. Stabilize facility 2. Achieve ecare business case 3. Leverage ecare to achieve additional benefits 4. Look for non-ecare improvement opportunities 5. Support system-wide improvement initiatives Optimization Leader Process Improvement Staff Physician Liaison Staff Application Specialist 12

13 Operational Ownership Dual Accountability System Executive process owners identified for each process redesign category Individual facility Executives assigned expected benefits Both are responsible and accountable for ROI benefits Hosp A Hosp B Hosp C Benefit 1 VP Benefit 2 VP 13

14 ecare Costs and Benefits by Year $80,000.0 $60,000.0 $40,000.0 $20,000.0 $- $(20,000.0) $(40,000.0) Expected Benefits Achieved Benefits Expenses Net Impact (vs. Achieved) Net Impact(vs. Expected) 14

15 Sentara ecare ecare Today EMR at 8 Sentara hospitals 87% CPOE (Computerized Physician Order Entry) Realized benefits ($62.3M) exceed plan ($51.6M) 155 SMG MD practice locations and 4 Community MD practices 130,000 MyChart patients (patient portal) ecare Innovations Smart Room emedsurg Vital Sign Alerts Inpatient Scheduling 15

16 Post Implementation Value Proposition Patient Centered Care 16

17 New Clinical Value from Epic Driving Clinical Process Improvements Standardizing best practices through protocols, order sets, and advanced analytics Identify and focus on high risk patients in real time Advanced analytics driving new clinical improvements Real time clinical algorithms and alerting (Sniffers) Better understanding of the clinical workflow Clinical 3 Project: Focus on improving care for high risk patients (Heart Failure, Pneumonia, Sepsis) 17

18 Advanced Analytics Greater insight into clinical operations Key clinical indicators identified by clinical experts Near real time availability Process Measures for Care Provided Heart Failure Patients 1. Inpatient ACE/ARB 2. Inpatient Beta Blocker 3. PO Diuretic by Day 3 4. Daily Weight Check Compliance 5. Patient Weight Loss 6. Diuretic w/in 6 Hours of Admission 7. Echo Ordered w/in 24 hours of admit 8. Heart Failure Order Set Usage Pneumonia Patients 1. Blood Culture Ordered 2. Sputum Ordered 3. UAT Legionella Ordered 4. UAT Pneumococcal Ordered 5. Chest X-Ray Ordered 6. Pneumonia Bundle Compliance 7. Bronchial Hygiene Assessment Performed 8. Pneumonia Vaccination Status Reviewed 9. Pneumonia Order Set Usage Sepsis Patients 1. ABX Administered w/in 1 Hour 2. Sepsis Blood Culture Draw w/in 1 Hour 3. Lactate Draw w/in 1 Hour 4. Sepsis Bundle Compliance 5. First Screening in ED 6. Q12 Sepsis Screening Compliance 7. First Screening w/in 4 Hours of Admission 8. Fluid Bolus Orders 9. Sepsis Order Set Usage 18

19 Clinical Algorithms and Alerting Keeping our Patients Safe Real time notification and alerting driven from clinical criteria Sepsis Sniffer: Creation of a clinical algorithm to run in the background Will avoid nurses having to perform manual Sepsis Screening every 12 hours during a patient s stay Vital Signs Alerting Alert and notifications driven from abnormalities in vital signs Faster responses to patient deterioration: 52 minute decrease in average response times to VSA score warnings 19

20 Additional Organizational Value Epic Benchmarking Allows us to tune our organization Compare implementation maturity levels Epic community can drive value at your local level Source Ourselves for Upgrades Internal source for Epic upgrade staff No outsourcing required 20 20

21 Challenges Upgrades put demands on the hardware and puts the software at risk Constantly increasing cost of IT Trying to always measure the value proposition of IT Lack of a low end Epic solution Epic Lite Migration of a technology driven company to a data driven company 21

22 22

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