If you are interested in learning more about the Practice Change Leaders for Aging and Health, you can find more information here.

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1 Amy Vandenbroucke, JD Associate Director Center for Ethics in Health Care Oregon Health & Science University 3181 SW Sam Jackson Park Road Portland, OR The following document is a business plan that I drafted as part of my Practice Change Leaders for Aging and Health (PCL) grant entitled Transforming End-of-Life Care Through epolst Implementation. I presented this report to senior leaders participating in the PCL program on June 4, 2015 during our Chicago meeting. The key element missing from this document is the licensing fee information for Vynca s product; this is missing since Vynca prefers for facilities to contact them directly for a quote. My intent was to draft a value proposition document that could be used by Oregon POLST Task Force Members who were interested in presenting Vynca s epolst product to their own leaders. Feel free to use portions of this report as may be useful to you. My only request is that whenever you use it that you let me know (vandenbr@ohsu.edu) so that I can report back to the John A. Hartford Foundation and The Atlantic Philanthropies, the two entities supporting this grant. If you are interested in learning more about the Practice Change Leaders for Aging and Health, you can find more information here. The Practice Change Leaders is generously supported by the Atlantic Philanthropies and the John A. Hartford Foundation

2 Transforming End-of-Life Care Through epolst (electronic Physician Orders for Life Sustaining Treatment) Implementation Executive Sponsor & Project Owner: I intend for this plan to server as a template for use by other Oregon POLST Task Force members, for them to present Vynca s epolst product to their own facility leaders; they would be the sponsors/project owners within their own facilities. Proposed Audience and The Ask : This document is focused towards hospital leaders. In Oregon, all major hospital systems use Epic as their electronic health record (EHR) system. The Ask is for hospital leaders to approve the allocation of the necessary resources at the hospital to implement Vynca s epolst system. Implementation can be completed in three months and requires: Licensing fee (currently unknown) for epolst. (Also staff time to negotiate needed contracts: licensing agreement, business associate agreement, virtual private network access, and license support and services agreement). Leadership support, hospital administration and departmental leadership buy-in: oncology, emergency department, family medicine, internal medicine, geriatrics, hospitalists and information technology. Commitment to providing educational support for epolst implementation, including developing and disseminating educational materials, providing training sessions, staffing live help desk, and updating policies and procedures. Executive Summary: Within three months, Vynca s epolst system can transform the paper process of writing and acting on a medical order into an electronic one, capitalizing on EHR benefits. Implementation of epolst is a hospital s investment in a consistent, repeatable process for POLST form completion that will: reduce errors, unwanted hospitalizations, and provision of unwanted treatment; potentially reduce 30-day readmission costs; increase just in time educational opportunities; and ensure a patient s most recent POLST form is easily and immediately located so treatment consistent with his/her wishes can be provided. Description: epolst transforms an inconsistent paper process into a consistent electronic one by migrating POLST functions in the hospital s EHR over to Vynca; Vynca can be viewed as an extension of the hospital s EHR that only houses POLST forms. Vynca s fully integrated webbased platform includes (or will include): Single login functionality with direct access to epolst within Epic and an immediate indicator of a POLST visible in the patient header; Auto-completion of POLST Form fields, such as patient demographic information and health care professional (HCP) information (name, license #, date of signature); Just in time education capabilities for patients (videos, materials that can be printed) and health care professionals (institutional policies and procedures, information about having a POLST conversation, information about POLST, including how to complete one); and Bi-directional capability with Oregon POLST Registry (OPR) for submitting and retrieving POLST Forms (OPR is currently building their system to connect with Vynca)- this function should be available by the end of OREGON EPOLST IMPLEMENTATION BUSINESS PLAN 1

3 POLST was designed to improve patient care and reduce medical errors by using a medical order form (POLST Form) to record the treatment wishes of someone who is seriously ill or frail and nearing the end of life; POLST is portable and intended to be used out-of-hospital and during care setting transitions. After having at least one conversation with the patient or his/her surrogate that includes diagnosis, prognosis and treatment option information, as well as the goals of care, the HCP will order appropriate treatment options on the POLST; the original is provided to the patient, a copy is kept in Epic and Oregon law requires a copy be sent to the OPR unless the patient opts out. Successful implementation creates a consistent electronic workflow that eliminates the errors inherent in a paper system while also providing additional benefits available only electronically. Current Paper Process Supply chain management of paper forms (ordering, distribution) Paper based POLST education materials need to be printed or ordered and distributed POLST videos (just in time patient education). Must have website saved or do an online search to access. Videos are 4-13 minutes long and not segmented. Sending to OPR requires scanning POLST Form and faxing to OPR (Takes days from form completion to POLST being available in the OPR) 18% of POLST Forms have an error that makes the form invalid. Errors include missing patient demographic and HCP information as well as incompatible order sets Must call OPR to confirm current POLST orders if original POLST not present epolst Improvements epolst located in patient header within Epic POLST education materials easily printed from epolst POLST videos within the system. Videos have been divided into smaller segments for more targeted education. Automatically sent to OPR when POLST is finalized online Auto-completion of form fields from Epic information and epolst form logic eliminates errors. epolst pulls current POLST from OPR into hospital s Epic system (later 2015) Approach: The final product will be Vynca s epolst system embedded within the hospital s Epic system and bi-directional capabilities with the OPR. Measurable/Anticipated Outcomes: Within three months, the hospital could have a single, consistent and repeatable POLST process that includes: (1) a fully functional way to electronically complete POLST forms, easily locate current POLST forms, and clear documentation of the epolst process; (2) just in time education available in a click for both patients and health care professionals; (3) bi-directional capability with the OPR (pending OPR completion later this year); (4) improved ability to elicit, know and honor patient treatment wishes; (5) the ability to track operational efficiency and conduct quality assurance activities, including audit tracking, reports of epolst utilization, and identifying or what department may need more support. Additionally, epolst reduces a hospital s number of invalid POLST forms to 0. Currently 18% of forms are invalid because of a completion error; invalid forms are not actionable (and not OREGON EPOLST IMPLEMENTATION BUSINESS PLAN

4 entered into the OPR) and, therefore, can lead to unwanted hospitalizations, potential legal action for provision of unwanted treatment, and patient and family dissatisfaction. Errors- and invalid forms- are eliminated through: Auto-completion of patient demographic information. Of the invalid POLST forms, 47% are missing/have an illegible name and 15% are missing/have an illegible date of birth. Auto-completion of HCP information upon form finalization. 20% of invalid forms are missing HCP signatures and 33% are missing the date of the HCP signature. Epic s individual authentication process will automatically complete these fields. Prohibiting incompatible order sets. Ordering CPR and Comfort Measures Only is an incompatible order set yet 3% of POLST forms have this order set. In epolst an HCP will receive a warning and the system will not allow a POLST to be finalized if incompatible orders are chosen. Timeline: Since OHSU was the pilot site for Vynca, the time spent getting the system up and running, including coordination with OPR and Epic, was substantial. OHSU has identified the key implementation steps and an estimate of the timeline for a facility starting now: Key Implementation Step Timeline KPI Contract Negotiations 1-3 months Completion of Contracts Work Flow Documentation 2 weeks Future State Work Flow Documentation Completion Interface Build within Epic and Validation Testing 2 weeks Working System Security & Privacy Review 1 week Privacy and Security Officer Approval Operational Planning (Change Management Activities) 1 month Updated policies and procedures Communication Plan for Roll Out Help Desk Staff Trained Backload Processing 4 weeks Ability to view POLST Forms currently in EHR in epolst Enterprise Wide Go Live 1 day Ability for appropriate Epic staff to use epolst epolst showing in patient header Notes: (1) Several of these steps may be concurrent (2) OHSU, ORP or Vynca may have documents that can be easily modified (e.g., policies, roll out communications, implantation documentation, etc) reducing some time/effort (3) Timeframes vary based on institutional processes (e.g., contracting time) Expansion: epolst will eventually expand to all health care facilities (including long term care, nursing homes, and assisted living facilities) in- and potentially beyond- Oregon. Current next steps include: (1) an independent third party review of OHSU s implementation of Vynca s product; and (2) a 1 hour recorded national webinar to share lessons learned and findings related to POLST completion by OHSU and OPR staff involved with implementation in Fall Additionally, since epolst allows health care systems to track and audit the entire process, we anticipate future research and process improvements OREGON EPOLST IMPLEMENTATION BUSINESS PLAN 3

5 Financial Projection: Specifics are currently unknown but should be available in Fall Expenses include: Licensing fee for Vynca - unknown IT salary for time spent with integration and validating testing depends on facility Education efforts and training depends on facility While not having specific financial information, the value of epolst can easily be guessed through its implementation of a single workflow process. Institutional inconsistency usually means inefficient processes and potential increasing operational costs but it can also mean an increased risk of medical error and, potentially, increased medical malpractice liability. epolst streamlines the entire POLST process: All POLST forms are found in the patient header. A single, consistent location for POLST eliminates time searching for paper forms and supply management. Instead, POLST forms are easily located for review during an exam or during a medical emergency and eliminates a need to rely on patients to bring forms with them. POLST education materials are in a single location. Videos- including relevant segments- can be easily accessed and viewed through monitors or ipads in the exam room; materials can be printed; and institutional policies can be easily accessed. Automatic submission of POLST to OPR. Unless the patient opted out, a completed POLST is sent to the OPR. Automating this process removes human error of delaying or failing to submit the form - and assures compliance with Oregon law. Currently only 28% of forms are submitted to the OPR the date they were completed. o Like OHSU, most hospitals cumbersome process includes scanning the paper POLST into Epic and faxing a copy to the OPR. OHSU estimates an annual savings of $848 by automating this process (looking at 2,122 POLST forms scanned this past year, estimating the unit price per scan as approximately $0.40). o For patients, automation means EMS would have almost immediate access to their POLST. So if they had a medical emergency the day they completed a POLST- and that would not be unlikely within this population- it would be available for EMS to honor. Elimination of duplicate POLST forms. A patient may have multiple POLST Forms if s/he receives care in multiple systems but doesn t share that information and allows a new version to be completed. Each hospital currently has their most recent version on file but not necessarily the OPR s most recent- unless it has a policy to the OPR to check and confirm POLST orders. By the end of 2015, epolst will automatically query OPR and provide the hospital the current POLST orders. Beyond system improvements, hospitals will recognize other values in using epolst: Increased reimbursement opportunities. epolst provides a framework and materials for an advance care planning conversation (as well as an audit trail); these conversations are being reimbursed by Cambia and other private payors; CMS is expected to issue payment levels for these codes in Fall 2015 ( st 30 minutes valued at 1.50 RVUs and each additional 30 minutes valued at 1.40 RVUs). IT Savings. Providence (an Oregon hospital who implemented a homegrown epolst system) is looking to Vynca s epolst for the cost savings in having a third party manage all IT upgrades and revisions. In addition to no longer having to update Epic OREGON EPOLST IMPLEMENTATION BUSINESS PLAN

6 smartphrases, they also will no longer have to dedicate substantial time and effort to updating their system when a revised POLST form is issued (every 2-3 years). Quality assurance opportunities. epolst allows hospitals to improve processes by reviewing a number of metrics, including: time spent on POLST conversation, how often educational materials are accessed and how long is spent reviewing them, who is involved with completing a POLST form and how long is spent on that process, who is initiating POLST conversations, who is signing POLST forms (and who is not but perhaps should be), how often POLST forms are reviewed as part of an exam, etc. o HCPs may also find they can improve patient care with the increased access to POLST historical information such as previous POLST form orders, revision dates, changes and who/what entity was involved with each version. Media. Hospitals see value in both getting positive media and avoiding bad media. o Positive media. Generally, national publicity is worth more (ad value) than local and the value varies based on whether the article is posted on a website versus in print. However, a good story featuring the hospital nets approximately: Oregonian: $8,257-$34,544 Seattle Times: $1,338-$22,679 Washington Post: $16,513-$42,634 New York Times: $ $69,054 a. Bad media. With paper POLST forms, a patient could unknowingly be given a copy of an invalid POLST form. If the form is present but unable to be honored by EMS during a medical emergency, this could lead to bad media- epolst helps avoid this by eliminating errors. Avoiding medical error costs. Vynca estimates the provision of unwanted treatment to a patient with a POLST is $20K. Unwanted treatment or hospitalization can lead to legal fees (in house and external counsel, and settlement, mediation or litigation expenses). Having, and honoring, a POLST may also lead to 30 day readmission cost savings. Supply chain savings. Cost savings in eliminating paper forms and eliminating supply chain management for ordering or printing, distributing and conducting inventory checks. Risks and Mitigation: System risks are minimal. OHSU served as the pilot site for Vynca s epolst system and worked exhaustively with Vynca and Epic over the last two years to develop epolst within Epic. Now that this is completed, Vynca and OHSU estimate epolst can be implemented in any other hospital s Epic system in a matter of months. OHSU, OPR and Vynca have worked over the last year to create the bi-directional capability and will be testing it; when this is completed and available to all (estimate Fall 2015) this risk will also be minimal. Moving POLST Forms to a third party raises the risk for a form being unavailable when needed, but there are redundancies, including Vynca s geographical diversity in server locations and OPR being able to service as a back up via phone to obtain or confirm POLST orders. The biggest risk is lack of adoption by hospital staff but this can be managed through a wellmanaged roll out and education process, as well as supporting highly trained help desk staff. Request: Approval to allocate the necessary resources at the hospital to implement Vynca s epolst system OREGON EPOLST IMPLEMENTATION BUSINESS PLAN 5