HIMSS STAGE 7: ROI DEMONSTRATION. Vicent Moncho Mas, CIO Hospital Marina Salud de Dénia

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1 HIMSS STAGE 7: ROI DEMONSTRATION Vicent Moncho Mas, CIO Hospital Marina Salud de Dénia

2 Hospital: 206 beds 7 general ORs + 4 ambulatory Physician Staff: 200 Nursing Staff: 360 Facilitators: 40 (More than1,200 employees) Reference population of more than 150,000 inhabitants (+ tourism) Specialized care: 1 Hospital + 2 Integrated Health Centers Primary Care: 11 Basic Health Zones > 34 Health Centers and Auxiliary Offices

3 Public Service Private Managed Administrative concession granted for 15 years Direct supervision via AVS commissioner Service improvement investment Marina Salud builds the new Hospital Marina Salud builds a new CSI in Calpe Marina Salud builds a new CSI in Denia Integration of professionals There was a previous Hospital (100% managed by regional government; all employees depends from AVS HR Resources policy as civil servants and locum) At the time Civil servants (28%) and private employees (72%) Public Health Integrated Management Health Department s integrated Management (both Primary Care and Specialized Care)

4 Marina Salud chose the Cerner Millennium solutions because of their ability to provide clinicians with the information needed to improve patient care on all care venues in the healthcare network: at the hospital, at the health centres and at home. This innovative approach to healthcare services overcomes traditional limitations such as data duplicity and information inconsistencies; as well as to serve as a healthcare model to all of Spain. Dr. Luis Fidel Campoy Domene Councilman Delegate

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6 March 22th, 2007 Agreement signed July 2nd, 2007 Kick off October 8th, 2007 Scope Review May 25th, 2008 System Validation September 1st, 2008 Integration Test December 15th, 2008 Go live January 26th, 2009 Emergency s Department Start-up

7 DIRECCIÓN DE SISTEMAS Y TECNOLOGÍAS DE LA INFORMACIÓN COMMUNICATION SOLUTION GO LIVE 2º Nivel USERS High Management Committee; Clinical Record Committee CHANGE REQUEST C T O CHANGE REQUEST Middle Management CHANGE REQUEST Level 1 C A L L PCP/ PCU APPLICATION DEVELOPMENT AREA End Users INCIDETN QUERY C E N T E R SUPPORT AREA (HELP DESK) INCIDENT QUERY COMMUNICATION SOLUTION GO LIVE THIRD PARTY ESCALATION Level 3 Technology Providers

8 2012 HIMSS Stage 7 Paperless EMR and Data Driven Paperless Validation Clinical Decision Support Capabilities Entreprise DataWareHouse Downtime process Paperless Validation CDSC DWH Exception to ideal workflow determine need for 100 paper scanned Dose range checking Sepsis algorithm Decrease unnecessary Xray Preoperatory 7x24 Downtime process

9 2012 Total Annual Operating Expense ,00 Total Depreciation ,76 Total Payroll Expense ,28 Total IS Operating Expense as a percent of Total Operating Expense 3,80% Total IS Depreciation ,00 Total IS Salary Expense ,28 Total IS Operating Expense ,00

10 Very few hospitals have HIMSS stages 6 and 7 The impact of the EMR is evident in stages 6 and 7 (and not in previous ones) in: Quality of care Patient safety Operational efficiency Investment analysis HIMSS: Healthcare Information and Management Systems Society EMRAM: Electronic Medical Record Adoption Model

11 ROI = Gain from Investment Cost of Investment Cost of Investment Return on Investment is a tool that is widely used for analysis and decisionmaking. Its purpose is to quantify the return of any investment or intervention so that decision-making can be as objective as possible.

12 Project A: ROI 9% Project B: ROI 90% Costs A = Gain A = Costs B = Gain B = Not everything that counts can be counted, not everything that can be counted counts. Albert Einstein

13 ROI = Gain from Investment Cost of Investment Cost of Investment One principal investment in 2008 for all the system map. No previous hospital to compare. Difficulty to quantify some results.

14 Not everything can or should be quantified... But the minimum possible The results obtained come from multiple factors. It requires people, processes and systems. Persons Result With the information available it is not possible to determine the specific weight of each of them Therefore, scenarios are built that can help formulate work hypothesis according to the different environments. For example: Clinical Documentation Area: High scenario: 100% Medium scenario: 85% Low scenario: 80% Processes Systems Average stay in hospitalization: High scenario: 25% Medium scenario: 15% Low scenario: 10%

15 + income Increased billing Access to documentation Systematic registration Clinical Documentation Archive management Coding Increased productivity Nurses & ancilliary Physicians Other Documentation Documentation Continuity of care Continuity of care Reduced Stock EAD alerts 100% careplan Reduced Variability Virtual visits Preferenc e Cards Chest Rule Clinical decisions Safety Quality Efficiency Multum Sepsis Rule Blood Bank Screening Areas Emergency Department Hospitalization Surgical Block Imaging Diagnosis RIS-PACS Tracking Board Reduced Avg. LOS. Higher Occupancy RIS-PACS in EMR Change from IV to VO Reduced Avg. LOS. Not assessed Patient travel 0 Related Average LOS 10-30% Attributable Blood Bank 30-50% Required Tx Xray Rule 100%

16 Nursing: Examples of quantifiable benefits Benefit Contents Millennium Contribution Impact Amount Hours/year FTE Discharge All discharged patients have a 50% of the report's 5 Minutes per 11, report nursing discharge report content is generated automatically report Integration Continuity of care between Single database per 15 Minutes per 11,728 2, departments patient discharge Total 2.26 Some pending to measure: Reduced variability in nursing practice Wound care plans: 100% of patients Forms: documentation Reduction of the time dedicated to documentation and tasks of little added value Medications: requisitions and fills Diets: requisitions FirstNet Tracking Board (ED) Allows to know the patient workload and severity in real time Records related to quality Falls Pressure ulcers Urinary tract infections Some difficult to measure: It has allowed to assimilate the increase of work without increasing the staff or reducing quality It facilitates the incorporation of new providers The system itself guides the new providers It improves the quality and safety of care Circle of quality: measuring is first 'Now we know what we do and how we do it' There is an apparent effect of decrease in quality: now we document more and better, and detect incidents that were not previously recorded.

17 Physicians: Examples of quantifiable benefits Benefit Contents Remote visits Interconsultations and remote follow-up visits. %5 of following ones. Millennium Contribution Impact Amount Cases Hours /year FTE 10 Time per visit 116,562 5, reduced from 15 to 5 minutes Structured clinical information available anywhere, at any time. Protocols integrated in the system. Documentation Continuity of care between Single database per 10 Minutes per 11,728 1, areas. patient. discharge Operating Room Integration of 7 Minutes per 8,608 1, Documentation monitoring devices major surgery Total 2.27 Some pending to measure: Single database Continuity of care for post-resuscitation patients Vital signs can be contextualized in the hospital, requiring less interconsultations Requests (referrals) with structured clinical information Demand management support Implementation of process guides in the orders Integration of the prescription with Gaia Avoids a visit to Primary Care Remote home connection for providers on-call remotely Minimum response time Reduced physical presence time Some difficult to measure: Process-oriented management Solutions help to define them Reduced variability in clinical practice Facilitates coordination of care between levels Remote visits Anesthesia: preops Neurology, checks Cardiology, Endocrinology

18 Clinical documentation: Examples of quantifiably benefits Benefit Electronic Medical Record Contents The medical record is not paper-based Millennium Contribution Impact Amount Hours/year FTE Cerner Millennium 4 Minutes per 193,718 12, is the EMR movement (discharges, consultations, and minor surgery) Cerner Millennium 5 Minutes per major and 14,994 1, is the EMR minor surgery Message Center 5 Minutes per report 6, Coding Availability of all electronic clinical information Discharge report Discharge report is sent automatically to the Primary Care Physician Total 8.19 Some pending to measure: Coding: Discharge and minor surgery Scanning and document integration 100,000 documents per year 50% consents Non-integrated results, documents from other hospitals Integral documentation control Batch index (ECG, Cardiotocography, Urodynamics) Patient and third-party requests 4,000 per year Some difficult to measure: Requests for passive archive When requested, they are digitized and incorporated into Millennium

19 Reducing average length of stay The healthcare management model included in Cerner Millennium has allowed to reduce the average length of stay by 10% and to increase occupancy to 89,7% Because of this the hospital has not had to enable 58,3 beds, generating a theoretical savings of 8,1 million in staff. Single patient database Integration of information Less documentation time 100% of patients with standardized plans and care. Multum alerts (medication): modification of the order in 37.2% of alerts 100% system availability Avg. LOS: 6.9 Avg. LOS: ,728 discharges 209 beds Occupancy: 89.7% Occupancy*: 85% - 14,807 stays 85% occupancy* beds beds beds 3.57 FTE**/bed 38, /FTE - 208,3 FTE - 8,101, Scenario Low Medium High Impact 10% 15% 25% In 5 years 4,050, ,075, ,126,550.77

20 Increasing occupancy of theor The healthcare management model included in Cerner Millennium has allowed an increase of the occupancy of the operating rooms from 60% to 70%, and this fact implies a saving of 4,5 FTE. Reduced cancellations Increased punctuality Real-time data Scheduling adjustment by analyzing the surgical waiting list Quarterly planning Biweekly adjustment Occupancy: 60% 2 FTE/OR nurses 0,5 FTE/OR assistants 38, /FTE Occupancy: 70% ORs nurses FTE assist. FTE - 175, ,187 surgeries Major surgery ORs (12): 9 for scheduled surgery 1 for emergency surgery 2 not functioning Minor surgery and tests: 2 ORs 2 rooms Obstetrics area: 1 OR for C-sections Staff: 2 nurses per OR + 1 assistant for every 2 Scenario Low Medium High Impact 10% 20% 30% In 5 years 87, , ,534.57

21 Improving admission processes Availability to schedule from any part of the Department (not only the hospital) The patient can make an appointment from any location, avoiding travel time Centralized request system High specialization is not required for scheduling appointments Simplifies the management of human resources: Higher efficiency due to higher versatility Allows providers to schedule appointments Allows establishing complex scheduling processes, making several people responsible Multi-phase PowerPlans In multi-appointments various people can schedule appointments (by area) without requiring a specialization in this type of complex appointments: Agenda Structuring Spaces according to priority Schedule care structures, not people (i.e.: spine disease agenda, not Dr. C) Clinical information related to the appointment Saves time and travelling for users Versatility and flexibility when assigning personnel Improved demand management: Prioritization according to clinical criteria Simplifies the referral request by Primary Care Does not require 24-hour hospitalization admission Admission for emergency surgery by the surgeon himself. Simplifies complex appointment scheduling Medical transport management Third-party referral management Fast detection and reaction in the event of problems Reduced OR cancellations Feedback in real time allows to react quickly in the event of incidents

22 Other processes Preference cards Costs per process Stock reduced by 35% 500,000 Financial cost reduced by 34% 15,000 x 5 years = 65,000 Autoverification 24-hour pharmacist is not required 4 pharmacists RIS-PACS Avoids physical support 116,872 x 2.5/study x 5 years = 1,460,900 Tx Xray rule Avoids pre-operative X-rays in patients under 60 years of age without pathologies that require them Effect on costs Effect on queue management Blood bank Multi-phase plan for pre-operative Cancellations due to lack of blood have decreased Time between order and surgery has decreased Cervical cancer Alert in case of alarming result Reduced gynecologist visit time Automated sending of letters in case of normal results Time X-rays Cost (euros) Total (euros) avoided 84 days , year , years 4, ,402.84

23 There are more than 36 processes still not quantified. The culture of impact assessment has been incorporated into the workflow of implementing improvements

24 The definition of insanity is doing the same thing over and over again and expecting different results". Albert Einstein

25 Thank you!