Successful HITECH/Meaningful Use Roll Out. Methodology to Drive Organizational Change

Transcription

1 Successful HITECH/Meaningful Use Roll Out Methodology to Drive Organizational Change

2 Presentation Overview Vanderbilt University Medical Center Scope of services Challenges with HITECH/MU Stage I Governance structure Operating structure Performance monitoring, financial modeling and audit readiness Lessons learned Approach to Stage II, ICD- 10, PQRS

3 Vanderbilt University Medical Center Includes the Medical Group and Clinics, University Hospital, Monroe Carrell, Jr. Children s Hospital and Psychiatric Hospital beds 1200 credentialed billing providers 58,000 discharges 120,000 emergency room visits 1,790,000 ambulatory visits

4 History of Vanderbilt EHR : Vanderbilt used the MARS system developed by John Vries and Russell Yount at the University of Pittsburgh Medical Center A gradual replacement strategy led to the elimination of the MARS system; it was officially turned off in May, : VUMC began planning to implement StarPanel in all 100+ outpatient clinics by 2003

5 Regulatory Challenges CMS published final rule on July 28, 2010 (876 pages) Interpretation of rules was time consuming and clarification difficult to obtain Quality measures complex Multiple Federal and State timelines VUMC follows academic fiscal year Hospitals follow federal fiscal year EPs follow calendar year Medicaid programs on different payment schedule than CMS

6 Project Challenges Significant buckets of work identified in a tight timeframe Gap analysis of current tool configuration versus the certification standards Certification vendor selection and process Consensus on common workflows to drive tool enhancements to meet certification requirements Consistent implementation of workflows and tools to meet Meaningful Use

7 Time Challenges To maximize revenue potential, early certification and attestation was critical Potential for Medicare 44K per EP over 5 years Potential for Medicaid 64K per EP over 6 years Hospital based variable, derived from Medicare and Medicaid volumes Earliest payment for incentives started May, 2011

8 Time Challenges

9 Meaningful Use Challenges Effort entirely focused on the EPs Completely electronic does not equate to Meaningful Use Tools were developed in silos Providers had little input in the development of tools Wide variation in workflows and use of tools Lack of policies and clear role definitions for users System speed

10 Cultural Challenges Distrust between Providers, Informatics and Operations Many priority projects with finite resources Physician and faculty autonomy versus standardization of workflows, policies and procedures, and use of the EHR Innovation versus transaction processing

11 Governance Structure

12 Initial Project Goals Promote coordination of patient care through integrated EHR tools Increase adoption of EHR tools at the provider level Reduce variation in work flows Maximize revenue opportunities based on HITECH/MU payment schedules Focused on EP (Eligible Provider) attestation Engage Department Chairs and medical leadership in driving improvements

13 Initial Project Organization Meetings with COO, CEO, CIO and CFO to set institutional priorities Drafted a high level revenue opportunity timeline Executive sponsorship assigned to the CEO and CIO Work assigned to the COO COO drafted multiple work teams to perform gap analysis and create action plans Met every other Friday 3:30-5:00

14 Examples of Work Teams Technical groups focused on certification Privacy and security standards Medication reconciliation, patient summary, problem list, allergies Operational teams focused on clinic workflows to drive tool development and revision Intake, during visit, discharge Quality measure selection and measurement

15 Executive Committee Oversight Formalized an Executive Steering Committee Members included: CEO CIO CFO COO CQO Chief Privacy and Security Officer Medical Staff Executive Leadership

16 Role of the Executive Committee Formalized via a charter Key functions Reviewed report from work teams Served as decision maker at critical project junctures Resource allocation Finalized revenue projections for inclusion in the annual and 5 year budgets Approval of a communication strategy for key stakeholder groups

17 Operational Teams

18 Operational Teams Cross functional team Operations, Finance, Informatics, Training, Reporting, Quality, Safety Met weekly to discuss tool pilots, issues and road blocks Unresolved issues elevated to Steering committee

19 Components of EHR for HITECH EPIC for scheduling - Demographics In-take assessment form PSS (Patient Summary Services) Problems Medications Allergies Clinic Summary - clinical summary RxStar (e-prescriber, CPOE)

20 Electronic Tools Created Components of Intake Assessment Race and Ethnicity Smoking status Structured problems list Clinic Summary Clinic Summary printing mechanism Back-end reporting Reporting tools

21 Tool Challenges Back-end mapping across systems EPIC (Outpatient) Medipac (Inpatient) Clinic Summary Printing Reporting Operational Measures Meaningful Use Measures

22 Operational Roll Out Team Team Structure 4 Senior Operations Engineer 14 Operations Engineers 6 Clinical-RNs 8 Operations Roll Out Plan Cohort strategy Training strategy

23 Cohort Training Timeline 8/1/2011-8/31/2011 Complete Pilot of Star Tools 10/3/ /30/2011 2nd Cohort Training 4/2/2012-6/29/2012 3rd Cohort Training 9/1/ /1/ /1/ /1/2011 1/1/2012 2/1/2012 3/1/2012 4/1/2012 5/1/2012 6/1/2012 7/1/2012 8/1/2012 9/1/2012 9/1/ /14/2011 1/2/2012-3/30/2012 7/2/2012-9/30/2012 8/1/ st Cohort Training 3rd Cohort Training 5th Cohort Training 9/30/2012

24 Project Schedule WEEK_1 WEEK_2 WEEK_3 WEEK_4 WEEK_5 WEEK_1 WEEK_2 WEEK_3 WEEK_4 WEEK_5 WEEK_1 Team 1 Access Current State Team 1 Implement & Train Monitor & Tweak Team 1 Access Current State Team 1 Implement & Train Monitor & Tweak Team 2 Access Current State Team 2 Implement & Train Monitor & Tweak Team 2 Access Current State Team 2 Implement & Train Monitor & Tweak Team 3 Access Current State Team 3 Implement & Train Monitor & Tweak Team 3 Access Current State Team 3 Implement & Train Monitor & Tweak

25 Meaningful Use Rollout 1 st Cohort Cardiology 48 Medicare EPs Gastroenterology 21 Medicare EPs Internal Medicine 48 Medicare EPs Medical Oncology 13 Medicare EPs Neurology 32 Medicare EPs Vanderbilt Heart and Vascular Institute - MCE Vanderbilt Digestive Disease Center - TVC Vanderbilt Adult Primary Care Suite I, II, III, IV Vanderbilt-Ingram Cancer Center PRB Basement Vanderbilt Breast Center - OHO TVC OHO

26 Staff and Physician Buy-in During assessment phase main objective was to build relationship with faculty and staff Staff training was first Training was based on clinical assessment Some clinics required more training than others Training consisted of both operational workflow as well as tool training

27 Performance Monitoring Financial Modeling Audit Readiness

28 Performance Monitoring Operational Operational measures were more stringent than Meaningful Use measures Designed to measure everyday workflow accountability Based on every visit All providers measured using Tableau EPs NPs, Residents S.VANDERBILT.EDU/Presentation

29 Performance Monitoring CMS measures only Meaningful Use Measure and report only on EPs Two reports All CMS elements RxStar measures CPOE e-prescribing Business Objects reporting tool

30 Performance Monitoring Meaningful Use

31 Performance Monitoring Meaningful Use

32 Financial Modeling Identified approximately 700 EPs Central Business Office (CBO) coordinated the EP registration (individual signatures) CBO monitored billing thresholds Operations provided Meaningful Use thresholds CBO then completed the attestation process for each EP Established process for CBO to monitor new providers

33 Financial Modeling

34 Financial Modeling

35 Financial Modeling

36 Audit Readiness Created a template to cover all aspects of Audit Stage 1 Objective Stage 1 Measurement VUMC Interpretation of the Objective VUMC Applied Exclusions VUMC Measurement Calculation Certified EHR Technology Formal VUMC policy and procedure Training/Communication Data sources

37 Audit Readiness Documentation Menu Set Objective #10: Syndomic surveillance data MEANINGFUL USE 42 CFR 495.6(d)-(g) Stage 1 Objective Stage 1 Measure Medicare Eligible Professional (EP) Capability%to%submit%electronic%syndromic% surveillance%data%to%public%health%agencies%and% actual%submission%according%to%applicable%law% and%practice.% CMS%Denominator:% Not a calculated measure CMS%Defined%Terms: % Public%Health%Agency%![75!FR!44367*68]! 495.6(e)(10)(i) % VUMC%Interpretation%of%the%Objective%(and%rationale):% Performed%at%least%one%test%of%certified%EHR% technology's%capacity%to%provide%electronic% syndromic%surveillance%data%to%public%health% agencies%and%followkup%submission%if%the%test%is% successful%(unless%none%of%the%public%health%agencies% to%which%an%ep,%eligible%hospital%or%cah%submits%such% information%have%the%capacity%to%receive%the% information%electronically).% CMS%Numerator: % Not a calculated measure CMS%Exclusions: % 495.6(e)(10)(ii) % EP%who%does%not%collect%any%reportable%syndromic% information%on%their%patients%during%the%ehr% reporting%period%or%does%not%submit%such% information%to%any%public%health%agency%that%has%the% capacity%to%receive%the%information%electronically. % 495.6(e)(10)(iii) Menu Set Objective #10: Syndomic surveillance data StarPanel%2011.1% Position%Title(s)%(and%names%of%incumbents)%responsible%this%measurement:% Oversight:% Implementation:% Calculation%Documentation % Maintenance%Documentation:% Oversight: %HITECH%Steering%Committee% Implementation:%Administrative%Director%VMG%Admin%HITECH/Meaningful%Use% %Daniel%Bonn% Calculation%Documentation: %Assistant%Director,%Finance% %Scott%McConnell % Maintenance%Documentation: %TBD% Formal%VUMC%policy%and%procedures:% N/A% Training/Communication:% N/A% Data%source(s):% Not%a%calculated%measure% % % VUMC%collects%syndromic %information%and%routinely%shares%this%information%with%public%health%agencies. % However,%none%of%the%public%health%agencies%currently%accepting%syndromic%date%from%VUMC%were% willing%to%take%the%information%in%the%format%specified%by%onc%certification%(see%attached%ekmail). %VUMC% will%continue%to%work%with%the%public%health%agencies%to%be%able%to%submit%this%data%using%our%certified% tools,%but%for%now,%vumc%is%claiming%an%exclusion%for%all%vumc%providers%since%no%public%health%agency% could%take%the%certified%file%to%complete%a%test.% VUMC%Applied%Exclusions:% All%VUMC%EPs%are%claiming%an%exclusion%for%this%measure%due%to%the%lack%of%a%public%health%agency% capable%of%receiving%the%information.% VUMC%Measurement%Calculation%(including%numerator,%denominator%or%exclusions%as%applicable):% Not%a%calculated%measure% Certified%EHR%Technology:% Date%Last%Updated: %February%4,%2013% Date%Last%Updated: %February%4,%2013%

38 Lessons Learned

39 Executive Committee View Establish the Governance Committee with clear accountability at beginning of the project Gain consensus on how workflows and provider input drive tool development early in the process Hardwire a process to ensure ongoing quality data collection and reliability of data Begin look ahead to Stage II earlier currently analyzing 672 pages of the final rule

40 Operational View Informatics/Operational partnership is key Process flow must drive informatics tool development Operational roll out team to go from clinic to clinic was key to successful roll out Monitoring and quick follow up

41 Looking forward to HITECH II ICD 10 PQRS

42 HITECH II Implications for Hospitals Transitions of Care Summary of Care: The EP that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50 percent of transitions The EP that transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 10 percent of transitions either (a) electronically transmitted using CEHRT to a recipient or (b) using a nationwide health information network

43 HITECH II Implications for Clinics More Robust Clinical Summary including: Patient name, provider name and office contact information Date and location of the visit and reason for the visit Current problem list, medication list and medication allergy list Procedures performed during the visit Immunizations or medications administered during the visit Vital signs taken during the visit (or other recent vital signs) Laboratory test results and list of diagnostic tests pending Clinical instructions Future appointments Referrals to other providers Future scheduled tests Demographic information maintained within smoking status Care plan field(s), including goals and instructions Recommended patient decision aids (if applicable to the visit)

44 ICD 10 Overlap Informatics resource allocation to ICD-10 or HITECH? Utilizing CPO technology enhancements for HITECH and ICD-10 Physician workflow analysis leading to new technology to assist with ICD-10 Using new partnership with informatics and operations to drive ICD-10

45 PQRS and Other Quality Measures Kick-off plan Review the required data elements for each measure Determine what data is already being gathered in a reportable format Determine if we can gather missing data in a structured manner Update tools and workflows to gather new elements Develop a process to generate the file to upload to CMS

46 PQRS and Other Quality Measures Challenges We need to incorporate quality monitoring into our every day practice and workflows We can t let data collection negatively impact the workflows for the sake of checking a box A significant portion of the information will have to manually abstracted Resourcing

47 Questions