Our way to measure ROI: The Marina Salud Cerner Experience

Our way to measure ROI: The Marina Salud Cerner Experience Oslo, 31 st of October 2013 Juan Manuel Lacalle Martínez IT Development Manager

INDEX 1. Introducing Denia s Health Department 2. ROI study fundamentals 3. ROI samples 4. Conclusions

Denia s GEOGRAPHICAL Health Department SCOPE (I) Population: More than 150,000 residents (Health department is financed mainly per capita) Tourism: From March to October Municipality: 34 towns [ Dènia: approximately 40,000 Vall d Alcalà: around 200 ] Total area : 297 square miles (759 km²) Population density: 635 people per square mile (245 hab/km²) Geography: Complex orography. Numerous mountains, valleys and hilly coast

Department OPERATIONAL of Health. SCOPE Dénia. RED ASISTENCIAL MARINA SALUD 1 Hospital 2 Integrated Health Centers (Specialized care) 32 Primary Care Centers (Managed in 11 Basic areas)

Department OPERATIONAL of Health. SCOPE Dénia. (II) 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 depended 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 working together)

Example: Overview IT structure for CERNER MILLENNIUM support (VIII) Clinical Transformation 1. IT Strategy Simplifed Information systems map Benefits-measure-oriented 2. Hospital Information System scope Full support for HealthCare processes (Collaboration, Guidance, Continuity of care) EMR & Data driven (HIMSS Level 6 and 7) 3. Clear Change management strategy IT organization & service rules (three levels) 4. Clear Change management workflow Incident Management (Call center) Change Management (Clinical Transformation Office) 5. Representative users engaged & committed Results based agreement Clinical adoption leadership Transversal vision in change management 6. Clear and public rules to manage change Public priorization criteria (patient, professional, company)

Department 1. IT Strategy of Health. Dénia.

Denia s 2. Hospital Health Information Department System (VII) scope CERNER MILLENNIUM s implantation scope FIRST LEVEL CARE SERVICES BY SCOPE AMBULATORY HEALTHCARE EMERGENCY HOSPITALIZATION SURGERY AMBULATORY CONSULTATION HOSPITAL EMERGENCIES MEDICAL URGENT SURGERY DIAGNOSTIC PROCEDURES AND TREATMENTS PRYMARY CARE EMERGENCIES SURGICAL MAJOR HOSPITALIZATION SURGERY MEDICAL DAY UNIT HOME CARE EMERGENCIES INTENSIVE CARE MAJOR AMBULATORY SURGERY SURGICAL DAY CENTER HOME CARE MINOR AMBULATORY SURGERY OUTPATIENT PHARMACY OBSTETRICS SECOND LEVEL CARE SERVICES (SUPPORT SERVICES - ALL SCOPES) INPATIENT PHARMACY STERILIZATION IMAGING AND RADIOLOGY CLINICAL DOCUMENTATION PREVENTIVE MEDICINE BIOLOGICAL DIAGNOSIS ADMISSION REHABILITATION BLOOD BANK PRE-ADMISSION ARRANGEMENTS & APPOINTMENTS SOCIAL WORK

Denia s 2. Hospital Health Information Department System (VII) scope CERNER MILLENNIUM s implantation scope FIRST LEVEL CARE SERVICES BY SCOPE AMBULATORY HEALTHCARE EMERGENCY HOSPITALIZATION SURGERY AMBULATORY CONSULTATION HOSPITAL EMERGENCIES MEDICAL URGENT SURGERY Exception! (Primary Care Ambulatory Consultation) DIAGNOSTIC PROCEDURES AND TREATMENTS PRYMARY CARE EMERGENCIES SURGICAL MAJOR HOSPITALIZATION SURGERY MEDICAL DAY UNIT HOME CARE EMERGENCIES INTENSIVE CARE MAJOR AMBULATORY SURGERY SURGICAL DAY CENTER HOME CARE MINOR AMBULATORY SURGERY OUTPATIENT PHARMACY OBSTETRICS SECOND LEVEL CARE SERVICES (SUPPORT SERVICES - ALL SCOPES) INPATIENT PHARMACY STERILIZATION CERNER MILLENNIUM IMAGING AND RADIOLOGY CLINICAL DOCUMENTATION PREVENTIVE MEDICINE BIOLOGICAL DIAGNOSIS ADMISSION REHABILITATION BLOOD BANK PRE-ADMISSION ARRANGEMENTS & APPOINTMENTS SOCIAL WORK

Example: 3. Clear change IT structure management for CERNER Strategy MILLENNIUM support (III) Basics USERS High Management Committee; Clinical Record Committee Middle management End users Change Requests Incidents Querys DIRECCIÓN DE SISTEMAS Y TECNOLOGÍAS DE LA INFORMACIÓN User Request Management Reception Classification Knowledge management Analysis of impact Prioritization CHANGE MANAGEMENT Requirement management Analysis Design Implementation System Test User Aceptance Test Implantation (go live) Communication INCIDENT MANAGEMENT Search for known solution Escalation User conformity management Problem management Progress report Communication Incident Management vs Change Management All users can register incidents or queries, but not all users may request changes Change management requires communication between peers Three-level-based structure: Level 1 Direct End User support Help users in the use of the system Level 2 System Evolution & Clinical Transformation Adaptation management & implementation Level 3 Solution provider support management (SRs) Specialised support management (SLAs).

Example: 4. Clear change IT structure management for CERNER workflow MILLENNIUM support (V) Operational Functioning 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

Example: 5. Representative IT structure users for engaged CERNER & MILLENNIUM committed support (VII) Clinical Transformation CLINICAL TRANSFORMATION OFFICE Managed by Vicent Moncho (CIO) Coordinated by Dra. Ms. Elisa Teodoro (Obstetrics and Gynecology) Dr. Mr. José Chordá (Internal Medicine) Dr. Mr. José Mut (Pediatrics) Dr. Mr. Angel Mauri (Emergency) Dra. Ms. María José Mulet (Primary Care) Ms. Francisca Atiénzar (IT Manager) Mr. Juan Manuel Lacalle (IT Manager) Dr. Ms. María José Martínez (Biological Diagnosis) Dr. Mr. Jaime Poquet (Pharmacy) Ms. Ms. Carmen Bohigues (Nurse coordinator) Ms. Ms. Rosario Ivars (Nurse supervisor) Contract agreement signed with IT Department

Example: 6. Clear and IT public structure rules for to CERNER manage MILLENNIUM change support (VIII) Clinical Transformation DIRECCIÓN DE SISTEMAS Y TECNOLOGÍAS DE LA INFORMACIÓN COMMUNICATION SOLUTION GO LIVE 2º Nivel USERS High Management Committee; Clinical Record Committee CHANGE REQUEST Level 1 CHANGE REQUEST C T O PCP/ APPLICATION Change Request Reception Phase Classify Middle Management CHANGE REQUEST C A L L PCU DEVELOPMENT AREA Prioritise End Users INCIDETN QUERY C E N T E R SUPPORT AREA (HELP DESK) INCIDENT QUERY Development order fullfilment COMMUNICATION SOLUTION GO LIVE THIRD PARTY ESCALATION Reply (Feedback) Level 3 Technology Providers Development planning review APPLICATIONS SUPPORT. INCIDENT & CHANGE MANAGEMENT PROCESS INCIDENT MANAGEMENT PROCESS UNPLANNED DEVELOPMENT PROCESS (35% fte) Design decision support User acceptance test (UAT) INCIDENT RECEPTION PROCESS PROBLEM MANAGEMENT PROCESS GO LIVE PROCESS Go live support Phase CHANGE REQUEST EVALUATION PROCESS CHANGE REQUEST PLANNING PROCESS PLANNED DEVELOPMENT PROCESS (65 % fte) Go live plan validation CHANGE REQUEST RECEPTION PROCESS CHANGE REQUEST ESPECIFICATION PROCESS Communication validation

SAMPLES Facts Preoperative blood reserve Circuit early diagnosis of cervical cancer Automatic shipping of discharge reports to primary care Implementation of the rule for early detection of infection with sepsis Reduction of CXR applications in preoperative protocols First Sepsis algorithm implementation in Spain. No other hospital has been able to implement such a complex process Nurse satisfaction 95%. Nurses are more than 50% of the organization. Annual cost turnover of nurses could cost at least 1.7M 37.2% of physicians modified their CPOE thanks to Multum: Meds Adverse Events Each MAE cost arounds 3000 euros Triage time improved to 9.2 min. Medium ED LOS 6.48 hrs

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 11,728 977.33 0.56 report nurse discharge report content is generated automatically report Integration Continuity of care between Single database per 15 Minutes per 11,728 2,932.00 1.69 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.

PHYSICIANS: EXAMPLES OF QUANTIFIABLE BENEFITS Benefit Contents Millennium Contribution Impact Amount Cases Hours /year FTE Remote visits Interconsultations and remote Structured clinical 10 Time per visit 116,562 5,828 971 0.56 follow-up visits. %5 of following information available reduced from 15 ones. anywhere, at any time. Protocols integrated in the system. to 5 minutes Documentation Continuity of care between Single database per 10 Minutes per 11,728 1,955 1.13 areas. patient. discharge Documentation Operating Room Integration of monitoring devices 7 Minutes per major surgery 8,608 1,004 0.58 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 Avoiding 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: pre-ops Neurology, checks Cardiology, Endocrinology

CLINICAL DOCUMENTATION: EXAMPLES OF QUANTIFIABLY BENEFITS Benefit Electronic Medical Record 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 Contents The medical record is not paper-based Millennium Contribution Impact Amount Hours/year FTE Cerner Millennium 4 Minutes per 193,718 12,914.53 7.47 is the EMR movement (discharges, consultations, and minor surgery) Cerner Millennium 5 Minutes per major and 14,994 1,249.50 0.72 is the EMR minor surgery Message Center 5 Minutes per report 6,824 568.67 0.33 Coding Availability of all electronic clinical information Discharge report Discharge report is sent automatically to the Primary Care Physician Total 8.19 Some difficult to measure: Requests for passive archive When requested, they are digitized and incorporated into Millennium

MORE SAMPLES Preference cards Costs per process Stock reduced by 35% 500,000 Financial cost reduced by 34% 15,000 x 5 years = 65,000 Auto verification RIS-PACS 24-hour pharmacist is not required 4 pharmacists Avoids physical support 116,872 x 2.5/study x 5 years = 1,460,900 Tx X-ray 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 Time X-rays Cost (euros) Total (euros) avoided 84 days 112 12.02 1,346.24 1 year 988 12.02 11,875.76 5 years 4,942 12.02 59,402.84 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

AND MORE 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) 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 Clinical information related to the appointment Feedback in real time allows to react quickly in the event of incidents

Conclusions (our experience) Cerner Millennium s implementation project (2007-2009) We are using the same MILLENNIUM version since 2009 When we opened the hospital in 2009 many users, especially physicians, had a bad opinion about the design of the system, they weren t confident in the tool The Clinical Transformation Office (2010) When users get involved in driving the system with the Clinical Transformation Office they checked that the tool should be used to help them to do their job better applying a crossover vision to workflows When this inflection point was achieved, this implied from the organization perspective that some processes were improved HIMSS Level 7 (2011-2012) This was not a direct target for our company, but it was achieved as a consequence of this change in our ways of working Process improvement and ROI (2012 and so on) Currently is the basis for the CTO s internal philosophy and prioritization We can work this way because we can measure We can measure because we have the tools and the criteria to do that from the patient perspective, from the professional perspective and from the company perspective Same company, same tool, same people, different organization, different culture,, different results

Conclusions (our experience) 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 HIMSS level 7 award ceremony in Copenhagen 2012