David Kwo ehospital Programme Manager o Independent specialist in EHR implementation o Interest: integrated systems + integrated care o 35 years in healthcare management + IT o Worked on EHR projects in US, UK + Singapore o Last 30 years in UK CIO for NHS hospitals CIO for NHS in London o Implemented leading EHR products Epic, Cerner, Allscripts, GE + Meditech o Leader of Health IT practice of PWC, UK o Consulted for >100 hospitals o Responsible for Epic implementation at CUH 1
1. Standardisation in UK 2. Standardisation at Cambridge 3. Standardisation for Denmark } In 2003, National Programme for IT } Vision: standard EPR systems across the UK } 12.7bn programme across 5 regions } NW, NE, West, SE, London (where I was RID) } Catchword: Ruthless Standardisation 2
} My role: Regional Implementation Director for the London region } In charge of 1bn IT spend for 32 hospitals, 31 primary care trusts and GP practices } Impact on >150,000 doctors, nurses, allied health professionals, administrators } NPfIT: a failed national EHR standardisation programme because } Large IT suppliers = centre of change mgt IT suppliers didn t know health culture, EPR software Didn t know health change management Potentially part of the solution mix, but not the centre } Ruthless standardisation The programme was IT-led, not clinician-led Appointing a few clinicians to the team did not work Needed to put clinicians in the driving seat from start } Answer to your question: apocalypse 3
} Cambridge University Hospitals } Our Epic journey } Key lessons } Cambridge University Hospitals 4
Major academic medical centre in Cambridge, UK 1,000 beds; 9,000 staff; 192 specialties 66,000 admissions; 100,000 ED attendances 600m annual income Service and Research specialities: transplants, cancer, neurosciences, paediatrics and genetics, maternity care } Cambridge University Hospitals } Our Epic journey 5
} Jun 11: Procurement start } Dec 12 Business case approved } Apr 13 Award contracts (Epic,HP) } Oct 14 Go-live in 60 days } Single integrated record, accessible by all } Improved patient safety, quality care, outcomes } Clinical decision support } Standardised care, minimised clinical variation Reducing adverse drug events } Increased clinical productivity Reductions in test utilisation/drugs costs } Preventative/predictive care Increased compliance e.g. VTE assessments Early management of infections, sepsis, MRSA Improved chronic disease management e.g. diabetes, COPD, through patient portal 6
Our Epic journey - timeline ehospital Timeline 2013 2014 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Contracts 1. Training 2 months 2. Validation 2 months 3. Workflow, build 4. Testing, training, go-live 6 months 8 months 18 months } Inspiring leaders } Shopping for the right EHR } Mobilising staff } Managing the project } Controlling risks } Changing thinking } Transforming behaviour 7
Our Epic journey - scope Hospital-wide functions Departmental functions Specialty systems Other facilities 1. Orders 2. Clinical Documentation 3. Prescribing 4. PAS 5. Medical Records 6. Reporting/ D. Warehouse 7. Research 1. Radiology 2. Pathology 3. ED 4. Theatres 5. Clinics 6. Maternity 7. ICU 8. Pharmacy 1. Cancer 2. Cardiology 3. Transplant 4. Ophthalm y Interfaces Conversions Kiosk Patient Portal GP Portal Handheld devices etc. Large scale programme Communications and Engagement Operational Readiness Systems integrator Programme Management Office More discipline than methodology Configuration mgt (doc t, version) Project plan, risk mgt, benefits mgt Design Authority for IT Intelligent Client Function (ICF) 8
Risk Management: Embedded in project culture A pro-active process Issues are actions Risk Assessment: Impact x likelihood Risk Log Risk Manager Risk Reviews: Programme Board/month } Programme cost 40m Epic + 140 HP over 10 years } IT costs (% of hospital budget) 1.3% historically 2.9% now with EHR 4.7% industry standard (Gartner 2011) 9
ehospital direct benefits Increased formulary compliance 7,257,600 Fewer medical records staff 12,640,900 Fewer transcription staff 19,206,200 Fewer ward clerks 3,917,600 Fewer appointments/reception staff 8,648,600 Reduction in printing & stationary requirements 3,135,000 Reduction for unnecessary diagnostic tests 20,250,000 Income protection CQUIN payments 3,564,000 Income protection: Avoid 30 day readmissions penalties 7,460,100 Reduced senior nurse hours 10,149,300 IT staff salary savings transferred to HP under TUPE 8,064,000 Core IT system maintenance contracts 13,773,250 Other IT non pay 9,513,600 Total ehospital direct benefits 127,580,150 Support for transformational benefits (upside case) Reduction in clinical variations in care 0 Fewer adverse drug events 76,076,000 Increased nursing productivity (Agency nursing - Medicine Division) 892,500 Increased nursing productivity (Bank nursing - All Division) 53,793,634 Increased nursing productivity (Overtime - all divisions) 1,421,799 Preventative care - infections/sepsis 0 Reduced wastage of drug stock - saving of.25% on whole drug budget 1,304,750 Reduced antibiotic prescribing - saving of.25% on non- excluded drugs budget 306,000 Improved clinic scheduling 16,943,573 Improved theatre scheduling 0 Total transformational benefits support 150,738,256 10
} Epic application: 120 Core Project (20 months) 20+ Dept (12-18 months) 62 Trainers (3-4 months) 1000 Super-Users (3 months) Infrastructure: 100+ IT Epic staff: 61 Total staffing: 1,400+ staff Doctors 21 Nurses 20 Pharmacists 10 AHPs 18 11
Also } Part-time staff } Annual leave in UK } Office space } Post-live: 75% } Data: clinical terming (SNOMED CT) } Processes: for example Ordersets Discharge summaries Clinical coding } Clinical policies: Design Authority } IT applications: Design Authority } IT infrastructure: 6000 PCs (outsourced HP) } We have advantage of poor current state 12
} Cambridge University Hospitals } Our Epic journey } Key lessons } Scaling for large hospital staffing shock } Big bang approach the only way } Project management large scale needed } Staff budget up to go-live; post go-live } Project team offices these are serious } Infrastructure multiple sub-cultures } Scope management Design Authority } Epic is the best supplier and product } but, Epic is not strong on PM and testing 13
} Culture eats strategy for breakfast } What is clinical readiness to change? In US, doctors status is high: low readiness In UK, doctors status is high: low readiness In Denmark? } In my humble opinion Standardisation requires process automation first Also, standardisation is not the only objective You can raise standardisation, reduce variations and improve outcomes, but e.g. if this is achieved in a segmented, non-patient focussed environment, then we still have sub-optimised care overall Therefore, my view is that we need to see standardisation within a wider framework 14
} Integrated care needs integrated systems } Hospital based projects tend to focus on location specific care } Can lead to information silos } Potential medical errors due to lack of visibility of whole patient record/process across settings } E.g. drug contra-indications missed if clinical data is not shared between GP and hospital systems 15
} } The system should support all 1. People 2. Processes 3. Places The system should feature 1. Intelligence 2. Integrity of patient data 3. Integration across settings, teams, facilities Integrated System Model Processes People Places 16
Integrated System Model Processes People Assess Review Plan Schedule Order Prescribe Case manage Procedure Research Audit Educate Collaborate Prevent Pathway - - Places Patient Home Patients GP Doctor Nurse Specialist Call Centre Care Teams - - - - - - GP Surgery Hospital Clinic Community Clinic Integrated System Model a virtual 3D digital grid...not new concept Processes People Places P 17
Integrated System Model distinguishing features for integrated care Processes People Places P Integrated System Model distinguishing features for integrated care Processes People 1. Intelligence: Clinical decision support Preventative/pro-active alerts Protocols and guidelines Intelligent care pathways Clinical trial eligibility Places 18
Integrated System Model distinguishing features for integrated care Processes People 2. Integrity of data: Single electronic patient record Single data schema Single version of the truth Strong security model Strong information governance Places Integrated System Model distinguishing features for integrated care Processes People 3. Integration platform Fully integrated applications Fully integrated database platform Fully integrated technical platform P Places 19
} See Gartner Report G00206865 21 Sep 2010 20
} there is tangible proof of this model Acute EPR systems GP systems Community systems Patient portal Mental health systems Telehealth /care mhealth Social care systems 21
} Fully integrated EPR at core of architecture } Cross care settings } Case management } Telehealth communication channels } Patient access to doctor and health record } Population care } Consolidated disease register } Real-time embedded clinical protocols } Secure access by remote health facilities } Analytic tools for high volume complex data } Integrated care needs integrated systems 22
} it s really hard to replicate this model } Replication to achieve this model Route A single main EPR product across settings Route B multiple clinical systems products across settings (using interoperability standards IHE, HL7, ITK) Route C mixed economy 23
Intelligent Integrated Integrity Route A Route C? Route B? Integrated systems developments over time Intelligent Integrated Integrity Route A Route C? Route B? Integrated systems developments over time 24
} Integrated Systems are necessary for Integrated Care } There is a proven architectural model } Challenge: route maps to model } In my humble opinion Standardisation is essential Standardise clinical behaviours Across the depts in a hospital Across hospitals Across healthcare sites in the region Across the regions Standardise EHR/technology architecture to underpin it does this exist here? If so, Denmark can lead the world in standardising care in a truly patient-centred, integrated care way 25
} In terms of standardisation 1. National level in UK: mistakes made, apocolypse 2. Hospital level at Cambridge: on-track to standardise 3. In Denmark: you could be world-leaders in standardisation if (a) you have patient-centred organisational and technical standards in place (integrated care for the patient) (b) you have the right clinical professional and project management cultures in place } Standardisation National level in UK: mistakes made, apocolypse Hospital level at Cambridge: on-track to standardise At regional level in Denmark: you could be worldleaders in standardisation if (a) you have the true patient-centred organisational and technical standards in place (integrated care for the patient) (b) you have the right clinical professional and project management cultures in place 26
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Thank You } there is research evidence to show the benefits of this approach 28
Computerized clinical decision support systems for chronic disease management: A decisionmaker-researcher partnership systematic review Pavel S Roshanov1, Shikha Misra2, Hertzel C Gerstein3,4, Amit X Garg5, Rolf J Sebaldt3, Jean A Mackay6, Lorraine Weise-Kelly6, Tamara Navarro6, Nancy L Wilczynski6 and R Brian Haynes3,4,6* Implementation Science 2011 6:92 Results: Of 55 RCTs included trials, 87% (n = 48) measured system impact on the process of care and 52% (n = 25) of those demonstrated statistically significant improvements Sixty-five percent (36/55) of trials measured impact on, typically, nonmajor (surrogate) patient outcomes, and 31% (n = 11) of those demonstrated benefits. Conclusions: A small majority (just over half) of CCDSSs improved care processes in chronic disease management and some improved patient health. 29