Download ehr achievement - HIMSS Analytics

Honoring Industry Leaders In Health IT
Adoption For Improved Patient Care
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EHR ACHIEVEMENT
HIMSS16 Annual Conference & Exhibition
February 28 - March 4, 2016
Dear Friends,
The organizations featured on these pages are among an elite group at the leading edge of health IT,
achieving Stage 7 status on the HIMSS Analytics EMR Adoption Model ℠ and /or the Ambulatory EMR
Adoption Model ℠. They have demonstrated superior implementation and utilization of health IT that
has directly resulted in organization-wide advancement in patient care and operational efficiencies.
As market leaders, HIMSS and HIMSS Analytics share the dedication and commitment to moving the
industry forward through the optimization of health IT that these Stage 7 organizations exemplify.
Join us in congratulating them on their success.
Regards,
H. Stephen Lieber, CAE
President and CEO,
HIMSS
John P. Hoyt, FACHE, FHIMSS
Executive Vice President,
HIMSS Analytics
Congratulations on leading the way in health IT adoption for improved patient care.
HIMSS Analytics Stage 7 Cocktail Reception is brought to you in part by:
EHR Achievement
HIMSS Analytics EMRAM Stage 7
HIMSS Analytics Stage 7 status is awarded to hospitals and clinics that have reached the highest level on the EMR
Adoption Model (EMRAM) and the Ambulatory EMR Adoption Model. The EMRAM identifies and scores hospitals
and clinics using a progressively sophisticated eight-stage model that charts the path to a fully paperless
environment. This prestigious industry award was introduced in 2009 by honoring 15 organizations that had
attained Stage 7 in their EMR journey.
2015 Stage 7 Recipients
Avera McKennan Hospital &
University Health Center
76 Ambulatory Facilities
St. Elizabeth Edgewood
St. Elizabeth Florence
St. Elizabeth Fort Thomas
St. Elizabeth Grant
Bon Secours - DePaul Medical
Center
1 Ambulatory Facility
111 Ambulatory Facilities
Good Samaritan Hospital
Stanford Children’s Health - Lucile
Packard Children’s Hospital
Stanford
126 Ambulatory Facilities
26 Ambulatory Facilities
Carolinas HealthCare System Cleveland
Carolinas HealthCare System Kings
Mountain
Carolinas HealthCare System Lincoln
Carolinas HealthCare System NorthEast
Carolinas HealthCare System Pineville
Carolinas HealthCare System Union
Carolinas HealthCare System University
Carolinas Medical Center
259 Ambulatory Facilities
Centura Littleton Adventist Hospital
Centura St. Catherine Hospital
St. Catherine Hospital
St. Mary Medical Center
The Community Hospital
The National Institutes of Health
Clinical Center
Nebraska Medicine - Bellevue
Nebraska Medicine - Nebraska Medical
Center
4 Ambulatory Facilities
Leonard J. Chabert Medical Center
Ochsner Baptist Medical Center
Ochsner Medical Center - Baton Rouge
Reading Hospital
206 Ambulatory Facilities
Texas Health Arlington Memorial
Hospital
Texas Health Harris Methodist
Hurst - Euless - Bedford
Texas Health Presbyterian Hospital
Plano
WellSpan Surgery & Rehabilitation
Hospital
Yale New Haven Health System
Yale - New Haven Hospital
Congratulations on reaching Stage 7! Here’s a great way to
connect with other high-achieving executives from Davies and
Stage 7 organizations in North America
HIMSS Executive Institute
Designed exclusively for high-performing health IT leaders, HEI…
• Brings high-achieving health IT leaders together to understand, achieve and promote
optimal value from the use of IT in a health setting
• Allows members to share their extensive knowledge and experience to enhance
their own organizations’ business and clinical outcomes, and to support other
organizations in their journeys toward earning Davies and Stage 7 achievements
Driven by its members, for its members
All programming and activities of the Executive Institute are created by its members for its
members. HEI holds monthly webinars on member-chosen topics, including:
The HIMSS Executive
Institute gives Davies and
Stage 7 executives a unique
opportunity to meet and
mingle with their peers, and to
work together to continue to
positively transform health and
healthcare through the best
use of IT.
– Skip Hubbard
HIMSS Executive Institute
• Maximizing Value from Your Health IT Investments
• Revalidating Your Stage 7 Status + EMRAM v2.0
• Population Health, HIMSS Maturity Models and more
Join us at HIMSS16
HEI activities at HIMSS16 reflect current members’ networking and education needs:
•
•
•
•
HIMSS Executive Institute Lounge, with daily breakfast and lunch discussions
Roundtable Luncheon: Cybersecurity Challenges to Your Organization and Its EHR
Reserved seats at the SUPERNAP Data Center Tour
VIP seating at keynotes
Share your experience and thought leadership with other high-performing
executives while enabling others to join your ranks as transformational
leaders. Join the HIMSS Executive Institute today.
Learn more:
www.himss.org/HEI
Profile
Avera Health System comprises over 15,000 health professionals and
support staff, including over 1000 physicians and advanced practice
providers committed to the mission and vision of caring for patients
in 7 states for over 100 years. Avera provides an array of services to
meet the needs of more than 2.2 million residents in the upper
Midwest with the base of operations in Sioux Falls, South Dakota.
Avera represents many physician specialties and 10 clinical services
lines in 5 geographic regions of care. These regions represent 38
hospitals, 21 long term care facilities, 160 clinics, with integrated
home health, and the award winning Avera eCARE telehealth
service.
All Avera facilities share a common, faith-based mission and vision,
centered on ministry, people, quality, service and financial stewardship. Avera is committed to delivering evidence based medicine
increasing the quality, safety and efficiency of care to our patients.
The Challenge
The Upper Midwest is rural in its setting. Vast distances exist
between care facilities for many of our patients. Avera Health has
harnessed technology to offer electronic alternatives for patients to
minimize travel from their home community to a larger, urban
center.
Avera Health has a long-term commitment to health information
technology. Avera has been HealthCare’s Most Wired and Wireless
since their inception for a total of 14 and 10 times respectively. In
addition, Avera won the Most Wired Innovator Award in 2011 and
2012 for Avera ePharmacy and eEmergency services. Avera Health
has placed a strong emphasis on system integration. Our Avera
Electronic Medical Record (EMR) is based on a single, integrated
record for each patient across the entire Avera Enterprise. In
addition, over the course of the MEDITECH implementation, Avera’s
largest hospital, Avera McKennan, has achieved American Nurses
Credentialing Center Magnet status four times, placing them in an
elite class of less than 30 hospitals in the world.
Implementation Overview
In 2006, Avera embarked on an enterprise EMR selection process.
We chose to continue our sixteen year relationship with MEDITECH.
The contract was signed in 2006. In November 2007, five hospitals
went live with the MEDITECH Client Server platform. We deployed
all clinical, financial and administrative modules. To complement
this implementation, physician and nursing leadership was
established in IT. At this same time, Avera went live with diagnostic
radiology picture archiving and communication system (PACS) in all
settings of care. From 2007 to 2014, Avera also installed what was
then Lake Superior Software (LSS) and now MEDITECH Ambulatory
in all of its ambulatory clinics. Other vendor partners include
Nuance®, GE Centricity™, Phillips VISICU® and Xcelera, OBIX Perinatal
Data System®, ProVation® Medical and QuadraMed®.
Progress and Innovation
In the fall of 2010, Avera began its computerized physician order
entry (CPOE) implementation. We partnered with Zynx Health™ to
provide content. A physician governance structure was created.
Physician Review Teams (PRTs) were responsible for reviewing and
maintaining content of order sets and electronic documentation
templates (pDoc). These review teams included a pharmacist and
nurse. In the fall of 2011, Avera went live with CPOE and electronic
provider documentation in all hospitals. We have maintained
greater than 90 percent utilization of CPOE and greater than 80
percent utilization of pDoc. As part of this implementation,
electronic prescribing of medications was implemented in all
hospitals and clinics. We currently are sending more than 10,000
electronic prescriptions per week.
In 2012, Avera began its journey “Transforming Patient Safety, One
Scan at a Time: Every Patient, Every Medication, Every Time” to 100
percent bedside barcode medication verification (BMV). We utilized
lean and Six Sigma principles throughout the implementation. This
process reduced the severity of medication errors by 33 percent.
Avera partnered with the South Dakota Health Information
Exchange (HIE) in 2014. To date, we have exchanged messages with
34 Health Information Services Providers (HISP), sent and received
over 350,000 Direct message transactions with 1100 providers
accounting for 189 facilities. Two highlights of this project include
working to coordinate long-term care with patient discharge
In 2014, with a state grant, Avera and MEDITECH partnered with the
South Dakota Department of Health to create a bidirectional
interface to the state immunization database. This one of the
nation’s only bidirectional immunization interfaces. This has created
enormous efficiencies for our hospitals and clinics as well as
preventing duplication of immunization for patients.
In 2015, Avera McKennan has implemented VOALTE® as our
inter-provider communication platform that lets care teams inside
and outside the hospital access and exchange information securely.
VOALTE® the vendor, is also an acronym for voice, alert and secure
text, combining these methods of communication into one application. Connexall® is the middleware for alerts from equipment (patient
monitors, nurse call) and critical lab values from MEDITECH. We
have the ability to assign appropriate patient care staff to appropriate alarms. Alarm escalation and cancellation is bi-directional with
secure text.
The Avera Clinical and Business Intelligence group has created
multiple dashboards, supported by our Health System’s Data
Repository (DR). Meaningful Use Measures and National Quality
Measures for HAC/HARM events, including Ventilator Days, Foley
Catheter Days, Central Line Infections, Catheter-Associated Urinary
Tract Infections, Antibiotic Utilization and C. difficile rates are
electronically abstracted, completely eliminating manually abstraction, allowing for aggressive local performance Rapid-Cycle-Process-Improvement by our clinicians. Avera Health is extending the
power of the DR and analytics into additional System strategies,
including predict appropriate staffing
models and Sepsis care. Avera Health is one of one hundred
hospitals selected by CMS to participate in the eCQM, electronic
submission of Clinical Quality Measures.
Avera has incorporated personalized medicine and pharmacogenomics as clinical decision in provider workflow. Our primary focus to
date has been on metabolism of opioids, neuropsychiatric medications, anti-platelet therapy, and tamoxifen for breast cancer. Prior to
surgery or treatment, a genetic profile is performed at the Avera
Institute for Human Genetics. A Personalized Pharmacogenomics
Report, including medication recommendations based on the
patient’s genetic profile, personal health history, and home medications is completed in Physician Documentation (Pdoc). This report is
sent electronically to the ordering provider. Rules were built in both
acute and ambulatory ordering modules to alert providers with the
patient’s genetic profile results when ordering these medications.
Return on Investment
Avera Health has successfully qualified for Meaningful Use Stage 2
for 100% of its hospitals and 98% of its providers. We completed
attestation for Stage 1 (both years) as well as Stage 2, Year 1 and will
attest to the same percentages for Stage 2 Year 2.
We have significantly reduced our hospital transcription by 90
percent, resulting in reduced costs for chart handling, paper charts
and personnel assembling those charts. The HIM department has
saved over ten million dollars since implementation of pDoc in 2011.
Space that was dedicated for these activities has now been
transformed into revenue generating space for our radiology service
line.
With a fully integrated EMR across all environments of care, we have
seen a significant reduction in days in accounts receivable.
The recent implementation of ICD-10 for the Avera system was a
“non-event.” Avera has seen no change in number of queries to
providers and reimbursement rates over the last three months of
2015 have remained stable.
Lessons Learned
With the 2007 MEDITECH implementation, there was a corporate
decision to create multiple health care information system (HCIS)
databases based on five geographic regions. This was not recommended as best practice; however, the corporate environment at
Avera during those years lent itself to this decision. Over the years,
this structure has created many difficulties with exchange of data,
standardization of workflows within our organization. Avera is
currently implementing the MEDITECH 6.1 platform. This will be a
single database implementation.
Looking to the Future
HIMSS Analytics Stage 7 “healthcare organizations support the
sharing and use of patient data that ultimately improves process
performance, quality of care and patient safety. Clinical information
can be readily shared via standard electronic transactions, with all
entities within health information exchange networks. This stage
allows the healthcare organization to support the true sharing and
use of health and wellness information by consumers and providers
alike.” We strive to be OneAvera in all aspects of care. The electronic medical record is no exception. Avera continues to make every
effort to be completely paperless in all facilities with the interests of
our patients, front and center of everything we do.
Profile
CHA is a three-hospital system based in Cambridge, MA. CHA acts as
the Cambridge Public Health Commission and Public Health Department of the City of Cambridge and serves as a teaching hospital for
Harvard University and Tufts University. CHA employs 4,323 staff,
including 690 physicians, and serves more than 140,000 patients in
Boston’s Metro North region. CHA has received NCQA Level 3 Medical
Home recognition for ten of its twelve primary care practices, achieved
HIMSS Stage 6 for Acute and Ambulatory in May 2015, and HIMSS
Stage 7 for Ambulatory in September 2015.
The Challenge
CCM: Cambridge Health Alliance is a safety net health organization and
cares for some of the most disadvantaged patients in Massachusetts.
This population is, by definition, high risk for poor health outcomes. As
part of our transition to the Accountable Care Organization, it is
important to identify those patients that are higher risk and provide
services to help them navigate the healthcare system. Our challenge
was to create a method by which to identify high risk population, learn
about the needs of this population, and create a system that can help
support this population to increase their health. The organization is
spread over 5 cities and the populations throughout those cities are
diverse. There are multiple different cultures, languages, and access to
healthcare in those different locations. We also provide different
services in each of these locations. Our goal was to help identify this
population, implement a complex care management program for these
patients, and increase the health of this population. We also hoped to
show a financial benefit by estimating the annualized cost avoidance
based on the emergency and Hospital services provided for these
patients.
Implementation Overview
CCM: The high risk population was identified by two methods. First,
primary care providers were given a list of patients who met certain
criteria of high ED and inpatient activity. They were asked to validate
that these were high risk patients in their panels and to complete
referrals to complex care managers. The complex care managers then
validated the PCP referrals to ensure that the patients were high risk,
using standard criteria including any of the following: a) more than 10
ED visits in a 12 month period; b) more than 3 inpatient admissions in
the 12 month period; c) greater than 75% inpatient stay probability; or,
d) greater than
90% risk score. These patients were required to have impactable
conditions such as chronic kidney disease, congestive heart failure,
severe psychiatric illness, substance abuse, diabetes, chronic obstructive pulmonary disease. After these patients were identified, they were
enrolled into complex care management. During this time the patients
were evaluated for barriers to improving their health and were
provided support systems to minimize these barriers. Complex care
managers also created patient care plans that identified each patient’s
goals and action plan.
Resulting Value / ROI
CCM:
Identifying high risk patient population:
We used a combination of criteria to identify a high risk population
with conditions that we could impact with complex care management.
About one half of the patients who were identified using high ED or
inpatient utilization were not validated by the primary care providers
as being high risk.
Willingness to participate:
About one quarter of the patients identified were appropriate and
willing to enroll in complex care management, but 40% of the patients
who qualified either declined participation or were unable to be
contacted.
Cost avoidance:
From the 77 patients in the high risk population identified and enrolled
into complex care management, an annualized cost avoidance of
$809,645 was achieved.
Patient care plans:
Care plans played a pivotal role in helping understand each patient’s
barriers, priorities, goals and services which would help the patients
improve their health. These care plans were reevaluated every 6
months while the patient was enrolled in complex care management.
Ream chose Imprivata Confirm ID because of the breath of two-factor
authentication options it supports. Ream was particularly impressed
by Hands Free Authentication’s ability to meet the user needs
outlined by his Clinical Informatics team. “Hands Free Authentication
is the key to maintaining meaningful patient-to-provider interaction,”
says Ream. “Ensuring that patients receive the time and attention
they need, without technology interruptions during their clinic visits,
is extremely important for improving patient satisfaction. With Hands
Free Authentication, prescribers no longer have to pay attention to
multiple screens or manually enter multiple passcodes. Instead,
prescribers remain patient-based while enjoying the more efficient,
technology-enabled workflows.
Lessons Learned
CCM:
Patient Identification:
It is critical that the healthcare organization identify high risk patients
including a validation process which includes the primary care
providers. This will help inform the selection process and help focus
attention on the very high risk populations.
Improvement Opportunity:
It is extremely important that the organization focus on patients who
have conditions which can be improved with additional services.
Engagement:
Many patients who are identified as being appropriate for complex
care management may either decline to participate or be difficult to
contact. This is a very difficult population since this population is
either not engaged in improving their health or has social/environmental barriers to engagement. Working on ways in which we
educate and improve the engagement of patients will be a continued
challenge.
Care Plan:
Creating a care plan provided the opportunity for the care manager
and the patient to sit together and document barriers and goals. This
allowed the complex care manager to focus on areas in which the
patient was engaged. The care plan documented the goals and action
plan and was reevaluated every 6 months, which helped improve
patient engagement and provide accountability for the patient.
Cost:
Providing focused services to complex care patients has significant
cost avoidance and is essential in providing complete care to complex
patients as well as providing a financial benefit to the organization.
Profile
Carolinas HealthCare System is the one of the nation’s leading public,
not-for-profit healthcare systems.
• 39 hospitals and 900+ care locations in the Carolinas and Georgia
• More than 7,000 licensed beds
• 11 million patient encounters per year
• 2,500+ system-employed physicians, 15,000+ nurses and 60,000
teammates
• More than 50 disease-specific certifications from The Joint Commission
• Charlotte region’s only Level I trauma center
• One of five academic medical centers in North Carolina
• One of the largest HIT and EMR systems in the country
HIMSS Analytics EMR Adoption Model Stage 7
2013 - Carolinas Medical Center Mercy
2015 - Carolinas Medical Center (including Levine Children’s
Hospital), Carolinas HealthCare System Cleveland, Carolinas
HealthCare System Kings Mountain, Carolinas HealthCare System
Lincoln, Carolinas HealthCare System NorthEast, Carolinas
HealthCare System Pineville, Carolinas HealthCare System Union,
and Carolinas HealthCare System University
HIMSS Analytics Ambulatory EMR Adoption Model Stage 7
2015 – Carolinas HealthCare System Medical Group (270 practice
locations to date representing 901 providers)
The Challenge
The Carolinas HealthCare System EMR program set out with a goal of
a single patient record across the System. This goal would require the
implementation of new EMR foundation capabilities, integration with
core revenue cycle and ancillary systems, and expansion of capabilities
including a Patient Portal and Health Information Exchange.
This foundation would then be built upon to further the vision and
system strategy of Carolinas HealthCare System with advanced
functionality such as decision support, evidence-based medicine, and
patient engagement tools.
OUR VISION
Carolinas HealthCare System will be recognized nationally as a leader
in transformation of healthcare delivery and chosen for the quality
and value of services we provide.
SYSTEM STRATEGY
Carolinas HealthCare System will achieve its vision through the
development of a single unified enterprise focused on developing
enduring relationships with our patients based on superior personalized service and high quality outcomes.
Implementation Overview
Carolinas HealthCare System began its EMR journey in 2005 to create
a single patient record across the System. In 2006, the implementation of nursing and ancillary documentation, pharmacy automation,
barcode medication administration, and order entry capabilities began
and spread across multiple acute facilities. Simultaneously physician
office deployments started which enabled key functions including
nursing documentation, electronic messaging among the care team,
electronic prescribing, and health maintenance alerts. The patient
had one electronic record enabling seamless flow of information
between care settings.
CPOE leveraging evidence-based medicine, provider documentation,
and advanced decision support capabilities followed in 2011 in both
the acute and ambulatory areas.
The implementation and adoption of these foundational EMR capabilities were integral to enabling more advanced capabilities including:
Resulting Value / ROI
Quality and Patient Safety:
• Creation of a paper-less environment
• VTE clinical decision support improved VTE ordering compliance from
71% to 96%
• Enabling over 15,000 annual virtual visits, with the EMR as a
foundational element
• The advancement of the Dickson Advance Analytics (DA2) program
utilizing analytics to identify, measure, and improve care and quality
outcomes
• Advanced decision support capabilities allowing advancement in
management of Sepsis, VTE, asthma, catheter infections, readmission
reductions, and overall quality measures
• MyCarolinas, the Carolinas HealthCare System patient portal,
advancing patient engagement and providing patients with a single
source to their
healthcare records
• The launch and implementation CareConnect, a Health Information
Exchange uniting all Carolinas HealthCare System facilities regardless of
EMR and connection with affiliated physician and hospitals across the
Carolinas
“As the first healthcare system to achieve Stage 7 for both hospitals
and physician offices in North and South Carolina, it shows our
commitment and dedication to our patients to provide access to
quality health and care,” said Craig Richardville, FACHE, MBA, senior
vice president and chief information officer. “Using the electronic
medical record to its fullest potential connects our clinical providers
and our patients across all points of health and care. That means our
patients experience a seamless integrated system of care from their
work or home, to their physicians’ offices, to the emergency department, to the hospital, at all points of care. Most importantly, our EMR
engages our patients to become full partners with their providers to
live healthier lives.”
• Improved the HBIPS Discharge measure from 72 % to 89% through
Q3 2015
• Improved IMM from 98% in 2014 to 99% through Q3 2015
• Over 98% of all inpatients are managed via an evidence-based order
set
• Improved Ambulatory Appropriate Care Score by over 30 percentage
points
Efficiency and workflow:
• Savings through a greater than 60% reduction in transcription lines
• Scanning of documents on the nursing units reduced time to
availability in the EMR by as much as 3 days.
• Establishing a paperless environment enabled centralization of acute
Medical Records and Coding operations
Lessons Learned
• Executive leadership and support for the EMR program and goals are
key to success
• A well-established governance structure to guide direction of the
EMR program and to prioritize optimization projects through objective
and value-based criteria will continue to serve the organization long
after initial implementations
• Engage physicians and clinician leaders in the design of
evidence-based content and EMR workflow design
• Your training approach must expand beyond preparing users for the
go-live event, to also support ongoing education, communication, and
coaching to cultivate adoption of best practices and achievement of
EMR goals
Profile
Centura Health, founded in 1996, manages the assets of two sponsors
under a joint operating agreement. For more than 100 years, Centura
Health hospitals and services have been helping people to live
healthier, longer lives. Our sponsors, Catholic Health Initiatives and
Adventist Health System, have long provided compassionate,
leading-edge care to those in need throughout the region. Our mission
is to extend the healing ministry of Christ by caring for those who are
ill and by nurturing the health of the people in our communities.
Centura Health is focused on providing affordable, world-class care
through an integrated network in Colorado and Western Kansas. Over
17,000 of the best hearts and minds in medicine, along with 6,000
physician partners, serve more than one million patients each year.
In 2007 we saw the potential to integrate several clinical systems into a
common, secure Electronic Health Record (EHR) system to make
patient health information available across all Centura Health facilities
while preserving patient privacy and information security. Centura’s
EHR currently contains approximately 2.4 million patient records,
making it the largest integrated health network in the region. Centura
Health has fifteen Stage 7 hospitals, with the most recent designation
of St. Catherine Hospital in Garden City, Kansas, in September 2015.
The Challenge
Centura facilities and the system as a whole had attempted several
times to address blood product management in the past. However, no
project had been truly successful or sustainable. With a dyad partnership in place, the CMO could bring to his colleagues convincing
evidence that Centura facilities were purchasing more blood than
others in our market, and more than our sponsor systems predicted
based on hospitals with similar service and size. Our VP of Supply
Chain participated in every discussion with the medical leadership and
committed resources to supporting an initiative to change our
processes and our clinical behavior. We embarked upon a blood
product management initiative in 2013 which included addressing the
clinical decision making around the use of packed red blood cells in
our facilities. At that time, 7.5% of admitted patients received a blood
transfusion, and each patient received an average of 2.96 units. To
address this, we set a goal during fiscal year 2013 to utilize a massive
transfusion protocol and embark on a system-wide educational
campaign to bring ED transfusion practices in
line with currently accepted guidelines. In 2014, we embarked on a
similar project targeting non-trauma, non-emergency related blood
utilization. We viewed this as an opportunity to utilize our EHR in a
manner that would benefit our patients and clinicians, while at the
same time properly managing the use of this very precious resource.
Implementation Overview
Our clinical content development process is governed by a multidisciplinary team comprised of physicians, nurses, informaticists, pharmacists, information technology, and quality and safety leaders. This team
meets with the clinical and operational leaders who want to effect
change in clinical behavior in order to work out each detail of the EHR
support for the clinical change project. In this instance, the content
management team worked with the trauma and ED directors to sift
through available options in adjusting the EHR and chose the best fit
for the problem being addressed. In 2013, our trauma service line
directors developed a system-wide consensus on utilization of pRBC
during trauma resuscitation. Our ED Directors agreed on a standardized approach to transfusion in non-trauma emergency cases.
Acknowledging that these resuscitations are quite fast paced and
generally the physician does not spend a lot of time at a computer in
the midst of these situations, it was felt that a standard ED transfusion
order set, if written well, could facilitate appropriate use of blood
products during ED resuscitation. This order set was written and put
into production in mid-2013. All other avenues to order transfusions in
the ED were removed from the EHR at that time.
To address non-trauma blood product utilization, in 2014 we convened
a group of subject matter experts (including blood bank experts,
pathologists, hospitalists, orthopedic surgeons, trauma surgeons, and
ED physicians) to develop guidelines for safe and appropriate use of
pRBCs in non-trauma, non-ED situations, and developed an education
campaign for our medical staffs. We confined transfusion ordering to
an order set, fixed the quantity to default to one unit, and instituted a
new decision support rule in our EHR to support our new guidelines.
However, these guidelines had to include a unique aspect that
acknowledged the fact that we deliver medical care in some locations
that are at elevations above 6500 ft. Only with our ability to acknowledge and validate the medical decisions that are made for transfusion
targets at high elevations were we able to reach system-wide consensus on implementation of this new decision support pathway.
The following are identified as generally accepted thresholds for
transfusion of pRBCs at Centura Health:
• HGB less than or equal to 7 g/dL
• Acute blood loss: > 20% Estimated Blood Volume
• Hematologic or oncologic diagnosis
• Hgb 7-10 g/dL with underlying disease that could cause tissue hypoxia
(Acute MI, CVA, CHF, COPD for example)
• Elevation > 6,500 ft
When pRBC transfusion is ordered and the most recent hemoglobin
is greater than 7.0 g/dL, the ordering provider will be asked to
indicate the reason for transfusion. Also, it is recommended that
only one unit of packed red cells be transfused unless the patient is
actively bleeding or in an emergency situation so that the hemoglobin and clinical situation can be re-evaluated to determine the need
for additional units.
The intended outcome of this 2-year long project was to ensure
that we are using this precious resource in clinically appropriate
situations and not putting our patients at unnecessary risk by
transfusing blood when other means of treatment may be more
appropriate.
Changes made in the EHR included:
• We restricted the ability to order a blood transfusion to an order set.
• For the ED order set, we specified the quantity for each blood product to
speed order entry.
• For the inpatient transfusion order set, we defaulted the number of pRBC
units to transfuse to one.
• For non-trauma patients, we instituted a rule that checks that most recent
hemoglobin, looking back 72 hours across encounters. If the most recent
hemoglobin was 7.0 or greater, the ordering provider receives a warning.
Override reasons include one of high elevation of the treatment site
or of the patient’s home address, in addition to other clinically appropriate reasons for an override. We developed education regarding
clinical indications for transfusion including the more restrictive
hemoglobin threshold now accepted as reasonable, the ‘new’ principle of transfusing the least amount needed, and introducing the alert
described above. This education was presented to each of the 15
hospitals medical staffs via meetings, conferences and existing local
communication methods.
Resulting Value / ROI
Since the inception of the project we have experienced a 58 percent
decrease in the utilization of pRBCs compared to 2012. In 2013, 7.5
percent of our admitted patients received transfusions, whereas in
2015 only 6.2 percent received transfusions. This constitutes 2,328
patients who were spared the risks of blood administration as a
result of this effort. Additionally, in 2013 our units/patient ratio was
2.96. In 2015 this was reduced to 2.74. All facilities have shown a
decrease in both the number of units transfused and the number of
patients who received transfusion, despite an overall growth in
number of patients treated in our system.
Because transfusion reactions and adverse events are relatively rare
and there is poor consensus on incidence, it is difficult to quantify the
avoidance of adverse events for patients. However, conservatively,
we may have avoided 23 acute febrile reactions, 4 cases of TRALI and
one case of TACO. BBGuy.org Reaction Summary Chart; © 2012, Joe
Chaffin, MD
Given a cost of $225/unit of pRBC, $40/unit processing cost (does not
include complex antibody processing, or nursing administration), and
6,542 avoided units, we estimate our two year cost savings to be
approximately $1.5 million.
This change in clinical decision making required approximately 6
months of clinical expert meetings, four months of educational effort
and two changes in our EHR. Although our clinical pathology
colleagues had worked to change behavior in this area for several
years prior, the key factors to the success of this attempt was the
involvement of our supply chain colleagues and our newly functional
EHR content management process.
Lessons Learned
This project succeeded because our content management process
developed strong support from physicians, blood banks, supply
chain and analytics. The key difference was the involvement of our
supply chain experts who brought an area of expertise to the table
that had previously been untapped. These experts were essential in
bringing our blood product vendors into the discussions so that we
could better understand the supply chain from donation to
administration. Their involvement also provided us with comparative data and Centura-specific purchase and waste data that was
needed to signify the importance of this project. The creation of the
dyad leadership model between supply chain and medical leadership has been invaluable in our successful execution.
Dividing the massive topic of blood product utilization into smaller
segments by asking the trauma experts to work together and
address their needs, then sequentially asking the ED, then non-trauma medical experts to follow suit, was done as a practical matter
originally, but in the end was seen as a smart method to slowly
address the culture change that was needed. Discussions with
involved or affected physicians in one group cross-pollinated the
other groups, so that the non-trauma change management was
quite minimal.
Profile
Community Healthcare System (CHS) is comprised of three
not-for-profit hospitals in Northwest Indiana: Community Hospital in
Munster, St. Catherine Hospital in East Chicago and St. Mary Medical
Center in Hobart employing 6582 healthcare providers. CHS is an
875-bed system with 40,477 annual discharges, 212,579 patient days,
556,821 outpatient visits and 131,582 ED visits making CHS the one of
the busiest systems in Northwest Indiana. The CHS vast network of
care locations includes Hartsfield Village, a Continuing Care Retirement Community in Munster, outpatient, physician practices,
behavioral health, occupational health, home care, a medically-based
fitness center, cancer research foundation, cancer support center
surgical and rehabilitation centers. Community Healthcare System
hospitals are regional leaders in orthopedics, cardiac cancer care,
women’s health services and bariatric medicine, and offers a broad
range of healthcare services. Organizationally, CHS has been highly
recognized for quality care and acknowledged for meeting the highest
healthcare standards in the nation by The Joint Commission (TJC) and
has been ranked among the top 1% in the nation for overall clinical
excellence. CHS supports the area's largest cancer treatment and
research programs, which is linked to the National Cancer Institute
and major research cooperatives around the globe.
The Challenge
On April 28, 2014, a middle aged male walked into the Emergency
Department of Community Hospital with typical symptoms of a
respiratory infection including cough, fevers, and fatigue. He was
evaluated and admitted to the hospital with respiratory isolation
precautions and a presumptive diagnosis of bacterial pneumonia. The
next day while being evaluated by an infectious disease specialist,
there was a suspicion for Middle East Respiratory Syndrome (MERS), a
new viral pathogen not yet seen in the United States. Within 48
hours, the Indiana State Department of Health (ISDH) had a possible
positive diagnosis in lab testing and the Centers for Disease Control
and Prevention (CDC) confirmed the positive finding the next
afternoon. The CDC held a national news conference confirming their
findings within an hour of their confirmatory testing.
In the 16 hours between the possible positive lab testing by the ISDH
and the CDC confirmation, we had to identify every hospital staff
member, clinician, visitor, patient and EMS personnel that might have
been exposed to this highly contagious virus with a presumed
mortality rate of roughly 30%. The patient had traveled throughout
the hospital including ED registration, ED waiting room, ED treatment
room, radiology, multiple elevators and onto an in-patient nursing
unit. When we were informed of the positive lab confirmation, we
had one hour to notify every individual on this list, pull them from
active duty, immediately replace each one in a mission critical role and
others within an acceptable time frame. We had to continue to
deliver on our Mission to provide highest level of quality healthcare to
our community. Through the utilization of multiple technologies, we
were able to identify 53 employees that were exposed to the patient
before additional CDC requested isolation protocols were initiated.
Great care was placed on crafting appropriate messages to our
employees, physicians, patients, media and the community. Providing
credible, timely information to reduce fear and misinformation to all
audiences was critical. Immediate steps were taken to develop
messages and provide access to information in a variety of ways. We
quickly discovered that the amount of phone calls and inquiries from
both internal and external sources was overwhelming. Hot lines to
receive phone calls were set up in conjunction with the ISDH as the
hospital’s operators were unable to field the volume of calls received.
During the first 48 hour period, our hospital operators processed
more than 300 calls and inquiries. We had another 300 calls placed in
the external media line that we set-up. This call volume does not
include all the calls make to the ISDH.
The next couple of weeks of intense local, regional and national
media attention, on-site CDC monitors and advisors, and resource
management via our Incident Command Center created a high
degree of distractions that could have led to an increased level of
errors, delays in care and nosocomial spread of the virus. We also
had to very carefully protect the confidentiality of the individual with
the MERS virus while under a high level of public scrutiny and
concern. Our ability to rely on the workflows and policies we built
and solidified during our clinical transformation across the system
with the implementation of EPIC, prevented us from wavering in our
Mission.
CHS was able to safely provide care and fulfill the mission without
any safety lapses or delays even with a large contingency of staff on
leave for 14 days while they were monitored daily for signs of MERS.
With the integrated use of technology, swift and quick action was
taken to identify, contain and address the needs of the organization
and the community. No other individuals contracted the MERS Virus
from CHS.
Implementation Overview
In July of 2009, we started our journey towards an integrated EHR to
tie together clinical, financial and operational objectives. We went
live at each of our three hospitals in 2011 in a phased approach with
full documentation and rolled out CPOE 12 months later. Various
module implementation and system optimization have been ongoing
with strong executive support. As we have become virtually
paperless, the EHR functions across the continuum of clinical care
provided with almost every clinical staff member entering information into the electronic patient record. This makes it easy to track
who has been providing care to which patients and when.
During product selection for call-light/nurse-call system, we were
specific in the requirements for clinical integration, enhanced patient
safety and improved communication as goals. In addition to
implementing a traditional nurse-call system, CHS’s goal was to
include enhanced technology integration which included hand held
phones, staff tracking and integration with clinical documentation in
Epic. Multiple vendors were evaluated, CHS chose Rauland Technologies for the nurse-call system, integrated with Ascom wireless
phones and Versus GPS tracer tag technology. One of the benefits of
the Rauland’s call-light system was not solely to improve direct
patient care, but to have supporting documentation through the
electronic system to validate how much time was having to be spent
in the patient’s rooms. This advanced technology allowed us to
“right-size” staffing measures to reduce waste and to make sure we
had the correct amount of staffing mix.
Goals for the integration of these technologies are as follows:
Call-light system integration
1. Provide immediate notification to the “mobile” nursing staff.
2. Provided concurrent and retrospective data to allow for utilization
of statistics.
3. Long range plan for future integration with ongoing development
and technology to enhance care for both immediate and future
needs.
4. Allowed a stronger connection between current personal devices
(ASCOM/pagers) and patient care.
5. Provided evidence in length of time that call-lights were on
without being answered in effort to allow staff to see and improve
their performance.
6. For improved security, we also installed video cameras in the
public areas of the Emergency Department and many hallways on
our inpatient floors.
This allowed our security team to oversee the safety of staff and
patients at all times.
Resulting Value / ROI
Once the employees were identified who were exposed to the MERS
virus, management’s primary focus was to insure the health and
safety of the staff, patients, visitors and the community at large. It
was imperative all individuals exposed were quickly and accurately
identified and communicated with to elevate questions and mitigate
fears. A comprehensive plan was provided to the exposed individuals and an initial plan for their safety was provided. Once the
employees were communicated with, they had the initial set of
blood work done to test for the virus and mandatory two week
isolation period began to isolate those employees to decrease any
exposure of the virus to others. Since this was the first case in the
United States and limited data was available from the World Health
Organization, the CDC was unsure of the risks of exposure. So the
hospital acted with an abundance of caution in the approach to the
MERS CO-V virus. Utilizing CHS’s technology investments, CHS was
able to identify all exposed employees and reduce fear of individuals
who were concerned they had been exposed. CHS followed the CDC
and ISDH guidelines for persons at highest risk of developing
infections. Those with close contact of the case where defined as
any person who provided care for the patient including a healthcare
provider not wearing recommended personal protective equipment,
family member or someone with similarly close physical contact, any
person who stayed at the same place (e.g. lived, visited) with the
patient while the patient was ill. The following was how CHS
leveraged these technologies:
1. EPIC
Utilizing our Electronic Medical Record, reports were utilized to
determine who documented on the patient before the isolation
protocol occurred.
2. Rauland/Versus/ASCOM
Utilizing the nurse call system and tracer logs, CHS was able to
determine the staff who came in contact with the patient, the time
of the exposure and the job classification of the employee.
3. Security Cameras
Utilizing the security cameras, CHS had the ability to identify staff
who entered the room as well as visitors or other patients that had
been exposed to the patient while waiting prior to treatment. Active
surveillance determined no visitor or other patients were exposed to
the virus while waiting.
4. CHS determined the no patients or visitors were exposed to the
MERS Co-V virus. However, it was determined 53 employees were
exposed prior to CDC enhanced isolation request.
5. Testing for the employees and family of the patient was implemented as defined by the CDC and the ISDH.
6. No visitors or other patients were exposed during the patient’s
stay.
Lessons Learned
• The CDC was able to get valuable information on exposure rates to
document and learn the risks of transmitting MERS between
patients. Since the World Health Organization had limited data, this
one case through the technology tracking abilities implemented,
provided data that may have taken 100s of cases to identify
• Hospital staff want to do whatever they can to improve patient
care and that includes using modern technology. Once staff
overcame their initial fears, they have adopted to an EMR completely. This is evidenced by the fact that it took us only twenty-four (24)
hours before we switched from an implementation process to an
optimization one. Roughly three (3) years after transitioning to an
EMR, staff went from a complete paper-based EMR to an electronic
one and felt delayed when an unplanned downtime required a
temporary switch back to paper.
• It is important for staff to remain current on technological
advances in healthcare so they could determine how best it can be
used to enhance patient care. Staff adopt to new technology better
when they are involved in the selection and implementation. They
want to make sure that it will enhance patient care and not solely
change it.
• Communication – Integration of a communication system, i.e.
telephones, is important and essential to handle large volumes of
calls. Long range plan for integration of telephone services
system-wide was implemented following this incident. Consistent
feedback to stakeholders is necessary to reduce gossip and reduce
fear
• Vendor support is essential to managing a crisis especially with
usage and optimization of technology available as well as rapid
changes that need to occur especially in an EMR.
Profile
Hattiesburg Clinic is a physician-owned multispecialty medical group
that was established in 1963 in southeast Mississippi by 10
physicians. It has since grown to 350 providers covering 41 specialties, serving a market area of approximately 525,000 patients and
providing outpatient services of over 750,000 office visits and 22,000
surgeries annually. To improve healthcare in Mississippi, the state
with the highest chronic disease burden, worst mortality rate, and
lowest physician-to-patient ratio in the U.S., we believe that expansion of the care team is crucial. Furthermore, a better delivery model
for population health is contingent upon having standardized tools
and workflows that are electronically connected throughout an
organization such as ours that spans over 80 locations and 18
counties.
Summary
In 2014 and 2015, Hattiesburg Clinic developed 4 programs that have
relied heavily upon clinician input and EMR tools to streamline
workflows and improve quality:
1. Diabetes outreach:
We have expanded the care team into rural areas to deliver endocrinology services, so our patients no longer have to commute such long
distances for these specialty resources. Using a team composed of an
endocrinologist, nurse practitioner, dietician, and case manager,
patients receive comprehensive diabetes care in their primary care
physician’s office, and the care plan and results are incorporated in
the shared medical record amongst all team members. We provide
the case manager with standardized documentation and reporting
tools, along with dashboards to display performance metrics and
analytic tools. The case manager has frequent points of contact with
patients between office visits using a variety of communication
methods including mail, telephone, patient portal, and telemedicine.
With identification and addressing of social and behavior barriers,
intense education and connection to resources, and frequent
medication adjustments made via electronic messaging between the
members of the care team and patients, results have been very
positive. Over 250 diabetics have been enrolled, and 97% have had
sustained A1c reduction over the course of 18 months. Average A1c
has improved from 9.6 to 7.5, and the percentage of patients with an
A1c greater than 9 has plunged from 59% to 1%.
2. Chronic Pain Management:
Standardizing the workflow with the use of EMR tools has allowed for
better assessment and monitoring of patients. Using tablets in the
waiting room, patients complete questionnaires such as PROMIS and
PHQ-9, and the discrete data is immediately incorporated into the
medical record at the visit. With synopsis reports, this discrete
patient-entered information is correlated with medication dosing,
drug screens, labs, pain contract material, and results of imaging
studies and pain procedures. Genomic data is incorporated within
the medical record as well, and decision support tools alert providers
throughout the organization with metabolism information if narcotics
are prescribed. Pulling all this information together, a registry for
these patients allows for generation of reports for close tracking, and
this helps facilitate accordance with appointments, ancillaries and
medications.
Hattiesburg Clinic received the Stage 7 Award on
November 16, 2015
3. Medicare Annual Wellness Visits (AWVs):
Beginning in March 2015, a team of registered nurses was
employed to perform Medicare AWVs. Previously, these visits were
done exclusively by physicians in our organization; in 2014, only 801
visits occurred. Transitioning to this nurse-based program while
building standardized documentation tools to ensure compliance
with CMS requirements not only increased the number of visits
performed, but it also aided in the visits being done correctly.
Technology allowed us to be positive that these visits were
performed the same way in all of the 36 primary care locations. As
of December 1, 2015, we have completed 6,561 fully-compliant
visits and are projected to reach over 9,500 by the 12-month mark
of the program. More importantly, quality has improved as a result
of this project. Fulfillment of items such as depression screening,
Health Risk, Fall Risk, and ADL Assessments has improved from less
than 1% to 95% for patients seen in this service as nurses complete
a checklist of requirements for the visit and electronically notify the
primary care provider of concerns areas. Likewise, other wellness
items such as pneumococcal vaccination for patients over 65 has
improved from 33% to 68%, and mammogram screening adherence
has improved from 41% to 83%.
4. Medicare Chronic Care Management (CCM):
A desire to expand the care team proved to be a challenge in a
fee-for-service environment, so we felt that Medicare’s Chronic Care
Management code, new in 2015, was an opportunity to help fund
such efforts. Similar to AWVs, we again felt a standardized toolset
for enrollment encounters and serial documentation was needed
for this service to guarantee compliance and promote quality.
Technologically, we helped our EMR vendor develop those tools and
began providing the CCM service to patients in April. Clinically, a
steering committee of primary care physicians and specialist subject
matter experts developed 22 disease-specific protocols for following
these patients. With the implementation of each protocol, we built
disease-specific tools within the EMR to allow the nurses to
document discretely, track patients, and easily communicate with
patients’ primary care providers. Through December, we have
enrolled over 1,900 patients, and these numbers continue to rise.
Case managers have panel sizes from 250-300 patients and are
centrally managed but imbedded in the primary care settings. The
ROI on the venture has been favorable, and we continue to promote
the project and expand the efforts. Like with nurse AWVs, more
important than the quantity of services we have provided is the
outcome of this intervention. For instance, in the diabetic population, patients followed in the CCM service compared to Medicare
patients not followed in CCM are twice as likely to be up-to-date on
eye exam, foot exam, and lab testing. A further addition to this
project in the fall of 2015 was incorporation of predictive modeling
data to do two things: first to focus more intense management on
CCM-enrolled patients who are at higher risk of ER usage and/or
hospitalization, and second to promote CCM enrollment for the
patients with high risk scores. Beyond what is ‘required’ for CCM,
we are also capturing self-efficacy and intervention data to help
mold our efforts of the future. Leveraging the EMR has been critical
to the success of the CCM program, not only in performing the
services in a compliant fashion but also in a way that is advancing
our goal of providing better care. While still too early to make
conclusions regarding the ultimate long-range target of better
quality with lower cost, CCM has clearly had significant favorable
impact on both patients reporting a sense of feeling
better-cared-for and physicians reporting an ability to function more
efficiently and effectively.
We are still early in our journey of population health and have a
path ahead full of additional opportunities. We are making positive
strides, and it has only been by leveraging Health IT that we have
been able to take the important first steps toward closing care gaps
that are so widely prevalent in our region of the country. Looking
forward, we embrace the exciting challenges still to come, fully
understanding that using HIT is paramount to our efforts.
Profile
The MetroHealth System consists of one acute care hospital and 17
ambulatory sites with nearly 500 attending physicians, close to 400
physicians in training, 1,200 nurses and 6,500 total employees. On an
annual basis The MetroHealth System records about 1,000,000
ambulatory visits, more than 100,000 emergency department visits
(Level 1 Trauma Center), and approximately 28,000 inpatient admissions. The MetroHealth System is a teaching affiliate of Case Western
Reserve University School of Medicine and is the essential (public)
healthcare system in northeast Ohio.
The Challenge
The MetroHealth System was the first essential (public) healthcare
system in the U.S. to install the Epic electronic health record,
beginning in the outpatient setting in 1999. We wanted to continue
our leadership in the implementation, adoption, and innovative use
of health information systems and our commitment to health
information technology as one of the keys to becoming a successful
healthcare system of the future. Achieving HIMSS Analytics EMR
sm
Adoption Model Stage 7 status in our ambulatory settings
facilitated the expansion of our health information exchange to the
Social Security Administration and the Veterans Administration and
helped us standardize and streamline ambulatory work flows.
sm
Achieving HIMSS Analytics EMR Adoption Model Stage 7 status in
our hospital facilitated real-time/near real-time scanning and
elimination of paper processes to achieve a “paperless” healthcare
system, enhanced bar-code medication administration, and closed
loop pharmacy medication preparation, among other quality,
efficiency, and patient safety activities.
As an academic healthcare system, we also saw achieving HIMSS
sm
Analytics EMR Adoption Model Stage 7 recognition as a critical
foundation for additional teaching and research opportunities.
Preparing our case value studies forced us to evaluate the impact of
some of our electronic health record innovation to date. It also helped
us set up systems to further innovate in the future as we adapt to a
rapidly changing healthcare environment.
Implementation Overview
A multidisciplinary team of administrative, operational, clinical,
and technical staff began planning for our electronic health
record implementation in the mid-1990s. We became the first
essential (public) healthcare system to install Epic in the ambulatory setting beginning in 1999, and we have progressed over the
sm
past 15 years to achieve HIMSS Analytics EMR Adoption Model
Stage 7 status. Between 1999 and 2002, we installed Epic’s
outpatient scheduling, registration, billing and clinical care
(documentation and ordering) modules in all of our ambulatory
sites. In 2004, we installed Epic’s emergency department module.
In 2009, we installed Epic’s inpatient pharmacy system and
converted to Epic in all of our inpatient clinical care areas. In
2011, we turned on Epic’s health information exchange, personal
health record, and e-prescribing. In 2013 we implemented bar
code medication administration. In 2014, we transitioned to Epic
in our operating rooms and for anesthesiology and laboratory
information system.
Resulting Value / ROI
Ambulatory Areas
Depression Screening
Implemented 9-question Patient Health Questionnaire (standardized
depression screening tool) in all primary care sites to screen for
depression. Increased depression screening by 15 fold and diagnoses
of depression by 23%. (K Palcisco, DC Kaelber, R Cebul, and L Stokes.
Using Electronic Health Record (EHR) Tools to Improve the Screening
and Recognition of Depression. American Medical Informatics
Association Annual Symposium. Washington DC. 2013. [Abstract
Presentation])
Immunizations
Implemented immunization decision support for all pediatric
immunizations (our work in this area has been designated by the
Epic Corporation as a “clinical program” standard), as well as
developed automated messaging system to notify parents/guardians of adolescents due for immunizations, resulting in a 25%
increase in adolescent immunizations. (D Bar-Shain, M Stager, A
Runkle, J Leon, and DC Kaelber. Direct Messaging to Parents/Guardians to Improve Adolescent Immunizations. Journal of Adolescent
Health. 2015. [Accepted])
Pediatric Hypertension
Used Epic electronic health record data to extrapolate isolated finding
of underdiagnosed pediatric hypertension to expose system-wide
underdiagnosis of hypertension in children and adolescents (designed
as one of the top 10 breakthroughs in stroke and cardiovascular
medicine by the American Heart Association in 2007) (ML Hanson, PW
Gunn, and DC Kaelber. Underdiagnosis of Hypertension in Children
and Adolescents. Journal of the American Medical Association. 2007
Aug 22; 298(8):874-9. PMIS:17712071). Implemented clinical decision
support to increase the diagnosis of pediatric hypertension by 50%.
(D Bar-Shain, K Palcisco, PJ Greco, and DC Kaelber. Using advanced
electronic clinical decision support to improve the quality and
recognition of abnormal blood pressure values in children. Pediatric
Academic Societies Meeting. Washington DC. 2013. [Oral Presentation])
Referral Completion
Developed Epic electronic health record based processes to increase
the 30-day referral completion rate from ~48% to ~63% throughout
The MetroHealth System on all referrals. Resulted in ~6,700 additional visits and ~$1 million in increased net revenue per month throughout The MetroHealth System. (MH Fratantonio, A Masih, M
Kauffman, and DC Kaelber. Data to Dollars – Using Electronic Health
Records to Complete Referrals. American Medical Informatics
Association Annual Symposium. Washington DC. 2013. [Abstract
Presentation]).
Hospital
Acinetobacter Outbreak Support
Used a suite of Epic electronic health record based tools in support of
an Acinetobacter (pathogenic bacteria) outbreak. In conjunction with
other efforts, these tools decreased the incidence of Acinetobacter in
hospitalized patients by more than 60%. (Recognized by an Association
of Medical Directors of Information System award.)
Code Status Reconciliation
One of the first healthcare systems in the U.S. to implement code
status reconciliation in our Epic electronic health record at
discharge. This tool led to a 50% increase in the use of Do Not
Resuscitate - Comfort Care and a 100% increase in the use of Do Not
Resuscitate – Comfort Care Arrest – Do Not Intubate status in the
transition from the inpatient to the outpatient setting.
Duplicate Labs
Implemented several duplicate lab clinical decision support tools
that resulted in a 50% decrease in duplicate lab testing and saving
of thousands of dollars in expenses annually. (A Noto, P Greco,
and DC Kaelber. An analysis of clinical decision support for
repetitive urine culturing. American Medical Informatics
Association Annual Symposium. Washington DC. 2011. [Poster])
Heparin Errors
After a sentinel event related to a heparin overdose, implemented a suite of Epic electronic health record based tools and
redesigned a number of Epic electronic health record processes
related to heparin. In the three years since implementing these
tools and changes, no heparin errors with patient harm have
been identified.
System-wide
Health Information Exchange:
The MetroHealth System has conducted health information exchange
more than 250,000 times and currently exchanges information
thousands of times per day with other systems that have the Epic
electronic health record – the Veteran’s Administration, and the Social
Security Administration. We have shown that when robust health
information exchange occurs, upwards of 80% of the time a test is not
ordered that otherwise would have been ordered, and approximately
15% of the time, an inpatient admission does not occur that otherwise
would have occurred (DC Kaelber, R Waheed, D Einstadter, TE Love, and
RD Cebul. Use and Perceived Value of Health Information Exchange
– One Public Healthcare System’s Experience. Am J Manag Care
[Special Health Information Technology issue]. 2013; 19(10 Spec No.
10):SP337-343. PMID:24511888.
Our Epic electronic health record has also generally:
1. Increased research grant funding
2. Attracted and retained trainees and attending physicians
3. Decreased malpractice cases and led to more efficient resolution of
malpractice cases
4. Decreased operational costs and increase revenue in numerous way
Lessons Learned
Technical and “Non-Technical” issues:
Electronic health records are 10-20% about “technical” details/issues
and 80-90% about “non-technical” details/issues, which are critical to
getting the electronic health records implemented and adopted.
Implementation and Post-Implementation:
Although implementing electronic health records is a huge undertaking, implementation is only the “tip of the iceberg.” To achieve the full
value of these systems, most of the work occurs after the system is
live. The staffing, resources and structure is different during the
implementation and post-implementation part of the cycle, but do not
overlook post-implementation. Once a system is implemented, the
post-implementation phase lasts forever.
Informatics:
Developing an informatics team – made up of clinical staff who
understand the technical functioning of the clinical information
systems – is one of the keys to successful implementation, adoption
and ongoing use of a clinical information system, and seems to be
frequently overlooked/undervalued.
Profile
MultiCare is a not-for-profit healthcare organization with more than
10,000 employees and a comprehensive network of services
throughout southwest Washington. We are a 1,130 bed tertiary care
organization with 2,486 credentialed providers, 1,024 of whom are
employed. There are 42,426 admissions per year and 451,999 annual
outpatient visits.
Today, MultiCare is made up of five hospitals to include 4 adult and 1
pediatric trauma center. These consist of Allenmore Hospital, Auburn
Medical Center, Good Samaritan Hospital, Mary Bridge Children's
Hospital and Tacoma General Hospital. There are also numerous
outpatient specialty centers, primary and urgent care clinics, as well
as a variety of other services and community outreach programs.
MultiCare has 2 hospitals and more than 100 ambulatory clinics
which achieved HIMSS Analytics Stage 7 in January 2015. The
location now being recognized as Stage 7 is Good Samaritan Hospital.
HIMSS Stage 7 for Good Samaritan was awarded on March 23, 2015.
The Challenge
Our strategy involved the implementation of an enterprise-wide
electronic health record to create “one patient, one record”—a
seamless experience for patients no matter where they received care
at MultiCare. The ultimate goal of transforming the way care is
delivered at MultiCare led the executive team to conclude that an
investment in leading edge technology was the key to offering the
best care for our patients, to ensure patient safety, and to improve
the efficiency of our care teams. To reach our goal, MultiCare decided
to build our electronic health record using an integrated platform
instead of selecting various systems that were the “best of breed.” An
integrated platform would reduce the technical challenges and need
for interfaces common with non-integrated systems and our data
would be held in a single repository. Another key decision was to take
our concept of “one patient, one record” and expand this to include
our community. We decided to offer our community providers access
to the electronic health record by creating an Application Service
Provider (ASP) network called CareConnect™– giving regional
providers secure access to the patient’s data outside of the MultiCare
delivery system.
Implementation Overview
A multidisciplinary team of healthcare operations and information
technology staff spent 1996 reviewing ambulatory practice management systems with the goal to standardize to a single platform.
In1996 after much discussion of our strategic direction, Epic’s
ambulatory electronic health record (EHR) and practice management
applications were selected. The ambulatory clinics went live in
February 1998 with the practice management applications. The EHR
was implemented at our first location in August 1998. The roll out
across our ambulatory locations continued through 2000. In 2004,
the enterprise suite for inpatient and acute care was selected. A
formal kick-off was held in September 2005. In 2007, 3 hospitals
went live with admission, discharge, transfer, billing, revenue
applications, clerk order entry and an electronic medication administration record. In 2008, clinical documentation for all staff was
implemented along with Computerized Physician Order Entry (CPOE).
Several modules have been implemented since that time to include
Radiant, Home Health, Hospice, OpTime and Anesthesia. Bedside
Barcode Medication Administration was implemented in all areas
across acute care with the exception of Interventional Radiology and
Gastrointestinal Lab. Our current approach to implementation is big
bang, with all functionality going live at one time. This approach has
been used in our last two hospital implementations and in all of our
clinics. In addition, there is extensive device integration across the
system to include monitors, ventilators and Point of Care Testing
equipment. MultiCare currently has a single platform of Epic across
120+ sites of care.
Resulting Value / ROI
MultiCare has seen significant benefit...
Access:
o Know the patient’s story and ensure that the information follows
the patient
o Physicians can now access immediate, accurate patient information from anywhere at any time
o Patients can access their information via MyChart powered by
MultiCare
o Improved communications between clinicians
Accuracy:
o 27 percent increase in documentation of the plan of care by at
least two disciplines
o 30 percent increase in order legibility
o Electronic health record shows the same medications, patient
history, allergies, etc. at any location where the patient is seen
o Medication reconciliation is standardized throughout the
organization and built into clinical workflows
Efficiency:
o 75 percent decrease in callbacks to in-house pharmacies
o 30 percent reduction in transcription volumes
o Average 30 percent decrease from disposition time to patient
admitted time in the Adult EDs
o Operating Room scheduling turn-around-time under 2 minutes
o Mean laboratory order turnaround time reduced by 30 percent
o Median imaging order turnaround time reduced by an average of
50 percent
Financial Performance:
o $12M in net benefit as a result of improved Patient Responsibility
collections
o $5M reduction in claims with open denials
o $1,029,808 in avoidable write-offs
o $585,000 in staff reductions in Patient Financial Services
o $20M in improved cash collections
Lessons Learned
Executive Sponsorship and Ownership:
The implementation of MultiCare Connect must be owned, championed, and actively supported by organizational and clinical leadership. System implementations are often seen as IT projects, but
without the engagement of the clinical end-users and their leaders,
success cannot be realized.
Organizational Priority and Commitment:
As with any large organization, multiple initiatives and priorities will
compete for the “number one” spot. The success of an implementation of this magnitude requires consistent communication to the
organization about the electronic health record and the benefits it
brings both to the patient and employee populations. MultiCare
provided consistent messaging from the top down so that employees
both understood and were excited about MultiCare Connect. Leaders
were committed to meeting milestones and clearing obstacles. Even
staff members in support departments who never utilize the system
provided rallying encouragement during the implementation. During
the first week of the 2008 go-live, several of those departments
hosted cheering stations whose sole purpose was to encourage the
clinical staff and give them quick breaks from their work. Booths
featuring Las Vegas-style events, cooking demonstrations and the
opportunity to “limbo for a latte” let those who were deep in the
midst of their go-live learning curve get a well-deserved mental
break and see how the rest of the organization was behind them.
Investing in People:
MultiCare knows that a multimillion dollar technology investment
without an investment in people is just a very expensive technology
venture. Through seminars, brown bag sessions, education and
communication the project team made people the heart of the
implementation. Care for the patient is always at the forefront and
employees understand that their feedback is welcome and incorporated.
System-Wide Culture Change:
Moving from a paper record, or even a stand-alone electronic health
record, to a system-wide record requires the ability to be flexible and
open to change. Leaders from MultiCare’s Organizational Effectiveness Department hosted change management seminars to educate
staff members on simple things like attitude and environmental
changes they could make to help ease the transition. The project
team also presented “road show” demonstrations on the clinical
units, at department meetings, in doctors’ offices, and in the
cafeteria so that all future users could get an early look at the system
and be prepared to adopt our new electronic health record.
Have Fun:
Many members of the project team have worked on this initiative for
years (the original implementation of the electronic health record
began in our ambulatory clinics in 1998). Within the project, we try
to remember that encouragement, recognition, and time for levity
are key aspects of keeping those team members engaged.
Profile
The Clinical Center is the research hospital at the National Institutes of
Health (NIH) campus in Bethesda, MD and is the nation’s largest
hospital devoted entirely to clinical research. Since the hospital’s
opening in 1953, NIH scientists have worked with volunteer patients
to create medical innovations. Clinical Center successes include
pioneering the cure of cancerous solid tumors with chemotherapy;
the use of nitroglycerin to treat heart attacks; identifying a genetic
component in schizophrenia; conducting the first successful replacement of a mitral valve to treat heart disease; and the creation of blood
tests to identify both Acquired Immune Deficiency Syndrome (AIDS)
and hepatitis. These and other research concepts pioneered at the
Clinical Center have been adopted as standard practice in medical
treatment throughout the world.
The Clinical Center has been a leader in the “bench-to-bedside”
concept. Its specialized hospital design places patient care units in
close proximity to research laboratories. This model supports
interaction and collaboration among clinical researchers. The Clinical
Center also offers world-class training in clinical research for
physicians, dentists, nurses, medical students and other members of
the medical research team. This environment, offering access to the
most advanced techniques, equipment and ideas, attracts a global
network of scientists.
The original Warren G. Magnuson Clinical Center, built in 1953, adjoins
the Mark O. Hatfield Clinical Research Center, which opened in 2005.
The hospital has 240 inpatient beds, 11 operating rooms, 82 day
hospital stations, critical care services and research labs, an ambulatory care research facility and a complex array of imaging services. The
Clinical Center is also one of the few facilities in the world with
state-of-the-art infrastructure that allows for isolation capabilities and
infection control while patients participate in clinical research studies.
Patients at the Clinical Center consent to participate in research
studies, also called protocols, and are treated without charge.
Admission is selective: only those patients who have a medical
condition being studied by NIH Institutes or Centers and who meet the
specific inclusion criteria can enroll in the studies. There are currently
approximately 1,500 clinical research studies underway at the Clinical
Center, including those focused on cancer, infectious diseases, blood
disorders, heart disease, lung disease, alcoholism and drug abuse.
More than 500,000 patients from all 50 states, and from countries
around the world, have participated in clinical research at the Clinical
Center.
The Clinical Center began using an electronic medical record in 1976
which was configured to meet the unique needs of the research
environment. In 2004, the electronic medical record was upgraded to
the current system. Since then, the functionality has continued to
expand and extensive integration has been achieved with other
clinical and research systems at the NIH. In June 2015, the NIH Clinical
Center was certified as HIMSS Analytics Stage 7.
The Challenge
Pharmacogenomics, also referred to as pharmacogenetics (PG), is the
science that examines the inherited variations in genes that dictate
drug response and toxicity. Knowledge about PG can optimize the use
of medications.
Our goal was to implement clinical decision support (CDS) to provide
PG information and recommendations to the prescriber at the time of
medication ordering. We felt that sufficient information existed about
recommendations for drug-gene variation pairs so that obtaining
“genetic” information could be considered part of routine clinical care.
We first implemented CDS for medications where HLA gene variations
predict for severe dermatologic toxicity. In the second phase, CDS was
implemented for drugs where Drug Metabolizing Enzymes and
Transporters (DMET) gene variations can predict drug dosage,
response, or toxicity.
Implementation Overview
We felt that institutional support was critical to the implementation.
The Medical Executive Committee and the Director of the Clinical
Center enthusiastically supported our program. We formed a
Pharmacogenetics Implementation Task Force composed of informaticists, physicians, pharmacists, nurses, pharmacologists, and geneticists
to review the clinical information and to make clinical recommendations. These medication-related recommendations need approval
from the Pharmacy & Therapeutics (P&T) Committee prior to
implementation. The implementation task force has now become a
formal subcommittee of the P&T Committee and is co-chaired by a
physician and pharmacist.
Medications included in our PG program are configured on order set
forms, which allows combining medication and lab tests in one view and
also allows clinical decision support (CDS) algorithm to be configured
behind the order set form. The CDS first looks for the results of the
pharmacogenetic test. If the result is present, the CDS then provides a
recommendation specific to the test result and clinical information
known about the drug-gene variation pair. If a result is not found, the
prescriber can order the pharmacogenetic test directly from the order
set form.
We decided on a two-phased approach based on two primary factors.
The first phase was to implement CDS for medications where HLA-associated gene variations (i.e. abacavir, allopurinol, carbamazepine) are
associated with severe hypersensitivity reactions (i.e. toxic epidermal
necrolysis, Stevens-Johnson syndrome). Although these reactions are
not common, our institution felt that this was an important medication
safety effort and that preventing even one severe reaction was cost-beneficial. Our Department of Transfusion Medicine performs high-resolution DNA-sequencing for HLA gene variants. This allows us to control the
name of the test, which is important for data retrieval.
The second phase of the program was to implement CDS for drug-gene
variation pairs that are associated with DMET. One example would be
mercaptopurine and thiopurine metyltransferase (TPMT) where better
initial dose estimates which prevent severe hematologic toxicity can be
made by knowing TPMT metabolizer status. Implementation of this
phase required identifying a lab that can perform this test according to
CLIA regulations and in a cost-efficient manner. The DMET test we use is
a chip that can determine over 220 genes and over 1,000 single
nucleotide polymorphisms. We needed to devise a method where the
results can be transmitted from this outside lab into our EHR in an
actionable format to work with our CDS. This effort required a large
multidisciplinary team.
The clinical approach for the second phase is consistent with our overall
philosophy about making genetic information available to the patient.
PG genes are inherited and therefore do not change over a person’s
lifetime. We decided that all of the information is part of clinical care so,
rather than obtaining informed consent, we decided to create a
standardized education document. Although we implement CDS only for
P&T Committee approved drug-gene variation pairs, we make all of the
information available to the prescribers and to the patient either
through a .pdf file (phenotype data) or electronically (raw data). This
allows future use of the information and also allows clinicians to make
individual decisions about using the data, although we did not build
specific CDS for that drug. We consider this to be the preliminary steps
towards pre-emptive PG testing.
“ The power of an EHR comes from implementing
clinical decision support. As part of Clinical
Decision support pharmacogenomics is a key
first step to precision medicine.”
J. McKeeby, CIO, NIH Clinical Center
Resulting Value / ROI
• Optimized medication use and promoted medication safety by
reducing the possibility for adverse medication reactions, predicting
drug response, and predicting drug dosage.
• Clinicians adopted to the program and ordered pharmacogenetic tests.
• Patients, as gleaned from a presentation about our program, were very
enthusiastic about access to pharmacogenetic information.
• The very broad multidisciplinary approach brought several departments together into a much stronger bond than existed before this
project.
• Set the foundation for pre-emptive pharmacogenetic testing and for
other clinical genetic tests.
Lessons Learned
• Creation of an institutional approval structure in advance is critical to
the success of implementing a program that might be considered
controversial (i.e. providing “genetic” information).
• A multidisciplinary team is essential to implement complex decision
support. Our effort would not be successful if we didn’t include the local
experts from several disciplines.
• Be open to changes after initial implementation. Although we tested
the initial phase of the program with several medical groups, we made
several changes soon after implementation because several users
thought the program could be improved. Continued evaluation led to
further changes after one year of use.
“Positively affecting the treatment of our patients
is the power of precision medicine.
The implementation of Pharmacogenomics at the
NIH Clinical Center has been a success.”
J. McKeeby, CIO, NIH Clinical Center
Profile
Nebraska Medicine includes two acute care hospitals: Nebraska
Medical Center, a 621 bed acute-care facility, the state’s largest and
highest-rated hospital, and Nebraska Medicine – Bellevue, a 55 bed
full-service hospital. The hospitals serve patients from all 50 states
and more than 50 countries internationally.
U.S. News & World Report has consistently named Nebraska
Medicine the top hospital in the state and Becker’s Hospital Review
recognizes Nebraska Medicine as one of the 100 Best Hospitals in
America. Nebraska Medicine has an international reputation for
providing solid organ and bone marrow transplantation services and
houses one of the nation’s three biocontainment units that have
successfully treated patients with Ebola and is capable of caring for
anyone exposed to a contagious and dangerous disease. Nebraska
Medicine is designated as a Magnet hospital for nursing excellence
and in December 2015 achieved HIMSS Analytics EMR Adoption
Model™ Stage 7 for both Nebraska Medicine hospital locations.
The Challenge
Telemetry:
Nebraska Medicine has a complex and highly-specialized patient
population and high bed occupancy, in which all beds are MDI
tele-capable; however, utilization of telemetry significantly exceeded
benchmarks with like institutions. Data showed approximately 65
percent of patients hospitalized for longer than 24 hours spent the
majority of their hospital stay on telemetry and 70 percent of
telemetry orders were not canceled until the patient was discharged.
Excessive telemetry causes increased work for patient care teams,
who must respond to false alarms; can cause complications for
patients without risk for cardiac events or stroke; and can be taxing
on the organization’s Heart Monitoring Unit,. As Nebraska Medicine’s
patient population continues to expand, continued high telemetry
utilization would also require significant capital investment to add a
second central monitoring hub. Decreasing telemetry utilization
would ensure Nebraska Medicine staff could meet the growth needs
within the organization.
Ebola:
Nebraska Medicine has been a national and international leader in
preparing for bioterrorism. Nebraska Medicine houses one of three
of
the nation’s biocontainment units, which opened in 2005. When the
most severe outbreak of Ebola in history erupted in Africa in 2014,
Nebraska Medicine became a world leader in treating patients
infected with the Ebola virus. A natural evolution of this extraordinary patient care, the world looked to Nebraska Medicine to lead the
way in both screening and prevention of Ebola transmission in the
U.S. Nebraska Medicine was faced with a challenge to not only
determine the appropriate clinical care for acute Ebola patients, but
to ensure the biocontainment unit patients received the same safety
measures and standards of care as all other patients treated by the
organization.
Implementation Overview
Telemetry:
The Nebraska Medicine Clinical Effectiveness team, comprised of
clinical, technical and quality team members, has the goal of
optimizing patient care, reducing variability, decreasing cost and
improving patient outcomes. To support earlier discontinuation of
telemetry in patients, this clinical effectiveness team focused on a
commonly-reported reason for not discontinuing telemetry:
providers involved with a patient’s care were unaware of why
telemetry was started and therefore, were hesitant to discontinue it.
The clinical effectiveness team was able to leverage its multidisciplinary membership to implement changes within the system in 16
weeks. To remedy the identified situation, an indication requirement
was added to all telemetry monitoring orders. Additionally, a decision
support tool in the electronic health record was created to require
review of the telemetry order after 48 hours and provide a quick
method of discontinuing telemetry if no longer indicated.
Ebola:
Nebraska Medicine leveraged tools within the electronic health
record to provide comprehensive screening at all access points across
the care continuum and to document patient care being provided to
hospitalized Ebola patients within the biocontainment care area,
including medication administration and barcode scanning. Despite
care providers being clothed in protective gear from head to toe,
processes were developed to ensure EMR and medication safety
technology was integrated into the bedside care process. These tools
and processes can now be applied to other contagious diseases,
including the highly infectious Middle East Respiratory Syndrome
virus (MERS).
Additionally, in August 2014, shortly after the Ebola epidemic became
known, Nebraska Medicine quickly introduced a screening algorithm in
its emergency department. Leaders also identified a need for screening
and applying protective measures across all access points to clinical
services, including scheduled inpatient admissions and ambulatory visits
and procedures; by October 2014, an electronic version of the screening
process was developed and implemented organization-wide. The
electronic health record includes a “smartform” that is adaptable for
screening in corresponding patient care areas and provides decision
support, instructing caregivers which post-screening actions to take.
Best practice advisories were developed to ensure appropriate providers are notified following the screening and to alert providers if travel
risk factors were identified and isolation precautions should be
immediately adopted.
Ebola:
The successful development of protocols and practices in providing care
to Ebola patients and screening patients for Ebola led to national
prominence and grant funding for Nebraska Medicine. The return on
investment includes better preparedness for future events, for Nebraska
Medicine and the nation.
This initiative required close coordination between information
technology analysts; operational leaders across multiple patient care
areas; laboratory experts; training resources; report writers; and
infection control and infectious disease clinical experts.
• Creation of Nebraska’s Bio-Safety Level-3 laboratory on campus
As the Ebola epidemic continued, an additional need was identified:
conducting surveillance for community members and/or professional
caregivers who may have been exposed to the contagious Ebola virus.
With collaboration from local health departments, Nebraska Medicine
created a temperature monitoring application which allowed a care
team to easily record and monitor temperature and symptoms for
exposed individuals.
Resulting Value / ROI
Telemetry:
• Increase in provider-discontinued telemetry orders prior to discharge,
demonstrating that providers are evaluating the continued appropriateness of telemetry monitoring and discontinuing telemetry when
appropriate
• Decrease in percentage of patient days with telemetry, as orders are
discontinued earlier in the patient’s stay; the project goal was to
decrease average telemetry days per patient by 0.75 days and the actual
achievement was 0.85 days
• Estimated cost savings of $40 per day for an annual savings of
$560,000
• Reduction of Heart Monitoring Unit technicians’ workload by 12
percent, achieved in the first five months following implementation
• Additional benefits include an improvement in patient satisfaction
upon discontinuation of telemetry and a decrease in alarm fatigue due
to telemetry alarms
• National Ebola Training & Education Center (1 of 3)
• Regional Ebola Treatment Center (1of 10)
• Partnership with CDC and Emory University beginning in December
2014 to train U.S. hospitals, health departments and health care
providers
• Partnership with CDC to provide rapid Ebola treatment center site
visits/assessments to various U.S. hospitals (55 as of January 2016)
• Recognized as a global resource for information, training and research
• Development of The Nebraska Ebola Method, available on Apple
iTunes U
Lessons Learned
Telemetry:
Working in partnership with clinical care teams, technology can be
leveraged to provide information at the point of care to aid in decision
making. Clinical effectiveness teams can quickly identify the cause of
the problem and work collectively to identify technology solutions that
support patient care workflows. Rapid roll out of projects can be
facilitated through an effective governance and department structure to
support rapid, quick wins.
Ebola:
• Develop standard process to ensure technology is utilized at the
bedside for all patients, even when providers are clothed in protective
gear
• Develop a robust travel screen and algorithm that can easily be
modified and adapted for current disease profiles
• Ensure resources are available to be able to quickly modify the
“smartform” when necessary
• Identify an individual to assume leadership and act as the liaison
between operational leaders, clinical experts and the information
technology analysts to ensure workflow and dataflow alignment
• Include system and infection control trainers as well as report writers
in project planning
Profile
Headquartered in Evanston, Illinois, NorthShore University HealthSystem (NorthShore) is a comprehensive, fully integrated healthcare
delivery system serving the Chicago region. The system includes four
hospitals: Evanston, Glenbrook, Highland Park and Skokie. NorthShore has annual revenues of $1.8 billion, employs about 10,000
people and has approximately 2,100 affiliated physicians. More than
800 of these physicians belong to the NorthShore Medical Group, a
multispecialty group practice with 100-plus office locations.
NorthShore retained its focus on delivering superior care while facing
this challenge before the changes to value-based care were defined
or certain. The decision was made to pre-emptively leverage existing
competencies in Analytics and Data Warehousing to embark on
several transformational projects. These projects, Programmatic
Evaluation Tools (PET) and Ambulatory Reporting Tools (ART), have
resulted in considerable cost savings and more efficient population
health management.
As the principal teaching affiliate for the University of Chicago
Pritzker School of Medicine, NorthShore is dedicated to excellence in
medical education and research. Combined with NorthShore’s
established reputation for advanced information technology and its
strong clinical environment, this affiliation represents an exciting
advancement in patient care for the Chicagoland area. HIMSS
Analytics Stage 7 Ambulatory EMR Adoption Model status was
achieved in April 2013.
These tools allowed our Quality and Finance teams to rapidly
evaluate questions about clinical and financial standardization in
ways that were impossible in the past. The successful implementation of these tools placed NorthShore at the forefront of clinical
analytics nationwide and allows us to supply our leaders and
clinicians with real-time business intelligence and decision support
that only a handful of organizations across the country have access
to.
The Challenge
The core mission of NorthShore University HealthSystem (NorthShore) is to preserve and improve human life. This mission is
supported and achieved through the provision of superior clinical
care and focus on quality improvement. The landscape of healthcare
continues to change and along with it, a new focus from volume to
value-based care. With this, the goal was set to develop applications
that transformed EMR data into actionable business intelligence that
identified unwanted practice variation, supported quality improvement workflows, aided real-time clinical decision-making and
evaluated the effectiveness of interventions.
These projects involved a tremendous amount of work in both
planning and execution. As a team, Quality, Clinical Analytics,
Finance, and Data Warehouse groups worked collaboratively to
define metrics, manage the project timeline and regularly assess
their own progress. The group partnered closely to ensure fields
were correctly identified, calculated, captured, validated and named
to generate new summary tables and data marts that contain
approximately 1,000 enriched fields newly available to consumers.
These new fields are the product of complex calculations, some
requiring thousands of lines of code.
Resulting Value / ROI
Tangible and intangible results achieved. Tangible results
include savings (cost, time, resources), reduced medical
errors, outcomes (i.e. patient quality and safety, financial or
operational) and creative use of physical space formerly
occupied by hard on-site files. Intangible results include such
things as clinician and patient satisfaction, etc.
• Using IBMs Cognos™ tool, parameterized reports were
developed that allow front-line decision makers in Quality and
Administration to analyze and test hypotheses around
practice variation, gaps in clinical care, and high utilization
cohorts. Furthermore, this infrastructure provides a platform
for integrating reporting back into our EHR. Using the ART
infrastructure we have created a daily reporting mechanism
that feeds our EHR’s native reporting tool with our ART data
and provides a daily panel of chronic disease patients that are
in need of labs or follow-up that has significantly improved
our ability to get patients in for necessary tests.
• Using the ART integrated EHR reporting system our
administrative staff that supports our primary care physicians
in contacting patients that are due for diabetic testing have
experienced a significant increase in both efficiency and in
patient compliance. The tool updates daily and captures the
outcome of patient contacts that feed back into ART and
adjusts the daily report accordingly. Compared to the
previous paper reporting system that updated monthly, this
more integrated data delivery system has shown an increased
rate of compliance with less staff.
• Using the PET hypothesis testing tools, we have identified
significant cost savings in our spinal fusion procedures related
to unnecessary Doppler testing and changes in implants used.
This platform led to the identification of major clinical practice
variation in spine surgery and produced regular feedback for
clinicians. This resulted in a reduction of the cost of 1-2 level
spine surgery by $1,587; an annual cost savings of $714,150.
• This project, like many others NorthShore Heath I.T has
implemented, reflects the collaborative nature of our
interdisciplinary relationships, as well as our diligence and
dedication to serve our patients.
Lessons Learned
This project reinforced the need to draw from our extensive
pool of expertise in order to create a cross-functional team of
clinicians, analytics and health information technology
professionals. Selecting the best individuals for this project
from day one led to the production a superior end-product
designed to meet the needs of the user community.
Profile
Ochsner Health System (OHS) is one of the largest independent
academic health systems in the United States with 26 owned,
managed, and affiliated hospitals and more than 60 health centers
across the greater New Orleans, Baton Rouge, North Shore,
Mississippi and Bayou Regions. In addition to this, the OHS clinic
group practice surpassed 1,000 physicians in 2015 and is supported
by an additional 1,500 affiliated and clinically-integrated physicians
in more than 90 medical specialties and sub-specialties.
Ochsner Baptist, a campus of Ochsner Medical Center, is fully
accredited and staffed by more than 600 physicians and specialists.
The 156-bed facility, located in Uptown New Orleans, features all
private, inpatient rooms, an intensive care unit, state-of-the-art
operating rooms, and two cardiac catheterization labs. Ochsner
Baptist is also home to the Women's Pavilion, an advanced care
facility that offers standard and specialized obstetric and gynecological needs, gynecological robotic surgery, high-risk maternal fetal
medicine physicians, and alternative birthing options. Additionally,
Ochsner Baptist has a 24-hour, full-service emergency department.
The 6,000 square foot emergency room is staffed by a team of
board-certified ER physicians, offers two trauma rooms and 12
patient rooms and is equipped with specialized geriatric amenities
for seniors. Ochsner Baptist received the HIMSS Stage 7 Award in
April of 2015.
Ochsner Baton Rouge, a campus of Ochsner Medical Center, is a fully
accredited hospital staffed by more than 300 physicians. The
149-bed facility is located in Baton Rouge, LA. and features private
room options, 24 hour emergency care, advanced specialties such as
open heart surgery, as well as gynecological and general surgery
robotic-assisted surgery with the da Vinci machine. OMC-BR also
features a newly renovated family birthing center with alternate
delivery options and is the area’s only certified nurse midwife
program. The family birthing center features 3 labor and delivery
rooms, 2 birthing tubs, 2 cesarean rooms and a level III NICU.
Ochsner Baton Rouge received the HIMSS Stage 7 Award in March of
2015.
Leonard J. Chabert Medical Center (LJCMC) was opened in 1978 with
a dual purpose: to provide quality healthcare and to educate the
next generation of health professionals. Today, the 156 licensed bed
hospital and 26 clinic specialties function as a full-service institution
for inpatient services with extensive outpatient services, as well as a
teaching facility for approximately 30 residents and fellows and
approximately 386 medical students. LJCMC is managed by Ochsner
Health System under the direction of Terrebonne General Medical
Center and offers specialty services for Asthma, Bilateral Tubal
Ligation, Disease Management, Medical Nutrition Therapy, and
Tobacco Control. LJCMC received the HIMSS Stage 7 Award in April
2015.
The Challenge
Ochsner Health System was founded in 1942 and has a long, rich
history embedded around its mission and vision to serve, heal, lead,
educate and innovate. It is one of the largest independent academic
health systems in the United States. OHS has vowed through its
vision to be a global medical and academic leader who will save and
change lives, as well as shape the future of healthcare through their
integrated health system, fueled by the passion and strength of our
diversified team of physicians and employees. We realized that none
of this could be done without continuously growing our information
services and technology departments as the technology world
advanced. We had no standardized or best practice content across
OHS, and recognized that what software and applications we did
have needed to be updated and advanced. OHS needed one highly
integrated, standardized EMR across the entire system to support
and meet the rapidly evolving needs in healthcare. That being said,
we also needed an EMR that supported the unique workflows of our
many specialties, and one that could be enhanced as needed for
different specialties and departments. In addition, we needed an
EMR to assist us in more efficiently integrating with community and
affiliated physicians to manage entire patient populations. All of this
needed to be done not only to support our mission and vision, and
standardize care across our system, but also to improve end-user
and patient experience, quality of patient care, and help meet
meaningful use incentives.
Implementation Overview
Ochsner Health System brought together a multidisciplinary team
of information services and technology staff in 2008 to begin the
review and selection process of electronic medical record vendors.
In 2010 the decision was made to contract with, and implement
Epic as our EMR system. OHS decided to phase out implementation based on hospital regions in order to enable sufficient and
proper support during go live and implementation periods. We
took a big bang approach during each facility implementation, and
formal kick-off for the overall project began in October 2010. The
North shore region went live first in December 2011, and all other
Ochsner facilities followed in the next 1-3 years. OMC-Baptist went
live March 2013, then OMC-Baton Rouge in June 2013, and
Leonard Chabert Medical Center in June of 2014. Go live implementation included device integration in all critical care areas
including ED, ICU, PACU, and OR, as well as CPOE and clinical
documentation. We also pushed out Afga PACS, Pyxis, and CVIS, a
home grown cardiology procedure documentation system at go
live. OHS facilities are interfaced with numerous other applications
including RALS, Soft lab, Progeny, Links, GE Viewpoint, Magview
mammography, and multiple procedural area interfaces. Our
institution is also live with multiple health information exchange
applications including Epic Care Everywhere, Ochsner Community
Connect, Surescripts HISP, EpicCare Link, and My Chart Patient
Portal.
Resulting Value / ROI
Medical Device Integration:
o OHS inpatient facilities have greatly reduced the amount of
time nursing and other clinical staff such as patient care techs and
respiratory therapists spend on manually entering in data by
having data from many of our bedside medical devices directly
interface into the EMR. This includes all hemodynamic monitors
in our critical care areas, ventilators, as well as glucometer and
ISTAT data. Many of our facilities also have Rover IPod touch
devices, with hyperspace access to enter VS in real time, as well as
complete worklist tasks and medication administration. This
interfacing not only improves the accuracy of the data in the EMR
by eliminating manual transcription errors, but also ensures quicker
clinical decision support by having real-time data available.
o Increased patient access to their medical information as well as
richer, more advanced information sharing via My Ochsner patient
portal
o My Ochsner patient portal not only provides patients access to
pertinent diagnostic studies, notes, and visits, but also enhances
and promotes communication between patients, doctors, and
other clinicians.
o My Ochsner patient portal also provides quick and easy access
for patients to schedule their appointments online via the portal, as
well as request an appointment and cancel appointments
themselves. Through focused and intentional promotion of the
patient portal, OHS has significantly increased our percentages of
patients who schedule their appointments online. We have
discovered that this in turn correlated to a decrease in no shows for
those patients who scheduled their appointments via the online
patient portal versus no shows for patients who did not schedule
online. OMC Baptist for example, increased online scheduled
appointments by 6% from 2013 to 2015, and decreased its no show
rate from scheduled online appointments by 3 % (from 17% to 14%
in 2015). In addition, the no show rate from scheduled on line
appointments in general is significantly lower. In 2015, OMC Baptist
had a 14% no show rate for patients who scheduled online, and a
36 % no show rate for patients who did not schedule online.
o OHS has even further enhanced the patient portal by becoming the first Epic System client to successfully integrate the new
Apple HealthKit into its EMR. Now it is easier than ever for
patient’s clinical data such as heart rate and blood pressure to be
uploaded and integrated into their patient record at the physicians’
recommendations. This ultimately drives a dramatic and positive
impact on patient care and satisfaction by enhancing provider and
patient access, which increases adoption by patients and then in
turn, providers.
Integration and use of the EMR to impact quality outcomes:
o Effectively using Epic helped Chabert Medical Center (CMC) to
significantly decrease CAUTI rates at CMC, and eventually eliminate
Catheter Acquired Urinary Tract Infections (CAUTI) in 2015. New
processes were implemented, and new workflows were created in our
EMR to systematically review orders for insertion, duration, and
necessity of indwelling catheters. Order sets were enhanced in EPIC
for placement and removal of catheters with stipulations for physicians
to monitor, cancel, or alter orders. In addition to this, flowsheets for
documentation allow staff and physicians to accurately monitor
patients intake and output, the need for continuing foley catheter the
patients overall progress. Finally, best practice alerts remind physicians
of timeliness of catheter removal. The outcome of all of these
interventions, along with end user education resulted in a decrease in
CMC CAUTI rates from 2013 to 2014 (Epic go live), and zero CAUTIs in
2015.
Lessons Learned
• OHS provider and administrative leader buy-in was very important
throughout the course of the project. These were key players in
helping set the tone for the very large change that we were undergoing. Our change management methodology was followed rigorously,
which helped gain buy-in from everyone from the executive leadership
teams to the front-line staff.
Achieving Meaningful Use Stage 2:
o Epic helped OMC Baptist, Baton Rouge, Chabert, and all OHS
facilities to achieve Meaningful Use Stage 2 by streamlining processes
and allowing us to meet all of the required measures. Transitions of
care created a particular struggle for OHS facilities as it did for most of
the country. Aware of end user struggles with this measure, as well as
the technical aspect of sending summaries of care electronically, a
multi-disciplinary team was created to focus on this area. The follow
up activity in Epic was moved to its own section in the physician
discharge navigator, and physicians were educated on the requirement
and new workflow. Nurses and clinical staff received education on the
correct transition of care workflow and how they could help complete
the necessary requirements. All OHS facilities were able to achieve the
percentage required for transitions of care, and ultimately achieve
Meaningful Use Stage 2 status.
• Mandatory system training was critical to our success. All users had
to attend in person training prior to gaining Epic access. This was
strictly enforced by leadership and administration.
• Super user utilization at go live and ongoing is both instrumental and
required for successful implementation and ongoing support. Super
Users all OHS hospitals are trained in advanced nursing functions as
well as physician workflows to be that first line of support for our
clinical users. Super users should always have a clear role, and are
instrumental in educating their staff on continual updates, changes,
and Epic Upgrades. Super User participation from every department
is key to the success of Epic utilization at OHS.
Profile
Reading Health System includes Reading Hospital, a 647-bed acute
care hospital located in West Reading, Pennsylvania, and Reading
Health Rehabilitation Hospital, a facility in Spring Township, featuring a 50-bed skilled nursing unit and a 62-bed inpatient rehabilitation unit. We also provide office-based primary and specialty care
through Reading Health Physician Network, in-home nursing care
through Affilia Home Health, and retirement living through The
Highlands at Wyomissing. An extensive network of outpatient
services are provided through offices and urgent care walk-in
centers throughout the region. Reading Hospital was awarded
HIMSS Stage 7 on September 28, 2015.
The Challenge
Since the inception of our stroke center, care processes have continued to evolve resulting in significant improvement in stroke mortality and length of stay. However, our percentage of patients eligible
for IV tPA who actually received this treatment in < 60 minutes was
low with a rate of 15% for 2012. Our stroke team functioned in a
challenging environment which included multiple instances of an
ambulatory EHR, separate vendors for the ED EHR and inpatient
laboratory, imaging results and computerized physician order entry.
A stroke patient in the ED could simultaneously have paper and
electronic documentation as well as electronic orders from two
separate electronic systems in addition to handwritten orders.
Implementation Overview
In the summer of 2012, Reading Health System began the implementation of EpicCare Ambulatory EHR and in February of 2013, its
acute hospital and rehabilitation hospital went live in a “big bang”
on EpicCare Inpatient, ASAP (ED), Stork (OB), Anesthesia, Optime,
Willow (pharmacy), MyChart (patient portal), EpicCare Link
(independent provider portal), ADT/Prelude (registration), Cadence
(enterprise scheduling), and Resolute (hospital billing). Philips iSite
PACS had been implemented several years prior to EpicCare.
Resulting Value / ROI
In order to improve door-to-CT initiation times, nursing work flow
changed such that the stroke patient was brought directly to a CT
scanner in the ED. Triage nurses now use a stroke narrator which
provides them the ability to document the National Institutes of
Health Stroke Scale (NIHSS) in a structured fashion and to document
one-step medications all within work flow. In addition, ED physicians
use a stroke navigator that prompts them to document inclusion and
exclusion criteria for thrombolytic therapy. Clinical decision support
tools within the navigator informs the physician whether the patient
is a candidate for intravenous tPA or provides the opportunity to
document why tPA was withheld. In addition, because the patient's
weight is documented electronically, the pharmacist is able to more
rapidly calculate the correct tPA dose for the patient.
Prior to the implementation of Epic, ED nurses had an electronic
albeit manual documentation process for medication administration. This made it difficult to determine the exact time of tPA administration and as such, had limited the ED’s efforts to improve
door-to-drug times. With the implementation of Epic, our ED nurses
began to use a bar-coded medication administration which captured
the time of tPA administration electronically. ED physician documentation captured through the navigator and electronic capture of the
NIHSS through the narrator facilitates reporting and registry data
collection and submission.
In the two years following Epic implementation, we have seen
continued improvement in care processes and outcomes. The
door-to-CT initiation and door-to-CT interpretations steadily
improved reaching 27 and 31 minutes, respectively as of December
2014. The percentage of eligible patients receiving tPA in less than
60 minutes also improved dramatically. In 2013, there was a 60%
increase in patients receiving tPA and in 2014 we exceeded the
AHA/ASA target by achieving the 87% level on this metric. The
entire stroke team has access to all the important data that supports
timely decision-making and our neurology and interventional
neurology consultants can access the patient’s records, laboratories,
and digital images remotely, obviating delays in care.
Reading Health System’s Stroke Center has received numerous awards from Healthgrades including “America’s 100 Best Hospitals” for stroke care
three years in a row (2013-2015) and was awarded the AHA/ASA 2015 Get with the Guidelines Stroke Honor Roll Elite Quality Achievement Award.
Lessons Learned
Having the support of the Reading Hospital Board and Administration was a critical factor for success not only in the vendor selection process but
also in setting expectations for mandatory training and actual use of the EHR by clinicians.
The engagement and input of our clinicians in the workflow validation process were invaluable. It would have been difficult to have achieved our
level of success without them.
Ambulatory and inpatient optimization committees composed of practicing clinicians have provided valuable expertise and feedback regarding
the effectiveness of order sets, alerts, and workflow in a rapidly changing practice environment.
A process for ongoing training and support of clinicians including at-the-elbow observation and system utilization analytics can provide key
insights that can lead to improved efficiency and satisfaction.
Profile
St. Elizabeth Healthcare operates six major facilities throughout
Northern Kentucky and more than 110 primary care and specialty
office locations in Kentucky, Indiana and Ohio. St. Elizabeth is
sponsored by the Diocese of Covington and is a member of the
Mayo Clinic Care Network. St. Elizabeth is a mission-based
organization committed to improving the health of the communities it serves, providing more than $121 million in uncompensated
care and benefit to the community in 2013. The organization
employs 7,400 associates, has 1,200 licensed beds, and has an
employed physician group with 314 physicians and 71 mid-level
providers. For more information, visit www.stelizabeth.com. Stage
7 award was achieved on August 12, 2015.
The Challenge
Starting in 2005, the Chief Nursing Officer (CNO) decided that an
electronic system was needed to streamline and standardize
clinical documentation, and drive evidenced based practice
through clinical decision support. During the search for an
electronic health record (EHR), St. Elizabeth made the strategic
decision to acquire two new hospitals and to start a hospital
employed physician group. These decisions steered the EHR
search from a clinical documentation system to an enterprise EHR.
The search quickened when these decisions were made because
the new hospitals being purchased needed to transition from their
legacy systems to a St. Elizabeth provided EHR. The goal of the
enterprise EHR was to standardize clinical, financial, and administrative processes across the expanding organization.
Implementation Overview
A multidisciplinary team consisting of clinicians and administrators
was formed in 2007-2008 to review enterprise electronic health
record vendors. After evaluating the prominent enterprise grade
EHR’s, the decision was made to move forward with Epic. In
October of 2008, a contract was signed with Epic Systems to
implement their EHR software. The EHR implementation kicked off
in the fall of 2008 and Ambulatory sites began rolling out in
January of 2010 with full practice management functionality.
Hospital rollouts followed in April and October of 2010.
The initial hospital rollouts included nursing clinical documentation
via Optime, ASAP, and Stork, along with the implementation of
ADT, clerk order entry, Willow, and Radiant. Device integration
started at go live in one ICU and since has been rolled out to all
ICU’s, procedural areas, L&D and emergency rooms. CPOE was
implemented in May of 2012 and advanced nursing documentation including BCMA and electronic care plans and patient
education followed in November of 2013. Additional modules
including Anesthesia, Beacon, Case Management, and Infection
Control have been rolled out. Device integration has expanded to
anesthesia machines, infusion pumps, and there are plans to
integrate portable vital sign monitors, ventilators, and dialysis
machines in 2016. The organization currently utilizes Cerner as its
Laboratory Information System (LIS) and has plans to implement
Epic Beaker in 2017.
Resulting Value / ROI
• Transcription has been reduced by approximately 69% since the
implementation of computerized physician documentation. This
reduction has decreased the costs affiliated with transcription
services and the resource time to manage tracking of transcription
signatures. Providers utilizing real time Epic documentation tools
have provided more real time access to critical patient information
for the entire healthcare team.
• A best practice alert (BPA) has been implemented to alert nurses
if a patient has exceeded their 24 hour acetaminophen limit. This
decision support has decreased the number of patients who have
had their acetaminophen daily dose exceeded in half. The rates
decreased from 0.85 events per 1,000 patient days prior to the
alert to 0.4 events per 1,000 patient days post implementation.
• Decision support tools were utilized to decrease catheter associated
urinary tract infections (CAUTI). These tools were utilized to guide
appropriate ordering, promote regular assessment, prompt for timely
removal, and guide aseptic techniques for insertion and continued use.
Reporting tools were utilized to monitor compliance of staff utilizing
documentation tools and to allow for monitoring. These tools have
been instrumental in decreasing CAUTI rates from around 3.5 events
per 1,000 catheter days prior to EHR implementation to approximately
0.8 events per 1,000 patient days.
• St. Elizabeth has been named a Top Performer on Key Quality
Measures by the Joint Commission. The ability to achieve this distinction is largely due to utilization of the EHR. Decision support within the
EHR promotes compliance with required documentation and evidenced
based practice in support of required core measure requirements.
Electronic documentation allows for concurrent reviews of charts
instead of retrospective reviews, which allows the quality department
to catch potential fall outs before they occur. The organization has
moved from 70.37% compliance with VTE core measures in 2012
prior to CPOE to 99.4% compliance in 2015. This measures metrics
have been advanced utilizing BPA’s, order sets, concurrent reviews, and
ongoing education.
• Utilizing an order set to encourage appropriate ordering of blood
transfusions based on evidenced based guidelines, the average
hemoglobin level transfused at decreased from approximately 8.1 g/dL
to 7.3 g/dL in an 18 month time period after order set implementation
and education. This resulted in an approximate 32% reduction in cost.
Based on average adverse event data, this reduction resulted in 94
complications and 21 deaths avoided.
• Our patients are better connected to their healthcare providers and
they have real time access to their health information through
MyChart, Care Everywhere and electronic visits. St. Elizabeth has
approximately 109,000 active MyChart users, which represents greater
than 50% of patients served. The organization has performed 2,500
electronic visits. In July of 2015, the organization exchanged 14,000
records through Care Everywhere with 72 other health systems utilizing
Epic.
Lessons Learned
• Change Management:
Developing a strong change management process with the various
disciplines during go live and after is critical for success. During St.
Elizabeth’s implementation, many change management committees
were developed that were influential in decision making during
implementation and have continued as the ongoing decision making
bodies as changes and enhancements are requested. These groups are
also utilized to make decisions on and prioritize enhancements with
upgrades. Example committees include the Nursing Informatics
Committee, Medical Informatics Committee, Optime Workgroup, and
Ambulatory EMR Committee.
• Retraining:
End-users are only able to retain a certain amount of information
during initial training, so only the most important information is trained
initially. St. Elizabeth did not have a retraining initiative after go live
and therefore many end-users and departments created their own
workarounds. The organization would have benefited from a retraining
to clarify workflows and documentation questions that came up during
go live.
• On-going Communication:
During go live, develop a communication strategy that is supported by
all user groups. St. Elizabeth continuously struggles with how to deliver
notifications, changes, and enhancements to the necessary user
groups.
• Credentialed Training Program:
A credential trainer or super-user program is critical for ongoing
education. St. Elizabeth established a train the trainer credentialed
trainer program with the initial go live and this program is relied on and
a critical component for relaying information to nursing staff for
upgrades, new applications, and continued technology implementations.
Profile
Lucile Packard Children’s Hospital Stanford, the heart of Stanford
Children’s Health, is a leader in world-class, nurturing care and
extraordinary outcomes in pediatric and obstetric specialties,
with care ranging from the routine to the rare. Together with
Stanford Medicine physicians, nurses, and staff, the hospital and
network can be accessed through partnerships, collaborations,
outreach, specialty clinics and primary care practices at more
than 60 locations in Northern California, and 100 locations in the
western United States.
In October 2015, Lucile Packard Children’s Hospital Stanford/Stanford Children’s Health was awarded the HIMSS Analytics EMR
Adoption Model Stage 7 recognition, and all 167 of their network
practices received the Stage 7 Ambulatory Awards.
The Challenge
In 2012, the organization began the process of implementing Epic
as their new comprehensive Electronic Health Record (EHR)
system. This was an essential step toward the goal of “one
patient, one record,” allowing each patient to have one integrated, easily accessed and updated medical record, shared across
the full continuum of care.
During this same time, Lucile Packard Children’s Hospital Stanford
and Stanford Children’s Health developed a new network of 130
pediatric and obstetric providers in 40 locations across the Bay
Area. This network has now grown to over 60 locations. More
than half of the physicians within the faculty and network
practices were first-time EHR users. In the initial rollout plan, the
hospital was scheduled to convert first to Epic, followed by the
faculty and network practices over the following two-year period.
During the implementation process, it became quickly evident
that the entire enterprise would operate more successfully and
efficiently, and meet the goal of “one patient, one record,” sooner
if the conversion covered all inpatient and ambulatory areas as
quickly as possible. It was a herculean effort, made possible by
the hard work and dedication of the operational, clinical and
technical teams, to complete an accelerated organization-wide
series of go-live conversions within a four-month period in the
summer of 2014.
As one of the highest-acuity hospitals in the nation, Ed Kopetsky,
Chief Information Officer, likened the conversion to, “reengineering the plane while it was in flight.” On the day of go-live, the
hospital was at 100% census and the cutover had to go off
without a hitch. At the time of the cutover, several years of
detailed historical patient data transitioned to the new system
and the all-new Epic revenue cycle and administrative functions
also went live.
Implementation Overview
Detailed planning for the conversion to Epic began in 2011.
Project approval and kick-off started in early 2012 with immediate
efforts dedicated to team recruiting and training. Very sophisticated patient workflows, order sets and clinical rules were accommodated along with multifaceted integrated testing and an
extensive end-user training program was completed. These
endeavors culminated in a series of go-live conversions:
• May, 2014 – Lucile Packard Children’s Hospital Stanford,
Revenue Cycle and some Faculty Practices
• July, 2014 – Stanford Children’s Health Network Practices
• August, 2014 – Remaining Faculty Practices and Oncology
(Beacon)
“These awards are a testament to quality and
innovation by a very dedicated team of
research, teaching and care delivery colleagues
throughout our academic medical center, hospital and network. Together, we are leading the
way to improve access and quality of care for all
children and expectant mothers.”
Ed Kopetsky, Chief Information Officer
Resulting Value / ROI
Patient Experience and Access:
• Integrated patient care workflows, care plans and follow-up care were
greatly enhanced.
• MyChart, the interactive patient portal of Epic, allows patients to
request appointments and prescription refills, make payments and view
immunization records and lab results.
Costs Savings:
• $600K a year is saved in transcription costs.
Revenue Improvements:
• $21 million increase of cash collected adjusted for census and acuity.
• $21 million improvement in final billing in FY15.
Interoperability:
• 23 percent reduction in Hospital Accounts Receivable Days.
• Since the conversion to Epic, over 3 million patient records have been
exchanged with 195 organizations in 48 states using Care Everywhere.
This is particularly valuable due, as the specialty services and quaternary care provided at the hospital are largely physician-based referrals.
Lessons Learned
Safety:
• Creating realistic and complex integrated testing scenarios allowed us
to find and address challenges before they became patient care issues.
• The implementation of Bar Code Medication Administration (BCMA)
resulted in a 30 percent decrease in medication errors.
• Chemotherapy Computerized Provider Order Entry resulted in
four-times the improvement in chemotherapy infusions prepared
24-hours ahead and greatly improved the coordination of care to these
complex patients.
Innovation:
• Lucile Packard Children’s Hospital Stanford is the first children’s
hospital to remotely monitor glucose levels of children with Type 1
Diabetes with automatic data capture that goes into the EHR.
• Apple’s Healthkit platform was integrated with Epic’s electronic health
record system.
• Epic’s Slicer Dicer, a self-service tool, easily allows providers to
manage data within their patient population to improve the quality of
care.
• Internal, knowledgeable team members are extremely valuable.
• Establishing a fully staffed training team to work with providers
one-on-one, not only during go-live but also during the first year after
implementation, is key.
• Effective governance from the executive team all the way to clinical
and operation leadership is essential to promoting organizational wide
change.
• Customized training classes and follow-up sessions with clinicians
were very effective and appreciated.
• The magnitude and corresponding budget for “At-the-Elbow” support
is significant and expected by most providers. There is a need for
supplemental support for several weeks post go-live.
Profile
Sutter Health is an integrated delivery network of more than 5,000
physicians and 48,000 employees providing comprehensive care to
over 3,000,000 patients annually in more than 100 communities in
Northern California. Sutter Health supports our communities with
acute and ambulatory care settings, home health and hospice
services, outpatient surgery and specialty care centers, medical
research and training programs.
Challenge
Sutter Health is guided by four key themes:
• Patients at the center of everything we do
• Uncompromised pursuit of excellence
• Enable caregivers to excel at giving care
• Lead the transformation of health care
As the largest geographically contiguous, non-profit system in the
United States, we aim to deliver a consistent, high value patient
experience in the geographically and socioeconomically diverse
communities we serve. According to our CEO Patrick Fry, a tremendous amount of health care expense—perhaps more than one
fifth—is largely due to poorly coordinated care, over treatment and
variation. The challenge before us was to design a health information technology implementation strategy that would support a
patient-centric, evidence-based care delivery model that promotes
essential clinical collaboration between interdisciplinary teams,
reduces unwarranted clinical variation, and engages patients to be
co-partners in improving their health. Upon this framework, we
want to empower our clinical teams to leverage health IT to innovate
how care is delivered.
Implementation Overview
Sutter Health has partnered with Epic Systems Corporation since the
late 1990s. The first Sutter Health ambulatory care clinics implemented Epic in 1999. Sutter subsequently launched one of the
nation's earliest implementation of Epic's MyChart, My Health
Online, in 2001. In order to support a consistent, seamless patient
experience, Sutter Health extended the early implementation of the
Epic electronic health record (EHR) as a single instance across our
ambulatory and acute care delivery network. Today, this represents
the largest single instance of the Epic EHR in the world with over 10
million patient records. We also have a single instance of Epic
MyChart, My Health Online, with over 60% actively enrolled
ambulatory patients and over 1 million patients using this service to
access their data and collaborate with their care teams to improve
the health of their families. This ecosystem of integrated care
teams and engaged communities of patients has empowered Sutter
Health to create new opportunities for care delivery.
Resulting Value/ROI
Each Sutter Health patient enjoys a singular, fully integrated medical
record shared and leveraged by every care team member across the
care continuum from ambulatory to acute care settings across the
enterprise.
• Over 700,000 of Sutter Health’s patients have established CareEverywhere linkages to exchange over 11 million clinical documents,
improving the care coordination and safety of the patient care with
our community partners.
• Launch of My Health Online has created new opportunities for
clinical care, convenience and patient outreach. To date, over 1
million patients have exchanged 4 million secure patient messages,
booked 1 million appointments and viewed 25 million lab results.
Patient messages are typically answered in less than 4 hours. Sutter
Health today receives 23% of its total patient payments via My
Health Online. Delivery of patient-centric decision support via My
Health Online has led to efficient and cost-effective advances in
patient outreach, leading to a three-fold increase in patient
adherence to mammogram and cervical cancer screening recommendations and discovery of over 140 previously undiagnosed
hepatitis C patients now potentially eligible for treatment to
achieve sustained virological response (cure).
• Sutter Health was recently ranked as California’s top health system
in heath care quality by the Lewin Group.
• Implementation of a prescription renewal “wizard” to add clinical
decision support such as biometric and condition specific laboratory
data to every refill encounter improves patient safety and provider
efficiency.
• Full benefits realization of health information technology
investments require continuous reinvestment in our people and the
system itself. We have committed 25% of our Meaningful Use
Incentive Dollars to both sustainably improve the EHR skill level of
our end users and redesign EHR-enabled workflows to promote
provider efficiency and patient safety.
• Ambulatory Computerized Provider Order Entry now accounts for
99.58% of all orders.
• Implementation of EHR documentation tools and voice recognition software reduced transcription costs by over $4 million.
• Implementation of EHR tools reduced mortality from severe sepsis
or septic shock from 19% to 11% within 4 months of implementing a
novel clinical decision support program.
• Two Sutter Health physicians, David Butler and Albert Chan, have
received the Epic PACAcademy Award (Physician of the Year),
awarded annually to a physician member of the Epic community,
selected by his/her peers, in recognition of outstanding contributions to the Epic community.
Lessons Learned
• Every clinical transaction, from direct patient encounters to online
clinical interactions, provides us an opportunity to care for and
delight the patient.
• A common, health IT-enabled care delivery platform has integrated a geographically dispersed health system under a singular goal of
improving the care experience through reduction of unnecessary
variation and fostered new opportunities for innovative health care
delivery.
• “Ultimately, it is all about how we can serve our patients and their
families, not the technology.”
Profile
WellSpan Health is an integrated health system that serves the
communities of central Pennsylvania and northern Maryland. The
organization is comprised of a multi-specialty medical group with more
than 850 physicians and advanced practice clinicians, a home care
organization, six respected hospitals, more than 15,000 employees,
and over 140 patient care locations. WellSpan has been recognized by
IMS Health as one of the Top 100 Integrated Health Networks in the
United States and by Health Imaging and IT as one of the nation’s “Top
25 Connected Healthcare Facilities.”
In 2015, WellSpan Surgery and Rehabilitation Hospital achieved HIMSS
Analytics electronic medical record adoption model (EMRAM) level 7
status. This 73 bed hospital opened in 2012 and includes
state-of-the-art operating rooms and rehabilitation equipment.
WellSpan Surgery and Rehabilitation Hospital features 48 beds
dedicated to rehabilitation, 25 post-surgical inpatient beds and four
operating rooms for orthopedic and neurosurgical patients. This
modern, patient-centered facility offers advanced orthopedic, spine,
and neurosurgical treatment, as well as orthopedic and traumatic brain
rehabilitation.
The WellSpan Surgery & Rehabilitation Hospital is accredited by CARF
International. By pursuing and achieving CARF accreditation in 2012,
and reaccreditation in 2015, the WellSpan Surgery & Rehabilitation
Hospital has demonstrated that it meets international standards for
quality and is committed to pursuing excellence. CARF is an independent, nonprofit accrediting body whose mission is to promote quality,
value, and optimal outcomes of patient-care services through a
consultative accreditation process that centers on enhancing the lives
of the persons served. Founded in 1966 as the Commission on
Accreditation of Rehabilitation Facilities, and now known as CARF
International, this accrediting body establishes consumer-focused
standards to help organizations measure and improve the quality of
their programs and services.
WellSpan Surgery & Rehabilitation Hospital also received a three-year
accreditation from Det Norske Veritas (DNV) in 2014. This hospital is
one of only four in Pennsylvania to achieve DNV accreditation. DNV
Healthcare is the leading accreditor of United States hospitals
integrating ISO 9001 quality compliance with the Medicare Conditions
of Participation. ISO 9001 is a series of standards that define, establish
and maintain an effective quality assurance system.
In September 2014, WellSpan Surgery & Rehabilitation Hospital was
one of two hospitals with fewer than 100 beds selected as a top
performing facility by National Research Corporation in its “Path to
Excellence” program. This recognition is based on the highest
percentage of patients rating the hospital a “nine” or “ten” on patient
satisfaction measures. Winners of the Path to Excellence Award were
selected from the extensive database of National Research Corporation’s client hospitals for their performance over the past four
quarters. Winning this award demonstrates that the WellSpan Surgery
& Rehabilitation Hospital is committed to providing patient-centered
care.
WellSpan Surgery & Rehabilitation Hospital was identified as one of
eight hospitals in the country where at least 95% of its patients
responded “Yes, I would definitely recommend this hospital.” This was
based on Hospital Consumer Assessment of Healthcare Providers and
Systems (HCAHPS) survey results reported to CMS’ Hospital Compare
databases, regarding post-surgery patients.
WellSpan Surgery & Rehabilitation Hospital is listed in Modern
Healthcare magazine as the fifth highest scored hospital for
value-based purchasing reward/penalty, 2015 (readmissions, value
based purchasing and hospital acquired condition score).
The Challenge
WellSpan Health prides itself on providing safe and reliable healthcare
to its patients. Despite continuous attention to error-proofing of care
delivery processes, WellSpan found that low-frequency, high-impact
events still occurred.
Heparin-Induced Thrombocytopenia (HIT) is an unpredictable
immune-mediated adverse drug reaction (ADR) associated with the
use of unfractionated heparin (UFH) and low-molecular-weight
heparin. Although it occurs in less than 5% of patients receiving
heparin, HIT can have devastating consequences including thromboembolism and death. The risk of these complications can be lessened
with optimal management of HIT, which includes active surveillance,
prompt recognition, heparin discontinuation, ordering confirmatory
laboratory tests, and initiation of an alternative non-heparin anticoagulant. Unfortunately, this ADR is not always promptly recognized or
managed appropriately. We present such a case, along with the
alerting and work-flow redesign solution implemented to facilitate
more timely recognition and intervention.
In June 2014, an ADR report was submitted through the WellSpan
safety reporting system involving an unexpected inpatient mortality
due to HIT. The patient had a relatively uneventful postoperative
course after undergoing aortic valve replacement surgery until his
platelet count suddenly dropped by more than 50%. He subsequently became unresponsive, was diagnosed with multiple ischemic
strokes, and a possible pulmonary embolism. He died the following
day after suffering multiple cardiac arrests and further decompensation.
This case triggered a multidisciplinary meeting of key stakeholders
from pharmacy, nursing, patient-safety, laboratory informatics, and
clinical informatics. A laboratory report of all confirmed cases of HIT
over a two-year period at WellSpan was obtained and each individual case was investigated. In a few cases, absence of routine platelet
count monitoring was thought to have contributed to delayed
recognition of thrombocytopenia and HIT. Recognition was delayed
by more than three days in four cases. In each of those identified
cases, the patient suffered at least one thromboembolic event.
The Solution
As a result of the above described analysis, multiple inter-related
strategies were developed by the multidisciplinary workgroup. The
first strategy was the creation of an automatic rule in Cerner
Millennium that would look for a resulted platelet count on all
patients receiving UFH, and if a platelet count had not been resulted
in the previous forty-eight hours, a Complete Blood Count would be
ordered for the next morning’s lab draw (Figure 1).
Next, an alert was created, which would fire on all patients experiencing a 50% decrease in platelet count from a baseline level prior to
heparin administration. This alert advises the clinician of the drop in
platelet count, a hallmark of HIT, and presents a validated HIT risk
stratification tool, the 4T’s score, in a structured format for completion by the clinician.
Additional information is displayed within the alert to assist with risk
stratification, including a graph of platelet count trend correlated
with heparin administration and recent imaging results for thrombosis. Using a color-coded error-proofing approach, the pre-test
probability of HIT is calculated from structured responses within the
4T’s score, with low-risk scores being shaded as green (Figure 2),
moderate-risk as yellow, and high-risk as red. As a further
error-proofing measure, in the case of moderate to high-risk scores,
a link to an evidence-anchored HIT treatment order set is embedded
in the advisory message (Figure 3). In the case of low-risk scores, this
link is intentionally not available.
Results
In a one-month retrospective data sample conducted after the
go-live date, the HIT alert fired on 49 patients. One patient, who
was identified by the tool, had laboratory-confirmed heparin-induced thrombocytopenia with thrombosis. HIT was promptly
recognized in this patient after the alert fired, heparin administration
was discontinued, and alternative anticoagulation was initiated. The
patient was subsequently discharged home. A separate laboratory
report confirmed that this was the only case of confirmed HIT during
the same time period.
Resulting Value
• Automated lab ordering process for disease surveillance
• Just-in-time alerting of potentially significant drops in platelet
count with consistent standardized risk stratification using a
validated tool
• Link to a best practice order set imbedded in the clinician’s
workflow
• Increased provider awareness for a rare, but serious adverse drug
event
Lessons Learned
• Maintaining high clinical decision-support sensitivity, while
avoiding excessive provider alerting can be difficult. With a low-frequency, high-impact event such as HIT, the goal of our alert is 100%
sensitivity. Although an algorithm was developed to identify
patients with potential HIT, based on heparin exposure and a
decrease platelet count, patients with other causes of thrombocytopenia could not be excluded.
• Optimization of new clinical decision support technology is an
iterative process. Within months after implementation, an additional option was added for clinicians who had “No Clinical Suspicion of
HIT” in order to appropriately suppress the alert for that patient
encounter. This increased the alert response rate and encourages
appropriate use of the HIT order set.
• By implementing a solution, related solutions may present
themselves. In the process of evaluating the outcomes of this
intervention, our laboratory services department posited that
management of patients with suspected HIT could be expedited by
providing confirmatory testing in-house, instead of as a “send-out”
test. It has been conjectured that in-house testing would provide
results faster thus enabling the clinician to deliver patient care with a
higher degree of safety.
Profile
Yale-New Haven Hospital is a 1,541-bed private, nonprofit teaching
hospital that ranks among the premier medical centers in the nation.
Including the Yale-New Haven Children’s Hospital, Yale-New Haven
Psychiatric Hospital, Smilow Cancer Hospital and the 2 Yale-New Haven
Hospital campuses at York Street and the Saint Raphael Campus, YNHH
is regularly included among the Best Hospitals in the U.S. in the annual
U.S. News & World Report rankings of specialty services. With two
main campuses, Yale-New Haven is the largest acute care provider in
southern Connecticut and one of the Northeast's major referral
centers. YNHH achieved Stage 7 status on September 18, 2015.
The Challenge
Yale-New Haven Hospital has a long history of leveraging electronic
medical records and other technology to enhance care, quality, safety,
and workflow efficiency. YNHH was one of the first hospitals in the
nation to adopt computerized provider order entry (CPOE) in the early
1990s and by 2010 had a robust inpatient and ambulatory EMR
deployment. The approach to that point, though, was a “best of
breed” model with several clinical, ancillary, and EMR solutions in use
at YNHH, its satellites, and affiliate hospitals across the Yale New
Haven Health System, which includes Bridgeport Hospital, Greenwich
Hospital, and the Northeast Medical Group. With multiple EMRs in
use across and within our hospitals, care continuity and data analysis
were hindered. Our partners in the Yale School of Medicine, were also
challenged by disparate medical record technologies that limited
integration and research capabilities. In 2010, we recognized the need
to transform our technology base to enable longitudinal care,
population health, clinical, operational and business analytics, support
research and to empower delivery of higher value.
Implementation Overview
In July of 2010, we completed due diligence on EMR selection,
choosing the Epic EMR and revenue cycle platform for Yale-New Haven
Hospital, Bridgeport and Greenwich Hospitals, the Northeast Medical
Group and the Yale Medical Group. We endeavored to deploy a single
electronic medical record for our patients across all sites of care and in
tandem offered Epic access via Community Connect contracts to
community providers and agencies with whom we share patients. We
implemented Epic as a big bang strategy at each hospital and in a
rolling manner through the physician practices in the Medical Groups.
Our initial implementation included the core EMR for inpatient and
ambulatory as well as the registration, scheduling, billing, pharmacy,
radiology, cardiology, transplant, oncology, obstetrics, ophthalmology,
anesthesia, operating room, health information management,
reporting and data warehouse, patient portal, and provider remote
access portal applications. YNHHS has been a Care Everywhere
participant since 2010. In the few years following our initial implementation we have added the Epic modules for bed management,
care management, population health and are in the process of
implementing Beaker (Laboratory) and ICON (Infection Control)
modules. The Epic solutions are fully integrated to critical third party
solutions for PACS, Anatomic Pathology, Blood Bank, Radiation
Oncology, biomedical device integration (BMDI) and various business
and clinical support solutions.
Resulting Value / ROI
Through fiscal year 2014, YNHHS saw $150.6 M in benefits from Cost &
Value initiatives driven through and supported by the EMR, financial
and analytics platforms. These annual benefits are expected to remain
sustainable through fiscal year 2015 and beyond. The following
examples reflect results specific to Yale-New Haven Hospital.
The cost and value positioning initiative was built on strong partnerships between YNHHS’s finance team, analytics and ITS team, and
clinical teams. These teams applied data collected through Epic to
identify and track opportunities to increase efficiencies, reduce waste,
and drive down the cost of patient care and leveraged the Epic EMR to
deploy real-time decision support and other tools to drive changes.
Through
these partnerships, YNHHS measured results across health system and
the following are examples from Yale-New Haven hospital, who
achieved Stage 7:
Financial Results:
o Blood Utilization Management
Applied streamlined transfusion protocols [$200,000]
o Optimize Abdominal Surgery
Reduce complications of small and large bowel surgery patients
[$2,000,000
o Oncology Medications use
Reduce inpatient administration of Rituximab and Ifosfamide
[$921,000]
o Head and Neck Care Process Redesign
Reduced ALOS for H&N ENT patients [$214,000]
o Sickle Cell Care Redesign
Reduce ALOS and readmissions for sickle-cell patients [$2,300,000]
o Hip Fracture
Reduced ALOS and Quality Variance Indicator (measure of adverse
event) incidence [$235,000]
Clinical Quality Results:
o Duplicate Laboratory Tests
Reduce redundant lab ordering through real time clinical decision
support [20% reduction in tests ordered]
o Clustering Care
Reduce patient awakening between 8PM and 6AM by redesigning
medication administration standard schedules and decision support
for laboratory draw times and vital signs schedules- [35% reduction in
patient awakening episodes]
o Facilitate smoking cessation
Created clinical alert to drive referral to cessation services and orders
for nicotine replacement products [34% referred to the Quit Line;
43% had medication orders placed; Tobacco use disorder was added
to the problem list in 48%; Email messages sent to patient’s PCP 99%
of the time]
o Improving Medication Reconciliation
Pharmacist-Pharmacy Technician led medication reconciliation
workflow targets high risk patients; EMR enables patient identification, retrieval and documentation of med history, and care team
communication [35% increase in admission medication reconciliation
rates in high risk populations]
o Tele-ICU
Remote, centralized intensivist oversight of critical care patients
across the health system has enabled cost-effective, specialist care in
all of the ICU’s and resulted in decreased cost/case and LOS.
Research:
o Enhancing patient outreach for research
Created a research portal within the EMR patient portal to inform
patients of research trials and enlist their interest in clinical trials. [To
date over 500 patients have been recruited]
Care Team Communication:
o Auto-routing of provider notes
Upon closing the encounter in Epic, the specialist’s note is auto-routed to the Primary Care Provider (PCP) of record. This improves the
communication among the care team and has saved ~20-30
minutes/provider/day.
The strategies YNHH employed to improve value depends on data
from three sources: the electronic medical record (Epic), the
advanced cost accounting system (Strata), and comprehensive quality
metrics. Quality Variation Indicators (QVI)s were developed to track
rank-ordered adverse hospital events or conditions not present on
admission.
Analyzing QVIs captures the frequency and cost of complications in
care delivery and allows the clinical review teams to determine levels
of preventability, clinical significance, and provider attribution for the
QVIs.
YNHH uses the collected data to drive clinical standards through
system-wide order sets, decision support, and streamlined care
processes. Real-time and retrospective delivery of patient and
operational data help providers see the benefits of clinical redesign
for their patients, and helps the YNHH team optimize resources and
patient outcomes with monthly results reflected in the System’s
financial statements.
As shown in the Revenue and Expense per Equivalent discharge
graph, YNHHS has reduced the cost of care each year since FY 2011,
when Epic implementation began, through the cost and value
positioning initiative. And in 2013, when Yale-New Haven Hospital
implemented Epic, revenue per case began to increase due to more
accurate and complete data capture, while the costs continued to
decline.
Lessons Learned
o Stakeholder engagement in understanding and design of the new
platform is critical to success in the short term at implementation and
most importantly in the long term in leveraging the tools for success.
Coordination across teams and across organizations is central to
creation of a common, standard build within the EMR. Proper
payment incentives should be considered to ensure clinician participation.
o Workflow analysis and design require attention and resources to
pave the way for the EMR and related technologies. Implementing
these tools will uncover many workflow and communication
inefficiencies at play in your health system. Focus on getting the
workflow right and consistent with the EMR tools pays dividends in
the long run.
o Taking the time to celebrate successes reinforces the value of the
work and bolsters morale during the stress of major change characteristic of large implementations like the EMR.
o Adhere to timelines, scope, and budget. There will be a natural
tendency to want to slow down, to make things perfect, or to do
more analysis. Moving quickly and sticking to timelines enables you
to move through the initial change, fight inertia, and move through
implementation to the really important work of improving performance and quality. Maintaining the pace helps you drive necessary
decisions toward that goal.
o Maintain vigilant focus on safety, quality, the patient experience
and key performance indicators to ensure a successful transition and
to avoid unexpected adverse outcome.
2015 Stage 6 Recipients
ABC Pediatrics
1 Ambulatory Facility
Arrowhead Regional Medical Center
1 Hospital
Abdel-Misih/ Bennett, MDs
1 Ambulatory Facility
Arthritis & Osteoporosis Center, LLC
3 Ambulatory Facilities
Advanced Care Obstetrics & Gynecology
1 Ambulatory Facility
Ascension Health
40 Hospitals
AdvantageCare Physicians
36 Ambulatory Facilities
Athens Regional Health Services, Inc.
1 Hospital
Advocate Health Care
1 Hospital
Atlantic General Health System & Hospital
1 Hospital
Affinity Women’s Health
2 Ambulatory Facilities
Baldwin Area Medical Center
1 Hospital
Agnesian HealthCare
3 Hospitals
21 Ambulatory Facilities
Banner Health
2 Hospitals
16 Ambulatory Facilities
Alexandar Bunt, DO
1 Ambulatory Facility
Baptist Health
1 Hospital
Alpena Regional Medical Center
7 Ambulatory Facilities
Baptist Memorial Health Care Corporation
13 Hospitals
163 Ambulatory Facilities
1 Ambulatory Facility
Barnabas Health
6 Hospitals
Appalachian Regional Healthcare System
2 Hospitals
Baylor Scott & White Health
1 Hospital
Arkansas Children’s Hospital
1 Hospital
Black River Memorial Hospital
1 Hospital
Andrea & Fred Kahn
Boston Medical Center
1 Hospital
Children’s Hospitals & Clinics of Minnesota
2 Hospitals
Brandywine Medical Associates
3 Ambulatory Facilities
Christiana Care Health System
Brandywine Podiatry
8 Ambulatory Facilities
Christiana Institute of Advanced Surgery
3 Ambulatory Facilities
Burgess Health Center
1 Hospital
CHRISTUS Health
1 Hospital
Calvert Memorial Hospital
1 Hospital
Citizens Memorial Healthcare
2 Ambulatory Facilities
Cancer Treatment Centers of America
4 Hospitals
Community Health Systems, Inc.
1 Hospital
Cape Fear Valley Health Systems
2 Hospitals
Community Hospital of the Monterey Peninsula
1 Hospital
Carolinas HealthCare System
4 Hospitals
15 Ambulatory Facilities
Community Medical Centers
1 Ambulatory Facility
CaroMont Health
1 Hospital
Catholic Health Initiatives
2 Hospitals
27 Ambulatory Facilities
Complete Family Care
1 Ambulatory Facility
Contra Costa Health Services
1 Hospital
10 Ambulatory Facilities
Catholic Health Services of Long Island
1 Hospital
Cook County Health & Hospitals System
2 Hospitals
18 Ambulatory Facilities
Central Florida Health Alliance
2 Hospitals
Cottage Health System
3 Hospitals
Center for Addiction & Mental Health - Toronto Central LHIN (7)
1 Hospital
Covenant HealthCare
1 Hospital
Children’s Healthcare of Atlanta
3 Hospitals
CoxHealth
1 Hospital
Children’s Hospital Los Angeles
1 Hospital
Daniel Toocheck, Dr.
1 Ambulatory Facility
DC Medical
1 Ambulatory Facility
Family Practice of Hockessin
1 Ambulatory Facility
Delaware Cardiovascular Associates
11 Ambulatory Facilites
Family Wellness Center
1 Ambulatory Facility
Delaware Family Medicine
1 Ambulatory Facility
Fanny J. Berg, Dr.
1 Ambulatory Facility
Delaware Surgical Group
2 Ambulatory Facilities
First State Endocrinology
2 Ambulatory Facilities
Dignity Health
31 Hospitals
First State Family Practice
1 Ambulatory Facility
Duke LifePoint Healthcare
First State Foot & Ankle
4 Hospitals
1 Ambulatory Facility
Duke University Health System
156 Ambulatory Facilities
First State Podiatry
1 Ambulatory Facility
East Alabama Medical Center
1 Hospital
Fitzgibbon Hospital
1 Hospital
East Boston Neighborhood Health Center
3 Ambulatory Facilities
Floyd Memorial Hospital & Health Services
1 Hospital
Emory Healthcare, Inc.
1 Hospital
EvergreenHealth
1 Hospital
Excela Health
1 Hospital
Fort HealthCare
30 Ambulatory Facilities
Franciscan Alliance
10 Hospitals
68 Ambulatory Facilities
Family Health West
1 Hospital
Franciscan Care Services
1 Hospital
Family Medical Associates of Delaware
1 Ambulatory Facility
Fremont Health
1 Hospital
Family Medical Centre
1 Ambulatory Facility
Geisinger Health System
6 Ambulatory Facilities
Genesis Health System
40 Ambulatory Facilities
Hendry Regional Medical Center
1 Hospital
Graham Hospital Association
1 Hospital
Heritage Valley Health System
2 Hospitals
Grande Ronde Hospital, Inc.
1 Hospital
Hoag
3 Hospitals
Greater Waterbury Health Network
1 Hospital
Holy Redeemer Health System
1 Hospital
Great River Health Systems, Inc.
17 Ambulatory Facilities
Hope Medical Clinic
1 Ambulatory Facility
Greenville Health System
2 Hospitals
Hosmane Cardiology
2 Ambulatory Facilities
Gundersen Health System
2 Hospitals
Hudson Physicians
1 Ambulatory Facility
Hallmark Health System
2 Hospitals
Hugh Chatham Memorial Hospital
1 Hospital
Harrison County Hospital
1 Hospital
Indianapolis Gastroenterology & Hepatology
1 Ambulatory Facility
Hawaii Health Systems Corporation
1 Hospital
Indiana University Health
1 Hospital
HCA - Hospitals Corporation of America
138 Hospitals
Infirmary Health
3 Hospitals
Health Quest
3 Hospitals
Inova Health System
66 Ambulatory Facilities
HealthSouth Corporation
30 Hospitals
Irene Szeto, Dr.
1 Ambulatory Facility
Hector J. Maya, Dr.
1 Ambulatory Facility
Jackson County Health Care Authority
1 Hospital
Hemphill County Hospital
1 Hospital
Jackson Health System
3 Hospitals
James Volpe, Dr.
2 Ambulatory Facilities
Laurel Medical Associates
1 Ambulatory Facility
John Muir Health
2 Hospitals
Lawrence Memorial Hospital
12 Ambulatory Facilities
Jupiter Medical Center
1 Hospital
LifeBridge Health
1 Hospital
Kane County Hospital
1 Hospital
LifePoint Health
23 Hospitals
Kansas Medical Center
1 Hospital
Linda L. Lawton, DPM
1 Ambulatory Facility
Karl Zimmerman, MD
1 Ambulatory Facility
Loma Linda University Health
24 Ambulatory Facilities
Katherine Shaw Bethea Hospital
1 Hospital
7 Ambulatory Facilities
Los Angeles County, Department of Health Services
1 Hospital
Kent Perdiatrics
1 Ambulatory Facility
Lubbock Heart Hospital
1 Hospital
Madison Health
1 Hospital
Kent Pulmonary Associates
2 Ambulatory Facilities
Khan OB-GYN
1 Ambulatory Facility
Margaret Mary Health
1 Hospital
Knoxville Hospitals & Clinics
1 Hospital
Marshall Health System
2 Hospitals
Lakeland Regional Health
13 Ambulatory Facilities
Martin Luther King Jr. Los Angeles Healthcare Corporation
1 Hospital
Lakewood Health System
1 Hospital
Mason General Hospital
1 Hospital
10 Ambulatory Facilities
La Rabida Children’s Hospital
1 Hospital
Laughlin Memorial Hospital, Inc.
1 Hospital
Marita M. Fallorina, MD.
1 Ambulatory Facility
Maternity & Women’s Health
2 Ambulatory Facilities
Matagorda County Hospital District
1 LHospital
Mayo Clinic Health System
1 Hospital
Medical Associates of Bear
2 Ambulatory Facilities
MedStar Health
1 Hospital
Memorial Community Health, Inc.
1 Hospital
Memorial Health Care Systems
3 Ambulatory Facilities
Memorial Health System
1 Hospital
Memorial Hospital at Gulfport
1 Hospital
Memorial Hospital of Sweetwater County
1 Hospital
MemorialCare
2 Hospitals
Mercy Health
2 Hospitals
MercyRockford Health System
50 Ambulatory Facilities
Meritus Health
1 Hospital
Methodist Healthcare
3 Ambulatory Facilities
Metro Health
13 Ambulatory Facilities
Middletown FamilyCare Associates
2 Ambulatory Facilities
MidMichigan Health
60 Ambulatory Facilities
MidWest Medical Center
1 Hospital
Milford Regional Healthcare System, Inc.
1 Hospital
Mission Regional Medical Center
1 Hospital
Moffitt Cancer Center
1 Hospital
4 Ambulatory Facilities
Mohsin Ansara, MD. FAAP
2 Ambulatory Facilities
Mosaic Life Care
54 Ambulatory Facilities
Morehead Memorial Hospital
1 Hospital
Mountain States Health Alliance
1 Hospital
MultiCare Health System
1 Hospital
1 Ambulatory Facility
Munson Healthcare
4 Hospitals
MUSC Medical Center
10 Ambulatory Facilities
Muscogee (Creek) Nation Health System
1 Hospital
Nanticoke Health Services, Inc.
1 Hospital
Nash Health Care
1 Hospital
Navicent Health
2 Hospitals
Nemaha County Hospital
1 Hospital
Nephrology Consultants
3 Ambulatory Facilities
Northwestern Medicine
111 Ambulatory Facilities
Nevada Regional Medical Center
1 Hospital
Novant Health
10 Hospitals
New Hanover Health Network
2 Hospitals
NuHealth
1 Hospital
New York - Presbyterian Healthcare System, Inc.
1 Hospital
Niagara Falls Memorial Medical Center
1 Hospital
Nieva T. Duque, MD.
2 Ambulatory Facilities
Nicklaus Children’s Hospital
1 Hospital
North Caddo Medical Center
1 Hospital
North Canyon Medical Center
1 Hospital
North Kansas City Hospital
1 Hospital
North Mississippi Health Services, Inc.
7 Hospitals
Oaklawn Hospital
1 Hospital
Oconee Regional Health System, Inc.
1 Hospital
OhioHealth
2 Hospitals
25 Ambulatory Facilities
Olathe Health System
32 Ambulatory Facilities
OSF HealthCare
3 Hospitals
117 Ambulatory Facilities
Overlake Hospital Medical Center
1 Hospital
Pagosa Springs Medical Center
1 Hospital
NorthBay Healthcare System
2 Hospitals
Parkview Health
8 Hospitals
152 Ambulatory Facilities
Northeastern Vermont Regional Hospital
1 Hospital
Partners Healthcare System, Inc.
1 Hospital
Northern Arizona Healthcare
2 Hospitals
Patient First Medical
1 Ambulatory Facility
Northwell Health
5 Hospitals
Piedmont Healthcare
1 Hospital
Northwestern Medical Center
1 Hospital
PIH Health
1 Hospital
Pioneers Memorial Healthcare District
1 Hospital
Samaritan Health Services
5 Hospitals
Pomona Valley Hospital Medical Center
1 Hospital
Sanford Health
1 Ambulatory Facility
Prime Healthcare Services, Inc.
2 Hospitals
San Juan Hospital
1 Hospital
Princeton Community Hospital Association, Inc.
1 Hospital
SCL Health System
154 Ambulatory Facilities
Princeton Healthcare System
1 Hospital
ProHealth Care, Inc.
5 Ambulatory Facilities
ProMedica Health System
1 Hospital
Pulmonary & Sleep Consultants
2 Ambulatory Facilities
Seaford Internal Medicine
3 Ambulatory Facilities
Sharp HealthCare
1 Hospital
Sheridan Memorial Hospital
1 Hospital
Singing River Health System
Queen’s Health Systems
2 Hospitals
2 Hospitals
Redwood Area Hospital
1 Hospital
SMA Medicine - Internal Medicine - Endocrinology - Pediatrics
1 Ambulatory Facility
Regional Medical Center
1 Hospital
Somerset Hospital Center for Health
1 Hospital
Rehabilitation & Welless (Apex)
1 Ambulatory Facility
South Side Family Practice
Ridge Family Practice, PC
2 Ambulatory Facilities
Robert Wood Johnson Health Network
2 Hospitals
Rural Health Management Corporation
1 Hospital
Rutland Regional Health Services
1 Hospital
Saint Luke’s Health System
6 Hospitals
17 Ambulatory Facilities
2 Ambulatory Facilities
Southwest Memorial Hospital
1 Hospital
Sparrow Health System
2 Ambulatory Facilities
Spartanburg Regional Healthcare System
2 Hospitals
Spectrum Health
8 Hospitals
77 Ambulatory Facilities
Spine & Orthopedic Specialist
3 Ambulatory Facilities
Susquehanna Health
1 Hospital
Springdale Internal Medicine
1 Ambulatory Facility
Sutter Health
4 Hospitals
St. Anthony’s Medical Center
22 Ambulatory Facilities
St. Bernard’s Healthcare
1 Hospital
St. Charles Health System
4 Hospitals
St. George Corporation
1 Hospital
Swisher Memorial Hospital
1 Hospital
Tamesis Rheumatology
1 Ambulatory Facility
Tampa General Hospital
20 Ambulatory Facilities
St. Joseph’s Healthcare System
2 Hospitals
Tenet Healthcare Corporation
5 Hospitals
St. Lawrence Health System
1 Hospital
1 Ambulatory Facility
St. Luke’s University Health Network
6 Hospitals
157 Ambulatory Facilities
Stillwater Medical Center
1 Hospital
Success Healthcare
1 Hospital
Sumner Regional Medical Center
1 Hospital
Surgical Associates of New Castle
3 Ambulatory Facilities
Surgical Care Associates
1 Ambulatory Facility
Susan B. Allen Memorial Hospital
1 Hospital
Terrebonne General Medical Center
1 Hospitals
The Cambridge Health Alliance
2 Hospitals
The Children’s Hospital of Eastern Ontario - Champlain LHIN (11)
1 Ambulatory Facility
The Toronto East General Hospital - Toronto Central LHIN (7)
1 Hospital
The University of Chicago Medicine
3 Hospitals
The University of Kansas Hospital
1 Hospital
The University of Texas System
1 Hospital
6 Ambulatory Facilities
TriHealth
1 Hospital
Trinitas Health
1 Hospital
Trinity Health
4 Hospitals
Trinity Mother Frances Health System
3 Hospitals
62 Ambulatory Facilities
UC HEalth
1 Hospital
167 Ambulatory Facilities
UCI Medical Associates, Doctors Care
51 Ambulatory Facilities
University Hospitals Health System
1 Hospital
13 Ambulatory Facilities
University of California
503 Ambulatory Facilities
University of Michigan Health System
103 Ambulatory Facilities
University of Rochester Medical Center
2 Hospitals
71 Ambulatory Facilities
University of South Carolina Department of Medicine
21 Ambulatory Facilities
University of Utah Health Care
1 Hospital
UHealth - The University of Miami Health System
30 Ambulatory Facilities
University of Virginia Health System
1 Hospital
UK HealthCare
2 Hospitals
UW Medicine
1 Hospital
34 Ambulatory Facilities
UNC Health Care System
3 Hospitals
30 Ambulatory Facilities
Union Hospital
1 Hospital
United Medical Clinic of DE
3 Ambulatory Facilities
UnityPoint Health
16 Hospitals
Universal Health Services, Inc.
77 Ambulatory Facilities
University Health
11 Ambulatory Facilities
University Hospital
1 Hospital
Vail Valley Medical Center
1 Hospital
Valley Regional Healthcare
1 Hospital
Vidant Health
53 Ambulatory Facilities
Virginia Commonwealth University Health System
1 Hospital
27 Ambulatory Facilities
WakeMed Health & Hospitals
2 Hospitals
67 Ambulatory Facilities
Walnut Hill Medical Center
1 Hospital
Wellforce
1 Hospital
5 Ambulatory Facilities
WellSpan Health
1 Hospital
WellStar Health System
5 Hospitals
Western Missouri Medical Center
1 Hospital
Western Reserve Hospital
9 Ambulatory Facilities
William C. Egan, MD.
1 Ambulatory Facilitiy
Wyoming Medical Center
1 Hospital
Yampa Valley Medical Center
1 Hospital
Congratulations to all the Stage 6 Achievers!
International Stage 7 Achievers
Hospital Dénia “Marina Salud”
Dénia, Comunidad Valenciana
Spain
Radboud Universitair Medisch Centrum
Nijmegen, Gelderland
The Netherlands
Seoul National University Bundang Hospital
Gyeonggi-do, Seoul
South Korea
Universitätsklinikum Hamburg-Eppendorf
Hamburg, Hamburg
Germany
Peking University People’s Hospital
Beijing, China
Sheng Jing Hospital of China Medical University
Shenyang, China
TEDA International Cardiovascular Hospital
Tianjin, China
King Faisal Specialist Hospital and Research Centre
Family Medicine Clinic
Riyadh, Kingdom of Saudi Arabia
Thank you for joining us in celebrating all of the Stage 7
achievers! We look forward to seeing you next year at
HIMSS17!
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