Addressing the ARRA Requirements: Perspectives from Three Very Different Organizations Steven H. Shaha, PhD, DBA Quality & Outcomes Team Allscripts September 2010 For further information or clarification, contact Steven H. Shaha, PhD, DBA –

The Hurdles Keep Appearing For further information or clarification, contact Steven H. Shaha, PhD, DBA –

2010 Meta-Analysis of Electronic Health Records “… to drive substantial gains in quality and efficiency, simply adopting electronic health records is likely to be insufficient.” “… simple alerting is ineffective … “ “… policies are needed that encourage the use of electronic health records in ways that will lead to improvements in care.” Electronic Health Records’ Limited Successes Suggest More Targeted Uses Health AffairsHealth Affairs, 29, no. 4 (2010): Interpretation: Pop-up alerts and basic CDS are ineffective. Advanced Clinical Decision Support and the Outcomes Approach is mission-critical to success. Interpretation: Pop-up alerts and basic CDS are ineffective. Advanced Clinical Decision Support and the Outcomes Approach is mission-critical to success. Caution: All EHRs are NOT created equal … For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Notify Improved Outcomes Individually and collectively For Doctors For Nurses For Others From Doctors From Nurses From Others For Doctors For Nurses For Others The Evolution of Health Care Information Retrospective Automated Reporting Retrospective Automated Reporting Concurrent Synchronous Care Concurrent Synchronous Care Prospective Predictive Care Prospective Predictive Care Retrospective Manual Reporting Retrospective Manual Reporting Real-Time Outcomes Optimization Best care and best scores while the patient is still there The Power to Change Outcomes The best in advanced Clinical Decision Support Continuous Clinical Decision Support Engine Clinical Intelligence and Automated Assessments Extracted from multi-disciplinary documentation “Our” Recommended Treatments e.g. Order sets, pathways, algorithms, evidence-based medicine, inter- disciplinary documentation templates Providing the best care and achieving optimal quality and performance Providing the best care and achieving optimal quality and performance For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Managing patient populations and the compliance of their treatment with quality and patient safety initiatives... And performance Optimized Data Transparency and Reporting Continuous improvement, and the implementation and adoption of best practices The Evolution of Health Care Information Retrospective Automated Reporting Retrospective Automated Reporting Concurrent Synchronous Care Concurrent Synchronous Care Prospective Predictive Care Prospective Predictive Care Retrospective Manual Reporting Retrospective Manual Reporting Achieving Care Management and Performance Management simultaneously e.g. Indwelling Catheter UTIs, chronic disease management, sepsis reduction, infection control For further information or clarification, contact Steven H. Shaha, PhD, DBA –

“Clinical Decision Support” – Many Meanings Alert-based “Guardrails” BUT After error Interrupts workflow Alert fatigue Non-responsiveness conditioned Error Avoidance Order Sets with alerts Best practice maps Errors reduced Within workflow Fewer alerts Best Care Every Time. Errors designed out. BEST Practice built in. CPOE automagically. “Recalculating”. Automated documentation. Higher alert efficacy Where HIT Lives Beginning CDS Eclipsys CDS: Intelligent Eclipsys CDS: Intelligent For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Performance and results are optimized with information The good become better, The best become unbeatable The goal Right information to the right person at the right time and place … For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Good for awareness, but retrospective hindsight is not appropriate as the main view for piloting … Good for awareness, but retrospective hindsight is not appropriate as the main view for piloting … For further information or clarification, contact Steven H. Shaha, PhD, DBA –

The Struggle for Insight in the EMR/EHR Industry Oversight Shift to Shift, Day to Day and Week to Week Minute to Minute and Patient to Patient ? For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Data Transparency and Visibility: The Ability to Manage through Analytic Tools Oversight –Business and Clinical Decision Support –Clinical Analytics Vigilance Shift to Shift, Day to Day and Week to Week –Clinical Analytics –Tracking board, Clinical Summary Real-time Clinical Quality and Case Management Minute to Minute and Patient to Patient –Tracking Boards –Intelligent Order Sets –Notifications & Alerts Retrospective analysis Data for redesign Strategic perspective Fixing problems still doable Monitor change Operational/care perspective Fluid change Live figures Process/care perspective For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Meaningful Use For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Meaningful Use For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Meaningful Use For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Meaningful Use For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Meaningful Use For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Meaningful Use For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Meaningful Use For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Intelligent Order Sets vs. CPOE Alone 59.2% fewer medication-related errors reached patients when managed on Intelligent Order Sets w/CDS (p<.0001) Patients managed through Intelligent Order Sets w/CDS experienced significantly fewer errors (p<.0001) CPOE Alone Intelligent Order Sets 31.2% fewer alerts for Users of Intelligent Order Sets w/CDS (p<.0001) 122.8% more responsive to the fewer alerts they received for Users of Intelligent Order Sets w/CDS (p<.0001) For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Post implementation 71.7% Decrease in 3NE Med Errors versus Pre-implementation organization-wide mean baseline (p<.001) 42.5% in 3NE Med Errors versus Post implementation organization-wide mean (p<.001) 42.5% in 3NE Med Errors versus Post implementation organization-wide mean (p<.001) Zero Med Errors in 3 of past 7 months Post implementation (p<.001) 50.7% Decrease in organization-wide Med Errors versus Pre-implementation baseline (p<.001) Medication Administration Errors For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Improved Stroke Outcomes 40.5% Greater Clinical Excellence Impact of Stroke Outcomes Toolkit: Comparative Quality with versus without With CDS-rich Order Set Without Stroke Care Best Practices For further information or clarification, contact Steven H. Shaha, PhD, DBA –

With Outcomes Toolkit, Including CDS-rich Order Set Without Outcomes Toolkit Financial Impact Length of Stay 16.0% fewer (p<.001) 11.4% lower $509 average (p<.05) Readmissions in 31 Days Discharge Patterns 35.7 % fewer readmissions (p<.001) Improved Stroke Outcomes 9.4% more (p<.001) 21.4% fewer (p<.001) With Outcomes Toolkit, Including CDS-rich Order Set Without Outcomes Toolkit 12.7% lower $209 average (p<.05) Estimated Impact: $230k-565k Annualized With Outcomes Toolkit, Including CDS-rich Order Set Without Outcomes Toolkit 7.5% lower average LOS 0.35 fewer days avg. (p<.001) For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Significant reduction in Pressure Ulcers * Achieved through a multi-faceted process supported by KBC * Data reflect the findings of physical audits of charts and patients conducted quarterly per regulatory standards. National average between 9% and 4% depending on acuity Financial Impact estimated from $2.2 M and $14.8 M, depending upon which financial model is leveraged from the literature and CMS figures Quarter/Yr Pressure Ulcer Rate Q1 06Q4 05Q2 06Q3 06Q4 06Q1 07Q2 07Q3 07Q4 07Q1 08Q2 08 Natl. Avg. Rate Trend Post Mean 69.0% reduction to Post-implementation average of 2.39% (p<.001) 7.62% 18-month pre-implementation baseline Four consecutive Quarters at zero (p<.001) Q1 Q2 Q3 Q4 Q1 Q2 Q3 That’s approximately 367 fewer patients developing stage 3 or 4 decubidi each year (p<.001) For further information or clarification, contact Steven H. Shaha, PhD, DBA –

With CPOE alone With Advanced CDS Order Sets Weeks Compliance with Evidence-Based VTE Prophylaxis Improved Prophylaxis 97.4% Reduced Alerts (p<.001) 145.3% Increased Assessments (p<.001) 139.6% Improved Assessment Rate (p<.001) 97.4% Reduced Alerts (p<.001) 145.3% Increased Assessments (p<.001) 139.6% Improved Assessment Rate (p<.001) For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Statistically Significant Impact on VTE Rate $736,578 *reduced variable costs (p<.001) 0.8 Days reduced mean LOS (p<.001) * Annualized for Hips at risk only, quantified at mean organization-computed variable costs of $2,439/case. Control limits reflect Poisson distribution. DVT/VTE Rate per Bed Day Intelligent Order Set Week 95% Confidence Interval 95% Confidence Interval 95% Confidence Interval 95% Confidence Interval 62.6% decrease in mean DVT/VTE rate (p<.001). From mean rate of.431 to % decrease in variation (p<.001) That’s approximately 302 fewer patients suffering from VTEs each year * For further information or clarification, contact Steven H. Shaha, PhD, DBA –

For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Improvements in Blood Sugar Management Month Post-Implementation Pre-Implementation 16.6% Mean reduction in day 1 post-op in Blood Glucose (p<.0001) 25.8% reduction from highest to lowest in day 1 post-op Blood Glucose (p<.0001) 14.4% Mean reduction in day 2 post-op in Blood Glucose (p<.0001) 24.5% reduction from highest to lowest in day 2 post-op in Blood Glucose (p<.0001) Punch Line: Surgeons using smart order sets WITHOUT Endocrine consults Biphasic insulins. Combine a rapid-acting with an intermediate-acting insulin Biphasic insulins. Combine a rapid-acting with an intermediate-acting insulin For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Achieving Blood Sugar Management Goals Month Post-Implementation Pre-Implementation 24.9% Mean improvement in percent of cases managed within BG goals day 1 Post-op (p<.0001) 56.3% improvement from worst to best (100%) in percent of cases managed within BG goals day 1 Post-op (p<.0001) For further information or clarification, contact Steven H. Shaha, PhD, DBA –

Mediastinitis Outcomes Month 69.7% Reduction (p<.001) 6 Consecutive months at zero infections (p<.001)* * 95% confidence interval for most recent data estimated from twelve previous inclusive months Implementation of Portland Protocol for blood glucose management Blood glucose management below 200 increased from 47% to 96% (p<.001) Length of Stay reduced by 1.0 days (p<.001) Seven fewer infections annually (p<.001) Savings of between $308,490 1 and $80,500 2 annually (p<.001) For further information or clarification, contact Steven H. Shaha, PhD, DBA –