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Utilizing Health IT to Lower Costs and Improve Outcomes in a Rural Health System Cherokee Indian Hospital Michael Toedt, MD, FAAFP, CDR, USPHS Clinical.

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Presentation on theme: "Utilizing Health IT to Lower Costs and Improve Outcomes in a Rural Health System Cherokee Indian Hospital Michael Toedt, MD, FAAFP, CDR, USPHS Clinical."— Presentation transcript:

1 Utilizing Health IT to Lower Costs and Improve Outcomes in a Rural Health System Cherokee Indian Hospital Michael Toedt, MD, FAAFP, CDR, USPHS Clinical Director, Cherokee Indian Hospital Cherokee, NC

2 1. Understand how to utilize health-IT to produce population statistics to inform leadership of health trends and challenges. 2. Describe a practical method to use health-IT as a part of a system of measurement and feedback to achieve desired goals and objectives. 3. Identify useful point-of-care decision-support tools. 4. Suggest ways to develop and support interconnectivity and information-sharing with local and regional partners. Cherokee Indian Hospital Objectives:

3 Cherokee, North Carolina Cherokee Indian Hospital

4 Primary medical home for majority of the over 14,000 members of the Eastern Band of Cherokee Nation 17,000 primary care visits/yr 20,000 ER visits/yr 20-bed inpatient unit 156,000 prescriptions filled/yr Ancillary services Satellite clinics Specialty clinics Cherokee Indian Hospital

5 Mission Vision Values Goals Clinical Nursing Finance Operations Engineering Human Resources Board Purpose Ord. 410 Mission, Vision, Values Macro Strategies or Goals Tactical Strategy (Organizational Objectives/Performance attributes) Divisional and Cross-Functional goals Departmental objectives Employee Performance Appraisal system Incentive system

6 Mission Vision Values Goals Clinical Nursing Finance Operations Engineering Human Resources The Mission of the Cherokee Indian Hospital is to be the health system of choice for members of the Eastern Band of the Cherokee Nation by providing accessible, quality healthcare in a caring, culturally sensitive and healing environment through responsible management of the Tribe’s resources

7 Our EHR: RPMS Resource Patient Management System (RPMS) as the database for patient information. Developed in the 1970s The Patient Care Component (PCC) and the Indian Health Service Electronic Health Record (EHR) are tools to enable the entry of patient data into the database. PCC developed in the 1980s A number of packages have been added to improve the functionality of the RPMS system. Cherokee Indian Hospital GOOD AFTERNOON Welcome to RPMS HEAL ER ADMIN

8 Cherokee Indian Hospital Laboratory Appointment System Appointment System Patient Registration Patient Registration Dental Emergency Room Emergency Room PCC Patient Database PCC Patient Database Elder Care Public Health Nursing Pharmacy Behavioral Health System Behavioral Health System Women’s Health Women’s Health PCC Data Entry RCIS Immunization Radiology Case Management CHR Surgery

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10 Cherokee Indian Hospital

11 RPMS-EHR – Additional Systems Integration I-Care population management VISTA imaging – scanned documents Spectra PACS – radiology Quest – lab package NC Immunization Registry NC Controlled Substances Registry WNC Datalink – 16 WNC Hospitals Clinical References / Decision Support

12 1. Understand how to utilize health-IT to produce population statistics to inform leadership of health trends and challenges. 2. Describe a practical method to use health-IT as a part of a system of measurement and feedback to achieve desired goals and objectives. 3. Identify useful point-of-care decision-support tools. 4. Suggest ways to develop and support interconnectivity and information-sharing with local and regional partners. Cherokee Indian Hospital Objectives:

13 Mission Vision Values Goals Clinical Nursing Finance Operations Engineering Human Resources Board Purpose Ord. 410 Mission, Vision, Values Macro Strategies or Goals Tactical Strategy (Organizational Objectives/Performance attributes) Divisional and Cross-Functional goals Departmental objectives Employee Performance Appraisal system Incentive system

14 Cherokee Indian Hospital Uses for population statistics: Define the major health issues of the population: Diabetes, CVD complications, obesity, cancer, substance abuse and depression are our major health issues Define and track disease trends, clinical and administrative outcomes Strategic planning and administrative decision support Anticipate resource needs Advocacy Cherokee Indian Hospital

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16 Growth in Pediatric Services

17 Each micro-system must have the ability to record, track, pool, and analyze its population health statistics Recording and tracking – EMR Data pooling must be done in a safe, searchable database Data must be exportable for further analysis Cherokee Indian Hospital Ability to “Mine the Data” is Essential

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19 Cherokee Indian Hospital

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21 Mission Vision Values Goals Clinical Nursing Finance Operations Engineering Human Resources Improve access to timely and efficient patient care services Develop an organizational culture that fosters safe, effective, equitable, patient-centered care in a culturally sensitive and healing environment Prepare (grow) the organization to meet the health care needs of the community over the next 5 years

22 Mission Vision Values Goals Clinical Nursing Finance Operations Engineering Human Resources Board Purpose Ord. 410 Mission, Vision, Values Macro Strategies or Goals Tactical Strategy (Organizational Objectives/Performance attributes) Divisional and Cross-Functional goals Departmental objectives Employee Performance Appraisal system Incentive system

23 Cherokee Indian Hospital Monthly/Quarterly population health reports to Hospital Governance and Tribal Leadership: clinical indicators patient satisfaction customer concerns human resource indicators financial indicators

24 Organizational ObjectivesPerformance Measures Access 30% The average time to the 3rd available appt for continuity appts is less than____days 0 to 10 days days >20 days 0.2 Increase in the percentage of patients seen by a provider that are on the provider's panel [lbaseline 45%] >55% between 50% and 55% between 45% and 49%0.2 Decrease composite wait times for pharmacy and ER by the end of the 3rd - actual performance is % of target within ____% of target within ____% of target within ____% of target0.2 Utilization: kept appts as percentage of total available is above ____% 65-70% 70-75% >75%0.2 Access Performance Measures

25 Culture 40% Overall customer satisfaction as measured per surveys in key clinical areas: primary care in OPD, ER and the Inpatient Unit Based on Comparison to the Jackson Group database average 97% - 100% 100% - 103% >103% 0.20 Decrease the percentage of customer concernsNo increase in total number Decrease by 3% Decrease by 5% 0.10 Quality Composite Score>7 of 10 indicators met or exceeded targets >3<7of 10 indicators met or exceeded targets <3 of 10 indicators met or exceeded target 0.40 Improve Employee Satisfaction scores in the “Quality” Section of the Annual Employee Survey >80% positive responses >75% positive responses >70% 0.20 Vacancy and Turnover Rates for Medical and Nursing StaffCIHA 2008 Data turnover nursing = 7.04% turnover medical = 12.5% turnover dental = 5.56% vacancy nursing = 4.00% vacancy medical = 16.67% vacancy dental = 5.56% 0.10 Organizational Culture Measures

26 Mission Vision Values Goals Clinical Nursing Finance Operations Engineering Human Resources

27 Growth 30% IT Infrastructure Projects [timeline/budget] 0.30 Facility Projects [timeline/budget] 0.20 Finance Indicators 0.40 CIHA Operating Margin - 1.8% - > $2,200,000 - >561, $1,290,000 $ 444,217 Cash on Hand days days days 209 Percentage of Indirect Cost Compared to Tribe Indirect Cost30.6% % % 26.2% Growth Performance Measures

28 Other sources of data to mine: FI claims reports Contract Health Services - Regional Impact: $15,000,000 billed specialty-care services outside of the facility, most of it spent directly in western NC Cherokee Indian Hospital

29 Example: Tactical strategy to offer services in-house if we can provide equal or better service at same or lower cost FI claims reports- revealed high utilization of contracted orthopedic services Drill down and subsequent financial analysis revealed more cost-effective alternative- Orthopedic PA improved access to care better care coordination surgical intervention often not necessary when patient responds to conservative measures better outcomes with attention to physical therapy both before and after surgical intervention Cherokee Indian Hospital

30 PT - Orthopedic Clinic Redesign Example: Osteoarthritis of the Knee Primary Care Provider Orthopedics PA Physical Therapy Orthopedic Surgeon / Sub-Specialist Arthroscopic surgery Realignment osteotomy Arthroplasty Diagnostic testing Range of motion/flexibility exercises Quadriceps strengthening Patellar taping Joint injections of corticosteroids or hyaluronic acid injection Activity modification Self-care Weight loss Low-impact aerobic fitness Analgesics for pain

31 Example: Tactical strategy to offer services in-house if we can provide equal or better service at same or lower cost FI claims reports- revealed high utilization of contracted respiratory therapy services and respiratory DME Drill down and subsequent financial analysis revealed more cost-effective alternative- hired Respiratory Therapist to see patients and manage DME referrals improved access to care better care coordination $200,000 in savings realized in first two years Cherokee Indian Hospital

32 1. Understand how to utilize health-IT to produce population statistics to inform leadership of health trends and challenges. 2. Describe a practical method to use health-IT as a part of a system of measurement and feedback to achieve desired goals and objectives. 3. Identify useful point-of-care decision-support tools. 4. Suggest ways to develop and support interconnectivity and information-sharing with local and regional partners. Cherokee Indian Hospital Objectives:

33 Mission Vision Values Goals Clinical Nursing Finance Operations Engineering Human Resources Board Purpose Ord. 410 Mission, Vision, Values Macro Strategies or Goals Tactical Strategy (Organizational Objectives/Performance attributes) Divisional and Cross-Functional goals Departmental objectives Employee Performance Appraisal system Incentive system

34 Cherokee Indian Hospital Specific targets for selected clinical indicators Monthly scorecards for individual providers and for provider-nurse teams Hold staff accountable at the individual performance management level iCare – provides real-time population (panel) management tool used by nurse team lead

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36 Mission Vision Values Goals Clinical Nursing Finance Operations Engineering Human Resources Board Purpose Ord. 410 Mission, Vision, Values Macro Strategies or Goals Tactical Strategy (Organizational Objectives/Performance attributes) Divisional and Cross-Functional goals Departmental objectives Employee Performance Appraisal system Incentive system

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38 Cherokee Indian Hospital

39 1. Understand how to utilize health-IT to produce population statistics to inform leadership of health trends and challenges. 2. Describe a practical method to use health-IT as a part of a system of measurement and feedback to achieve desired goals and objectives. 3. Identify useful point-of-care decision- support tools. 4. Suggest ways to develop and support interconnectivity and information-sharing with local and regional partners. Cherokee Indian Hospital Objectives:

40 HIT Decision Support at Cherokee Indian Hospital RPMS/EHR 1. Clinical Reminders 2. Medication package 3. Graphing capability 4. HTML links through EHR Vista Imaging WNC Data Link NC Controlled Substance Registry Database NC Immunization Registry Policy Tech ® i-Care

41 What is iCare? iCare is a Population Management software tool that helps you manage the care of your patients. The ability to create multiple panels of patients with common characteristics (e.g., age, diagnosis, community) allows you to personalize the way you view patient data. iCare is a Windows-based, client-server graphical user interface (GUI) to the IHS Resource and Patient Management System (RPMS). iCare retrieves important patient information from various components of the RPMS database and brings it together under a single, user-friendly interface. Source: Indian Health Service (IHS) Webpage

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43 RPMS/EHR Decision Support: Clinical Reminders Guideline adherence; standards for: Preventive care Disease management

44 RPMS/EHR Decision Support: Postings Ready visualization of and quick access to: Crisis Notes Pain Contracts Allergies Warnings

45 RPMS/EHR Decision Support: Medication Package Medication selection at CIH is assisted by: Built-in pop-up allergy and interaction alerts. Setup of RPMS/EHR to display preferred formulary meds with most commonly used doses arranged by therapeutic category and/or clinical setting. Drill-down menus show medication-specific dosing guidelines.

46 RPMS/EHR Decision Support: Graphing Capability

47 RPMS/EHR Decision Support: HTML Links Facilitate access to: Reference literature / standards of care / guidelines Disease risk calculators Dosing calculators E&M calculators Patient education protocols and codes and teaching materials

48 RPMS/EHR Decision Support: HTML Links Lexicomp® Facts and Comparisons® Micromedix® Natural Standard® King Guide to Parenteral Admixtures® Drip Rate Calculator Vanc/Gent Kinetics CIH Medications/Solutions Manuals Policy Tech® Up-to-Date® IHS National Councils-NC4 Cochrane Database® IHS Provider Framingham Calculator Strongheart Calculator E&M Calculators IHS Patient Education Protocols and Codes

49 RPMS/EHR Decision Support: Templates with Standards of Care Diabetes Care Templates VTE Prevention R/O MI Orders Substance Abuse

50 1. Understand how to utilize health-IT to produce population statistics to inform leadership of health trends and challenges. 2. Describe a practical method to use health-IT as a part of a system of measurement and feedback to achieve desired goals and objectives. 3. Identify useful point-of-care decision-support tools. 4. Suggest ways to develop and support interconnectivity and information-sharing with local and regional partners. Cherokee Indian Hospital Objectives:

51 Cherokee Indian Hospital WNC Data Link 16 hospitals serving western North Carolina (WNCHN founding members) $2.5 million in federal funds and $1 million from The Duke Endowment

52 Cherokee Indian Hospital WNC Health Network Founding Member Map

53 Cherokee Indian Hospital WNC Data Link Long-Term Goal: Allow every WNC resident to have a longitudinal electronic medical record that can be accessed and updated in real time by any authorized provider. Short-Term Goal: Allow the secure exchange of electronic patient information between WNC hospitals.

54 Personalized Access Firewall Portal Access Management AccessPt.Software IBM WebSphere Application Server Secure Connections (VPN) Notification Firewall CP Homehealth Firewall Clinical Data CP Rehab Clinical Data Mission Clinical Data Pardee Clinical Data Transylvania Information on the patient is available through a portal view across the system to the various physicians with proper authorization Although clinical information for Jane Doe is located at each of the 5 facilities, the combination of the Portal and AccessPt. presents a consolidated view, producing a virtual EMR across the enterprise.

55 Cherokee Indian Hospital

56 Cost Savings of WNC Data Link Estimated $1 million savings through prevention of adverse drug events Estimated $400,000 savings through eliminating need to retrieve and fax paper records Estimated $2-4 million savings through elimination of ordering of redundant tests

57 Cherokee Indian Hospital Quality Improvements at Cherokee Indian Hospital Domestic violence screening 1%80% Tobacco use screenings 43%80% BP at target control73%79% Healthy cholesterol levels 71%75% Breast cancer screenings 39%49% Alcohol use screenings 4%82%

58 Cherokee Indian Hospital 2008 HIMSS Nicholas E. Davies Award of Excellence in Public Health Cherokee Indian Hospital

59 1. Health-IT is a valuable tool that can be mined to produce population statistics to inform leadership of health trends and challenges. 2. It is essential as a part of a system of measurement and feedback to achieve desired goals and objectives. 3. Many useful point-of-care decision-support tools are widely available. 4. It is important to partner with local and regional cooperatives to develop and support interconnectivity and information-sharing with local and regional partners. Cherokee Indian Hospital Summary:

60 Cherokee Indian Hospital For additional information: Michael Toedt, MD, FAAFP, CDR, USPHS Clinical Director Cherokee Indian Hospital Cherokee, NC


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