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Jerome A. Osheroff, MD, FACP, FACMI Principal, TMIT Consulting, LLC Adjunct Associate Professor of Medicine, U. of PA April 2012 1.

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Presentation on theme: "Jerome A. Osheroff, MD, FACP, FACMI Principal, TMIT Consulting, LLC Adjunct Associate Professor of Medicine, U. of PA April 2012 1."— Presentation transcript:

1 Jerome A. Osheroff, MD, FACP, FACMI Principal, TMIT Consulting, LLC Adjunct Associate Professor of Medicine, U. of PA April 2012 1

2  Executive summary  Overview of the CDS/PI Collaborative  Overview of the CHCF-funded pilot project ◦ Phase I, Oct 2011-Mar 2012 [complete] ◦ Phase II, Apr 2012-Mar 2013  The CDS configuration template  Template use, benefits, evaluation  Next steps 2 TMIT Consulting, LLC

3  Many organizations have joined a Collaborative to enhance how they use CDS to address performance improvement imperatives  A CHCF-supported pilot project ran from 10/11 thru 3/12: ◦ 9 CDOs participated to test whether such collaboration would be valuable ◦ Participants improved their CDS and PI efforts by using a structured form for documenting and sharing CDS strategies for 2 targets (VTE, diabetes) ◦ All sites got benefits, recommended next steps, and plan ongoing participation  Next the Collaborative will, with further CHCF support: ◦ Engage more providers in completing and sharing target-focused CDS configurations ◦ Improve tools for completing and sharing templates, cover more targets ◦ Develop and share other tools to support target-focused CDS/PI project management ◦ Engage other stakeholders (e.g. vendors, RECs) more deeply in collaborative activities ◦ Explore mechanisms to make the Collaborative self-sustaining 3 TMIT Consulting, LLC


5  Providers face strong and increasing drivers (MU, ACA, VBP, etc.) to improve specific care outcomes associated with quality, safety, costs  Effective CDS is critical for these improvements but complex, expensive, and challenging to get right  Absent widely applicable and vetted target-focused CDS strategies, providers seek collaboration to ‘Get better faster – together’  Other stakeholders (e.g., EHR/HIT vendors, federal agencies, payers) also play critical CDS/PI roles and are likewise interested in collaboration to advance the state of the art and practice 5 TMIT Consulting, LLC

6  Accelerate local CDS and PI efforts by documenting, sharing, and enhancing target-focused CDS strategies  Foster development and use of tools that support this strategy sharing and local value realization  Include many provider organizations and PI imperatives  Provide major benefits for all stakeholders; especially Care Delivery Organizations, but also EHR/HIT Vendors, Payers, Federal Agencies, and others  Leverage strategies for improving outcomes with CDS from compendia such as the HIMSS CDS Guidebook SeriesHIMSS CDS Guidebook Series TMIT Consulting, LLC 6

7  All-time HIMSS bestseller, book of the year (2005)  Widely used by CMIOs/others  ~100 contributors  Bestseller, HIT book of the year (2009)  Co-sponsors include AHRQ, 3 CIS vendors  6 co-publishers 7  New (2/12)! >100 contributors  Guidance on successful programs and interventions  Addresses hospitals, systems, practices, vendors  Worksheets underpin template; ‘Tasks’ define CDS success path TMIT Consulting, LLC

8 “A process for enhancing health-related decisions and actions with pertinent, organized clinical knowledge and patient information to improve health and healthcare delivery.” Improving Outcomes with CDS. HIMSS. 2012  Very broad: way beyond alerts, order sets  Includes many things providers are already doing (though often not optimally) TMIT Consulting, LLC

9 To improve targeted healthcare decisions and outcomes, well developed and deployed CDS interventions must provide: the right information (evidence-based, actionable…), to the right people (clinicians and patients…), in the right intervention formats (alert, order set, answers, documentation tools, data display…), through the right channels (CIS, internet, mobile…), at the right points in workflow (decision/action...) Addresses: What, Who, How, Where, When TMIT Consulting, LLC

10  Care delivery organizations across country  EHR suppliers (Allscripts, Cerner, Epic, GE, QuadraMed, Siemens)  Federal agencies (ONC/AHRQ/CDC)  Beacon Communities  Society partners (HIMSS, Scottsdale Institute, Society of Hospital Medicine)  CDS and analytics suppliers  Clinical transformation consulting firms TMIT Consulting, LLC 10

11  Over 140 participants and growing steadily (driven by word-of-mouth)  California Healthcare Foundation (CHCF)- supported pilot enabled a Project Manager to be engaged, and the feasibility and value of CDS/PI collaboration activities to be tested  The pilot size, speed, and value exceeded expectations  CHCF funded a follow on one-year Collaborative phase focused on scaling and sustainability TMIT Consulting, LLC 11

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13  Validate that Collaborative goals are feasible - and work toward them is valuable - by demonstrating that: ◦ Provider organizations would refine and use a template for documenting and sharing target-focused CDS intervention approaches ◦ Participating organizations could agree on specific targets for joint attention and on a common template for documenting interventions ◦ Using the templates locally, and sharing completed versions across organizations, would add value to local CDS/PI efforts  Engage key stakeholders in following and supporting the pilot efforts, and generate ongoing participation beyond the pilot  Ultimately, drive widespread, CDS-enabled improvements in patient outcomes, especially for high priority targets 13 TMIT Consulting, LLC

14  9 provider organizations met weekly 10/11/11 thru 12/11/11 to refine a CDS configuration template and discuss their effort to get value from using it locally  7 organizations chose VTE as inpatient target focus and 2 chose diabetes as outpatient target focus  Group used a private website/discussion group;  Used frameworks/tools from the HIMSS CDS guidebook series to underpin work  Used full Collaborative to follow and provide input on pilot efforts and prepare for scale; conducted all- participant meeting on 11/28/11 (see Appendix)  In March 2012, formally evaluated pilot effectiveness TMIT Consulting, LLC 14

15  Commitment to PI, systematizing care processes, leveraging HIT investments  Limited CDS/PI resources but high stakes; be more efficient/effective, learn from others  Successful experiences with other PI collaboratives (get and give help)  Enhance innovation and accelerate its spread throughout their health systems  Improve patient engagement and support  Establish best practices for CDS interventions TMIT Consulting, LLC 15

16 Inpatient (VTE Prophylaxis): 1.Ascension/St John Providence Health System (Cerner) 2.Hennepin County Med Ctr (Epic) 3.Lehigh Valley Health Network (GE) 4.MetroHealth System, Case Western Reserve U. (Epic) 5.New York Hospital, Queens (AllScripts) 6.Texas Health Resources (Epic) 7.University of Pennsylvania (Allscripts) Outpatient (Diabetes Management): 1.University of Pennsylvania (Epic) 2.Veterans’ Administration (Homegrown) TMIT Consulting, LLC 16 Note: organizations listed in darker font participated most intensively in developing and using the template and sharing results

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18  Starting point was worksheets from HIMSS 2012 book, Improving Outcomes with CDS: An Implementer’s Guide  Pilot sites iteratively refined this material, based on successive efforts to use it in local CDS/PI meetings  Template has 3 parts: ◦ Diagrammatic overview of workflow and CDS interventions ◦ Tabular view of workflow steps, corresponding target-related activities, current/planned CDS interventions at each step ◦ ‘CDS Five Rights’ view documenting the ‘what/who/where/how/when’ for CDS interventions focused on the target  Different sites used different combinations of these 3 components in their local work TMIT Consulting, LLC 18 To view complete template, see online Users’ Guide

19 B. History & Assess. A. Pre- encounter C. Form. care plan D. Docu- mentation Z. Pop. mgmt. K. Post visit/home care J. Dischg or svc transfer & referrals H. Results/ new events G. Execute Therapies/ Procedures F. Order handling E. Orders/ Rx I. Consult requests Pre-visit questionn aires; facesheets Pattern recogni- tion logic Knowledge delivery/ interactive ref Structured documen- tation Order sets; error checking Error checking; alternatives Pt. educ guides; follow- up care prompts Alerts, monitors Time- based monitors; pt. reminders RECOGNIZE PATTERNS FFORMULATE PLAN COMMUNICATE (also I) EXECUTE PLAN RESPOND TO EVENTS TMIT Consulting, LLC 19 When? How?* * Template provides sample interventions for each workflow step; i.e. the ‘How’ items in the grey boxes

20 Example: VTE Prophylaxis-related Workflow and Interventions TMIT Consulting, LLC 20

21 Example: VTE Prophylaxis-related Workflow and Interventions TMIT Consulting, LLC 21 Generic Workflow Step Target-specific Clinical Actions/Workflows/Decisions CDS Interventions that Are Currently Implemented CDS Interventions that Are Potentially Promising, but Not Yet Implemented Requirement to document patients who are contraindicated for VTE prophylaxis Part of VTE order sets – requiring therapy or documentation of contraindication  Part of structured H&P with built-in risk assessment tool  Identification of patients at risk based on past medical history F. Order Handing Identification of at-risk patients who are not on VTE prophylaxis Not done Require corollary orders Coumadin orders must be made daily and must be accompanied by a INR order for the next morning Recommend dosing based on indication Suggested dosing based on indication on Coumadin order form Coumadin compliant diet Combined diets, e.g. diabetic and Coumadin compliant diet

22 Objective Core ActionWorkflow Content Delivery Delivery Logistics CDS Five Rights dimensions When (Workflow Step) What (Information) How (Intervention Type) Who (Person) Where (Channel) Population Management Z Recognize patterns Pre-encounter A Demographics, conditions, care gaps, self-progress Per Worksheet 6-1 Patient, Admin, Case Manager PHR/ Registry/ EHR Recognize patterns / Formulate Plan of Care History/Assess. B History/Physical data, medications, prior data review, inferred conditions Nurse/ Physician EHR, flowsheets, data facesheets VTE risk assessment Answers to comprehensive prompts enable some fields within VTE risk calculator to auto populate. Comprehensive Prompts (Smart Documentation Forms) NurseEHR Appropri­ ate VTE Prophy­laxis Calculator displays appropriate therapy modalities based on individual patient risk. VTE Risk Assessment Clinical Calculator (Relevant Data Summaries) PhysicianEHR TMIT Consulting, LLC 22 * Template provides sample intervention what/how/who/where for each workflow step

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24  High-level target-focused CDS strategy review ◦ Standard assessment/communication tool for CDS approach  Get stakeholder consensus/input, identify gaps  Understand different approaches/results across health system  Organize qualitative/quantitative intervention impact reporting ◦ Roadmap for target-focused CDS activities  Guide decisions about PI opportunities and potential CDS interventions  Plan for best practice care and optimal CDS (which evolves) 24 TMIT Consulting, LLC

25  Detailed CDS configuration planning ◦ Consider each dimension of CDS Five Rights (e.g., all care team roles and intervention types) ◦ Optimize use of current support tools, determine need for new tools and approaches ◦ Link MU reportable measures (VTE) to CDS configuration 25 TMIT Consulting, LLC

26  Better local CDS stakeholder engagement/communication ◦ With recipients; leadership; CDS, IT, and quality teams; clinicians ◦ Stakeholders better visualize and enhance their inter-related efforts ◦ Specifies CDS PI opportunities by making explicit current thinking and deployments focused on applying CDS to specific imperatives  Enhanced strategic planning ◦ “The exercise of categorizing and describing our [CDS/PI] strategies has been very useful and demonstrated the importance of stepping back from ‘the weeds’ to get the big picture of where our efforts are going” ◦ Workflow diagram provides a holistic view of CDS activities and opportunities across all care processes vs. in isolation ◦ Better understand need/opportunities to improve patient engagement 26 TMIT Consulting, LLC

27  Improved CDS execution ◦ Explain why current CDS approaches not working well ◦ Broaden approach to CDS toolkit, recipient and workflow support opportunities, e.g.:  Reassess VTE risk after admission  Consider diabetes CDS opportunities across care continuum ◦ Leverage CIS & CDS capabilities better and understand/address limitations  Knowledge sharing accelerates progress ◦ Learn from other organizations’ approaches/results 27 TMIT Consulting, LLC

28  8* out of 9 sites reported that using the template was somewhat to significantly useful for local stakeholder engagement, CDS/PI strategic planning, and/or CDS implementation  In terms of the net effect of the project on each organization’s CDS/PI efforts, all 9 sites said it was somewhat to significantly helpful  8 sites anticipate continued use of the template in their organization**  All 9 sites indicated that they would like to continue to participate in the Collaborative 28 ** 9 th site would use the template if there were a large group sharing completed templates TMIT Consulting, LLC * 9 th site didn’t have an active CDS project focused on the target during the pilot

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30 1. Foster adoption/value from CDS strategy sharing for additional provider organizations and cover more topics 2. Deepen and integrate engagement of CDS stakeholders other than providers 3. Develop a sustainability plan for maintaining/enhancing the Collaborative 30 TMIT Consulting, LLC

31  Get ≥10 more providers using template  Refine Users’ Guide to enable this use and value without weekly meetings and ‘hand holding’ used to engage sites during pilot  Create electronic fill-in-the-blank version of the template that is more user-friendly  Refine and deploy next-generation online ‘shared library’ for completed templates 31 TMIT Consulting, LLC

32  Cover at least 3 more PI imperatives  Establish forums such as regular target-specific teleconferences and online discussions wherein Collaborative participants can review and accelerate their respective target- focused CDS/PI work  Develop/use template for documenting and sharing target- focused CDS/PI project management tasks (e.g., stakeholder engagement)  Explore feasibility/value from organization-specific sub- communities to discuss challenges and implementation best practices among facilities in large health systems; goal is to accelerate CDS/PI innovation and spread within the system 32 TMIT Consulting, LLC

33  Preventable complications (Safety) ◦ VTE ◦ Catheter-associated infections (Blood stream, urinary) ◦ Adverse drug events  Condition management/Core Measures (Quality) ◦ Cardiovascular (CHF, AMI, Blood Pressure, Smoking) ◦ Diabetes  Efficiency (Cost) ◦ Readmissions (CHF, AMI, pneumonia) ◦ Early sepsis detection Note: Pilot sites addressed targets in blue TMIT Consulting, LLC

34  Create vendor-focused sub-communities to ensure vendor tools are used effectively in PI  Consider other related sub-communities  Conduct cross-stakeholder explorations into enhanced inter-related value propositions from Collaborative, including a possible CDS/PI pilot of this value involving payers, Regional Extension Centers, providers, and EHR vendors 34 TMIT Consulting, LLC

35  HIT/analytics vendor supports Collaborative subgroup consisting of its clients, for CDS configuration documentation and sharing, and best practice development using a template version adapted to its specific CDS related tools; by-product is insights into how vendor can enhance its CDS tools focused on one or many PI imperatives  Payer supports Collaborative subgroup within its network to identify and disseminate successful PI practices focused on targets of particular interest to the population covered  Health-system oriented sub-community as noted earlier 35 TMIT Consulting, LLC

36  National clinical condition-focused initiative supports Collaborative subgroup to focus on identifying successful CDS practices focused on that target, and accelerating spread of these practices on a widespread basis  Clinical Transformation consultancy builds subgroup of its clients to identify and spread CDS/PI best practices faster  Federal agencies (e.g. ONC, CDC, AHRQ) interested in enhancing use of HIT to address population health goals create sub-communities for these purposes (e.g., define and spread successful CDS practices leveraging Beacon Communities, REC’s etc.) 36 TMIT Consulting, LLC In Thread 2, we will explore creating these potential sub- communities and examine how they inter-relate with each other and the broader Collaborative to achieve shared goals

37  Identify mechanisms to make Collaborative self-sustaining (leveraging Threads 1&2) ◦ Make the collaboration activities self-perpetuating (e.g., via Users’ Guide and related approaches to systematize steps in the Collaborative’s value delivery process) ◦ Create plan for ongoing funding in return for value delivered to stakeholders 37 TMIT Consulting, LLC

38  The pilot validated the hypothesis that the Collaborative delivers value to providers  There is strong, multi-stakeholder interest in scaling the pilot activities  We have established Phase II funding from CHCF in order to: ◦ Scale provider engagement and value ◦ Cultivate cross-stakeholder value propositions ◦ Develop a sustainability plan 38 TMIT Consulting, LLC

39  Project Director: Jerry Osheroff, MD ◦  Project Manager: Lynne Schabert ◦  Project Website/Discussion Group (Private to Collaborative) ◦  Informational Website on Project (Public) ◦ Includes form to request entry into the Collaborative ◦  Users Guide for Collaborative and Template (Public) ◦ Includes: configuration template; slides about it that pilot sites used locally ◦  HIMSS CDS Guidebook Series ◦ 39 TMIT Consulting, LLC

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