1. Measuring Quality and Clinical Performance Indicators at Partners HealthCare System Blackford Middleton, MD, MPH, MSc Corporate Director, Clinical Informatics R&D Chairman, Center for Information Technology Leadership Partners HealthCare System, Inc. Brigham & Women’s Hospital Harvard Medical School

2. Overview Partners Healthcare System, Boston — High Performance Medicine — The HPM-X Informatics Infrastructure Reporting in an EMR — LMR Report Central — Quality Dashboards Early experiences with Quality Dashboards Q&A

3. Partners HealthCare System Ten hospitals, 7000 physicians $6.4B in revenues 4M outpatient visits and 160,000 admissions/year $1B in biomedical research annually Teaching affiliate of the Harvard Medical School Founded by the Brigham and Women’s Hospital and the Massachusetts General Hospital

4. Information Systems Descriptive Numbers Operating budget (FY07) = $158M Capital budget (FY08) = $45M Number of users = 54,000 Devices on the network = 71,000 Locations on the Partners network = 140 Electronic Medical Record physician users = 3,800 (> 90% of AMC PCPs; ~ 50% of Specialists) Patients with data in the clinical data repository = 4,000,000 Medical images on line = 450,000,000 Orders entered hourly through Computerized Provider Order Entry (across Partners) = 1,000 LMR (ambulatory EMR) transactions per day = 1M Calls to the Help Desk each month = 18,000

5. HPM comprises five System-wide projects with one common goal: To deliver better care to patients. Care that is:  Safer  Better coordinated  More reliable in delivering proven interventions Systems that support providers in “doing the right thing.” To deliver better care to patients. Care that is:  Safer  Better coordinated  More reliable in delivering proven interventions Systems that support providers in “doing the right thing.” What is High Performance Medicine? http://www.partners.org/about/hpm.htm Dr. Jim Mongan

6. 1.Investing in quality and utilization infrastructure  Information systems applications  Informatics Infrastructure (data, knowledge, services) 2.Enhancing patient safety by reducing medication errors system- wide 3.Enhancing uniform high quality by measuring performance to benchmark for select inpatient and outpatient conditions 4.Expanding disease management programs by supporting activities for certain patients with chronic illnesses 5.Improving cost effectiveness through managing utilization trends and analysis of variance Quality Efficiency Initiative Focus Infrastructure What are the High Performance Medicine Initiatives?

7. Discrete vs. Shared: Data, Knowledge, Logic Many Partners’ applications utilize discrete data, logic and knowledge or rules; most are not integrated across sites – creating islands of information and supporting varying levels of functionality.

8. The Future: Shared Data, Knowledge, and Logic – Partners SOA Strategy Common ‘Shell’ or Clinical Portal Shared Logic, Dictionaries, and Rules ( Enterprise Clinical Services, Medication Services and Knowledge Management) LOGIC (Services) Enterprise Repository (s) Problems, Meds, Allergies, Labs, Orders, Notes, etc. Dictionaries And Rules Data (Knowledgebases) Dictionaries And Rules Data (Knowledgebases) MGH OEBWH OELMR Future clinical applications will take advantage of shared repositories of enterprise data, knowledge, and logic, in a services-oriented architecture

9. Secure Clinical Communication And Notification of Results Intuitive Chart Summary Automatic Reminders Summary Flowsheets Coded Clinical Data Customizable Desktop

10. SFQD R&D Team Acknowledgements Clinical Informatics — Jonathan Einbinder, MD, MPH — Julie Greim, MSc — Tonya Hongsermeier, MD, MBA — Qi Li, MD, MBA — Maya Olsha-Yehiav — Matvey Palchuk, MD, MSc — Alan Rose, MSc Clinical and Quality Analysis — Julie Fiskio — Andrea Melnikas — Svetlana Turovsky, MD — Lana Tsurikova, MA, MSc — Lynn Volk, MA — Tony Yu, MD, MSc Clinical Investigators — Jeff Linder, MD, MPH — Jeff Schnipper, MD, MPH — John Orav, PhD Application Development — Irene Galperin — Nina Plaks — Anatoly Postilnik — Boris Rudelson — Michael Vashevko Clinical Systems Management — Lynn Klokman — Eunice Jung Other — Steve Flammini, CTO — Joanne Tremblay — Cindy Spurr — Cindy Bero — Liz Mort, MD — Alan Cole, MD AHRQ R01HS015169 Blackford Middleton, PI

11. CAD / Diabetes Smart Form Integrated into a visit note Customized views tailored to medical condition(s) of the patient Guided data review Central note-writing section — Multiple ways to document a note — “Formlets” for selected coded data entry Tailored Decision support section Patient View — Activates patient around goals of care

12. CAD/DM Smart Form Smart View: Data Display Assessment, Orders, and Plan Assessment and recommendations generated from rules engine Documentation Window Lipids Anti-platelet therapy Blood pressure Glucose control Microalbuminuria Immunizations Smoking Weight Eye and foot examinations Lipids Anti-platelet therapy Blood pressure Glucose control Microalbuminuria Immunizations Smoking Weight Eye and foot examinations

13. CAD/DM Smart Form Medication Orders Lab Orders Referrals Handouts/Education

14. What is a Quality Dashboard? Physician feedback system Clinician-level view of performance on problem-oriented quality indicators Comparison to: — Clinic peers — National benchmarks Drill-down capability — Summary measures  List of Individual Patients  Patient Charts/Smart Form

15. ARI Quality Dashboard Provider Name Clinic Name

16. CAD Quality Dashboard Targets are 90 th percentile for HEDIS or for Partners providers Zero defect care: Aspirin Beta-blockers Blood pressure Lipids Zero defect care: Aspirin Beta-blockers Blood pressure Lipids Red, yellow, and green indicators show adherence with targets

17. CAD Quality Dashboard

18. Sort Prioritize by deficiency points

19. CAD Quality Dashboard Filter. For example, patients with blood pressure not at goal who have had 0 or 1 visit in the past year Clicking on name opens patient’s Smart Form

20. Lessons Learned: Quality Dashboards Biggest barriers to use are related to the health care system — What are the drivers (carrots and sticks) to QD use? Pay for performance Reimbursement for case management — For chronic diseases, QD may be more effective as a case management tool

21. Lessons Learned: Quality Dashboards Other major barrier is related to quality of the data — Absolute need to tie patients to providers, edit panels, deal with missing data — Won’t change behavior unless the data are believable Big societal trends will drive quality measurement — Can providers be proactive? (EHR data better than billing data)

22. Conclusions Smart Forms and Quality Dashboards offer new workflow and decision support methods to manage acute and chronic medical conditions using EHR technology Both have potential to improve care, demonstrate EHR value to providers, and drive EHR use Much work remains to be done

23. Where Are We?

24. Thank you! Blackford Middleton, MD bmiddleton1@partners.org