# Presentation: 153382

## Donald Crandall, MDClinical Informatics ConsultantTrinity Health Sept 2007

***Achieving success  with Integration of HIT in Ambulatory Care***

## Trinity Health – Our Communities

- Fourth-largest Catholic health system in the United States
- Operating revenues of      $5.7billion
- 44,950 FTEs
- 7,315 physicians – 95% private practice community hospital based
- 25 Ministry Organizations, 44 hospitals (29 owned and 15 managed), 379 outpatient clinics/facilities, numerous long-term care facilities, home health and hospice programs, and senior housing communities in seven states

## The Scale of Change

**How big is Genesis?**
- Project Genesis will involve:
- Implementation of 20+ information systems
- Across 17 Member Organizations and 23 hospitals
- Redesign of 300+ business and clinical processes

## Trinity Health Genesis Clin/Rev Schedule as of  June 2007

- Trinity Health Genesis Clin/Rev Schedule as of  June 2007

- Muskegon
- July 2004

- Sioux City
- Sept 2005

_**F03/05**_

- Grand Rapids
- Oct 2004

_**FY06 **_

- Mason City
- July 2005

_**FY07**_

- Battle Creek
- Feb 2005

- Completed

- In Process

- Not Started

_***Key:***_

- Oakland
- March 2007

- Macomb
- April 2005

- Port Huron
- Mar. 2003

- Clinton
- Oct 2007

- Dubuque
- Feb 2006

- Livonia
- March 2006

_**FY08**_

_**FY09**_

- Boise
- Jan 2009

_**FY10**_

- Ann Arbor
- June 2009

- Columbus
- TB Confirmed
- Late Fall 2009

- HQ Upgrade
- Aug 2006

- Fresno
- Oct 2008

- South Bend
- April 2008

- Silver Spring
- July 2008

- Domain Split
- Jan 2007

- CTT
- ACS & CHF

- Cerner Upgrade
- May 2006

- MC-Network
- Phase I
- July 2007

- MC-Network
- July 2008

- MC-Network
- Sept 2008

- Cerner
- Upgrade Alpha
- Sept 2007

- Livonia
- Ortho Tot Joint
-  PI Pilot

**ACS/CHF**
**PI Pilot-Oakland**
**Mar 2007**

- Cerner
- Upgrade Main
- Jan 2008

- FY08 Genesis
- Doc Mng
- Bundle

**Genesis Related Dependent Pilots:**
**Inet-Macomb Oct 2007 required for Silver Spring**
**Enterprise Sched Battle Creek Mar 2008 required for South Bend**
**Care Planning Dubuque required for Silver Spring**
**Surginet Battle Creek Mar 2008 **

## Genesis Accomplishments

- 10 ministry organizations live on in-patient system as of 7/2007
- Three ambulatory clinics live on PowerChart Office
- Avg. # of physicians placing orders per day (actually doing it themselves) is >850
- Orders processed per day > 300,000
- Avg. chart openings per day > 160,00
- Avg. HQ-Cerner ADT transactions per day > 50,000
- Avg. concurrent users per day during peak hours
-   (08:00-16:59) > 1200
- Peak concurrent users > 1500
- Simultaneous synchronization to 2 data sites

## Transformation: 1 Part Technology +    2 Parts Culture & Work Process

**Transformation:**

**Notes:**
300+ PROCESS CHANGES
PERCENTAGE OF WORKFORCE AFFECTED: 70%

## Scope:  Applications Installed

_**CLINICAL  APPLICATIONS**__                      _(Cerner/Millennium)
** ****Power Chart - Orders and results**
**Clinical documentation**
** ****PharmNet - Pharmacy **
** ****FirstNet: Emergency Dept.**
** ****RadNet: Radiology Dept.**
** ****SurgiNet: Operating Room **
** ****INet: ICU**
** ****Profile - HIM application**
** ****EMPI**
** ****CPOE**
** ****Power Note 2G Physician documentation**
***PowerChart Office ***

**Notes:**
THIS IS TECHNICAL COMPONENT: MASSIVE IMPLEMENTATION EFFORT
 COORDINATION AND INTEGRATION CRITICAL
 MUST TIE TO REDESIGNED PROCESS OR UNLIKELY TO WORK: TOO COMPLEX

## Ambulatory Electronic Medical Record

- Patient Demographics
- Current Allergies
- Active Medication (Medication reconciliation)
- Problems and Diagnoses
- Family history, social history, inactive problems
- Notes & Documentation
- Discharge summaries, care plans, visit notes, consultations
- Test Results
- Orders

- Copyright © 2006 Trinity Health, Novi, Michigan

## Physician Office Management System

- Practice Operations
- EMPI, Patient registration, patient scheduling
- Charge capture
- Financial Management
- EDI/Claims submission, claims management, patient billing & accounts receivable, collection management
- Management Reporting
- Standard A/R Reports. Ad Hoc reporting & queries, productivity tracking
- Additional Advanced Capabilities
- Managed Care support, Web-based capabilities

- Copyright © 2006 Trinity Health, Novi, Michigan

## Gartner Magic Quadrant

- Physician Office Systems 2006

## Ambulatory EMR

- Healthcare would benefit from physician office EMR’s that integrate office and hospital information
- Current systems do not yet support highly efficient physician office workflow
- 80% of office visits in practices of less than 5 docs
- EMR’s of all types are relatively expensive
- Vender landscape is challenging
- Most health systems are not invested in supporting independent physician offices

- Copyright © 2006 Trinity Health, Novi, Michigan

## Ambulatory EMR- Cont.

- Change in regulatory environment creates opportunities and challenges
- Adoption rates are slow, better in larger groups
- Typically less than 20% of EMR functionality is being used
- Even when technology is given away, adoption issues continue (Wellpoint and the State of Mass.)
- Lack of knowledge, workflow re-design, efficiency and risk are probably more significant barriers

- Copyright © 2006 Trinity Health, Novi, Michigan

## Percent of office-based physicians with selected features of EMR systems (standard error)

- Copyright © 2006 Trinity Health, Novi, Michigan

| EMR system feature | All Physicians | Fully electronic | Partially electronic |
| --- | --- | --- | --- |
| Patient demographics | 21.4 (1.6) | 91.5 (2.7) | 82.3 (3.8) |
| Physician clinical notes | 17.7 (1.6) | 82.2 (5.8) | 65.4 (4.9) |
| Lab results | 17.2 (1.6) | 80.9 (5.5) | 63.4 (5.0) |
| Nurse clinical notes | 14.0 (1.5) | 75.6 (6.1) | 46.0 (5.7) |
| CPOE | 13.4 (1.3) | 73.5 (5.1) | 40.4 (4.5) |
| Test orders | 12.7 (1.3) | 67.6 (5.2) | 40.2 (5.6) |
| Clinical reminders | 10.7 (1.1) | 57.9 (5.5) | 33.3 (4.3) |
| Public health reporting | 5.4 (0.9) | 34.2 (5.1) | 12.1 (2.8) |

- Catharine W. Burt, Ed.D., U.S. Department of Health and Human Services

## Adoption Challenges

- Lack of resources
- EMR financial benefits do not flow to physician
- Lack of integration
- Lack of IT standards

- Copyright © 2006 Trinity Health, Novi, Michigan

- Obstacles to implementing information technology
- American College of Physician Executives Technology Survey March/April 2004

## Stark Law Exceptions and Safe Harbors

- Copyright © 2006 Trinity Health, Novi, Michigan

|  |  | Health System Contribution Allowable under Safe Harbor Laws* | Components |
| --- | --- | --- | --- |
| Implementation | Hardware | No | PC,s Scanners, Tablets, Routers, Wireless Access |
|  | Network & Data | Yes | Telecom / Data Charges |
|  | Software | Yes |  |
|  | Interfaces | Yes | ADT with Hospital, Lab System, Reference Labs, Transcription |
|  | Implementation Services | Yes | Set-up, Training |
| Ongoing | Support | Yes |   |
|  | Transaction Services | Yes | Automatic Appointment Calling, Electronic Statement Processing, Claim Editing |

- A Maximum of 85% of cost can be contributed by health system
**(Not a legal opinion )**

## Path to Clinical Transformation

- Utilization
- Standardization
- Transformation
- Challenging in the Ambulatory environment

## Obstacles to Ambulatory ERM Implementation and Utilization

- Specialty specific templates
- Training requirements
- 1 three hour sessions, 2 one hour follow-up sessions
- This after physician has training on in-patient system
- Loss of productivity in early learning curve
- Buy in from all physicians in group
- Integration with:
- Back-end office management systems
- Front end registration and scheduling
- Integration with in-patient system
- What is the right amount and format for in-patient information
- Cost and lack of standardization

- Copyright © 2006 Trinity Health, Novi, Michigan

## Current Stasis, Challenges, Issues

- Current Status:
- Trinity is 1/3 to 1⁄2 complete with implementation of Genesis
- Trinity has made limited progress with Genesis-enabled clinical transformation
- PGVA recommendations - focus on clinical process transformation to obtain value from Genesis
- Challenges:
- Capturing and measuring value through improvement in clinical workflow
- Front-end customization to achieve adoption has led to proliferation of order sets that do not necessarily lead to better outcomes
- Missed expectations with some Cerner components
- Recognition of on-going software upgrade requirements
- Limited industry experience, high resource demand for “customizations”, and personnel “burnout”
- Technical risk mitigation strategies
- Key Questions:
- How do we continue implementation while significantly ramping up clinical transformation?
- How do we increase value and reduce risk?

**Notes:**
Great teams make real-time adjustments to the game plan to optimize outcomes
Op Revenue of Live Sites as % of TH Total = 35%
Op Expense of Lives Sites as % of TH Total = 35%
CMAED % of Live Sites as % of TH Total = 36%
FTE’s % of Lives Sites as % of TH Total = 35.5%
Op Income of Live Sites as % of TH Total = 26%

## Questions?