There is probably no other industry today that is more fraught with difficulty than healthcare. The healthcare leader simultaneously has to drive major reductions in costs while adopting rapidly evolving value-based care models and creating new structures to align physicians, all while achieving superior quality scores.

These challenges have opened windows of opportunity for innovative provider organizations to make key changes in care delivery models to both lower the cost of care and increase quality. While the innovations vary, the characteristics of successful projects are identical:

• Providing strong leadership to remove barriers to change
• Using information technology to augment decision-making at the point of need
• Reengineering care processes to support evidence-based care standards
• Using advanced analytics to make more informed decisions.

McKesson’s Better Health 2020TM framework defines the core competencies that will be required over the next decade as healthcare continues to transform:

• Optimizing performance and quality
• Coordinating care across settings and stakeholders
• Navigating evolving payment models
• Maximizing technology’s value as a foundation for growth

This issue of Performance Strategies concludes this series on the theme of “doing more with less” by highlighting a number of organizations that have demonstrated success and strengthened their Better Health 2020 competencies through innovative clinical projects. The other issues in the series focus on optimizing operations and improving financials.

Peninsula Regional Medical Center (PRMC), winner of McKesson’s 2013 award for clinical excellence, maximizes the value of its technology investment by using its systems to facilitate and support new care processes. For example, PRMC tackled the challenge of proactively identifying patients at risk for deterioration in order to intervene before an adverse event such as cardiac arrest occurs.

Using information already captured in its enterprise electronic health record (EHR) PRMC implemented a process that leverages IT to apply a scoring mechanism for constantly evaluating changes in patient vitals. The system alerts care team members to initiate care protocols or perform a detailed patient evaluation. PRMC estimates it has saved $2.3M in direct care costs in nine months while reducing cardiac and respiratory arrests by 67%. Read about PRMC and the strides they’ve made in improving outcomes and reducing costs.

Coordinating care across settings and stakeholders has long been a challenge for most healthcare systems, yet UnityPoint Health-Methodist did just that to improve care for chronic obstructive pulmonary disease (COPD). Using an EHR combined with advanced analytics, patients with a diagnosis or potential diagnosis of COPD were properly stratified according to evidence-based care guidelines across the settings of care. This knowledge drove a risk-based care model that ultimately led to a reduction in readmissions and a 50% increase in pulmonary rehabilitation referrals. Read about UnityPoint Health-Methodist’s achievements in creating a repeatable process for addressing chronic conditions.

New Jersey is a leader among the states embracing the evolving value-based care models. With the foresight to see the need for fluid information exchange across settings, Barnabas Health, which has two accountable care organizations, worked with competitors to create Jersey Health Connect. The exchange enables regional caregivers to access past patient care information, leading to a reduction in duplicate testing and potential medication conflicts while improving the efficiency of caregivers. Read about Barnabas Health and the journey to Jersey Health Connect.

St. Francis Medical Center focused on improving the quality of care by using evidence-based guidelines to change its care model for critical care patients by identifying those at risk for delirium upfront. Using a standard assessment tool, they proactively assess and document the condition, and provide immediate interdisciplinary consultation and treatment. With fewer complications and delirium-related consequences, they’ve been able to reduce extra care and length of stay. Read how St. Francis has improved performance and quality.

While clinical excellence always has been the mission of Englewood Hospital and Medical Center, the advent of health reform and changing payment models drove the need to use advanced health IT in supporting improved workflow and outcomes. Englewood has established a single, extensive improvement initiative supported by medication administration bar-coding, information to help with decision-making at the point of care, and detailed clinical documentation for a longitudinal patient record. Read how Englewood is using people, process and technology to drive change.

Evidence-based care is a well-regarded approach for improving care delivery. Now organizations can use an evidence-based approach to improve the accuracy of staff scheduling. Predictive staffing helps managers schedule the right number of staff at the right time and with the right skill level, helping improve financial performance and quality of care. Read how novel technologies can leverage an organization’s data on historical patient demand and combine it with real-time patient activity data to improve and optimize staff scheduling.

There are no easy answers to the cost and quality challenges of healthcare in America, and there are innumerable factors driving change that are beyond the control of health systems. However, these organizations have demonstrated material cost reductions while advancing their missions of providing high-quality care. While the future is unclear, the path to success is not.

Now is the time to empower clinical leaders to make bold changes in care models: ones that embrace clinical decision support technology, interoperability, and advanced analytics. Doing so can help caregivers improve clinical efficiency, reduce variability of care, and hard-wire evidence-based decision making – ultimately leading towards optimal patient outcomes and financial performance

Andrew Mellin, MD, MBA, is vice president and medical director of McKesson’s Enterprise Intelligence business unit. Dr. Mellin’s current areas of focus include designing new care models to support healthcare reform, creating novel cognitive support tools for clinicians, and improving outcomes through clinical process management tools. Previously, he was the Medical Director for Excellian at Allina Hospitals & Clinics where he was responsible for the physician adoption and optimization activities of an enterprise EHR at 11 hospitals and 60 clinics throughout Minnesota.

• Failures in planning, including assessments, treatments and goals
• Failure to communicate (patient to staff, staff to staff and staff to physician)
• Failure to recognize deteriorating patient conditions

At Peninsula Regional Medical Center (PRMC), we decided to attack these challenges and improve the care of our patients by quickly identifying those with deteriorating conditions and applying a consistent process for appropriate intervention.

This process would enable us to reduce the number of “Code Blue” medical emergency responses to resuscitate a patient and avoid the mortality that often follows these events. By initiating proactive vs. reactive care, we believed PRMC could use health IT to help us hard-wire a consistent method for delivering timely care to patients at risk of mortality.

Empowering Proactive Care

To help us identify patients that are at risk for a Code Blue, we implemented Modified Early Warning Scores, or MEWS, supported by our clinical information technology. MEWS is an evidence-based scoring methodology that uses patient vital signs to predict and alert caregivers of a patient’s declining conditions so they can intervene.

In our MEWS project, the vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation and temperature) are gathered automatically from documentation already being done in the electronic health record (EHR). The data is analyzed behind the scenes by rules-based “if/then” clinical alerts to calculate a score. The MEWS score is used to drive a standard process of assessment for intervention.

Many institutions have proven the MEWS alerting system to be helpful, but very few have used an electronic method to deploy it. By having the score calculated automatically and introduced into the clinical workflow, caregivers can quickly intervene using a Rapid Response Team (RRT) call, when appropriate, versus having the patient deteriorate to an emergent condition. This intervention ultimately helps to reduce Code Blues, and the risk for poor outcomes and mortality associated with them, as well as unplanned transfers for critical care.

The MEWS score enables intervention before the deterioration requires the need for a Rapid Response team, or worse, the patient status goes to Code Blue.

Implementing with a Multidisciplinary Approach

To implement the project, we used the Define-Measure-Analyze-Improve-Control (DMAIC) approach to measure, implement and re-measure the effectiveness of the tool and our process. Project leaders included a multidisciplinary team of clinician leaders from across departments. The triggered alerts enabled us to improve our team approach to bedside care with accelerated information exchange between ancillaries.

Our MEWS project included improved documentation of the care plan and entry of vital signs by certified nurse aids, development of care alerts for deteriorating conditions, clinical documentation of assessment escalations and use of analytics to evaluate the clinical data.

Clinical staff was educated, and prior to go-live, behind-the-scenes inspectors performed preliminary workflow assessment and evaluated initial care alerts.

Achieving Results in Improved Quality and Reduced Cost

In the first three months of a pilot of the system on a nursing unit, there were no Code Blues or mortalities. Over a nine-month period, the unit saw a 67% decrease in Code Blues and a 76% increase in Rapid Response Team (RRT) calls, which meant that care teams were addressing changing patient conditions more promptly. The pilot also saw fewer transfers to an intensive care unit, indicating that interventions were preventing the need for transfers.

By being proactive versus reactive, we can prevent costs for additional care and an extended length of stay. We calculated our savings using estimates from a Minnesota hospital, which found that Code Blue survivors cost an additional $20,684 in care, and non-survivors cost an additional $3,329.

For Code Blues that occurred on the nursing unit prior to the MEWS initiative, we would have saved more than $400,000 for one nursing unit. For the nine-month nursing unit pilot, our 67% reduction in Code Blues translates to an estimated $2.3 million in savings. We estimate a potential savings of $3.2 million if we can prevent Code Blues altogether in the medical/surgical units. Since the pilot, PRMC is live on three more units, with continued reduction in Code Blues and an increase in rapid responses.

Continuing the Benefits of Proactive Care

The care alert is the key element to trigger the assessment and proactive plan of care. We have shown that the electronic MEWS results are repeatable, and the standard process we instituted has been culturally sustained. Because the score provides objective data, it becomes a source of truth for the caregiver.

Clinicians trust evidence-based data, and with the MEWS scoring and alerts, we can initiate care proactively, which improves patient outcomes and reduces costs through more effective use of intensive-care resources.

Peninsula Regional Medical Center (PRMC) is the winner of McKesson’s 2013 Distinguished Achievement Award for Clinical Excellence. This is the third time PRMC has won a McKesson award for its clinical improvements. The annual awards program recognizes customers that have achieved notable results in improving healthcare quality and patient safety through the effective deployment of Horizon Clinicals® and Paragon® clinical solutions.

Dr. Snyder joined Peninsula Regional Medical Center (PRMC) in 2002 as a hospitalist, and currently is the chief medical information officer and chief quality officer. He also acts as the physician advisor for utilization review and case management, is involved in the development and implementation of a fully integrated clinical informatics system, and specializes in clinical data mining and physician engagement using evidence-based educational and informatics tools. He is an advisor to the National Quality Forum HITAC committee and the Maryland Health Information Exchange development board (CRISP). In 2010, he received the AMDIS award for his efforts in using clinical informatics to promote patient safety. In the same year, he was honored as one of the Top 25 Clinical Informaticists by Modern Healthcare magazine. Dr. Snyder represented PRMC in 2009, 2011 and 2013 when they won McKesson awards for clinical excellence.

John Morcom has been a respiratory therapist for 42 years. He served as a critical care and senior therapist for 32 years before joining PRMC’s IT department, where he has worked for six years as a clinical analyst for McKesson ED and CPOE clinical solutions. In addition, he has served as director of respiratory services and the chairperson for PRMC’s Code Blue committee for the past three years. He also served as a clinical instructor for Salisbury University’s School of Respiratory Therapy for eight years.

Creating a sustainable resource, by definition, means doing so without damage to or depletion of another resource. Yet we’re spending 18% of our Gross Domestic Product (GDP) on healthcare, with a projection by the Congressional Budget Office of 25% by 2025.2

That’s not sustainable.

So the real and complex challenge becomes: how can we wring out waste when it is seemingly intertwined with quality? In an attempt to fix what ails us, how can our healthcare system prevent throwing out the proverbial baby with the bathwater?

Bending the Curve

Since our 2002 founding, NEHI (formerly the New England Healthcare Institute) has made it our mission to bring together diverse perspectives from the national healthcare community, finding mutual solutions to mutual challenges. To focus much-needed attention on the issue of waste, we collected and distilled the results of nearly 1,500 peer-reviewed studies, conducted our own root-cause analysis, and identified, for the first time, exactly where the waste in healthcare is and how much it costs – both prerequisites to devising ways to remove it from the system.

Working in partnership with the WellPoint Foundation, we then launched “Bend the Curve,” an education campaign offering actionable ways healthcare leaders can reduce spending without sacrificing quality. By helping identify effective solutions, we’re hoping to help transform the healthcare landscape — waste and all.

Finding the Macro Waste

As the rising tide of chronic disease threatens to swamp our healthcare system, so too does our own cycle of reactivity and scatter-shot clinical practices. Accordingly, the top four drivers of waste are clinical in nature:

• Unexplained practice variation
• Medication underuse
• Adverse events
• Non-urgent ED use

The good news is that these drivers illuminate significant opportunities to reduce costs:

• Preventing readmissions = $25 billion in savings
• Reducing hospital admissions for ambulatory care-sensitive conditions = $31 billion in savings
• Decreasing medication errors = $21 billion in savings
• Addressing ED overuse = $38 billion in savings
• Reducing Antibiotic Overuse = $63 billion in savings
• Reducing Vaccine Underuse = $53 billion in savings
• Improving medication adherence = $290 billion in savings3

That’s $521 billion in waste and potential savings alone. And it doesn’t include the additional savings realized by the impact of one driver (medication adherence) on another (hospital readmissions).

1Identifying the Micro Waste

While it’s important to examine the waste issue from the macro level, it’s also vital to view it from the ground, at the level of the patient.

When my husband Patrick was diagnosed with cancer, our experience exposed a number of smaller contributors to waste. Although his care was generally good and his caregivers compassionate, they were often unaware of inefficiencies.

For example, there was the surgical resident who opened the $180 suture removal kit, but had to toss it out because he’d forgotten to don surgical gloves. And there was the nurse who repeatedly delivered pills when Patrick was unable to take anything by mouth. Her hospitalist didn’t like to use electronic prescribing, so the medication order was difficult to track and change.

Then there was the time we visited the ED, and by the time I’d parked the car, Patrick was being taken for a repeat MRI and unnecessary insertion of a PICC line, ordered by the ED physician because nobody could find Patrick’s chart from the previous week’s MRI test at the same hospital. At the end of his inpatient stay, we received the old fashioned triplicate discharge planning form. The form would have left any lay person rather uneducated about their loved one’s homecare needs, yet responsible for coordinating the post-hospital care plan.

While these are individual examples of “micro waste,” they collectively offer a much bigger opportunity for macro improvement.

The Evidence for Innovative Solutions

How can hospital administrators mobilize to root out and quash waste? Start by understanding your performance. Gather data, data and more data. This is where health IT helps organizations innovate and transform clinical care into a well-oiled, cost-effective, high-quality delivery system.

Case in point: decision support solutions can help providers to practice better evidence-based medicine, which in turn improves quality and reduces readmissions. Analytics and automation help caregivers identify and hard-wire safe clinical practices. And in the future, improved performance also will mean increased reimbursements.

Electronic pharmacy solutions help to significantly reduce medication errors. Electronic health records (EHRs), CPOE and other electronic information exchange systems not only help improve patient safety, but support more efficient coordination of care among providers, help reduce redundant tests and procedures, and promote more cost-effective, safe transitions within the hospital or to another setting.

Moreover, innovative hospitals also will use technology to help create patient-centered medical homes (PCMH), enhance patient education, improve medication adherence and prevent chronic disease. By developing evidence-based programs, smart hospitals will make up-front investments that pay long-term dividends.

Another action item for hospital leaders: learn from each other. Look for successful examples of clinical quality improvement and waste reduction — like the organizations highlighted in this publication — and develop a strategy that works for you.

Doing More…With Less

The evidence is in and clearer than ever: each segment of the healthcare system must confront the physical and economic harm of wasteful care.

Wendy Everett, ScD, is a nationally recognized healthcare thought leader who passionately supports innovative approaches to stem rising costs and inefficiencies in the system. With a breadth of healthcare experience spanning 40 years, Dr. Everett oversaw the formation of the New England Healthcare Institute (now called NEHI) in 2002 as its first president. Under her leadership, the national health policy institute has generated ground-breaking research on medical innovation, patient safety, healthcare spending and healthcare information technology, and has influenced significant national policy changes.

Dr. Everett also has served various philanthropic foundations and non-profit organizations, including UCSF Medical Center, Brigham & Women’s Hospital, the Robert Wood Johnson Foundation, the Kaiser Family Foundation, and the Institute for the Future. She earned two bachelor of science degrees, and holds master’s and doctoral degrees in health policy and management from Harvard University.

The changing healthcare landscape and a desire to improve community health compelled UnityPoint Health-Methodist to take a close look at our care delivery systems. Like others, we must find innovative ways to serve our patients and protect reimbursement by improving outcomes, reducing readmissions and better coordinating care. As Albert Einstein said, “We cannot solve our problems with the same thinking we used when we created them.”

As a result, we established a Center for Evidence-Based Medicine to help us adopt and implement standard procedures and tools that would help us follow best practices across the continuum of care. We believed that following the patient as they transition through the settings of care would enable us to better manage population health for a chronic condition.

Our first focus was improving the care of patients with chronic obstructive pulmonary disease (COPD). Although COPD was an organizational priority, there was no evidence-based standard of care in place across our care settings. Only 20% of patients were properly diagnosed with spirometry (pulmonary function testing). Some physicians assumed all smokers had COPD and treated them accordingly. Follow-up – including rehabilitation referrals, management of medication needs and post-discharge care – was lacking.

We implemented an evidence-based standard for our COPD patients across care settings called GOLD (Global Initiative for Chronic Obstructive Lung Disease). GOLD promotes clinical collaboration and coordination. In the process, we created a disease management model that could be replicated for other conditions.

Interdisciplinary Success

Effective teamwork and interdisciplinary cooperation helped us maximize programs already in place, minimize meeting time and ensure rapid implementation. Rather than mandate adoption, we decided to use the influence of leading caregivers to effect change.

We formed a core group that included a passionate physician champion who is a pulmonologist, an administrative sponsor, representatives from nursing and an evidence-based medicine dyad of a physician and nurse to model best practice behavior. This group in turn worked with subgroups and met daily to move the project forward. A larger group of physicians, nurses, social workers, pharmacists, case managers, and information technology staff, met only three times for final approval of the subgroups’ work. To speed implementation and give a better overall view of the process, care enhancements were submitted for approval as a package versus one at a time.

Improving Care Coordination

With the help of analytics, UnityPoint Health-Methodist has implemented a coordinated care management process for COPD patients that eliminates silos and focuses on transitions of care across the continuum. Organizations outside the health system also are included, such as nursing homes, medical supply companies and long-term, acute-care facilities.

We shared standardized enterprise tools with these entities, including a COPD assessment tool that uses a “stoplight” method (green-yellow-red) of assessing patient status. It enables caregivers and patients to know the proper care action to take for each level, such as calling 911, the home health facility or the primary care physician. Other tools included patient education materials, a dyspnea assessment tool, a hand-off process for care transitions, and a “teach-back” methodology in which the patient repeats back key pieces of care information.

When patients are discharged from the ED or inpatient care, they are referred to homecare, a transition coach, pulmonary rehabilitation or the nurse advisory line as well as their primary care physician. Care is now:

• More effective. From the start, care is evidence-based, with standard order sets used for admission and discharge. Having standard order sets based on best practices helps us provide optimal care.
• More efficient. Care duplication and variation are minimized. Patient education materials are streamlined and standardized.
• Safer. Comprehensive information is available in real-time to all clinicians, linking inpatient, the ED, our medical group’s physician offices, pulmonary rehabilitation, homecare and our Nurse Advisory Line. Care transitions are shared to ensure patients receive appropriate follow-up monitoring and referrals.

Rapid Results

With consistent processes and coordination across the continuum of care, we’ve minimized inappropriate variation and duplication – and achieved immediate improvements in COPD care. Within three months, 20 new care measures were in place to help ensure consistent processes. Diagnosis with spirometry increased, home health referrals increased, readmissions decreased for patients seeing a transition coach, and the number of pulmonary rehabilitation patients doubled.

The hospital’s Clinical Excellence Committee monitors all results via a dashboard. If results are below expectations, action plans are developed. We continue to tweak processes to improve results. Initially, readmission rates did not decrease as rapidly as hoped. High-risk patients now see a pulmonologist after discharge before transitioning to their primary care provider to ensure more comprehensive care.

Culture Change

Use of the enterprise model for cross-setting care has enhanced chronic disease management of COPD patients. Most importantly, it has changed the culture at UnityPoint Health-Methodist. With care coordination and collaboration, everyone, including the patient and his or her family, knows the patient status and the standards for treatment – from admission to discharge to referral to follow-up. We designed our model for use with other conditions. Currently, we are replicating the process for our diabetes patient population, and we hope to apply it to our heart failure patients in the near future.

UnityPoint Health-Methodist was a finalist for McKesson’s 2013 Distinguished Achievement Award for Clinical Excellence. The annual awards program recognizes customers that have achieved notable results in improving healthcare quality and patient safety through the effective deployment of Horizon Clinicals® and Paragon® clinical solutions.

Jasmine Holloway is currently Director of Center for Evidence-Based Care, Call Center, First Call Nurse Triage, and Magnet at UnityPoint Health-Methodist, in Peoria, Ill. She previously served as Director of Information Technology at the hospital. She has been a nurse for 43 years and worked in different specialties in nursing.

The catalyst that sparked our adventure into an exchange occurred in 2007, when Atlantic Health System began looking for a way to connect its hospitals and affiliated physicians. Because only 10% of those physicians had implemented an EHR, it landed on the RelayHealth software-as-a-service (SaaS) connectivity platform from McKesson’s connectivity business.

The platform provides cloud-based access to hospital-based laboratory and radiology results, cardiac diagnostic tests, consult notes and discharge summaries. After the service met with rapid adoption, Atlantic Health added non-affiliated physicians, essentially creating a local HIE.

Once the government tied interoperability to the meaningful use of EHRs, interest grew in Atlantic Health’s model, and so did the HIE.

On the Front End of Disruptive Change

In September 2009, the CIOs from Atlantic Health, Barnabas Health, JFK Health System and St. Peter’s Healthcare System came together to discuss joining together in an HIE. We decided to leverage the RelayHealth technology platform we already were using to connect within our own walls.

Meaningful use requirements, along with Office of the National Coordinator (ONC) grant funding, provided the economic incentives we needed to sell the initiative internally and to launch a sustainable structure. By the time the organization incorporated in February 2010, there were 18 healthcare entities that became founding members of Jersey Health Connect.

The Benefits of Patient Data Exchange

The purpose of the exchange is to bring value to the patient by bringing value to the clinician, but it’s the accountable care dividends that provide the return on investment (ROI). Barnabas Health has two accountable care organizations (ACOs) that participate in the Medicare Shared Savings Program where the provider assumes the risk for achieving outcomes tied to savings.

Seeing all available data on your patients, whether from another hospital, a nursing home, a reference lab, even referral doctors outside your ACO, is critical to managing the patient. With robust data exchange in place, we are starting to see the clinical value.

For example, a patient can walk into the St. Barnabas ED, and if he presented in Atlantic Health’s Morristown Medical Center last month, we can see what tests were done, what medications were dispensed, and so on. If the patient had a CT scan during that admission, the physician can think twice about ordering one today. The Continuity of Care Document (CCD) standard introduced with meaningful use, which becomes more detailed at Stage 2, enables the treatment team to see the patient’s history without recreating it from scratch.

Interoperability Outsourced

Interoperability is not easy. Technical challenges include managing patient IDs, reconciling duplicates, blocking private information and verifying access. Initially we looked at building our own framework. Then we saw how the SaaS platform would help us get up and running quickly, without having to implement or finance a complex infrastructure. JHC participants can purchase modular subscriptions for services that address our specific business needs.

Key components of the HIE include:

• Record locator service for linking participants’ data to the right patient, so authorized clinicians can locate and review records from any provider within the exchange
• CCDs, the Stage 1 Meaningful Use standard, for exchanging human-readable health summaries between clinicians and with patients
• Secure messaging for HIPAA-compliant communication between clinicians and with patients
• Lab and radiology results reporting, which can eliminate unnecessary duplicate tests and improve throughput
• Personal health records, which serve as the repository for aggregated data and enable patients to access their health record

Selling Itself to Clinicians

Nothing beats positive clinician feedback to boost sustainability. When the president of the medical staff says good things about the HIE, and that enthusiasm reaches other executives, it means more than all the metrics in the world.

Shortly before the HIE went live, Barnabas Health transplant specialists were in my office asking for immediate access. They saw that the HIE would quickly provide them with information on patient histories and potential matches that previously took dedicated resources and a staggering amount of research.

Sustainable Exchange
JHC’s business model has been self-sustaining from the start. The ONC grants and stimulus incentives have helped, but ongoing funding by exchange participants fuels our growth. We must be able to demonstrate ROI to each potential new participant. Currently we track usage by active physicians and registered patients. Soon we expect to see fewer denials and reduced length of stay.

Today, JHC includes more than 27 entities, including 23 healthcare systems, long-term care organizations, several large medical groups and 1,700 physicians. With nearly 2.5 million transactions a month, we are the nation’s fourth¹ largest HIE in volume of directed transactions. With ACOs and other evolving payment models at our doorstep, we are already contemplating new forms of collaboration. We have only scratched the surface on how secure data exchange can help drive breakthroughs in areas like clinical research and disease management.

¹ Based on testimony delivered by Micky Tripathi, president and CEO of the Massachusetts eHealth Collaborative, to a joint meeting of the Office of the National Coordinator policy and standards committees (HITSC/HITPC). When compared to the list of directed transaction volumes for state-wide HIEs, Jersey Health Connect’s volume would place it fourth in the list, even though it is only a regional HIE.

Jersey Health Connect won the 2011 Collaboration Award from the College of Healthcare Information Management Executives (CHIME).

Michael McTigue is vice president and chief information officer for Barnabas Health, the largest not-for-profit integrated healthcare delivery system in New Jersey and one of the largest in the nation. Barnabas Health’s two large teaching hospitals, Newark Beth Israel Medical Center in Newark and Saint Barnabas Medical Center in Livingston are home to the only state-certified burn treatment program and one of the nation’s first Living Donor Transplant Institutes.

Since we admitted our first patient in 1890, Englewood Hospital and Medical Center (EHMC) has been driven by a vision to provide compassionate care in a humanistic environment. The advent of healthcare reform compelled us to find meaningful ways to advance this mission of clinical excellence while tackling the transition to value-based reimbursement.

We turned to health IT to help us create a roadmap for change. Our most pressing challenge was a dramatic overhaul of our clinical information systems to help our physicians and staff continue to provide the state-of-the-art, high-quality care our community had come to expect. Goals included:

• Improved patient safety and satisfaction
• Fewer medication and transcription errors
• Widespread adoption of computerized physician order entry (CPOE)
• Enhanced communication
• Increased efficiencies

A True Team Effort

From day one, we set the expectation that everyone must “own the change” to ensure a successful result. Front-line staff, physicians and hospital leadership all stepped up. Every part of the hospital was involved. Interdisciplinary teams from all clinical areas, the medical staff, IT, business and finance studied the impact of technology on medication management, documentation, communication and care delivery.

After months of preparation, we launched the most comprehensive process improvement initiative in EHMC’s history: the implementation of a fully integrated clinical information system to improve safety, satisfaction and efficiencies. The “big bang” go-live of 14 clinical and business applications took place in a single day. It included CPOE, point-of-care, bar-code medication administration and interdisciplinary clinical documentation for nurses and physicians.

Significant Impact, Exceptional Results

We’ve realized exceptional results in all our target areas:

Patient Safety. Within a few weeks of go-live, CPOE adoption and compliance was more than 80% (exceeding Leapfrog standards and meaningful use requirements). Adoption has increased further to 92%. We achieved a high adoption rate by teaming seasoned physicians with tech-savvy physicians, and we offered a physician “cyber lounge” along with a 24/7 support desk. Strong engagement with our physician champions helps us sustain this remarkable rate, which contributed to a 90% drop in transcription errors in the first year as well as a 40% reduction in medication errors.

Patient safety is further enhanced with better medication management. Medication administration bar-code scanning compliance is 90%. Medication verification and reconciliation is 98% at admission and 99% at discharge, which helps ensure the patient is on the right medication regimen while they are with us in the hospital as well as when they leave.

Patient Care. The new systems support EHMC clinicians with the right information at the right time, helping them to make more informed clinical decisions at the point of care and adhere to standardized care processes. With caregiver collaboration, we built easy-to-use electronic order sets to target specific high-risk patient populations.

Our best-practice efforts have led to greater care efficiencies and improved outcomes, especially for preventable hospital-acquired conditions. Most significantly, our rate of venous thrombo embolism (VTE) has dropped 67%. Soon we will implement our clinical decision support-driven order sets that we built to apply best practices for high-risk perinatal and congestive heart failure patients.

Patient Satisfaction. We have incorporated patient advocates into our care delivery. In addition to providing patients and families with education and information on their condition, they are oriented to the enterprise patient visibility white boards where they can further monitor their loved one’s status.

Now patients can review their summary of care and discharge summary electronically. As a result, our Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores have improved steadily, with 82% of patients reporting they are satisfied with the discharge information we provide. Plans are in the works to roll out an online self-service kiosk for patients where they can register, schedule and view appointments and tests, view lab results, review account information.

Moving Forward with Confidence

Integrating health IT with our improvement efforts has empowered EHMC with advanced capabilities to address rapidly evolving demands for improved clinical, operational and financial outcomes. We’ve used it in myriad ways to help us hard-wire our policies and processes, streamline clinical and administrative workflows, support and coordinate quality care, and inform decision-making at the point of care. As we prepare to mark 125 years as the regional leader in providing high-quality care to our community, we know we have the tools we need to move forward with confidence in a complex, changing healthcare environment.

Englewood Hospital and Medical Center was a finalist for McKesson’s 2013 Distinguished Achievement Award for Clinical Excellence. The annual awards program recognizes customers that have achieved notable results in improving healthcare quality and patient safety through the effective deployment of Horizon Clinicals® and Paragon® clinical solutions.

Ronald J. Fuschillo, Jr., joined EHMC as vice president and chief information officer (CIO) in the summer of 2010. He is responsible for overseeing the medical center’s information systems, infrastructure, security and applications, and for leading the implementation of McKesson clinical and business applications. Mr. Fuschillo came to EHMC from Rutland Regional Medical Center in Vermont, where he served as VP and CIO.

Cio Dela Riva joined EHMC in 2000. After 10 years as the administrative director of Cardiac Services, she joined the IT Department as the clinical informatics director responsible for managing the implementation of McKesson clinical systems and the initiation of a formalized informatics team. Ms. Dela Riva came to EHMC from The Mount Sinai Hospital and Medical Center, New York City, where she served as Clinical Manager for the Cardiac Surgery and Cardiac Cath Lab departments.

Healthgrades’ Distinguished Hospital Award for Clinical Excellence™ 2013 ranks Englewood Hospital among the Top 5% of hospitals in the US for clinical performance. In addition, it has been recognized as a BEST REGIONAL HOSPITAL by U.S. News & World Report, which ranked the medical center fifth in the New York metro area. In addition, it received a Hospital Safety Score of “A” by The Leapfrog Group for upholding stringent standards in the critical areas of safety, quality and efficiency.

At Saint Francis Medical Center, we assessed our clinical care strategies for efficiency and effectiveness. To stay competitive, we decided to focus on our specialized Critical Care Units (CCU) where the costs and risks remained high. We zeroed in on delirium to reduce patient complications and length of stay, and to improve our clinical and financial performance.

The Clinical Condition: Delirium

A confused, disoriented state, delirium causes complicated clinical and financial challenges for critical care patients and providers. Often undetected, the condition affects up to 80% of patients in intensive care, and costs between $4 and $16 billion annually in the U.S.¹ The longer that patients are delirious, the greater the chance for increased morbidity, mortality, prolonged hospital stays and cognitive dysfunction.²

These statistics prompted the Center for Medicare & Medicaid Services (CMS) to propose delirium as one of the hospital-acquired conditions (HAC) for which they will not pay. Although it has not been added as an HAC yet, we believed that by proactively monitoring for delirium, we could achieve better outcomes and protect reimbursement for episodes of care.

Implementation Plan

Historically, the general approach to stabilizing critically ill patients has been long periods of immobility and bed rest, often with mechanical ventilation – which increases the risk for delirium. To achieve our goal of proactively addressing patients at risk for delirium, we conducted an evidence-based review of clinical practices for delirium management.

The protocol we’ve implemented is specific to critical care and is based on the Agency for Health Research and Quality’s (AHRQ) Clinical Practice Guideline for delirium. This interdisciplinary project incorporates the ABCDE bundle, which includes awakening and breathing trial coordination (respiratory therapy), careful sedation choice (pharmacy), delirium monitoring and documentation (critical care nurses), and early exercise and mobility (physical therapy) to reduce the incidence of modifiable delirium in the future.³

To implement our new delirium policy and protocol, we conducted bedside and classroom education across interdisciplinary departments to improve clinician collaboration. Now when a patient is admitted to the CCU, we assess their risk of delirium. By identifying patients at risk for the condition upfront, we can assess and document the condition, and provide immediate interdisciplinary consultation and treatment. Delirium assessment continues for all patients throughout their length of stay in the CCU.

An automatic consult is sent to the Pharmacy, Respiratory Therapy and Physical Therapy departments for every positive delirium assessment. We also provide patients’ families with an educational brochure to promote their active participation in the process. As a result, we have experienced fewer complications and delirium-related consequences and costs.

Upon transfer from the CCU, we communicate essential information regarding the patient to the transitional site of care. This communication promotes care continuity and improved patient outcomes.

Tools to Support the New Process for Delirium Management

To support the improvement program, we implemented multidisciplinary tools and processes:

• Richmond Agitation Sedation Scale (RASS) scores for critical care patients were incorporated into our clinical documentation system to assist caregivers in determining sedation levels.
• We created an ICU Delirium Chartable Review (CRv) for nursing assessments, and we added revised nursing interventions, RASS scales and spontaneous breathing trial results. Improved communication between the CCU nurse and the respiratory therapist during the trial for patients receiving sedation enabled us to wean them from the ventilator in a safe, timely manner.
• Real-time care alerts generated automatic consults to Pharmacy, Respiratory Therapy and Physical Therapy departments for every positive delirium screen.
• Interdisciplinary care team members worked collaboratively at the patient bedside, and through advanced notifications at their workstations, we minimized the risk and potential complications of delirium for our most critically ill patients.

Tangible results

Since the project has been implemented, we have improved clarity, accuracy and continuity for the detection and management of delirium. Within the first 10 months, 23% of all Intensive Care Unit (ICU) patients had positive screenings for the condition, and of those, 100% received immediate interdisciplinary consultations and interventions.

Our efforts have resulted in a reduction of 0.5 days on mechanical ventilation while receiving conscious sedation, which can reduce the length of stay in the ICU. Prompt review of medications revealed the fact that some patients on conscious sedation received minimal pain medication, which led to the revision of the Spontaneous Breathing Trial and Conscious Sedation Policies. Patients achieved mobility earlier due to the improved timing of physical therapy consultations.

We believe our evidence-based, standardized approach will be repeatable for other patient populations. The approach reinforces the importance of providing ongoing and comprehensive physical, functional, and psychosocial assessments that are unique to every age group.

Early detection, combined with multidisciplinary interventions for delirium can minimize the risk of complications for critically ill patients. As a result, Saint Francis has improved patient safety and outcomes, and we’ve reduced costs by reducing length of stay. Promoting quality of life for patients and their families also helps to protect the business health of the hospital.

Saint Francis Medical Center was a finalist for McKesson’s 2013 Distinguished Achievement Award for Clinical Excellence. The annual awards program recognizes customers that have achieved notable results in improving healthcare quality and patient safety through the effective deployment of Horizon Clinicals® and Paragon® clinical solutions.

Linda Heitman is a professor of Nursing and an Advanced Practice Nurse consultant. Her areas of expertise focus on adult health issues (cardiovascular) and critical care. In her Nursing faculty role, she teaches critical care to undergraduate students and pathophysiology to graduate students preparing for an Advanced Practice Nursing role. She also serves as a reviewer for The Journal of Cardiovascular Nursing. Dr. Heitman has a PhD in Nursing from Saint Louis University. She is certified as an Adult Health Clinical Nurse Specialist with the American Nurses Credentialing Center (ANCC).

Barbara Mueller, RN, BSN, CCRN, CSC, has been with Saint Francis Medical Center for more than 30 years. Currently she is project leader for the Clinical Information Systems department and for Saint Francis’s initiative to improve delirium management. Previously, she received the Leader of the Year Award from Saint Francis and served as the ICU and inpatient acute dialysis manager. In her role, she is responsible for managing its use of McKesson’s clinical software solutions.

Lisa M. Job, RN, MSN, ACNS-BC, is the Clinical Nurse Specialist in the Cardiac Intensive Care Unit at Saint Francis Medical Center. Lisa also has served on the faculty of the Medical-Surgical Department at Southeast Missouri State University in Cape Girardeau, Mo. She graduated with a Master’s Degree in Nursing, Clinical Nurse Specialist in Medical-Surgical Nursing. Lisa is a Board-certified Clinical Nurse Specialist in Adult Health by the ANCC.

Saint Francis Medical Center has been named one of the “Top 100 Best Places to Work in Healthcare” for 2012 by Modern Healthcare magazine for the fifth consecutive year.

Not only are the state-run heath insurance exchanges slated to launch in January as part of federal health reform, but private insurance exchanges are quickly taking root to cater to employers and their workers.

Experts say that private exchanges could have an even greater impact on benefits than public exchanges. That’s because the employer-based insurance market dwarfs the individual insurance market and employers are eager to reduce costs and get workers more engaged in their own health management.

“Exchanges are going to be a permanent, significant part of the healthcare world going forward because they are a powerful, adaptable way of meeting a wide variety of employer needs,” says Chris Bernene, partner at Oliver Wyman, a benefits consulting firm.

Unlike the public insurance exchanges, which will offer only health insurance, private exchanges will sell a wide variety of products. Mercer, a major benefits consulting firm, is launching its exchange called Mercer Marketplace in 2014. In April, Mercer announced its first 10 participating health insurance carriers, which include Aetna, Cigna, Humana, United Healthcare, Health Net and Blue Cross and Blue Shield of Florida. Other participating carriers include major disability, life, dental, vision and even pet insurers.

“There are very few points of similarities between the private and public exchanges beyond the word ‘exchange,’” explains Eric Grossman, senior partner at Mercer. “A private exchange requires an affinity for eligibility. You can’t just walk in off the street.”

Private exchanges will generally offer coverage through defined contributions. The way it works is an employer will pay a defined amount per worker or family annually and then the worker will take that money and purchase insurance on the exchange.

Health insurers participating in Mercer Marketplace are required to offer seven different benefit plans ranging from the bare-bones of just above what is required for carriers to participate in the public exchanges, to a rich plan that covers nearly 93% of total care. Employers are not required to offer all seven to their workers. Employers must have at least 100 eligible employees to participate in Mercer Marketplace.

“We will work with each employer to decide what to offer,” Grossman says.

In private exchanges, products are standardized, cutting down on employer resources necessary to manage benefits. Mercer will use its call center near Des Moines, Iowa, for customer support, fielding calls from employees typically handled by in-house HR personnel.

Other leading consulting firms Aon Hewitt and Towers Watson are also creating private exchanges. As are individual insurance carriers such as regional Blues plans.

Private exchanges offer health plans another avenue to reach customers. Indeed, some insurers will participate in multiple private exchanges. Towers Watson in late April announced the first batch of participating carries for its marketplace—called OneExchange—that included insurers also signed up for the Mercer exchange.

Private exchanges also give health plans richer data to create tailored products, Bernene says. For instance, carriers can design products and service bundles geared towards specific medical needs, he says.

Health plans already use claims data to target and stratify members. Pairing claims data with other sources allows for a more complete picture of risk. For instance, appointment-scheduling trends can offer forward-looking information on inpatient facility usage. Shopping patterns in the exchange can offer clues to consumer behavior and socioeconomic status as well, Bernene says.

Early adopters among employers are expected to be large players in retail and hospitality with lower-wage workforces, Bernene says.

“It’s a lot easier to control costs with this model,” he says. “In its most basic form, it’s a lever to shift costs, but to others with a long-term view, it’s about accountability and choice.”

However, employers with higher-wage workers could also jump in. At least half of employers are willing to try a private exchange if it means a 10% cost savings, according to a 2012 Oliver Wyman report.

“Over time, if the exchanges become a mechanism for improving the employee experience, then they could be very attractive to a wide range of employers,” Bernene says.

Grossman of Mercer describes the level of interest from employer clients as “unprecedented.”

An attractive aspect of the private exchange model, Grossman agrees, is cost control.

“An exchange, by definition, creates a retail mindset for the consumer,” Grossman says. “In that way, we do expect the exchanges to accelerate the pace of innovation. There is going to be intense pressure to control costs without taking away benefits. The challenge is, Can we construct networks and manage care in a way that can control costs?”

To help you keep track, I’ve listed six big reports released this year by leading industry thinkers, and I’m ranking them—from lowest to highest—by the potential savings that their recommendations would generate if the recommendations were implemented. Here goes.

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Name: “Preserving Medicare for Future Generations: Market-Based Approaches to Reform”

Savings: No specific dollar amount cited

Sponsor: American Enterprise Institute

Release: April 16

Pages: 63 (four separate reports)

Link to Report: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf405538

Favorite Part:  A competitive bidding program through which private health plans would contract with Medicare to provide beneficiaries in a defined geographic area with coverage would “…not be a big deal to implement.”

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Name: “Policy Options to Sustain Medicare for the Future”

Savings: $133 billion over 10 years*

Sponsor: The Henry J. Kaiser Family Foundation

Release: Jan. 30

Pages: 232

Link to Report: http://www.kff.org/medicare/upload/8402.pdf

Favorite Part: A four-page list of 124 acronyms used in the report

* From raising Medicare eligibility age to 67 from 65; one of several dozen recommendation to reduce costs or generate new revenue for the program

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Name: “Medicare Essential: An Option to Promote Better care and Curb Spending Growth”

Savings: $180 billion over 10 years

Sponsor: The Commonwealth Fund

Release: May 6

Pages: 11

Link to Report: http://content.healthaffairs.org/content/32/5/900.full.pdf+html

Favorite Part: Combines Medicare Part A benefits (hospital care), Part B benefits (physician care) and Part D benefits (prescription drugs) into one benefit called “Medicare Essential” that covers all three

_________________________________________________________________________

Name: “Strengthening Affordability and Quality in America’s Health Care System”

Savings: $220 billion over 10 years*

Sponsor: Partnership for Sustainable Health Care

Release: April 11

Pages: 40

Link to Report: http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf405432

Favorite Part: Diversity of sponsoring organizations (Ascension Health, Pacific Business Group on Health, Families USA, National Coalition on Health Care and America’s Health Insurance Plans)

* From state “gain-sharing” programs; one example of savings from report’s multiple recommendations

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Name: “A Bipartisan Rx for Patient-Centered Care and System-Wide Cost Containment”

Savings: $560 billion over 10 years

Sponsor: Bipartisan Policy Center

Release: April 18

Pages: 142

Link to Report: http://bipartisanpolicy.org/sites/default/files/BPC%20Cost%20Containment%20Report.PDF

Favorite Part:  If the plan fails, a “fallback spending limit” would kick in that would cap increases in Medicare spending per beneficiary

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Name: “Bending the Curve: Person-Centered Health Care Reform”

Savings: $1 trillion over 20 years

Sponsor: Engelberg Center for Health Care Reform at the Brookings Institution

Release: April 29

Pages: 49

Link to Report: http://www.brookings.edu/~/media/research/files/reports/2013/04/person%20centered%20health%20care%20reform/person_centered_health_care_reform.pdf

Favorite Part:  $1 trillion over 20 years

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As the reports attest, the strategies to simultaneously improve care, lower costs and enjoy a healthy bottom line are out there. Whether the government has the political will and industry leaders have the management foresight to implement them is another story.

I’ll be following up this column with another after the next round of system reform reports comes out.

Thanks for reading.

David Burda, a veteran healthcare business and policy journalist, is editorial director of Better Thinking for Better Health.

Read Utterback’s column on McKesson Homecare Talk.