This month's community call will focus on Clinical Transformation and Core Measures and is part one of a planned two part series on Clinical Transformation. We will start with a high level view of what Clinical Transformation can accomplish within an organization, then drill down to the Core Measures and the workflow within OpenVista. What are Core Measures? Current and future Core Measures are a series of comparative performance measures developed by a number of quality forums and presided over by the Joint Commission (for details see: http://tinyurl.com/cv8zm9). This topic is clinical in nature and will likely be useful to physicians, nurses and others interested in outcomes. Please feel free to forward this invitation to any colleagues or associates who you believe would find this topic of interest or would like to participate in the discussion. What: Clinical Transformation (Part I) - Stage 6 EHR Big Bang Effect - Core Measures - Primer - Demonstration - Future vision - Discussion - Open Project Updates - OpenVista/GT.M Integration - CCD/CCR collaboration - Medsphere.org: Tip of the month When: February 19, 12:30 - 2pm Pacific Where: Dial-in: (888) 346-3950 // Participant Code: 1302465 Web conference: http://www.medsphere.com/infinite/ === The community calls are listed on the Medsphere.org event calendar (http://medsphere.org/community-events/) and we will update each month's call as the agenda is solidified. Details and Recording is available here: http://medsphere.org/blogs/events/2009/02/19/community-call-february-2009

1. Webinar: http://www.medsphere.com/infinite/
Voice: (888) 346-3950
Participant code: 1302465

2. Clinical Transformation, Part I
February 2009 Community Call

3. Presenters
• Edmund Billings
• Janine Powell
• Karen Small
• George Lilly
• Fay Struble
• Jon Tai
• Hartsel Bryant

4. Agenda
• Clinical Transformation
• Core Measures
– Primer & Workflow
– Demonstration
– Future Vision & Discussion
• Open Project Updates
– CCD-CCR Project
– OpenVista/GT.M Integration
• Medsphere.org: Tip of the Month

5. Clinical Transformation
Edmund Billings, MD

6. Clinical Transformation
Using the HIT system to achieve clinical improvements:
• Eliminate “Never Events”
• Patient Safety
• Quality Improvement
• Population “Disease” Management
6

7. Legislation and Initiatives
Never Events States-to-Date: 23
• 10/2008 “Never Events”
– Starting 10/2008 Medicare & Major Payors will not
reimburse for serious preventable events (E.g.Infections,
embolisms, pneumonia)
– Being adopted by 23 States with payers planning to not
reimburse and/or hospital associations planning to not
charge for these events.
• 08/2008 - Mass quot;Healthcare Reform Actquot;
– Implementation of EHRs in all provider settings,
– By 2015. statewide interoperable Heath Information http://www.msnbc.msn.com/id/26140511
Exchange
– A first year funding of $25 million, projected eight year
$200 million investment.
“ By 2012 for statewide adoption
• 09/2008 - The Stark Law of CPOE would be required for hospital
– The proposed bill would direct that EMR/EHR open-source licensure.”
technology be developed and made available to health
care providers at quot;a nominal cost.quot;
“ …provision of an open source health
information technology system that is either
new or based on an open source health
information technology system, such as
VistA….”
7

8. Clinical Transformation Initiatives & Impact
$1,500,000
Insurance providers est of saved life
$20,000
Adverse drug event ($16,000-$24,000)
$40,000
Cost of a VAP
$750
Cost of a vent days
15%
Medication reconciliation to reduce ADE (15%-20%)
$25,546
Cost surgical infection
$10,845
Cost of a pressure ulcer
$25,000
Cost of a bloodstream infection
$1.24
Cost savings from automating forms
25%
Reduction in ventilator days through bundle compliance
8

9. 9

10. Industry Recognition
10

11. Why Stage 6 is Critical?
• Supports Clinical Transformation
“Stage 6 hospitals have achieved a significant advancement in their IT capabilities
that positions them to successfully address many of the upcoming industry
transformations we will be experiencing in the near future (e.g. HIPAA Claims
Attachment, pay for performance, and government quality reporting programs)”.
• Share Data with Stakeholders
“Stage 6 hospitals are also well positioned to provide data to key stakeholders (e.g.
payers, the government, physicians, consumer and employees) to support
electronic health record (EHR) environments and regional health information
organizations (RHIO’s).”
Stage 6 Hospitals: The Journey and the Accomplishments, Mike Davis HIMSS Analytics, 2007.
11

12. Transformation
ADOPTION IS NECESSARY BUT INSUFFICIENT
not just adoption
Value is shared goal, now the
steps:
1. Implement to assure the
technology is deployed and
configured to support work
processes.
2. The technologies enable the
people to “use” the
technology effectively.
3. Now, the people can use the
system to change their
processes and realize value.
12

13. 3 Transformation Steps
1. Adoption
1. Departmental automation - orders management - CPOE
2. Clinical usage
3. Necessary but not sufficient
2. Operational Transformation
1. System itself is closed loop and fills holes
2. Efficiencies, information access and accountabilities
3. Clinical Transformation
1. Use clinical content to address specific patient safety and clinical
guidelines
2. Target specific outcomes with order sets, templates, clinical reminders
13

14. Medication Administration: CPOE & BCMA
Automate
Before
After
a
Provider writes a
Reviews Current renews,
Reviews new, renews, Flag Patient Places Chart in
Medications ,modifies, or DC’s Chart for Orders Rack
11 Steps
an order
Barcode
Nurse Reviews Is medication Drug is dispensed Nurse Checks 5 Nurse Administers
Nurse Reviews Medication Nurse Administers
Nurse Pulls Chart Yes
orders Floor stock? To patient Rights Medication
orders Administration Medication
Checks 5 rights
No
Unit Secretary or
Unit Secretary Nurse faxes/tubes/
Pulls Chart or puts in
pharmacy system
Are there Any
Drug Medication Order
Medication Order
Pharmacy Enters Pharamcy Verifies Pharmacy Tech Is medication
Interactions or No No is Dispensed to
Pharamcy Verifies Pharmacy Tech
Order into System Order Fills Order Floor stock? is Dispensed to
is this the Unit
Order Fills Order
Unit
correct Dose
Yes Yes
Medication is on
Notify Physician
Unit
14

15. Stage 6: Operational Transformation
Care
Decrease time from Rx order to dispensing: 15-20 minutes
Decrease Dx report turnaround: minutes, not hours
Decrease Rx order errors
Shift of RN time from documentation to patient care
Order Result
Decrease length of stay
Charge Capture & Claims
Increase in charge capture
Reduction in uncoded account days
Improved Case mix index improvement
Discharged-Not-Final-Billed (DNFP): Dec AR days
Decrease coding denials
HIPAA Attachments
Order/Doc Claim
15

16. How does it support clinical transformation?
1. Establish RN and MD usage
2. Plan: prompt for standard of care
– Order Set
– Template
– Clinical Reminders
3. Measure outcomes
– Midland 5 million Lives
– Never Events
– Core Measures
– Safety Checklists
– Big Seven Chronic Diseases
– Oncology Regime Tracking
4. Benchmark & Scoreboard
5. Iterate
16

17. Central Line-Associated Primary Bloodstream
Infection Rate
30.00
Central Line Primary Bloodstream Infection Rate
24.39
25.00
20.00
Per Thousand
88% Improvement
15.00
in 18 months
10.00
5.00
2.95
0.00
Jul-Sep 2005 Feb 2007-Jan 2008
Time Period
The Central Line-Associated Primary Bloodstream Infection (BSI) Rate per 1000 Central Line-Days
improved from a mean of 24.39 (1 of 41 Jul-Sep 2005) to 2.95 (4 of 1355 Feb 2007 – Jan 2008).
17

18. Key Transformation Components
Roadmap
Today
• Richer CDSS at Point of Care
• Integrated EHR
– EBM Care Protocols
• No interoperability excuses – Rules-based activity monitoring
• CPOE – Interruptive alerts
– Passive recommendations
• Closed loop orders and
– Contextual access to references
BCMA
• Clinical Dashboard
• Clinical documentation
– Population Management
• Content
– Benchmarking
– Order Sets
– Scoreboarding
– Templates
• Community Collaboration
– Clinical reminders
– Sharing content
• CDSS: Rx Error Checking
– Sharing best practices
– Proving standards of care
“Health Improvement
Technology”
“Its integrated and it works”
18

19. Core Measures
Fay Struble
Janine Powell
Karen Small
Edmund Billings, MD

20. Problem
• Hospitals have to hire full time staff to monitor and manage
collection of data needed for compliance with regulatory and
billing issues.
The Joint Commission on Accreditation of Healthcare Organizations
(JCAHO) has created Core Measures standards in order to increase
patient safety, improve the quality of care, disseminate evidence
based practices, and identify high reliability health care
organizations.

21. What are core measures?
• Core Measures are sets of clinical care performance guidelines that the
Joint Commission has established
From research
Past reporting
Current best practices and evidence based care
• Used for reimbursement purposes (Center of Medicare & Medicaid
Services)
• Used for research activities directed to improve the quality of care
• Help identify and distinguish high reliability health care organizations
• Identify and disseminate evidence-based practices and to set national
benchmarks

22. Overview
• For 2008, hospitals are required to collect and transmit data to
The Joint Commission for a minimum of four Core Measures sets
or a combination of applicable Core Measures sets and non-Core
Measures. The measure sets currently available for selection are:
Acute Myocardial Infarction (AMI)
Heart Failure (HF)
Pneumonia (PN)
Pregnancy and Related Conditions (PR)
Hospital-based Inpatient Psychiatric Services (HBIPS) – (Beginning
with October 1, 2008 discharges)
Children's Asthma Care (CAC)
Surgical Care Improvement Project (SCIP)
Hospital Outpatient Measures (HOP)

23. Poll

24. Value
Medsphere, in its attempt to keep their clients compliant with these new
regulatory guidelines, has created a content-driven solution utilizing
Clinical Reminders, health factors, and tailored templates. Clinical
Reminders provide real time point of care assistance, as well as
retrospective patient reporting.
Core Measures content is designed to provide hospitals with real
time capture and retrospective reporting on Core Measure
regulatory requirements while reducing the time required to
manage and monitor the initiatives increasing compliance and
revenue

25. Core Measure Initiation Workflow

26. Demo

28. Poll

29. Core Measures
• Future Vision
• Discussion

30. Open Development Projects
George Lilly & Fay Struble
Jon Tai

31. Community CCR/CCD Project*
Opensource CCR and CCD support
for VistA based systems
Project Update
February 19, 2009
by
George Lilly
glilly@glilly.net
* This project has been funded in part with Federal funds
from the National Institutes of Health, under Contract No.
HHSN268200425212C, “Re-engineering the Clinical Research
Enterprisequot;.

32. Topics
Definition
Purpose
Snapshot
Highlight
Contributors

33. Defintion
Definition: The Continuity of Care Record (CCR) is a
machine readable and human readable ASTM XML standard
data set of a person's clinical status

34. Poll

35. Purpose
The CCR dataset has many intended purposes including the
exchange of medical records, synchronization with clinical
repositories, and the transformation into clinical messages
Exchange of medical records:
Between two EHR systems (VistA<->VistA and VistA<->Other)
With a Personal Health Record (PHR) – like Google Health or
MS HealthVault
Synchronization with clinical repositories:
For clinical decision support
For research and clinical trials – as with the Electronic
Primary Care Research Network (ePCRN)
Transformation into clinical messages
XSLT transformation into a Continuity of Care Document (CCD)
For use the the National Health Information Network (NHIN)
For CCHIT Certification
For HIPAA Claims Attachments
Transformation into XML Web Service messages for ePrescribing

36. CCR/CCD PROJECT SNAPSHOT 2/19/2009
Picklist
Web
File CCD Transformation
Processing
Service
ePCRN
Connection
CCR Batch
Parameters
Template Processing ePrescription XML
Fileman Parameters
Support
Lab Date Limits
CCR Meds Date Limits Fileman
Template File Checksums
Processor Menu
Vitals Date Limits
Template Import
Options Codes
XPath Library XML RPC Variables RPC
MUMPS Temporary Globals
Fileman CCR Elements
Export Import (Accessioning)
Family History Advance Directives Lab Results Vital Signs Alerts/Allergies
Procedures Support Payers Medications Problems Actors Medication Advisories
(ePrescribing)
Encounters Functional Status Immunizations Alerts/Allergies
Plan of Care Medical Equipment Social History
GTM GTM
Cache GTM GTM Cache
WorldVistA
OpenVista FOIA VistA RPMS
EHR
Legend Planned In Development Testing In Production Recent Change

37. Poll

38. Highlight
Recently, we demonstrated the transformation of our CCRs into
level 2 CCDs thanks to an XSLT transformation contributed by
Ken Miller

39. Contributors
HP George Lilly
KRM John McCormack
Medsphere Ben Mehling
Robert Morris University Dennis Menor
Seqeuence Managers Ken Miller
University of Minnesota Kevin Peterson
Christopher Anderson Chris Richardson
Nancy Anthracite Mike Schendel
Lee Castonguay Fay Struble
Duane DeCorteau Thomas Sullivan
Emory Fry Chris Uyehara
Sam Habiel David Whitten
Greg Woodhouse
Jose Lacal
JohnLeo Zimmer

40. OpenVista/GT.M Integration Project
Jon Tai

41. Activity Numbers
28 bugs filed
51 commits in 8 branches
32 messages discussing 6 proposals
Many more on Hardhats
6 blog posts

42. Last Month
Settled on filesystem layout and Linux permissions scheme
Wrote proof-of-concept code to create OpenVista instances,
perform backups
Identified areas in OpenVista that will require modification
Wrote proof-of-concept code to allow M-based tools in
OpenVista to start/stop TCP listeners
Started developing test plans
Started packaging various utilities, including GT.M itself

43. This Month
Finalize design decisions
Switching “namespaces”
KIDS and “routine tiers”
File more bugs
Not just defects – includes task/feature bugs
Having all tasks in the tracker will allow us to better track work
completed and work remaining
Makes it easier for others to get involved
−
Start on implementation

44. Get Involved
Code is available on Launchpad
Not production ready; for developers only
Bugs are in Launchpad
You can help!
File a bug
Comment on a bug with suggestions
Create a branch and fix a bug yourself
Not sure how to get started?
Post on Medsphere.org with your interests; we'll find
something for you!

45. Medsphere.org Tip of the Month
Hartsel Bryant

46. Demo