2014 Most Wired07.09.14 by Matthew Weinstock H&HN Assistant Managing Editor, Suzanna Hoppszallern
This year's Most Wired hospitals are moving deeper into data analytics and population health management. It's a steep climb.
To understand what it means to be a Most Wired hospital, head about 40 miles east of Indianapolis to Rushville, Ind., and pop into Rush Memorial Hospital.
While there, it is likely you'll find clinical and administrative leaders leveraging information technology systems to improve operational performance.
"Our hospital administrative team reviews data weekly and monthly with the aim of reducing errors or increasing percentages," explains Jim Boyer, chief information officer of the critical access hospital. "Most of the data are delivered in the form of reports, clinical decision support or scorecards across the organization, thus impacting patient care."
A prime example of that impact: zero patient harms between September 2012 and September 2013, an achievement the hospital hit as part of the Health Research & Educational Trust's Hospital Engagement Network. Structured data from the health IT system created an environment in which clinical teams could target specific areas to reduce readmissions and improve quality across the board, Boyer says. Leadership also relies heavily on IT systems to position the organization for the next generation of care delivery.
"To get to the future state, our strategy reflects around second-curve metrics, thus aligning our health care system, physicians, clinical and nonclinical people across the continuum of care," Boyer says.
It's a strategy mirrored by many of the hospitals appearing on the 16th annual Hospitals & Health Networks' Most Wired list. These hospitals have effectively deployed such foundational technologies as computerized provider order entry, alerts and medication matching at the bedside, and now are eyeing data analytics and population health management. These are steep hills to climb.
Among Most Wired hospitals, 36 percent conduct controlled experiments or scenario planning to make better management decisions and to do forecasting, according to the 2014 Most Wired Survey. The percentage drops to 27 percent for all respondents. Additionally, 61 percent of Most Wired hospitals, compared with 49 percent of all respondents, use predictive modeling and data to improve decision-making across multiple departments. From a glass-is-half-full perspective, these characteristics are on the rise from previous years.
"We see leaders thinking about business intelligence tools. We also see consistency among hospitals' delivering quality metrics to clinicians," says Chantal Worzala, director of policy at the American Hospital Association. "The question is, 'Can we give them time to build out better analytical tools?' "
Worzala echoes a near-universal concern that federal mandates for hospitals and physicians to adopt health IT systems were too much, too fast. To be sure, hospitals have been putting electronic health records in place at a staggering rate. Nine in 10 hospitals possessed a certified EHR in 2013, up from 29 percent in 2011, according to a May report from the Office of the National Coordinator for Health Information Technology. Yet, the ONC data, based on an AHA survey, show that the vast majority of hospitals — 60 percent — had a basic EHR, meaning it lacked such advanced tools as clinical decision support.
Additionally, in the rush to meet Stage 1 meaningful use requirements, some hospitals implemented systems without fully assessing the impact on clinical processes, says Russell Branzell, president and chief executive of the College of Healthcare Information Management Executives, a partner on the Most Wired Survey.
"In many cases, the systems were not built for maximized workflow," he says. "We are seeing hospitals now having to reinvent processes or retool their systems. That's disappointing because it is like putting in a whole new EHR."
Acknowledging provider concerns, federal regulators in May proposed extending the compliance time lines for meaningful use Stages 2 and 3. ONC and Centers for Medicare & Medicaid Services officials also noted that vendors have not been able to keep pace with the demand to get certified products to the market. At press time, a final rule was not anticipated until at least September, which means that hospitals still could face compliance deadlines this summer.
The march to value
Regardless of CMS' overture of increased flexibility, CIOs completing the Most Wired Survey say the next hurdles to jump revolve around analytics, population health and the overall push to a value-based environment.
"We are using real-time algorithms within and outside of the EHR to look at risk, and predict and inform clinical and operational pathways," says Steve Hess, CIO, University of Colorado Health. "While still early, we are starting to see patterns related to how our patients are interacting with our system and the reimbursement impact of those changes. It is important that our systems are set up to provide the complete patient picture and to ensure that the patient is getting the appropriate care in the appropriate setting at the right time."
Creating a more complete view of patient patterns is critical to population health management. Just as important is creating scenarios in which clinical and claims data are viewed together, says Rose Higgins, senior vice president and general manager, population and risk management at McKesson Health IT, a survey sponsor.
"You need both to be successful," she says. "Seeing them together will provide a better picture of what's happening at the population health level and will be important as hospitals take on more risk."
Hospitals are just beginning to scratch the surface of what's possible. Roughly one-third of all respondents and 43 percent of Most Wired hospitals integrate clinical and claims data that are accessible, searchable and reportable across the continuum of care. Also on the population health front, 69 percent of Most Wired hospitals and 55 percent of all respondents conduct a retrospective analysis of clinical and administrative data to identify areas for improving quality of care and reducing costs.
As hospitals move toward accountable care and other value-based models, CIOs need to be front and center in the strategic and tactical discussions, says Branzell, a former health system CIO.
"We should be facilitators for those discussions," he says. "A big part of this is figuring out what data clinicians need to do their jobs well. What data support the workflow and improved efficiencies? It's got to be a collaborative effort. It is not something that IT does on its own."
Making the right decisions
Most Wired hospitals also are ramping up activities around patient engagement, which will prove vital in a value-driven health care economy. The focus isn't just on kiosks and electronic bill pay, although those aren't insignificant. Rather, there's considerable activity around all aspects of patient engagement, including chronic disease monitoring and mobile health applications. For instance:
• 82% of Most Wired hospitals allow patients to check test results via a portal.
• 53% of Most Wired hospitals offer patients with chronic conditions self-management tools via a portal.
• 58% of Most Wired hospitals offer an mHealth app that provides access to the patient portal.
• 40% of Most Wired hospitals offer secure messaging.
Although some of these percentages may seem low, given the pace of IT adoption in other parts of the economy, they are indications that health care is catching up. Having learned their lesson from Stage 1 meaningful use, though, some CIOs recognize that they need to be deliberate in how they move forward.
"The proliferation of devices that capture electronic information, the integration with health information exchanges, and the automation of many of the clinical and operational systems have led to many advances that we have never had previously," Hess says. "But it also leads to a lot of data that may not be clinically relevant or relevant for the specific episode of care. We need to find ways to collect all of that data, but eliminate the 'noise' to enable our clinicians and staff to efficiently and effectively make the right decisions."
For a list of the 2014 Most Wired click here.
Ochsner Health System, New Orleans
Engaging Patients in a Different Way
Warner Thomas understands that the move to value is about more than changes to reimbursement streams. Ultimately, it's about becoming more patientcentric.
"We realize that health care is becoming more retail-based and more transparent with patients who are more educated and will be armed with more information," says Thomas, president and chief executive officer of Ochsner Health System, New Orleans. "With that, we have to be more patientcentric and focused on their needs."
Technology is front and center in that effort.
"We're looking at how we can build a relationship with our patients," he says. "Amazon is constantly building relationships with its customers. How can we be that proactive? Can we connect with them to find out if they exercised today? Did they take their medication? We don't want to be a pest, but a resource. That's what we have to do in this transition."
Recognizing the need to meet patients on their terms, Ochsner is piloting a mobile-friendly program at its flagship primary care site. Through O Bar, patients get help downloading health apps appropriate to their lifestyles to smartphones or tablets. A team of Ochsner staff combed through thousands of mHealth apps and cultivated what they consider to be the best of the best. The eventual goal is to allow data to flow from the apps into Ochsner's electronic health system, which is expected to lead to greater patient engagement.
"We understand that everything is becoming more mobile and more tech-oriented," Thomas says. "Instead of fighting that, we are embracing it."
It doesn't stop with MyFitnessPal.com and Fitbits, though. Ocshner has built an EHR system that integrates disparate parts of the delivery system and provides physicians and other providers a comprehensive view of a patient's profile. That includes giving post-acute providers access to a portal that contains discharge summaries and other relevant parts of the continuity of care document.
A robust disease registry tool also helps providers to engage specific populations better around their care, says Lynn Witherspoon, M.D., senior vice president and chief medical information officer. Ochsner is able to tabulate data from its EHR, community providers and insurers to then funnel that information back to physicians for action.
Witherspoon says that all of these elements fit into a larger strategic goal of creating a more patientcentric system.
"Patients have more freedom to move among providers," he says. "It is our job to help them understand why coordination is in their interest."
Truman Medical Centers in Kansas City, Mo.
Using Data in a Meaningful Way
At Truman Medical Centers in Kansas City, Mo., data is king.
From the patient home to the bedside to the executive suite, data drive key clinical and operational decisions, often in real time.
"Technology is involved in every initiative we have," says Mitzi Cardenas, senior vice president for strategy, business development and performance integration, and CIO. "It gives clinicians and business leaders the ability to view information in a way that is significant to them, and it is delivered at the point of care or the point of business operations. We need to do more, though. The industry needs to do more to present data in a more meaningful way."
If the past is any gauge, TMC will be doing more, and doing it quickly. In 2009, TMC ramped up efforts to roll out an electronic health record system across its two hospitals and 50-plus ambulatory sites. By August 2010, the EHR was up and running. Deploying the EHR was a tactical goal; the real strategic imperative was to put a system in place that improved decision-making, says Charles Shields, who replaces the retiring John Bluford as chief executive of the system this month. Shields was chief operating officer at TMC Lakewood.
TMC leaders are keenly aware of the critical role that information technology and data play as more care is delivered outside of the hospital.
As part of a Center for Medicare & Medicaid Innovation grant, TMC has been targeting interventions for patients with chronic conditions. The focus is on high-cost ZIP codes, mainly in the city's urban core. There are high-tech and high-touch aspects, says Cardenas. Data in the EHR help to identify patient populations, individual histories and care needs. An alert system lets practitioners know when a patient shows up at a facility.
"We are building a relationship with them so we can have more successful interactions," she says.Aside from the grant, TMC is working in other interesting ways with patients who have chronic diseases. A patient advisory panel at Lakewood, for instance, has been instrumental in helping to evolve the patient portal.
Shields hopes to expand the concept throughout TMC, noting that he and his peers need to "quit thinking like a hospital." Patients have more choices and hospital leaders need to adapt and show value. Identifying patient populations early in their disease state and developing interventions will be key."That is where we are going to be able to show value — devoting the right resources to the right groups," Shields says.
Gritman Medical Center, Moscow, Idaho
Following the Patient
With the University of Idaho in its backyard, Gritman Medical Center in Moscow faces a challenge unlike most rural communities: a fairly transient patient population.
"We are in a university town — actually there are two of them nearby — and there are a lot of students coming in the fall and leaving in the summer," says Kane Francetich, chief information officer at the critical access hospital. Washington State University is about nine miles away, just across the state border.
Keeping tabs on patients who visit Gritman providers but who may head off to another part of the state during their summer hiatuses can prove challenging. Participation in a robust health information exchange, though, extends the medical center's reach and helps with the continuity of care. Such critical information as problem and allergy lists, lab results and other portions of the continuity of care document are uploaded to the Idaho Health Data Exchange.
"The data include not just the Gritman health record, but information from other providers across the state," says Francetich, who serves on the HIE's board. "That helps us to treat them and make sure information becomes available to their primary care provider. It is a powerful tool for us."
As Francetich knows, the health information technology landscape is littered with promising attempts at information exchange that eventually fell victim to the proverbial sustainability question. IHDE originally was propped up by a grant, but is now supported by subscriber fees paid by hospitals and doctors.
The value proposition for Gritman's leaders is pretty simple: "Focusing on our patients and being able to deliver high-quality care," says hospital CEO Kara Besst. As a critical access hospital, Gritman can't take care of every patient and every ailment, so the need to transfer records along with patients is imperative. The medical center also is working with community physicians, neighboring hospitals and post-acute providers to ensure that the right information is being transmitted to the right setting.
A former chief financial officer, Besst says improved patient care is a key variable in determining the return on investment for HIT, a fact that isn't lost on the board of trustees. "Our board is very involved. Kane has done a nice job of putting together a strategic IT plan and presenting it to our board on a regular basis. They know where we are and where we are going. And they've been involved since before the push for meaningful use," she says, referring to federal requirements that hospitals adopt HIT systems.
How Can YOU Become One of Health Care's Most Wired
For the 16th year, H&HN has named the Most Wired hospitals and health systems based on the Most Wired Survey. The 2014 survey results build on the analytic structure that was implemented in 2010 after two years of redesign. The methodology sets specific requirements in each of four focus areas. If any of these requirements are not met, the organization does not achieve the Most Wired designation. Thus, an organization may have many advanced capabilities, yet not achieve Most Wired status. The four focus areas are listed below.
1 | Infrastructure
• Identity management, access controls and audit capabilities
• Data recovery plan testing and disaster recovery restoration capabilities within 72 hours
• Security technology safeguards, including encryption for laptops and mobile device passcodes
• Regular risk analysis, security assessments and penetration testing
• Wireless networks for electronic health records accessible by clinicians and staff
2 | Business and administrative management
• Expanded use of electronic payer transactions
• Automation of revenue-cycle processes
• Partially automated management systems for supply chain and use of bar-code technology
• Quality scores delivered electronically to clinical leaders
• Patient flow automation
• EHR, computerized provider order entry, security and privacy training for physicians and nurses
• Human resource management and training systems
• Enterprise decision support and business intelligence
3 | Clinical quality and safety (inpatient/outpatient hospital)
• CPOE for medication orders
• Point-of-care medication administration systems and automated medication management
• Patient demographics, vital signs and status, and documentation recorded as structured data
• Routine use of EHR by clinicians for patient care including medication reconciliation and discharge instructions
• Physician access to clinical pathways/order sets and medical image review across care settings
• Clinical decision support enabled for drug allergy alerts and drug interaction alerts
• Digital clinical imaging/picture archiving and communication system in hospital and clinic
• Electronic recording of quality data
• Electronic recording of infection control data
4 | Clinical integration (ambulatory/physician/patient/community)
• From inpatient or emergency department admission, electronic copies of discharge instructions and health information to patients using EHR
• Physician-office EHR connectivity for clinical documentation and viewing results
• Physician office e-prescribing
• Online health information for patient education
• Interoperability of applications within hospital
This year, 680 hospitals and health systems completed the survey, representing more than 1,900 hospitals — more than 30 percent of all U.S. hospitals. Even with additional requirements, the number of organizations designated as Most Wired increased to 375 organizations. H&HN uses the same criteria to name the 25 Most Improved and the 25 Most Wired–Small and Rural.From a set of separately submitted essays, a panel of hospital and information technology leaders identifies noteworthy IT projects and names the Innovator Award winners and finalists. IT projects are evaluated on achievement of a business objective, creativity and uniqueness of concept, scope of solution and impact on the organization.
The 2014 Most Wired Survey was made possible by the generous support of AT&T, McKesson and CareTech Solutions, and in cooperation with the College of Healthcare Information Management Executives, the American Hospital Association and H&HN.
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