Using EHR ROI to Invest in Quality Steve Robertson

(1)

Using EHR ROI to Invest in Quality

Steve Robertson

(2)

2 Serving our communities for

more than a century

• 4 hospitals

• 34,166 admissions

• 44+ clinic sites

• 1300 physicians

FY09 data.

Kapi‘olani

Medical

Center for

Women &

Children

Pali Momi

Medical

Center

Wilcox

Health

Straub

Clinic &

Hospital

(3)

Our 2002 Challenge

• Mandates to Build an Electronic

Health Record and Improve

Quality

• Immediate Need to Reduce Costs

– System lost $34M in 2002

How do we accommodate a $32M EHR investment?

(4)

Premiums Rank Among the

Lowest in the Country (49

th

_).

Cost of Living is the Highest in the

Country.

Average Hospital Operating

Margins in 2003

Was

Negative 6.5%

4

(5)

Copyrighted and published by Project HOPE/Health Affairs as Katherine Becker and Amitabh Chandra, “Medicare Spending, the Physician Workforce, And Beneficiaries’

Quality of Care”, Health Affairs, 4/7/2004, doi: 10.1377/hlthaff.w4.184, p 187. The published article is archived and available online at www.healthaffairs.org/.

We’re different

5 2002 WHO

Sweden

$2,585

Finland

$2,027

Denmark

$2,831

Norway

$4,128

U.S.

$5,453

(6)

What’s the Business Case?

• Fewer Medical Errors, Adverse Drug Events

• Improved Outcomes through better care

coordination, best practice alerts, health

maintenance reminders

• Improved Patient Engagement

• Enhanced monitoring for improvements in

clinical Quality.

(7)

What’s the Business Case?

• Fewer Medical Errors, Adverse Drug Events

• Improved Outcomes through better care

coordination, best practice alerts, health

maintenance reminders

• Improved Patient Engagement

• Enhanced monitoring for improvements in

clinical Quality.

(8)

8 Return on Investment Sources

over 10 years

(9)

Rather than Focus on Expenses Alone, We

Focused on Net Revenue Improvement

2 to 5% of Net Revenue is lost from an inefficient

Revenue Cycle.

More than 50% of Business office activity is spent on

rework getting information that should have been

provided during the patient stay.

9 ROI

Net Revenue

Expenses

(10)

Interfaces.ppt

TACS

TSIS

Custom Code

Patient

Management

Patient

Accounting

BLIP, RTIF

SMS

Cloverleaf

Interface

Engine

TIF, Custo m HL7 Batch TI F

HCS Medics

Pharmacy

KMC/PM Daily Charge Manual File Copy Via Operators Via 48 Records

SunQuest

Clinical Labs

Daily Charge FTP Upload Via 48 Records thru Cloverleaf

Pyxis

Meds Dispensers

KMC/PM Day-end Rx Orders Billing Informati on SMS Lab Orders ADT, Custom HL7

Clinicomp

KareLink

SMS RMS

*At KMCWC, most (95%) radiology orders are placed

in Invision. KMCPM place nearly 100% of all Orders in RMS. Once Order is entered in either RMS or Invision, Barcode is Laser printed from

RMS. Charge is posted in Invision only after bar code

is swiped. Orders & Results, Custom HL7 ADT & Orders Custom HL7 Dictation

Lanier

System

Recording Procedure Status (work list) ADT, HL7 VPN ADT Daily and Hourly Transtat & Medquist

Data

Control

Phone Connection Transcribe Recordings ADT Extract Daily File Download

3M

APR-DRG

PCP/Discharge Daily Extract MJK001 Daily Birth Date Updates Uploaded to SMS Via Screen Scraper DOH Birth Certificate VPN SMS Reports Distribution

Lab Results, non-HL7

Bar-code Reader

DCL Fax

Machine

(Young Street) Printed Rx Order (Tubed)

TSI

Daily SMS Flat File Extracts via VSDM & PA/PM Segment Handlers Weekly APR-DRG, Birth weights, flat file transfer from Cascade

GEAC

GL

HHIC/NPIC Birth Data & Demographics Monthly Flat File Transfer

User Transmitted Budget Extract Flat file xfr Flat file of PA Charge s sent monthly via Custom Code

Cash Receipts

(MS Access) ??Flat File Transfer

NEC Px

Phone System

Host Fax

ORSOS

KMCWC/KMCPM Registration prints _Schedules OR clerk manually enters non-SPD charges (services) into SMS from ORSOS (future: create 48 Records and batch this via FTP, TBD) ORs generate a materials usage list of SPD items (inventory depletion based on “sticker” bar code system). OR send this list daily to SPD. SPD manually enters MRN and account # into ESI. ADT, MPI

Updates SMS ORSOS Work list (RTIF display) when a patient is scheduled. Registration uses this to register the patient.

ESI/Titan

(A/P)

Check

Reconciliation

(Mainframe Custom Code) Accounts Payable

End-of-month flat file Once per month, G/L

personnel dial up and download flat files of “paid or cleared” checks from BOH and First Hawaiian. Users reformat the files in Excel and move to the GL server.

Reconciliation Report: Open Check report ESI Paid Check report Data Control Upload “paid or cleared” check file to Mainframe

Custom

Code

Daily upload (flat file export). Converted to 48/49 records by custom code for posting to PA.

Patient Refunds, flat file, bi-weekly

Cleared Checks, flat file, once per month

Mag Filer IRS HMSA Lab Results, HL7 RTIF, Custo m HL7 Data Control

Premis

UB-92/ 1500 Flat Files Claims via Modem Payer Billing: UB92 Claims sent daily at 5am (Paper prints out on 24th

floor). ~55% of all claims are electronic. Some 1500’s are sent out; these are manually entered into Premis.

ERA

Payer Remittance: HMSA and Medicare

(HMSA posts on bulletin board, NDC provides Medicare remit files via clearing house). Flat files, HMSA is picked up on Thursday, Medicare is daily.

Telepath

Telephone

Two flat files from ad hocs in SMS. One containing PA info for IVR. The other is guarantor info for out dial system. Xmit daily by 7:30am. Custom Code (mainframe) Aloha Care Provides tape of remittances List of claims sent out electronica lly. This is used to generate 7M records(co mments) in SMS. Flat file, Sent daily at 6pm. Aloha Care Formatted Remittance Flat file, weekly

Flat file containing payment, adjustment, and comments. Processed in SMS. HMSA is every Friday, Medicare is daily by 5:30pm.

Ceridian

Ensemble

Flat File Transfer Checks Issued Flat File Transfer

Checks Issued

Time &

Attendance

OneStaff

Actual Hours worked. Not built, but ready to be worked.

Employee Schedules, flat file XFR Once per day.

Employee Hours Worked Flat File XFR Employee Demographics, flags, update authorities Flat file, daily XRF

+Medic

KMS (KCC) CBO

Microtechn.

Blood-Gas

Data Manager

Praxis

Clinics (FDC/OB-GYN Ultrasound, PEDS) Bi-weekly 7-9 flat files containing payroll data by individual are transferred. This provides input for productivity reports.

Monthly file transfer of Rev 3 Report data. This file used for reconciliation. Dual Entry of SMS ADT 1099s Orders entered manually into SMS by unit secretaries. Lab, Radiology, Dietary Orders entered in KareLink.

As of July 6, 2001

Catalog Download (ESI Items) Daily, Batch File ADTs, Lab Results, non-HL7

Catalog Download Hl7 Radiology Transcribers Procedure Status (work list) Pt Jacket All Rx Orders

Tubed Issues by Department, report file. Once per month.

NIS3

NT (Gamma) Neonatal Database (Dr. Balaraman) RMS results into KareLink

ESI/Nova

(Materials Management)

QA-Line

ADT and Procedures Daily File Download

Payer Billing: 1500 Claims sent EDI daily to Clearinghous e (via Modem) HMSA: 1500 Claims sent EDI daily via Modem (separate from clearinghouse ) Praxis handles paper 1500s and electronic 1500s for Clinics

Cascade

(MR Encoder) Real-time, ADT, TIF, GENIE HL7

SMS

Classific. Data RTF GENIE HL7 thru Cloverleaf DOH BCData Electronic xfrTSI, _APR/DRG s COR

Orders _{Res. Sched.}

Tempus

Encompass

Fax Server

Web Server Voice Dialer

Write into RMS

DSO

(11)

…so, we

Doubled Down

_{: $32M$57M}

Replace Rev Cycle systems AND install an EHR

Electronic

Health

Record

Revenue

Cycle

Documentation

Order Sets

Edits and Alerts

Transparency

(12)

One Neck to Choke

• CEO Consolidated

Registration, Hospital

and Professional Billing,

HIM into one Division

……under the CIO.

Focus on ‘System’ ROI not ‘EHR’ ROI.

(13)

13 Stage 6

EMR

Planning

Dec 2001

EMR

Abandoned

June 2002

Contract

Signed Sep

2003

EMR Straub

Clinics Feb

2005 - 2009

EMR Kaua‘i

Med Clinic

Nov 2004

Rev Cycle

Wilcox/KMC

Feb 2005

Rev Cycle

Kapi‘olani

Sep 2006

Rev Cycle

Straub

Jul 2007

Full EMR

Pali Momi

Jun 2008

Full EMR

Kapi'olani

Nov 2008

Full EMR

Wilcox

Oct 2010

Full EMR

Straub Hosp

Oct 2009

Rev Cycle

Pali Momi

May 2005

Kapi‘ola

ni Health

Straub

Clinics &

Hospital

Wilcox

Health

Merger

Registration/Scheduling/ADT

Inpatient

Clinicals

Ambulatory

Clinicals

Ancillaries

Hospital

Billing

Professional

Billing

Community Physicians

EMR/Practice Management

Health Information Exchange

Seven Year Project, 105 Major

Implementations Spanning dozens of

locations

Governance & Culture Challenges

(14)

2 Project Manager’s Success evolved into a

Dedicated Revenue Integrity Team

…if you don’t document, it’s

14 Experience: Compliance Officer, Case Management,

Coder, Patient Accounting, Nursing, Patient Access,

Pharmacy Tech, Information Technology, Project

Managers

(15)

Avoidable Write-off

2008

Improvement

How EHR Enabled

Improvement

Late charges

$728,000

Physician charges created

by documentation update

in EHR instead of paper

charge sheet process

Missing or inaccurate

National Drug Code (NDC) for

drug billing

$629,000

Order and medication

administration record

(MAR) available to central

pharmacy biller

A Few Examples

15

(16)

Avoidable Write-off

2008

Improvement

How EHR Enabled

Improvement

Medical Necessity Denials

$315,000

Improved Medical

Necessity documentation.

Improved reporting and

better communication.

Past Claim Filing Deadlines

$154,000

Eliminated paper chase

between Clinical

departments and the

business office. Drive

Accountability through

workqueues.

A Few Examples

16

(17)

Hospital Bad Debt and Avoidable

Write-Offs

~$4M Net Revenue

saved annually

17 0.68%

Reduction

(18)

Cost to Collect $1

Pre-Conversion

Post-Conversion

18

(19)

19 Hospital Gross AR Days

Pre-Conversion

Post-Conversion

(20)

20 In thousands

ROI = 9.0% without ARRA

12.3% with ARRA

(21)

+ROI Sources

21

(22)

-8.0%

-6.0%

-4.0%

-2.0%

0.0%

2.0%

4.0%

6.0%

2001

2003

2005

2007

2009

2011

2013

(23)

The Second Mandate:

Improved Clinical Quality

In 2009, we began to apply the

same focus on improving Clinical

Quality, and to leverage our

capabilities to negotiate Pay for

Performance contracts with payers.

(24)

“ I can tell if we are going to have a good

financial month for the system by how

many really sick babies we have in our

NICU.

There is something morally wrong in hoping for

sick babies.

We are switching our payment systems so we are

rewarded for the quality of care we provide, not

the number of sick babies in our hospital.”

(25)

The Virtual

Patient Centered

Medical Home

25 Electronic Health Record

Standardized best practices

(Electronic Protocols)

Measure and Reward Success

Team Care

Customer

Driven

Care

Powered through

electronic Clinical

60%

65%

70%

75%

BP Control in Diabetes Patients

50% Percentile

75% Percentile

(33)

40%

45%

50%

55%

A1C Good Control Diabetes Patients

50% Percentile

75% Percentile

90% Percentile

(34)

What’s Next?

• Clinically Integrated Physician Hospital

Organization: Hawai‘i Physician Partners

• Leverage our internal experience

• 120 private plus 360 employed physicians

working collaborative to transform care in

Hawai‘i.

(35)

KEYS TO SUCCESS

Patient Engagement

Wellness

Patient

Experience

Chronic

/Complex

Disease

Management

Population

Management

Technology

Quality

Primary Care

Access

Efficiency

Clinically

Integrated

Physician Hospital

Organization

(CIPHO)

SUSTAINABLE HEALTH CARE

(36)

36 122 Hospitals/Systems

Hawai‘i Pacific Health

• 4 Hospitals

• 49 Outpatient Centers

• 120 Community Physicians

• 145 US Mainland Care Systems

(37)

Thank You!

• Steve Robertson

– Executive Vice President and Chief Information

Officer, Hawai‘i Pacific Health