David Kwo eHospital Programme Manager
o Independent specialist in EHR implementation o Interest: integrated systems + integrated care o 35 years in healthcare management + IT
o Worked on EHR projects in US, UK + Singapore o Last 30 years in UK
• CIO for NHS hospitals • CIO for NHS in London
o Implemented leading EHR products • Epic, Cerner, Allscripts, GE + Meditech
1.
Standardisation in UK
2.
Standardisation at Cambridge
3.
Standardisation for Denmark
} In 2003, National Programme for IT
} Vision: standard EPR systems across the UK } £12.7bn programme across 5 regions
} NW, NE, West, SE, London (where I was RID) } Catchword: “Ruthless Standardisation”
} My role: Regional Implementation Director for
the London region
} In charge of £1bn IT spend for 32 hospitals, 31
primary care trusts and GP practices
} Impact on >150,000 doctors, nurses, allied
health professionals, administrators
} NPfIT: a failed national EHR standardisation
programme because
} “Large IT suppliers = centre of change mgt”
◦ IT suppliers didn’t know health culture, EPR software
◦ Didn’t know health change management
◦ Potentially part of the solution mix, but not the centre
} “Ruthless standardisation”
◦ The programme was IT-led, not clinician-led
} Cambridge University Hospitals } Our Epic journey
} Key lessons
§ Major academic medical centre in Cambridge, UK § 1,000 beds; 9,000 staff; 192 specialties
§ 66,000 admissions; 100,000 ED attendances § £600m annual income
§ Service and Research specialities: transplants, cancer, neurosciences, paediatrics and genetics, maternity care
} Cambridge University Hospitals } Our Epic journey
}
Jun 11: Procurement start
}
Dec 12 Business case approved
}
Apr 13 Award contracts
(Epic,HP)}
Oct 14 Go-live in 60 days
} Single integrated record, accessible by all
} Improved patient safety, quality care, outcomes
} Clinical decision support
} Standardised care, minimised clinical variation
◦ Reducing adverse drug events } Increased clinical productivity
◦ Reductions in test utilisation/drugs costs } Preventative/predictive care
◦ Increased compliance e.g. VTE assessments ◦ Early management of infections, sepsis, MRSA
◦ Improved chronic disease management e.g. diabetes,
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
eHospital Timeline
2013 2014
4. Testing, training, go-live
C
ontr
ac
ts
1. Training 2.
Validation 3. Workflow, build
18 months
6 months 8 months
2 months 2 months
Our Epic journey - timeline
} Inspiring leaders
} Shopping for the right EHR } Mobilising staff
} Managing the project } Controlling risks } Changing thinking
Hospital-wide functions Departmental functions Specialty systems Other facilities 1. Orders 2. Clinical Documentation 3. Prescribing 4. PAS 5. Medical Records 6. Reporting/ D. Warehouse 7. Research 1. Radiology 2. Pathology 3. ED 4. Theatres 5. Clinics 6. Maternity 7. ICU 8. Pharmacy 1. Cancer 2. Cardiology 3. Transplant 4. Ophthalm’y • Interfaces • Conversions • Kiosk • Patient Portal • GP Portal • Handheld devices • etc.
Our Epic journey - scope
Large scale programme
•
Communications and Engagement
•Operational Readiness
•
Systems integrator
•
Programme Management Office
•
More discipline than methodology
•Configuration mgt (doc’t, version)
•Project plan, risk mgt, benefits mgt
•Design Authority for IT
Risk Management:
• Embedded in project culture
• A pro-active process
• Issues are actions
Risk Assessment: Impact x likelihood
Risk Log
Risk Manager
Risk Reviews: Programme Board/month
}
Programme cost
◦ £40m Epic + 140 HP over 10 years
}
IT costs (% of hospital budget)
1.3% historically
2.9% now with EHR
eHospital direct benefits
Increased formulary compliance £7,257,600 Fewer medical records staff £12,640,900 Fewer transcription staff £19,206,200
Fewer ward clerks £3,917,600
Fewer appointments/reception staff £8,648,600 Reduction in printing & stationary requirements £3,135,000 Reduction for unnecessary diagnostic tests £20,250,000 Income protection CQUIN payments £3,564,000 Income protection: Avoid 30 day readmissions penalties £7,460,100 Reduced senior nurse hours £10,149,300 IT staff salary savings transferred to HP under TUPE £8,064,000 Core IT system maintenance contracts £13,773,250
Other IT non pay £9,513,600
Total eHospital direct benefits £127,580,150
Support for transformational benefits (upside case)
Reduction in clinical variations in care £0
Fewer adverse drug events £76,076,000
Increased nursing productivity (Agency nursing -‐ Medicine Division) £892,500 Increased nursing productivity (Bank nursing -‐ All Division) £53,793,634 Increased nursing productivity (Overtime -‐ all divisions) £1,421,799
Preventative care -‐ infections/sepsis £0
Reduced wastage of drug stock -‐ saving of .25% on whole drug budget £1,304,750 Reduced antibiotic prescribing -‐ saving of .25% on non-‐excluded drugs budget£306,000
Improved clinic scheduling £16,943,573
Improved theatre scheduling £0
} Epic application:
§ 120 Core Project (20 months)
§ 20+ Dept (12-18 months) § 62 Trainers (3-4 months) § 1000 Super-Users (3 months) § Infrastructure: § 100+ IT § Epic staff: 61
§ Total staffing: 1,400+ staff
Doctors 21
Nurses 20
Pharmacists 10
Also
} Part-time staff } Annual leave in UK } Office space
} Post-live: 75%
} Data: clinical terming (SNOMED CT)
} Processes: for example
◦ Ordersets
◦ Discharge summaries
◦ Clinical coding
} Clinical policies: Design Authority
} IT applications: Design Authority
} IT infrastructure: 6000 PCs (outsourced HP)
} Cambridge University Hospitals } Our Epic journey
} Key lessons
} Scaling for large hospital – staffing shock… } Big bang approach – the only way
} Project management – large scale needed } Staff budget – up to go-live; post go-live… } Project team offices – these are serious } Infrastructure – multiple sub-cultures… } Scope management – Design Authority
} Culture eats strategy for breakfast } What is clinical readiness to change?
◦ In US, doctors status is high: low readiness
◦ In UK, doctors status is high: low readiness
◦ In Denmark?
} In my humble opinion
◦ Standardisation requires process automation first
◦ Also, standardisation is not the only objective
◦ You can raise standardisation, reduce variations and
improve outcomes, but e.g. if this is achieved in a segmented, non-patient focussed environment, then we still have sub-optimised care overall
◦ Therefore, my view is that we need to see
} Integrated care needs integrated systems
} Hospital based projects tend to focus on
location specific care
} Can lead to information silos
} Potential medical errors due to lack of
visibility of whole patient record/process across settings
} E.g. drug contra-indications missed if
} The system should support all
1. People
2. Processes
3. Places
} The system should feature
1. Intelligence
2. Integrity of patient data
3. Integration across settings, teams, facilities
Integrated System Model
Peo
ple
Processes
Integrated System Model
People Places
Patients GP Doctor Nurse Specialist Call Centre Care Teams - - - - Assess Rev iew Pla n Sc he dul e Ord er Pr esc rib e Case manage Pr oc ed ur e Res earch Au di t Ed uc ate Co lla bo ra te Pr ev en t Pa th w ay - - Patient Home GP Sur ger y Hospita l Clinic Com mun ity C linic - - Processes
Integrated System Model – “a virtual 3D digital grid” ...not new concept
Peo
ple
Places Processes
– distinguishing features for integrated care Peo ple Places P Processes
Integrated System Model
– distinguishing features for integrated care
Peo
ple
Places Processes
1. Intelligence:
• Clinical decision support • Preventative/pro-active alerts • Protocols and guidelines • Intelligent care pathways • Clinical trial eligibility
– distinguishing features for integrated care Peo ple Places Processes 2. Integrity of data:
• Single electronic patient record • Single data schema
• Single version of the truth • Strong security model
• Strong information governance
Integrated System Model
– distinguishing features for integrated care
Peo
ple
Places Processes
3. Integration platform
• Fully integrated applications • Fully integrated database platform
} there is tangible proof of this model Acute EPR systems GP systems Community systems Patient portal Mental health systems
} Fully integrated EPR at core of architecture
} Cross care settings
} Case management
} Telehealth communication channels
} Patient access to doctor and health record
} Population care
} Consolidated disease register
} Real-time embedded clinical protocols
} Secure access by remote health facilities
} Analytic tools for high volume complex data
} it’s really hard to replicate this model
} Replication to achieve this model
◦ Route A – single main EPR product across settings
◦ Route B – multiple clinical systems products across
settings (using interoperability standards IHE, HL7, ITK)
Intelligent Integrated Integrity Route C? Route B? Route A
Integrated systems developments over time
Intelligent Integrated Integrity Route C? Route B? Route A
Integrated systems developments over time
£££££ £££ £££ £££ £ £ £ £ £ ££ ££
}
Integrated Systems are necessary for
Integrated Care
}
There is a proven architectural model
}
Challenge: route maps to model
} In my humble opinion
◦ Standardisation is essential
◦ Standardise clinical behaviours
Across the depts in a hospital
Across hospitals
Across healthcare sites in the region
Across the regions
◦ Standardise EHR/technology architecture to
} In terms of standardisation
1. National level in UK: mistakes made, apocolypse
2. Hospital level at Cambridge: on-track to standardise
3. In Denmark: you could be world-leaders in
standardisation if
(a) you have patient-centred organisational and technical standards in place (integrated care for the patient) (b) you have the right clinical professional and project
management cultures in place
} Standardisation
◦ National level in UK: mistakes made, apocolypse
◦ Hospital level at Cambridge: on-track to standardise
◦ At regional level in Denmark: you could be
world-leaders in standardisation if
(a) you have the true patient-centred organisational and
technical standards in place (integrated care for the patient)
(b) you have the right clinical professional and project
Thank You
} there is research evidence to show the
“Computerized clinical decision support systems for chronic disease management: A decisionmaker-researcher partnership systematic review”
Pavel S Roshanov1, Shikha Misra2, Hertzel C Gerstein3,4, Amit X Garg5, Rolf J Sebaldt3, Jean A Mackay6, Lorraine Weise-Kelly6, Tamara Navarro6, Nancy L Wilczynski6 and R Brian Haynes3,4,6* Implementation Science 2011 6:92 Results: Of 55 RCTs included trials,
87% (n = 48) measured system impact on the process of care and 52% (n = 25) of those demonstrated statistically significant improvements Sixty-five percent (36/55) of trials measured impact on, typically,
non-major (surrogate) patient outcomes, and 31% (n = 11) of those demonstrated benefits.
Conclusions:
A small majority (just over half) of CCDSSs improved care processes in chronic disease management and some improved patient health.
