april 2013 adel a. al-marshad, md emergency medicine uc san diego health sciences

April 2013Adel A. Al-Marshad, MD

Emergency MedicineUC San Diego Health Sciences

“ Information should follow the patient, and artificial barriers – technical, business-related, bureaucratic – should not get in the way ”

– David Blumenthal, MD, Former Director, ONC

Technology, Innovations and Emergency Medicine – Where is the Value?

• Providers in the ED: Full picture of the patients, including access to previous tests, becomes available real time

• Providers in the ambulatory setting: Understanding of when their patients end up in the ED due to an exacerbation – could it have been avoided?

• Providers out in the field (EMS): Close alignment with hospital if acute action is required – long term potential to generate hot-spotting data.

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Overview• Funded by ARRA HITECH Act administered by

the Office of the National Coordinator for Health Information Technology

• $15 million over three years to use health IT to improve health care delivery in San Diego as model for nation

• Transition from a grant-funded initiative to an self-sustaining independent organization providing services to the health care community

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• No dominant health care entity (Scripps, Sharp, Kaiser, Rady, UCSD)

• 24% of all 30-day readmissions occurs at a different hospital than the first admission (nearly 30% for Medi-Cal patients)

• 15% of all ED patients and 69% of “frequent fliers” were seen in multiple hospitals

San Diego

Cardiovascular Disease Childhood ImmunizationsSyndromic Surveillance

Redundant TestsED/hospital Readmissions

San Diego Beacon

• Build and Strengthen Health IT• Community Health Information Exchange

• 3 Part Aim

• Test Innovative Approaches

Kaiser

SD VA/DOD

EMS

County PH

Clinics

Others

Hospitals

Initiatives

Meaningful Use

• Improve Quality, Population Health, Costs

Cardiovascular Disease Childhood ImmunizationsSyndromic Surveillance

Redundant TestsED/hospital Readmissions

San Diego Beacon

Improve Cost, Quality, andPopulation Health

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www.sandiegobeacon.org

Health IT

• Two recent studies indicate significant cost savings, reduction in testing in EDs with access to community HIE

HIE: Quality & Cost

• Patients seek care at different systems– Lack of timely patient information at point-of-care

• Care not coordinated among providers– Medical errors– Risks of unneeded evaluation

• Increased Costs– Repeat testing– Redundant evaluations

Care Transitions Initiative

• Collaboration between San Diego County HHSA and San Diego Beacon Community

• Reduce 30 d readmissions for high-risk population by connecting these patients to social services in the community

• 460 pts enrolled from 3 sites: UCSD-Hillcrest, Scripps-Mercy, Sharp Memorial

San Diego County ED patients and visits by type of user: 2008-2010.

Patients Total Visits^

Type of User* N % N %

Infrequent User (<6 visits) 895,489 96.73 1,592,453 78.97Frequent User (6-20 visits) 28,569 3.09 333,648 16.55Super User (>=21 visits) 1,661 0.18 90,436 4.48

Total 925,719 100.0 2,016,537 100.0

*Based on number of visits in a one year period of time between January 2008 and December 2010.

^Includes all visits between January 2008 and December 2010.

ED Visits in San Diego

Care Transitions Initiative

• Initial Results: 18% baseline 30d readmission rate reduced to 13%

Other Initiatives

• Real-time reporting for Public Health Meaningful Use

• EMS Hub: Transmit & track EMS data• Targeted readmissions reduction efforts• Messaging & notification to providers, health

plans, and payers • CRM Device data and other innovation

initiatives

Test Innovative Approaches

• Frequent Fliers / Hot Spots– 1% of SD population generates over 10% of 911

EMS calls– Disproportionately consume acute, emergency,

and safety net healthcare resources– Care provided is often mismatched with need

creating a recurring cycle

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San Diego Beacon Community• The EMS hub is an active real-time information exchange between pre-

hospital providers and hospitals in San Diego. The system currently serves the entire San Diego City EMS region (1.7million) and 3 receiving hospitals, with expansion plans to all area hospitals.– Since launching 6 months ago, over 40,000 prehospital records have been

sent electronically to hospitals including field 12-lead ECGs; reducing false activations of the cardiac catheterization lab, improving resource utilization and reducing costs.

– During the first 6 months of the project, total field cardiac catheterization lab activations were reduced for the 3 area hospitals compared to the period before the intervention

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• eRAP– Utilize 911/EMS data to identify FF (name), HS

(location), or key word– Trigger alerts to EMS case manager– Case manager coordinates with healthcare

providers, social services, law enforcement to get the right care for the individual

• Senior services, Housing, Treatment, other resources

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Test Innovative Approaches

• Alerts & Actions

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Test Innovative Approaches

Specific PatientsProject 25

Specific Neighborhood Hot Spots

ImageTrend MN

EMS HubSan Diego

San Diego, CA

eRAP

• eRAP alerts to EMS Case Manager initiated in October 2011

• Decrease in repeat visits to ED and subsequent admissions

UCSD Visits by eRAP patients

eRAP Alerts & P-25 Program

• Project 25 Example– eRAP alerts created for Project 25 clientele– Project 25 – Homeless clients identified by high

911 usage. Clients enrolled in housing and social support program funded by the United Way

– eRAP alerts case manager real-time when Project 25 client accesses 911

• Field Electronic Record & NLP Alerts

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Test Innovative Approaches

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Test Innovative Approaches

Elderly patient with frequent falls, 911 access, ED/hospital visitsElectronic alert fired on APS text in pre-hospital recordCase manager evaluated patient in field, contacted Adult Protective Services and directed patient to appropriate social services support

eRAP Alerts & P-25 Program

• P-25 Impact at UCSD– Comparison of ED visits by P-25 clients 6 months

before and 6 months after enrollment

Financial Impact

Ambulance ECG Transmission• Reduced false-positive catheterization activations at

San Diego hospitals with significant cost savings

• UCSD, Rady, Navy, Sharp live on EMS Hub

Public Health Reporting

• Over 700,000 lives covered to meet Meaningful Use Stage 1 reporting requirements for Immunization Reporting (participants include UCSD, Rady, Sharp, Council of Community Clinics)

• SDB to have SDIR mirror server to meet MU Stage 2 requirements

• Testing for Syndromic Surveillance reporting

Bangor Beacon Community• The value of exchange: Medical records are shared through our statewide

health information exchange – HealthInfoNet. Right now, 22 hospitals and several ambulatory practices across the state are participating.– Early results for “high risk/high cost patients” who are actively being case

managed (note: interventions include more than access to HIE, n = 721, comparing baseline to 6 months):

• Patients with at least one ED visit: 26.5% down to 17.7%• Patients with at least one non-urgent care visit: 19.9% down to 12.8%• Patients with at least one hospitalization: 25.7% down to 14.2%

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Greater Cincinnati Beacon Collaboration

• The value of ED alert systems to patients, families and providers: 69 Beacon physician practices are currently receiving alerts, 18 to go. Participating hospitals include Mercy Health, TriHealth, UC Health, Cincinnati Children’s, St Elizabeth Health Center, The Christ Hospital– The practice transformation has begun when the team is learning how to best

respond to the alert and “pulling the patient in for care” rather than expecting the patients to call after an ED visit of hospitalization.

– Around 60% of the time, the patient had X-ray done while at the ED. Practice outreach to that family has made them aware of open access scheduling in the practice and helped coach the family on how to handle episodes in the future.

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CCTP

• Community-based Care Transitions Program

• $15m grant over 3 years• Partnership between the HHSA/AIS, Palomar

Health, Scripps, Sharp and UCSD -11 hospitals with 13 campuses

• Targets 21,000 Medicare SD lives for case management and care coordination

• Goal to reduce 30day readmissions rate

Community HIE• Patients seek care at different system - Lack of

timely information • Lower Quality - care not coordinated among

providers • Increased Costs – repeat testing, evaluations• Providers access patient information during

treatment encounter– Summary information (meds, allergies,

problem lists)– Documents (DC summaries, notes, procedures)– Images (radiology, ECGs, etc)

Long-term Vision

• Clinical benefit and improved care– Patients, providers, organizations

• ROI for all participants– Patients see personal health value– Care delivery efficiency gains, lower costs– Support new care models (case management,

coordination, ACOs)– Federal funding for providers connecting to other

organizations electronically

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EMR/HIEDevices - Geneva Healthcare

SummarizedHistory

At-a-glanceDashboard

Heart FailureMonitor

Latest EpisodeInfo

EMRIntegration

In-ERInterrogation

Upload

ExpandableEP Window

IDCO ProfileData

EmbeddedEKG

NSF 1237174, Information & Intelligent Systems – Project Dates: 2012-2016

DELPHI• Develop a platform to enable integrated access

to, analysis and use of all data relevant to health – medical record, genomic, behavioral, environment (built/natural)

• Overall vision is to develop and pilot a local “ecosystem” with low barriers of entry to mobile device and app developers of all kinds

• Partners: Qualcomm, SD Beacon Community, SD County, SANDAG, CONNECT

PI: K. Patrick; Co-PI’s: C. Baru, T. Chan, S. Dasgupta, B. Griswold, J. Huang,

L. Ohno-Machado, Y. Papakonstantinau

DELPHI

Multiple sources of health data• Webified hospital

medical record systems• Personal health data

(weigh-ins, run info on apps, meals…)

• Genomic data(mutations, …)

• “Environmental” data(pollution, food deserts…)

• Online research troves(journals, some data)

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SAND

AG

Messaging/Notification• System can utilize ADT moment or patient index

list to generate message/notification and recipient– Secure direct email addresses available

• Limited clinical data to reduce risks– Consent vs HIPAA requirements

• Utility for providers, plans, payors, others– In development with CHG, Molina– Interest from UHG, P25, others

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Messaging/Notification• Real-time patient event notifications• ED visit, hospital admission/discharge• Secure delivery of event information to interested

parties (secure email or website posting)

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Relevant components of ADT Registration Message

MSH|DATETIME|REGISTRATION EVENTPID|MRN^LOCATION|LNAME^FNAME^MNAME|DOB|SEX|ADDRESS|PHONE NUMBER|PV1|INTERNAL PROVIDER ID^PROVIDER NAME^PROVIDER LOCATION^PROVIDER TYPEDG1|DIAGNOSIS|

Community Governance

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• Independent entity established• Initial board slate with representation from

major healthcare providers in San Diego

Dan Gross Sharp COO Rob Smith, MD VA CMO

Albert Oriol Rady CIO T. Gehring CEO, SDCMS

David Guss, MD UCSD DEM Chair N. Macchione HHSA Director

Bill Spooner Sharp CIO L. Ferrari Anthem/BC

Joe Traube, MD Scripps CMIO J. Burritt, RN Kaiser

S. Escoboza CEO, HASDIC N. Diaz CEO, CHG

S. O’Kane CEO, CCC R. Brown CEO, Scripps Green

PHI Security

• Each participating organization maintains its own consent policy around sharing health information

• No clinical data are stored centrally• Data storage and transmission protocols

adhere to the most recent security guidelines

Long-term Vision

• Clinical benefit and improved care– Patients, providers, organizations

• ROI for all participants– Care delivery efficiency gains, lower costs– Support new care models (case management,

coordination, ACOs)– Federal funding for providers connecting to other

organizations electronically

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Questions?

Adel A. Al-Marshad, MDaalmarshad@ucsd.edu