Urgent CareIntegrating point of care service into a longitudinal health system
Rob Rohatsch, MD, CEO, Banner Urgent Care / Occupational Health ServicesDana Kosmala-Runkle, MD, Sr. Director, Medical Informatics
William Holland, MD, VP Care Management and CMIO
Banner at a Glance
Our Mission:Making healthcare easier, so life can be better.
Our Strategy:
Local ProblemHow does Banner Health fully integrate Urgent Care into its health system to drive increased
accessibility and coordination of care delivery?
Historically, Banner has not been in the urgent care business. The landscape in the healthcare industry is changing rapidly. Over the last several years, Banner has been transforming from a hospital company to a health integration company. Banner recognizes that in order to be successful, we must have a laser focus on a consumer-centric strategy. Now more than ever, personal household economics are driving how patients make their healthcare decisions. The link between quality healthcare and cost containment has been well studied. In order to fully operationalize strategy around this concept, Banner recognizes the need for increased accessibility into the system. A robust urgent care platform addresses these two critical legs of the triple aim “chair.” The third support leg is the patient experience, an area where Banner has always placed emphasis. Well-run urgent care centers can provide care to an estimated 25-75 percent of patients seen in the emergency department. Here is the rub: They can do it for 20 percent of the cost. When those numbers are coupled with a consumer experience driven by short wait times and delivering the “wow” factor, it becomes a powerful value proposition in a competitive market.
“…cost containment…the need for increased accessibility into the system. A
robust urgent care platform addresses these two critical legs of the triple aim
“chair.” The third leg is the patient experience….”
Value Proposition of Urgent CareAccess
• Create additional
primary care access
points (leakage
prevention)
• Provide lower cost
setting for non-
emergent care
• Decant unnecessary
ED utilization
Market Share
• Grow footprint in
markets
• Lower-cost entry
point (new patient
capture)
• Brand awareness
and/or recognition
PopulationHealth
• Treat patients with
chronic health issues
to reduce ED use
• Refer patients back to
their PCP
• Capture unassigned
patients who need
episodic care
On-Demand Care
Primary Care
Specialists
Diagnostics
Outpatient
Hospitals
CLICK-IN WALK-IN CALL-IN
Email | Retail | Skype | Urgent Care centers | Real-time appts
High MarginLow Volume
Low MarginHigh Volume
Customer-first Centric Delivery Model
Banner’s Urgent Care Strategy – On Demand Medicine
• Healthcare environment changes• Volume to value-based care
• Population health
• Consumer-focused• Right level of care at the right time/place
• Patients with no primary doctor
• In-network referral
Phoenix
Colorado
Tucson / Casa Grande
BUCS Payor Mix
Design and Implementation
Best of Breed vs. Full Integration
“No one has been able to do this using a big box EHR solution—ever….ever.”
Efficiency vs. Integration
Best of Breed Integrated EHR
Benefits• Created specifically for
Urgent Care workflows• Available out of the box
• Longitudinal record• We already own it
Challenges• No integration with clinics,
EDs, hospitals • Cost
• No urgent care model• Short timeline to create• “Competing priorities”
We had to do something to stop the papercuts…Nine page paper chartTwo page demographic
form at check-inPaper discharge instructions
Efficiency vs. IntegrationDiscussions kept coming back to Efficiency vs. Integration
• But does it have to be either/or?• Could we have both Efficiency AND
Integration?
Operational Requirements/Industry Standards
• Keep total LOS under 60 minutes• Keep provider documentation to less than
two minutes• Keep it simple
Data Driven Decisions
Design Decisions• Registration—what to use and how soon?
• Tracking Board vs Ambulatory Organizer vs LaunchPoint?
• Provider Documentation: Dynamic Doc vs. PowerNote?
• Workflows?
• Cerner user positions?
• Encounter types?
• How would we handle results?
• Longitudinal record?
Could We Build an Urgent Care Model?
• Minimal vendor recommendations for Urgent Care • Short time frame to implement final product• Used engineering principles to build foundation (~80%)• Once foundation is established, take to operational and/or
clinical team for final detailed decisions• “It’s easier to edit than to create”
Provider Visit Workflows
MA / Nurse Intake to Depart Workflows
Initial “Governance”• Rapid Timeline• Full Day Design Sessions with
Stakeholders• CEO and CMO of Banner Urgent Care
Services• Operational Leaders• Informatics (Physician, Nursing, Pharmacy)• IT• Cerner consultants
• Workflow decisions, clinical content, registration, orders, documentation, radiology, lab, disposition, …
Urgent Care CCG created January 17th, 2017
ED
Pulmonary
Palliative Care
NICU/Newborn
Neurosciences
Critical Care
Behavioral Health
Anesthesia
Pediatrics
Women’s Health
Post Acute Care
Medical Imaging
Primary Care
Hospital Medicine
Cardiology
Surgery
Pharmacy & Therapeutics
Infectious Disease
CV Surgery
Oncology
Ortho
Clinical Leadership
Team
Program management
CCGs and Clinical Practice
Development
InformaticsClinical & Medical
Professionals assist with
design & build
Quality
CPAClinical
Performance Analytics
Clinical Education
Process EngineeringClinicians and
Engineers assist with Design
Purpose: Define expected clinical practices for Banner Health based on best available evidence, including practice-based evidence.
Urgent Care
“Engineering” New Models
• Research practices
• Reach consensus on requirements
Define
• Describe reliable workflow and roles
• Develop tools
Design• Communicate
and train• Address issues• Monitor
Implement
Six Month Initial Rollout39 clinics fully integrated EHR with Banner Health
• 11/01/16 Banner Urgent Care Services becomes official• 01/01/17 Banner Urgent Care Providers become Banner employees• 02/07/17 Cerner Practice Management implemented • 04/18/17 Cerner PowerChart EHR implemented in 39 UC Facilities
Support Model: 39 Urgent Cares BIG Bang• Day 1-4: Command Center
– Issue resolution – Enhancement requests– Physician Informatics– Nursing Informatics – IT– Support team
• Day 1 and 2: 1 Banner or Cerner trainer at the elbow• Day 3 and 4: 1 trainer for 2 sites• Day 5: Transition to Operations and to Service Desk
Post Go-Live: Longitudinal Record
Comprehensive patient data
– Medication history
– Procedures
– Labs and radiology, etc.
Keys to Success
• Stakeholder engagement
• Commitment to timeline and scope
• Prior process standardization
• Two days onsite at the elbow support
• Transition to call center for support
Value Derived
Length of Stay by Provider• Keep total LOS under
60 minutes
• Keep provider documentation to less than two minutes
• Keep it simple0
10
20
30
40
50
60
70
80
90
100
AVG
LOS
(MIN
)
INDIVIDUAL PROVIDERSJUNE 2018
60 minute target
Length of Stay and Patients Seen
On average for all Urgent Care providers there has been 2.54 minutes decrease in time spent in the patient’s chart
Time Savings of 19.8%
Providers in all Banner Urgent Cares saved, on average each month, 81.5 days of charting time from May 2017 to April 2018
Actual Time Per Patient
Banner Health Goal: Documentation Time per Patient under 2 minutes for all Urgent Care providers
Documentation Time Per Patient
$4.50M cost savings by reducing provider time
Other Technologies DeployedEnhanced Customer Experience
0%
5%
10%
15%
20%
25%
Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18
Utilization of Clockwise12 month Online Patient Trend
YTD Data Trend on LOS & NPS
56
51
48
4341 40
60.2%58.9%
65.5%
71.3% 70.4%73.3%
35
40
45
50
55
60
65
70
75
80
Jan Feb Mar Apr May Jun
Min
utes
NPS vs LOS for BUCS YTD
LOS (min) NPS (%)
AVERAGE NPS BY INDUSTRY LEADER
73
76
78
55
33
28
21
* - Source: Satmetrix U.S. Consumer 2017 Benchmarks at a Glance
NPS/Performers by Industry*
Left Without Treatment (LWOT) Rate2.21%
2.05%
1.51%
0.92%0.79%
0.91%0.79%
1.13%
1.31%
0
10,000
20,000
30,000
40,000
50,000
60,000
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
May June July August September October November December January
Volume % LWOT
ED Transfer Rate • Streamline transfers
– Provider to Provider communication
– Pre-arrival forms completed in Cerner
– BHTS when needed to identify specialists
– Longitudinal record supports ED communications
2.55% 2.48%2.32%
2.06%
1.62%
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
September October November December January
Financial Accomplishments: Text Messaging Approach
48% of patients who paid from text messages did so on the day they got the text thru the patient portal.
Ongoing Integration: Technology and Specialty
BUCS & OHS BrainScope• 19 cases to date• EEG results• BFI results
EKG Real Time Results• EKG reads within
15 min• 4 HVN groups
Cardiology Consults• 15 Min TOT• Reduced ED
XFers• Downstream
referrals
Ortho Consults• BMG ortho• Shared PACS• Nov. 2018
Banner Urgent Care Timeline
NOV 1st
Banner Urgent Care Services is an Official Banner Health Service Line
NOV 1st
Zotec Implemented for Revenue Cycle/Billing
AUG SEP OCT NOV DEC JAN FEB MAR APR MAY2018
NOV DEC JAN FEB MAR APR MAY JUN JULOCT
JAN 17th
Urgent Care Clinical Consensus Group (CCG)
2017
JAN 1st
Urgent Care Providers are now Banner Employed Providers
MAR 9th
Real-Time Radiology Reads in Phoenix Clinics)
MAR 3rd
CPM ImplementationAPR 18th
Cerner Implementation in 39 Banner Urgent Care Clinics
JUN 20th
Clockwise MD Go-Live
AUG 1st
Casa Grande Acquirement
AUG 1st
Real-Time Radiology Reads in Tucson Clinics
NOV 17th
BrainScopeJAN 1st
Colorado Expansion
JAN 1st
Official Positions created for Provider Leaders and Site Coordinators
MAY 1st
Oncology Urgent Care Clinic
MAY 1st
Pediatric Urgent Care Clinics
Thank You