the role of process improvement, and information technology in achieving our nation’s 21 st...

The Role of Process Improvement, and Information Technology in

Achieving our Nation’s 21st Century Healthcare Goals

The Role of Process Improvement, and Information Technology in

Achieving our Nation’s 21st Century Healthcare Goals

C. Martin Harris, M.D.Chief Information Officer, Cleveland Clinic

Executive Director, eCleveland Clinic

Quality

Care Coordination / Prevention

Cost

Focusing on Healthcare’s21st Century Challenges

Value EquationValue Equation

Value = Quality

Cost

%

10

8

6

4

2

0Primary Reoperation

STS

STS

1.0% 1.0%

CABG MortalityCABG MortalityNational Benchmark Data

Quality of Diabetes Care: Patients Treated by Physicians using EHR vs. Paper Medical Records

Quality of Diabetes Care: Patients Treated by Physicians using EHR vs. Paper Medical Records

Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365:825-833. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsa1102519#t=article

* Even after adjusting for patient demographic characteristics and insurance type, differences remain significant; p<0.001

% of Patients Receiving CareA significantly higher

proportion of patients being treated by physicians with

EHRs received care that aligns with accepted treatment

standards*

Composite:All Four Recommended

Care Processes

Measurement ofGlycated Hemoglobin

KidneyManagement

PneumococcalVaccination

EyeExamination

51%

7%

95% 93%

83%

15%

63%

31%

86%78%

EHR Practices Paper-Based Practices

Health Outcomes for Diabetes Patients: Patients Treated by Physicians using EHR vs. Paper Medical Records

Health Outcomes for Diabetes Patients: Patients Treated by Physicians using EHR vs. Paper Medical Records

Source: Cebul, R. D., M.D.; et al. (2011). Electronic Health Records and Quality of Diabetes Care. New England Journal of Medicine, 365:825-833. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsa1102519#t=article

* Even after adjusting for patient demographic characteristics and insurance type, differences remain significant; p<0.005

% of Patients Receiving CareA significantly higher

proportion of patients being treated by physicians with

EHRs obtained better outcomes*

LDL Cholesterol < 100mg/dl or Use

of Statin Drug

Non-Smoker

GlycatedHemoglobin <8%

BP<140/80mm

Hg

44%

16%

87%

82%

71%

48%56%

39%

66%

52%

Composite:At Least Four of FiveOutcomes Standards

33%34%

BMI<30

EHR Practices Paper-Based Practices

MyPractice:Electronic Medical

Record System


Record System

Dr.Connect:Improved

Communication; Improved Care

MyPractice:●

Community

eHealth Services

VirtualVisit:Patient/Physician

Interaction Globally

MyConsult:Your First Choice for

a Second Opinion

MyChart:Your Personal

Health Connection

MyMonitoring:Ongoing Condition

Reporting from Home

Providers Patients

MyPractice●

Hospital

ClevelandClinic

HHFairview Hospital

Lakewood Hospital

HH

Lutheran Hospital

HH

Ashtabula County Medical Center

HH

Euclid Hospital

HH

Hillcrest Hospital

HH

South PointeHospital

HH

Marymount Hospital

HH

ClevelandClinic

Florida

HHMedinaHospital

HHLorain Family HealthAnd Surgery Center

FHCFHC

Elyria FamilyHealth Center

Westlake FamilyHealth Center

FHCFHC

FHCFHC LakewoodFamily Health

Center

FHCFHC

Strongsville Family Health and Surgery Center

FHCFHC

Brunswick FamilyHealth Center

FHCFHCWooster FamilyHealth Center

FHCFHC

Independence FamilyHealth Center

FHCFHC Solon FamilyHealth Center

FHCFHC

Chagrin Falls FamilyHealth Center

FHCFHC

Beachwood FamilyHealth and Surgery Center

FHCFHC

Willoughby HillsFamily Health Center

FHCFHC

FHCFHC

R.E. JacobsHealth Center

Lou Ruvo Centerfor Brain Health

Las Vegas, Nevada

FHCFHC

ClevelandClinic

Toronto

FHCFHC

S.T.J. Health Center

HC HC

Twinsburg FamilyHealth Center

FHCFHC

MyPractice Electronic Medical Record

Patients

Front Desk

NursesPhysicians

Schedulers

Residents

Researchers

Physicians: 7,043

Residents / Fellows: 2,553

Pharmacists: 393

Other End Users: 38,776

Patients in the EMR: 6,351,317

Encounters: 35,591,311

Prescriptions: 70,720,222

Orders: 218,125,905

Total Results: 703,501,604

Cleveland Clinic User and Encounter StatisticsThrough September, 2011


Ambulatory Functionality

• Messaging

• Schedule

• Results

• Documentation

• Physician Order Entry

• Best Practice Alerts


Inpatient Functionality


• Inpatient Census

• All Results

• Medication Administration Record

• Vital Signs and I&O

• Documentation

• Computerized Physician Order Entry (CPOE)


Record System

eResearch:Research

Standardization: Real Data; Real Results

Dr.Connect:Improved


MyPractice●

Community

eHealth Services




a Second Opinion


Health Connection


Reporting from Home

Providers Patients


Health Connection

MyChart

Patient Services• View medical information

• View health reminders

• View schedule

• Prescription renewal request

• Online appointment scheduling

iPhone App:• Test Results

• Messages

• Appointments

Future / Past

• Preventive Care

• Health Summary-Meds, Allergies, Problems, Immunizations

MyChart

MyChart2222

3333

ClevelandClinic

HHFairview Hospital

Lakewood Hospital

HH

Lutheran Hospital

HH

Ashtabula County Medical Center

HH

Euclid Hospital

HH

Hillcrest Hospital

HH

South PointeHospital

HH

Marymount Hospital

HH

ClevelandClinic

Florida

HHMedinaHospital

HHLorain Family HealthAnd Surgery Center

FHCFHC

Elyria FamilyHealth Center

Westlake FamilyHealth Center

FHCFHC

FHCFHC LakewoodFamily Health

Center

FHCFHC

Strongsville Family Health and Surgery Center

FHCFHC

Brunswick FamilyHealth Center

FHCFHCWooster FamilyHealth Center

FHCFHC

Independence FamilyHealth Center

FHCFHC Solon FamilyHealth Center

FHCFHC

Chagrin Falls FamilyHealth Center

FHCFHC

Beachwood FamilyHealth and Surgery Center

FHCFHC

Willoughby HillsFamily Health Center

FHCFHC

FHCFHC

R.E. JacobsHealth Center

Lou Ruvo Centerfor Brain Health

Las Vegas, Nevada

FHCFHC

ClevelandClinic

Toronto

FHCFHC

S.T.J. Health Center

HC HC

Twinsburg FamilyHealth Center

FHCFHC

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

MyChart Patients: 371,903

• Near Real-Time Management Information

Challenges: Beyond Technology

Supply Category Surgeon 1 Surgeon 2 Surgeon 3 Surgeon 4 Surgeon 5

Implants $3,818 $3,048 $3,844 $4,065 $4,002

OR Time 364 377 432 360 357

Misc. Supplies 258 225 948 158 200

Blades & Knives 79 123 79 95 138

Sutures 21 27 29 21 27

Others 580 740 647 602 650

Total $5,120 $4,540 $5,979 $5,301 $5,374

• Within the surgical services resource area, surgical supplies are categorized into several functional categories

Challenges: Beyond TechnologyNear Real-Time Management Information

Blade Type Surgeon 1 Surgeon 2 Surgeon 3 Surgeon 4 Surgeon 5

BLADE,STRYKER 277-96-250 RECIPROCATING 1.85

BLADE,STRYKER 277-96-275 RECIPROCATING 1.85 9.42

BLADE,STRYKER 277-96-300 RECIPROCATING 9.80 12.02 5.16

BLADE, STRYKER 2108-156 34.53 39.02 37.11 33.78

BLADE, STRYKER, 2108-182 0.99 46.77

BLADE,5627-10-500, DEPUY 45.94 7.89

BLADE,5627-11-500, PFC SIGMA 61.59 13.81

SAWBLADE, STABLECUT, 506076 9.88

BLADE SAGITTAL, 2108107004 0.50

BLADE,STRYKER,2108-189 34.05 39.61 37.11 30.13

Total 78.88 123.25 78.63 94.51 137.53

• Average cost per Encounter• Cost variation for one type of blade reflects frequency of use



• Context-Based Training



• Context-Based Training

• Shared Goals and Incentives


Cleveland Clinic Community Physician Partnership, Medical Mutual Explore Innovative Relationship to Enhance Coordination and Quality of Care

First of its kind in Ohio, program will reward superior quality and efficient care, promote move toward performance-based payment

11/9/10

Cleveland Clinic Community Physician Partnership (CPP) and Medical Mutual of Ohio have signed an agreement to form an innovative relationship to enhance coordination and quality of care across northeast Ohio.

“This proposed affiliation with the Cleveland Clinic Community Physician Partnership will enhance provider collaboration and build a delivery model that puts the patient at the center of the care continuum,” said Delos M. Cosgrove, MD, CEO and President of Cleveland Clinic. “This type of coordination encourages communication between patient, provider and insurer with the goal of ultimately improving outcomes and building accountability for a higher level of care for our patients.”

Quality


Cost


Nearly Half of Americans Have One or More Chronic Diseases

Wu S, Green A. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October 2000

45%

133 Million Americans

Centers for Disease Control and Prevention. Chronic Disease Overview page. http://www.cdc.gov/nccdphp/overview.htm. April 6, 2007

U.S. Patients with One or More Chronic Conditions Account for Three in Four Healthcare Dollars Spent

Chronic Disease Healthcare Costs = ~$1.58 trillion

U.S. Healthcare Spending (2006) =

$2.1 trillion

25%

75%

Online Care Coordination and Diabetic Management


Co

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Fin

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Time

Diabetics, particularly those with multiple co-conditions, spend 2.3 times more on healthcare than non-diabetics

Preventive ActivitiesPatient Responsibility

(Episodic Physician Supervision)

Problem-RelatedHypertension / Heart

Interventions

Reduced HealthMaintenanceCompliance

Vision / CoronaryComplications

(Increase Likelihood)

Hospitalizations

Patient-DrivenScheduling


Record System

Dr.Connect:Improved


MyPractice:●

Community

eHealth Services




a Second Opinion


Health Connection


Reporting from Home

Providers Patients

MyPractice●

Hospital


Reporting from Home

MyMonitoring

MyMonitoring Health Information

ExchangePublic / Private

MyPractice: Physician Results View

Patient Flowsheet Data

MyMonitoring

MyChart

Health Information Exchange

Public / Private

Dear Patient,You are managing your blood sugars well. Keep up the good work. Continue watching what you eat and doing your moderate, daily exercise.

Please schedule your next office appointment for 120 days from now.

Message me if you have additional questions.

Cost ReductionCost Reduction

Medicare spending per patient UCLA Medical Johns Hopkins Massachusetts Cleveland Clinic Mayo Clinic during last two years of life Center Hospital General Hospital Foundation (St. Mary’s

Hospital)

Total Medicare spending $93,842 $85,729 $78,666 $55,333 $53,432

Inpatient site of care $63,900 $63,079 $43,058 $34,437 $34,372

Outpatient site of care $14,125 $13,404 $11,509 $8,906 $7,557

Skilled nursing/long-term care facility $6,891 $3,287 $15,149 $5,101 $7,114

Other sectors of care $8,926 $5,959 $8,951 $6,889 $4,389

Executive Summary, April 2008

Service Line Cost Management

Cost Management Initiative • Standardize materials and services to improve consistency (predictable outcomes) and reduce unnecessary costs

Sustainable Way of Working1. Create a standard approach to Service Line Cost Management

- Definitions- Roles and Responsibilities- Data Analysis & Interpretation- Improvement Implementation

2. Educate & develop the ongoing organizational capability within Cleveland Clinic Health System - sustain an environment that continually scrutinizes costs


• Driven by multi-disciplinary team- Liver Transplant Surgeons- Infectious Disease- OR Nurse Managers- Transplant Coordinators- Pharmacy- Continuous Improvement- Supply Chain- Finance

• Analyze cost across continuum of care- Reviewed costs from all resource areas

• Focus on factors the team can control- The Institute has identified opportunities to reduce costs in the OR

Cost ReductionCost ReductionLiver Transplant Cost Management Team

Liver Transplant Cost Management Team

Direct Cost per Encounter by Resource Area

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

Path/Lab Pharmacy Surg Svcs Nursing Resp/Pulm Imaging Others

2010 2011

• Excluding acquisition costs, direct cost per encounter decreased from $47,834 to $43,588

Cost Reduction: $4,245

9%


Technical Direct Cost per Encounter

YTD June 2010 & YTD June 2011 (Adjusted for LOS outliers)

Cost ReductionCost ReductionKnee Replacement (DRG 470)

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

SurgicalServices

Nursing Rehab Anesthesia Pharmacy Path/Lab Resp/Pulm Others

2010 2011

Cost Reduction: $507

6%



Co

st (

Fin

anci

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nd H

um

an)

Time

$

Online Scheduling

Online CareCoordination

Online,Physician-Supervised

GlucoseTrackingPatient-Driven

Scheduling




Interventions




Hospitalizations


Health MaintenanceCompliance

Ongoing Education

Quality


Cost



Record System

Dr.Connect:Improved


MyPractice●

Community

eHealth Services




a Second Opinion


Health Connection


Reporting from Home

Providers PatientsPublic / Private

Sector Connectivity

MyPractice●

Hospital

Cleveland Clinic Pilots Microsoft HealthVault

CLEVELAND, Nov. 10, 2008 / PRNewswire via COMTEX / — Cleveland Clinic, a World-class academic medical institution and leader in health information technology, today announced collaboration with Microsoft Corp., a worldwide leader in software, to pilot the patient-controlled data exchange between Microsoft® HealthVaultTM, a Web-based personal health platform; a suite of widely-used digital medical devices; and e Cleveland Clinic MyChart®, Cleveland Clinic’s electronic personal health record (PHR) system.

Today, more than 150,000 Cleveland Clinic patients use eCleveland Clinic MyChart®. The short-term pilot, begun on Monday, Nov. 3, is the first pilot in the country to follow multiple diseases in the clinical delivery setting using multiple at-home devices such as glucometers, heart rate monitors, weight scales and blood pressure monitors.

True Value of Health Data Exchange to Cleveland Clinic PatientsTrue Value of Health Data Exchange to Cleveland Clinic Patients

All data available to Cleveland Clinic treating

physicians

Patient transfers data from all physicians, hospitals, retail pharmacies, commercial laboratories and digital devices.

Physicians Hospitals Com. LaboratoriesRetail PharmaciesHome Devices

Patient transfers data to Cleveland Clinic MyPractice

MyPracticeElectronic Medical Record System

NHINStateHIE

In three days Mr. Jones receives his second opinion verifying that he needs surgery, but Cleveland Clinic specialist recommends valve repair instead of replacement.


Mr. Jones fills out online medical questionnaires and sends required scans and test results to Cleveland Clinic.

Mr. Jones fills out online medical questionnaires and sends required scans and test results to Cleveland Clinic.

After being diagnosed with a heart condition requiring surgery by his doctor at home in Arizona, Mr. Jones goes online to request a MyConsult remote second opinion from a cardiology specialist at The Cleveland Clinic

After being diagnosed with a heart condition requiring surgery by his doctor at home in Arizona, Mr. Jones goes online to request a MyConsult remote second opinion from a cardiology specialist at The Cleveland Clinic

Because Cleveland Clinic is considered a national center of excellence for heart surgery, Mr. Jones schedules his surgery and flies to Cleveland.

Before he leaves, he signs up for the Microsoft HealthVault personal health information management service, and imports all the information related to the care he has received in Arizona—this includes his laboratory tests, hospitalizations and medication history.

Because Cleveland Clinic is considered a national center of excellence for heart surgery, Mr. Jones schedules his surgery and flies to Cleveland.

Before he leaves, he signs up for the Microsoft HealthVault personal health information management service, and imports all the information related to the care he has received in Arizona—this includes his laboratory tests, hospitalizations and medication history.



What Cleveland Clinic knows about

Mr. Jones prior to his arrival.

Mr. Jones chooses to share his health history with his Cleveland Clinic specialist and, by simply selecting “send to Cleveland Clinic,” ensures that everything his surgical care team needs to know about him is in his eCleveland Clinic MyPractice electronic medical record before he ever leaves Arizona.

Mr. Jones chooses to share his health history with his Cleveland Clinic specialist and, by simply selecting “send to Cleveland Clinic,” ensures that everything his surgical care team needs to know about him is in his eCleveland Clinic MyPractice electronic medical record before he ever leaves Arizona.

All of Mr. Jones’ care is documented in the eCleveland Clinic MyPractice electronic medical record system.


Mr. Jones travels to Cleveland Clinic, for mitral valve repair surgery, confident that his care team on both sides of the United States is virtually working together to deliver the best care possible.

Mr. Jones travels to Cleveland Clinic, for mitral valve repair surgery, confident that his care team on both sides of the United States is virtually working together to deliver the best care possible.



Before he is discharged, Mr. Jones signs up for MyChart so that he can securely connect to his own personal health information and receive messages from his care team anywhere there is an Internet connection.

Before he is discharged, Mr. Jones signs up for MyChart so that he can securely connect to his own personal health information and receive messages from his care team anywhere there is an Internet connection.

Then he travels to Florida to spend a month with his sister while he recuperates.


And because his physician at home signed up for Cleveland Clinic’s DrConnect service, every aspect of Mr. Jones’ treatment progress is securely available to his primary care doctor.

And because his physician at home signed up for Cleveland Clinic’s DrConnect service, every aspect of Mr. Jones’ treatment progress is securely available to his primary care doctor.



While he is in Florida, Mr. Jones uses Microsoft HealthVault to utilize Cleveland Clinic’s MyMonitoring services. Through a secure Internet connection, he downloads daily information from his digital scale and blood pressure monitoring device into HealthVault, which then sends it to Cleveland Clinic’s electronic medical record system and MyChart so that he and his physicians can work together to keep him on the right track..




Now fully recovered, Mr. Jones returns home to Arizona where he receives his ongoing follow-up care from his own physician while staying connected to his Cleveland Clinic care team through MyChart, MyMonitoring, and DrConnect for his local physician. He also knows that all the other Cleveland Clinic eHealth services are still available to him should the need ever again arise.




MyChart

DrConnect

MyConsult

Monitoring

MyPractice

And because Microsoft HealthVault is interfaced with the Cleveland Clinic MyPractice electronic medical record system, he can assemble and store a comprehensive history of all the treatment he received from any healthcare provider which will be available to him and the providers he chooses in the future.

And because Microsoft HealthVault is interfaced with the Cleveland Clinic MyPractice electronic medical record system, he can assemble and store a comprehensive history of all the treatment he received from any healthcare provider which will be available to him and the providers he chooses in the future.

MyChart

DrConnect

MyConsult

Monitoring

VirtualVisit

MyPractice

Confident, Empowered

Patient

Security,Access and

Control And because Google Health and Microsoft HealthVault are interfaced with the Cleveland Clinic MyPractice electronic medical record system, he can assemble and store a comprehensive history of all the treatment he received from any healthcare provider which will be available to him and the providers he chooses in the future.

And because Google Health and Microsoft HealthVault are interfaced with the Cleveland Clinic MyPractice electronic medical record system, he can assemble and store a comprehensive history of all the treatment he received from any healthcare provider which will be available to him and the providers he chooses in the future.



Co

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Fin

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Time

$

Online CareCoordination

Online Scheduling

Online,Physician-Supervised

GlucoseTrackingPatient-Driven

Scheduling




Interventions




Hospitalizations


$

Health MaintenanceCompliance

Ongoing Education

Coaching

Health Maintenance

Ongoing Education

Value-BasedU.S. Healthcare

System

Quality


Cost


the role of process improvement, and information technology in achieving our nation’s 21 st...

Documents

quality cost slide

quality of diabetes

ecleveland clinic slide

century challenges

value equation value

century healthcare goals

information technology

chief information officer