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University of Michigan
US National
Health/HealthCare Informatics/IT
1
32
4
UMHS• Hospitals and Clinics• Medical School• Nursing School
UHS
School of Dentistry & Dental Clinics
SPH
Non HIPPA Covered Entity
Institute for Human Adjustment
• Psychology clinic (East hall)
School of Social Work• Family Assessment clinic
UM Athletics
CAPS; Counseling and Psychological Services
Hospitals & Clinics• 7 hospitals & Surgery Centers;
UH, Mott, VV women’s, CVC, Kellogg Eye, EAA Surgery Center, Livonia Surgery Center• 4 Specialty Centers;
Comprehensive Cancer, Diabetes, Depression, Geriatrics• 120 + Clinics (40 Health Centers)-
MI & OH
Facts;• 22,000 Faculty & Staff• 885 hospital beds expanding to 1035 (new Mott/VV)• 45,000 inpatient admissions• 80,000 Emergency Visits• 1.8 million outpatient visits/surgeries• $2.1 B Operating Revenue vs $2.02 B expenses.
Medical School• 1600 Faculty (188 Endowed Professorships)• 1850 enrolled students• $436 Million Research Funding ($366M + NIH funding)• 80 facilities, 4.6 million Gross ft2• $1.3 B total Revenue
Nursing School118 Faculty1844 enrolled students
M-net; Referring Physician Communication Network• 12,000 physicians• >2000 items sent/day• +600 physicians direct
access to Careweb
UHS• 150 Employees (25 clinicians; 10
care &
Specialties• 80,000 visits (70% student, 30% Fac/staff)• $18million operating budget ($5M fee for
service)
School of Dentistry• 410 Faculty (110 full, 300 part time)• 650 Students (444 DDS, 104 hygiene, 81 Grad)• 145,000 visits
Wide Range of Patient Ages & Services.
Large and diverse Student PopulationPopulation care, Etoh & drug, STDs, Psych/Social, Injury(prevention), Lifestyle/health-education
International Students (and Foreign travel)
Skin Cancer/Melanoma
Multidisciplinary Aortic
Congenital Heart Disease
Head & Neck Cancer Cranial Base
Multidisciplinary Adrenal
Cancer/Endocrine Oncology
Multidisciplinary Liver Cancer
Multidisciplinary Pancreatic CA
Bladder Cancer
Center for Stem Cell Transplantation
Fetal Diagnosis and Treatment Center
Heart Rhythm Center
Michigan Sensitized Candidate
Program (MISCAP)
Multidisciplinary Cerebrovascular
Disorders
Multidisciplinary Craniofacial
Anomalies
Multidisciplinary Interstitial (Fibrotic)
Lung Disease Sarcoma
Thoracic Insufficiency Respiratory
Syndrome
University of Michigan Esophageal
Cancer Program
Total number of persons age 65 or older, by age group, 1900 to 2050, in millions
Tot
al n
umbe
r of
per
sons
in m
illio
ns
0
20
40
60
80
100
65 or Older
85 or Older
20501900 1950 2000Projected
Mortality
Angus, CCM,2001
Angus, CCM,2001
1) 750,000 Hosp. Admits
2) 215,000 deaths
3) $16.7 billion (1995 dollars)
4) A top ten consumer US hospital Costs.
AsthmaCongestive Heart FailureDiabetesHypertensionCoronary Artery DiseaseCOPDChronic Kidney DiseaseStrokeDementia/Alzheimer’s
1.
Affect more than 130 million Americans
1.
Account for 70% of all deaths in the US.
1.
Costs of care account for more than 75% of the nation’s $2 trillion medical care costs.
5 million Patients with CHF in
US
1% of population over 65
years old
>400,000 new cases/yr.
160% increase in
hospitalizations over past 10
years.
~ 50% mort. in 3 years• < half of 4200 patients on Tx
list will
receive a heart Tx.
Total number of persons age 65 or older, by age group, 1900 to 2050, in millions
Tot
al n
umbe
r of
per
sons
in m
illio
ns0
20
40
60
80
100
65 or Older
85 or Older
20501900 1950 2000Projected
Cooper, Circ 2000
OECD, 2009
©2010 California HealthCare Foundation
Health spending exceeded $2.3 Trillion in ‘08, expected to exceed $2.5 trillion in ‘10.
©2010 California HealthCare Foundation
35% health spending in elderly is private dollars.
©2010 California HealthCare Foundation
©2010 California HealthCare Foundation
Medicine used to be simple, ineffective, and relatively safe.
Now it is complex, effective, and potentially dangerous.
“The mystical authority of the doctor used to be essential for practice, now we need to be open and work in partnership
with our colleagues in health care and with our patients. We must recognize and encourage our patients’
right to make
fully informed decisions about available treatments and provide care and support, not just technically advanced interventions.”
Chantler, 1999.
Value (quality/cost) vs
Control Costs
Safety
Accountable Care OrganizationsPatient Centered Medical Homes
Personalized Medicine (Genomics)
Meaningful Use {of EMRs}
Deloitte
Monitored, coordinated and integrated care using electronic medical records and personal health records
Information technology is used to appropriately support optimal patient care, performance measurement, patient education, and enhanced communication
Innovation such as …cyber-visits, …self-monitoring devices are available….
The ability to measure and Report on the Quality of Care-the goal is not just reduce costs, but to do so while maintaining or improving quality of care= ValueRequires the ACO to accept accountability for the total costs of care and population-level quality outcomes. Miller, Harold
“I am fain to sum up with an urgent appeal for adopting …some uniform system of publishing the statistical records ofhospitals. There is a growing conviction that in all hospitals,even in those which are best conducted, there is a great andunnecessary waste of life …
In attempting to arrive at the
truth, I have applied everywhere for information, but inscarcely an instance have I been able to obtain hospitalrecords fit for any purposes of comparison …
If wisely used,
these improved statistics would tell p us more of the relative value of particular operations and modes of treatment than we have means of ascertaining at present.”
Florence Nightingale
Notes on Hospitals, London. 1863
1.5% = comprehensive EMR8% = basic system17% = CPOE11% to 23% = CDS
45% have “NO Plans” for CPOE or CDS.
Population(s)
Meaningful Use
Hersh, OHSU
ARRA= American Recovery and Reinvestment Act 2009• HITECH=Health Information Technology for Economic
and Clinical Health Act$27B incentives for EHR adoption by:
Eligible providersHospitals
$2B direct grants by Fed agencies; training, pilots, etc.• ONC= Office of the National Coordinator (Final rule July,28th, 2010)
EHR Standards Implementation specificationsCertification criteria
• CMS;
Ties incentive payments/penalties to MU specificationsMedicaid; CMSMedicare; States.
ONC= Office of the National Coordinator• HITECH technology interventions map to 5 goals
for US Healthcare System;Improving quality, safety & efficiencyEngaging patients in their careIncreasing coordination of careImproving the health status of the US populationEnsuring privacy and security of patient data
• Requires use of certified EHR technology;1.In a meaningful manner. (CDS, CPOE)2.For electronic exchange of health information to improve
quality of health care. (HIE)3.To submit clinical quality and other measures selected by
the Secretary for HHS.
Deloitte, 2011
10-1-2012
7-1-2013
Functional Requirements1. Computerized Physician Order Entry (CPOE) 2. Drug-drug, Drug-Allergy Checking3. Generate and Transmit Electronic Prescriptions (eRX); EP only4. Maintain up-to-date Problem/Diagnosis List5. Maintain Active Medication List6. Maintain Active Medication Allergy List7. Record Vital Signs8. Record Demographics9. Record Smoking Status10.Report Quality Measures to CMS and the States11. Implement Clinical Decision Support
Health Information Exchange (HIE) Requirements12. Provide Patients with Clinical Summary of Office Visits13. Provide Patient with Electronic Copies of Health Information14. Implement Capability to Exchange Key Clinical Information
HITECH Privacy And Security15. Implement Systems to Protect Patient Data
51
Architecture funded by State HIE Cooperative Agreement
51
11/30/2011 52UMHS HIE Strategy
Data Center Migration (completed)
E-Prescribe
Exchange Server & MS Outlook
Coded Diagnoses
C&W Activation & Unified Communications
Lab System Cerner to SCC
Radiology IS Upgrade
CPOE System upgrade
ICD-10 conversion; Oct, 1st, 2013
Window’s 7 migration
Health Information Exchange (HIE)
Education for Clinical IT• Implementation• Advanced Training• Updates
Operational Management(Historical. e.g. quality,
billing, reporting etc.)
Biomedical
Research
Trials
Quality
Reports
Clinical Data
Warehouse
Comparative
Effectiveness
Research
Population
Research
‘Omics
Repository
Administration
Systems
Patient Care(Electronic Health
Record)
Multiple Clinical
Systems
Research
WarehouseClinical Data
Repository
External
OrganizationsExternal
Organizations
‐De‐Identification‐Consents
‐Identity Management‐Vocabulary Mapping
J. G. DeWitt, 2010
58
Population
Research
Marts
Operational
Management
Biomedical Research
Cancer
Research
Virtual Network
Tools
Vocabulary/Ontology
Mapping
UMHS Biomedical and Clinical Data Flow
External
OrganizationsExternal
Organizations
Trial
Analysis
Virtual
Trials
Federation
Collaboration
Cohort
Identification
Claims
Comparative
Effectiveness
Research
PHI
Quality
Reporting
EMPI
Clinical Data
Warehouse
Patient
Recruitment
Translational Research
Informatics
Framework
CTMS
Research
Warehouse
Consent
Trial EDC
Tissue
ConsentClinical LIS
Tissue
BankHigh Throughput
‘Omics
LIS
De‐identification
eIRB/ProtocolsIdentity
Management
Clinical Data
Repository
Patient
Scheduling
Foreign Documents
Import
Registration/
ADT
Billing
Electronic
Health Record
Historical
Patient Data
Document
Image
Repository
Internal
Recipients
‘Omics
Repository
Departmental
Applications
Transcription
EMPI
Patient CareHIPAA/IRB Wall
I.
Review of Epic Modules
Primary Vendor Model – 3 Year View (Stage 1) =
60
I.
Review of Epic Modules
Primary Vendor Model – 5 Year View (Stage 2) =
61
I.
Review of Epic Modules
Primary Vendor Model – 10 Year View (Stage 3) =
62
Q1 Q3Q2 Q42010
Q5 Q7Q6 Q8 Q9 Q11Q10 Q12 Q13 Q15Q14 Q162011 2012 2013
University of Michigan Health SystemStages 1 & 2 Implementation Sequence and Capital vs . Operating View
Pre‐
Cont
ract P
lann
ing, D
evelop Sta
tem
ent o
f Wor
kCon
trac
t Si
gned‐J
une 20
10
Stage 1
Pro
ject K
icko
ff‐A
ugus
t 201
0
Q17 Q19Q18 Q202014
ICD‐10 Deadline
“Month 1”
Q22Q21 Q23 Q242015
C&W Hospital & Clinics Move
Stage 2
Proj
ect Pl
anni
ng, P
roje
ct Tea
m T
rainin
g @ Epi
c/Ce
rtifi
cation
and In
itial Int
erfa
ce and W
orkf
low A
nalysis
Wor
kflo
w V
alidat
ion
Sta
biliz
e
Resolute Professional Billing, Research Integration
ADT & Prelude Registration
Resolute Hospital Billing inc . Coding & Abstracting
EpicCare Ambulatory EMR, MyChart Shared Patient Record & Care Everywhere , including Temporary Interfaces of Clinical Data with CareWeb ‐Research Integration
Temporary Interfaces: ADT/Registration to Eclipsys & CareWeb, charges from Eclipsys, charges from Worx, New interfaces: ADT downstream, DMS, plus more
Pro
ject K
icko
ff‐A
ugus
t 201
0
Cadence Enterprise Scheduling & Welcome Kiosk(+)
ASAP Emergency Department & Ambulatory Care Pilots ,HIM, Research Integration
Opt
imize
Capital Expense Operating Expense
Production Support & Maintenance
Cadence Scheduling, ADT & Prelude Registration, Resolute PB, Resolute HB, Coding and Abstracting, Research Integration
Sta
biliz
e
Opt
imize
Capital ExpenseSta
biliz
e
Opt
imize
Operating Expense
Production Support & MaintenanceED, Ambulatory Care Pilots, HIM, Research Integration
Production Support & MaintenanceAmbulatory Care, Research Integration
Stage 3 Startup
Stage 2a Planning & Implementation (HODs, Kaleidoscope/Ophthy, Therapies, Nurse Triage , Welcome, etc. )
Capital Expense Operating Expense
Capital Expense
Capital Expense
12,000 Active users
1,500 Order sets
11,000 Individual order items
>400 Active maintenance/enhancements
>150 New configuration requests/month
19 Million Orders to date• 500,000 orders/month
Turnaround Time for Stat and Now Orders
Metrics on Clinical ImprovementTi
me
(Min
utes
)
Mott
UH/CVC
UM-CareLink VTE Assessment Orders vs Reminder Alert
322 278 279 211 227
1368
2256 21782433
13314
2102323023
25514
0
500
1000
1500
2000
2500
3000
May June July
Augus
tSep
tembe
r
Octobe
rNove
mber
Decembe
r
Janu
ary
Month (May 2008 - January 2009)
Num
ber o
f Ord
ers
0
5000
10000
15000
20000
25000
30000
Num
ber o
f Ale
rts
VTE Assessment OrdersVTE Assessment Reminder Alerts
UMHS Policy in place re VTE Assessment
VTE Reminder Assessment Alert in Production on 10/22/2008
84 Years
International
High Level Conceptual Diagram‐‐
Future State:
Research Interface with the Clinical Record
Genomics data
workbench(es)
UMHS Data Warehouse
Population‐
Risks
Assay‐
Specific
Disease‐
Specific
Qual/Outcomes
Organ
Systems
Demographics
eThority
(billing)
ClickCommer
ce
(IRB)
Research Administration
Systems
Terminology
Resources(ICD‐10,
caDSR,
SNOMED,
etc.)
External
Resources
(PubMed,
GenBank,
KEGG, GO,
etc.)
I2B2 Cohort
Discovery &
Data Mining
CDR
Clinical & Business Systems
Data Sharing
with External
Collaborators
I2b2SHRINE
CTSAscaBIGTCGA
Nursing Docs
Radiology
Pathology
Pharmacy
CareLink/Eclipsys
MiChart/Epic & Legacy
Biorepositories
Proteomics
Metabolomics
ChIP‐Seq
Next‐Gen
Sequencing
Health
Sciences
Library
Resources
ResearchData
Managemen
tSystems
Quality, Population Mngt
&
Research QualityMetrics Data Marts
ResearchCore
Facilities/‘Omics’
HIEPt PortalProvider
PortalPati
ent.
ResearchAdministration
Systems
I.
Revenue CycleFinance/BillingRegistrationScheduling
II. Clinical systems1.
ED
Legacy;2.
UHS
Carelink3.
Ambulatory Care
Careweb4.
Opthalmology
Centricity5.
Stage III & IV.
Others……
CAD
Clarity
Terminology mapping systems
Common Specimen Identifier Services
Messaging Bus & ETL Services
Honest Broker & Security Infrastructure
Quality,
Outcomes
and CPI
BC/BSCMS
JHACO
i2b2SPORES
Industry:Pharma/Biotech
Research Systems
BiomedicalEngineering
HistoricalData
Research Data
Management
Systems
Registries
OpenClinica
Velos
BioDBX
RedCAP
Research Data Warehouse
Messaging Bus, ETL & External Collaboration Services (SOA, caGRID, SHRINE, ...)Vocabulary & Terminology Mapping Services (ICD-9/10 SNOMED, IMO, caDSR, ...)
Research Administration
Systems
Common Identifier Services (Patient, Provider, Research, Specimens, External Mappings)
HIPAA/IRB Services (Honest Broker, De‐ID Consent Management, …)
Epic Clarity
Patient Care Systems
Centricity
Documentation
Radiology
Pathology
Pharmacy
CareLink/Eclipsys
Others…
Scheduling
Revenue Cycle
Emergency Med.
Ambulatory
Research CoreFacilities/‘Omics’
InternationalData Sharing
with External
Collaborators
CTSAscaBIGTCGA
Epic EHRLegacy +
ULAM
TissueBiorepositories
Metabolomics
Proteomics
Bioinformatics
Next‐Gen
Sequencing
Bioinformatics and Systems
Biology Workbenches
Collexis
eThority
(billing)
ClickCommerce
(IRB)
Research Pre,
Post‐
Award
Industry:Pharma/BiotechI2b2/
SHRINE
Others …
Demographics
Diseases
Individuals
Populations
Portals / Providers, Payers, P. Health D
atabases / HIEs
/ NHIN
Campu
s System
s
IT Security
HSDW
i2b2
High PerformanceCloud Computing
&Data Storage
IT Security
• Reporting• Visualization• Analysis &• Data Mining
IT Security
Research &
Quality Metrics
Data Marts
Brian Athey
& ECRIT 1/11/11
Health
Sciences
Library
Resources
NIH-Specific &External Data Resources
(PubMed, GenBank,
KEGG, GO, etc.)
SPORES
Others
CIDSSAnalytics
& ReportingTools
QualityMetrics
Reporting &Peer Review
Education
CADCDREducation
KnowledgeRepository
Research
AdministrationData Warehouse
Others…
M‐Pathways
CTools/Sakai 3
Curriculum Evaluation System
Clinical Scheduling
ComprehensiveClinical Assessment
Exam
Admissions
UMHS Data Architecture Future State: Unifying the Three Missions‐‐
Education, Research, & Patient Care