Sepsis Bundle Compliance
Sepsis is the leading cause of hospital mortality. Sepsis diagnoses are present in 40% of MU Health Care’s mortalities. Compliance with the 3- and 6-Hour Sepsis Bundles (a set of early interventions to be performed within 3 and 6 hours of identification, aimed at reducing sepsis mortality) are critical. Dashboards have been developed for retrospective analysis, however real-time information is necessary for timely, appropriate care.
The Tiger Institute Development at the Edge (TIDE) team has developed a first-of-its-kind, Sepsis Bundle Compliance Tool which gives providers real-time insight into the multi-factor, narrow bundle compliance time line and enables them to ensure appropriate care is delivered in a timely manner. The tool indicates whether each element was met, is at-risk of being out of compliance, or was not met. Providers can also review relevant clinical information including lab results, medication administration times, and fluids administered directly within the tool.
We believe real-time information to support standardization of care will support bundle compliance and result in a corresponding reduction in Sepsis mortality.
SMART Results Graphing
Only about half of the 78 million US adults diagnosed with hypertension have their blood pressure (BP) controlled. Recent research has identified the important role of home BP measurements, considered equal, or even superior, to clinic BP measurements in their predictive value.
However, home BP data in its numerical form—often provided by patients as written notes or submitted through telehealth applications—may not be used to its fullest potential. Visualization of home blood pressure data values may prove to be the solution; however, current EHR systems do not have adequate capabilities for informative visualizations of home-entered values.
Beginning in February 2017, our TIDE team designed and developed a graphical display of BP measurements and provided for patients to easily record home BPs through their MU patient portal account. The team used Fast Healthcare Interoperability Resources (FHIR) standards to develop this view for both patients and physicians.
The physician view accommodates numerous patient-entered home BPs and includes intuitive display of target range and a smoothing line indicating rolling average. This view, which makes judgment about BP control more accurate, is now available (since February 2018) with the patient portal and within workflows for ambulatory primary care physicians in the Cerner Millennium EHR.
The team also developed a medication time line to correspond with times of home and/or clinical BP measurements. This can help a clinician more easily determine the effects of medication on a patient’s blood pressure so he or she can make a more informed adjustment to drugs and/or dosage. Research evaluation is underway.
Reducing Unnecessary Blood Transfusions
Blood transfusion can be a life-saving procedure, however, liberal transfusion strategies are associated with increased length of stay, morbidity, and mortality compared to restrictive transfusion practices. In the United States, blood transfusion has been named one of the top 5 overused medical procedures, and it is estimated that as much as 40% of all blood product transfusions may be unnecessary. These unnecessary transfusions cause direct patient harm, generate excessive costs for health systems, and waste important, limited resources.
A team of MU Health Care and Tiger Institute associates used Clinical Decision Support (CDS) embedded in the EHR to provide relevant, evidence-based information to clinicians at the time of ordering to support best practice. This Value Creation Office project goal was to reduce unnecessary red blood cell (RBC) transfusions by 20% through implementation of clinical decision support for transfusion ordering.
In December 2017, the team implemented CDS alerts to fire for patients with a hemoglobin level greater than 7.0 g/dL (or no hemoglobin level documented in the past 24 hours) when a clinician placed a RBC transfusion order. The alert excludes neonatal intensive care unit patients, as well as all operating room and emergency transfusion orders.
Between December 2017 and April 2018 the CDS alert fired a total of 885 times resulting in cancellations of the RBC transfusion 62 times.
Through June 2018 the overall mean RBC transfusion rate (total number of RBC units transfused/total number of inpatient discharges) fell by 10% from the mean baseline rate since CDS was implemented in December 2017. This 10% reduction results in annual hard cost saving of $241,000, not including indirect costs of approximately $1,000 per RBC unit transfused.
In the first four months after CDS implementation, the ordering physician canceled 7.0% of RBC transfusion orders that received the CDS alerts. The annualized rate of canceled transfusions equals a total of 222 RBC units saved per year. After the team targeted education to service lines with high transfusion rates, they saw a 29% reduction in alert overrides.
The team continues to monitor alert overrides and RBC transfusion rates, and it will continue targeted patient blood management education for additional service lines. Next, the team plans to implement CDS alerts for other blood product transfusion orders, such as plasma, platelets, and cryoprecipitate, to further reduce unnecessary transfusions.
Virtual Pharmacist Provides Cost-Effective Way to Promote Quality Care
Pharmacists at MU Health Care are changing the way they help patients and providers with the help of HealtheRegistries.
In early 2016, they launched a virtual pharmacy program named ViPRx. Through the program, a virtual pharmacist combs patients’ medical records for medication appropriateness at more than 60 locations — a task that would otherwise be nearly impossible.
The virtual pharmacist pays close attention to medications that could impact individuals living with diabetes. HealtheRegistries scorecards solution tracks how the pharmacist’s recommendations would likely improve clinical indicators.
Within the first year, the virtual pharmacist’s recommendations helped MU Health Care improve all diabetes registry clinical indicators, such as cholesterol and glycated hemoglobin levels.
How does the program work?
A few days before a patient visits a clinician, the virtual pharmacist reviews his or her history and medications, paying close attention to medication and dosage appropriateness, medication adherence, potential medication interactions, and checking that all immunizations are up-to-date. If necessary, the virtual pharmacist then recommends possible medication changes to the clinician.
Similarly, after the patient visit is complete, the pharmacist reviews prescriptions written by the clinician and intervenes if necessary.
ViPRX helps physicians if their patients have any medication issues,” said Bushra Muraywid, pharmacist. “It helps them address issues in a quicker manner because they don’t have to do as much background work. It’s being done for them.
The virtual pharmacist can make suggestions and intervene at each clinic.
Throughout 2016, clinicians agreed with the pharmacist’s lab monitoring suggestions 78% of the time, and they agreed with non-adherence counseling 72% of the time.
Improving diabetic care
One of the biggest successes came through improvements in diabetic care. Suggestions to change medications can enable improved patient health.
The solution shows how those recommendations helped improve diabetic indicators, such as glycated hemoglobin (HbA1c) and low-density lipoprotein (LDL) cholesterol levels.
HbA1c tests provide an overall picture of blood sugar levels, with lower counts signaling healthier patients. HbA1c less than or equal to nine rose from 66% in March 2016 to 72% in December of that year.
In addition, the number of patients who had their LDL rate under control rose from 65 to 74%.
Continuing ViPRx roll-out
When ViPRx launched in March 2016, only one clinician used the program. Throughout the year, family medicine, internal medicine, and endocrine specialists began to use the system, and the program continues to expand. Now the program is beginning to expand across other Health Network of Missouri members, with Capital Region Medical Center rolling out ViPRx first.
The project aims to improve clinical outcomes and reduce cost for individuals with diabetes covered by Capital Region Medical Center’s insurance. To accomplish this they will use HealtheIntent registries to enable pharmacists to perform targeted management and recommend appropriate interventions.
We wanted to make the program scalable and look at it over a long term,” said Brad Myers, executive director of pharmacy and laboratory services. “We’re not creating a program designed for today without thinking about tomorrow.
Since November 2014, the patient/provider portal has had more than 18 million page views, with 7 million views this past year alone. In the last year, patients and providers messaged each other more than 650,000 times (a year-over-year increase of 225%) and patients self-scheduled appointments more than 22,000 times (a 120% increase over last year.)
Enrollment in the portal continues to climb with more than 103,000 portal accounts, a year-over-year increase of 22%, representing 41% of MU Health Care’s patient population.
The innovation teams at Tiger Institute continue to develop new ways to improve the patient experience and to improve communication between patients and their providers.
Our implementation of HealtheRegistries not only aligns with payor priorities and other quality initiatives, it also empowers patients to manage their own health with their provider.
The Health Scorecard, available through the patient app, shows how the patient is doing on various measures and when additional screenings are due to maintain or improve health status through one or more of the following registries:
- Three Wellness Registries (Adult, Senior, Pediatric)
- Six Chronic Disease Registries (Diabetes, Heart Failure, Chronic Obstructive Pulmonary Disease, Hypertension, Ischemic Vascular Disease/Coronary Artery Disease, and Asthma)
- One Acute Condition Registry (Ambulatory Urgent Care)
In total, we support 32 measures, including these additions from the past year:
- Screening for Osteoporosis for Women (Senior Wellness)
- HPV Vaccination (Pediatric Wellness, Adult Wellness)
- Shingles Vaccination (Senior Wellness)
Patients can now enter their blood pressure readings taken outside a clinical setting into their MU Health app. Not only can it help them track their own numbers, but it also feeds data into the EHR so that their providers can see how they are doing outside visits.
This gives patients and providers an easy way to determine the effect of medication and ensure the patient has the best options to control hypertension.
Regional and Statewide Relationships
MU Health Care and Tiger Institute have been working with health care providers throughout Missouri to extend both technology and services. In doing so, we are establishing the foundation for value-based care, which will result in improved health of populations, reduced costs of care for individuals and communities, and an enhanced experience and outcomes for Missourians.
Care Partner Connections
Tiger Institute Health Alliance Health Information Exchange
We continue to expand our membership in Tiger Institute Health Alliance Health Information Exchange (TIHA HIE). Recent additions include health care providers in Columbia, Fayette, Macon, and Sedalia, Missouri. The HIE now boasts more than 803,000 unique patients and over the last year usage increased by an additional 71% after last year’s 193% jump in usage.
The national eHealth Exchange standard provides a way for HIEs to connect to health organizations and other HIEs. Our eHealth Exchange connections include:
- SSM Health (Missouri)
- Veterans Administration (nationwide)
- DaVita Dialysis (nationwide)
- Missouri Health Connect (MHC) (Missouri-based HIE)
The MHC connection makes the Tiger Institute Health Alliance the first and only Missouri HIE to be connected to all HIEs in the state, driving unparalleled value for our members.
Additionally, the Tiger Institute Health Alliance helped MU Health Care become one of the first Cerner clients to connect to the CommonWell Health Alliance, a national health information exchange network. This connection lays the foundation to obtain clinical information on patients directly from their providers throughout the United States and supplements the robust data already available in our HIE.
MPact Clinically Integrated Network
Mercy, Mosaic Life Care, MU Health Care, and others, consisting of more than 3,000 physicians and 48 hospitals, work together through this multi-state, regional network to improve quality, access, and care. The network members create value-based contracts for improved care and operational efficiencies. We are aggregating data from Health Network of Missouri into HealtheIntent to enable members to report MPact quality metrics.
Health Network of Missouri
MU Health Care is a member of the Health Network of Missouri, LLC (HNM), a collaborative comprised of more than 1,000 hospital beds, nearly 11,000 employees, and approximately 1,200 employed and affiliated physicians who care for patients in central, northeast, and southeast Missouri.
Major HNM initiatives include:
- Improve patient health outcomes
- Share data and best practices
- Improve access to care
- Coordinate patient care among various providers through a clinically integrated network
- Lower health care costs
- Create efficiencies to benefit patients and HNM communities
Members of HNM include:
- MU Health Care
- Bothwell Regional Health Center, Sedalia
- Capital Region Medical Center, Jefferson City
- Hannibal Regional Healthcare System, Hannibal
- Lake Regional Health System, Osage Beach
HNM also brought on its first affiliate, Compass Health, a behavioral health system based in Clinton with sites across the state, and the organization has plans to add more. Affiliate members can participate in membership benefits, but they do not have board representation.
Through HNM, each hospital or health system improves its ability to serve the health care needs of its own community and preserves its independence. The health systems work together to share best practices in business, clinical, and operations.
Cerner supports HNM members by providing technology infrastructure at a price that eliminates tech as a barrier to adoption. In return, Cerner receives reimbursement when value is achieved through the partnership. As HNM members take on risk for delivering value, so does Cerner.
Tiger Institute has extended Cerner’s HealtheIntent population health management platform at MU Health Care to one HNM member organization to coordinate and manage care for residents of rural Missouri communities. Two additional members will be added by the end of the year, with other members coming on board in 2019.
This shared IT infrastructure aggregates clinical and billing data from various EHR systems (Cerner, Epic, Meditech, eClinicalWorks and Allscripts) as well as payor/claims data from third party administrators, in near real-time and normalizes the data. With this common platform, we:
- Track performance on identified quality and cost metrics
- Identify and manage opportunities for improvement across the network
- Manage chronic conditions and wellness goals
- Risk stratify and manage high-cost patients across the care continuum
To govern the partnership, we created a Value Partnership Committee (VPC) with representation from each HNM member and Cerner to evaluate value opportunities, identify strategies and resources needed to improve performance, and measure outcomes. The first value charter approved by the VPC is the extension of MU’s virtual pharmacy program (ViPRx) to Capital Region Medical Center, with the intent to extend to other HNM sites in the future. (See related story on page 19).
Direct Employer Contracting
Cerner is developing plans to supply services to support MU’s Direct-to-Employer initiative. These services include but are not limited to analytics, wellness, care management, utilization management, third party administrator, benefits administration, telehealth, health navigation, and health coaching. This initiative is targeted to begin in Boone and Cole counties but will grow as MU’s Custom Network grows, across HNM members and other Missouri communities.
The mission of the Tiger Institute is to transform the health and care of Missourians. Value-based care models have encouraged regional partnerships among health care organizations working to achieve population health management and operational economies of scale. To support hospital business sustainability and growth objectives, we need scalable, advanced technology and care innovation.
We aim to have one integrated EHR to support the flow of health information between organizations to create a more seamless patient experience.
Capital Region Medical Center Joins Tiger Institute
In March 2018, Capital Region Medical Center agreed to have one integrated and efficient EHR to support seamless care across both its organization and MU Health Care. Combining the strengths of an academic health center with those of a community hospital, this agreement will lay the foundation for future shared services and clinical pathways between CRMC and MU Health Care. With Cerner and Tiger Institute’s experience and presence throughout the region, CRMC will be better prepared to face the ever-changing health care landscape.
MU Health Care will extend its Cerner Millennium platform to CRMC, with plans moving forward to implement an integrated EHR and revenue cycle management solutions to support improved health outcomes and optimized revenue functions at CRMC.
As an affiliate of MU Health Care since 1997, the extension to CRMC will further the health system’s well-established collaboration with Cerner through Tiger Institute.
CRMC’s affiliation with MU Health Care is an important strategy to help us provide higher quality care to the communities we serve together,” said Gaspare Calvaruso, president, Capital Region Medical Center. “We are excited to be able to leverage that affiliation to also work with Cerner. Our strategic vision of constantly evaluating and adapting to the changing health care landscape aligns with Cerner, and we are confident they will support us in improving care now and into the future.
“With our close relationship with MU Health Care through the Tiger Institute, this extension to CRMC will continue Cerner’s support of the health and well-being of people across the state of Missouri,” said Joanne Burns, senior vice president and chief strategy officer, Cerner. “This new relationship furthers our ongoing effort to use Cerner’s technology and IT services to meet the needs of patients statewide, as well as improve the health care experience for clinicians and those people receiving care.”
Tiger Institute also supports growth through other local relationships in the region. Columbia Surgical Associates was the first practice to become a wholly owned subsidiary in 2014, and in October 2016, Columbia Family Medical Group joined MU Health Care as well.
This past year we brought Fulton Family Medical and Columbia Ear, Nose & Throat into the fold. These practices retain high autonomy while adopting our EHR and taking advantage of the services and infrastructure of MU Health Care and Tiger Institute.
Tiger Institute looks forward to collaborating with other provider groups and health care organizations in mid-Missouri so others can benefit from a shared EHR. As recently as Aug. 15, 2018, MU Health Care signed a non-binding letter of intent to acquire St. Mary’s Hospital in Jefferson City. In particular, we at Tiger Institute will contribute to the due diligence necessary to fully understand the technology environment and transition options at St. Mary’s.
Driving Growth From Within
As relationships with other organizations across Missouri continue to grow, so too does MU Health Care. With a goal to grow the cardiovascular service, MU looked to the Tiger Institute to provide data and data analysis to help drive strategic business decisions.
COLUMBIA, Mo. (Oct. 31, 2018) — Lake Regional Health System and University of Missouri Health Care are collaborating to provide patients with improved access to their health information. Patients at MU Health Care and Lake Regional Health System ambulatory clinics will share their electronic health record (EHR) and patient portal from Cerner, a global leader in health care technology, to support a smooth transition, regardless of where they receive care.
As the health care landscape continues to change, it’s important that we explore ways to improve the health of patients throughout Missouri,” said Jonathan Curtright, chief executive officer of MU Health Care. “We are thrilled to partner with Lake Regional Health System to bring our academic system of care and shared medical record to the Lake of the Ozarks. We are confident that this extension will ultimately enhance coordination of care across the lake region and that the patient experience will be enriched.
Dane W. Henry, FACHE, chief executive officer of Lake Regional Health System, noted that MU Health Care and Lake Regional have a history of collaboration as founding members of the Health Network of Missouri. The collaborative network was formed in 2014 to improve access and the coordination of care for Missourians.
Lake Regional’s involvement in the Health Network of Missouri has expanded our relationship with MU Health Care and other regionally collaborating health systems,” Henry said. “At the heart of our affiliation is a desire to use information technology to innovate better ways to care for our shared patients. Improving the flow of health information for our providers and their patients supports improved care coordination, enhanced patient experience and the goal of better health outcomes. Leveraging this relationship and working with the Tiger Institute for Health Innovation is a bold step toward the future for Lake Regional and the communities we serve.
EHR and IT operations for MU Health Care are managed by the Tiger Institute for Health Innovation, a unique private/public partnership between Cerner and MU designed to transform health care for Missourians. The collaboration with Lake Regional follows an extension of MU Health Care and Cerner’s IT expertise to Capital Region Medical Center in Jefferson City earlier this year.
Through the Tiger Institute, we continue to expand our relationship with MU Health Care and the regional health systems it extends our solutions and collaborative services to,” said Joanne Burns, senior vice president and chief strategy officer, Cerner. “With the support of our technology and expertise, relationships like the one between MU Health Care and Lake Regional help doctors, nurses and staff in Missouri and across the globe improve people’s health and their health care experiences.
Lake Regional’s clinics will transition to Cerner Millennium®, a health care IT platform designed to support and engage consumers through their health care journey across venues of care — from the doctor’s office to the hospital and clinics. The Cerner Millennium platform will provide Lake Regional staff with a digital record of their patients’ health history, providing an up-to-date view of an individual’s health and well-being. Through the new online, integrated patient portal, people will be able to securely message doctors, schedule appointments and access their health history across Lake Regional, Capital Region Medical Center and MU Health Care.
In addition to extending EHR connections with MU Health Care and Capital Region Medical Center, Lake Regional will also become a member of the Tiger Institute Health Alliance health information exchange. The health exchange connects Missouri hospitals, clinics and post-acute care providers, allowing different organizations to electronically share and use up-to-date patient records.
About University of Missouri Health Care
As the state’s premier academic health system, University of Missouri Health Care offers a full spectrum of care, ranging from primary care to highly specialized, multidisciplinary treatment for patients with the most severe illnesses and injuries. Patients from each of Missouri’s 114 counties are served by approximately 6,000 physicians, nurses and health care professionals at MU Health Care. MU Health Care facilities include Ellis Fischel Cancer Center, the Missouri Orthopaedic Institute, the Missouri Psychiatric Center, University Hospital, and Women’s and Children’s Hospital in Columbia. Affiliates include Capital Region Medical Center in Jefferson City, Columbia Family Medical Group, Columbia Surgical Associates and Rusk Rehabilitation Center. New clinic locations in 2017 include Family Medicine – Fulton Family Health and the Family Medicine clinic in Ashland. MU Health Care is a founding member of the Health Network of Missouri and MPact Health. More than 50 MU Health Care outpatient clinics in central Missouri receive outpatient visits exceeding 550,000 annually. For more information, visit http://muhealth.org.
About Lake Regional Health System
Lake Regional Health System provides comprehensive health care services to residents and visitors throughout the mid-Missouri region. The hospital is a Level II Stroke Center, Level II STEMI (heart attack) Center and Level III Trauma Center. Lake Regional also provides a wide range of specialties, including cancer care, heart care, orthopedics and women’s health. Plus, Lake Regional operates primary care clinics, Express Care clinics, rehab therapy clinics, programs for home health and hospice, and retail pharmacies. To learn more, visit www.lakeregional.com.
Cerner’s health technologies connect people and information systems at more than 27,500 contracted provider facilities worldwide dedicated to creating smarter and better care for individuals and communities. Recognized globally for innovation, Cerner assists clinicians in making care decisions and assists organizations in managing the health of their populations. The company also offers an integrated clinical and financial system to help manage day-to-day revenue functions, as well as a wide range of services to support clinical, financial and operational needs, focused on people. For more information, visit Cerner.com, The Cerner Blog or connect on Facebook, Instagram, LinkedIn, Twitter or The Cerner Podcast. Nasdaq: CERN. Smarter Care. Better Outcomes. Healthier You.
Lake Regional Health System: Jennifer Bethurem, director of public relations, firstname.lastname@example.org, 573-348-8755
Cerner: Austin Cozzolino, public relations, email@example.com, 816-786-2154
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