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
- Saint Francis Healthcare System, Cape Girardeau
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.
MU’s strides in precision medicine can be conceptualized as “big data” that uses rapidly accumulating information systems related to the genome, metabolome, microbiome, environment, biosensor technologies, and individual behaviors, among others. Although precision medicine is more than just genomics, these data sets are particularly relevant for many areas of physician practice.
Genomic data presents many challenges for the current generation of EHRs, including:
- Data storage
- Data life cycle
- Data standards,Complexity of order entry
- Complexity of data interpretation
However, the EHR is rapidly becoming a platform that uses new standards, such as HL7 FHIR (Fast Health Interoperability Resources) and SMART (Substitutable Medical Applications and Reusable Technology). These platforms enable third-party developers to rapidly integrate next-generation applications into EHRs.
This “SMART on FHIR” framework enables Clinical Decision Support (CDS) strategies that leverage “hooks” to provide:
- Context-sensitive information
- Alternative choices for providers
- Access to more in-depth applications, if needed
The EHR can already capture the phenotypic and clinical information to enhance personalized medicine. We believe this capability presents a unique opportunity for precision medicine at MU.
Planning for the future
In January, we held a retreat to identify areas where MU faculty can make unique scientific contributions that do not largely duplicate research at peer institutions.
We chartered four interdisciplinary teams to identify pilot projects in the domains of oncology, cardiovascular disease, autism spectrum disorders, and “Beyond Next Generation Sequencing”.
Through these pilot projects, we will grow biospecimen collection standards, storage protocols, information analytics and workflows needed to support each of these initiatives.
We charged a fifth team with developing a proposal for a technology-enabled, clinical decision support precision medicine project.
Through these pilot projects, we will expand the technical manpower needed to enhance the biomedical informatics infrastructure at MU.
Expanding our industry partnerships
Industry partnerships represent a source of potential research funding. As such, we are building on our successful engagement with our first partner, and are investigating other industry partnerships.
With one partner we aim to develop an application for the efficient collection, organization, and presentation of tumor board data and references.
Efforts are underway to build Phase II of the project, which impacts development using SMART on FHIR technology. We are having conversations about where we want to take the relationship over the next five years — beyond the end of the project.
We are also talking with two premier device companies. One proposal is a Joint Research Data Center that will merge implanted rhythm management device data with MU’s clinical data to explore and develop new predictive models for cardiac interventions.
An early demonstration project focuses on our ability to integrate a cloud-connected enteral feeding device into the Cerner EHR. This demonstration project will help develop a research platform for putting translational device-related decision support into practice.
Exceptional access to data
Over the next year, MU looks to extend our leadership in the Greater Plains Collaborative (GPC). Initially funded by the Patient Centered Outcomes Research Institute, this Community Data Research Network (CDRN) represents a critical opportunity for continuing to expand research funding.
Many GPC members use competing EHRs, so participation is an opportunity to demonstrate MU, Tiger Institute, and Cerner capabilities in the data sharing arena. As a full participant in the Patient-Centered Outcomes Research Network, we continue to enhance our Common Data Model (CDM). This work enables participation in nationwide trials, such as Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness, “ADAPTABLE” clinical trial.
Our next milestone is to enhance the CDM with American Community Survey data to enable participation in a nationwide diabetes study called Natural Experiments for Translation in Diabetes.
I2B2 continues to be a centerpiece of our data-related cyberinfrastructure plan. Our focus has been on both ensuring quality of I2B2 and continuing to enhance with new datasets.
Over the next six months, we will move a copy of this tool to our local environment. This will increase the scale of this critical asset to support researchers and make us more agile in the marketplace.
In the past, we would often support research with a time-intensive, one-time build of a research dataset. In the future, we will direct those same resources at enhancing the existing I2B2 clinical ontology with geospatial and publicly available data (such as the American Community Survey Data).
More large-scale research projects
In early 2017, the MU Research Computing Support Services group successfully completed the security review process for a High Performance Computing (HPC) environment capable of storing/processing ePersonal Health Information.
This Secure4 environment lets us do large-scale health and bio-informatics projects, such as data mining and predictive algorithm development.
Our first demonstration projects center around the availability of HealthFacts data in the HPC environment.
With more tools and infrastructure in place, along with well-defined common goals, we look to a future in which our partnership can further enhance research at MU.
Collaboration the key to becoming a regional and national player
In 2018 we will focus on how to bring Cerner and Tiger Institute capabilities together to further our clinical research priorities and mission. In this environment, we look to maximize the benefit from industry partnerships.
Through the GPC CDRN and our participation with the Kansas City Area Life Sciences Institute, we are solidifying our relationship with University of Kansas Medical Center on the Kansas City side.
A recent Clinical and Translational Science Award partnership with Washington University is a move toward strengthening our relationships in the St. Louis area. The objective is to streamline the environment to enable researchers to take discoveries and turn them into clinical practice with Bio-Medical Informatics as a key enabler.
Through these partnerships, we will grow MU’s iconic standing in the research community.
In July 2017, Tiger Institute Board of Governors agreed to move forward with the implementation of Cerner’s revenue cycle to replace existing systems for registration, scheduling, patient accounting, and practice management.
Our goal is to finalize contracting by end of 2017 and kick off the project in the summer of 2018. A clinically integrated revenue cycle will benefit the health system by helping further prepare us to compete in the future.
Reasons to begin this change now include:
- Reimbursement shifting from fee for service
- Need to tie charges to clinical activity for alternative payment models
- Industry moving to integrated platforms
- Aging Platform in GE
Single sign-on streamlines our users’ login experience by ensuring the username/password used to log into all computers is the same as the credentials required to sign into all Cerner Millennium applications.
Our users like having one set of credentials to remember, and calls to the Help Desk for password resets dropped significantly.
Finally, single sign-on was a prerequisite for several health system-wide projects and required for projects to meet their timelines.
Follow Me Technology
With Follow Me Technology users can log into a virtual desktop running on specific hardware within the health system and have that same session “follow” them whenever they log into another PC.
This time saver completely changes our users’ workflows. No longer do they have to sign into each computer they use. Instead, they sign into all applications once at the beginning of the day. This capability saves significant amounts of time once a user is properly trained and comfortable with the new workflow. iAccess “tap-and-go” functionality, in which users log in with their badges, is coming soon.
With the aging Pyxis dispensing system, MU Health Care opted to undertake a system-wide replacement with the integrated RxStation solution. Beginning in August 2016 with the pilot, through August 2017, Tiger Institute completed the largest-to-date implementation of RxStation. Nine semi trucks delivered the components needed for customizable configurations across the health system.
Benefits to pharmacy include further decentralized dispensing of medications, automated reconciliation of controlled substances, and integration of formulary and patient management within the EHR. Pharmacy now offers more than 90% of available medications through the automated dispensing cabinets, compared to less than 40% with Pyxis, a 56% increase. Medications filled at cart fill with Pyxis was at 42% and now has dropped to less than 5% with RxStation, an 89% decrease.
Nursing can now see the patient record and queued medications at the dispensing cabinet and have immediate access to verified medication orders. They can queue up their medications from their workstation prior to approaching the cabinet, minimizing any wait times. Nurses can also create any needed patient/drug labels at the station.
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