Advancements in Analytics
MU Health Care and the Tiger Institute are committed to ensuring value-driven outcomes for our patients through the collaborative delivery of intuitive and prescriptive information, which enables agile, data-driven decisions by clinical and operational leaders.
Over the last year, analytics leaders from various business and clinical domains have come together to create a strong, inclusive governance structure; develop the roadmap for the future; and provide advanced analytics to support the university’s strategic goals.
Using a centralized strategy with decentralized teams, we have a single point of intake for the organization’s analytics requests. By working together in this way, we can reduce confusion for end-users, eliminate redundancy and inefficiency, and create transparency across the organization. This methodology also will help us better understand and meet our broad analytics needs.
Key components of our prioritized roadmap to support value-based outcomes include:
- Enhancement of existing enterprise data warehouse (EDW) capabilities
- Development of an analytics hub
- Establishment of strategic communication points
Taken together, these steps will help us ensure our analytics strategy aligns with the needs of various business and operational leaders.
Our EDW roadmap builds on existing Tiger Institute-developed EDW/Business Intelligence (BI) capabilities, which have historically focused on the Revenue Cycle space.
We have made remarkable progress since launching our Value Driven Outcomes and Analytics structure in January,” said Kristin Hahn-Cover, MD, chief quality officer. “This leadership team rapidly articulated our desired future state, with deep insights into the information, collaboration, and support needed to get us there.
In particular, the HealtheIntent population health platform has enabled us to develop clinical and claims-based EDW capabilities for the first time. Our plan is to create a true EDW by moving all data into a single repository.
We are also planning for one centralized analytics hub for finding and serving analytics deliverables. This hub will allow us to improve efficiencies and transfer knowledge throughout the organization.
Building on this work, we designed and built a new series of cardiovascular service line insights. Through our collaboration and our scalable EDW and BI capabilities, we can expand these insights to all clinical service lines to create cohesive, directional information for decision making support throughout MU Health Care.
2/21/19 | Delivering Results
Managing Emergency Department Overcrowding With NEDOCS
In collaboration with Cerner’s Emergency Medicine group, Tiger Institute developed the National Emergency Department Overcrowding Score (NEDOCS) component for display on the ED Real Time Dashboard. The NEDOCS algorithm provides an overcrowding score based on factors in the ED, including number of waiting patients, free beds, and ED patients on ventilators — among others.
By sending alerts to providers and hospital administration, staff can mitigate the factor(s) contributing to department overcrowding, and to get patients seen and moved to the appropriate level of care more quickly.
Our development work is available to the broader Cerner ED Dashboard client base, and as such, the NEDOCS component and alerting system now provide value to more than 15 health systems.
Making Surgery Easier for Patients and Families
Team InteGrated Enhanced Recovery (TIGER) is a new protocol, which helps MU Health Care better prepare patients, shorten hospital stays, make pain more manageable, and reduce direct costs associated with radical cystectomy (a procedure where surgeons remove all or part of the bladder.) Because of the protocol’s success, the team is adapting it to impact other kinds of surgical procedures.
Tiger Institute associates and MU Health Care staff members built new tools in the EHR to track patients’ progress and lay out a daily care plan. A nurse navigator helps guide each patient along all steps of his or her surgery — from preparation to post-operation.
Improved pain management
The TIGER protocol encourages preemptive pain medications and informs patients about alternatives to narcotics for pain management.
Three days after the operation, patients in traditional care used a total median of 413 morphine milligram equivalents (MME), while those using the TIGER protocol had a median of 275 MME.
Improved care plans, fewer drugs and other improvements helped patients spend less time in the hospital. Those who experienced the normal procedure had an average length of stay (ALOS) of 10.5 days. However, those who used the TIGER program had an ALOS of only six days.
Patients didn’t realize they were going home four days sooner,” said Mark Wakefield, MD, associate chief medical officer. “They were better prepared for surgery, more engaged in their own recovery, had less post-operative pain, and returned to a better condition sooner after surgery.
A reduced length of stay, along with fewer drugs and other items related to surgeries, helped reduce the median cost of a cystectomy surgery by 25%.
Similar work continues to improve other major surgical cases, such as liver or pancreas resections, colon surgeries and lung surgeries. These teams have already started developing protocols and are in various stages of implementation.
1/24/19 | Empowering Wellness
MU Health Care Surpasses Readmissions Goals for Congestive Heart Failure
To improve patient outcomes, MU Health Care staff set a goal to lower congestive heart failure (CHF) readmissions by 5%. The EHR intervention project proved so successful, MU Health Care cut CHF readmission numbers by nearly a third. The project received the MU Health Care CEO Award, which recognizes innovative solutions to complex problems.
The improvement team worked with cardiologists and other key stakeholders to build tools and develop an algorithm within the EHR to lower CHF readmissions. The algorithm digs through EHR data, comparing information from the current admission and the patient’s medical history to determine if the patient may have CHF. If the algorithm identifies the patient, it prompts several possible actions. For example, in some cases, a physician receives an alert informing him or her the patient potentially suffers from heart failure. In most instances, however, when a patient is identified with heart failure, the provider does not receive an alert.
To remove ordering burden and alert fatigue, the algorithm automatically fires certain tasks to appropriate care team members. For example, it prompts nurses to take daily weight and inputs and outputs, patients to view CHF-related videos and the pharmacy and nutrition teams to perform specific tasks. The cardiac rehabilitation team also receives tasks for education and outpatient cardiac rehabilitation.
Communication between teams is vital,” said S. Hasan Naqvi, MD, associate chief medical officer. “Using technology allows us to increase communication, better assess patients, and ultimately, make significant improvements in patient outcomes.
Projects like this, where IT staff join clinical performance improvement teams, bring success with the combination of the robust IT solutions and the diligent work of MU Health Care clinicians.
This algorithm is now available as a standard for all Cerner Millennium implementations.
Blood transfusions have the power to save lives. But when used inappropriately, they can harm patients, generate excessive costs and waste an important, limited resource.
Armed with studies showing up to 40 percent of transfusions in the U.S. are unnecessary(1), University of Missouri Health Care leaders saw an opportunity to improve patient safety and reduce costs by implementing a red blood cell (RBC) transfusion clinical decision support alert.
The Big Bang Theory at MU Health Care and Capital Region Medical Center
MU Health Care is replacing its legacy revenue cycle system (GE/IDX), which has been in place for nearly 40 years, with Cerner’s Revenue Cycle.
Cerner was the clear choice to help us achieve clinical and financial integration throughout our health system and optimize the revenue cycle,” said Jonathan Curtright, CEO, MU Health Care. “MU Health Care and Cerner have a long-standing relationship. We share a similar vision of health care for the next five, 10, 20 years and beyond.
MU Health Care will integrate Cerner’s registration, scheduling, patient accounting and practice management solutions, and transaction services with the existing Cerner Millennium EHR.
Integrating this data will help MU Health Care streamline the financial experience for staff and patients while controlling the organization’s cost to collect.
Concurrently, Capital Region Medical Center is implementing Tiger Institute’s instance of our EHR and other Cerner applications at MU Health Care, replacing CRMC’s current EHRs (Meditech and eClinicalWorks).
Separately, these are both major projects. But to make things more interesting, we decided to combine them into one big bang go-live scheduled for March 2020. Hundreds of associates from Cerner, CRMC, MU Health Care, and the Tiger Institute will help us ensure we have a smooth transition to the new platforms.
MU Health Care’s and CRMC’s transitions to one integrated system will give doctors and nurses access to one complete digital record of their patients’ health history, including clinical and financial data, which will help them improve outcomes.
Precision Medicine Collaborative Forum
In 2018 Tiger Institute partnered with the newly formed MU School of Medicine Center for Bio-Medical Informatics (CBMI) to launch the Precision Medicine Collaborative Forum. Together, we plan to facilitate the formulation, launch, and support of multidisciplinary collaborative research projects. Our primary focus will be on research programs that improve human health care and outcomes.
For investigators who want to participate in the collaboration, we assess project requests in line with the forum’s charge to create, participate in and support collaborative multidisciplinary health care and patient outcome improvement research projects.
The forum meets bi-weekly with an open invitation to all clinical investigators with relevant research interests.
We plan to increase investigator productivity (e.g., more publications and external funding) by supporting them with:
- EHR data
- Data science/informatics
- Innovating within the clinical workflow
Solution Partner Testing
Tiger Institute is a valued tier one member of Cerner’s Solution Validation Partner Program. We have consistently ranked in the top one or two clients every quarter in volume for the last four quarters.
We partner for more pre-general availability projects than any other client, sharing what we learn and identifying defects to improve the software.
For the 2017 calendar year, we partnered on 91% of all pre-general availability projects when we had the corresponding workflow and solution already in use.
Some additional highlights over the last four quarters include:
- Identified 100% of defects prior to go live
- Averaged less than 100 days for project duration
- Improved cross-organization collaboration
Some examples of the projects we tested that are now live in the production environment include PowerChart Touch ONE Doc App Advancement, Know Me View, SMART Zone, Waveform, ED Real Time Dashboard with NEDOCS details, and Video Visits—Cloud App Development.
By The Numbers
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
- 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.
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