Lisa Gulker Director, Clinical Transformation The Detroit Medical Center

The Chief Clinical Information Officer: Leading Innovation and Delivering Excellence

The Detroit Medical Center

Part of Vanguard Health Systems 8 hospitals in Detroit area (29 hospitals in 5 states) Large network of ambulatory services Pioneer Accountable Care Organization (ACO) Diverse mix of organizational cultures One Cerner Millennium database, RHO client Taking 2012 Code Upgrade in 12/2012

DMC Holds HIMSS Level 6 Adoption Rating

Stage 7
Complete EMR; CCD transactions to share data; Data warehousing; Data continuity with ED, ambulatory, OP 1.0% 1.0%

Stage 6

Physician documentation (structured templates), full CDSS (variance & compliance), full R-PACS

3.2%

3.5%

Stage 5

Closed loop medication administration

4.5%

5.9%

Stage 4

CPOE, Clinical Decision Support (clinical protocols)

10.5%

10.7%

Stage 3

Nursing/clinical documentation (flow sheets), CDSS (error checking), PACS available outside Radiology

49%

48.4%

Stage 2

CDR, Controlled Medical Vocabulary, CDS, may have Document Imaging; HIE capable

14.6%

14.1%

Stage 1

Ancillaries Lab, Rad, Pharmacy All Installed

7.1%

6.7%

Stage 0

All Three Ancillaries Not Installed

10.1%

9.6%

Eight Hospitals = Eight Cultures

Each hospital site presented a unique leadership, clinical practice, financial, and operational environment.
Academic, urban, community, large and small hospitals Private physicians Hospital-employed Mid-level providers Rehab, Pediatric, and other specialty hospitals/service lines

Why is the CCIO role is so critical?

Ownership Engagement Empathy

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2004-2005: Dire Financial Reality and Creating a Competitive Edge

Detroit Medical Center
Primarily landlocked in city of Detroit Declining market share Worsening payer mix Old infrastructure Limited capital resources

Board-level decision to use QUALITY OF CARE as differentiator in marketplace

Leverage EMR as driver of improved quality
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Scope of Cerner EMR Launch (4/06-5/07)

8 Hospitals in 13 Months Big Bang at each site Components implemented Clinical Leaders decided on the scope Ownership from the very beginning
Patient access & patient flow Communication and work assignment Orders management CPOE house-wide Clinical documentation Nursing, Respiratory, Therapies Pharmacy workflow Medication Administration BCMA and electronic MAR

Patient Discharge FirstNet (Emergency Department/A&E) expanded functionality PharmNet (Pharmacy System) Discharge Prescriptions Downtime solution local access on unit computer device

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Success Factors: Clear Vision For Everyone

Significant CEO and Board Support
Committed 67% of capital budget to this one project Committed to success (Paper is not an option)

Only the best and brightest clinicians were picked to lead the project, everyone needed to know how important success was to our survival Clinically-driven project IT supports, but does not lead (not an IT project) Point of Service Ownership of process workflow Not an initiative that will increase speed or increase efficiency
One standard of care system-wide
Evidence Based, multidisciplinary approach Seamless care not bound by geography Patient safety, quality, value, care reliability drive change Alignment of quality and financial data points
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KEY COMPONENTS: Governance infrastructure

WORKFLOW DESIGN DECISIONS Clinical Councils
STRATEGY Leadership Steering

CLINICAL OVERSIGHT Pharmacy Therapeutics

SINGLE STANDARD Clinical Technical Comm

OPERATIONS EMR Steering

EMR Success Factors

Use ethical imperatives of excellence, patient safety to enable clinicians to tolerate the churn of change AND create ownership Never underestimate how difficult and stressful that change will be Driven by need for discriminating difference for the health system in a very competitive environment
Implementation had to be rapid, thorough and deep

Vendor as partner; deep experience in clinical transformation and technology over many clients.
The vendor was not accountable to lead the project, however
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Uphill Leadership: Why it isnt easy

Nature of the End Users definition of success Varies by experience, by the minute, by session Utility: Can I use this easily? If I cant, it isnt good Points of View: Informatics and Clinical Transformation Informaticist Does it work? How many clicks? Is it friction-free to the end user? Is it slick? Is it 100% dependable? Clinical Transformation Does it present information to the clinician when information is needed? (wisdom) Does it tell the story? Can any clinician who needs the information see it? Does it ENHANCE or at least support workflow? What is the BENEFIT to the patient? Is excellence predictable?

CCIO = Ownership
A leadership lens for focus NOTHING comes in between or in front of the patient and the clinician or clinical intervention.

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Ownership: Patient Safety Trumps the Project Plan

CCIO = Innovation through Engagement EMR Awards Electronic Submission of Quality Data Daily Huddle Dashboards Smart Rooms & Device Integration

The EMR Awards Program Engagement Through Innovation at the Point of Care

EMR Award Summary 2007-2012

Total number of Submissions by Clinicians = 869
Total number selected for awards 129 Total number completed 112

Total number in process 17

Average completion time approximately 6 months

Visibility on DMC Intraweb

Daily Huddle Dashboard

Daily Huddle Dashboard

Empathy
A personal connection to meaningful work.

Acknowledging that real world experience and human connection cant be fully represented by data and facts. Informed intuition helps decision-makers transcend conventional wisdom in order to serve their peer clinicians.
Wired to Care Dev Patnaik
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CCIO - Empathy
The map is not the territory. - The CCIO has an intuitive understanding of the realities of clinical practice. - Empathy is the antidote for the process map it is the secret ingredient that brings clinical transformation.
Wired to Care Dev Patnaik
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The Natural History of Breaking

Phases and interventions There is a choreography to practice, believed to be whole, complete by a caring expert Implementing HIT/EMR is an insult/disruption/interference to that experience What happens in response? = What we have always done Doesnt work any more as situation is changed Reaction to any consequence both intended and unintended Reaction to disruption as interruption, consequence of both interruption, which may be either intended or unintended.

BREAK

Innovator

A Robust EMR/CIS But Has It Achieved Its Intention?

Safety and Healing Do our clinicians have the information they need to make wise and safe clinical decisions? Does the technology support healing as an intention? Quality Is the information in our EMR current, reliable, and accurate? Value Does use of our EMR contribute to achieving our strategic goals as a health system? (mass personalization)

Vital Signs Workflow

Vital Signs Acquisition After EMR but Before Device Integration

Patient

Vital Signs Measured with VSM VS Data to Paper Worksheet

Worksheet in Pocket

VS Entered into EMR

Unintended Consequences
26/30 sets of vital signs were documented accurately in the EMR, resulting in a 87% accuracy rate. The transcription error rate was 13%. The average data latency was 24.1 minutes.

The process sources of transcription error were 1. from the vital signs device to the PCA paper worksheet (50%) and 2. from the PCA worksheet to the EMR (50%).

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Unintended Consequences
Increased Number of Transcription Events Increased Potential for Transcription Errors Increased Data Latency Decreased Data Accuracy Workflow Interference Workflow Inefficiency In Other Words
Less than Predictable Excellence!

Building Opportunities

Discussion and Collaboration