Case Study "Dignity Health: Implementation of an EHR Alliance Bridging Acute and Ambulatory Care" This session will provide a unique learning opportunity focusing on the Dignity Health $1.8B implementation program to meet horizon 2020 as we transform healthcare. The initiative encompassed a 42 hospital health IT implementation in the acute care setting. Mr. Lowe will also review the challenges associated with governance and review lessons Learned from the project. Learning Objectives: ∙ Key implementation points ∙ Integration with Ambulatory strategies for a full market approach ∙ What’s next – business intelligence

1. Dignity Health: Implementation of an EHR
Alliance Bridging Acute and Ambulatory
Care
Raymond Lowe
Senior Director Enterprise Clinical Implementations
EHR Alliance
October 24, 2012
Email: Raymond.lowe@dignityhealth.org

2. Objective
• This session will provide a unique learning opportunity focusing on
the Dignity Health $1.8B implementation program to meet horizon
2020 as we transform healthcare. The initiative encompassed a 42
hospital health IT implementation in the acute care setting. Review
the challenges associated with governance and review lessons
Learned from the project.
• Learning Objectives:
∙ Key implementation points
∙ Clinical Integration with Ambulatory strategies
∙ What’s next – business intelligence
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3. Dignity Health
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4. Who is Dignity Health
• Dignity Health, headquartered in San Francisco, Calif., provides
integrated, patient and family centered care to more than six million
people annually.
• We are the fifth largest health system in the nation with 10,000
physicians and 55,000 employees across Arizona, California, and
Nevada.
• Dignity Health is committed to delivering compassionate, high-
quality, affordable health care services with special attention to the
poor and underserved.
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5. Who is Dignity Health
• Assets: $13.1 billion
• Net Operating Revenue: $10.6 billion
• General Acute Patient Care Days: 1.8 million
• Community Benefits and Care of the Poor: $1.4 billion
• Acute Care Beds: 8,800
• Skilled Nursing Beds: 800
• Acute Care Hospitals: 40
• Clinics/Ancillary Care Centers: 150
• Medical Foundations: 11
• Active Physicians: 10,000
• Total Employees: 55,000
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6. Our Vision
A vibrant, national health care system known for service, chosen
for clinical excellence, standing in partnership with patients,
employees and physicians to improve the health of all
communities served.
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7. The Quality Chasm
“Between the health care we have and the
care that we could have lies not just a gap, but
a chasm.”
Institute of Medicine Crossing the Quality Chasm: A New Health System for the 21st
Century. Janet M. Corrigan, Molly S. Donaldson, Linda T. Kohn, eds. Washington, D.C.
National Academy Press. 2001
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8. Responding to the Call
• There is compelling evidence that there are great
opportunities to redefine healthcare
– To reduce clinical errors
– To improve clinical and cost outcomes
– To improve reliability on delivery of best practices
• Crossing the chasm will require:
– Putting advanced decision making tools in the hands of care
providers
– Treating the creation and exchange of information as an integrated
system
– Standardize key processes around evidenced based best practices
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9. A Bridge to Better Care
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10. EHR Alliance
Program Overview
Ray Lowe
Senior Director, IT Acute Care Strategy

11. Dignity Health Has Multiple Strategic Initiatives
Executing In Parallel
Fiscal FY12 FY13 FY14 FY15 FY16
Year Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
Acute EHR (Cerner & Meditech)
Ambulatory EMR (Allscripts & Mobile MD)
EHR Meaningful Use Stages 1-3
Meaningful Revenue Cycle Standardization (Siemens & Artiva)
Use
HIPAA 5010
Revenue
Cycle ICD-10 (Various Vendors)
Lean Process Transformation
Compliance
Compliance Deadlines
Transformational
Care

12. What is Clinical Standardization and Why is it Beneficial?
Standardization is the process of decreasing unnecessary
variation to improve quality and efficiency outcomes of care
– Processes done the same way every time decrease mistakes and oversights
– Processes done the same way each time become more efficient
– Reliability increases; events or steps in a process are more predictable
Key component of clinical transformation
– Facilitate the measurement of quality, safety and service outcomes
– Improve operational and clinical quality outcomes
– Increase the speed of a “sustainable” deployment
– Decrease the cost of ongoing support
– Decrease cost of care
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13. From Standardization to Better Outcomes
From EVIDENCE To BEST PRACTICES To OUTCOMES
Order Sets Standards Outcomes
Top 80% of all Dignity Health Clinical Decision Support
Ace-Inhibitor on discharge
Admissions Therapeutic Guidance Beta-Blocker on discharge
(by vol and cost) Lipid therapy compliance
Ace-Inhibitor Reminder Platelet inhibitor
AAA Repair - Postop Beta-Blocker Reminder Reduction in adverse drug events
Acute Renal Failure - Adult Admit HMG CoA Reductase Inhibitor Reminder Influenza Vaccine compliance
AMI ED Evaluation Platelet aggregation Inhibitor Reminder Pneumococcal Vaccine compliance
Appendectomy - Postop Admission Risk Assessment Tool Smoking Cessation education
Asthma Adult Admit Short acting Rapid-Release Nifedipine Alert
Craniotomy - Postop Reductions in LOS / OI
Influenza Vaccine Reminder Reduction in preventable falls
Critical Care Management Pneumococcal Vaccine Reminder
Diabetes - Inpatient care Reduction in preventable skin
Smoking Cessation Education Reminder breakdown
DKA - Adult Admit
Drug-Lab interactions
PCI -Postprocedure
PNA PCP - Adult Admit Drug-Drug interactions
TIA - Adult Admit Drug-Allergy interactions
Total Hip Knee Replacement - Postop Adverse event surveillance
TURP - Postop Delayed discharge surveillance
UGIB - Adult Admit Fall Risk assessment - alert
Unstable Angina NSTEMI - Adult Admit Skin Breakdown risk assessment - alert
UTI - Adult
Vaginal Hysterectomy - Postop
Unstable Angina NSTEMI - Adult Admit
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14. Board Approved FY2013 Schedule

15. Lessons Learned EHR
Acute Implementation

16. 6 Keys to Project Success
• Effective Collaboration • High Standards/Value on Excellence
– It takes everyone – Be the example that everyone else wants to
follow
– Break down the barriers (IT, Clinical, Revenue
Cycle, Physicians, Vendors)
– Communicate, communicate, communicate
• Culture of Transparency • Emphasis on Community and Culture
– Create an environment that supports issues – Medical Center will continue providing care
reporting and escalation long after the days of EHR implementation
have come and gone
– Transparency facilitates information flow─
both up and down
• Sound Structure and Governance • Focus on Process vs. Product
– Work toward a common vision – In projects of this scale, individuals can’t fix
every problem. But everyone can work to
– Execute within project structure create pathways for healthy resolution of
– Fine tune as you go (always learn) issues
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17. SUCCESS…
• The EHR Implementation will only be successful if all
of us are successful doing our part.
– “If you could get all the people in an organization rowing in the same
direction, you could dominate any industry, in any market, against any
competition, at any time.”- Patrick Lencioni
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18. Communication
 A solid communication plan should be built, executed and monitored with
adjustments as needed
 Communication needs to occur at all levels
• Communicate the shared vision
• Communicate decisions, as well as the logic behind those decisions
• Communication plans for both facility and project team
• Communicate accomplishments
• If people don’t talk it out, they will act it out
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19. Communication and Performance through Change
The Performance Dip
Organizational Change
Initiative Complete
Uninformed
Business Performance
Informed Optimism
Optimism/
Uncertainty
Denial
Anger Acceptance
Testing
Pessimism
Despair/
Skepticism
Time
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20. Governance
 Strong governance and leadership is needed from the start
 Governance process should support having the difficult conversations and
making difficult decisions
 Interdisciplinary governance committees need to exist and must include
facility managers and directors
• Solid decision-making process that supports timely, sound decisions and eliminates
waffling on previous decisions
• Leadership has to be onboard for the governance to be effective
• The project team and facility need to hear the vision from leadership
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21. Trust and Culture Best Practice Infrastructure
Enterprise
Guidance
People Process Technology
Human Resources Enterprise Governance Dignity Health
Organizational Effectiveness “The What” and “The How” Information Technology
Change Acceleration Transformational Care
Process
Implementation Project Team, EHR Physician Champion, Enterprise Physician Informaticist Escalations for
Implementation Program Director, Director Clinical Informatics, Executive Sponsor Enterprise Guidance
Management Decision Group
People Process Technology
Clinical Informaticists MPAG (Multidisciplinary Local IT/FSO Leadership
EHR Physician Champion Phyisican Advisory Group) Facility IT Site Director
Facility Super Users CPIC (Process Project Infrastructure
Accountability Key Department Leaders Improvement Committees) Resources
Transformational Care
Implementation Program Director, EHR Physician Champion, Director Clinical Informatics, Executive Escalations for
Sponsor Enterprise Guidance
Facility Executive Steering Committee
Executive Sponsor
CEO, COO, CFO, CNE, VPMA
IT Site Director Escalations for
Feedback Enterprise Guidance
EHR Physician Champion
Director Clinical Informatics
EHR Alliance Cerner Engagement Leader
NSSA Facility Governance Model Implementation Program Director
9/17/2012
EHR Alliance Senior Directors
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22. Key Areas of Focus
• Project Resources:
– Ensure resources have the proper skill set (project and facility)
• Project Management
– Strong project team structure, including a clear chain of command and
authority should be in place
– Clearly-defined issues management and escalation process supported by
all team members and leadership
• Strong document management and version control solution should be used
• Structured and consistent team meetings
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23. Key Areas of Focus
 Testing
• Sufficient number of testing cycles and time for each cycle
• Test systems available for third-party applications
• Issues tracking, reporting and documented re-testing/regression testing
 Training
 Set expectation on training percentage required for go live … and stick to it
 Provide opportunities for practice
 Develop a training domain strategy, including a fully built-out, tested
environment containing enough data for successful training
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24. Key Areas of Focus
 Go-Live Planning, Execution and Transition
 Begin go-live planning early in the process and conduct multidisciplinary
team review meetings until all details of the cutover are identified
– Conduct a mock-live event
– Leverage production support resources and prepare for transition
– Reach out to sister hospitals for go-live support
– Go-live command center team should be properly trained; need good issues
triage and tracking processes in place
– Plan for ongoing optimization efforts well in advance of live event
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25. Clinical Integration

26. What is Clinical Integration (CI)?
CI System Quality Metrics
– Population and disease management
Hospital Physician
Quality Metrics & Cost Savings – Better coordination improves quality of
care
– Population focus means business model
Governance
takes holistic view of wellness
Financial or Risk Sharing
Shared
– Model promotes rewards for improved
Savings
and Risks
quality and lower cost of patient care (risk
Care Coordination
sharing model)
 Creates incentives for providers to
find cost savings
 Increases care coordination
 Reduces overall costs
 Shifts from encounter-focused to
patient-focused care
Sharing clinical data at
the CI level, across the
team, promotes an
Patient emphasis on care
coordination and taking
a long-term, holistic
view of wellness.
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27. Key Clinical Integration Capabilities: Technical Tiers
Communications
Quality Metrics
Information
Reporting
Analytics & Reports
Data Integration,
Data Integration Management, &
Aggregation
Workflow, Data
Extraction &
Data Acquisition Collection from
Multiple Clinical &
Financial Systems
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28. Key Clinical Integration Capabilities:
Core IT Components
Communications
Patient Portal Provider Portal
Secure Patient – Provider Secure Provider-Provider Clinical Decision
Management PHI /
Messaging Messaging Support (CDS)
Personal Health
Record (PHR) Clinical Information Delivery
Analytics & Reports
Quality Metric Analysis & Reporting
Data Integration Match Patient’s Data Match Providers
& Patient EMPI & Provider EMPI
Data Integration, Conforming, Normalization, & Standardization
Data Acquisition
Clinical Data Repository
Extract Clinical Data Extract Clinical Data Extract Claims Data
(Internal Systems) External Systems (Rx, Labs, etc.) (Internal /External Systems) 28

29. Transforming Data with
Analytics

30. Opportunities and Challenges
Opportunities Challenges
• Evidence Based Medicine • Managing Data Complexity
• Improved Treatments • Ensuring patient
Confidentiality
• Intervene earlier
• Changing Medical Practices
• Avoiding False negatives
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31. The transformation journey
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32. Transformation
• Improving outcomes and point of care decisions
– Analyze the patient population
– Supporting diagnosis and research
– Active diagnosis
– Point of care Decisoning
– Create values and the potential to improve outcomes.
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33. Example Quality Metrics Dashboard
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34. Questions?