Opening Keynote"From Patient to Population: Providing Optimal Care - The Role for Technology" Ronald Paulus, MD, MBA President & CEO Mission Health System

1. 11
From Patient to Population: Technology’s
Role in Providing Optimal Care
Ronald A. Paulus, MD
President and CEO
Mission Health
April 13, 2013

2. 22
Managing Both Individual and
Population Health
My Geisinger Transformation Experience

3. 3
Geisinger Health System
Careworks Convenient
Healthcare
Non‐Geisinger Physicians
With EHR
Last updated 08/18/09
Geisinger ProvenHealth Navigator Sites
Contracted ProvenHealth Navigator Sites
Geisinger Medical Groups
Geisinger Specialty Clinics
Geisinger Inpatient Facilities
Ambulatory Care Facility
Geisinger Health System Hub and Spoke Market Area
Geisinger Health Plan Service Area

4. 44
Geisinger
Transformation Infrastructure

5. 5
Alerts
Prompts/Reminders
Order Sets
Automated care plans
Patient portal messages
Information Rx
…
Effectors
…
EBM Guidelines
Patient Preferences
Formulary/Economics
Other Inputs
EHR
Clinical,
Schedule
…
Real-time Clinical Status
Decision
Support
CDIS
Normalization, Transformation,
Analytic Application
FinanceClaims Ops
…
Clinical Decision Intelligence System (CDIS)
Consumer
Portal

6. 66
Population Health Optimization
The Patient: Diabetes

7. 7
Diabetes Bundle
Measures FY07
HgbA1C measurement X
HgbA1C control X
LDL measurement X
LDL control X
Blood pressure control X
Retinal exam
Urine (protein) exam X
Foot exam
Influenza immunization X
Pneumococcal immunization X
Smoking status X
Use of ACE/ARB for microalbuminuria/DM nephropathy
Use of ACE/ARB for hypertension
Patients who receive/achieve ALL of the above X
Yearly
Yearly
Once
Non-smoker
Yearly
Yearly
Yearly
Yes
Yes
< 100
< 130/80
Quality Standard
Every 6 months
Yearly
< 7
Measures FY07
HgbA1C measurement X
HgbA1C control X
LDL measurement X
LDL control X
Blood pressure control X
Retinal exam
Urine (protein) exam X
Foot exam
Influenza immunization X
Pneumococcal immunization X
Smoking status X
Use of ACE/ARB for microalbuminuria/DM nephropathy
Use of ACE/ARB for hypertension
Patients who receive/achieve ALL of the above X
Yearly
Yearly
Once
Non-smoker
Yearly
Yearly
Yearly
Yes
Yes
< 100
< 130/80
Quality Standard
Every 6 months
Yearly
< 7

8. 8
DM Best Practice Alert/Order Set

9. 9
Patient Reminder View
CDIS

10. 10
Diabetes Bundle Results
Primary Care Average (n=23,404)

11. 11
CAD Bundle Primary Care Results Average
(n=14,714)

12. 1212
Population Health Optimization
The Patient: CABG

13. 13
Research Ties

14. 14

15. 15
GHS Receives One “All In” Global Fee
• One fee for the ENTIRE 90-day period including all
surgery-related care:
– ALL surgery-related pre-admission care
– ALL inpatient physician and hospital services, including
cardiologists, cardiac surgeons, anesthesia, consultants, etc
– ALL surgery-related post-operative care
– ALL care for any related complications or readmissions
• Eliminates perverse incentives

16. 16
Process Redesign: Work Flow

17. 17
Process Redesign: Hardwiring

18. 18
Clinical Outcomes
Before With Change
ProvenCare ProvenCare (% Reduction)
(n=132) (n=181)
In-hospital mortality 1.5% 0%
Patients with any complication (STS) 38% 30% 21%
Patients with >1 complication 7.6% 5.5% 28%
Atrial fibrillation 23% 19% 17%
Neurologic complication 1.5% 0.6% 60%
Any pulmonary comp 7.3% 4.0% 46%
Blood products used 23% 18% 22%
Re-operation for bleeding 3.8% 1.7% 55%
Deep sternal wound infection 0.8% 0.6% 25%
Readmission within 30 days 6.9% 3.8% 45%

19. 19
Financial Outcomes
• Hospital:
– Net revenue +12.3% (with expenses only +5.6%)
– Contribution margin +17.6%
– Total inpatient profit per case improved +$1,946
• Health Plan:
– Paid out 4.8% less/case for CAB locally
– Paid out 28-36% less for CAB at locally vs. other providers

20. 2020
Population Health Optimization
The Population

21. 21

22. 22

23. 23

24. 24

25. 25

26. 2626
Mission Health Overview

27. 27
Service Area

28. 28
Mission Health: 127 Years of Exceptional
Service to WNC
• Created, governed and owned by WNC for the exclusive
benefit of WNC
– We are the only such health system remaining…
• Unwavering commitment to not-for-profit healthcare,
quality and community service
• A Thomson Reuters/Truven Analytics “Top 100 Hospital”
and “Top 15 Health System”

29. 29
Our BIG(GER) Aim
• Achieving the DESIRED OUTCOME for each patient:
– WITHOUT harm
– WITHOUT waste
– WITH an exceptional experience

30. 3030
Core Focus: Service Excellence,
Patient Safety and Quality

31. 31
Leadership Rounds

32. 32
Our Journey Towards an Exceptional
Experience: Our Tools
• Communication in Healthcare
• Relationship Centered Leadership
• Meetings with Departments with Next Step Action Plans
• Quality Leadership Rounds
• Redesign Work

33. 33
Result: Overall Patient Experience
65
74
80
76
68
75
80
76
89.4
84.3
88.5
90.1
84
91.2
89.2
60
65
70
75
80
85
90
95
Apr‐Jun 09
Jul‐Sep 09
Oct‐Dec 09
Jan‐Mar 10
Apr‐Jun 10
Jul‐Sep 10
Oct‐Dec 10
Jan‐Mar 11
Apr‐Jun 11
Jul‐Sep 11
Oct‐Dec 11
Jan‐Mar 12
Apr‐Jun 12
Jul‐Sep 12
Oct‐Dec 12
Patient Satisfaction Scores
“Overall Quality of Care”
Percentile Ranking
National Percentile Ranking

34. 3434
System Redesign
Safety

35. 35
Chief Patient
Safety Officer
(MD)
-----------------
Executive
Director
Quality &
Safety (RN)
MD/RN
PSO pair
(Emergency
Services)
MD/RN
PSO pair
(Critical
Care
Services)
MD/RN
PSO pair
(Acute
Care
Services)
MD/RN
PSO pair
(TBD)
MD/RN
PSO pair
(Anesthesia
Services)
MD/RN
PSO pair
(Surgical/
procedural
Services)
Physician:Nurse
Partners

36. 36
2 3 4 5 6 7 8 9 10 11 12 1 2 3
2012 2013
ESE 2 2 1 2 2 6 4 5 8 2 4
PSE 2 16 30 39 62 63 69 77 68 77 86 94 73 69
SE 1 1 1 2 4 3 1 1 1
0
10
20
30
40
50
60
70
80
90
100
Count PSE/SE/ESE Count by Month: End of Feb 2012 ‐ Mar 2013

37. 37
Top Patient Safety Events (PSEs)
Categories
• System Priorities:
– Specimen Labeling
– Bar Code Med Administration
– Missed Orders
• Other Top Categories:
– Delay in Diagnosis / Treatment
– Med Errors
– Critical Equipment
– Patient Identification
– Handoff

38. 38
Causal Tree Analysis: Chemotherapy Admin
MITOX Dose
Administered Early
OR
RN believed it was
time to administer
Med available in Pyxis –
Interpreted as time to
administer
Conversation w/Dr.
was mis-interpreted
to mean ok to
administer
Pretest results
OK
Timing info in eMAR
is usually wrong for
Chemo
Didn’t see timing in
written order
Didn’t see timing in
roadmap
Second check
didn’t catch
timing
2nd
RN new to
Chemo
2nd
RN assumed
more experience
RN was right
AND
Urgency to
administer med
before PM shift
Handwritten
orders and
roadmap can be
hard to read
First dose commonly
not on time (but w/in
acceptable tolerance)
Practice for RNs
to not re-time
chemo on eMAR
AND
Can either drop
or add doses if
eMAR is
adjusted
Use of “days”
can be
confusing w/
12hr doses
RN trying to
alleviate
workload from
pm shift
Staffing and
retention – too
few chemo
certified nurses
on pm
System may
interpret time
change as
request for add’l
dose
RN not
accustomed
to meds being
so early
Chemo
delivered much
earlier than
time for which
dose scheduled
AND
AND
Dr. assumed RN
question was
regarding results of
uncommon 2nd
Echo
2nd Echo
recently
completed
RN didn’t
explicitly ask
about timing
AND
Patient can be
late
Prework timing
can vary
Missed
shortening
fraction in
initial Echo
evaluation
Unusual to use
shortening
fraction in the
protocol
Early delivery is
common for evening
chemo doses
Chemo
pharmacist
evening coverage
not always
available
RN used eMAR
for timing instead
of paper MAR
Paper MAR isn’t
always created
Lack of
understanding of
how to use paper
MAR in
conjunction with
eMAR
R1.1
SBAR not
followed
1.0
1.1
1.1.1
1.1.2
1.1.3
1.2.1
1.2.2
2.0
2.0.1
2.0.2
2.0.3
2.1.1
2.1.2
2.1.2.1 2.1.2.2
3.0 4.0
4.1.1
4.1.2
4.1.3
4.2.1
4.2.2
4.2.3
5.0 6.0
5.1.1
5.1.2
5.1.3
5.2.1
5.2.2
5.2.3
5.3
5.4
0.0
0.1
R1.1
R1.2
R5.1
R1.2
R1.2
R1.2 R2.1
R4.1
RNs not calling
Pharmacy to
adjust eMAR
times
4.5
RNs unaware
they should do
this
4.5.1
Lack of formal
procedure
4.5.2
R1.2
SBAR not
yet rolled-out
in Peds
1.2.3
R3.1
R1.1
R2.2
R1.1

39. 39
Aggregate PSEs/ESEs – System Teams’ Progress
% Complete

40. 4040
System Redesign
Workflow

41. 41
Mission re:Design
ED
Med/Surg
2012 2013 2014
Aug –
Sept
Oct –
Dec
Jan –
Mar
Apr –
June
July –
Sept
Oct –
Dec
Jan –
Mar
Apr –
June
July –
Sep
Oct –
Dec
Surgery
VSM
VSM
VSM
Realize outcomes/returns
Realize outcomes/returns
Realize outcomes/returns
PharmacyVSM Realize outcomes/returns
SupplyVSM Realize outcomes/returns

42. 42
Culture
Nursing Documentation - iView Redesign
• Workflows are standardized
and nurses are satisfied with
their documentation and
workflow.
• Improved Nurse Satisfaction
with Documentation: 31% to
90%.
• Improved Nurse Satisfaction
with Workflow: 32% to 69%
People
Patient

43. 43
iView Redesign: What Nurses Said

44. 4444
Results

45. 45
Left Without Being Seen: Single Mobile
Point of Discharge
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
Weekly LWBS %
9/2/2012 ‐ 3/16/2013
• Increase in Hospital Census
• Increased LOS
• Influx of New Hires
• Influenza
Flu
Epidemic

46. 46
Low Acuity Throughput Patient
Satisfaction– Preliminary Outcomes

47. 47
Reduced Urinary Tract Infections
Statistically significant improvement from Before to After

48. 48
Reduced Respiratory Infections
Ja n
2 0 1 2
O ct 20 11
Jul 2 0 11
A pr
2 0 11
Ja n
2 0 11
Oc t 2 0 1 0
Jul 2 0 1 0
Apr
2 0 1 0
Ja n
2 01 0
Oct 2 00 9
0 .1 0
0 .0 8
0 .0 6
0 .0 4
0 .0 2
0 .0 0
M o n t h
RateofRespNIMs-MSICU
_
A v g = 1 .8 9 %
U C L= 5 .5 1 %
LB = 0
B e fo r e P r o je c t D u r in g A fte r P r o je c t
C o n tr o l C h a r t o f R e s p i r a to r y N I M s - M S I C U
A v g = 3 .7 4 %
A vg = 1 .8 7 %
U C L= ~ 9 .2 5 %
U C L = ~ 5 .6 5 %

49. 49
Peri-Operative Glucose Control
BEFORE
Red: value far out of range
AFTER
AFTER
Green: value in range

50. 50
Date
Days
Dec-12
Aug-12
Apr-12
Dec-11
Aug-11
Apr-11
Dec-10
Aug-10
Apr-10
Dec-09
Aug-09
5.0
4.5
4.0
3.5
3.0
2.5
2.0
1.5
_
X=2.777
UCL=3.781
LCL=1.773
Before After
1
COLI - ALOS
P‐Value – 0.016

51. 51
Reduced the use of ICU Propofol
0
100
200
300
400
500
600
Oct‐10
Nov‐10
Dec‐10
Jan‐11
Feb‐11
Mar‐11
Apr‐11
May‐11
Jun‐11
Jul‐11
Aug‐11
Sep‐11
Oct‐11
Nov‐11
Dec‐11
Jan‐12
Feb‐12
Mar‐12
Apr‐12
May‐12
Jun‐12
Jul‐12
Aug‐12
Sep‐12
Oct‐12
Nov‐12
Dec‐12
Jan‐13
Feb‐13
Mar‐13
Apr‐13
Propofol Bottles Removed ‐ Coli
Bottles Removed, Coli
Linear (Bottles Removed, Coli)

52. 52

53. 53
Improved Medication Reconciliation on
Admission

54. 54

55. 55
Improved Communication at Handoffs in
Cardiac Catheterization Lab

56. 5656
The Bottom Line

57. 57
Reduced Risk‐Adjusted Mortality
(Top 16% of US Comparison)

58. 5858
Future Steps…

59. 59

60. 60

61. 61
Summary: Technology and Care
Optimization
• Direct patient care
• Population/sub-population analytics
• Predictive modeling
• Trend analysis, local norm development
• Decision Support
• Hard-wiring of core care process changes
• Care process automation
• The list goes on…it’s really everywhere