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					       HIMSS-MN Chapter
         Learning Session
Interfacing Ambulatory Applications
                   September, 2003
                   AGENDA
You’ll learn about HealthPartners & our:
   System interfacing strategy;
   Interfacing strategy evolution and future
    considerations;
   Implementation challenges encountered and key
    strategies to mitigate risk;
   Key success factors in ambulatory systems
    interfacing;
   Ongoing issues and limitations of interfacing.
                        Members/Patients
     HealthPartners - a consumer-governed health care organization
     Mission - To improve the health of our members, our patients and the community.

      Health                   Hospitals:                                  Institute for
                    HP                                HP       Central   Medical Education
                                - Regions
       Plan       Medical        as well as:         Dental     Minn.     Institute for
                                                                          Clinical Systems
      (medical
                  Group &       Hudson, Amery,      Group &    Group      Improvement
      & dental                    Osceola &
     functions)    Clinics     No. St. Paul Trans    Clinics   Health      Research
                                 Care Center                               Foundation




     Administrative support: such as Legal, Information Services, Communications




Contracted Network:
                                                         This is a functional
-Medical
-Specialty
                                                         depiction of who we are;
-Hospital                                                not an organizational chart
     About HealthPartners
    Medical Group & Clinics
 550 Physicians, multi-specialty group
 Key component of not-for-profit
  integrated care delivery & financing
  organization
 43 clinic sites

 250,000 HealthPartners members +
  100,000 fee-for-service patients
     About HealthPartners
    Medical Group & Clinics
 1.5 million visits per year
 1.5 - 2 million claims per year

 Appointment scheduling:

    average of 5/minute,

    7AM - 9 PM, 365x14;

    peak of 10/minute;
    About HealthPartners
    Dental Group & Clinics
 60 Dentists, including specialties
 Key component of not-for-profit
  integrated care delivery & financing
  organization
 16 clinic sites

 215,000 HealthPartners Dental
  members, 100,000 use our clinics
Our technology                      Designing our
                                    care system to
trajectory                          pursue “perfect
                                    care”

                                                  Our
                                                  work
           1                                      now
                                                         -P2
           9
                     1999                -Access         -EpicWeb
           9                             -EpicWeb in     View &
                           -Satisfaction                 Extended
           8     -Business -1st paperless specialties
-EMR              systems clinic                         -Scanning
 pilot           -Resolute - Some scanning               -Common HIT
 1997
                           -Prelude,                      Systems
         HPMG   &C          Cadence                      - Dental EDR
System Interfacing Strategy
Business Drivers -
   When choosing best of breed systems, interfacing
    is part of the package;
   Home grown Patient Profile not enough;
   Electronic Medical Record adoption:
      Build a history and manipulate it for more
       effective care;
      Creating a one stop shop means more efficient
       care delivery;
System Interfacing Strategy
Led to a Strategy -
   Standardization -- HL.7, “move away from that
    point-to-point interface and no one gets hurt...”;
   Interfaces implemented which improve workflow;
   Interfaces before rollout if possible;
      and a history load too!

   Interfaces that meet provider needs and wants
    (I.e. how do we generate buy in)
Our interface
trajectory
   1996-7          1998-9


- Reg. (‘96)   - Lab Billing
- Sched.       - Regions
- Claims         ADT
- MSR
- RX and       - Turned off
  Claims RX      Claims RX
- Trans.
- Lab
Graphing of Lab results
     The Pursuing Perfection
            Initiative
   Robert Wood Johnson Foundation
    (RWJ) with the Institute for Healthcare
    Improvement (IHI) issued a call for
    proposal, “Pursuing Perfection:
    Raising the Bar for Health Care
    Performance” in February, 2001
       Where did the term
      “pursuing perfection”
           originate?
   “Crossing the Quality Chasm” published by IOM
    in early 2001 is a call for a sweeping redesign of
    health care
       Our Direction… changed:
HPMG & C Mission
   To improve the health of our members, patients and our
    community
HPMG & C Direction
   To pursue perfect care, service and access at a cost that is
    affordable
Care Systems Mission
   To make it easy for patients and practice teams to do the right
    thing, right 100% of the time
EMR Direction
   To implement EpicCare Hyperspace in a manner that makes it
    easy for our practice teams to pursue perfect care at a cost that
    is affordable
                                  I. Patient Results
                            Setting Aims for Improvement
                                   Mission (purpose)
                      “What we strive for” (aims for improvement)


                            II. The Care Itself
                                 - Simple Rules
                               - Design Concepts


              III. Organizational Supports for Change
-Patient-centered - Financial viability       -Teamwork
- Measurement     - Communication            - Effective use of technology
-Leadership       - Cultural Change          - Change Model
                  - Systematic approach to process design
                  - Employee/Physician Learning, Growth and Alignment

                IV. Environmental Supports for Change
                               - Payment methods
                                 - Transparency
                    -Clinical education/regulation/liability
                        -Dissemination/external spread
      We’re Implementing the
       Planned Care Model

Informed, Activated     Continuous
                                             Prepared
      Patient            Healing
                                           Practice Team
                       Relationships




                      Health Information
                         Availability
      Prepared Practice Teams Engage the
        Patient in a Continuous Healing
                  Relationship
   Patient’s perception of the
    healer’s awareness of
    problems in daily activity,
    feelings, social activity, pain,        Continuous
    social support, physical                healing
    activity.
                                            relationship
   Healers explanation of the
    problem
                                          Patients want:
   Patient involved as much as             - 65% information

    they want in decisions                  - 25% comfort
What makes this different?
   All team members know who each other are (defined group)

   All team members understand the planned care model

   All team members understand their role as well as others within the team
    (based on job title and not the individual)

   All PPTs will base their care on established best practices (e.g. ICSI
    guidelines)

   All PPTs will base their care on STEEEP principles

   Teams are augmented by but not dependant on technology (you can’t wait to
    form a good team until you get a complete EMR)
           Prepared Practice Teams
          Work Across the Continuum


ABCD      ABCD       ABCD     ABCD       ABCD    ABCD      ABCD     ABCD    ABCD      ABCD      ABCD      ABCD      ABCD




Primary                                          ER     Specialty   Home   CareLine   Nursing   Hospice   Urgent
          Hospital   CHP    Behavioral   Trans                                                                     Case
Care                                                                Care              Home                Care
                            Health       care                                                                      Management
      Our Health Information
        Technology Vision
   To create a system that makes it easy for our
    patients and providers to do the right thing
    right, and guarantees patients and providers
    unfettered access to the health information
    they need, whenever or wherever they need it,
    100% of the time.
          Interfacing Strategy
               Evolution
   Initially, identify and deploy key interfaces before
    application rollout to provide valuable data at the
    beginning (chart history);
   Ongoing, parallel interface development with
    application rollout or key business needs;
   Recognition that reconciling interfaces must occur
    within workflow context;
   Vision: Six Sigma Interface Quality & Care Quality
          Interfacing Strategy
               Evolution
   Initially, identify and deploy key interfaces before
    application rollout to provide valuable data at the
    beginning (chart history);
      Easy to do the right thing at the right time;

      No need to reference the paper chart or PPS;

      History load makes it truly meaningful;
          Interfacing Strategy
               Evolution
   Ongoing, parallel interface development with
    application rollout or key business needs;
   Recognition that reconciling interfaces must occur
    within workflow context;
          Interfacing Strategy
               Evolution
   Vision: Six Sigma Interface Quality & Care Quality
                 Six Sigma
   Adopting the goals of Six Sigma quality means
    setting tolerance limits for defective products at
    such high levels that fewer than 3.4 defects
    occur per million visits (or opportunities).
     Diabetes (as an example)
   Diabetes affects approximately 5% of
    HealthPartners patients and accounts for about
    15% of total health care dollars
   For every 1% reduction in HbA1C’s, we estimated
    we could save $10 million, and more importantly,
    patients would benefit by having fewer
    complications
     Diabetes (as an example)
   Only one-third of the care systems and doctors in
    the U.S. provide diabetes care at the minimum
    standards recommended by the American
    Diabetes Association (ADA)
    Six Sigma View of Diabetes
   If 70% of our patients with diabetes have a HbA1C
    of <8, that’s 300,000 defects/million
   If we fulfill the comprehensive diabetes measure
    for only 7% of our patients with diabetes, that’s
    930,000 defects/million
   And our current performance is at national
    benchmarks!
System Interfacing Strategy
Thus a revised Strategy -
   Standardization -- HL.7, “move away from that
    point-to-point interface and no one gets hurt...”;
   Interfaces implemented which improve workflow
    and STEEEP (Safe, Timely, Effective, Efficient,
    Equitable, Patient Centered);
   Interfaces before rollout if possible;
      we still love that history load!

   Vision: Six Sigma Interface Quality & Care Quality
Our interface
trajectory
   1996-7         1998-9        2000-1      2002        2003       2004


- Reg. (‘96)   - Lab Billing - Scanning
                                         - Pathology - New      - Lab Orders
- Sched.       - Regions     - Outbound - Regions      Dental   - RX orders
- Claims         ADT           Sched. &                System
                                           OP RX
- MSR                          Reg.        Dispensing
- RX and       - Turned off - Dictaphone - Turned of
  Claims RX      Claims RX - Radiology RX
- Trans.                     - Dental      pending
- Lab                          Membership orders
           Interface Statistics
   23 Ambulatory Interfaces in service (19 more
    ‘hospital-only’) :
    • Transcription             • Lab Results/Orders
    • Scheduling/Registration   • Pharmacy Prescriptions
    • ADT/Membership            • Radiology
    • Scanning                  •Automated Dispensing

   4.7 million messages per week through interface
    engine (At Six Sigma -- still 17 errors per week);
                              Care Delivery Systems and Interfaces
                                                   Charges                                                                                                                                                            Eclipsys TSI
                                                                                                                                                                                                               Decision Support - reporting,
Optifil Automated Refill
   System (clinics)                                                                                                                                Submission/                                                       Gold and Silver
                                                                                                              Submission/      Electronic            Remit
 Microlog IVR Retail,            Mediware WoRx IP                                                               Remit          Commerce
   Mail Order, Web                  Rx System
Voice rresponse and Rx                                                                                                                                                                                                  AIMS UHS
      refill orders                                                                                                                                        ADS Plus                       Code 1 / Group 1      Patient Equipment System
                                     Pyxis IP Rx                                                                                                                                             Address
    AutoScript Rx                 Dispensing System                               Epic Systems                                                                                              Verification
  Dispensing System
      (hospital)
                                                                                    Identity MPI                                                             HDX                                                 Film Tracking Xray fiim
                                                                                                                                                                                              CCI Collection         tracking system
                                 Rx Express OP Rx
                                                                                    Prelude Registration                                                                                          Tool
Facts & Comparisons                   System                                        Cadence Scheduling
Drug information system
                                                                                    EpicCare/EpicWeb EMR                                                                                                       MIDAS Quality Assurance
                                                                                                                                                        3M Codefinder                           HSS APG
Rx2000 Medication refill                                                            Resolute Patient Accounting                                                                                 Grouper        & Utilization Review & CM/
                                 BTI Home & Hospice    ADT                                                                                                                                                              QA (future)
   system(hospital)                                                                 Clarity Reporting                                                                                         (EasyGroup)
                                                                                                                                                       HSS EasyGrouper
                                   Flexilab (Misys)                                                                                                     DRG Grouper
       CoPath Pathology
                                      Laboratory
                                                       ADT                        Scanning/Indexing                                                                                                              Claims, Medical, Dental,
                                                                                                                                                                                                                       Pharmacy
                                                                                                                                                                                                                      Focus Extract
                                  RALS Laboratory                                                                                                                   McKesson MEDIPAC
                                   POC Testing                                                                                                                          Patient Management
                                                                                                                                                                         Patient Accounting
       eMed PACS Digital               IDXRad
                                                                                Orders/          ADT/                                                                    Patient Scheduling                           NDC Premis
           Imaging                    Radiology
                                                       ADT                      Results/      Membership/                                                                 Medical Records                            Pervasive 2000
                                                                                                                       Flashpoint                                          Chart Tracking
                                                                               Financials     Demographics                                                                       IIP
         Teletracking                                                                                                 Charge Entry
       PreAdmit Tracking
                                 CSR Materials Mgmt    ADT                                                                                                                                                        Lawson Financials
                                                                                                                                                                                                                    General Ledger
                                                                                                                                                                                                                     Fixed Assets
        Teletracking Bed            Teletracking                                                                                  ADT                                                                              Accounts Payable
            Tracking               Patient Tracking                                         Quovadx                                                                     ADT            Charges                   Materials Management
                                                                                                                               Orders/
                                                                                        Interface Engine
          Dictaphone                                                                                                           Results/
         Digital Dictation          Chartscript                                                                                Charges                                                                                   Cyborg
                                    Transcription                                                                                                                                                              Payroll & Human Resources
      Medquist Upload of
                                                                                                                                                                        Eclipsys RAMPIS
      vendor transcriptions                                                                                                                                              Order Communication
                                 SOE Dental Practice                                          Dictaphone                                                              Patient Care Documentation
                                      System                                                                                                                                    Results                                    API
        TransWeb Trans.                                                                       Transcription
                                                                                                                                                                                                                   Time & Attendance
           info sharing
                                                                                                                            Synersource                                                                             Staff scheduling
                                                                                                                            Transcription
                                                                                            Dictaphone EXS, EXT &
                                                                                                                              Interface
                                                                                             EXV) Digital Dictation
       Optical Surfacing
                                                        Labels/ Demographics
                                                               /Orders
         Optical Point of                                       Membership
             Service



       QSI Dental Practice
                                      Administrative Systems
            System                      Membership
                                        Claims
                                        Auths

                                                                                                                                                 Legend
                                      Clinical Systems
                                         PPS                                                                                   Future           Non CDS                Pilot          Followup
                                         Immunizations
                                         DEC Pt Scheduling                                                                   Last updated Friday, September 12, 2003 11:40
                                                                                                                                                   AM
                    Care Delivery Systems and Interfaces - ADT/
                                                                                                                           McKesson MEDIPAC
                                   Membership                                                                              Patient Management
                                                                                                                            Patient Accounting
                                           Rx Express OP Rx                                                                 Patient Scheduling
   BTI Home &
                                                System                                                                       Medical Records
    Hospice
                                                                                                                              Chart Tracking
                                                ADT
                                                                                                                                    IIP
                                                                                                         ADT
 CoPath                                   Flexilab (Misys)     ADT                                                                               ADT
Pathology                                    Laboratory                  ADT

 eMed PACS                                      IDXRad                                                                      Eclipsys RAMPIS
                                                                ADT                  Quovadx
Digital Imaging                                Radiology                                                                   Order Communication
                                                                                 Interface Engine
                                                                                                                               Patient Care
                                     GE MUSE Cardiology        ADT                                                            Documentation
                                                                                                                                  Results
 Dictaphone                                    Chartscript
Digital Dictation                              Transcription
                                                                        Membership
                                      SOE Dental Practice
                                           System
                                                                                                         Epic Systems
                                                                      Administrative                       Identity MPI
             QSI Dental                                               Systems                              Prelude Registration
           Practice System                                              Membership           ADT/          Cadence Scheduling
                                                                        Claims            Membership/      EpicCare/EpicWeb EMR
                                                                        Auths             Demographics
            Optical Point of                                                                               Resolute Patient Accounting
               Service                                                                                     Clarity Reporting
                                                                      Clinical Systems                   Scanning/Indexing
         Optical Surfacing                                               PPS
                                                                         Immunizations                                      Legend
                                                                         Pt Scheduling                    Future          Non CDS                 Pilot            Followup

Last updated Friday, September 12, 2003 3:00
                     PM                                                                                    File location: is7 server/admin/cdlt/cds documentation/cds applications
        Interface Reconciliation
   Riddle me this...
     How do we know what is going through the interfaces is
      the right stuff and the right quality?
     When is an ordering physician not an ordering
      physician?
     How flexible is the HL.7 standard? (hint: think yoga)

     Now how complicated could a billing interface possibly
      be?
   What’s important about interface reconciliation?
     Interface Reconciliation
Q. What’s most important about interface reconciliation?
1. The vendor’s model of your business?
2. Your model of your business?
3. HL7’s model of your business?
4. CMS’ model of your business?
5. An application user’s model of your business?

A. 6. All of the above together (or the story of Ordering
   Physician…)
        Interface Reconciliation
   The real world is a messy place
   Interfacing systems requires
       Vigilence
       Engineering
       Systems Theory
       Discipline
         Samples of...


…how interfaces can make it
easier to deliver more perfect
care.
  Alternative Medications are
recommended for target drugs.
Drug allergy interaction checking
 occurs when ordering in Epic.
Entry of Patient’s Problem List will
    provide continuity of care
SnapShot screen in Epic provides Health
             status items on one page..
Health Maintenance
Health Maintenance/ Disease
        Management
Some issues with and limitations
         of interfacing

   ROI is required too -- technology is expensive;
   Achieving Patient and Provider satisfaction is
    challenging;
   Variation of people in processes;
      Return on Investment
   Reduce staffing (e.g Medical Records, Charge
    Entry)
   Reduce Dictation/Transcription volume
   Decommission/reduce Legacy systems
      PPS

      Dictaphone/Chartscript

   Improve Pharmacy
      Increase generics

      Increase in-house fills

   Reduce postage & materials
          Satisfaction Survey
              Background
   Prior to 2003, this survey was conducted with
    paper by hand at each of the clinics
   This was conducted in March-April 2003 using an
    Internet-based tool.
   Approximately 1600 EPIC users were E-mailed.
   452 Answered the survey (28% response Rate)
               EMR Climate
   Respondents generally feel favorable.
   84% were Satisfied or Very Satisfied with “My use
    of Epic has improved my ability to deliver better
    care to my patients.”
   Substantial opportunities exist to make EPIC more
    useful.
         Question: Patient’s IP or ER
       Information availability in EPIC
• 60% were satisfied or        The patient's inpatient hospital information or ER
                                    information is readily available in Epic.

  very satisfied with                         100%

                                              90%


  Hospital or ER info                         80%

                                              70%

  available in EPIC                           60%




                                    Percent
• Specialty Care Nurses                       50%

                                              40%



  had Significantly                           30%

                                              20%


  greater satisfaction                        10%

                                               0%


  than other groups.                                 Other   Primary Care Nurse        Primary Care
                                                                                         Provider
                                                                                                          Specialty Care Nurse

                                                                                                    Type of User
                                                                                                                                    Specialty Care
                                                                                                                                      Provider
                                                                                                                                                     Total




• Providers had less                                                  Very Satisfied    Satisfied    Dissatisfied   Very Dissatisfied   Blank




  satisfaction than non-
  providers.        Spec Nurses Satisfaction
     Question: Patient’s Follow-Up
dictation from previous visits is timely
               available
• 78% were Satisfied          The patient's follow-up visit dictation from the previous
                                        visit is available in a timely fashion.

  or Very Satisfied.                            100%




• Primary Care
                                                90%

                                                80%

                                                70%

  Providers had                                 60%




                                      Percent
  Significantly greater                         50%

                                                40%



  Satisfaction than                             30%

                                                20%


  other groups.                                 10%

                                                 0%


• Providers had less                                   Other   Primary Care Nurse        Primary Care
                                                                                           Provider
                                                                                                            Specialty Care Nurse

                                                                                                      Type of User
                                                                                                                                      Specialty Care
                                                                                                                                        Provider
                                                                                                                                                       Total




  satisfaction than non-                                                Very Satisfied    Satisfied    Dissatisfied   Very Dissatisfied   Blank




  providers.
                    PCP Satisfaction
    Question: Patient’s records from
      outside visits are available.
• Only 33% were                      100%
                                            The patient's records from outside visits are available.


  satisfied or very                  90%




  satisfied
                                     80%


                                     70%



• Specialty Care                     60%




                           Percent
                                     50%


  Providers had                      40%


                                     30%

  Significantly greater              20%



  Dissatisfaction than               10%


                                      0%


  other groups.                                Other   Primary Care Nurse        Primary Care
                                                                                   Provider
                                                                                                    Specialty Care Nurse

                                                                                              Type of User
                                                                                                                              Specialty Care
                                                                                                                                Provider
                                                                                                                                               Total




• Providers had less                                            Very Satisfied    Satisfied    Dissatisfied   Very Dissatisfied   Blank




  satisfaction than non-
  providers.                                Specialty Care Provider Satisfaction
   Challenges & Risk Mgmt
Implementation challenges encountered and key
  strategies to mitigate risk
 Details, details, details;

    When is an encounter not an encounter?;

    How many flavors of provider do you have?

 Vendor negotiation and achieving data alignment

 Ensuring integrity across multiple systems over
  long periods of time (e.g. DR, maintenance).
MD Fields/Flow by System


Cadence               Medipac PM            RAMPIS                 I/E                   Sunquest              Medipac PA            TSI

Resource              -----                 -----                  -----                 -----                 -----                 -----
PCP                   PCP                   PCP                    PCP                   PCP                   -----                 -----
-----                 Admitting             Admitting              Admitting             -----                 -----                 -----      Lab
Attending             Attending             Attending              Attending             Attending             Servicing             -----
Referring             Referring             Referring              Referring             Referring             Referring             -----
-----                 -----                 Ordering               Ordering              Ordering              Ordering              Ordering


Cadence               Medipac PM            RAMPIS                 I/E                   IDXRAD                Medipac PA            TSI

Resource              -----                 -----                  -----                 -----                 -----                 -----
PCP                   PCP                   PCP                    PCP                   -----                 -----                 -----      Radiology
-----                 Admitting             Admitting              Admitting             -----                 -----                 -----
Attending             Attending             Attending              Attending             ?????                 Servicing             -----
Referring             Referring             Referring              Referring             -----                 Referring             -----
-----                 -----                 Ordering               Ordering              ?????                 Ordering              Ordering



Functional descriptions of MD fields:
PCP               Primary Care Physician. This is patient level info in Medipac, and doesn’t typically change with each encounter.
Admitting         The staff MD that admits the patient to the hospital. Encounter level data – should not be a resident.
Attending         The staff MD responsible for the patient’s stay in the hospital, and accountable on the charge/claim record.
                  Encounter level data – should not be a resident.
Referring         Not typically used for billing -- a true referring physician who sent their patient to Regions Hospital.
                  Encounter level data - often contains a clinic name.
Ordering          Represents the actual MD who requested the order, and might be a resident, staff, advanced practice, etc.
                  This is order/charge transaction level data. This field is the only MD that is currently extracted to TSI.
Servicing         Medipac charge transaction term for the ‘billing’ physician, usually the attending.

Other MD names in circulation ………
Supervising              A staff MD that supervises the resident.
Scheduling               A default name or resident name used for scheduling purposes, but is then updated to appropriate
                         Attending MD at visit check-in.
Billing                  See Servicing.
Staff                    A physician who has Regions Hospital professional privileges that have been authorized by credentialing.
    Epic           Interface Engine        DEC              ChartScript


Registration          Registration       Registration
-H#                   HP Patient?         -Mini Reg
-Careline#               Yes



                      Permanent          Permanent
 Permanent
                         HP#               HP #
    HP#




    Appt
                           Pt Info         Pt Info
  Scheduled


Appt Check In                            Appt Check In
                      Appt Check In

                                                             Appt Check In


                                                             Transcribed Note
                     Transcribed Note

                                         Transcribed Note

Transcribed Note      Transcribed Note


                                          OK Encounter #


                                           Enc # not ok-
                                           generate error
                                              report


 Radiology Order     Radiollogy Order                        Radiology Order




 Radiology Note       Radiology Note                          Radiology Note



                                          Radiology Note
                                                                                  Epic/Chartscript
                                             in PPS
                                                                                interface data flow.
                                                                                Last updated 11/13/
                                                                                         02
       Key Success Factors
Key success factors in ambulatory systems
  interfacing
 Discipline -- in people, in processes;

 Integrated analysis encompassing workflow, data
  flow, and time;
 Remembering that it’s usually about people,
  occasionally about data (e.g. transcription errors);
 Continually improve people, process, technology

 Six Sigma attitude.
    Interfacing Strategy Future
          Considerations
   Interfaces can be powerful and are critical;
      ROI vs. InterfacesRUs;

      2004 requests for 12 more: Sleep Clinic (3),
       Pulmonary Function (3) , Cardiology (4),
       Gastroenterology (2);
   What’s likely coming?
      Interrogatory interfacing between hospital
       systems?
      Shift to patient-centric agent?

				
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