Nurse Executives: Agents of Change in the Health Care Revolution

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Nurse Executives Agents of Change in the Health
Care Revolution

• Realizing the Promise
• Health Care in the Electronic Age

Laura L. Adams, MSN President and CEO, Rhode
Island Quality Institute Faculty, Institute for
Healthcare Improvement, Boston, MANovember 4,
2005
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Content Outline

• The Need and the Opportunity
• A Live Experiment in Rhode Island
• Being an Agent of Change in Your Community

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Unwarranted Variation in Care Delivery
Nearly one-half not based on best-known
science
of Recommended Care Received
64.7 Hypertension 63.9 Congestive Heart
Failure 53.9 Colorectal cancer 53.5 Asthma 45.4
Diabetes 39.0 Pneumonia 22.8 Hip Fracture
Source Elizabeth McGlynn et al, RAND, 2003
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The Cost and Quality Opportunity
Practice Variation
30 of direct health care outlays are the
result of poor-quality care MBGH, Juran, etal
2002 20 to 30 percent of the acute and chronic
care that is provided today is not clinically
necessary. Becher, Chassin 2001 cost of poor
quality was nearly 30 of the expense baseThe
biggest opportunities were in the core medical
processes that comprise the majority of what we
do. Mayo Clinic Costs associated with poor
health care account for 30 of the premiums
people pay. David Lawrence, MD The cost of poor
quality in health care is as much as 60 of
costs Brent James, MD, IHC
Unnecessary Cost
Fisher, Wennberg, et al, Annals of Internal
Medicine, 2003
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Projected U.S. HealthExpenditures and Waste
3.3 T
Unnecessary Cost
990 B
1.7 T
Aggregate Waste 7.4 Trillion
515 B
Source U.S. Department of Health and Human
Services, Gordian Project analysis
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Projected Health Expenditures and Waste Per One
Million Population
13 B
Unnecessary Cost
4 B
7 B
Aggregate Waste 30 Billion
2 B
Source U.S. Department of Health and Human
Services, Gordian Project analysis
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Daniel Sands, MD Zyx Corporation
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The Paper Record
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Handwriting Analysis
Paper Kills!
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National Health Information Infrastructure Net
Estimated Annual Savings 132 Billion
Inpatient EHR
Community Health Information Exchange
Ambulatory EHR (Advanced)
Sources Johnston, J., et al. The Value of CPOE
in Ambulatory Settings and Pan, E., et al. The
Value of Health Information Exchange And
Interoperability, Center for Information
Technology Leadership, 2004, 2004. Based on the
Experience of Early Adopters
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Where We Stand Today

• EHR Adoption Rates in the U.S. are way below
  other countries

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Misaligned Incentives Drives Lack of Capital
Physician Practices
Others
Ambulatory Computer-based Physician Order Entry
Source Center for Information Technology
Leadership, 2003
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The Others (89)
Purchasers of Health Care
Other
Federal
State/Local
Households
Medicaid
Medicare
Employers
Source Health, United States, 2002
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What About the Tipping Point?
Tipping Point
Cut-over
100
0
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Cumulative Users
HealthAlliant, 2004
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No one can whistle a symphony
it takes an orchestra. -H.E. Luccock
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Content Outline

• The Need and the Opportunity
• A Live Experiment in Rhode Island
• Leading in Your Community

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The Rhode Island Quality Institute (RIQI)

• A collaboration among hospitals, health care
  providers, insurers, consumers, business, academe
  and government for the purpose of improving
  health care quality, safety and value in Rhode
  Island.

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RI Quality Institute

• Statewide multi-stakeholder collaborative with
  the mission of improving health care quality,
  safety and value
• Catalyzed in 2001, incorporated in 2002
• Freestanding Not-for-Profit 501(c)3
• Funded by participant contributions, grants,
  contracts and payment for services
• 21 Board members
• Hospitals, physicians, nurses, pharmacists,
  consumers, health insurers, professional
  associations, the QIO, business, academe and
  state government
• One organization/person--one vote on the Board
• Consensus is the primary decision-making mode
• High levels of participation beyond the Board
• Lean structure

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The Principles that Guide the RI Quality Institute

• Collaborationfirst and foremost
• Real improvement in quality, safety and value is
  required
• Focus on system improvements that none of us can
  achieve alone
• Transparencythe right to know
• Commitment to a patient/consumer-centric system
  with an emphasis on patient control, privacy and
  security
• Senior leaders required

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The enemy is disease The enemy is error
The enemy is waste

Not each other
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The Quality Institutes Strategic
Agenda
Improving Care in the ICU
Statewide e-Prescribing
Health Care Information Exchange/
Interoperability and Electronic Health Record
Adoption
Benefit realization in the short term
Benefit realization longer-term, but broad and
very substantial
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RI Statewide HIT Strategy

• Lower the barriers to getting the clinicians the
  tools they need
• -Information Technology
• -Best Practices Matching Care to Science
• -Supports to Implement
• -Connectivity
• Involve consumers early
• Financing via a Public-Private partnership
• Aligning reimbursement with significantly
  improved quality and lower cost

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Decision Support Creates Value
Share of Savings Generated
Treatment
Diagnostic
Redundancy
Errors
Source SBCCDE, CITL, Gordian Project analysis
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The State of HIT Deployment in RI

• A shared vision and solid relationships among
  competitors/adversaries has been built
• These key pieces are underway
• Electronic prescribing as starting point and a
  toe in the IT water for many physicians
• Data sharing across the state (MPI
  project/backbone for interoperability) Public
  health playing a major leadership role
• Innovative approach to statewide EHR adoption
• Physician-led group purchasing collaborative
  forming as a separate company to provide
• Group purchasing
• Support for implementation and maintenance
• Integration with the CMS DOQ-IT program

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The Vision of EHR of RITo Close the EHR
Adoption Gap in RI

• Help all RI physicians deliver higher quality,
  safer care and substantially lower the barriers
  of entry to HIT by
• Decreasing the cost of purchase of a high-end EHR
• Decreasing the risk of purchase of an EHR
• Decreasing the cost and complexity of connecting
  to the statewide Master Patient Index
• Providing strong implementation support locally
• Providing excellent maintenance support locally
• Helping them transition to a new care model

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The State of HIT Deployment in RI (cont.)

• These key pieces are underway (cont)
• Payment system/incentives redesign
• Consumer engagement
• Legislative engagement
• Business model exploration

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The Most Important Lessons Weve Learned

• Keep the main thing the main thing
• Abide by the principles
• Rapid learning is a required skill
• Choose leaders very carefully
• There is no instant pudding

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Content Outline

• The Need and the Opportunity
• A Live Experiment in Rhode Island
• Being an Agent of Change in Your Community

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Colorado Health Information Exchange (COHIE)

• Consortium founding members
• Shared mission of training health care providers
• The Childrens Hospital
• Largest provider of pediatric specialty care
• Denver Health
• 150,000 Denver residents (25 of the
  population)
• Kaiser Permanente of Colorado
• Third largest HMO in the State
• University of Colorado Hospital
• Largest teaching hospital in Metro area

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Some Massachusetts Initiatives
Massachusetts eHealth Collaborative
(MAeHC) Facilitator of the last mile connection
(intra-community)
Northern Berkshire MAeHC Funded
Massachusetts Health Data Consortium The
convening, incubator, and committee hosting
organization
MA SHARE The business that operates the
technology grid (inter-community)
Newburyport MAeHC Funded
Massachusetts Technology Collaborative Facilitator
of computerized provider order entry
Safe Health Info Fallon Clinic, FCHP, and
UMass Memorial
Brockton MAeHC Funded
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Indiana Health Information Exchange www.ihie.com
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Patient Powered www.patientpowered.org
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www.nhinwatch.com/page.cms?pageId5RHIOS
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There is no power for change greater than when a
community discovers what it cares about. -Meg
Wheatley
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I have heard it said by cynics that the
quality of medical care would be far better and
the hazards far less if we, like pilots, were
passengers in our own airplanes.
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We are. -Donald M. Berwick, MD,
CEO Institute for Healthcare
Improvement