Exploiting Health IT to Improve Health (case studies from the MetroHealth Davies award) March 2, 2016

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1 Exploiting Health IT to Improve Health (case studies from the MetroHealth Davies award) March 2, 2016 David Kaelber, MD, PhD, MPH CMIO & Vice-President of Health Informatics The MetroHealth System Professor Internal Medicine, Pediatrics, Epidemiology, and Biostatistics Case Western Reserve University

2 Conflict of Interest David Kaelber, MD, PhD, MPH Consulting Fees: UpToDate North America Advisory Board Other: CareSource Board of Directors

3 Agenda Background Case Discussions HIV/Hepatitis C Diabetes Acinetobacter/MDRO Other Cases Discussion

4 Learning Objectives Summarize areas where health information technology can improve care Analyze different types of health IT interventions and they way in which they can improve care Identify one new area in your own healthcare system where health information technology can be used to improve care

5 MetroHealth and Epic Ambulatory EHR (EpicCare w / Cadence, Prelude, & Resolute) EHR in ED (ASAP) Inpatient EHR (Epic w/ Inpatient Willow and Beacon) CareEverywhere, e-rx, MyChart, Nurse Triage Epic Enterprise Contract, MU Stage BCMA, EpicCare Link, Welcome ADT, Beaker, Bedtime, OpTime, Research, SBO Epic 2014, Kaleidoscope (3/7/15) 1 st public healthcare system in US to install Epic in the outpatient setting (1999)!!! 1 st public healthcare system in US w ith Epic to achieve HIMSS Stage 7 EMRAM Ambulatory & Hospital recognition (2014)!!!

6 HIT-enabled External Recognition Underdiagnosis of Hypertension in Children and Adolescents (2007 American Health Association top 10 cardiac research advances) Electronic Medical Record Assisted Design of a Cluster-Randomized Trail to Improve Diabetes Care (2008 Cluster randomized for informatics research recognized by the American Medical Informatics Association (AMIA) as one of the top 10 informatics advances) Electronic disease reporting for public health (2009 2nd site to implement Electronic Support for Public Health (ESP) software) Electronic Health Records and Quality of Diabetes Care (2011 one of the AMIA top 10 informatics advances) Advanced Clinical Decision Support for Vaccine Adverse Event Detection and Reporting (2011 1st site in the US to automate detection and reporting of vaccine adverse events to the CDC) Using the EHR to combat Acinetobacter (2011 Association of Medical Directors of Information Services (AMDIS) award) Stepping Stones of Pediatric Hypertension: Advanced Decision Support Helps Identify High Blood Pressures (2013 American Academy of Pediatrics National Conference and Exhibition Council of Clinical Information Technology best poster award) Over 30 vendor presentations Over 75 peer-reviewed abstracts/publications Over a dozen external research grants More Epic clinical programs then any other Epic customer 6

7 Case #1 - HIV/Hepatitis C Opportunity Statement How can the electronic health record be used to increase evidence based screening of infectious diseases of high prevalence among the population MetroHealth served. Special thanks to Dr. Ann Avery, Dr. Peter Greco, and Dr. Melissa Osborn

8 HIV/Hepatitis C Reminders Alerts in EHR to providers Alerts in PHR to patients

9 HIV Results HIV Pre-Intervention Post-Intervention Time Period 7/2005-6/2010 7/2010-6/2015 Total Tests 10,350 34,628 Tests per month Total positive tests Positive tests per month Proportion of tests positive for HIV

10 Hepatitis C Results HCV Pre-Intervention Post-Intervention Time Period 7/2000-6/2013 7/2013-6/2015 Total Tests 5,066 19,833 Tests per month Total positive tests Positive tests per month Proportion of tests positive for HCV 15.3% 4.0%

11 HIV Financial ROI 225% increase in screening for HIV 11% increase in positive HIV tests 50% decrease in proportion of positive HIV ~2-3 new HIV cases (FROM SCREENING) being diagnosed per year Early HIV diagnosis (we have seen increase in CD4 count in newly diagnosed patients) can: Save $75,000 in healthcare costs for the person diagnosed Decrease horizontal and vertical transmission which can save up to $400,000 lifetime costs per HIV case. $75,000 X 2 = $150,000 in potential healthcare savings annually ~$10 cost per test X ~7,000 pt/year = ~$70,000/year in additional costs (estimated initial costs of EHR/technology implementation - ~$10,000) (estimated annual ongoing costs of EHR/technology implementation - ~$1,000) Health Protection Agency. HIV in the United Kingdom: 2011 Report. London: Health Protection Services, Colindale. Published November Accessed 4 May Brennan, V et al. The Public Health and Economic Impact of Early Diagnosis and Early Treatment in HIV in the UK (Poster). Presented at: Gilead Best Practice Sharing Event. 19 May Unpublished data.

12 Hepatitis C Financial ROI 2500% increase in screening for Hepatitis C 560% increase in positive Hepatitis C tests 60% decrease in proportion of positive Hepatitis C tests ~335 new HCV cases being diagnosed per year Diagnosing someone with Hepatitis C at Stage 1 of liver cirrhosis instead of Stage 3 liver cirrhosis can save up to $10,000 of lifetime expenses $10,000 X ~335 = ~$3,350,000 in potential healthcare savings annually $92 cost per screening test X 7,383 pt/yr = ~$679,282 $504 cost per confirmation test X 335 pt/yr= ~$168,840 Total healthcare costs for screening = ~$848,122/yr (estimated initial costs of EHR/technology implementation - $10,000) (estimated annual ongoing costs of EHR/technology implementation - $1,000) Schwarzinger M et al. Lifetime costs attributable to chronic hepatitis C from the French healthcare perspective (ANRS No121188). 48 th International Liver Congress, Amsterdam abstract 49, 2013.

13 Case #2 - Diabetes Opportunity Statement How can the electronic health record be used to increase evidence based processes and long-terms outcomes for chronic diseases (in this case diabetes) among the population MetroHealth served (over almost a decade) Special thanks to Dr. Randy Cebul and Dr. Peter Greco

14 Diabetes

15 Diabetes

16 Diabetes

17 Diabetes Care % /1/2007 3/1/2008 6/1/2008 9/1/ /1/2008 3/1/2009 6/1/2009 9/1/ /1/2009 3/1/2010 6/1/2010 9/1/ /1/2010 3/1/2011 6/1/2011 9/1/ /1/2011 3/1/2012 6/1/2012 9/1/ /1/2012 3/1/2013 6/1/2013 9/1/ /1/2013 3/1/2014 6/1/2014 9/1/ /1/2014 DM_CARE A1CDONE NEPHRO EYEEX PNEUMO Diabetes care measures: diabetic eye exam performed (EYEEX) pneumococcal vaccination (PNEUMO) Monitoring/treating kidney impairment with ACE inhibitors or ARBs (NEPHRO) A1c performed (A1CDONE) Interventions: 1-updated BPAs, 2 comparative reports (initial), 3 diabetic patient care plans (letters), 4 discrete documentation for eye and foot exams, 5 comparative reports w/ financial incentive, 6 updated diabetic patient care plans (goals, barriers, and interventions functionality), 7 Synopsys reports, 8 updated provider level diabetic patient lists

18 Diabetes Care 60 % /1/ /1/2008 6/1/2008 9/1/ /1/2008 3/1/2009 6/1/2009 9/1/ /1/2009 3/1/2010 6/1/2010 9/1/ /1/2010 3/1/2011 6/1/2011 9/1/ /1/2011 3/1/2012 6/1/2012 9/1/ /1/2012 3/1/2013 6/1/2013 9/1/ /1/2013 3/1/2014 6/1/2014 9/1/ /1/2014 DM_CARE % EYE % NEPHRO 40 12/1/2007 5/1/ /1/2008 3/1/2009 8/1/2009 1/1/2010 6/1/ /1/2010 4/1/2011 9/1/2011 2/1/2012 7/1/ /1/2012 5/1/ /1/2013 3/1/2014 8/1/ /1/2007 4/1/ /1/ /1/2008 4/1/2009 8/1/ /1/2009 4/1/2010 8/1/ /1/2010 4/1/2011 8/1/ /1/2011 4/1/2012 8/1/ /1/2012 4/1/2013 8/1/ /1/2013 4/1/2014 8/1/ /1/2014 % PNEUMO % 100 A1CDONE 85 12/1/2007 5/1/ /1/2008 3/1/2009 8/1/2009 1/1/2010 6/1/ /1/2010 4/1/2011 9/1/2011 2/1/2012 7/1/ /1/2012 5/1/ /1/2013 3/1/2014 8/1/ /1/2007 4/1/ /1/ /1/2008 4/1/2009 8/1/ /1/2009 4/1/2010 8/1/ /1/2010 4/1/2011 8/1/ /1/2011 4/1/2012 8/1/ /1/2012 4/1/2013 8/1/ /1/2013 4/1/2014 8/1/ /1/2014

19 Diabetes Outcomes % /1/2007 2/1/2008 4/1/2008 6/1/2008 8/1/ /1/ /1/2008 2/1/2009 4/1/2009 6/1/2009 8/1/ /1/ /1/2009 2/1/2010 4/1/2010 6/1/2010 8/1/ /1/ /1/2010 2/1/2011 4/1/2011 6/1/2011 8/1/ /1/ /1/2011 2/1/2012 4/1/2012 6/1/2012 8/1/ /1/ /1/2012 2/1/2013 4/1/2013 6/1/2013 8/1/ /1/ /1/2013 2/1/2014 4/1/2014 6/1/2014 8/1/ /1/ /1/2014 DM_OUT A1CLT8 BPLT14090 LDLLT100STAT BMILT30 NONSMOKING Diabetes outcome measures: not smoking (NONSMOKING) blood pressure <140/90mmHg (BPLT14090) body mass index <30 (BMILT30) LDL<100 or on statin (LDLLT100STAT) achieving optimal glycemic control (HbA1c <8%) (A1CLT8) Interventions: 1-updated BPAs, 2 comparative reports (initial), 3 diabetic patient care plans (letters), 4 discrete documentation for eye and foot exams, 5 comparative reports w/ financial incentive, 6 updated diabetic patient care plans (goals, barriers, and interventions functionality), 7 Synopsys reports, 8 updated provider level diabetic patient lists

20 Diabetes Outcomes % DM_OUT 12/1/2007 4/1/2008 8/1/ /1/2008 4/1/2009 8/1/ /1/2009 4/1/2010 8/1/ /1/2010 4/1/2011 8/1/ /1/2011 4/1/2012 8/1/ /1/2012 4/1/2013 8/1/ /1/2013 4/1/2014 8/1/ /1/2014 % BPLT /1/2007 4/1/2008 8/1/ /1/2008 4/1/2009 8/1/ /1/2009 4/1/2010 8/1/ /1/2010 4/1/2011 8/1/ /1/2011 4/1/2012 8/1/ /1/2012 4/1/2013 8/1/ /1/2013 4/1/2014 8/1/ /1/2014 % /1/2007 5/1/ /1/2008 3/1/2009 8/1/2009 1/1/2010 6/1/ /1/2010 4/1/2011 9/1/2011 2/1/2012 7/1/ /1/2012 5/1/ /1/2013 BMILT30 3/1/2014 8/1/2014 % /1/ /1/2008 8/1/ /1/2008 4/1/2009 8/1/ /1/2009 4/1/2010 8/1/ /1/2010 4/1/2011 8/1/ /1/2011 4/1/2012 8/1/ /1/2012 4/1/2013 8/1/2013 NONSMOKING 12/1/2013 4/1/2014 8/1/ /1/2014 % /1/ /1/ /1/2008 3/1/2009 8/1/2009 1/1/2010 6/1/ /1/2010 4/1/2011 9/1/2011 2/1/2012 7/1/ /1/2012 5/1/ /1/2013 A1CLT8 3/1/2014 8/1/2014 % /1/2007 4/1/ /1/ /1/2008 4/1/2009 8/1/ /1/2009 4/1/2010 8/1/ /1/2010 4/1/2011 8/1/ /1/2011 4/1/2012 8/1/ /1/2012 4/1/2013 LDLLT100STAT 8/1/ /1/2013 4/1/2014 8/1/ /1/2014

21 Diabetes in Cleveland area ( Electronic health records and quality of diabetes care. Cebul RD, Love TE, Jain AK, Hebert CJ. N Engl J Med Sep 1;365(9):

22 Diabetes Financial ROI ~8% of diabetics (881 patients) had overall improved care A1C, lipids, and blood pressure control program saves 7-10% of healthcare expenses for diabetic patients (~$75-$100 per patient per month; ~$900-$1200 per patient per year) $1020 X 881 = ~$900,000 in healthcare savings annually (estimated initial costs of EHR/technology implementation - ~$250,000) (estimated annual ongoing costs of EHR/technology implementation - ~$25,000) Fitch K, Pyenson BS, and Iwaasaki K. Medical Claim Cost Impact of Improved Diabetes Control for Medicare and Commercially Insured Patients with Type 2 Diabetes. Journal of Managed Care Pharmacy. 19(8):

23 Diabetes Financial ROI Changes in Hospitalizations for ACSC in Cuy. Co. DM, HF, & HBP -4.7% # of Hospitalizations for ACSC 120, ,000 80,000 60,000 40,000 20, , , % 72,039 65, % 41,35642,958 County Better Health non-bh

24 Diabetes Financial ROI AVERTED: 2,200 HOSPITALIZATIONS $15.4 MILLION IN COSTS Averted Hospitalizations Increased Each Year # of Hospitalizations Averted and Cost Savings [Cuyahoga County] 2,500 2,000 1,500 1, ($3.5M) 830 ($5.7M) 848 ($6.3M) 2,210 ($15.4M) Academy Health, Total

25 Diabetes Financial ROI 17 amputations averted!!!!!! BETTER CARE -> BETTER HEALTH -> LOWER COSTS

26 Case #3 Acinetobacter/MDRO We are having an outbreak of multi-drug resistant Acinetobacter. This is an emergency. You have to fix this as soon as possible. -Director of Infection Control (call to CMIO cell phone)

27 Acinetobacter/MDRO Opportunity Statement How can the electronic health record be used to assist in an overall MetroHealth System response to Acinetobacter specifically and multidrug resistant organisms generally. Special thanks to Matt Kaufman and Jen Conti

28 MDRO in Patient Header

29 MDRO in Patient Name Hyperlink

30 MDRO Clinical Decision Support

31 MDRO Notification to Other Staff

32 Acinetobacter Population Reporting Tool for infection control staff along with: Daily s Paging upon admission of positive patient or positive culture

33 Results UGM hyperlinked patient header, 2 hyperlinked isolation status, 3 MDRO SBAR report, 4 MDRO schedule column, 5 MDRO best practice alert, 6 Acinetobacter/MDRO patient lists with daily s, 7 MDRO patient pages from ADT system to infection control staff, 8 MRDO surveillance culture order Association of Medical Directors of Information Services (AMDIS) Award in 2011

34 Results 100% 95% 90% 85% 80% 75% 70% 87% 98% 98% 98% 97% 97% 98% 98% 98% 98% 99% 98% 99% 99% 99% 95% 96% 97% 98% 97% 96% 97% 98% 99% 99% 99% 98% 98% 98% 98% 96% 96% 97% 97% 97% 98% 98% 99% 95% 96% 95% 96% 94% 93% 93% 93% 93% 94% Hand Hygiene Compliance Monthly Composite for Dec 2010 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 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Summary for Hospital Acquired MDR Acinetobacter Count HAI MDR Acinetobacter Count HAI MDR Acinetobacter Rate IT interventions include: 1 hyperlinked patient header, 2 hyperlinked isolation status, 3 MDRO SBAR report, 4 MDRO schedule column, 5 MDRO best practice alert, 6 MDRO patient lists with daily s, 7 MDRO patient pages from ADT system to infection control staff, 8 MRDO surveillance culture order IT EVS notification Rate per 1000 Patient Days

35 Acinetobacter Financial ROI ~33% decrease (12/month to 9/month) in baseline Acinetobacter cases (continuing to decrease) $25,000 X 36 patients = $900,000 in healthcare savings annually (estimated initial costs of EHR/technology implementation - $100,000) (estimated annual ongoing costs of EHR/technology implementation - $10,000)

36 Davies Award Clinical Value Cases Case Description Value Heparin (high risk medications) Code Status Reconciliation Depression Screening Vaccine Adverse Event Reporting (VAERS) Automated Patient Clinical Messaging Internal Referral Completion Hospital Acquired Conditions (HACs) Core Measures Blood Pressure (HTN) Diagnoses Research and Improvement EHR tools/processes to improve Heparin use Code status reconciliation at discharge Advanced CDS for screening and initial management Automated detection and reporting of VAERS to CDC Automated texts and calls for patient reminders Reporting and processes to increase internal referrals EHR tools/processes to decrease CAUTIs and VAPs EHR tools/processes to improve CHF and ETOH measure EHR research/tools/processes for pediatric/adult HTN diagnosis PSN heparin errors with harm from 3 in 2011 to 0 >3 fold increase in non-full code code status orders Increased screening by 15 fold and detection by 230% 30 fold increase in VAERS reports # needed to message 4 (immunizations, labs, radiology) 30-day referral completion rate 48%->61% Annually 102 infection (1 death) and $2.6 M saved 10-15% CHF measure increase 25% ETOH measure increase 21% improved vital signs >100% in diagnosis 36

37 Davies Award Financial Value Cases Case Description Value Historical Ambulatory EHR ROI Last 5 years EHR ROI Cost/benefit analysis of ambulatory EHR ( ) Cost/benefit analysis of integrated EHR ( ) Ambulatory yr 5; $9.3 M direct annual benefit ~$20 M direct annual benefit; ROI even w/o federal incentives 37

38 Thank-You/Discussion This Davies award enterprise application would not have been possible without the efforts of thousands of people throughout the MHS and our partners over the last two decades. These individuals (past and present) share a vision for health information technology. They have worked and continue to work together to enable the MetroHealth System to use health information technology to help achieve the MetroHealth System s vision to be the most admired public health system in the nation, renowned for our innovation, outcomes, service and financial strength. We dedicate this Davies enterprise application to all the individuals who have helped make the accomplishments documented in the application possible and to our patients and community whose health we are continuously working to improve. - Davies Enterprise Award Dedication/Acknowledgement 38

39 Questions Dr. David Kaelber