94
EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department of Emergency Medicine Executive Director, Emergency Services Chief Innovation Officer University of Colorado Health National Quality, Clinical Risk and Safety Conference September 29, 2017

EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

  • Upload
    others

  • View
    1

  • Download
    0

Embed Size (px)

Citation preview

Page 1: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

EMERGENCY CARE REDESIGN:

THE DIGITAL NEXT STEP

Richard D. Zane, MD, FAAEM

The George B. Boedecker Professor and Chair

Department of Emergency Medicine

Executive Director, Emergency Services

Chief Innovation Officer

University of Colorado Health

National Quality, Clinical Risk and Safety Conference

September 29, 2017

Page 2: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Conflicts and Disclosures

My opinions are my own and do not represent the University of Colorado, the Board of Regents of the University of Colorado or the State of Colorado

Department and System Equity and Revenue Positions

Burst IQ

Scribe America

RxRevue

AgileMD

LeanTaas

Knowledge Factor

Page 3: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

The Digital Next Step

An abbreviated case study

Using data to inform process and improve quality

digital solutions for 3 problems

Page 4: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

UCH ED Case Study

Page 5: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

• Only academic medical center in the region

• 639 beds

• 48,909 annual admissions

• 1,000,522 outpatient encounters

• 101,374 ED visits annually

• Over 6,000 staff and faculty

• Magnet status for 10 years

• 2011 and 2012 UHC Quality Award

winner

• #1 hospital in Denver – US News & World

Report

• #15 – US News & World Report

University of Colorado Hospital

Page 6: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

$3.2 billion in revenue

10 hospitals

2,220 hospital beds

21 freestanding ED

31 total

9 Urgent Care Centers

113,315 admissions and OBS visits

11,512 babies delivered

66,111 surgeries

550,000 emergency visits

1.6 million unique patient lives

University of Colorado Health

Page 7: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Go Back to 2013

Capacity constraints

Patient and provider dissatisfaction

Damaged relations with EMS & provider community

Move to new facility

….in 8 months

Page 8: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 9: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 10: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Guiding Principles

Patient Centered

Data Driven

Central Discipline

Local Control

Page 11: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

11

“We have a strategic plan.

It’s called doing things.”

Page 12: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Setting the Vision

Focus on the wildly

important

Challenge everything

… But focus on the

wildly important

Speak with 1 voice

Page 13: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

ED Clinical Leadership Overview

ED Leadership Committee

Process

Improvement

Committee

Clinical Operations

Committee

Clinical Quality and

Safety Committee

13

Page 14: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Quality

Patient Satisfaction

Staff/Faculty Satisfaction

Patient Throughput/Flow

Hours per Patient Visit

Efficiency & Productivity

Staff Cost

Waste – Non Value Add

Variability & Errors

Sentinel Events

Patient Wait Time

Hunting & Gathering

Door to Provider Time

Budget Neutral

INCREASING WHILE… DECREASING

TO REMAIN

14

Page 15: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Process Improvement Methodologies 15

Page 16: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

16

Page 17: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Current State – Employee Mix

Providers

RNs

Techs

17

Page 18: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

18

Page 19: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Current vs. Future: Standards of Work

ROLE ACTIVITY Future % of Role

MD

Patient Care up

Waiting time (lab) down POCT

Waiting time (pt not ready) down Transfer to tech

Looking for unstocked items down Transfer to CS

Waste Time unchanged

Charting unchanged

RN

Patient Care up

Drawing blood/starting IV down Transfer to tech

Stocking down Transfer to CS

Transport down Transfer to Transport

Cleaning Room down Transfer to EVS

Waste Time unchanged

Charting unchanged

Pod Tech Patient Care up

Stocking down Transfer to CS

Transport down Transfer to Transport

Cleaning Room down Transfer to EVS

Waste Time unchanged

19

Page 20: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Evidence Based Approach 20

Page 21: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

RPM Recommendations

Increased Throughput

thru Improved Processes

Elimination

of triage and

the waiting

room

Job Righting

Team Nursing

Point of Care

Testing

Clinical

Decision

Unit

Housekeeping,

Transport,

Central Supply,

Scribes

21

Page 22: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

High Fidelity Testing

22

Page 23: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Implement

23

Page 24: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

ED Patient Flow 24

Page 25: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Standard Work: Pivot Lead Tech Owners Approved By: Revision Date

ED Charge Nurses

ED Techs

April Koehler, RN

Rob Leeret, RN

Kelly Bookman

10/4/13

Purpose Define the role of a Pivot Lead Tech

Goals: Decrease LOS, decrease door to provider, no WR, direct rooming of high acuity patients.

Scope Presentation to front entrance of the Emergency Department through placement in patient exam room or Intake room

Definitions Open bed

Pivot Lead Tech

Front End Tech

Pivot CTA

Intake Room

Red Patient

Any staffed bed in department

Minimum requirement: ED Tech with minimum 3 months experience in ED setting

combined with completion of Pivot Lead Training Class

See requirements for an ED Tech; Roles divided into Vitals Tech and Runner Tech.

Responsible for placing patient in Intake Room and/or transporting patient to

exam room in Main ED

See requirements for CTA

Chief complaint and assessment done by Intake MD. Initial vital signs done by front

end vitals tech

High acuity patient…..

25

Page 26: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Intake/Front End Best Practices

Male exposure to STD

URI symptoms

Rash

Extremity pain after minor trauma

Back pain w/o neuro deficits

Dental pain

Medication refills without symptoms

Chronic pain

Low mechanism MVC

Conjunctivitis with no concern for corneal abrasion

Classic UTI symptoms in otherwise healthy young female

Mild cellulitis

Insect bite

Mild allergic reaction

Wound check

Suture removal

Mild anxiety

Numbness/tingling with normal neuro exam

Neck pain

Epigastric pain classic for gastritis

26

Page 27: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

27

Page 28: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

* no previous data * no previous data * no previous data

* no previous data

* no previous data

99218 OBSERVATION CARE,LVL I

33.7% 17.5% 2.48

23.8% 25.5% -0.52

Standard Deviation vs.

Department MeanDept MeanProvider

CY15 DC from Intake

CY15 Sent to Supertrack

ECG Performed for Presenting Complaint of

Chest Pain (PQRS#54) or Syncope

(PQRS#55)

Provider Department Mean

100% 98.50%

FY15 Q3+Q4 12.09 7.82 3.52 FY15 Q3+Q4 3.02 2.13 3.03 FY15 Q3+Q4

DR. RICHARD D ZANEProvider Dashboard, Updated Through December 2015

RVU per Hour Worked Patients per Hour Worked - Main Department Overall Length of Stay - Main DepartmentProvider versus Dept Mean - 6 Quarter Analysis Provider versus Dept Mean - 6 Quarter Analysis Provider versus Dept Mean - 6 Quarter Analysis

164 183 1.19

Provider Dept Mean

Standard Deviation vs.

Department MeanProvider Dept Mean

Standard Deviation vs.

Department Mean Provider Dept Mean

Standard Deviation vs.

Department Mean

137 181 2.29FY16 Q1+Q2 3.25 2.11 4.29 FY16 Q1+Q2

Provider Dept Mean

Standard

Deviation vs.

Department Mean Provider Dept Mean

Standard Deviation

vs. Department

Mean

FY15 Q3+Q4 ED LOS for Inpt Admit (Door to Order) 137 185 4.42

143 118 -0.69FY15 Q3+Q4 ED LOS - Discharge Pts 183 200 0.88 FY15 Q3+Q4 ED LOS - Door to ED CDU Admit Order

FY16 Q1+Q2 ED LOS for Inpt Admit (Door to Order) 129 183 2.84 CDU Admit Decision to Depart - Not Included in Overall ED Length of Stay

FY15 Q3+Q4 CDU LOS Overall (Admit Order to DC, IP, TF Dispo) (hrs) 10.1 10.7 0.26

Percent of Total Billed Evaluation & Management, Critical Care and Observation Codes Q3 & Q4 FY15 Comparison

FY16 Q1+Q2 CDU LOS Overall (Admit Order to DC, IP, TF Dispo) (hrs) 9.8 10.5 0.37

Based on UPI Billing Data Provider Q1 & Q2 FY16 Dept Mean Q1 & Q2 FY16Provider Q3+Q4 FY15 Dept Mean Q3+Q4 FY15

CRITICAL CARE 99291 CRITICAL CARE,FIRST 30-74 MIN 2.7% 5.6%4.6%

99282 EMERG VISIT-LVL II 1.2% 0.7%

4.0%

99292 CRITICAL CARE,EA ADD 30 MN 0.0% 0.4%0.0% 0.0%

99285 EMERG VISIT-LEVEL V 24.2% 45.9%21.3% 28.0%

OBSERVATION 99234 OBSERV/HOSP SAME DATE/LOW 0.0% 0.0%0.0% 0.0%

99236 OBSERV/HOSP SAME DATE/HIGH 0.0% 0.1%0.6%

99235 OBSERV/HOSP SAME DATE/MODERATE 0.0% 0.0%0.0% 0.0%

Intake Metrics

99217 OBSERVATION CARE DISCHARGE 0.0% 0.2%0.0% 4.0%

99219 OBSERVATION CARE,LVL II 0.0% 0.0%0.3% 1.0%

99220 OBSERVATION CARE,LVL III 0.0% 0.7%3.7% 7.0%

1.0%0.0% 0.1%0.3% 2.0%

99284 EMERG VISIT-LVL IV 44.8% 26.0%

FY16 Q1+Q2 13.00 7.01 *

Provider versus Dept Mean - 6 Quarter Analysis

Discharge Length of Stay and ED LOS for Inpt Admit (Door to Order)

FY16 Q1+Q2 ED LOS - Door to ED CDU Admit Order 74 114

Provider versus Dept Mean - 6 Quarter Analysis

Door to ED CDU Admit Order and CDU LOS Overall (Admit Order to DC, IP, TF

Dispo) - Main DepartmentMain Department

Total FY16 Outside CME Hours Earned

1.50

1.74FY16 Q1+Q2 ED LOS - Discharge Pts 157 195 1.74

39.9% 28.0%

0.0% 1.0%

99283 EMERG VISIT-LVL III 25.8% 19.7%29.0% 23.0%

EMERG 99281 EMERG VISIT-LVL I 1.2% 0.6%0.3% 1.0%

-2.9% -0.4% 0.6% 0.5% 6.1% 18.9% -21.7% 0.0% 0.0% -0.1% -0.1% 0.0% -0.7% -0.2%

-10000.0%

-8000.0%

-6000.0%

-4000.0%

-2000.0%

0.0%

0.0%5.0%

10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%50.0%55.0%60.0%

99291 CRITICALCARE,FIRST 30-74 MIN

99292 CRITICAL CARE,EAADD 30 MN

99281 EMERG VISIT-LVL I 99282 EMERG VISIT-LVL II 99283 EMERG VISIT-LVL III 99284 EMERG VISIT-LVL IV 99285 EMERG VISIT-LEVELV

99234 OBSERV/HOSPSAME DATE/LOW

99235 OBSERV/HOSPSAME DATE/MODERATE

99236 OBSERV/HOSPSAME DATE/HIGH

99218 OBSERVATIONCARE,LVL I

99219 OBSERVATIONCARE,LVL II

99220 OBSERVATIONCARE,LVL III

99217 OBSERVATIONCARE DISCHARGE

CRITICAL CARE VISITS-EMERG VISITS-OBSERVATION

Provider Q1+Q2 FY16 Provider Q3+Q4 FY 15 Dept Mean Q1+Q2 FY16

0.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

Q3 (Jan - Mar) Q4 (Apr - Jun) Q1 (Jul - Sept) Q2 (Oct - Dec) Q3 (Jan-Mar)

FY15

Provider Dept Mean

Pts/Hr

0.00

0.50

1.00

1.50

2.00

2.50

3.00

3.50

4.00

Q1 (Jul - Sept) Q2 (Oct - Dec) Q3 (Jan-Mar) Q4 (Apr - Jun) Q1 (Jul - Sept) Q2 (Oct - Dec)

FY15 FY16

Provider Dept Mean

RVU/Hr

FY16 % Difference from Mean

Percentof Total

Mins

0

50

100

150

200

250

Q1 (Jul - Sept) Q2 (Oct - Dec) Q3 (Jan-Mar) Q4 (Apr - Jun) Q1 (Jul - Sept) Q2 (Oct - Dec)

FY15 FY16

Provider Dept Mean

0

50

100

150

200

250

Q1 (Jul - Sept) Q2 (Oct - Dec) Q3 (Jan-Mar) Q4 (Apr - Jun) Q1 (Jul - Sept) Q2 (Oct - Dec)

FY15 FY16

Provider - DC LOS Dept Mean - DC LOSProvider - ED LOS for Inpt Admit (Door to Order) Dept Mean -ED LOS for Inpt Admit (Door to Order)

Mins

0.0

5.0

10.0

15.0

20.0

25.0

020406080

100120140160180200

Q1 (Jul - Sept) Q2 (Oct - Dec) Q3 (Jan-Mar) Q4 (Apr - Jun) Q1 (Jul - Sept) Q2 (Oct - Dec)

FY15 FY16

Provider - Door to ED CDU Admit Order Dept Mean - Door to ED CDU Admit order Provider - CDU LOS Overall Dept Mean - CDU LOS Overall

Mins

Overal l LOS (Hrs)Std Dev

Std Dev

Std DevStd DevStd Dev

01/28/2016 01:48 PM

Page 29: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 30: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 31: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Results

31

Page 32: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

39

9

11 10

9 9 9 8

9 8

9 8 8

0

50

100

150

200

250

300

0

5

10

15

20

25

30

35

40

45

Num

ber

of

Patient

s -

Cens

us

Min

utes

- D

oor

to P

rovi

der

Door to Provider

Median minutes Goal Daily Census

32

Page 33: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

3.50%

0.65% 0.64%

0.23% 0.31% 0.27% 0.21% 0.18%

0.39% 0.28% 0.30% 0.26%

0.16%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

Perc

ent

of

Tota

l Patient

s Seen

LWBS

LWBS Goal

33

Page 34: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

34

204

172 182

173 165

158 159

147 152 151 147 150 150 148

0

50

100

150

200

250

6m prior to go-live2013 Q4 2014 Q1 2014 Q2 2014 Q3 2014 Q4 2015 Q1 2015 Q2 2015 Q3 2015 Q4 2016 Q1 2016 Q2 2016 Q3 2016 Q4

Min

utes

DC LOS Minutes Goal

Page 35: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

ED Staff Cost

$10,000

$11,000

$12,000

$13,000

$14,000

$15,000

$16,000

$17,000

$18,000

$19,000

250

300

350

400

450

500

550

600

650

700

750

Hrs/Day vs. Cost/Day

Hours

Cost

Hrs/Day Cost/Day

Pre Post

35

Page 36: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

National Database for Nursing Quality Indicators Mean Practice Environment Scale

75th

Percentile

25th

Percentile

90th

Percentile

90th

Percentile

90th

Percentile

Page 37: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Comparison to Benchmarks 37

Page 38: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

ADD PAPER HERE

Page 39: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

39

Page 40: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Process and Quality Redesign Site Visitors (2013-

Present)

Page 41: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

But………

Variability

Dissemination

Pace of Change

Can technology really be deployed in healthcare without

increasing cost and decreasing efficiency?

Page 42: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 43: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

43

Page 44: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 45: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 46: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 47: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 48: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 49: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

What about healthcare?

Page 50: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 51: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

pharyngitis

470,000

3,320

Page 52: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

How do we do this?

Embrace Innovation

Embrace Industry

Don’t reinvent the wheel

Take advantage of Colorado

CARE Innovation Center

Page 53: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

# 7 DIGITAL

HEALTH

FUNDING,

USA

145M INVESTMENTS

MADE IN 2015

125 ECOSYSTEM

COMPANIES

2015

TOP

10 DIGITAL HEALTH ACTIVITY

Colorado Digital Health

Ecosystem

Page 54: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Cedars Sinai

Mayo Clinic

Partners Health

Providence

Innovation Space Competition

Stanford

Cleveland Clinic

Johns Hopkins

UPMC

Integrated Academic Health Systems

Intermountain

Florida

Page 55: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Applied Decision Science Lab

• Team • Clinician Subject Matter Experts

• Physician Informaticists

• Physician programmers

• Implementation Scientist

• Economist

• Data architects

• Data scientist

• Data analyst

• Venture analyst

• One robust instance of an Electronic

• Horizontally and vertically integrated

healthcare system as lab

Page 56: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 57: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Solve problems

Would we want to be a customer If we do, you likely will

Is there a revenue opportunity

Is there an equity opportunity

Does the partner have a team

Have they had success

Are they well funded

Page 58: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Three problems (maybe yours?)

Nobody follows guidelines and Clinical Decision Support is too hard

Hard stops

Too many clicks

Nobody follows paper guidelines or leaves their work-flow

Over prescribing

Opioids are killing people

Can’t remember every medicine

Knowledge dissemination

Emailing a presentation and quiz is not dissemination

Page 59: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Can an EMR help providers make informed

decisions?

85%

5-75%

1/5

Alert/warning fatigue

24/7/365 50%

Clicked into submission

Kung, J, et al, Failure of Clinical Practice Guidelines to Meet Institute

of Medicine Standards

JAMA, 2012;172(21):1628-1633

Page 60: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

60

Page 61: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Can CDS be better?

Integrated into workflow

No hard stops

No alerts

Fewer clicks

Page 62: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Background

62

Goal: To integrate evidence based CDS into the EHR workflow

Approach

2013 The White Binder

2014 ED Physician Dashboard

Integrated into Epic clinical workflow!!!

Page 63: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 64: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

“SMART PathwaysTM” For Emergency Care

AgileMD is a software platform

that streamlines clinical workflow

and supercharges clinical decision

support within a health system’s

electronic medical record system.

Page 65: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

HOME

ALL PATHWAYS

ORDER-INTEGRATED

Page 66: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

<Insert graphic/screenshot/illustration>

QUEUE UP MULTIPLE ORDERS

HYPERLINK TO ORDER

Page 67: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

In a year

Page 68: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

v

Page 69: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

v

Page 70: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

\

Length

of

Sta

y in

ED

(min

ute

s)

Decreasing Length of Stay

Chest Pain

↓ 39 mins (18%)

Etoh

↓ 150 mins (62%)

Migraine

↓ 67 mins (36%)

Page 71: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Decreasing Variance in Length of Stay

Page 72: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Next

Nursing

Oncology

Thoracic Surgery

Primary Care

Page 73: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

The Prescribing Problem

Indications change day to day

Antibiotics are incorrectly and overprescribed

Patients have skin in the game

Opioids are a scourge

Biologics and immunotherapy

Page 74: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 75: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

75

The New Way Of Prescribing - Discharge Guidance

Page 76: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

76

Select Medication

Page 77: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

77

The New Way Of Prescribing - Sign Order

Page 78: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

78

UCHealth Development Partnership Results

• Launched October 2016

• Currently used by 182 prescribers in UCHealth’s largest ED

• Has been used for more than 2,000 prescription decisions since launch

• Prescribers are selecting an RxCheck recommendation 55% of the time

• Selection of RxCheck recommendations has grown 28% since launch

• UCHealth has identified 10 minutes of time savings, per prescriber during

each shift

Page 79: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Outcomes Data

Page 80: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Next

Expand to all 30 ED’s

Include >75% of all medications

Pilot with primary care

Pilot with Heart Failure

Partnership with Novartis

Partnership with Anthem

80

Page 81: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Opioids

Epidemic

Regulation

Prescription Drug Monitoring Program (PDMP) is next

to useless

81

Page 82: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

PDMP and Appriss

Page 83: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Appriss/PDMP platform

Page 84: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Appriss/PDMP platform

Page 85: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Results

Significant decrease in New prescriptions

Significant decrease in pills prescribed

Significant decrease in provider variability

PDMP utilization increased from 9% to 75%

Page 86: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Knowledge Dissemination

If it’s important, how do we teach 400 staff?

Is an emailed powerpoint and quiz the best we can

do?

HealthStream

Page 87: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

• Founded in 2000 and is based in Boulder, Colorado - formerly

known as Vivis Inc.

• Neuroscience-based education develops a learning software that

improves knowledge transfer and enables long-term learning

• Accelerated memory protocol systematically translates information

from a textbook, training document, or study material into a

learner’s long-term memory.

• Uses memory and learning characteristics to focus on acquiring,

retaining, and recalling.

• Professional test prep, industry (food, manufacturing)

Page 88: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Amplifire helps

hospitals find and fix the

confidently held

misinformation that

leads to patient harm

and financial loss.

Page 89: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 90: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 91: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department
Page 92: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Results

Knowledge acquisition and retention increased

significantly

Significantly higher pass rate

Outcomes pending……

Page 93: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

Our Partners

Active

Actively Pursuing

Inactive

XebraPro

CodaMedica

Hatten Antidot

e

SupplyNET

Nicklas App

iImpact

LifeBoard

Axlepia

Pending

Page 94: EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP · EMERGENCY CARE REDESIGN: THE DIGITAL NEXT STEP Richard D. Zane, MD, FAAEM The George B. Boedecker Professor and Chair Department

94

THANK

YOU