Industry sign banking oregon medical history myself
and also I think a very interesting speakers dr. Amy shamaton she medical information officer chief medical informatics officer also she's board-certified in internal medicine and in clinical informatics her med school is from here at OHSU her residency is from legacy she's also a double that she told me and so she is as local as it gets and John Kenickie dr. Hagee is is senior vice president and CIO of legacy you are so good the c-suite you can't get that is wrong and also you know he's well known to us because he's faculty here at demise and many of you have actually taken his excellent business informatics course which is awesome thank you 1997 and then he's an engineer training masters of Health Administration and Joe Nash was on my dissertation committee and John has actually been at OHSU before anetha VA and at Providence so comes to legacy with an extraordinary perspective on both healthcare as well as this is a clinical informatics Grand Rounds and therefore it is eligible for one hour of a MapR a category one credit and if you're a physician and you wish to avail of this after at any time email Lynch Wahby at SC h p WB SCH wabe l at OHSU dot edu and for those of you who are outside if you tweet the app OHSU informatics with the hashtag team icon we can take your questions if you have any at the end of the talk and so with that long-winded introduction welcome and I will see for the floor so welcome to OHS use water birthing class is not we're gonna be talking about it and everyone on the audio audience just didn't get that joke but there was a sign when we walked in water birthing class so I'm John Koenig yzma thank you very much dude for having us for having both Amy and me here we're gonna talk about EMR adoption model and the journey that organizations take in a EMR adoption but I'll start with a little bit about us thank you for mentioning we added this picture Silverton health down in Silverton is the rural health system that just joined our family officially yesterday June first was our kickoff we have two hospitals very large system but we're locally and we've had a long a.m. our journey we are on Epic we started the epic journey around 2008 in conceptual basis I was here CIO for the Center for Health and healing and then turned over to the hospital and I from that conversation from that interaction with epic just became a epic true believer you sort of join a cult when you work with that back they are an amazing company but what we want to talk about here is accreditation and this EMR adoption model so hims just definitions to start we'll use the acronyms a lot hymns is the professional Society for health IT practitioners it has both vendors and practitioners like us it is the healthcare information and management system Society and a number of years ago we'll talk about the history they adopted this model called the MRAM or EMR before EHR was or her if Microsoft resells fell checks your adopt your acronym EMR adoption model is what I wanted to start with this is the audience participation what designations or accreditation are you familiar with that hospitals seek you probably have badges on or big banners on oh it's just you hospital or Doernbecher hospital and you call out any you know Jayco the Joint Commission there are lots of them there are lots of them around that are awards and designations the hospital will go for MRAM is one of them legacy has a number of these and so just to set the stage for sort of these the idea of having external accreditation come in and look at your standards obviously the College of American Pathologists you're running an accredited lab you need to have a survey as we mentioned the Joint Commission drink Commission also has centers of excellence so do a lot of health professional societies and professional organizations so not to be outdone the hims professional Society or healthcare IT adopted this model for for for health care and let me turn it over to Amy who talks about what stage 7 the highest 8 means so I think the slide says it all what are you lunch now so just again a little bit of background so as many of you know hims is a nonprofit organization whose goal is to promote the best of information technology and management systems in the healthcare industry and their vision is really around improving health for the better use of technology and information and so they have created this adoption model for the EMR the purpose of which is to ensure that the most relevant clinical information is available to the clinical decision maker at the right place and at the right time so they created this model for the acute care setting in 2005 and it really reflects a typical manner in which a hospital system might progress toward a paperless system and introduces the concept of this roadmap they subsequently developed an ambulatory model in 2010 and now they have a continuity of care model which they developed in 2013 so it's a progressively sophisticated model starting with those systems that may be lab but not pharmacy or maybe radiology and lab but not pharmacy or whatever and progressively gets more sophisticated now interestingly this is not a static designation so when we validated for stage 7 in 2013 we met all the criteria obviously we became stage 7 we are now looking at revalidating which you do every three years and new things have come along so blood product administration module or blood bank matching is new so that's something that we have to raise our standard tune in order to meet stage 7 at this time breast milk scanning and another one that between our validations was the our code medication administration in the IDI as well as everywhere else so there's and then the other piece of this is that in 20 in January 2017 hims is looking at releasing essentially different criteria for all these stages so progressing the model forward and I believe stage zero essentially does way so state zero will then be the ancillary lab radiology and pharmacy all installed will now be stage zero so not all the stages come down like one step but they're there making the model more sophisticated just where do you think American healthcare data repository data from their from their documentation stage but the biggest part of validating for stage tell your story they can actually use the data that you're collecting in your system that no clinical data that's important sit on in a scanning basket for more than 24 hours and then other that's the benchmark is the vitals are integrated in nice use to show interoperability so caribou wear is great if you pair everywhere is only exchanging with other epic systems that doesn't count for this for stage seven you actually have to exchange with a non epic system at least one and and that bar will go up as well I'm sure all medications in epic even if you have to show that that that information gets put into the record at some point in time so it's important that you can then look at the full patient record and see what medications were administered through their Hospital course you have to show that you're using you don't have a culture of doctors walking by and giving verbal orders that would never happen right Jim every electronic repackaging variation 95% on barcode medication administration and what this means is that they at least tried to scan the medication in the patient ninety-five percent of the time it doesn't have to be successful because you know for multiple reasons barcode medication administration scanning is if the label gets a little upset with a little bend or something they don't scan very well and then as I mentioned earlier the breast milk and blood scanning for ambulatory stage one is access to clinical information stage two again the clinical data repository stage three clinical documentation support and basket functionality Stage four again CPOE with a prescribing as an as a at least being available and then Stage five as much around that patient health record and what we would call my chart Stage six includes some best practice advisories and health maintenance modifiers and patient reminders so reminding patients to come in for their health maintenance such as colonoscopy and then stage seven interoperability did analytics with the tools in epic parlance cooperative's care scenarios care everywhere exchanges as we discussed in the inpatient realm and then more than 95 percent CPOE for ambulatory so why profile with a stage seven organization is to use data to drive improved outcomes related to process ease financial clinical quality and safety and it's essentially so getting to dogs question the majority of hospitals are at Stage five with many moving toward Stage six and stage seven and then you can see on the ambulatory side the majority is actually down in stage one and two forward it's still a couple things one one of the things that would that surprised me is still two-person the hospital 2% of six thousand hospitals remain without lab radiology and pharmacy all three of them I mean just have those which have been around since the to get to get to stage one you have all three of those when hims got involved with the incoming Obama administration eight years seven years ago when we were putting together the work on ARRA the American Recovery and Reinvestment Act which provided the funding or meaningful use of certified electronic health records so folks from the incoming administration called hims to say you know we want to invest money and we'd like to get eletronic health records across the board and certainly get CPOE and closing the bar code medication administration but you get to the stage for where you have physician documentation and pharmacy online and what that would cost and so that's worth a twenty billion dollars from we use the goal was to get every US hospital to stage for the life of the HITECH Act and there's still about twenty percent more than 30 percent more than forty percent I mean so Stage six and seven across the u.s. is at what just over thirty percent okay verdict sis stage seven but if you include Stage six so 30 hospitals there's sixty five hospitals and Oregon's that were so pretty good adoption in the state of Oregon those five hospitals four of them are legacy is one of them is Kaiser oh it just you is not Steven so I thought it was pretty cool so this shows how long it takes to dig make national progress so over the course of nine years we've taken the majority of hospitals have gone from stage one and two five and six pretty impressive adoption rate over over time particular stage I went hospitals kind of get stuck where yeah I think it's a great question I think CPOE to get to stage seven of ninety 90 percent CPOE is hard I think that's a that's a that's a real this is an order entry I think is a real high Bertil high or a high hurdle to it yet I I think that the for us at legacy and here I think here the I would have talked to John done a lot about sort of our journey and I think OHSU is state is state six the scanning so the amount of paper like in the behavioral health units barcode administration medication administration in behavioral health and there's sort of the amount of paper you really to get from six to seven is really sort of no clinical paper generated that is a that is a very high bar how are those is it the data is that the right data views your denominator the number of hospitals are a number of hospital beds because again if you have twenty hospitals that have 30 beds each and that's only three percent of the hospital beds in the state I think it's a much different I think you're right certainly academic medical centers have historically been high on adoption of IT large systems epic systems which of course epic cells generally to the large and then it's us who have to host for a smaller but I think you're right in terms of us beds I bet that percentage would be a lot higher I'm just gonna say though I'm not sure it depends what you what you're looking for because the hospitals might be a better representation of patient access to you know a high stage Hospital care right I mean yes they might only have a few beds in some rural place but that's there's that whole community I think there's a huge barrier of course of cost so for legacies journey was about a hundred million dollars of capital and another hundred million in the operating so about a the budget for epic was about a hundred and twelve million we finished around 93 million so we came in under budget but that for us the meaningful use dollars represented about forty million dollars so it's really and that was my experience at Providence and I left here before we got meaningful yoose dollars in but roughly I've heard that average that about forty percent of your costs in EMR implementation will be covered by federal grants through Medicaid and Medicare through the meaningful use program but you have to come up with the sixty percent and that's that's a lot at Providence our investment was just over just north of 1 billion dollars yes yes the 40% is not given to you upfront its recovery a couple years later maybe I think it's the other thing for for ambulatory is the doctors offices that have to you know adopt and now with Macra I mean they're more for private physicians in private practice EMR adoption is is a high bar we host for a number of physicians it's a $5,000 upfront cost it was $15,000 and we're reducing that as we donate through a program that legacy offers are witches who doesn't offer that positions but there's just a high hurdle the other thing I think that it's a hurdle is stages of EMR so epic was our third EMR at Silverton which will go on epic in about 11 months they have five current EMRs we're just talking to st. Charles and Bend both OHSU and legacy have been friendly you know brethren to the st. Charles facility and they're there they have decided to go epic epic will be their fourth EMR in the last seven years so it's just it's so highly disruptive I think people are scared of it and it's a lot of money and a lot of organizational risk but done right it can mean a good difference a journey to China there-there adoption is coming along and they're very interested in this model internationally now as a benchmark so it'll be interesting changes over the next year so the road to stage 7 so to do stage 0 to 5 is really a online self-assessment so it's you answering questions about your system and organization and it places you essentially in a in a certain stage when you get to stage 6 you continue to do that online assessment and then you apply to essentially have a verification call we you get questioned pretty comprehensively about your system and such and then either do or don't get awarded stage 6 for stage 7 it's those first two it's the online self-assessment it's a online or it's a telephone call and then you have your criteria you then have an on-site visit with three reviewers including the hims representative an active CIO and an active CMIO from other systems so it's it's a it's a it's it's a reasonably rigorous day of system I'm more sedentary but both Amy and I are hims seven evaluators yeah yeah oh thanks so this is just an example of the day of the visit so you actually spend the majority of the morning sharing your story including how you've used your data and analytics to improve care and to improve your business operations so that's actually quite in my presence it's actually quite a fun piece of this because it actually celebrates the work that you and the team have done over time and when you go back and look at how much you've accomplished it's just it's actually really great for the group you then start doing floor visits and the the group of three goes on to the units and starts looking around for paper and starts asking questions and I'll tell some more stories about that later in the presentation they do take a good look at your medical records department because there's a lot to find in there the emergency department you go to pharmacy radiology you actually go to lab I miss that on here apologize and then the reviewers go off into a secluded room and make their decision as to whether you have successfully achieved the criteria for stage seven yeah what's the success rate when you get
somebody to come out and do that I mean today it's it's reasonably high but because they do that that pre-call to make sure that you're actually on track but I can tell you that some of the visits that I've been on it the team has been running around because they haven't really made their case in that first presentation as to how they're actually using data it's really interesting how hard that is for some teams to relay even I mean they have scads of data and they're doing all sorts of stuff but actually to really present that and show how it is affecting patient outcomes or or business outcomes or whatever you know they're they're trying to prove it's actually harder than then one might think and so I've actually I've done two were pretty but the team was like as you're as you're going around and and you're on the wards and looking at stuff if you've told them after their presentation that you didn't quite get this piece or one of them was actually with with ours it was actually coming up with a story around our disaster recovery because our servers our backup servers are in the same geographic location they're in stains if code barely blocks away and and that was an issue for the reviewers and so coming up with what our strategy is to deal with that and where we will be so I did the multi care review multi care is the system sort of like legacy in Tacoma and they were only evaluating one hospital to be stage seven and it was sort of their their lower acute not their their main hospital and what we found was there were there was paper which is okay paid clinical relevant paper generated and they had h-i-m come through and every day twice a day would go through the hospital and bring it down to central scanning and put it into epic but they didn't do that route they didn't do that run on Saturdays and son and and the requirement is that anything that's clinically relevant this paper is in online within 24 hours and so we gave them we didn't pass them but we said if you certify and then we had one of our reviewers go back to confirm but if you actually just start that means I am going around Saturdays and Sundays we would mean it was it's a rigorous but I would echo Amy's point that there's so much organization doesn't have to pay for it in downloading a sport except the recertification the organisation has to do so Tim's is putting a lot they pay our travel and expenses to go to the safe zone it's a fairly extensive a lot of money to pay so they want to make sure you're really ready before you do the on-site evaluation so what is the motivation for the hospital to go through this rigorous process what do they get in the end for it you were here's my slide than the next one of the things that I think that is important is that it is a national benchmark so it's you can guide yourselves against against something that says basically on a journey for electronic health record we it's one of the things that I struggled with and coming back and presenting it's plaque that goes in the lobby of all of our hospitals really beautiful and I think paperless and I said I know speaking to you all physicians it's hard for me to you know I recognize this is a journey and we need to continue to improve usability and the flow and the design electronic health records still are in their infancy there's a huge dependency of course on them but but having a benchmark I think is wonderful it is an externally validated measure of excellence so your achievement I think there's this other one the recognition and operation of incredibly hard work to really get to that point requires clinician leadership technology you know this is amalgamation of a lot of people working really hard and the higher end Ram designation and the seven-step stage seven has led and led to us as well at legacy hi better bond ratings and lower malpractice insurance because it is externally validated so the next slide is our attempt because we're unhappy there's the hospital health care most wired so this is self-report only there is no validation and so I've tended to call the most liar because if you are sort of extrapolate stretching the truth on how fabulous you are in an electronic health record the year that we received the state seven across all of our hospitals and amatory clinics the first organization to get both we did not get the most wired okay there's something odd about it but let me continue to go on in terms of what have studies now they're still coming out with this correlate stage seven hospital with better quality lower mortality better profitability and this is what this site so in terms of Joan your question of why would you do it first of all there's why would you want to achieve the paperless and I think that is the goal for us our hundred million dollar investment was moving towards healthcare that is driven by better information and better technology and that is translated to organizations around quality so this is the Joint Commission of the Joint Commission's quality measure performance and there are a number of measures with three or less or four or more of the measures met and you can see that there is a correlation not a causation potentially and so you know maybe higher performing hospitals also have a lot of other things I don't it's not a causal but it's correlated that that higher higher stage hospitals perform better on the quality measures for the Joint Commission another statistic is the Leapfrog Group so leapfrog is a Association or an organization and so representative hospital is an a leapfrog hospital safety grade and we're measure of having this score in the value-based purchasing and sort of where the organization is the sort of middle level performance when you are there's a higher mortality rates driven by health grade mortality in a lower MRAM score versus higher and then finally profitability financial performance this was measured remember the source of this one now but in terms of higher profitability the operating margin for organizations has appeared to be higher for organizations that are in state seven the question of causation versus correlation on these I think that because there's a little bit more discussion maybe and particularly this one where you know higher performing organizations financially may just the money money today implementation could be the other way around yes and then you know the other ones it may just be a surrogate marker of high reliability organizations in general yes yes there was a study one of our doctoral I think he finished the doctor'll one of our first doctor students was his name anyway doesn't matter he was one of the when D mice started the doctorate program he was one of our first students and he attempted to do Adam thank you Adam worked on our research on looking at stage six and seven versus quality measures and external measures and and my point after and it was not found there was it was not found to no correlation between six and seven hospitals and quality and all these other measures of success my point to that is six is a fairly low bar so if you have CPOE in just the IDI you can get Stage six seven is CPOE everywhere ninety percent adoption so I think safety the the higher bar of seven even though there are fewer hospitals I think is six is just too necessarily and he didn't find six and seven hospitals we're not necessarily better quality for years ago and EMR use you know it takes time to become really facile in using it and have the implications and develop the data to be able to run quality surveys and you know really promote quality so I think you I think you're very much right on at that point well the other thing I'd say too is that a lot of the quality and process measures are captured of a system that's designed to capture the data irrespective of whether the data are accurate or not mm-hm so for example there's been plenty of studies for example which show that everybody regardless of what smoking cessation they got all right not callously they got have the box checked on admission so if you have an order set that's put it as part of stage seven that has an automatic pre checked box you're processing quality measures will go up dramatically but that does not let say represent outcome outcomes and you know the best example that were CLABSI rates in the United States where as soon as it became part of meaningful use the incidence and prevalence of class C's dropped by 90 percent in three months after ten years of stability so again realizing that when systems are designed to improve reporting of measures that then are used to determine the effectiveness of the system it is a self-fulfilling prophecy in many ways that's a really good point still want the amount I remember the in in getting our doing our our survey and the point about you know how often is it sort of touch-and-go and I wasn't in the room were you in the room when they did the they were in imaging they did this the survey so that you know the surveyors are going in and talking and one of the radiologists says I'm glad you're here I hate that back I let me just tell you what I just don't like about this needs to change this needs to change our packs integrated and and the and our people that are accompanying are like just oh god he just blew just you know there we go we're not going to be stage seven and and the surveyor said well do you use it it's like well of course I can't do clinical care without it okay but yes it needs to be improved but it's not it's that you're still using the system so as I said Amy and I are both we have been independent CIO CMIO evaluations and so I've had the pleasure of looking at a number of sites in this order Stanford Hospital UCLA Cedar sinai and multi care up in Tacoma which is there were all really interesting interesting they were all epic all of them epic but not all not all epic of course is stage seven and not all stage seven is epic meant there are not too many but there are some meta tech state 7 and I think Cerner has a few as well but really good good programs but that about the week or maybe a right around the time that I was invited to go to Tacoma then they called a me and said would you go to China okay I'm gonna try that you go to Tacoma Chang shinyang China which is kind of near the North Korean border to do both hospital and impatient and it was amazing what they have done I'll show you these are a couple of the nurses I'm at and wanted so it's just an important I was just going to tell a couple stories about some of our reviews but one of the things is preparing your staff and we thought we had prepared our staff quite well and we even you know you can choose a little bit of who's around or which radiology department you go to or whatever I mean right that didn't work so well but I wanted the wards in at Good Samaritan Hospital we went up there and the reviewers are going around and they're asking about asking I think was an LPN actually what do you do in downtime and she said well I go in and I tidy up the patient's room and I make sure that they have anything that they want though their water you know pick up the newspapers and they're like no you know when when when it when the computers down and you can't like oh I just go over to another computer and I start taking our daytime staff had not experienced a downtime and so long they didn't even know what it was and so it actually brought up process for us we now actually are doing more downtime training both in the evenings during the days and what she's when she's not active so hilarious interestingly in Xianyang they have a vendor actually employs 20,000 people 20 of which are on-site at this hospital hospital is quite busy they see upwards of a thousand patients in their IDI on a daily basis that was a daily basis they see tens of thousands of patients in their clinics every day and in fact just for comparison what's what's an emergency department like OHS you see in a year like right so things have to be efficient and one of the things I was most interested in as I spoke to some of the specialists that we met with was how many patients a day are the specialists seeing and that range from fifty to a hundred patients a day I can tell you they are not held to the same documentation standards as we are here in the United States and but they are putting good information in the chart I mean it's very clinically relevant you know shorthand whatever but they're actually they are documenting and they don't have to worry about what needs to be in there for billing or such so fifty to a hundred patients a day so they took us to the outpatient clinic it's a big tower of a building and you walk into the building and there's hundreds of people waiting to get on the elevators to go upstairs and they walk us around we were like this special group of felt really weird but so this the revere group gets walked around to a private elevator and we go straight up he come out on his floor it felt like an airport there was Airport like airports eating there were monitors everywhere to tell patients who in the next patient up was or the next couple patients so you could kind of monitor the progress of that provider who you were going to see there were kiosks for the patients to make appointments for them to print out their prescription after their visits to or to send their prescription to the pharmacy if they chose to use the pharmacy in that building they then would get a text message on their phone if they so indicated on the kiosk as to when their medication was ready it was amazing I mean the experience was truly amazing their clinical rooms I have to tell initials in the room but was literally a desk a desk the doctor had their computer and the front of the desk was a stool there's a little sink in the room you wash your hands and watch there was a lot of medical equipment there wasn't a lot of comfort if it was a in the gynecologic clinic there was a backroom to take the patient to that they needed to do an exam but privacy was not a high point I would have to say interesting experience another journey on in China that I think be interesting is the one thing that they hadn't really figured out was the disaster covered and they didn't have they also their system was up 97% of done very high 90s percent of the time but the chief residents were the ones that would back up that floors data when they went home every night they all had these thumb drives so they would actually do the backup and that would be so if the system went down at any point in time they're the ones who got all the information so I went to an Obie Award and the word was made to hold I have to get this right 30 patients no 20 patients which would have no there are 20 rooms told 40 patients with two beds in each room and they had put a third bed in each room but there are 66 patients on the ward and so those additional patients were actually on air mattresses in the hallway that's how busy they're there and they they were I mean they're turning them through how many patients did that chief resident have everybody who was on that ward 66 patients wasn't clear to me how many interns or residents she had to assist her in that in that journey but just that the sheer volume of patients in this place was something that we truly want understand another interesting piece from that visit was length of stay was much higher than ours in the over ten range for many different kinds of patients because the clinic Doc's would actually admit patients if they needed a surgical procedure because the process of getting the surgery approved and and dealt with was much easier to put them in the hospital have that patient actually wait in the hospital to get the procedure than actually to schedule that as an outpatient so again a different system and and they work around it as they can oh just just because Doc's are seen 50 to 100 you know you ask you're like and how do you do that and one of the pieces was this is this is a big city where a lot of people come for care from rural areas and one of their one of one of the docs said to me it was I don't know how far that patient has come and I don't know you know if they have any place to stay from the night or I don't know what their social circumstances
re around this visit so it's I always feel obligated to see them so if there's patients waiting they just continue to see them because they don't know what potentially difficulties the patient would run into if they said no you need to come back tomorrow this is a just a screenshot of of their electronic health record but the the piece being that they actually had some pretty good crema to show it but unless you wish Nate do you read but they they were doing a lot of structured documentation they had a lot of shortcuts in in their documentation to pull stuff up they were very careful with how they did that interestingly making sure that the record was accurate this is to remind me of something I learned from dr. Richard Gibson as I was on a visit with him Sutter Health and we went into the medical records department and I don't know how many of you know Gibson but he's he's just a wonderful guy and he starts like going through this stack of things that need to be scanned and I'm like what's he doing and he's looking through an he pulls out like a physician note and he's like what's this and they're like and so the piece being that the documentation it needs to be in the electronic health record and even if you scan it in if it's if it's done your facility it really should be done in the record and so he really taught me a lot about during reviews and how to how to look for four different pieces that that people may or may not know about he was telling me about a visit he did early in his doing visits where he went into the the the site said that they their radiology was all digital they were sure of it and then they go into the radiology department and there's there's one machine that's putting out films and of course he finds it he's that kind of guy so he was he was actually a really good mentor for doing these visits because of how detailed he is and then this is the journey that we're actually embarking on right now is his blood product administration and and the matching out to the blood bank so we scan all of our blood products currently but it doesn't match back out to the blood bank which is an extra patient safety piece that that we would of course like to do we're struggling a little bit because we have Cerner on our on our lab side and epic on our clinical side and we don't want we don't want nursing to have to go into yet another program which would be serve blood product administration module to do it and an epic ins aren't actually having some trouble talking on this so our journey to our revalidation is is is a little stilted right now but do want to talk about I asked what would what does the organization get out of it and I think I've heard the same four organizations that are looking for the Baldrige criteria the value for us to not only reflect on our journey but also document what we had done was a great internal it was a motivator for us it was definitely a motivator to accomplish some things that we wanted to accomplish it was certainly ways we got a lot of data to heightened we had a couple hospitals that weren't meeting the bar code medication and the CPOE percentages that needed to be achieved and so got the visibility and encouragement to get that up which we do believe correlates with safety and so I think we're we're really good just going through the process itself I think had positive consequences for our organization I have enjoyed going through the other places I learn as you noted particularly I've done just epic US visits but everyone does epic a little bit differently and and so some of the things that I saw that we're really great have facilitated cross communication between epic customers and Cannavale that was an interesting you know very novel approach to it can we talk more about it after the visit and so the epic family is a very close-knit family to begin with but that's been a really neat part of doing this silly question make it to a certain stage do you ever get downgraded again wait so how often is the revalidation or the recertification every three years and how much does it cost to get an organization ready for each one of these site visits so again is this you know it's sort of like yo J Co was done by hospitals for hospitals and ends up basically again becoming a self-fulfilling prophecy so you know what is the what's the optimal type frame where the resources are required so how much it's one thing for a hospital to get ready how many hospitals are going to continue to continue to do this every three years this bar this is what we need to do we're done with this I think because it's an evolving model it's why I continue to be excited about revalidating because it actually continues to keep us at a certain level as I say we're struggling right now to do this we're in the throes of it trying to revalidate in October it's it's great for the team to I mean it's just one of those things to work towards but as John says I mean our team it just the excitement around the is an informatics team and and honestly the clinical teams as well was so worth the journey how much time we're we're it's part of our directors meeting currently it's really not that big of a deal we already had the CPOE reports written the BCM a reports written all those things that you have to go back and make sure you're still holding that standard and then as you do the gap analysis I mean it didn't take me very long to do the gap analysis partly because I'm a reviewer so I kept up on it but so there was the gap analysis and then there's a couple projects but some of which we I mean we'd already done we don't attend the breast mike scanning we'd already put our code medication administration into the IDI and so this is our this is our nuts not our only hurdle we have so one of the things that's occurred in a couple of our ICUs is multidisciplinary rounding and as a part of multidisciplinary rounding I'm finding because I looked at two units whose CPOE is not where I would have expected it to be and it actually has to do with multidisciplinary rounding where a nurse is putting in the orders for the day for the intensivists that's not CPOE that's a verbal order and so it's just tanked orders on that unit so we're we're working through some processes to see if we can you know shine that up and and and have the provider putting in the actual orders and so I mean it it brings up some spotlights some things that you might not have gone back and looked at again anyway I do think it's a really good question though because the number of hospitals in state seven are now is growing and the revalidation recertification is new as Amy said they are continuing to evolve they don't want to add a stage eight they talked about it and it's more like know now how care needs to continue to evolve and so we have this bar set or what we think excellence is about we're kind of competitive at like you see and so we want to slightly that we measure we measure saw repec doesn't number of benchmarks as well and how well you do in in epic adopting they have 800 of best practices and what percentage do you have adopted and then the epics stars is the name of their program so we're we've pursued that as well and but I think hospitals I think it will decide whether you want to achieve it or not fortunately what I think there as they continue the bar higher like more business intelligence and population health it is where we're going and so again having that external validation I think is worthwhile dr. Burdick there was some discussion a year or two back and I haven't followed it since then about eliminating the need to do both meaningful use documentation or a de stations and also the mram and and other ones and just consolidating the state do one or the other and you can get credit for meaningful use dollars by getting to mram stage seven or something like that has there been further discussion about trying to consolidate these I haven't heard such discussions but I'd be interested to ask names organization about that because that would be they were probably do it because it would promote more doing that but I that whole meaningful use we're audited so frequently and so that all the things you need to do for attestation I I sort of can't believe that the government would give that much authority to hims analytics to measure your compliance it's federal dollars and it'd be great the whole measurement industrial complex you know every group is the pqrs I mean they're just we're having to slice and dice data the measures that we give to Oregon Medicaid are different than we give to Medicare it's just as it's insane from a bi perspective and reporting perspective it'd be great if we could narrow she said yeah Don Berwick just in his most recent speeches was arguing that point that we're actually decreasing quality in health care because of an overemphasis on measurement and the measurement process and the industrial complex around measurement in health care well your point about order sets that have it auto checked whether you really do it or not there's a lot where I think the reality is is that as long as there's carrots or sticks people will do whatever they can to avoid the stick and eat the carrot even if they don't like vegetables and so electronic tools actually make it easier to you for you to show what you're doing because no longer can ignorance be considered or the prop for pretend point rights no longer is like well we don't have a way to document it that's automatically considered a negative women before was considered an indeterminant we've talked about state 7 and its meaning to organizations to even to clinicians to my question is really do you guys have a sense of whether this is a measure that patients understand and what you know what from from legacies perspective know how have you tried to market the idea of him so 872 patients and what kind of responses you've had it's a great question and we took when we got the designation we talked to our marketing people about do you want how do we want to you know do the press release so hims comes out with a press release that they release and then it's sort of the trade magazines pick it up but sort of what do we want to do with their or Gonia nor anything that particularly being the first in the world or in the country to have EMR stage seven across ambulatory and Clinics of Kaiser doesn't have that and so there's a point of local pride in Oregon for this and our marketing people I think very rightly we you know they talked to a couple of story a couple of reporters who were like I don't understand what the public interest in this would be so you know they're there to sell papers of course and so you know could you put me in touch with a patient whose experience was positive because of this technology or you know and your point I think there isn't
