Clinical Impact and Value of Workstation Single Sign-On. George A. Gellert, MD, MPH, MPA Associate CMIO, CHRISTUS Health San Antonio, Texas

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1 Clinical Impact and Value of Workstation Single Sign-On George A. Gellert, MD, MPH, MPA Associate CMIO, CHRISTUS Health San Antonio, Texas

2 The Challenge: Providers using EHRs must maintain the security of protected health information and HIPAA compliance What makes passwords effective complexity and frequent change also makes them difficult to remember Clinicians often must recall/regularly refresh passwords Time lost by clinicians entering multiple passwords and resetting them when forgotten diverts from patient care

3 The Solution: Single Sign-On (SSO) facilitates clinicians use of EHR technology, including CPOE and digital documentation Provides clinicians expedited access to EHR and clinical applications; eliminates password confusion and time wasted in password management; enhance info security via authentication Once logged in, clinicians need only tap or swipe enabled ID proximity badge on workstation card readers

4 Across hospital, tap and go enables users to pick up exactly where left off -- conveys rapid access to EHR/other functionality as location changes When clinician changes workstation, tap on badge reader brings most recent screen used to new screen SSO automatically locks workstations when care providers leave and re-authenticates when return Eliminates need to manually lock sessions or (unreliable) inactivity timers; prevents loss of work; reduces repetitive, manual logins

5 Expedites authenticated access to clinical applications used during a 12 hour shift, after which usual login must be repeated to enable another cycle SSO provides support for all types of applications including terminal, client server and cloud-based applications Password administration enables automated application password change, eliminating this task for clinicians

6 Impact Evaluation Methods: Quantitative evaluation of SSO impact in 6 CHRISTUS Health hospitals. CH is a mid-size IDN in 6 U.S. states & 4 nations; > 350 services, 50 hospitals, 15,000+ physicians EHR = MEDITECH Client Server Version 5.67 (also 3 others) SSO product = Imprivata OneSign Version 5.1 Reports on clinician SSO use: # deployed users; # active users; # logins; frequency of app access; average logins/user; average application events/user

7 Required migration from workstation PCs to a thin client and Cloud processing Migrated to a virtual desktop infrastructure (VDI) to enable clinician roaming across service lines 45 clinical software applications profiled and enabled SSO provided to MDs, RNs, mid-levels and roaming ancillary

8 7 day observation period of SSO usage in May 2016 Measured mean login duration to workstations pre-sso and compared to post-sso implementation Post-SSO involved 2 logins: 1st login of day to desktop (slightly longer time than pre-sso) and subsequent EHR logins using card reader/swipe technology (less time per login than pre-sso) Mean login durations were multiplied by # of total initial and subsequent logins

9 Assessed total time required for clinicians to login pre- and post- SSO; quantify benefit from decreased clinician login times Utilized national median hourly pay rates to translate hourly/shift time savings into dollar/cost savings for: - MDs - RNs - RTs - PTs - Dieticians Estimated cost savings by replacing PC hard drives with thin client

10 Results - Saved Time Analysis: There were 65,202 logins to the enterprise EHR by clinicians in 6 facilities over a 7 day period post-sso Potential 5078 SSO clinical users; 2256 active users (44.4%) Pre-SSO, manual keyboard login required 29.3 seconds = a total hours of clinician login time (over 7 days assessed) First of shift is 2 step login: access to Windows desktop required a mean of 30.1 seconds, then 4.5 seconds to EHR; total = 34.6 seconds

11 Results - Saved Time Analysis: Post-SSO - 12,936 first of shift logins (at 34.6 seconds each) = hours of clinician first login time over 7 days Over 12 hour shift, clinician reconnect to EHR required 16.4 seconds per login = a reduction of 12.9 seconds from pre-implementation

12 Results - Saved Time Analysis: No. subsequent clinician logins was 52,266 = total of hours of reconnect time to the EHR over 7 days Total post-sso clinician login time over 7 days is sum of initial login + subsequent login hours = hours total Reduction of clinician login time over 7 days was hours preminus hours post-implementation

13 Login Performance Parameter Frequency Cost Savings Total number logins to enterprise EHR over 7 days (6 hospitals) 65,202 Active clinical users of Single Sign-On (6 hospitals) 2256 Mean pre-sso manual keyboard login total time required per facility (7 days) 88.5 hours [7.4 shift equivalents] Mean post-sso clinician login time per facility (7 days) 60.4 hours [5.0 shift equivalents]

14 Results - Saved Time Analysis: A gain of hours of clinician time liberated over 6 hospitals (or 14 shifts of 12 hours) Equals 28.1 hours (2.3 shifts) per facility per week Per annum, hours or shifts of mixed clinician time liberated per facility First phase implementation of 18 hospitals will yield 2192 shifts or 26,302 hours of clinician time saved

15 Login Performance Parameter Frequency Cost Savings (USD) Mean post-sso reduction in clinician login time per facility (per week) 28.1 hours [2.3 shift equivalents] Mean post-sso reduction in clinician login time per facility (per year) hours [121.8 shift equivalents] $ 92,146 Expected total post-sso clinician login time savings when 18 hospitals implemented (per year) 26,301.6 hours [ shift equivalents] $1,658,745

16 Results Financial Analysis: Calculated the dollar cost savings of time for 3 clinician categories MDs, RNs, ancillary (PTs, dieticians and RTs) 28% of users were MDs, 54% were RNs, and 18% ancillary For RNs, used national average hourly wage = (USD) $34.50 Collapsed PTs, dieticians and RTs into a single category, average hourly wage = $32.20

17 Results Financial Analysis: Estimating MD hourly wages complex, income varies by specialty Divided MDs into 4 groups of highest EHR users issuing greatest volume of orders thru CPOE: hospitalists; EM physicians; general surgeons; all other MDs collapsed Estimated each group = 25% of EHR/applications use, thus SSO use

18 Results Financial Analysis: Used multiple MD specialty wage estimates: US Dept Labor, Becker s Hospital Review, Salary.com, Medscape Physician Compensation Report Hourly mean wage of USD $108 for hospitalists, $144 for EM physicians and $170 for general surgeons Averaging hourly wage of 4 categories = generic physician hourly wage of USD $ conservative estimate

19 Results Financial Analysis: Mean reduction in clinician login time per facility per year ( hours) translates into facility savings (value of clinician time liberated) = $92,146 USD per year, per facility When 18 hospitals have SSO, 26,301.6 hours of clinician time saved will produce a recurrent enterprise annual savings of $1,658,745 If underestimate by 10% savings = $1,824,620; if by 20% savings = $1,990,495

20 Login Performance Parameter Frequency Cost Savings Mean post-sso reduction in clinician login in time per facility (per week) 28.1 hours [2.3 shift equivalents] Mean post-sso reduction in clinician login time per facility (per year) hours [121.8 shift equivalents] $ 92,146 Expected total post-sso clinician login time savings when 18 hospitals implemented (per year) 26,301.6 hours [ shift equivalents] $1,658,745 (all USD)

21 Professional Category Percentage of All SSO Users [Annual Hours Liberated 8 Facilities] Estimated Hourly Wage Annual Value of Liberated Time/Cost Savings Per Facility Annual Value of Liberated Time/Cost Savings 18 Facilities Physicians (Hospitalists, Emergency Medicine Physicians, Surgeons and all others) 28% [ hours] $ $56,456 $1,016,301 Nurses 54% [14,202.9 hours] $34.50 $27,222 $490,000 Ancillary (Physical Therapists, Dieticians and Respiratory Therapists) All Professional Categories 18% [4,734.3 hours] $32.20 $8,469 $152, % -- $92,146 $1,658,745 (all USD)

22 Results Financial Analysis: Migration to WYSE devices achieved savings in averted new PC purchases Estimated USD $2.7 million over next 4 fiscal years ($675,000/year) Estimate the net total cost of SSO implementation approximately $700,000 (including WYSE device virtualization, but excluding other system elements already in place or serving other utilities)

23 Results Financial Analysis: Annual maintenance cost for SSO is $219,000 With savings rendered by SSO in clinician shifts at $1,658,745 per annum, additional savings on new PC purchases brings the annual total recurrent savings to USD $2,333,745 across 18 facilities SSO has achieved a substantial recurrent annual ROI, value delivery and net cost savings to our hospital system

24 Results Other: SSO has been a strong clinician satisfier - clinicians report SSO enabled them to focus attention on patient care rather than IT Clinicians reported high satisfaction with the improved ease/speed of access to clinical workstations and applications SSO can facilitate physician EHR adoption: Our implementation of digital documentation overlapped with SSO; physicians reported SSO enabled adoption of documentation and made CPOE use easier

25 Conclusions: SSO is an effective & cost-effective method to liberate clinicians from repetitive, time consuming logins to clinical applications SSO = significant and meaningful savings of clinician time and improvement in clinical workflow, clinician efficiency and productivity in these 6 hospitals SSO recommended in hospitals where clinician use of EHRs is substantial, and where clinical workflow involves substantial facility roaming

26 Conclusions: SSO can save time, improve security, reduce IT equipment costs and increase clinician productivity and satisfaction in today s complex healthcare organizational workflows For further information, please contact: ggellert33@gmail.com