Cedars-Sinai Health System Approach to Efficiency, Effectiveness and Appropriateness

Cedars-Sinai Medical Center Founded 1902 960 beds ~11,000 employees, 2,100 Medical Staff; 2,000 volunteers; 400 faculty; 470 research staff; 490 residents/fellows; 700 med student rotations Level I Trauma Center 6-7,000 babies delivered/year On average, every day we serve: 750+ inpatients; 270 ER patients; 120+ surgeries; 1,400+ outpatient visits & procedures 2

Guiding principles for Cedars-Sinai Medicine Maintain the highest quality patient care. Maintain a pluralistic medical staff. Inclusiveness and transparency. All do our part to improve efficiency. Information drives improvement. Continuous learning and improvement. 3

Cedars-Sinai Medicine: Approach Best Practices Applied to Care Delivery Model Redesign Utilizing Clinical Decision Support Patient & Physician Engagement Transparency 4

Best Practices Inpatient COPD Pneumonia Hip & Knee Replacement Non-Malignant Gyn Stroke ACS/AMI A Fib Chest Pain OB Sepsis Spine Surgery Cellulitis Gastroenteritis/Diverticulitis ICU/Monitored Beds/LOC Urology (Male) Stability Criteria for Discharge Respiratory Therapy Continuum of Care Preventing early inductions PTCA appropriateness End of Life including a comprehensive Human Caring Strategy Frailty Headaches Hypertension Heart Failure Back Pain Diabetes Pre-procedure testing guidelines Chronic Pain Cancer Referral appropriateness from PMD to Specialists Appropriateness of Utilization Imaging Ambulatory Surgery and Procedures Physical Therapy Pharmacy (high cost therapeutics and greater use of generics) Pathology/High Cost Lab Tests/Duplicate testing Transfusion of Blood Products 5

Elective Delivery <39 weeks 16.0% 14.0% 12.0% 10.0% Baseline Interventions CSMC Goal < 5% 8.0% N=6 (*5) 6.0% 4.0% N=2 N=2 N=2 2.0% N=1 N=1 N=1 N=1 0.0% 2009 2010 2011 2012 Jan '13 N=0 Feb '13 Mar '13 N=0 Apr '13 May '13 Jun '13 Jul '13 Aug '13 Sept '13 Oct '13 6

Hip and Knee: LOS Index Pre-dashboard milestones Initiative Proposal May 2010 Kicked off best-practice team July 2010 Approved by CIC January 2011 Approved by MEC February 2011 Order sets (printed) implemented Order sets (CS Link versions) approved by CIC and MEC Launched patient education class Order sets (CS Link versions) implemented Project Completed Solid red line indicates updated baseline FY11 LOSI: 1.02 Source: ROM 7

MEC Approved Indications for Inpatient Gastric Emptying Indication - Admission for unexplained nausea and vomiting Procedure not indicated as an inpatient in the following situations: Gastric bypass patients Post op ileus Unstable diabetes Pancreatitis Cyclic vomiting Performing the study when the patient is on the following classes of medications: o Proton Pump Inhibitors (e.g. Aciphex, o Antidepressants (e.g. Prozac, Zoloft, Paxil, Dexilant, Nexium, Prevacid, Prilosec, Protonix) o Calcium Channel Blockers (e.g. Diltiazem, Amlodipine, Verapamil, Nifedipine) o Narcotics (e.g. Morphine, Codeine, Darvocet, Demerol, Hydrocodone, Hydromorphone, Methadone, Oxycodone, Percocet, Vicodin) Continued chronic (duration > 1 month) symptoms Abdominal surgery in the past two weeks Abdominal pain without vomiting Sepsis Cymbalta, Effexor, Celexa, Lexapro, Wellbutrin) o Anticholinergics (e.g. Atrovent, Spiriva, Ditropan, Detrol, Benadryl, Dramamine, Dextromethorphan, Cimetidine, Lasix) o Prokinetics (e.g. Bethanechol, Erythromycin, Metoclopramide) 8

Number of Procedures Inpatient Gastric Emptying Studies 18 16 14 12 Project kick off, developed indications & approvals (GI, Imaging & Med PIC) MEC approved indications 10 8 Implemented indications 6 4 2 0 9

Cedars-Sinai Medicine: Approach Best Practices Applied to Care Delivery Model Redesign Utilizing Clinical Decision Support Patient & Physician Engagement Transparency 10

Why CDS? 75% of decision support interventions succeed when the information is provided to clinicians automatically, whereas none succeed when clinicians are required to seek out the advice. Predictors of Success Automatic provision of decision support as part of workflow Provision of decision support at the time and location of decision making Provision of recommendation rather than just an assessment Adjusted OR Computer-based generation of decision support 6 112 15 7 Kawamoto K, Houlihan CA, Balas EA, Lobach DF. Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success. BMJ. 2005 Apr 2;330(7494):765. PMID: 15767266 11

RBC CDS Alert Screenshot: August 2013 13

RBC BPA ALERT JUNE 2013 Results (N=803) 89, 11% MD Cancels Order Pt Received RBC 450 400 350 300 250 200 150 100 50 0 422 117 Override Reason 49 21 6 38 130 714, 89% 7 6 5 4 3 2 1 0 MDs: See Comments Blank 6 6 5 4 3 3 3 2 2 2 2 2 2 2 2 2 2 2 2 2 2 MD1 MD2 MD3 MD4 MD5 MD6 MD7 MD8 MD9 MD10 MD11 MD12 MD13 MD14 MD15 MD16 MD17 MD18 MD19 MD20 MD21 There were 72 MDs that ignored the alert once (1). 14

Blood Utilization: Red Blood Cell Transfusions Before and After Best Practice Alert (BPA) Monitoring, April 2012 to September 2013 9 Months Prior to Alert 9 Months After Alert 450 400 412 394 350 300 293 317 330 287 354 324 354 340 317 290 343 298 336 328 281 250 247 200 Before Best Practice Alert (BPA) April 12 to Dec. 12 After Best Practice Alert (BPA) Jan. 13 to Sept. 13 150 100 Average Prior to BPA April 12 to Dec. 12: 335 Units RBC/Month Average Post BPA Jan. 13 to Sept. 13: 315 Units RBC/Month; 6% Decrease 50 0 APR MAY JUN JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN JUL AUG SEP 2012 2013 Data courtesy of the Blood Bank CSMC Pilot Units: 4, 5 and 8 SE and SW 15

Case Counts Pre-transfusion Hemoglobin 2012-2014 50 45 40 35 30 25 20 2012 2014 15 10 5 0 0 2 4 6 8 10 12 14 16 18 Hgb Value 16

Xopenex Utilization Guidelines and screensaver implemented Xopenex removed from order sets CDS implemented 17

Choosing Wisely - Screen Shot 18

Impact Analysis Pre Intervention Jan 1 Sep 9 Post Intervention Sep 10 Nov 25 mean orders mean orders % change p-value Antipsychotics Patients 70 Benzo-Sedatives Patients 65 Butalbital Adults Vitamin-D levels 203 166-18.2% <0.001 133 116-12.5% <0.001 4.13 3.58-13.3% <0.04 322 286-13.7% <0.001 Rates per 10,000 encounters

Cedars-Sinai Medicine: Approach Best Practices Applied to Care Delivery Model Redesign Utilizing Clinical Decision Support Patient & Physician Engagement Transparency 20

Crimson Screen Shot 21

Transparency 22

Cedars-Sinai Medicine: Approach Best Practices Applied to Care Delivery Model Redesign Utilizing Clinical Decision Support Patient & Physician Engagement Transparency 23

Cedars-Sinai Medicine: Approach Best Practices Applied to Care Delivery Model Redesign Utilizing Clinical Decision Support Patient & Physician Engagement Transparency 24

Innovative Delivery Models Redesigning care models to better focus on prevention, population health and enhanced coordination across the continuum. Patient Enrollment Initial Wellness Visit and Assessment Care Plan Development Introduction to Care Team Ambulatory Primary Care Patient Centered Medical Home; Team Based Care Performance-driven PCP incentives Transparent data sharing on practice variation and clinical efficiency Post-dc follow up visit within 5 days Complex Care Management Pre-surgical preparation Specialty Services Use of evidence-based best practice guidelines to reduce variation Transparent data sharing on practice variation and clinical efficiency Wrap-Around Services Drug Therapy Management Programs Case Management and Social Work Advance Care Planning (Advanced Directive & POLST) Urgent Care Injection Center Refill Center with generic drug conversion protocols Dietician and Certified Diabetes Educator Outpatient Palliative Care Inpatient/Hospital Hospitalists and dedicated care managers at all facilities ER triage program to carefully avoid admission Discharge planning on admit to include ambulatory care manager as needed Daily hospital rounds One day LOS review Frailty program/interventions Inpatient to observation review Readmit review and referral to housecall or other appropriate program Post Discharge Calls Inpatient Palliative Care High Risk/Homebound Referrals Hospice and Palliative Care Referrals Skilled Nursing Facility (SNF) SNF Care Manager Nurse Practitioner s assigned to all SNF patients Post Discharge Calls Home Biometric Monitoring Nurse Practitioner House Calls Patient Portal / evisits 25

Dissemination within the Healthcare System Announce what you are doing before you do it Involve as many of the staff as possible choose champions wisely Be transparent Weekly Chief-of-Staff newsletter Multiple Dog and Pony shows to medical and non-medical staff, BOD, community What you did What the process was What are the results Where are we going with it What is next One-on-one Crimson sessions to educate docs Clinical decision support Publications Confidential - Do Not 26

Non-Malignant GYN: LOS Index Other milestones Implemented order sets (paper), pathway and patient education - January 2011 Completed TOC 28

CDS Process Approval and Implementation Step 1 Step 2 Step 3 Step 4 Internal and external data sources reviewed and analyzed to determine if there is an opportunity Comprehensive review of the literature and existing guidelines Best Practice team identified Review of the evidence and opportunity Step 5 Step 6 Step 7 Identification of opportunity and agreement on evidence Development of best practice and determination of need for CDS Approval by appropriate governance body: 1) IP - organized medical staff and 2) Amb-best practice advisory group 29

CDS Process Approval and Implementation (continued) Step 8 Proposal to Clinical Content Committee for Clinical Decision Support Opportunities Step 9 Solution finalized and built Step 10 Communication and education Step 11 Decision for Test of Change Pilot or House Wide Rollout Step 12 Performance analysis Step 13 Logic modification Step 14 Continued monitoring and refinement 30