Quality Improvement at Piedmont Healthcare

MARK COHEN, M.D. SHARES HIS PERSPECTIVES ON QUALITY IMPROVEMENT AT A MULTI-HOSPITAL SYSTEM IN ATLANTA OY MARK HAGLAND

Mark Cohen, M.D., Ph.D., is vice president of medical affairs and chief quality officer at Piedmont Atlanta Hospital, the flagship facility within Piedmont Healthcare, a five-hospital integrated health system. The system encompasses Piedmont Atlanta Hospital, a 488-bed tertiary care facility, as well as four community hospitals, 500 employed physicians, and 700 affiliated physicians.

Dr. Cohen, who continues to spend about 20 percent of his work hours in clinical practice as a a clinical cardiac electrophysiologist, has spent seven years in executive leadership at the health system-two years in his current position and five years prior to that as chief of quality, informatics, and IT for the Piedmont Heart Institute.

Dr. Cohen joined several other industry leaders on for a panel discussion, "Driving Improved Outcomes with Electronic Health Records," as part of the Health IT Summit in Atlanta, held April 15-16 at the Historic Academy of Medicine at Georgia Tech. The event is sponsored by the Institute for Health Technology Transformation (iHT2). Since December 2013, the Institute has been in partnership with the Vendôme Group, LLC, the parent company of Healthcare Informatics. He spoke recently with HCI Editor-in-Chief Mark Hagland regarding some of the challenges and opportunities Piedmont Healthcare is facing as it moves forward to create an outcomes-driven care delivery system. Below are excerpts from that interview.

LAYING THE GR0UNDW0RKF0R QUALITY IMPROVEMENT

Healthcare Informatics: Looking at all the opportunities available for clinical quality improvement work available, how have you and your colleagues prioritized your agenda for such work?

Mark Cohen, M.D., Ph.D.: There are two paths involved; one is an IT-based path, and were working very hard to make certain that our hospital is fully integrated into the structure of the larger parent system. Were half the size of the healthcare system, so we get a prominent vote, but we're not all of it The healthcare system has recently converted to Epic for its electronic health record (EHR); so all the employed physicians and all the hospitals; and we now have one Epic for Piedmont Healthcare, so we're utilizing Epic for this work-pathways, guidelines, order sets, clinical alerts, information integration, and systems integration.

HCI: How far has that initiative gotten so far?

Cohen: The EHR install was just completed; the last hospital went up three months ago. We're still in the stabilization phase, but for our Piedmont Healthcare patients, we have full integration of all information, and that by itself has been a big improvement.

HCI: What are the biggest areas of quality improvement that you and your colleagues are currently taking on?

Cohen: We're focusing on publicly reported measures: value-based purchasing and core measures; Joint Commission and Medicare outcomes reporting; and large buckets, such as mortality and serious safety event rates. Running in parallel is a significant effort on patient satisfaction, physician satisfaction, and staff satisfaction.

HCI: Has your organization had any involvement yet in the development of a patient-centered medical home program or accountable care organization?

Cohen: Not directly. We sometimes have to deliver results to some of those, so if there are specific metrics that an insurance company might need, or a social work agency working with a PMCH, well provide data, but I'm not personally involved in setting those up.

LESSONS LEARNED SO FAR

HCI: What have been the biggest challenges, and lessons learned, so far, in this overall initiative?

Cohen: We're not special; I think our challenges are very typical here. Our two biggest challenges are on the IT side and on the user/people side. On the IT side, the systems have just massive complexity; and the ability to effect change in the system is very limited. We have to be very, very careful of unintended consequences. An example came up today; we have recently implemented an inpatient hospice program; these are virtual hospice beds from which patients can receive hospice care in their hospital beds. That provides a tremendous clinical advantage. We try to physically cohort the beds, but that's not possible all the time. We enrolled a patient yesterday, and we discharged the patient administratively from the hospital, and admitted the patient to hospice while she was still in the bed. I got a message saying that that particular unit had not been set up to administer this, but the patient is so sick and fragile that she can't be moved; so we're going to sequester the patient's encounter and handle the financial and administrative aspects of that manually. It was some technical thing. We look at the information systems and functionality, and everyone has a slightly different vision of what the technology can and cannot do. In that instance, I inadvertently generated a huge number of hours of work for a significant number of people, just by doing what I thought we should do.

The other side of it is the people side; each individual person has a different vision of what their job is, their function, and their role. For many, working with the technology doesn't match up with their personal vision, and we end up running into the friction points. A physician does a new history and physical for a patient, but unknowingly calls it a progress note. The document creation form has options, so the computer now says, this patient does not have a history and physical. It starts sending reminders to the doctor, notifying me, and medical records, a cascade of alerts happens. Meanwhile, the physician is looking at the chart, saying, I'm looking at the screen, what are you talking about?

HCI: What would your advice be for CIOs and CMIOs, as they help to facilitate these kinds of broad initiatives?

Cohen: The technology has to work, so you must have reliability, must have highly developed downtime processes and redundant systems, as everyone becomes very dependent on the technology. The hard part is the people, and that we're touching aspects of people's identity and self-worth that will be triggered by changes in the technology in very profound ways, and understanding and assisting the users through the transitions is the most important part of the job. The technology is a given; the hard part is the user experience. Our system CMO said, imagine that the day we flip the switch, it's like being in a brand-new hospital, for the physicians. Every single thing about how you function has now changed.