The impact of high-capability electronic health records on length of stay. Presented by Steven Shaha, Center for Policy & Public Administration, UK, at HINZ 2014, 12 November 2014, 11.15am, Marlborough Room 3

1. EPR-delivered CPOE adoption rates PredictReduced LOS: The impact of high capability EMRs/EPRs
Professor Steven H. Shaha, PhD, DBA
Richard Schreiber, MD
Kevin Peters, RPh

2. Prof. Steven H. Shaha, PhD, DBAProfessor, Center for Public Policy & AdministrationPrincipal Outcomes Consultant, AllscriptsFormer Director of Research, KLAS
100+ peer-reviewed publications, 200+ peer-reviewed presentations, 2 books
Advisory and consulting work for 11 governments on four continents
Professor or Lectured or at 14 universities and graduate schools
e.g. UCLA, Harvard, Cambridge (UK), King’s College, London University, South Manchester, Yale, Princeton, Columbia, Cornell, Zayed Univ(UAE)
Advisory and consulting to 50+ non-healthcare organisations, including
Disney, Ritz-Carlton, Coca-Cola, New Line Cinema, IBM, AT&T,
Time Warner, Johnson & Johnson, Marriott, 3 Depts. of Defense,
and Pharma: Sanofi, Aventis, Novartis
Education:
PhD, Research Methods & Applied Statistics
DBA, Business Administration (PhD)
MA, MEd, BS
Disclosures & Bio

3. Sample of Peer-reviewed Journals
•Advance for Health Information Executives
•Advances in Patient Safety
•Agency for Healthcare Res & Qual(AHRQJournal)
•American Journal of Ob & Gynecology
•American Journal of Sports Medicine
•Applied Clinical Informatics
•Archives of Otolaryngology, Head &Neck Surg
•Breast Cancer Research and Treatment
•British Medical Journal of Quality & Safety
•Epidemiology and Infection
•Health Management Technology
•Healthcare Financial Management
•Healthcare Technology Management
•Intl. Journal of Medical Informatics
•Intl. Journal of Pediatric Otorhinolaryngology
•Intl. Journal for Quality in Health Care
•Journal of Arthroscopic and Related Surgery
•Journal of Clinical Ultrasound
•Journal of Emergency Nursing
•Journal of Mat, Fetal & Neonatology Med
•Journal of Neurosurgery
•Journal of Obstetrics and Gynecology
•Journal of Orthopedic Trauma
•Journal of Pediatric Emergency Care
•Journal of Perinatal Medicine
•Journal of Perinatology
•Journal of Shoulder and Elbow Surgery
•Journal of the Am Acadof PedOphth& Strab
•Journal of Ultrasound in Medicine
•Journal of Ultrasound in Ob & Gynecology
•Laryngoscope
•Nurse Executive Watch
•Nurse Leader
•Nursing Economics
•Pediatric Critical Care Medicine
•Pediatric Emergency Care
•Pediatrics
•RN Magazine
•Spine
•Intl. Journal of Pediatric Otorhinolaryngology
•The Journal of Bone & Joint Surgery
•Ultrasound in Obstetrics & Gynecology

5. The Dynamics in HealthcarePressure on every aspect of performance
“Variable demand with fixed capacity & poor patient flow.”
“Safety, quality and
value-based delivery.”
“Do more with less.”

6. Methods: EPR SQL Query
•Retrospective, correlational, interrupted time series
•66 consecutive months, 22 consecutive quarters
•76,972 discharges with 6,135,994 eligible orders from all inpatient floors:
–All pharmacy (medication and intravenous)
–Laboratory
–Cardiology
–Radiology imaging
–Nursing care
–Admission/discharge/transfer
–Consult
–Respiratory therapy
–Ancillary services (physical, occupational, and speech)
–Dietary
6 11/11/2014

7. Methods (cont.)
•All orders were integrated into the EMR/EPR:
–Source of the CPOE
–Corresponding results retrieval and repository
•Exclusions:
–Verbal orders
–Emergency department med order
7 11/11/2014

8. • Inverse relationship of LOS to CPOE Adoption
3.80
3.90
4.00
4.10
4.20
4.30
4.40
4.50
0
10
20
30
40
50
60
70
80
90
100
Pre Yr 1
Q1
Yr 1
Q2
Yr 1
Q3
Yr 1
Q4
Yr 2
Q1
Yr 2
Q2
Yr 2
Q3
Yr 2
Q4
Yr 3
Q1
Yr 3
Q2
Yr 3
Q3
Yr 3
Q4
Yr 4
Q1
Yr 4
Q2
Yr 4
Q3
Yr 4
Q4
Yr 5
Q1
Yr 5
Q2
Yr 5
Q3
Yr 5
Q4
CPOE % LOS Smoothed
Percent CPOE Adoption
Mean LOS
As CPOE adoption Rose, LOS Fell …

9. Discipline r Value Percent p-Value
House-Wide -0.798 0.637 63.7% <0.001
Cardiology -0.278 0.077 7.7% 0.036
Family Medicine -0.431 0.186 18.6% 0.008
Hospitalists -0.297 0.088 8.8% 0.032
Internal Medicine -0.799 0.638 63.8% <0.001
General Medicine -0.918 0.843 84.3% <0.001
Nephrology -0.513 0.263 26.3% 0.003
Hematology/Oncology -0.367 0.135 13.5% 0.015
Pulmonary -0.301 0.091 9.1% 0.031
General Surgery -0.695 0.483 48.3% <0.001
Orthopedic Surgery -0.782 0.612 61.2% <0.001
Thoracic Surgery -0.335 0.112 11.2% 0.022
Vascular Surgery -0.552 0.305 30.5% 0.002
Urology -0.483 0.233 23.3% 0.004
R2
• Predictive relationship for each discipline
… for each specialty:

10. 22 quarters, the case mix index (CMI) increased slightly but significantly
•for the organization as a whole
•as well as for 13 disciplines
•all concurrent with significant reductions in LOS for comparable time periods
NOT Attributable to Reduced Severity:

11. Further Analyses …

12. •Inverse relationship of LOS to CPOE Adoption
•The linear regression model: p<0.001
3.904.004.104.204.304.404.500.0%20.0%40.0%60.0%80.0%100.0% Average LOS -mvg avg Percent CPOE AdoptionCPOE as Predictor of LOS

13. 3.90
4.00
4.10
4.20
4.30
4.40
4.50
0.0% 20.0% 40.0% 60.0% 80.0% 100.0%
Average LOS - mvg avg
Percent CPOE Adoption
Polynomial model revealed the curvilinear relationship as
most significant solution: R² = 0.887
Representing a 25.03% increase in the R-square over the simple linear
model

14. 3.90
4.00
4.10
4.20
4.30
4.40
4.50
0.0% 20.0% 40.0% 60.0% 80.0% 100.0%
Average LOS - mvg avg
Percent CPOE Adoption
Clear indication of an inflection point at approx. 60%CPOE adoption
LOS begins to statistically fall as CPOE adoption reaches critical level
Precise inflection 58.31%, standard error of 4.05 (95% confidence interval 54.26-62.36%)
SQL with Analytics: Study, Test, Monitor

15. All EPRs?
Not guaranteed!

16. Average EMR Satisfaction
Average EMR Satisfaction
Shaha SH (2013). Comparative EPR Usability form the Clinician Perspective: What works and what doesn’t for impacting care. Digital Health Service Delivery – The Future Is Now. HIC 2013
Proceedings, Health Information Society of Australia, Melbourne, pg. 122.
Shaha SH (2013). Benefits and Outcomes: Models for Getting the Most Out of Your EPR. EPR Awareness Forum: Sharing Best Practice from UK, Europe and the US, Manchester, UK, May 2013.
Shaha SH (2013). Clinical Systems Applications and Related technology: Today and into the Future. HC 2013: The National Health IT Conf & Exh, Birmingham, England, April 2013.

17. Quick Example of Win-Win Teamwork …

18. Without
With CDS-rich
Order Set
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Impact of Stroke Admission Order Set:
Comparative Quality with versus without
Improved Stroke Outcomes
Impact of Stroke Outcomes Toolkit:
Comparative with versus without
CDS-rich Order Set
40.5% net
Greater Clinical
Excellence
80%+ Change
Stroke Care Best Practices
CPOE with Alerts Alone

19. Length of Stay
Discharge Patterns
CDS-rich Order Set Without Order Set
Discharge to Home Discharge to SNF Discharge to IP Rehab
Cost-per-Case Impact
CDS-rich Order Set Without Order Set
Average Direct Cost/Case Average Indirect Cost/Case
16.0%
fewer (p<.001)
11.4% lower Cost-per-Case
$ 628 avg (p<.05)
Readmissions in 31 Days
35.7 % fewer
(p<.001)
Improved Stroke Outcomes
9.4% more
(p<.001)
21.4%
fewer (p<.001)
12.7% lower Cost-per-Case
$249 avg (p<.05)
7.5% lower
0.35 fewer days avg. (p<.001)
CPOE with Alerts Alone
Est. Savings of $265k-$560k annualized
CDS-rich Order Set

20. 16.0% fewer
(p<.001)
Discharge Patterns
Improved Stroke Outcomes
Continue after Discharged
9.4% more
(p<.001)
21.4% fewer
(p<.001)
CDS-rich Order Set CPOE with Alerts Alone
Discharge to Home Discharge to SNF Discharge to IP Rehab

21. Care Coord Network Pre
Readmissions in 31 Days Length of Stay
Significantly fewer
(p<.001)
Better Outcomes after Discharge
Admissions to Nursing Homes and
Residential Age Care Facilities
Care Coord Network Pre
Significantly shorter
(p<.001)
Additional Efficiencies
• Capacity for 130 additional admissions
with NO staffing increases
CPOE and Alerts alone
CDS-rich Order Set

22. Discharge to Home Discharge to SNF Discharge to IP Rehab
16.0% fewer
(p<.001)
Discharge Patterns
Improved Stroke Outcomes
Continue after Discharged
9.4% more
(p<.001)
21.4% fewer
(p<.001)
CPOE and Alerts alone
CDS-rich Order Set

23. Readmissions in 31 Days
Better Outcomes after Discharge
Discharges to Home
Significantly fewer (p<.001)
And …
•Fewer ED/A&Evisits (p<.01)
•Fewer clinic visits (p<.01)
•Fewer PCP interactions (p<.01)
CPOEand Alerts alone
CDS-rich Order Set

24. 2
4

25. Lessons Learnt: •The EMR is not “electronified paper”
• Computers that Compute
• Programmability
• Clinical Intelligence
•Adaptability and Interoperability
• Rigidity vs. Openness
•Local Innovation then Broader
Standardization
• “What work here with our needs and capabilities”
• Try, refine, prove … then standardize … then innovate
•Access to Clinical Data
•Community Connectivity
•Outcomes-driven
• Clinical
• Efficiency
• Cash Releasing and Cost Reducing
• Clinician Satisfaction

26. Levels of Information: Needs and Perspectives