Redefining the Role of Hospitals

Building the 21st Century Health System Series, Chapter 1 of 5

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 About the Center for Health Transformation
The Center for Health Transformation, founded and led by
former House Speaker Newt Gingrich, is a collaboration
of leaders dedicated to the creation of a 21st Century
Intelligent Health System that saves lives and saves
money for all Americans. Members highlighted in this
report include: Siemens, Intermountain Healthcare,
Alegent Health, WellPoint, American Hospital Association,
Piedmont Hospital, and the Georgia Hospital Association.
For more information on The Center, please visit
www.healthtransformation.net.
About Siemens
Siemens Healthcare is one of the world‘s largest suppliers to the healthcare industry.
The company is a renowned medical solutions provider with core competence
and innovative strength in diagnostic and therapeutic technologies, as well as
knowledge engineering, including information technology and system integration.
With its laboratory diagnostics acquisitions, Siemens Healthcare will be the first fully
integrated diagnostics company, bringing together imaging and lab diagnostics,
therapy, and healthcare information technology solutions, supplemented by
consulting and support services.
We would like to thank Nancy Bucceri of Chaddsford
Planning Associates, LLC, for her assistance with this
Siemens Healthcare delivers solutions across the entire continuum of care —
report. For more information, please visit
from prevention and early detection, to diagnosis, therapy, and care.
www.chaddsfordplanning.com.


Foreword
By Newt Gingrich
Former Speaker of the House and Founder of the Center for Health Transformation
W. Edwards Deming once said, “It is not necessary to
change. Survival is not mandatory.” No quote is more
appropriate to the current debate over healthcare. We have
indeed reached a fork in the road. On one hand, we could
reject change and continue down our current path. But by
choosing this path we would accept a healthcare system
of perpetually rising costs, poor quality, and millions of
uninsured Americans.
On the other hand, we could embrace change — bold,
transformational change — to create a healthcare system
that delivers more choices of greater quality at lower costs
for every American. That’s what we at the Center for Health
Transformation are committed to creating: a 21st Century
Intelligent Health System. One that values individual health
over sickness. One that encourages individuals to become
healthier citizens. A system that uses modern technology to
deliver the best care in the world. And a system where every
American is insured.
This level of change is not only possible, but essential. From
costs, to insurance coverage, to quality, our current path is
simply unsustainable — as a nation, as communities, and as
individuals. But real change will require real change. It will
also require courage, leadership, and collaboration from all
sides — from citizens, employers, providers, insurers, and
policymakers of both parties.
To get there, we must implement four transformational
changes.
First, individuals must take an active role in becoming
healthier. We can do this by incentivizing individuals to make
responsible decisions through closer relationships with their
healthcare providers and through wellness programs that
reward healthy living.
1
 ingrich, N, Merritt D. Tackling costs of health care requires some huge changes.
G should follow.
Des Moines Register, June 13, 2007.
Second, we must create a culture of health that leads to
responsible choices. We can do this by redesigning public
and private institutions to encourage better individual
choices when it comes to health and wellness.
Third, we must dramatically improve and modernize the way
we deliver care. This must start with rooting out waste and
inefficiencies by fundamentally changing the way we pay for
care. We can do this by eliminating any financial incentive
to use tests, treatments, or therapies that are not directly
beneficial to the patient or the care process.
Lastly, we must radically change the way we finance health
insurance and healthcare. We can do this by increasing
Newt Gingrich
competition in the insurance market and by giving Former Speaker of the House
consumers more access to cost and quality data.
Hospitals and health systems can play a vital role in
achieving these goals. They can be centers of wellness,
working in partnership with community leaders, physicians,
employers, and citizen groups, to promote health — both
of the individuals they treat and the communities where
they reside. They can use the world’s latest technologies
and evidence-based processes to deliver the best care for
the right patient at the right time. And hospitals and health
systems can work with governments at all levels, as well as
with private insurers, to guarantee that care is affordable,
access is real, and that consumers have choice.
We are proud to partner with Siemens on this report,
highlighting how the country’s leading systems are
using health information technology to change the way
they practice medicine so that their patients and their
David Merritt
communities receive world-class care. From Computerized Project Director
Provider Order Entry (CPOE) and evidence-based medicine Center for Health Transformation
to community leadership and consumer engagement, they
truly are examples of excellence that the rest of the country

Introduction
Despite these challenges, we can see glimmerings of a brighter future, both for our
system as a whole and for hospitals and health systems specifically. With momentum
and success building in healthcare consumerism, chronic-care management tools,
and the widespread adoption of healthcare IT, we know what this brighter future
will look like: 100% insurance coverage; healthy and empowered consumers; readily
available quality and price information; a culture of health through early detection and
prevention; outcomes-driven payment; and ubiquitous, interoperable technology.

This transformation requires fundamental changes from all stakeholders in healthcare.

Hospitals and health systems have the unique opportunity — and most certainly have
the motivation — to embrace such change so that they can be a centerpiece of a 21st
century intelligent health system.

This level of change requires hospitals and health systems to embrace new values,
visions, goals, and metrics of success. Hospitals and health systems can:

1. Redefine the role of hospitals to be centers of community health. This requires that
There is no doubt from anyone in healthcare that we must change. As a
they move from an acute-based, volume-driven model to one that maximizes health,
country, it is estimated that within the decade, by 2016, total healthcare
wellness, prevention, early detection, and ongoing health management.
spending will more than double to $4.1 trillion a year and consume
2. Deliver safe, efficient, and effective care. This requires investing in cutting-edge
nearly 20% of our GDP. State Medicaid budgets are expected to more
technology, embracing new models and processes of delivering care, and using care
than double as well. And for individuals, health indicators are heading
guidelines based on evidence.
down, the number of Americans without insurance is heading up, while
3. Embrace production models of delivery and efficiency to improve outcomes. This
healthcare costs continue to rise.
requires incorporating proven systems of production like LEAN Six Sigma into all
aspects of clinical operations.
Today, hospitals and health systems are on the frontlines of this broken
4. Build a true consumer-focused organization with a genuine, core focus on the
system. They persevere every day in the face of mounting challenges,
patient’s experience and well-being. This requires building a model that creates a
chief among them:
culture of customer service and deploys the appropriate tools and technologies to
engage their patients.
• Uncompensated care for patients without insurance
5. Create an engaged, motivated, and passionate workforce. This requires internal
• Perpetually rising costs
changes to how they organize, educate, support, and compensate their employees
• The inability to hire enough nurses and other skilled providers
— from administrative staff to nurses to executives to physicians.
• Perverse payment models that encourage waste and inefficiency
• Growing demands of an aging population
These strategies are being championed by many organizations. This report highlights
• Overcrowded emergency rooms
examples of excellence from across the country in each of these areas, proving that
• Lack of broad technology adoption and, therefore, systemwide
hospitals and health systems are not helplessly trapped in today’s broken system. There
interoperability
are pioneers who are building that 21st century intelligent health system — with health
• Rising liability costs
information technology at its core — that we all desperately want to see. And with their
continued leadership, coupled with others emulating their innovation, we can indeed

 enters for Medicare and Medicaid Services, Office of the Actuary. National Health Expenditure
C
Projections 2006-2016. 2006. build a brighter future.

Redefining
the Role of Hospitals
Hospitals have long been the center of healthcare in communities across the country. Most citizens see their community
hospital as the place to visit when sick or in need of emergency care. Most do not see hospitals as a place for their ongoing
health, focusing on preventing disease rather than just treating it. But that is quickly changing. With a focus on developing
community-based programs, investments in continuous process improvement, and integrating the appropriate information
technology into the care-delivery process, hospitals and health centers can become centers of community health. The goal is
to maximize health by offering programs on wellness, prevention, early detection, and ongoing health management.

Meridian at Home –
Remote Patient Management
By 2020, almost 30% of New Jersey residents will be
60 years of age or older. And while most of them will
continue to live in their communities, nearly 13% of them
will have functional impairments that will threaten their
independence. Couple this with the potential caregiver pool
radically shrinking as the baby boomer generation ages,
healthcare costs continually rising, as well as life expectancy
increasing, the challenges seem daunting. To stay ahead of
this curve, Meridian Health in central New Jersey has been
steadfastly transforming its healthcare delivery system from
an acute-care model to one focused on maximizing health
and wellness for its community.

Meridian Health, a nursing Magnet designated health

system, provides health services and programs through
70 locations throughout Monmouth and Ocean counties,
including four hospitals, 7,500 employees, and more than
1,400 physicians. In 2006, Meridian introduced Meridian
at Home, an innovative approach combining traditional
home care services, information technology, and clinical
intervention strategies designed to keep patients out of the
hospital and in their homes.


 ew Jersey Foundation for Aging. Demographics in NJ.
N
http://www.njfoundationforaging.org.

Meridian at Home is a fully accredited program that effectively provides
patients with access to a continuum of services throughout their lives
while enabling them to maintain their independence. “This is the only
way we see of being able to care for our patients, provide them with the
highest possible quality of life, while keeping healthcare costs down,”
says Rebecca Weber, chief information officer of Meridian Health.
The project began by developing a strategic plan focused on what was
required to support the needs of Meridian’s aging community. Using its
own clinical and financial data from the previous ten years, Meridian
identified the following situations most prevalent for readmission in its
community:
• Congestive heart failure (CHF) and heart disease;
• Chronic obstructive pulmonary disease (COPD);
• Failure to manage medications.
“Meridian at Home is the
only way we see of being
able to care for our patients,
provide them with highest
possible quality of life,
while keeping healthcare
costs down.”
Rebecca Weber, Chief Information Officer, Meridian Health

Multidisciplinary teams for each situation determined the data to
be collected, trigger points, alerts, and interventions to provide the
best possible care for the community in these situations and leverage
information technology wherever possible. Other diseases such as
arthritis and diabetes have been added to the chronic-care program
as well.
The patient’s home is equipped with a wireless PC that is interfaced
to a patient portal. Discreet wireless motion sensors (not cameras)
are strategically placed throughout the home, constantly monitoring
activities of daily living such as getting out of bed, eating meals,
using the bathroom, and taking medications. This information is then
transmitted wirelessly to the portal where reports are generated and
reviewed by family caregivers through their home PCs or home-health
aids at Meridian. Monitoring devices collect clinical information such
as the effectiveness of blood clotting medicines, glucose levels, blood
oxygen saturation, blood pressure, fluid retention, etc., and transmit it
wirelessly to the patient portal where the results are measured against
trigger points.
When a trigger point is reached, an alert is generated, and the patient
is called by a Meridian home health aid to gather additional information
and relay further instructions.
A doctorate-level pharmacist reviews all medications for efficacy.
Medication changes are then sent directly to the home. If an alert
repeats itself after a medication is changed or an intervention is
completed, Meridian may send a care provider onsite. All of this is done
in conjunction with the patient’s physician.
Today, there are more than 100 participants enrolled in the pilot
program, and anecdotal evidence suggests that patients are staying
out of the hospital as a direct result. Patient satisfaction is extremely
high because they are enjoying a higher quality of life without fear of
being alone.
This kind of model, which focuses on maintaining health, preventing
complications, and avoiding unnecessary hospitalizations, can be
replicated in facilities across the country, be it in the most urban
environment or rural area. Hospitals can play this vital role if they have
the right priorities and invest in the right information technologies.
Bay Area Hospital – Where Community Drives Vision
“Today’s hospital is educator and employer, consumer and caretaker,
activist and advocate, missionary and merchant…a leader in assuring the
health and well-being of the community.” Such is the mission of Bay Area
Hospital in Coos Bay, Oregon, which greets every visitor to its website
with the message “Your Health is Our Care.”
Bay Area Hospital, founded in 1952, is the largest hospital on the
Oregon Coast and the region’s largest employer, yet it is a relatively
small community hospital with 129 beds, 130 physicians, and 1,000
employees. Despite its size, Bay Area has made the commitment to
leverage information technology to help it move care delivery into
the 21st century. Today, it is on an aggressive path to build a care
delivery system that standardizes clinical best practices and integrates
information technology with clinical workflow, making the clinical
process more efficient while improving patient safety. As a result
of its efforts, Bay Area has achieved outstanding success with CMS/
Joint Commission quality measures, including increasing pneumonia
vaccination rates by over 87%, consistently achieving 100% performance
in acute myocardial infarction care, and earning the “Most Improved
Surgical Care Improvement Project Program in Oregon” award from
Acumentra Health (Oregon QIO) in 2007.
Three years ago, the leadership team developed a strategic plan that
included building an electronic medical record (EMR) system with
its community defined as a foundational element. As a result of the
strategic planning process, six goals now drive the organization:
1. Measure clinical outcomes
2. Optimize patient safety
3. Employ best practices systemwide
4. Optimize efficiency
5. Establish a true partnership with the information systems vendor
6. Be a premier employer
From this plan, sprang a multidisciplinary steering committee that
provides overarching leadership to the EMR implementation. The
Steering Committee created a group of “change agents,” who are
representatives from virtually every area within the hospital and
parts of the community that work together to provide analysis, input,
and feedback on the planned project. There are 70 change agents
representing everything from environmental services to physicians,
nurses, clinicians, housekeeping, pharmacy, community agencies, and
even labor unions. Participants were selected based on demonstrated
leadership skills and, in some cases, the ability to serve as devil’s
advocates. “By including all the areas,” says Doug Gauntz, manager

of imaging services at Bay Area Hospital, “it broke down all the silos.
Every department began working together toward the same goal.” The
change agent concept, along with a continuous process improvement
methodology, proved so successful that it remains an integral part of the “We saw a four-day drop
in our A/R in the first six
planning and implementation process today.

Bay Area Hospital decided its best strategy for realizing quick gains
was to leverage the use of imaging technology as a migratory step to
a fully electronic environment. The first priorities were replacing the
months.”
radiology and transcription systems and then building all the base-feeder Bob Force, Business Office Manager, Bay Area Hospital
systems (lab, radiology, pharmacy) to create a clinical repository that
would add value to physicians and clinicians by providing easy access
to online results. “The basic philosophy is that we wanted the medical
There is much anecdotal evidence that the EMR strategy has been paying
record populated so there is a reason for them to be there, and their
off. Brenda Curtner, registered nurse and clinical informatics coordinator
whole workflow works better for them,” says Ben Pfau, vice president
on the Steering Committee says, “We’ve noticed improvements
of support services and executive sponsor of the EMR project. Order
in workflow processes. We know we’re getting fewer requests for
processing and some clinical documentation came next with medication
information on paper, and we know our quality and risk management
administration checking and additional documentation in progress for a
folks are using the EMR.” An infection-control nurse reports saving an
2008 implementation.
hour a day because she can more easily track where a patient has been
and who he has seen, and no longer has to transcribe information from
Early wins gave the project momentum. The business office trimmed
one report to another.
average A/R by four days within six months simply because documents, such
as history and physicals and discharge summaries, were readily available
Patient safety gains have been realized as well. If a patient has a reaction
to the insurance companies. The ability to view images online, which
to a contrast media, for example, the allergy information is automatically
eliminated the need to track films, resulted in significant productivity
integrated into the EMR, eliminating the potential for human error
gains.
because the information does not need to be transcribed into a second
repository as was previously required. Having immediate access to BUN
and creatinine results, important measures of kidney function, prior to
giving contrasts has been another big gain since radiologists no longer
have to track down the paper chart.

Labs drawn in the hospital in the morning are available remotely through
the physician’s portal in the practice that afternoon. Everything that
happens to a patient in the emergency department, including images,
is available remotely in the physician’s office the next morning. The OR
is able to do comparative images, while an ICU nurse is able to view
images to ensure proper placement of lines. Access to electronic patient
information has also streamlined the preoperative process. Dictated
progress notes can be available in the EMR within minutes. “Most of
our EMR-based patient safety measures have been incremental at
this point and that has been our philosophy,” says Pfau. “We have set
the foundation, and now we are ready to take on some of the major
strategies such as medication delivery and clinical measures.”

Bay Area Hospital is also taking on the challenge of providing more
effective coordinated care outside the hospital walls by working with
other providers to develop a community-based health information
exchange. This is critical in a pluralistic health system where the average
Medicare recipient sees two primary care physicians and five specialists
each year in addition to receiving various diagnostic, pharmacy, and
other services. The number of visits is even greater for Medicare
recipients with multiple chronic conditions who may see as many as 16
physicians.4 Safety and quality issues are common because providers
often do not have proper referral information, health history, discharge
summary, discharge medications, diagnostic test results, or other critical
information needed for proper follow-up and care.

This project required community stakeholders, all of which are separate

entities, to agree upon a unified clinical record that could be shared
electronically, thereby eliminating the inefficiencies and risks associated
with courier delivery of paper records. The group, led by the hospital,
consists of referring clinics, a local independent practice association, and
an imaging center.

Initial funding to develop the plan was provided through a federal

grant that enabled the group to hire a medical director to drive the plan
development and conduct a system evaluation. The initial planning
phase was completed in 2007, and the group is currently developing a
business model for sustained funding.

The Steering Committee has attributed Bay Area’s current success to

a combination of things including: champions at the leadership level
who have helped them stay focused; the change agents and associated
process; incremental cultural change to bring end-users on board
voluntarily; and a vendor partnership that is sensitive to the needs and
limitations of a small hospital. Barriers have been surmountable because
of the leadership strength and the top-down commitment to the
community and quality care.


 odenheimer T. “Coordinating Care – A Perilous Journey through the Health Care System.”
B
N Eng J Med. March 6, 2008;358(10):1064-1071.

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