CMIOs and Innovation: A North Shore-LIJ example

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The ability of CMIOs to initiate innovation is certainly limited by the amount of time spent dealing with issues related to Meaningful Use, ICD-10, or the Physician Quality Reporting System (PQRS), but according to Michael Oppenheim, MD, CMIO at North Shore-LIJ Health System based in Great Neck, N.Y., “I don’t think it just impacts our ability to innovate.”

“We even struggle to find the bandwidth for our informatics and IT teams to support very important optimizations to our EMR deployment,” he said. “When it comes to the innovation side of things we find ourselves really stretched because while we can squeeze optimization projects in here and there, it’s very hard find the time or mobilize the other resources we need for innovation.”

How can a CMIO work around this problem?

“One of the most important things we do is to focus our efforts in areas that deliver high value,” Oppenheim said. It doesn’t necessarily have to involve the organization’s EMR team, he added, because that team is being significantly impacted by Meaningful Use and is busy with deployments and ensuring the accuracy of quality measures.

“But we do have other tools that we can use that provide us with a lot of data, assisted by an IT team which is less strapped, and we can try to focus our efforts on initiatives that leverage value off of those systems,” he said.

Oppenheim pointed out that North Shore-LIJ has invested in an internal HIE connecting the system’s 15 hospitals, 400 outpatient and physician practices, 12 emergency departments, three skilled nursing facilities, as well as community physicians affiliated with the system. Since the HIE is “outside the fray as far as what’s going on with Meaningful Use, we’re able to do a lot of interesting and exciting things with our HIE that we couldn’t do with other platforms because of where their efforts are currently focused,” he said.

Oppenheim said North Shore-LIJ is interested in the idea of using capabilities of the HIE to support programs that are targeted towards patients for whom the health system has assumed some degree of financial risk or accountability for the overall wellness of the patient. For example, the HIE can maintain registries of patients in various programs and provide real-time notifications to practices or case managers if one of those patients visits an emergency department or anywhere in the health system. This enables physicians to contact the emergency department providers and allows case managers to assure that appropriate follow-up care is arranged.

Additionally, North Shore-LIJ has been able to utilize the resources of its Business Intelligence Competency Center to develop a tool for the management of disease states or clinical conditions of particular importance to the hospital system, one of which is heart failure.

“It can be a very tricky thing to identify patients who meet the criteria [for heart failure],” said Oppenheim. “With heart failure you may, or may not, see a reference to heart failure in an admission 'history and physical' note for any number of reasons. A patient may present with a symptomatic complaint such as 'difficulty breathing,' but hasn’t yet been fully diagnosed with heart failure at the time the note is created, or you may have someone who is not admitted specifically for active congestive heart failure (CHF) but you still need to address their prior history of congestive heart failure from a core measure perspective.”

What Oppenheim and his team did was build a dashboard designed to mine through the record looking for any number of indicators that would suggest that a patient had CHF. This included, for example, searching through problem lists from current and prior patient visits and identifying medications typically used for CHF, such as some kind of diuretic. Or it could involve identifying symptom keywords, such as "lower extremity edema" associated with CHF in the "history of present illness" narrative.

All of this data gets put into the patient dashboard, Oppenheim said, “and initially we starting sorting this list by the number of elements suggestive across the records, and the nurses started using that when they looked for heart failure patients to apply case management and other programs. They found it incredibly helpful in targeting the right patient population.”

Taking the project a step further, Oppenheim and his team were able to develop a scoring system that was not only predictive of heart failure, but of patient readmission for heart failure, as well. “We’re going through a more formal bio-statistical analysis of it now, and we’re putting it into a regression model to refine it and make it more predictive, he said. "That sort of tool becomes incredibly powerful for the delivery of a heart failure program, and we didn’t need anything from our EMR teams to be able to do it.”

Another North Shore-LIJ effort involving the utilization of the HIE has been aimed at identifying patients with significantly advanced illnesses in order to initiate appropriate end-of-life and goals-of-care discussions in that population.

“We applied the same approach,” said Oppenheim, which involved looking at a number of social and environmental factors, as well as an assessment of the patient—for example, their ability to ambulate and feed and toilet themselves.

“We pulled a dashboard together with a scoring system that can be used as a screening tool,” he said. “We did some basic statistical analysis and found that the scoring system . . . provides a high predictor of mortality. We’re able to support this clinical program and identify these patients in a way that we never, ever could have done without the support of an electronic database support. But it didn’t require any investment on the part of the teams that are currently consumed by EMR deployments and other things of that nature.”