Jeff Pelot Chief Technology Officer
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Jeff PelotChief Technology Officer
Jeffrey PelotChief Technology Officer, 6 years○
Prior leadership/management positions in Healthcare IT, total 10 years
○
Masters Degree, Regis University 1999, Information Systems
○
Awards:
Bio
Agenda About Denver HealthAbout Denver Health’s SystemsChallengesCurrent Technology ApproachThe Ultimate Challenge and a Potential Solution
Denver Health
Integrated public safety net institution5,300 employeesClosed medical staffAcademic programs Level I trauma center
Our Patients
160,000 unique patients visit annually25% of Denver population35% of Denver childrenBusiest Colorado hospital Largest Medicaid providerLargest uninsured provider
$3.1 billion in unsponsored care provided since 199210% of beds in metropolitan area but provide 40% of all unsponsored care$385M projected for uninsured care in 2010
Our Commitment to the Uninsured
Denver Health & Hospital Authority
Denver Cares
Correctional Care
Denver Health
Medical Center
Family Health Centers
Regional Poison Center and Nurseline
Denver Health Medical Plan
School-based Health Centers
Rocky Mtn Center for Medical
Response to Terrorism Rocky Mtn
Regional Trauma Ctr
911Public Health
Phase 1 (1996–1997)Build technology infrastructure (scalable, fault tolerant, adaptable)
Phase 2 (1998-2000) Support the financial business operation
Phase 3 (2001-Current) Implement integrated clinical applications
Denver Health’s High-Level Technology Strategy
Technology StatisticsMetrics 1997:
Images Viewed 3,100,205Servers 10○
Virtual Servers
0Desktops 800○
Thin-clients
0Printers 110Network Devices 200○
Managed Ports
2,300Vocera Badges 0Phone Sets 5,798VOIP Phone Sets 0Pagers 1,100Cell Phones 140Storage 2.19TBE-mail Users 400Core Applications 3Help Desk Tickets 8,700
Metrics 2009:Images Viewed 12,404,035Servers 540○
Virtual Servers
243Desktops 5,150○
Zero-clients 1,736Printers 983Network Devices 1214○
Managed Ports
19,000Vocera Badges 685Phone Sets 4,511VOIP Phone Sets 1,914Pagers 1,897Cell Phones 242Storage 140.4TBE-mail Users 7,419Core Applications 71Help Desk Tickets 32,839
Clinical Ancillary Systems
PathologyBlood BankPathologyLAB
RadiologyPACS Dictation
Emergency Department
Surgery
InpatientPharmacy
WomensServices
Interface Engines and Integration
ADT Orders Results
Charges
Core Clinical Systems
Order Entry
PatientDocumentation(Electronic & Scanned)
ClinicianPortals
Decision Support Systems
Data Warehouse
Severity Adjustment
Reporting Tools / Writer
Comparative Database
AccessOutcomes
MeasurementResource Utilization
Provider Profiling Benchmarking
Clinical Data Repository
Enterprise Patient Access and Aquisition
Admission /Registration
Enterprise Scheduling
Eligibility Verification
Consumer Portal
Denial Management
Technical InfrastructureInfrastructure
Design & Assessment
Server Management
Storage Management
Network Management
Telecom Management
Software & Integration
Workflow & EnterpriseManagement Systems
Document Imaging
Patient Tracking
Bed Management
Enterprise Access
Directory
Information System Application Components
Medical Necessity
Patient Identification
Financial Information SystemsPatient Accounting
Financial Information Systems General Accounting
Department / Support Services
Children’sServices
Grant Management
Marketing Education
Building Services
Foundation Transport
Security
Social Services
HR
Document Management
Coding
Medical Records
Transcription
Clinical Engineering
Property Management
Enterprise Patient Access / Acquisition / MPI
Clinician Interface Portal
Clinical Data Repository (Electronic Medical Record)
Workflow Management / Enterprise Management Systems
Decision Support Systems (Data Warehouse)
Interface Engines / Integration
Technical Infrastructure
Financial Information
Systems
Department & Support Systems
Clinical Ancillary Systems
Core Clinical Systems
Monitoring,Diagnostic,Patient Care
Systems
OutpatientPracticeManagement
Claims Editor Collections Payor /Relations
PatientBilling Cash Posting Contract
Management
Charges
General Ledger A/P Materials
Management
Payroll
Monitoring, Diagnostic,Patient Care Systems
IV Pumps Patient Monitors
EEG Sleep
EKGOutpatient Practice Management
EMR
PhysicianPortal
Desktop Management
Network Security
Disaster Recovery
Enterprise Application Stack
Time /Attendance
Telephone Triage / Referral
PhysicianStaff &
Credentialing
Outpatient Pharmacy
Intranet /Internet
Occ Health
Budgeting
MedicationAdmin (MAK)
Device Tracking
Breast Imaging
Risk Management
Cardiac Services
Utilization Review eRecruiting
Staff Scheduling
UserProvisioning
GeneralLedger
Reporting Data
Coding
Custom
Workflow Engine
Analytics
Nursing Care Plans
Order Entry
RespiratoryServices
Ventilators
Rules Engine eRX Patient Portal
Key
Completed
In Progress
Not Funded
Results(LCR), Common Vocabulary, DSS,Interface engine, may have Document ImagingStage 2
Clinical documentation (flow sheets), Clinical DSS (error checking), PACS available outside RadiologyStage 3
CPOE, Decision Support (clinical protocols, registries)Stage 4
Closed loop medication administrationStage 5
Physician documentation (structured templates), full Decision Support (variance & compliance), full PACSStage 6
Medical record fully electronic; CDO able to contribute to ICEHR as byproduct of SEHRStage 7 0.0%
0.3%
1.3%
2.1%
21.3%
39.3%
16.3%Stage 1 Ancillaries –
Lab, Rad, Pharmacy
Stage 0 All Three Ancillaries Not Installed 19.5%
% of USHospitals
Source: HIMSS Analytics Databases (derived from the Dorenfest IHDS+ DatabaseTM)
EMR Adoption Model Q1 2010
N = 4,298
Denver Health certified at Stage 5, next level is 7
Health IT spending per FTE is low (McKinsey Global Institute) and competes with medical technology and buildings
Non-clinical IT adoption vastly outpaces clinical IT adoption (HIMSS Analytics)
Systems that adopt IT are frequently rated as high quality (Most Wired and US News)
IT enabled organizations have better mortality rates (Most Wired and AHA)
A “natural” adoption rate for HIT (E health records) exists (Rand Health)
Numerous Digital “divides” exist
Health IT adoption impact is high, but requires networked systems, not just adoption (Rand, CITL, NEHI, Cisco)
What do we know about IT adoption in Healthcare?
Total Estimated Savings = $280 Billion
Projected Impact Is High
Ease of Technology Implementation
HIGHHIGH
HIGHLOW
Electronic Claims and Eligibility$62B5
Sources: 1. Center for IT Leadership, 2003; 2. American Health Quality Association, March 2004; 3. New England Healthcare Institute; 4. National Center for Policy Analysis; 5. Cisco analysis, April 2005
Interoperable Ambulatory Electronic Health Records (EHR)$78B1
Inpatient CPOE $44B3,5
Barcoding$5B2E-ICU
$8B3,5
StandaloneAmbulatory CPOE and EHR $44B1
Electronic Prescribing$29B4
Qua
lity
and
Safe
ty Im
pact
Physician- Patient Messaging$8B3,5
Disease Management,Remote Patient Monitoring$32B3,5
Focus areas:Systems availability
Full integration, work flow and analytics
Billing abilities
Reporting abilities
Standardization of over 500 processes
of care
HITECH compliance
Reduction in time to care
Manage health and focus on wellness, reduce overall costs
Technology Goals
Healthcare Challenges
•
Constrained to Budget•
Need Network Expertise Outside of Core Capabilities
•
Mostly Focused on Reactive Activities
•
Constrained to Budget•
Need Network Expertise Outside of Core Capabilities
•
Mostly Focused on Reactive Activities
•
Budget and Access to Capital Constraints
•
Challenge to Balance Between Cost & Quality
•
Budget and Access to Capital Constraints
•
Challenge to Balance Between Cost & Quality
TECHNOLOGYCOMPLEX & CRITICALAPPLICATIONS
RESOURCES
FINANCIAL
•
Constant Uptime- 24x7•
Often Requires Integration and Convergence
•
Constant Uptime- 24x7•
Often Requires Integration and Convergence
•
Critical & Life-Impacting•
Requires a Strategic, Master Plan
•
Ongoing Support Critical
•
Critical & Life-Impacting•
Requires a Strategic, Master Plan
•
Ongoing Support Critical
Health and Hospital Systems
In an ambulatory setting Physicians spend no more than 15 minutes with a patient
No time to wait for a typical logon
No time to logon again and again to specific applications
No time for system slowness
Absolutely no time for outages
All of the above are contributors to decreased revenue opportunities and Physician dissatisfaction
Information must be reliable, fast, and consistent
Radiology is 99% filmless with Picture Archiving and Communication System (PACS)Results available for radiology interpretation is less than 2 secondsRadiologists use voice dictation for all studies resulting in 100% elimination of external transcription costs; saving $15,000+ per month
PACS
Entered via CPOE monthly:Over 300,000+ orders Over 96% of laboratory orders Over 96% of pharmacy orders Standardization of over 500 processes of care with ~150 evidence-based order sets
CPOE, compilation of several apps
CPOE Reduction in Time to Care Laboratory Results
Laboratory results availability decreased 54.5% (142 to 63 minutes)
4/5/2010 Denver Health and Hospital Authority
54.5% Reduction
CPOE Reduction in Time to Care Medication Availability
Medication availability time decreased 83.4% (44 to 7.3 minutes)
83.4% Reduction
CPOE Reduction in Time to Care Radiology Results
Radiology results availability decreased 61.5% (1860 to 680 minutes) 61.5%
Reduction
DataWarehouse
Pharmacy RadiologyLaboratory
DemographicsFinancial
Pathology EncounterPulmonary GI Lab
Digisonics EDM Forms
OBTraceVueEMESISMed Recon ORSOS
2009
2007
2008
1998
CPOE MAK
Clinical Data Warehouse
ImmunizationsAsthmaAnticoagulationColorectal Cancer screeningHypertensionDiabetes MellitusAmiodaroneCervical cancer screeningBreast cancer screeningTraumaObstetrics
Registries
External to WarehouseAutomated in
Data WarehouseCurrent projects
Blood pressure controlled in 62% of our hypertensive patients vs. 24%
nationally
Cholesterol levels controlled in 70% of our diabetic patients vs. 35%
nationally
Adolescent vaccination rates for Tdap are two-fold higher than national rates
Trauma mortality rates lowest of any major trauma center in US with O/E
ratio of 0.441
Highest score for a safety-net hospital in University Health System
Consortium’s annual Quality and Accountability study last 2 years
Has It Made A Difference?
1American College of Surgeons National Benchmark Study
Codman AwardCIO Top 100LeapfrogNewsweek Top 10 HospitalsColorado CIO of the YearHospitals & Health Networks 100 Most Wired HospitalsComputerworld – Best Practices in Enterprise Management
Industry Recognition We think that we are on the right track
100% availability Fast ConsistentAvailable
At the point of care when and where needed
The Healthcare IT Challenge
Executive educationAnnual budget allocatedEnsuring uptime through
maintenance processesstaff allocation on off hours, etc.toolschange controlproblem ownership
Etc….
Denver Health Approach
Executive educationUnderstand the cost of HAUnderstand the complexity of HAUnderstand the cost of downtime in terms of patient care○
Opportunity for errors○
Quality○
Life threatening concerns○
Revenue opportunities○
Etc.
Business need always drives the strategy, i.e. does your business need this availability model or will something else work?
Annually based on 365 days per year99.5% equals 1 day 19 hours 48 minutes99.9% equals 8 hours 46 minutes99.99% equals 53 minutes99.999% equals 5 minutes
Denver Health Approach
The potential of shared infrastructure, not hosted (?)IaaS (Infrastructure as a Service)○
Highly redundant networks○
Shared storage platform with geographical site tolerancePaaS (Platform as a Service)○
Vmware○
XenIn a perfect world applications…
Users get to specify the type of service they requirePlatform-specific APIs would be standard ○
Vendors creating applications using standardized APIs could can then use a model based on SaaS or utility computing and employ it across a hospital network
Multi-tenanted applications bring down total cost, compared to a hosted model
The Cloud Concept
What We Are DoingOn the Network
•Two Core Distribution Frames• Dual pathing for most fiber runs•
Failures points pushed as far to the edge of distribution as possible• Survivability protocols through security (NAC)
In the Data Center• Two data centers• Clustered servers• Virtualized Servers• Virtualized iSCSI SAN, replicated storage
• Geographically separated• Instantly available in case of site failure•Backups• Every 10 minutes for critical systems•Disk to disk and disk to tape
In the Environment• Zero clients at every point of care
• Mobile sessions• Instant logons
The Network Redundancy
Reduce time by half for deploying new systems
Standard Security Configurations
Systems are exact copies ensuring “Gold Standard” build
Simplifies Upgrades
Simplifies Troubleshooting
Simplifies System Recovery
System Version Control
The Data Center Rapid Deployment Model Web Temp
MOSS CVE SQL
File Shares
SQL Temp
App Temp
OpenLink
OPL-V1
The Data CenterVMware & Future
• Virtual Lab• Testing Facility• Efficient Upgrade• Configuration
Management• Improve Patch
Management• Reducing
Downtime
• Minimize Impact to users
OPLProduction
Lab
CVE SQL
CVE SQL V1
OPL V1
Application Testing
The Data Center DR and BC
660 Data Center 990 Data Center
Memory
CPU
Memory
CPU
Memory
CPU
Memory
OS 1B
OS 2B
OS 3B
OS 1A
OS 2A
OS 3A
VMwareCluster Group
Two-WayReplication
Group Policy / User Mgmt/ Apps
Benefits
•Hot Desking•Built in smart card reader •Only 4 watts of power consumption •Half the size •Stateless •Truly a thin client , no embedded OS to maintain and no admin
•Clinician login time savings ($68/hr, 30 minutes per day, 260 productive days, 300 physicians)-$2,652,000 in time savings
•Help Desk call savings ($10/call, 1500 PCs about 40 calls per week, 52 weeks)-$20,800 in help desk costs
•Energy savings based on KW/hour (PC consumption/year $90.89, Sun Ray consumption/year $3.12, 1500 units)-$131,655 in energy savings
Individual Server Blades
Terminal ServicesVirtual Machines
ESX/GSX/MSVS/ZWSingle Installs
Citrix
Full PCs
Thin PCs
OS/ Thin Computing Software
Net
wor
k
Solaris / SunRay
Thin Client
Zero Thin Client
SunRay’s
Solaris / SunRay
SunRays
The EnvironmentZero Clients
What Remains?
Application availability is biggest challenge
Scheduled Outages• Downtime for patching• Downtime for maintenance
Unscheduled Outages• Downtime for system bugs• Downtime for system incompatibilities•Downtime for hardware failures in non redundant systems
System Slowness• Database problems• Incompatibilities•Poor programming
The Experts Say
“A well-executed Release Management solution will save you money and avoid unplanned downtime. Once code is built, an application development team's work is largely done, but it's just beginning for IT Operations.
IT Operations strives to ensure that the production environment is stable and secure, whereas Application Development wants to be agile and business focused, delivering new functionality at a rapid pace. So it is not surprising that there may be conflicts between IT Operations and Application Development. As a result it is often complex and problematic to deliver changes from development to production. Learn how you can dramatically reduce the risk and cost of releasing applications into production. With visibility into exactly what has changed in each package you can anticipate risks.”
Application Release Management, The Path to ProductionSerena Software white paper, May 2009
The Potential Fix
Build the Cloud, butEnsure that vendors and staff○ Adhere to:
Release ManagementChange ManagementConfiguration Management
Everyone MUST embrace the philosophy of SERVICE
DELIVERY
Benefits of the Cloud
It is better than a hosted service since there are no long-term commitments with a cloud infrastructure provider
Applications are standardized since they can be developed with the PaaS framework, which the cloud provides, or use the same APIs to access the infrastructure services
Standardization of the application would increase the reach of applications across systems without requiring much modification at the user's end
4/5/2010 Denver Health and Hospital Authority
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