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One Patient, One Chart, One Imaging Record,

a Journey to Simplification

Brad Cook

September 12, 2018

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Agenda

• Who we are – UNC Health Care

• Our EHR Vision and Journey to Enterprise Imaging

– EHR Vision and Governance

– Enterprise Imaging Vision & Execution

• Enterprise Imaging Model

• Governance framework

• Portfolio Simplification

• Achievements to-date

– Future Considerations

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Who We Are – UNC Health Care

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Integrated, not-for-profit health care

system, owned by the State of North

Carolina and based in Chapel Hill.

We provide comprehensive patient

care, facilitate physician education

and research excellence, and

promote the health and well-being of

all North Carolinians.

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Key Stats 2016

Net patient

revenues$4.6B

Licensed beds >3,400

Employees >30,000

Medical staff >5,400

Employed MDs >2,900

Surgeries >105,000

ED visits >430,000

Clinic visits >2.3M

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Orange

Caswell Person

Granville

Vance

Warren

Franklin

Northampton

Halifax

Ala

mance Durham

Wake

Chatham

Nash

Edgecombe

Wilson

Johnston

Wayne

Lee

Moore

Harnett

Sampson

Duplin

Pender

New Hanover

Brunswick

Columbus

BladenRobeson

Cumberland

Hoke

Scotland

Guilford

Randolph

Montgomery

Richmond

Stokes

Forsyth

Davidson

Rowan

Stanly

AnsonUnion

Mecklenburg

Cabarrus

IredellDavie

Yadkin

Surry

AlleghanyAshe

Wilkes

Alexander

Catawba

Lincoln

Gaston

Cleveland

Burke

Caldwell

Watauga

Avery

McDowell

Rutherford

Polk

Mitchell

Yancey

Buncombe

Henderson

Transylvania

Haywood

Madison

Swain

Jackson

Macon

Graham

Clay

Cherokee

Onslow

Jones

Lenoir

Greene

Pitt

Martin

Bertie

Hertford

GatesCamden

Pasquotank

DareTyrrellWashington

Beaufort

Hyde

Craven

Pamlico

Rockingham

Currituck

Perquimans

Chowan

Carteret

We serve North Carolina. Every day.

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Vision of One … Established in 2012for Enterprise EHR

2013(January – March)

• Planning and Guiding Principles

• Core Team Assembly and Training

• Subject Matter Expert - SMEs

• Key Decisions

2014 Go-Lives(April 4th Go-Live 1 and June 20 Go-Live 2)

• 3 Hospitals: UNC Hospitals; Chatham Hospital; Rex Hospital

and

• All their Physician Groups (Rex, UNCPN, UNC Faculty)

EHR@UNC

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Vision of One continued as UNC Health Care grewSo, did the challenges with a very diverse application portfolio

2015 Go-Live(May and June)

• New Ambulatory Clinics across 3 Hospitals – Caldwell, Johnston, High Point Regional

• EHR Optimization (Improving Existing Build)

2016 Go-Lives(May and June)

• 4 New Hospitals – Caldwell, Pardee, Johnston, HighPoint Regional

• Cardiology Module – all entities

• Lab Module – all entities

2017 Go-Lives(Oct – New Modules – all entities)

• Case Management

• Infection Control, Antimicrobial Stewardship

• Transfer Center

2018 Go-Lives• Homecare and Hospice Module – all

entities

• 2 New Hospitals – Nash and Wayne

EHR@UNC

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Backed by Governance

Guiding Principles: EHR@UNC’s “Constitution”

Mid Level Decisions

HighLevelDecisions

Detailed Decisions

~ 25% of decisions (moderate

impact)

~ 10% of decisions

(major impact)

~ 65% of decisions

(local impact)

Work Groups and Design Session

participants:

e.g., verbal order workflow definition

Design Teams:

e.g., decision to enter patient age or

date of birth

Executive and Steering Committees:

e.g., parameters of “localization” allowed

• Guiding PrinciplesCascading sponsors

and example of decisions:

Guiding Principles frame the design decisions to be made by the Work Groups and the Design Teams at large.

They are important as they support an efficient and empowered, decentralized decision-making process needed

to support EHR@UNC’s accelerated timeline

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UNCHCS Senior Executive Team

Information Systems Oversight Committee (ISOC)

Work Groups

Sub-Work Groups

Core Team

(Analysts)

Design Team

(SMEs)

Oversight Committee reviews

progress from the

Workgroups. Resolve

remaining conflicts

Escalate design/ standardization

decision conflicts, or potential changes to policy and practice

Workgroups working in conjunction

with Sub-Work Groups identify

decisions required to change current

clinical policy and clinical practices -

presented as a consensus agenda to

communicate all decisions that

change current processes.

Establish direction for Design Teams

Guide policy adoption

Approves budget/ SBAR’s

Define Vision and Goals

Define Guiding Principles

Define Key Decisions

Working with Core Analyst Teams,

Design Teams make design decisions

based on their decision rights

Sub-Work Groups resolves

conflicts from Design Teams,

approves change

recommendations. Escalates

to Work Groups as needed.

“Decision Rights”Delegation

Conflicts Escalation

Delegation & Escalation

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Str

ate

gic

UNCHS Senior Executive Team

UNCHS Information Services Oversight Committee

(ISOC)

Business & Rev

Cycle Work GroupClinical Work

Group

Research,

Analytics &

Reporting Work

Group

HCS Growth &

Expansion Work

Group

Innovation

Work Group

Enterprise Architecture,

Infrastructure & Security

Project Management Office

IT Leadership

Daily IT

Operations

(~70-80% of

resource

consumption)

• Strategic Initiatives

• System Imperatives

• Entity Committees

• Operational Committees

• Senior Leadership

• Service Requests

• Other Informal Requests

Request Intake & Initial Triage Requests

Supported by Operational &IT GovernanceIT Governance evolved to keep up with growth…

Tactical

Sub-Work Groups

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“Enterprise” Image Enabling the EHR

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One Patient One Chart didn’t address Enterprise Imaging

Imaging Strategies were Service Line focused and Facility based with

• IT infrastructure complexity; BC/DR planning challenges

• Immature imaging strategy and practices outside of Radiology and Cardiology

• With inability to exchange images

• Proliferation of stand alone point of care devices with no image retention

• Trying to turn EHR into an Imaging Repository

• No Enterprise Image Lifecycle Management Policy for electronically stored media

It only got worse with Health System growth

• 32 Systems in Imaging and Reporting Portfolio just across Radiology and Cardiology

• Not counting specialty systems

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Where we wanted to go

• Improved Access to Images across the

UNC Health Care enterprise

• Compliant and secure Data Sharing

• Reduced Management Complexity

• Interoperability and Data Exchange

• Sophisticated ILM Strategies

• Lower Total Cost of Ownership

• Take Back Control

Centralized

Secure

Image Lifecycle Management

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With new entities and a growing demand for new technologies…

Enterprise Architecture was bornPortfolio Simplification was first major initiative, and Enterprise Imaging a Major Focus Areas

Enterprise Architecture Mission and Focus

To compose holistic solutions that address enterprise business challenges

and support the governance needed to implement them

Establish IT solution roadmaps and blueprints for effective and efficient

enterprise solutions that will serve the business now and the future

Focus:

• Evangelize the “Enterprise” Perspective

Enterprise viewpoint, Interoperability focus, and Take the long-view (when appropriate)

• Increase Agility of IT

Consultant and “trusted advisor”, Proactive (get ahead of needs), and Adapt services

and solutions to meet the needs

• Foster Innovation

Build a body of knowledge, develop standards, define repeatable patterns to spend

more time on innovation

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Consolidate over time

Enterprise Imaging ModelCore Vision Achieved

Enterprise EHR

Web Viewer

Enterprise Imaging Solution

Vendor Neutral Architecture (VNA)

Multiple PACSDepartmental

Imaging Systems

Medical

Devices

Image Life Cycle Management

Tiered Storage – Long-term Retention

Modalities

Mobile

Devices

Image link to one

Enterprise Imaging solution

Partially Done

Complete for UNC EHR entities

External

Images

Future phase

Vision Expanded in 2017

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Enterprise Imaging Vision bundled with Portfolio Simplification

Vision endorsed by CEO roundtable, ISD Governance and Imaging Consortium

• Support for Portfolio Simplification had to come from the Top

• Carolina Value re-endorsed Portfolio Simplification

Enterprise clinical imaging strategy:

• Enterprise Imaging Model plan to drive strategy

• Not limited to Imaging Department areas

• Workflow improvement, compensating controls and image integrity was key

• Simplify Imaging Systems Portfolio

• Platform to promote innovation

Interdisciplinary team established to select an Enterprise Solution

• Led by Physician Chair and supported by IT Enterprise Architecture

• Initial Implementation Scope driven by Portfolio Simplification

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Turning Vision into Action

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Clinical Governance – Critical Foundation

Enterprise Radiology and Cardiology workgroups established to make key decisions

during enterprise EHR rollout still continue

• Physician and Executive Sponsors established to drive standardized workflows, and prioritize

optimizations

• Examples: Lung Screening, Palette optimizations, specialist participation for Bi-Rad

combinations

• Set the stage for more expansive enterprise imaging clinical governance

• Not just VNA, but all Imaging Solution decisions

System selection team primarily providers and clinical department representatives

• ISD co-chaired to support the clinical vision

• Group established project scope for initial rollout

Enterprise Imaging Workgroup established post rollout

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Clinical Enterprise Imaging Workgroup added under ISD

Governance Structure

Clinically Led, IT Supported

Functions as a platform for

• New project request review and approval

• Design decisions

• Prioritization when needed

• Promoting innovation

Collaborates with Imaging Consortium on

• Imaging product decisions

• Image Life Cycle Management decisions including Enterprise Image Retention Policies

Works within ISD Governance

• Integrating tightly with processes like IT Enterprise Architecture

• Focusing on workflow improvement, compensating controls and image integrity

• Continuing to support and expand the Enterprise Imaging Vision

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Adoption has led to significant gains

Benefits realized … Journey continues

Supports the One Patient One Chart Vision

Operational Efficiencies and Compliance

Reduction in annual support and enhancement costs; Fewer upgrades; and More

efficient support models

Architecture Simplification

Fewer interfaces; Fewer server and application foot prints; Focus now on business

continuity planning

Tighter Clinical Integration & better continuity of care

Examples:

• Timely access to images across enterprise facilitates time-sensitive consults with

rest of UNC Health Care System

• Reduction in repeat imaging tests

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VNA MetricsSince then, we have accomplished the following in parallel with EHR rollout for 6 hospitals &

related clinics

44 ClinicsImage Enabled Ambulatory Clinics with Radiology / Cardiology

Imaging Equipment

12 Portfolio

Simplification

Eliminated 9 PACS and 3 Reporting/Dictation systems

6 More planned for Replacement in 2018

31 POC

AreasDepartments & Functional Areas live on POC integration to VNA

600 Users/hr600 users per hour viewing exams with enterprise viewer during

the work day

9.4 Million 2.5 million exams archived to VNA over the last 24 months

6.9 million legacy studies converted and archived

1Image

RepositoryImplemented VNA w/Universal Viewer integrated with EHR,

providing a Longitudinal Image Record

Visible

Light

Enabled VNA for Visible Light Image Capture and Storage via EHR

smart phone/iPAD module, also providing Longitudinal Image

Record for those images

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What’s Next

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Enterprise Imaging Vision Realized and Expanded

+Extended the spirit of One patient, One Chart

to

One Clinical Enterprise Image Repository (Acuo VNA)

integrated with Enterprise EHR

Via One Common Viewer (Nil Read)

+Cloud Image Exchange

& HIEs

Enterprise EHR

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VNA / Nil Read Viewer

1Image

RepositoryImplemented VNA w/Universal Viewer integrated with EHR,

providing a Longitudinal Image Record

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VNA / Nil Read Viewer 3D

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VNA / Nil Read Viewer

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Dose Treatment Plans VNA / Nil

PDF stored in VNA

Nil DICOM-RT overlay

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UNCHCS Clinical Viewer Updates

Nil Tip sheet available on intranet - http://intranet.unchealthcare.org/epic/files/2017/nil

LMS Training – Activity Code HCSNILTRAIN

Log ticket though MySupport@UNC or call the Service Desk

© 2018 Epic Systems Corporation. Used with permission

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Combining EHR + PACS Scan Web + Nil

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Visual Light Imaging Web Tools

Standalone web-based tools offer flexibility for various use cases including restricted photos

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Combining Modality + PACS Scan Image Link

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Visual Light Imaging Mobile

Coming Soon: Button in Haiku / Canto / Rover to launch PSM

Imaging in the mobile arena is becoming more popular. Apps are integrating with cameras on tablets and phones

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Future of Enterprise Imaging at UNC Health Care

Continue the Journey … Image enabling all applicable areas across the

Enterprise

Optimize and Focus on Image Life Cycle Management

• Better tools needed for Image Integrity

Support the Enterprise Growth …

• 2 More Hospitals Planned for ISD on-boarding in 2018

• New EHR Modules being added in 2018 and 2019 require Imaging

Focus on Innovation and Telemedicine Support

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Convergence of Enterprise Content Management and Clinical Imaging

Enterprise Imaging Future at UNC Health Care

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New innovative uses of Artificial Intelligence applications

Enterprise Imaging Future at UNC Health Care

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Open Discussion & Questions

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Contact Information

Brad Cook

HCS-Application Developer ISD Clinical Imaging

Bradley.cook@unchealth.unc.edu