Promise

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Promise 2Improved Quality and Safety

• September 25, 2008

Moderator Julie Creamer, Senior Vice President
Quality and Planning Panel Carole Cotter, CIO
Lifespan Steve Hasley, M.D. Director Clinical
Interoperability Decision Support, UPMD Ed Marx,
CIO Texas Health Resources Farzad Mostashari,
M.D. MSPH Assistant Commissioner, Primary Care
Information Project New York City Department of
Health and Mental Hygiene Jerry Osheroff, M.D.
Chief Clinical Informatics Officer, Thomson
Reuters
Northwestern Memorial
HealthCare
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Agenda

• The IT Promise Improved Quality and Patient
  Safety
• Northwesterns Quality Agenda
• Communicating Impact

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The IT Promise Improving Quality and Patient
Safety
Does IT make a difference? Literature Review

• The earliest studies were done at the Regenstrief
  Institute in the late 1970s, evaluating the
  effectiveness of CIS on adherence to influenza
  vaccination. Since then, there have been
  hundreds of articles seeking to evaluate CIS in
  various domains quality, efficiency, and costs.
• Neumann, Parente, and Paramore (1996) reviewed
  eleven studies and presented a consolidated
  analysis of each. They found that fully
  automating administrative functions could save
  between 5 and 8 billion annually.
• The Most Wired report (Solovy, 2001) by
  Hospital and Health Networks and Deloitte
  Consulting shows that most wired hospitals have
  better control of expenses and higher
  productivity.

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Impact of HIT on Quality, Efficiency and Costs

• 257 studies examined
• 63 CDS Systems
• 37 Electronic Medical Records
• 13 CPOE
• 25 of studies came from 4 benchmark
  organizations with homegrown systems
• Conclusion Whether and how other institutions
  can achieve the quality and safety benefits
  demonstrated by the benchmark organizations is
  unclear.

Chaudhry B, Ann Intern Med. 2006144E-12-E-22.
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Benefits of an Integrated EHR with CPOE and CDS

• Anytime, anywhere access to legible patient
  information
• Complete legible orders with legible physician
  signature
• Ability to push real time information to
  clinicians
• Enable physicians to be alerted to hazards based
  on the individual patients medical history and
  current medications
• One source of truth, although there are
  potential risks
• Elimination of transcription
• Improvement turn-around times
• Medication
• Radiology procedure completion times
• Lab result reporting times

Mekhjian HS. J AM Med Inform Assoc.
20029529-539
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High Rates of ADEs in Highly Computerized Hospital

• High rates of ADEs may continue to occur after
  implementation of CPOE and related computerized
  medication systems that lack decision support for
  drug selection, dosing and monitoring.

Nebeker et al., Arch Intern Med. 2005
1651111-1116
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Medication Studies with CPOE plus CDS

• 25 improvement in ordering of corollary orders
  (medications and labs) (Overhage 1997)
• 55 reduction in serious ME, 17 (NS) decrease in
  preventable ADEs (Bates 1998)
• Significant decreases in antibiotic ADEs,
  susceptibility mismatches, antibiotic costs and
  total hospital costs (Evans 1998)
• 81 reduction in ME (studied in 4 phases) (Bates
  1999)
• Improvement in 5 prescribing practices (Teich
  2000)
• 13 and 24 decrease in inappropriate dose and
  frequency respectively for patients with renal
  insufficiency (Chertow 2001)

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Effect of CPOE CDS on ADEs

• Systematic Review
• Only 10 studies met inclusion criteria
• 7/10 homegrown CPOE/CDS
• 50 had a statistically significant improvement
  in ADEs
• 2/3 studies with commercial systems found a
  significant decrease in ADEs

Wolfstadt JI et al. J Gen Intern
Med200823(4)451-8.
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Technology Can Reduce Errors

• Studies demonstrating that technology can reduce
  rate of errors in three ways
• Preventing errors and adverse events
• Facilitating a more rapid response after an
  adverse event
• Tracking and providing feedback about adverse
  events
• Strategies for error prevention includes tools to
• Improve communication
• Make knowledge more readily accessible
• Require key pieces of information
• Assist with calculations
• Perform real time checks
• Assist with monitoring
• Provide decision support

Bates DW Gawande A, Improving Safety with
Information Technology, New England Journal of
Medicine, 2003, 348 (25)2526-2534
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NMHCs Strategic Plan Has Three Goals That Guide
the Organization

• To Provide the Best Patient Experience from the
  Patients Perspective
• To Recruit, Develop and Retain the Best People
  who Share the Organizations Values and Achieve
  Results
• To Develop the Resources to Achieve Our Mission
  and Vision Through Exceptional Financial
  Performance

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Improving Best Patient Experience Through our
Quality Program

• Eliminate avoidable adverse events
• Deliver evidence-based care
• Enable the best possible outcomes

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NMHs EHR with CPOE offers a Competitive
Advantage for Quality
Percentage of Hospitals with CPOE
Northwestern Memorial Hospital
Reference KLAS Enterprises, LLC CPOE Presented
by Adam Gale, April 24, 2008, Scottsdale
Institute Teleconference.
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Northwestern Memorial Hospital Provides the Best
Patient Experience from the Patients Perspective
Objectives
Deliver Care That is Safe and Without Error
Deliver Effective Care
Coordinate Care to Meet Each Patients Unique
Needs
Deliver Care That is Timely and Convenient
Deliverables
Top Decile Performance on Publicly Reported
Quality Measures
Incorporation of always practices that are
associated with improved outcomes
Initiatives/Tactics
Clinical Documentation
Standard Order Sets
CPOE Computerized Provider Order Entry
Rules and Alerts
Electronic Medication Administration Record (eMAR)
Outcomes Analysis and Reporting
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IT Solutions Ranked for Impact
additional factors not related to patient harm
include regulatory requirement(s) and/or end-user
efficiency
RPN Severity Rank x Occurrence Rank x Detection
Rank
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Shoulder Dystocia
Intrauterine pressure is caused by maternal
contractions
Anterior shoulder impacted on symphysis pubis
Brachial plexus stretching
DANGER
Brachial plexus damage Severe brain damage or
death due to hypoxia / acidosis if delay in
delivery
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OB Shoulder Dystocia Improvements

• Pre-Planned Emergency Response Protocol
• Training Sessions / Drills
• Birthing Simulator
• IT Enhancements Related to Clinical Documentation

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Shoulder Dystocia and Brachial Plexus Injury
Prevention
Brachial Plexus Injuries as a of Shoulder
Dystocias (Lower is Better)
Compliance with Protocol
Numerator all newborns whose medical record
indicates injury to brachial plexus (ICD9 767.6)
and whose mothers record indicates a shoulder
dystocia (ICD9 660.41). Denominator All cases
of shoulder dystocia.
Definition Documented compliance with
recommended shoulder dystocia practices for all
coded occurrences of shoulder dystocia.
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FY2008 Quality Goal Summary
Achieve Top Decile Performance on 80 of publicly
reported quality measures
Achieve 95 - 100 compliance with 80 of
targeted safe care practices

• Includes 10 safe care practices
• Central Venous Catheter Bundle
• Pressure Ulcer Prevention
• Birth Injury Prevention
• 1) Shoulder Dystocia
• 2) Pitocin Protocol
• 3) Escalation
• Clean Hands
• Patient Fall Prevention
• Foreign Body Retention Protocol
• Operating Room Time Out
• Accurate Medication Reconciliation
• 8 Must Reach or Exceed 95 - 100
  Compliance to Achieve Goal
• Performance
• Baseline 4/10
• FY08Q1 3/10
• FY08Q2 5/10
• FY08Q3 6/10
• FY08Q4 8/10

• Includes 32 Publicly Reported Measures
• Acute Myocardial Infarction
• Pneumonia
• Surgical Care
• Heart Failure
• Coronary Artery Bypass Graft
• Patient Satisfaction
• 26 Must Reach or Exceed Top Decile Performance to
  Achieve Goal
• Performance
• Baseline 13/32
• FY08Q1 18/32
• FY08Q2 20/32
• FY08Q3 24/32
• FY 08Q4 27/32

92 Enabled by Clinical IT