HIMSS 2013 Davies Enterprise Award Application Texas Health Resources. Core Case Study Clinical Value

Transcription

1 HIMSS 2013 Davies Enterprise Award Application Texas Health Resources Core Case Study Clinical Value Applicant Organization: Texas Health Resources Organization s Address: 612 E. Lamar, Arlington, Texas Submitter s Name: Mary Beth Mitchell, MSN, RN, BC, CPHIMS Submitter s Title: Chief Nursing Information Officer Submitter s marybethmitchell@texashealth.org Core Item: Clinical Value Participants in Clinical Value include the following teams: Health Informatics - Dr. Ferdinand Velasco, SVP, Chief Health Informatics Office Clinical Decision Support - Cheryl Skinner, RN, Director Clinical Decision Support Value Realization- Patricia Johnson, VP, ITS Physician Advisory Council- Dr. Luis Saldana, Chief Medical Information Officer Quality- Linda Gerbig, RN, SVP, Quality Risk Management- Marci Williams, RN, Vice President Risk Management Nursing Informatics - Mary Beth Mitchell, RN, Chief Nursing Informatics Officer Clinical Business Intelligence- Natalie Dion, Director Business Intelligence Clinical Informatics - Christy Benson, RN, Director Clinical Informatics Governance Desiree Bobadilla, RN Executive Summary: Texas Health has experienced significant value in the electronic health record (EHR), known as CareConnect, within our 14-wholly owned hospitals. CareConnect provides a conduit to better manage and support safety and quality initiatives through robust clinical decision support tools and reporting and analytic capabilities. The value of the EHR is significant in cost savings, cost avoidance and improving outcomes. For example, we have seen a 53% reduction in medication errors through our closed loop medication administration process, and a 36% decrease in adverse drug events due to the increasing use of CPOE by physicians, resulting in $1,853,410 in cost avoidance. In addition, we have reduced falls by 34%, with a cost avoidance of $1,003,950. More importantly, these outcomes have improved the lives of our patients. We have also seen significant improvement in compliance with evidenced-based protocols and procedures, which improves the quality of care we provide. Evidenced-based Order Set utilization has continued to increase, with an overall use of 65%, and as high as 90% for some order sets, such as stroke. This resulted in an appropriate care score of 90% when the order set is used. Nursing compliance of screening tools, such as Braden Skin Risk Assessment and Hendrich Fall Risk Assessment, have increased from 88% to 99%, and our indwelling catheter days have decreased from 1.8 to 1.2. These all support our need for standardization as well as providing patient care based on evidenced-based practice. THR-Clinical Value Page 1

2 1 Background knowledge THR has consistently been recognized as a national leader in quality. Through participation in many quality programs, we have provided benchmarking, both internally and externally, within our own programs, as well as with state and national quality initiatives. In addition, THR has 11 hospitals with either Magnet or Pathways to Excellence designation, and several quality initiatives around various clinical departments, such as NDNQI for nursing. We also participate in many quality and safety initiatives, such as Premier QUEST collaborative, Partnership for Patients, TeamStepps and Healthways Care Transitions collaborative. In 2004, we recognized the need for a fully integrated EHR between the 14 wholly-owned hospitals. We launched a program to build an EHR in alignment with THR s key strategic initiatives, including the goal to become the health care system of choice in the North and Central Texas regions. The overall project objective of the EHR implementation was to assure organizational focus on achieving the desired outcomes of improved quality, safety, efficiency and satisfaction. 2 Local problem being addressed and Intended Improvement The THR mission statement is to improve the health of the people in the communities we serve. In 2004, with three separate health care systems comprising THR, and 13 different and distinct hospitals, we knew implementation of an EHR was necessary to achieve our mission. There was little synergy of programing or sharing of information and best practices, and little standardization of evidenced-based practice and care across the continuum. In addition, most of the hospitals in our system were acting independently in their key initiatives and strategies. We needed an EHR to help drive our six system strategic initiatives over the next 10 years. In addition, the lack of standardization impacted various quality metrics across the organization. While some entities had excellent scores for Core Measures, SCIP, and other quality measures, the lack of standardization resulted in varied practices and inconsistent results. The decision to implement an EHR would provide a source of standardization of care, management of evidenced-based guidelines, robust clinical decision support for managing quality and safety initiatives, and serve as a means to enhance physician engagement. Within the context of the EHR, we developed strong clinical decision support tools and a robust value realization program to provide the means for assisting providers and other clinicians in managing the care of their patients, and for creating a way to monitor and demonstrate our value and outcomes. 3 Design and Implementation The EHR was designed and built over approximately 18 months. Many user groups had input into the design and build decisions. In addition, the governance structure of the EHR provided for definition around Guiding Principles that would become the foundation of how the EHR was managed. Key guiding principles were: Standardize documentation through one enterprise record for all entities each hospital is on the same instance of the EHR. THR-Clinical Value Page 2

3 Create evidenced-based order sets that are physician-designed and driven, to enhance physician adoption of the EHR. Establish robust clinical decision support rules to assist with management of key quality and safety initiatives, and to ensure compliance with regulatory documentation requirements. Create strong governance for change management. Develop analytics to monitor progress for value realization. Throughout the EHR design, key stakeholders met and not only designed the documentation components of the EHR, but also defined the order sets that would be built, ensured they reflected the latest evidence, and put processes in place for continued updating and monitoring of order sets. The medical staffs of all entities required CPOE competency for re-credentialing of all physicians. Quality data was reviewed and specific core measures and other opportunities for improvement were identified, and groups were assimilated to define how to improve results with the EHR design. We developed a venous thromboembolism (VTE) tool, which embedded VTE prophylaxis into all surgical order sets. Other key decisions impacted nursing care, such as design of falls and pressure ulcer management flowsheets to support assessment and interventions for fall risk, as well as for skin assessment and management of patients at risk for pressure ulcers. These early decisions supported our guiding principles and laid the foundation for ongoing development. As we saw improvement in care, more decisions were made to further advance our use of the EHR to enhance our quality and safety initiatives. Over the six years it took to implement all 13 original hospitals and the newly built hospital (Texas Health Alliance), additional decisions were made that impacted quality and safety. For example, bar-coded medication administration was implemented in 2011, with immediate results in decreased medication errors. Also, in 2012, we implemented the Modified Early Warning System, resulting in significant decreases in cardiac arrest. As in 2004, the strength of the EHR is part of THR s commitment to quality patient care, and the governance that drives these decisions to utilize the EHR as a tool to support these quality initiatives. 4 How was Health IT Utilized? The vendor for the EHR allowed us significant flexibility in designing the documentation. We used our existing tools, such as Braden Skin Assessment and the Hendrich Fall Risk Assessment, and built them into the system. We developed evidence-based order sets around standardized criteria for each of the 14 hospitals. The reporting tools within the EHR allowed us to develop reports and analytics to monitor our progress. We built rules and alerts to notify clinicians of patient safety concerns, or when documentation requirements were not met, or when a specific documentation was required. Our ability to build the EHR to our high standards helped us meet and exceed our quality thresholds. In addition, we used several collaboration tools, such as an authoring space in the order set build program which allowed for physician review and comment. Physicians could see the draft order sets, make recommendations for change, have their peers comment on their changes and then build the desired order set- all without having to disrupt the physicians to meet in specific locations at designated times. This helped immensely with the adoption of order sets. THR-Clinical Value Page 3

4 5 Value Derived/Outcomes The outcomes from our EHR implementation are significant. We have seen an increase in our quality scores, and decreases in safety and risk issues. These are due to several key areas around computerized physician order entry (CPOE) and clinical decision support (CDS). The technology of the EHR addresses the causes of medication errors and adverse drug events in several ways: Alerts that fire to clinicians at various points in the medication management process; CPOE-direct physician order entry Strong use of physician-developed evidenced-based order sets Integrated pharmacy information system Electronic medication administration record (emar) Bar-code medication administration The clinical value of the EHR has been proven over time in these areas: Adverse Drug events (ADE s) decreased 31% over five years because of CPOE, which decreases transcription errors Closed loop medication process including bar-coded medication administration, which decreases administration errors The use of smart pumps with guardrail software to alert the nurse when dosage parameters are exceeded, which decreases the incidence of large volume IV dosage errors. (Figure 1) This resulted in a medication error reduction of 36% in one year post-implementation with a 53% decrease over five years post implementation. Additionally, we have used CDS to remind physicians to order the catheter removal protocol, alerting the nurse to remove indwelling catheters within 48 hours after insertion to reduce postoperative urinary tract infections. The nursedriven protocol provides alerts and reminders for the nurse to assess the patient and remove the catheter if specific criteria are met. During the first 6 months of protocol use, indwelling catheter placement went from 2.95 days to 1.2 days. Even patients who did not have the protocol ordered had a reduction in line days due to nursing managing under the protocol criteria for all patients. THR-Clinical Value Page 4

5 Order sets contain all the required components to support evidenced-based practice and ensure that the necessary requirements for regulatory compliance, such as Core Measures or SCIP Measures are met. When order sets are used, we see better compliance with all regulatory requirements and clinical measures. Appropriate Care Score for Stroke- had CDS rules imbedded within the Stroke Order Set to ensure all criteria were met. All criteria for stroke management was 90% met when the order set was used, as opposed to 49% when the order set was not used. Nurse Screening also used CDS rules to automatically trigger specific flowsheet interventions when risk assessment scorings indicated a need for intervention. These are evidenced-based assessment tools, and the interventions are linked to the assessment to allow nurses to better manage patients at risk. All entities had improved documentation compliance for screening and intervention for Braden and Hendrich patient assessment tools, with a system average for screening and documentation going from 88% to 99% one year after implementation. As a result, the incidence of pressure ulcers have remained low at approximately 4.9% and the fall rate has decreased from 3.3% to 3.1% Additionally, the value of CDS also lies within our ability to better track and monitor for compliance to protocols, and manage expectations around our use of documentation tools. Reporting ability within CDS helps us identify what is working well, as well as areas of risk, or areas of under-utilization of the tools within the EHR. THR-Clinical Value Page 5

6 6 Lessons Learned Although the power of CDS is evident through our outcomes, we learned several things that continue to help us manage these tools as we go forward. Need to prioritize on the highest quality concerns where there is the most opportunity for improvement. Also, dedicated teams which evaluate and manage changes quickly can promote change with immediately available results. Do not change order sets too often. Order sets need enough selections to meet the needs of most physicians, and physicians need the ability to save their order sets as a favorite. We experience dissatisfaction with physicians losing their favorites when we make changes to order sets. Therefore, we have learned to be very deliberate in any changes to order sets. An alert or hard stop is not an answer to every problem. We get many requests for hard stops or alerts to help enforce documentation requirements, often resulting in frustration by clinicians and causing alert fatigue. As a result, erroneous data may be entered. It is more important to set a level of accountability for documentation requirements and use reporting to monitor compliance. An overabundance of alerts did not improve outcomes. A strong governance process is needed to manage requests for changes to order sets and documentation. User groups play a key role in the decision-making process for changes. Also, we implemented teams to assess requests based on patient safety or regulatory requirements. We want to meet those requirements quickly, but also require close evaluation to determine the impact on patient safety. The availability of CDS tools within the EHR also provides easy access to data that can be used for trending and monitoring. Thus, we are able to quickly analyze results, identify problems, develop and implement action plans, and assess for improvement. Even in areas, where we have not demonstrated significant improvements, such as pressure ulcer incidence, the value of the EHR is clear in our ability to monitor and evaluate the need for change. 7 Financial Considerations The financial impact of the use of order sets and CDS is significant in terms of cost avoidance. The benefit of closed loop medication administration, starting with CPOE, has the most significant financial impact because it includes all orders placed and all medications given. With the demonstrated 53% medication error reduction, we have experienced a cost avoidance of $1,853,410. This is based on the all cause calculation for medication errors (all cause medication error is $2,690; $7,500 with injury). Four years ago, all hospitals went to a structure where a hospital Fall Committee reported up to the system Fall Committee, which allowed for system review of fall data and enhanced the sharing of best practices. Since that time, we have reduced falls by 34%, with a cost avoidance of $1,003,950, based on Centers for Medicare and Medicaid Services rate of $4,850 per fall. To date, we have not seen a demonstrable decrease in our urinary tract infection rate, which is between 1.2% and 1.4%. However, research has shown that decreases occur in incidence and severity of catheter-related urinary tract infections (CAUTI) when catheters are removed within 48 hours of insertion. We also know that the average cost of a catheter-related urinary tract THR-Clinical Value Page 6

7 infection is $600- $2,800 per event. (AHRQ, 2006). We believe our continued use of the CAUTI protocol, reducing the number of catheter days, will show a decrease in related infections over time with significant cost avoidance. We plan to continue to monitor CAUTI rates and hope to report on this in the future. References 1. AHRQ Preventing Hospital-Acquired Venous Thromboembolism Medication Error Reporting THR SALT data CI DAM IHI.ORG Rozich JD, Haraden CR, Resar RK. Adverse drug event trigger tool: A practical methodology for measuring medication related harm. Quality and Safety in Health Care. 2003;12: PPBates, DW, et al, Effect of computerized physician order entry and a team intervention on prevention of serious medication errors, JAMA, VTE and PE Incidence from VTE reporting and THR CI DAM 5. WISQUARS Web Based Injury Statistics and Query THR-Clinical Value Page 7