Customizations of the EHR that Ensure Quality and Safety

Transcription

1 Customizations of the EHR that Ensure Quality and Safety Barry Aaronson MD FACP SFHM Hospitalist and Associate Medical Director for Clinical Informatics Virginia Mason Medical Center Clinical Associate Professor of Medicine and of Biomedical Health Informatics University of Washington BHI Colloquium Apr 2011

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4 Using Health Information Technology to Ensure Quality and Safety

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7 Preventing Potentially Avoidable Deaths Blood Pressure Heart Rate Resp Rate Death T-12 T-8 T-4 T-2 T-1 T Hours Critical Values 0

8 Sepsis

9 750,000 cases per year 200,000 deaths per year

10 Rapid Response Team SBP<90 HR>130 RR>24 SaO2<90% 3,000 Hospitals

11 Fire Station Model

12 Institute of Medicine 1999

13 Reason for Failure? There are 2 teams of players, one wearing white shirts and one wearing black shirts. Try to count the number of times the team wearing white passes the ball.

14 Reason for Failure? There are 2 teams of players, one wearing white shirts and one wearing black shirts. Try to count the number of times the team wearing white passes the ball.

15 Fire Station Model

16 Air Traffic Control Surveillance Model

17 Place image or screenshot here

18 Cerner Command Language- CCL

19 MPages RN Charts Routine Data CCL Script runs every 5 minutes Discern Desktop CCL Script Query Data Calc Function Write EWS Clinical Data CCL Script Web Page

20 Early Warning System

21 Single Blind Randomized Controlled Interrupted Time Feb 9, 2009 Series Trial On On On On On On On On 7 Day Intervals 4 Month Duration Quantitative and Qualitative 7/5/09 Assessment

22 Clinical Outcomes Potentially avoidable death rate Cardiopulmonary arrest rate outside ICU Unexpected transfer to ICU rate RRT Activation Rate

23 EWS Results On Off p Codes RRT Activations Deaths Transfer to ICU

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25 iphone

26 Safety

27 Quality

28 What is Quality?

29 Process of Care

30 Clinical Areas

31 Outcomes of Care

32 Processes of Care Also see whynotthebest.org

33 VM Quality Now MI with LV Dysfunction given ACE 97 3 Pneumonvax 95 5 Blood Culture Prior to Antibiotics 93 7 Influenza Vaccine 99 1 Heart Failure Discharge Instructions 99 1 CHF with LV Dysfunction given ACE

34 So what s good enough? Imagine 96% quality at VM 600 defective surgeries/year 501 defective transfusions/year 40,000 defective medication administrations/year 10,800 wrong meals served/year 68,000 defective bills sent/year 5,000 defective paychecks/year Slide Courtesy of Virginia Mason Institute

35 So what s good enough? Imagine 99.9% quality at VM 15 defective surgeries/year 17 defective transfusions/year 1,000 defective medication administrations/year 182 wrong meals served/year 17,000 defective bills sent/year 125 defective paychecks/year Slide Courtesy of Virginia Mason Institute

36 Defects are mistakes that go uncorrected The purpose of VMPS is to ensure zero defects Slide Courtesy of Virginia Mason Institute

37 Quality Goal MI with LV Dysfunction given ACE 100 Pneumonvax 100 Blood Culture Prior to Antibiotics 100 Influenza Vaccine 100 Heart Failure Discharge Instructions 100 CHF with LV Dysfunction given ACE

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39 Guideline Adherence Percent Days Percent Mortality 0 LOS 0 0 Clinical Stability at 7 Days Compliant Non-Compliant

40 Rate Hospitals with 1-5 Stars Based on Quality If all hospitals performed at the level of a 5-star rated hospital... 20,688 Medicare deaths could have been avoided while saving the US nearly $1.8 billion from 2007 through 2009.

41 ... information technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved over the coming decade.... the elimination of most handwritten clinical data by the end of the decade. 2001

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43 IT and Inpatient Outcomes 60 Notes CPOE CDS Percent Reduction Death During Hospitalization Death After MI Death After CABG Complications Survey of 41 Hospitals in Texas

44 Critical HIT Components Needed to Ensure Quality Computer System Discrete Data Right Software/Programing Realtime Provider Feedback Group (Team) Situational Awareness

45 Critical HIT Components Needed to Ensure Quality Computer System Discrete Data Right Software/Programing Realtime Provider Feedback Group Situational Awareness

46 VM Record Storage in Georgetown

47 UW Record Storage Sand Point Naval Hanger

48 Server Cabinet!"#$%&'%(&)*+,-.%/0+1*)-2,

49 30 Terabytes of Disk 7,500,000 Songs or 60 Years of Listening!

50 Tape Backup

51 Electronic Health Record $17,616 per bed in $12,060 for operating costs American Hospital Assn. study, "Continued Progress: Hospital Use of Information Technology," Feb. 27, $5,556 for capital costs 400 Bed Hosp-> $10 Million

52 Critical HIT Components Needed to Ensure Quality Computer System Discrete Data Right Software/Programing Realtime Provider Feedback Group Situational Awareness

53 Handwritten Note

54 Free Text Rads Report Clinical Notes, Pathology Reports

55 Discrete Data- Meds

56 Discrete Data- Orders

57 Discrete Data- Labs

58 Discrete Data- Forms

59 Discrete Data- Note

60 Discrete Data Problem List

61 Critical HIT Components Needed to Ensure Quality Computer System Discrete Data Right Software/Programing Realtime Provider Feedback Group Situational Awareness

62 mpages 62

63 Critical HIT Components Needed to Ensure Quality Computer System Discrete Data Right Software/Programing Realtime Provider Feedback aka Clinical Decision Support Group Situational Awareness

64 Retrospective Improvement Efforts Conferences Journal Clubs Section Meetings Housestaff Orientations Real Time M&M

65 Quality Safety Dashboard Refreshes q5min

66 Clinical Algorithm

67 Quality Safety Dashboard

68 Document Expires in 24 Hours

69 Quality Safety Dashboard

70 Specify Risk

71 Write Orders Heparin 5000u sq BID Heparin 5000u sq TID Enoxaparin 40mg sq qd SCDs

72 Critical HIT Components Needed to Ensure Quality Computer System Discrete Data Right Software/Programing Realtime Provider Feedback aka Clinical Decision Support Group (Team) Situational Awareness

73 Alert Fatigue CHF is on the Diagnosis List LVEF is <40% Creat <2.4 mg/dl No ACE/ARB Ordered Add ACE/ARB as per CHF Bundle? Lisinopril Losartan

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75 OR Dashboard

76 Bed Control

77 Hospital Dispatch

78 Harborview Cafe

79 White Board

80 Quality Safety Dashboard

81 UW ICU

82 Harborview ICU

83 Dashboard Study Design Measure of Compliance with Quality Parameter 6 Week Control Period 6 Week Intervention Period Control Unit No Dashboard No Dashboard Intervention Unit No Dashboard Dashboard

84 Med-Surg Dashboard

85 Measurevention Jason Stein Emory Greg UCSD

86 Critical HIT Components Needed to Ensure Quality Computer System Discrete Data Realtime Provider Feedback aka Clinical Decision Support Realtime Provider Feedback aka Clinical Decision Support Group Situational Awareness

87 Health IT- Ensuring Quality and Safety

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