Hospital Guidance Webinar Using the CPOE Tool Results for Quality Improvement PRESENTED BY: DAVID BATES, MD, MS C AND DAVID CLASSEN, MD, MS C
Overview Introduction What the current test looks like and changes we have made Changes to come in the 2018 test Challenges and Successes Guidance Discussion Quality improvement processes Scenario-Specific and Medication-Specific Information Hard stops Categories hospitals had the most difficulty with Guidance on those categories Q&A Session 2
The primary purpose of the CPOE Evaluation Tool is to evaluate CPOE clinical decision support as implemented, testing specifically the ability of the system to assist in avoiding medication related adverse events originating in orders for hospitalized patients 3
Steps for the Adult Inpatient Test 1. Print a list of Test Patients 5. Record responses from the Orders and Observation Sheet onto the Online Answer Form 6. Complete and submit the Affirmation 2. Enter the Test Patients in your hospital s production environment 4b. Prescriber must record any advice or information they receive from the system onto the Orders and Observation Sheet 7. View and print your results 3. Print the Orders and Observation Sheet 4. Have the prescriber enter and sign the Test Order(s) assigned to each Test Patient into your inpatient CPOE system 4
43% relative reduction for every 5% increase in the Leapfrog score (p=0.01) 4 fewer preventable ADEs/100 admissions for every 5% increase in the score Leung et al, JAMIA 2013 5
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Safety Results of CPOE Decision Support Among Hospitals 62 hospitals voluntarily participated Simulation detected only 53% of orders which would have been fatal Detected only 10-82% of orders which would have caused serious ADEs Almost no relationship with vendor Metzger et al, Health Affairs 2010 7
Jane Metzger, Emily Welebob, David W. Bates, Stuart Lipsitz, and David C. Classen, Mixed Results In The Safety Performance Of Computerized Physician Order Entry, Health Affairs, Vol 29, Issue 4, 655-663 Copyright 2010 by Project HOPE, all rights reserved. 8
Number of Hospitals Taking Test Number (N) of Hospitals 1800 1600 1580 1689 1691 1400 1200 1238 1000 800 931 600 400 200 214 288 455 0 2010 2011 2012 2013 2014 2015 2016 2017 N Hospitals 9
Average Percent Correct 70 Average % Correct 60 56.1 55.9 57.5 57 58.6 59.9 50 51.8 40 30 20 10 0 2010 2011 2012 2013 2014 2015 2016 Average % Correct 10
Overall Score Full Demonstration of National Safety Standard for Decision Support Substantial Demonstration of National Safety Standard for Decision Support Some Demonstration of National Safety Standard for Decision Support Completed Evaluation The Overall Score Description The hospital s CPOE system alerts prescribers to most common serious prescribing errors. Meaning that: Hospital responded to 20 test orders Hospital responded correctly to 50% of test orders across all categories The hospital s CPOE system alerts prescribers to many common serious prescribing errors. Meaning that: Hospital responded to 20 test orders Hospital responded correctly to 31%, but less than 50% of test orders across all categories The hospital s CPOE system alerts prescribers to some common serious prescribing errors. Meaning that: Hospital responded to 20 test orders Hospital responded correctly to 21%, but less than 31% of test orders across all categories The hospital s CPOE system alerts prescribers to few common serious prescribing errors. Meaning that: Hospital responded to 20 test orders Hospital responded correctly to less than 21%of test orders across all categories 11
Overall Score Insufficient Evaluation Time out of Test (Publicly reported as Incomplete Evaluation) Failed Deception Analysis (Publicly reported as Incomplete Evaluation) Description This hospital was not able to test a sufficient number of orders (< 20) to receive an overall score. However, the hospital may use the category scores for local hospital quality improvement efforts. The hospital is eligible to retake the test in 120 days. This hospital did not complete the CPOE Evaluation Tool within the allotted time. The hospital is eligible to re-take the test in 120 days. This hospital submitted responses that included potentially inaccurate results. The hospital is eligible to re-take the test in 120 days. 12
Future Enhancements Order Category Description Example CHOOSING WISELY INAPPROPRIATE ORDERING OF MEDICATIONS, LABORATORY TEST, RADIOLOGIC TESTS ORDERING OF VIT D LEVELS IN LOW RISK PATIENTS PREVENTION OF COMMON HOSPITAL COMPLICATIONS APPROPRIATE ORDERING OF INTERVENETIONS TO PREVENT HOSPITAL COMPLICATIONS -- CLABSI OR DVT ORDERING OF APPROPRIATE INTERVENTIONS FOR PATIENTS WITH CENTRAL LINES IN PLACE USABILITY OF CLINICAL DECSION SUPPORT EVALUATION OF USABILITY OF COMMON DECISION SUPPORT CAPABILITY USE OF THE IMEDESA TOOL EHR ERROR DETECTION EVALUATION OF COMMON EHR ERRORS USE OF THE ORDER REORDER RETRACT TOOL 13
Challenges Because there are many ways to deliver decision support, it is difficult to give hospitals credit for everything The test takes time and resources to complete 14
Successes Hospitals which have taken the test have improved a lot Test has improved with feedback from the broader community Increased the number of hospitals taking the test 15
What is Quality Quality is the degree to which we meet or exceed customer expectations 16
Background in Medicine Institute of Medicine (IOM) reports Nov 1999: To Err is Human March 2001: Crossing the Quality Chasm Brief History of Quality Improvement Scientific Management (Taylor, 1911) Assembly lines Statistical Process Control (Shewhart, 1931) Quality Improvement (Deming, 1955) Lean Production (Womack, 1990) Mass customization 17
IOM Definition of Quality (STEEEP) Six Dimensions of Quality in Healthcare Safe Timely Effective Efficient Equitable Patient centered IOM, Crossing the Quality Chasm 18
Quality Assurance vs. Quality Improvement Quality Assurance Meeting a specification or standard Taking sample measurements to measure performance Quality Improvement Continual process to improve performance Continual measurement and data feedback 19
Quality Improvement Methodology Focus on systems (Systems Theory) Develop ideas for change and test them (Scientific Method) Understand the variation of data measured continuously over time (Statistical Process Control or SPC) Understand reasons and motivation of people to act on data (common cause, special cause variation, diffusion of innovation) Use a balanced set of measures (Value Compass) 20
Improvement in Healthcare Expert knowledge Content knowledge System Thinking Statistical Variation Scientific Method Psychology of Change Paul Batalden, MD Traditional Improvement Continuous Quality Improvement 21
The Relation Between Quality Inspection, Regulation, Management, and Improvement Design Redesign Management & Improvement Number of Providers Sanctions Research & Development 0 Inspection & Regulation for Public Safety Level of Quality 22
Leadership Action Model 23
Scenario-Specific and Medication- Specific Information Scenario-Specific Information: Information that might appear when the test medication order (medication plus dose/route/frequency) is entered into the CPOE system for the test patient (with specific patient profile/demographics including diagnosis, lab values, and allergy, as applicable) Medication-Specific Information: Information that might appear anytime the medication is ordered for any patient, with any dose/route/frequency The Leapfrog Test Orders are meant to trigger scenario-specific information 24
Hard Stop Alerts Definition: alerts where the medication order is absolutely contraindicated The Principals: Should appear judiciously and infrequently There are very few alerts that would warrant a hard stop Examples of Cases DDIs would have to be absolutely contraindicated where there is no benefit of the drug combination that outweighs the risk (MONOAMINE OXIDASE INHIBITORS and SUMATRIPTAN ). This does not mean that all contraindicated DDI alerts from a vendor warrants a hard stop (Sildenafil Nitroglycerin should trigger a DDI alert but not a hard stop). Vincristine given intrathecally should be a hard stop since there has been multiple cases of this resulting in death or serious harm (Note: these specific cases are not tested in the CPOE Evaluation Tool) 25
Categories found to be the most challenging for most hospitals Drug Diagnosis Drug-Age Drug-Laboratory Drug-Monitoring Therapeutic Duplication 26
Drug Diagnosis Guidelines Focus on drugs to avoid in patients with GI bleeds, Stroke, Asthma and Liver disease. New test will also include drugs to avoid in pregnancy 27
Drug Age Guidelines Screening Tool of Older Persons Prescriptions (STOPP) version 2 Potentially inappropriate medications listed in STOPP criteria, unlike some of those listed in Beers criteria, are significantly associated with avoidable ADEs in older people that cause or contribute to urgent hospitalization Focus on Fall Risk Inducing Drugs (Antihypertensive agents, Diuretics, Sedatives and hypnotics, Neuroleptics and antipsychotics, Benzodiazepines, Narcotics ) De Jong, Marlies R., Maarten Van der Elst, and Klaas A. Hartholt. Drug-Related Falls in Older Patients: Implicated Drugs, Consequences, and Possible Prevention Strategies. Therapeutic Advances in Drug Safety 4.4 (2013): 147 154. 2015 Beers Criteria Avoid medication list. Where quality of evidence and strength of recommendation is high 28
Drug Lab and Drug Monitoring Guidelines Focus on nephrotoxic and/or renally cleared medications Focus on drugs with a narrow therapeutic range (aminoglycosides, carbamazepine, digoxin, lithium, phenytoin, phenobarbital, theophylline, warfarin) Labs to focus on : K, Cr, INR, and therapeutic drug levels 29
Therapeutic Duplicate Guidelines Should alert on drugs within the same drug class 2 Ace Inhibitors Captopril and Lisinopril 2 Statins Atorvastatin and Simvastatin 2 NSAID Ibuprofen and Naprosyn 2 Benzodiazepine Diazepam and Alprazolam Some drug classes are much more important than others; avoid those with evidence supporting e.g. ACE and ARB Should alert on brand and generic name of the same drug Ibuprofen and Motrin 30
Drug Dose Guidelines Focus on drugs with a narrow therapeutic range (digoxin) Drugs that can cause serious or immediate toxicity if given in excessive amounts (narcotics, benzos) Drugs on ISMP High Alert Med list since they have been known to cause harm when given incorrectly Hypoglycemic agents Anticoagulants Neuromuscular blockers Narcotics / Opioids 31
DDI Guidelines Refer to the Drug:Drug Interaction Information provided to hospitals by Leapfrog Phansalkar, Shobha et al. High-Priority Drug drug Interactions for Use in Electronic Health Records. Journal of the American Medical Informatics Association : JAMIA 19.5 (2012): 735 743. Payne TH, Hines LE, Chan RC, et al. Recommendations to improve the usability of drug-drug interaction clinical decision support alerts. J Am Med Inform Assoc 2015;22(6):1243 1250 Tilson, Hugh et al. Recommendations for Selecting Drug-Drug Interactions for Clinical Decision Support. American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists 73.8 (2016): 576 585. McEvoy, Dustin S et al. Variation in High-Priority Drug-Drug Interaction Alerts across Institutions and Electronic Health Records. Journal of the American Medical Informatics Association : JAMIA 24.2 (2017): 331 338 Phansalkar, Shobha et al. Drug drug Interactions That Should Be Non-Interruptive in Order to Reduce Alert Fatigue in Electronic Health Records. Journal of the American Medical Informatics Association : JAMIA 20.3 (2013): 489 493. 32
Selected Other Challenges How should hospitals govern their existing and future CDS activities and decisions? Finding the correct group of individuals that have the skill, knowledge, authority or influence to make changes Members may include a CPOE physician leader/champion, pharmacist, domain experts, IT, etc. Ongoing monitoring of effectiveness of the CDS Should monitor how often alerts are firing, how providers are responding System enhancements to support the CDS either internally with IS support or with your vendor 33
Q&A Session 34