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“We could have analysts in a centralized environment write reports. There is value in that,” says Jeffrey Ferranti, M.D., M.S., acting chief medical informatics officer and vice president of clinical informatics. “But we decided to let the clinicians themselves ask questions about patient safety more targeted to their specialty, and they are learning to ask innovative questions.”
Duke University Health System teams are developing tools such as the Adverse Drug Event Surveillance system. Every day a rules engine scans the clinical information systems of inpatients at Duke hospitals to look for patient demographics, lab results, and medication orders that may be indicative of potential harm. Another project involves computerized physician order entry (CPOE) metrics. A partnership between CPOE, health analytics, and IT patient safety team members provides users metrics related to clinical order sets and decision support. A CPOE survey provides feedback on clinical decision support, workloads, and safety concerns.
A tool called DEDUCE (Duke Enterprise Data Unified Content Explorer) supports quality monitoring and improvement efforts. “We could ask it to show all the diabetes patients in Durham County and what medications they are on,” Ferranti explains. It can identify outliers such as diabetic patients who haven't had their A1c hemoglobin levels tested recently.
“These tools also can help us see differences in outcomes in our three different hospitals, such as rates of C. difficile colitis,” he adds. “The difference between 0.5 percent and 1 percent is very hard for doctors to discern, but with the data warehouse we can identify problems and intervene.”
TRIHEALTH: PULLING DATA FROM MULTIPLE EHRs
Setting up a performance measurement scheme for ambulatory physicians using a multitude of EHRs is a challenge, but TriHealth, an integrated healthcare system formed as a partnership between Good Samaritan Hospital and Bethesda Hospital Inc. in Cincinnati, was undaunted. Beginning in late 2008, TriHealth, which has 250 employed physicians, created a clinical data warehouse that enables practices to generate on-demand reports about treatment recommendations, patient vital statistics and treatment compliance.
Led by Georges Feghali, M.D., chief medical officer for TriHealth, a quality committee came up with 12 priority protocols. “Then a clinical data warehouse committee made up of IT and physician leaders defined the components to extract, how we are going to build it, and if there are any missing data elements, how we can get that data,” explains John Ward, director of health system IT integration.
“One of the biggest challenges is working with the different vendors' applications in terms of trying to find where to extract data elements so we can normalize it,” says Ward. “So in terms of recording smoking status, five applications might put it in five different places in the chart, such as in social history or in physician notes. We had to go in and find all the places that might be, where to get it and in some cases change the workflows of physicians to standardize that. That was one of the most difficult aspects.”
TriHealth has a strong focus on the medical home model and has added nurse coordinators and diabetes educators for patient follow-up. Ward says it has already seen some practices make vast improvements since it started offering them more immediate and complete performance data.
For instance, one practice started in 2009 with only 16 percent of its diabetic patients meeting the definition of having their condition under control. That number changed to 32 percent in 2010. “That is a huge improvement,” Ward says. “I think the physicians have previously been starved for data, and are now thinking in a different way,” he adds. “They now think in terms of their populations with chronic conditions. That's how you get the dial to move.”
TIMELY DATA FOR CHRISTIANA CARE'S CLINICIANS
Digging deeper into clinical results in its own data warehouse has led to several performance improvements at Christiana Care Health System in Wilmington, Del.
Two years ago, the two-hospital system sought to better understand several performance issues, including extended hospital stays. Using a tool called CareDiscovery from ThomsonReuters, Christiana Care analysts and physician teams studied clinical performance and utilization management in specific diagnosis-related groups such as heart disease.
Donna Mahoney, director of data acquisition and measurement, leads a team of eight analysts working in the Center for Quality and Safety. She says her job is made much easier by the fact that Christiana Care has had a data warehouse in place for 15 years. “We can go to the data warehouse team with any issue we have. They are the ones preventing us from having to do this through chart abstraction, which would be quite difficult.”
