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Show Us the Evidence

December 31, 2009
by Mark Hagland
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With a solid IT foundation in place, hospitals are leveraging data to establish new clinical guidelines and change the face of patient care.

The folks at Children's Hospital of Pittsburgh don't just parrot the party line about using actionable data to optimize patient care; they live the creed. Not only do executives - including Vice President and CIO Jacqueline Dailey - regularly participate in executive patient-safety rounds across the hospital's units, but years after implementing core EMR and CPOE systems, they're using data from Children's itself, as well as from the national clinical literature, to modify care processes and establish clinical guidelines.

“We've leveraged the children's hospital national database in order to create and advance our antibiotic stewardship process,” says CMIO James Levin, M.D., Ph.D. “We found that we had been using more of a particular antifungal, AmBisome, than any other children's hospital in the country.” (The medication is used to treat unusual fungal infections, such as mold in the bloodstream, that can afflict immuno-compromised patients.) But new evidence emerged in clinical literature indicating that a different antifungal, Caspofungin, demonstrated the same efficacy, with fewer side effects.

So, using their robust data warehouse and reporting tools, Levin's colleagues in the pharmacy produced daily reports on antifungal use that went to pharmacists and to a clinician steering committee. Ultimately, they created a guideline that made Caspofungin the preferred medication (and the default in the hospital's CPOE system for that scenario), and led to a dramatic drop in side effects. The guideline has also saved the hospital tens of thousands of dollars in pharmacy costs per quarter.

This type of evidence-based care, however, would not have been possible had Children's not spent years laying the IT foundation. Not only was the hospital live with CPOE back in 2001, but that implementation had been preceded by a multidisciplinary effort to develop consensus-based order sets.

“We've done a lot of work here in terms of design, and in terms of the IT team spending a lot of time in clinical areas watching how people work,” says Dailey. “Really observing practice, and figuring out how we can have the biggest impact in terms of supporting physicians in the right way, supporting care at the bedside,” are the keys to making patient care safer, better and more cost-effective, she notes. Incidentally, Children's Hospital of Pittsburgh was one of seven pediatric hospitals in the country to earn “top hospital” ranking for patient safety in 2008 from the Washington-based Leapfrog Group. Dailey also credits support from senior leadership at Children's as well as its parent health system, the University of Pittsburgh Medical Center, with helping to facilitate the organization's success on the evidence-based care journey.
(from left) the executive team at children's hospital of pittsburgh: jacqueline dailey, vp and cio; steven docimo, m.d., vp of medical affairs and cmo; christopher gessner, president; and james levin, m.d., ph.d., cmio

(from left) The executive team at Children's Hospital of Pittsburgh: Jacqueline Dailey, VP and CIO; Steven Docimo, M.D., VP of Medical Affairs and CMO; Christopher Gessner, President; and James Levin, M.D., Ph.D., CMIO

Children's hospital of pittsburgh, part of the 20-hospital upmc health system

Children's Hospital of Pittsburgh, part of the 20-hospital UPMC Health System

Across the nation, a revolution

Richard bankowitz

Richard Bankowitz

The effort underway at Pittsburgh Children's is indicative of where industry experts believe healthcare is moving and must move. And that, many agree, means implementing EMR, CPOE, eMAR, advanced pharmacy, and other core clinical information systems, and leveraging those systems to drive improvements in quality, patient safety, efficiency, and cost-effectiveness. This is best accomplished through examining both clinical literature and hospitals' own clinical databases, and then creating a continuous loop of data reporting and data-driven process change in care delivery. In fact, there are several critical elements involved in using data to support improvements in care, among them, the creation of a culture of objectivity (see “Critical Success Factors,” p. 37).

And industry leaders say now is the time to move forward. One initiative pushing quality and safety of care forward is the CMS/Premier HQID demonstration program, which has combined data-driven quality improvement and pay-for-performance goals at more than 250 hospitals. According to Richard Bankowitz, M.D., vice president and medical director at Charlotte, N.C.-based Premier Inc., HQID hospitals have raised their overall quality by an average of 17.2 percent over four years, based on delivery of more than 30 care measures in five clinical areas.

Paul browne

Paul Browne

“We've found that the best performers in HQID have a few characteristics in common,” says Bankowitz. “First, all of them have created a culture of quality, in which everyone in the organization considers quality to be part of his or her job. Second, these organizations have a data-driven culture; they review data, figure out what works and doesn't, do small tests, and are very transparent in their use of data. And third, there is a culture of accountability, in which people take responsibility for the results of their unit or group team.”

The results that pioneering organizations have achieved in leveraging EMR, CPOE and other clinical IS to create evidence-based care processes are demonstrating quite clearly that there is tremendous potential to raise the standard of care. Examples include the following:

  • Leaders at Cincinnati Children's Hospital Medical Center have created a Center for Health Policy and Clinical Effectiveness to generate and coordinate evidence-based care practices for children's hospital and outpatient care. With the support of that office, clinicians have created more than 500 evidence-based order sets, and have achieved 95 percent compliance, says Uma Kotagal, M.D., senior vice president of quality and transformation, and Marianne James, vice president and CIO. James says her clinicians and IT professionals used an iterative process to continuously improve how IT can support evidence-based care-driven improvement.

  • At 44-hospital, Novi, Mich.-based Trinity Health, clinicians created hundreds of clinical order sets, 300 of which are evidence-based, say Vice President and CMIO J. Michael Kramer, M.D., and Senior Vice President and CIO Paul Browne. Kramer says Trinity's leaders created a multidisciplinary, evidence-based practice team that both examines the national clinical literature, and draws data out of the organization's database for use in developing the order sets. Once an order set has been piloted in one or more hospitals, the team helps implement it system-wide. “In addition to reaching a new level of transparency and accountability, we're headed towards a new age of discovery,” Browne says. “We can now compare thousands of patients who have had hip replacements at Trinity, see every step taken by every nurse and doctor caring for them, and discover what works and what doesn't, in a way we couldn't before. That's going to lead to a lot of improvements in the quality, consistency, and efficiency of care, and to advance the industry in ways we can't really conceive of today.” Trinity Health was named one of 10 top health system performers in the 2009 “Top 100 Hospitals: Health System Quality/Efficiency Benchmarks” study by Thomson Reuters.
    Gregory husk

    Gregory Husk
  • At the Continuum Health System in New York City, which includes Beth Israel Medical Center and three other hospitals, Gregory Husk, M.D., CMIO, and Colleen Lyons, corporate director of IT, have found that improving care quality requires continuous data analysis and modifications to order sets based on the analysis. For example, Beth Israel clinicians recently realized that having a single order set for the ordering of low-molecular-weight heparin was creating problems because of differences in the clinical appropriateness between patients who were undergoing hip replacement and those undergoing knee replacement. As a result, two separate order sets - or “nests,” in Continuum Health terminology - have been created for deep vein thrombosis prophylaxis for hip and knee replacement patients. Making such refinements is critical to leveraging the advantages of EMR, CPOE, and data warehouse implementation for care improvement, Husk says.
    Patty lavely

    Patty Lavely
  • At Memorial Health University Medical Center in Savannah, Ga., clinician leaders have been working to leverage data to analyze patient safety issues and improve the hospital's safety record. Clinicians at the 538-bed teaching hospital have used a program called “Create a Safe Day” to reduce serious patient safety events by 70 percent between 2007 and 2008, say Marty Scott, M.D., vice president for quality and patient safety. The number of events decreased from 12 in 2007 to four in 2008 and only one in 2009, he says. As for the IT facilitation of this work, the difference often comes from simple steps like making sure all necessary hardware is available to ensure universal clinician adoption on a day-to-day basis, says Patty Lavely, senior vice president and CIO. Memorial has been a solid performer in terms of its outcomes to date in the HQID demonstration project.

  • Aurora Health Care, a 15-hospital system based in Milwaukee, was the top performer of all 250 participating HQID hospitals in terms of clinical outcomes in both in 2008 and 2009. Philip Loftus, CIO and vice president of information services, cites the organization's commitment to improving core clinical outcomes, as well as its use of clinical information systems to support that work, as key factors in its success. In 2009, Aurora hospitals were top performers in 23 of 47 quality areas measured, and received 68 incentive payments, the most of any system in the country.

  • At Abington (Pa.) Memorial Hospital, leaders have implemented a software program that has brought evidence-based guidelines and clinical decision support to nursing and to the respiratory care, physical therapy, and dietary areas of the hospital. Not only do the clinicians love the program (from the Grand Rapids, Mich.-based CPM Resource Center), but the use of evidence-based guidelines in allied health areas is “changing the conversation” around how care is delivered at Abington, says Barbara Wadsworth, R.N., senior vice president, patient services, and CNO. Alison Ferren, vice president and CIO, says, “Implementing knowledge-based charting in nursing (and other allied areas) has really changed the way we've used clinical systems. It's really about getting the clinicians and the IT department to work collaboratively on care processes to provide the best care.”

All of these case studies present “irrefutable evidence” for data-driven, evidence-based care, according to Jeffrey Bauer, Ph.D., a healthcare economist and futurist who is a Chicago-based partner in management consulting at ACS Health Care Services (Dallas). In fact, Bauer is such a strong believer in evidence-based care that he says, “It should be made mandatory - at the level of the individual patient care organization, rather than at a federal agency level,” and implemented with intellectual rigor and objectivity. In addition, the whole evidence-based movement, he and other experts note, is strongly aligned with the desire of purchasers and payers to wring greater value out of dollars spent on healthcare, a desire that could be reflected in aspects of the federal healthcare reform legislation being debated in the U.S. Congress.

Geisinger Health System, a three-hospital, 41-clinic network based in Danville, Pa., has established itself as a leader in evidence-based care. Several years ago, cardiac surgeons at Geisinger came together to develop ProvenCare, a 41-step protocol for elective coronary artery bypass graft (CABG) surgery that is embedded into the health system's EMR, and requires documentation for variation from the set of rules.

Not only did Geisinger's leaders achieve a high level of adherence to the CABG protocol on the part of surgeons, they attached to CABG surgery a pricing guarantee that has drawn interest from purchasers, payers, and the news media. And since then, Geisinger clinicians have added percutaneous intervention (stenting), total hip replacement, cataract and gastric bypass surgery, and low back pain care into the ProvenCare program, and have created similar evidence-based care programs across such areas as diabetes and congestive heart failure.

Phil wasson

Phil Wasson

It's important to note how continuous the evidence-based care development process is, says James Walker, M.D., Geisinger's chief health information officer. “When people implement systems and processes, they think it will be ‘the end’; we certainly did,” Walker says. “But you can never design ideal processes. So we think of this as an optimization phase that goes on forever. And we go into our processes and ask what needs to be made safer and better and more efficient, and what about the EHR needs to be changed and made better.” The bottom line, Walker says, is that the clinician and IT leaders of pioneer organizations like Geisinger already know that getting onto the path of evidence-based care development marks just the beginning of an ongoing journey of improvement.

For CIOs, this industry-wide revolution will require further “embedding” into the clinical sphere, says Phil Wasson, vice president and CIO at SwedishAmerican Hospital in Rockford, Ill. “I think that any hospital CIOs who aren't yet in the clinical space need to get into that space pretty quickly,” says Wasson.

Christopher Gessner, president of Children's Hospital of Pittsburgh, says, “Five years out from here, what we're really focused on is responsible transparency and improving continuity of care, both within our organization, where we've made strides, and across our community.” Steven Docimo, M.D., the organization's vice president-medical affairs and CMO, adds, “Maintaining a long-term horizon on this is very important, because you have to keep everyone excited and motivated about the future of medicine. There are a thousand ways progress could be stopped. And every step of the way, there are people who need to be convinced that, while some of these steps will make more work for you in your office tomorrow, they will benefit patients and the organization in the long run.”

Healthcare Informatics 2010 January;27(1):34-38

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