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Low-Hanging Fruit: When It's Not Even Technical

September 7, 2010
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IT-facilitated reminders to improve care procedures

Three-and-a-half years ago, when I began research for the first of two books I’ve written on quality and efficiency issues in healthcare, I had a slight concern that I might end up coming across some case studies whose clinical care details would simply be too complicated or technical for me, as a layperson, to understand. In fact, the opposite turned out to be true. Not only did I not come across case studies that were too technical for me; in fact, every case study I came across that was worth writing about ended up having at its core a people or process problem, not some kind of super-technical clinical issue that was the equivalent of unwinding the human genome.

Case in point: urinary tract infections caused by catheterization. The problem is amazingly common, so common in fact, that it is the single most common hospital-acquired infection, and the first complication chosen for non-payment by Medicare, beginning in late 2008. The core problem? So often, urinary catheters are often left in patients for no good reason at all, which can mean, most often, that some simply forgot to remove a catheter in a timely manner, or, even worse, clinicians made the decision to leave a catheter in a patient for the convenience of clinicians (i.e., a nurse or physician would not thus need to remove the catheter, check for any problems, and then re-catheterize in a sanitary way).

Now comes a study, published this summer in the journal Clinical Infectious Diseases, by physician researchers at the University of Michigan, that found that, given the use of good reminder systems to encourage hospital staff to remove catheters promptly, hospitals can reduce the rate of catheter-caused urinary tract infections by a whopping 52 percent.

Of course, there are many ways to create and implement reminder systems, and not all of them are information technology-facilitated; but those that are, like the one at the University of Michigan health system, routinely avert more infections and are easier to implement and maintain. What’s more, as I’ve discovered in my research, the same general principles apply to central line infections related to venous catheterization. In fact, I found in my first book, Paradox and Imperatives in Health Care, that organizations such as Allegheny General Hospital in Pittsburgh, and Virginia Mason Medical Center in Seattle, whose clinicians work together to implement good patient care processes and procedures, and then wed those processes and procedures to IT-facilitated reminders, particularly via the EMRs of those organizations, can achieve tremendous success in central-line infection reduction. And of course, the same principles apply to urinary tract infections caused by urinary catheterization.

The good news here is that CIOs, CMIOs, VPs of clinical informatics, and others, can all be heroes in this arena, by bringing to light whatever catheterization infection problems might exist in their organizations, and using data, and the consensus-driven development of good care processes and procedures, to improve the situation, using the EMR and related clinical information systems to facilitate change and improvement. And in the process, they can improve their Medicare reimbursement profile, improve patient care outcomes, and dramatically improve patient satisfaction and comfort levels. The fact is, sometimes, the ostensibly simplest changes can be among the most effective. Certainly the catheterization situation (with regard to both urinary and central-line catheterization) is a clear example of low-hanging fruit just waiting to be picked. And in this case, it’s not even technical.




Thanks so much for your wonderful post! (And not just because you mentioned a certain book...!) I agree with you completely, and would love to have you write a whole blogpost (if you feel so moved) on the topic of your perspectives as a physician and clinical informaticist around CDS in the context of making very basic process changes that can improve care. What I find fascinating (and I learned this in the research and reporting I did for both of my books) is how so often, care delivery processes in hospitals and other patient care organizations have evolved in very non-strategic, non-conscious ways... So often, something is done a certain way "just because it's always been done that way," and for no better reason. What do you think as a physician and physician informaticist about the tremendous potential at the very granular, practical level, to provide the tools and supports for physicians, nurses, and other caregivers to surmount the inevitable patient safety and care quality problems that have arisen out of this kind of context? I'd love to know! Thank you again, Joe!

Great post. Interested readers will certainly find great lessons on finding L-H Fruit in another, great book, Improving Outcomes with Clinical Decision Support: An Implementer's Guide, by Osheroff, Pifer, Teich, Sittig, and Jenders.

Per Dr Osheroff, isolation is a common problem (underwater Rubik Cube picture from presentation by Osheroff at HIMSS, 2009)

Chapter 3, "Selecting and Specifying CDS Interventions" makes the point that you do in this post. When a gap between desired and current state is identified, it's important to look for the best intervention to meet the need. There are often less complicated and more direct solutions to preventing errors and optimizing or improving care, than the initial proposals. Although order sets or alerts can do the trick, as you point out, simpler forcing-functions are often better. And often non even technical.

Before reading either of these guides, of course, pick up a copy of Mark's book:   Mark's real-world examples provide critical insights and inspiration.  (There; now I feel better!)