Supporting Quality, Reducing Clinician Burden

1. 2nd Annual Regional Nursing Informatics Conference: Promoting Patient Safety Excellence Through Technology Supporting Quality, Reducing Clinician Burden

2. Objectives • State 3 examples of EMR activities that reduce clinical burden • Describe the workflows for 2 activities • Identify the limitations of prior efforts of quality compliance. • List 3 considerations that must be addressed in order to reduce clinical burden of quality alerts • Describe actions taken to ensure success • State those successes

3. Outline • Background • Nomenclature • Clinical Burden • Workflows • Real Live Examples • Implementation • The learning curve • Metrics • Questions

4. Background Evanston Northwestern Healthcare • ENH Hospitals and Clinics • Evanston Hospital • Glenbrook Hospital • Highland Park Hospital • ENH Medical Group • ENH Home Services • ENH Research Institute

5. Background • Characteristics • Integrated delivery network • physician office • hospital inpatient care • hospital outpatient care • home care • More than 50 sites of ambulatory care • Major teaching hospitals for Northwestern University with 720 beds and 40,000 annual admissions • Ranked #1 in the State of Illinois and #10 in the United States among multi-specialty independent research hospitals with total external grant awards exceed $115 million. • Fully integrated EMR across the Network

6. Background - EMR Project • 2001 – Decision & Contract Signing • 2002 – Plan / Build / Test / Training • 2003 – Training / Install Epic • 2004 – Make The EMR Work for Us • 2005 – Make The EMR Work for You

7. ENH’s Portfolio of EMR Products PatientData ONCOLOGY HOV My Chart ICU SYNOPSIS

8. 2004 Davies Award for Excellence –Organizational Award

9. Nomenclature • CUI • BPA • Programming Points • Order Validation • Navigators • Activity Tabs

10. My Soapbox! Current National Campaign To Save 5 Million From Harm (IHI, 2006) • Challenges to health care providers to create ever-safer patient care environments • Clinical Burden is immense • Technical Burden is immense • Regulatory Burden is immense In Essence We Need to Make The Systems Work for Us!

12. Reducing the Clinical Burden • Clinically meaningful alerts • Making it obvious • Data Capture as a result of normal workflow • Reduction of the memory load

13. Alerts Alerts are designed to: • Prevent • Communicate • Enforce They do this by interrupting the workflow-The trick is to do it in the most effective and informative way!

14. Considerations for Reducing the Burden of Alerts Use a Selective Approach: • Targeted audience • Present the user with the information and the tools to manage the alert • Identify patient populations using data entered through normal clinical workflows • Avoid conditional alert workflows • Education and Communication

15. Workflow – Text and CUIs

16. Workflow – Order Validation

17. Workflow – Identifying Eligibility

19. The Real Thing! MRSA

20. MRSA - Facts • 2001 through 2003 • Several MRSA outbreaks (USA 300) in neonatal ICU, orthopedic ward raising concern • 2004 • Screening of at risk populations introduced • Point prevalence survey at ENH found: • MRSA prevalence = 8.5%! • 2/3 not previously known • Baseline: ~100 hospital-acquired MRSA infections per year

21. Local Cost of MRSA HAI Ari Robicsek, MD- Hospital Epidemiologist Evanston Northwestern Healthcare

22. MRSA-Justification • Prevention of ~50 hospital-acquired MRSA infections per year will balance the 1,000,000 excess cost of MRSA surveillance Universal Surveillance gets Administrative Blessing

23. MRSA- Implementation • Initiated August 1, 2005 • Maximize compliance : One workflow with minimal decision points • Patient Safety: Reduce exposure to MRSA by early detection of colonized patients • Reduce Clinician Burden: Use available data to identify patients and communication information • Collect Data: Minimal non-workflow data collection. Reports fields, frequency and feedback mechanisms identified • Improve Quality: Reduce number of MRAS HAIs

24. Maximize compliance : One workflow with minimal decision points

25. Patient Safety: Reduce exposure to MRSA by early detection of colonized patients

26. Reduce Clinician Burden: Use available data to identify patients and communication information

27. The Metrics • Of 31,835 admissions tested, 6.4% were positive on admission • Accounting for false positives, true positive percentage was 5.0%

29. MRSA prevalence by DRG n = 8,586 30.0 25.0 20.0 Percent positive on admission 15.0 10.0 5.0 0.0 UTI CVA COPD C-section Psychoses GI Disease Vag Delivery Renal Failure CHF and Shock GI Bleed with CC Vag Delivery w/CC Joint Replacement GI Disorders w/CC Septicemia Age>17 Metabolic Disorders Pneumonia Age>17 Medical Back Probs

30. P , 0.001

31. ICU surveillance P , 0.001

32. ICU surveillance P , 0.001

33. ICU surveillance Universal surveillance P , 0.001

34. ICU surveillance Universal surveillance p < 0.01

35. ICU surveillance Universal surveillance Prevalence Density Ratio: 0.45 p < 0.01

36. *P=NS *P<0.05 (N = 831,757 patients)

37. Success Intra-admission MRSA infections -51

38. Lessons Learned MRSA • Specialty Departments need extra attention • Preference List Issues • Alert took user to order entry, but should have been order review • Verbal communication constraints

39. The Real Thing! Pneumovax

40. VaccinationFacts • Pneumococcal Vaccination is 75% effective in preventing pneumococcal bacteremia and meningitis which carries a high mortality for persons 65 years of age and older. • In the United States, only 56% of adults over the age of 65 years received the pneumococcal vaccine. • Only 38% of nursing home residents received the pneumococcal vaccine. • Only 28% of eligible patients receiving Pneumovax

41. ENH - % of Patients Meeting the Pneumococcal MeasureJan. 2005 – Dec. 2005 Achievable Benchmark of Care = 95.0%

42. Pneumovax-Justification • Failing the measure despite current efforts • Order sets • Education of Physicians and Nursing • Concurrent Tracking • Ordered and Discharged without

43. Pneumovax - Implementation • Initiated July 5, 2006 • Maximize compliance : One workflow with minimal decision points • Patient Safety: Protect against future pneumonia episodes • Reduce Clinician Burden: System identifies patients and presents support tools for the RN to adhere to protocol. Workflow documentation switches off alert. • Collect Data: Easy concurrent reporting tools for managers to track patients • Improve Quality: All eligible patients will receive Pneumovax

44. Maximize compliance : One workflow with minimal decision points

45. Reduce Clinician Burden: System identifies patients and presents support tools for the RN to adhere to protocol. Workflow documentation switches off alert.

46. Collect Data: Easy concurrent reporting tools for managers to track patients

47. Metrics

48. Pneumovax – Lessons Learned • Ordering delay • Missed vaccines • Education missed cultural issues • Political issues

49. The Real Thing! D/C Instructions

50. D/C Instructions • Workflow Streamlined • CUIs • Visual Trigger • Automatic Compliance