HIMSS Virtual Conference and Exhibition 11/19/08 Session #107B

1. Optimizing Local Clinical Decision Support to Address National Hospital Improvement Imperatives; Early Efforts Toward a Scalable Collaborative HIMSS Virtual Conference and Exhibition 11/19/08Session #107B Jerry Osheroff John Chuo Anwar Sirajuddin Donna Currie

2. Panel Desired Outcome/Agenda Desired Outcome: Attendees learn about collaborative processes and strategies that can enhance their CDS efforts and outcomes Agenda: Describe effort to build and leverage a collaborative to support CDS-enabled improvements in hospital clinical imperatives Hear from 3 of 6 organizations participating in the collaborative: why they joined, what they are doing, benefits in progress 20 minutes of Q&A: to help ensure that attendees realize desired outcome

3. Background on New HIMSS Collaborative CDS Initiative, and Implications for Attendees Jerome A. Osheroff, MD, FACP, FACMI Chief Clinical Informatics Officer, Thomson Reuters Adjunct Assistant Professor, University of Pennsylvania

4. Collaboration Starting Point: Shared Need and Opportunity to Improve Key Outcome VTE is leading cause of preventable hospital death Substantial costs for hospitals; beginning 10/08 CMS and other payers not reimbursing for this hospital acquired complication (and others) CDS is powerful tool for improving outcomes, but implementations are complex and often problematic HIMSS, SI, others have collaborated successfully on CDS best implementation practices Can we build on this success and create a dialog to accelerate local CDS-enhanced performance improvements?

5. Backdrop: Guides for Improving Care Processes and Outcomes with CDS www.himss.org/cdsguide 5 5

6. HIMSS/SI Initiative Goal: Develop scalable, validated guidance for provider organizations to optimize CDS to drive measurable local performance improvement on specific targets of high local and national priority. (Initial focus=VTE) Formed CDS Task Force within HIMSS 8/08 6 clinical sites: Advocate, CHOP, HealthEast, Memorial Hermann, Orlando, Texas Health Resources Other thought leader participants (CDS, performance measurement, benefits realization) and Scottsdale Institute HIMSS/SI will help with scaling

7. Deliverables: Near Term (HIMSS 4/09) Description of pilot site VTE CDS activities using scalable templates and processes Models for successful practices’ for applying CDS to VTE (given different CIS environments) Feedback about each site’s gap analysis based on model practices, and plans based upon this analysis Ideas for scaling initiative to other topics and organizations

8. Collaboration Process: Who and Why Who: Mostly CMIO types and related from prior collaborative efforts; focus on PI, CDS and VTE Why: Implications for scaling and engaging others (such as those in the audience)

9. Collaboration Process: How Calls, templates, wiki Calls: Agree on basic strategies (project scope, deliverables, etc.) Templates: Standard ways of describing activities Wiki: Meeting schedules, develop talks Takes time to re-orient workflow to make best use of wiki Have used a few wikis/Web 2.0 over various collaborations; inevitable technical bumps in the road

10. Overall Lessons Learned (So Far) Does seem to be a need for and value from such collaborations (see talks to come) Shared goal and early sense of value driving continued participation Need skilled staff to support collaboration process: agenda, minutes, documents, wiki management (HIMSS providing this) Time management a challenge (as always) - few hours/week/organization

11. So What? Implications for You and Your Organization This work is manifestation of evolution toward “mass collaboration” in society (see Tapscott’s Wikinomics) Such best practice syntheses and collaborations can accelerate local efforts; consider jumping into the HIMSS fray and/or beginning your own collaborative Engaging in HIMSS CDS efforts Review CDS guides and keep an eye on the CDS parts of HIMSS website (e.g. www.himss.org/cdsguides) Send an email to David Collins (dcollins@himss.org) if you’re interested in exploring participation in the VTE collaborative when it scales later next year

13. About Memorial Hermann

14. About Memorial Hermann • Memorial Hermann-TMC was recognized as one of 100 U.S. hospitals to make the greatest progress in improving hospital-wide performance over five consecutive years (2001-2005). • For the 18th consecutive year, Memorial Hermann TIRR ranks among America’s Best Hospitals in the U.S. News & World Report magazine’s annual survey. • Memorial Hermann Named A "Most Wired" Healthcare System for Fourth Consecutive Year in 2008

15. Memorial Hermann Fact Sheet • Total hospitals: 14 • Acute care: 9 • Children’s: 1 • Heart & Vascular: 3 • Rehabilitation: 1 • Regional affiliates: 21 • Managed acute care hospitals: 4 • Sports Medicine & Rehabilitation Centers: 27 • Retirement/nursing center: 1 • Home health agency: 1 • Annual emergency visits: 323,258 • Annual deliveries: 21,536 • Annual Life Flight air ambulance missions: 3,185 • Employees: 19,012 • Beds (licensed): 3,286 • Medical staff members: 4,194 • Residency programs: 26 | Fellowship programs: 48 • Physicians in training: 1,324 (physicians and fellows) • Annual community benefit: $229,152,000

16. Memorial Hermann IT Fact Sheet • 22,000+ devices connected to the enterprise network from 80 different locations • 4 data centers, 1 mainframe, 43 mid-range UNIX/VMS systems, 1000+ servers, 16,836 PCs, 5,023 printers, 561 scanners, 21 handheld devices • 22,400+ calls per month to the Support Center • 264,000 sessions per month on memorialhermann.org • 24,600+ Exchange Email user accounts • 12 million spam emails & 91,000+ network attacks blocked each month • 173 formal assigned projects • 56 telephone systems – 28,000+ phones, 8,000+ pagers, 2,434 Spectralink phones • 5.69 million unique person records in CARE4 with 17,654 total users • 9,289 unique physician users to CARE4 monthly • 300+ applications supported by ISD • 365 FTEs in the ISD organization and 106 located in the hospitals (471 total) • $20M capital budget and $59.5M expense budget in FY 09 • 3000+ Information Security access requests per month

17. VTE & Clinical Decision Support

18. Why are we participating? • Part of first collaborative effort • Experiences and best practices • Useful tool for CDS implementers

19. Next Collaborative Effort • Utilize principles from new guide • Create scalable CDS models of best practice for different clinical conditions/diagnoses • We almost missed the bus!

20. Why VTE? • Significant cause of morbidity and mortality despite the availability of effective therapies for prophylaxis • Non-reimbursement from CMS/other payers

21. Challenges to collaboration • Getting everyone together at the same time! • Using Wiki • Overcame these challenges!

22. Our Objectives • Learn the different processes • Identify what would best work for us • Share our experiences • Outcomes

23. What are we doing today?Memorial Hermann • Using online tool within EMR • Risk Assessment • Recommended Prophylaxis • All inpatients greater than 17 yrs • Physician completes risk assessment and orders prophylaxis • Nursing monitors compliance

24. Different organizations are quite different: VTE prevention initiative CIS implementation Different process One single goal Optimizing CDS to Prevent and Treat VTE What are we doing today?Other Organizations

25. Key Take Away Points • Our process is more physician driven • VTE Outcome Metrics

26. Next Steps for Project • Continue to work on identifying core CDS elements that can be scalable across different organizations • Identify best practices • Implement best practices • Do these best practices work?

27. Children’s Hospital of Philadelphia Clinical Decision Support for VTE Prevention

28. About CHOP • 430 beds • 34 sub specialties • Nearly 50 Sites within the CHOP network • HIS: • Sunrise Clinical Manager, Manual access database for reporting (CS Stars safetyNET) • EPIC • CDS related governance overview • Executive Council of the medical staff --- ECMS IS --- CDS subcommittee For the 6th consecutive year, CHOP ranks as the number one Children’s Hospital in the U.S. News & World Report magazine’s annual survey.

29. Why is VTE prevention Important? • Hospital acquired VTE is potentially life-threatening and may; • Prolong length of hospital stay • Require invasive treatment • Result in chronic disability, the need for follow-up care and long-term anticoagulation • Overall risk of VTE in children is much lower than in adults, but children often have multiple risk factors • Cases of hospital acquired VTE have occurred at CHOP

30. Improvement Aim • To reduce the potential for harm through the use of mechanical and chemoprophylaxis by increasing the compliance with the clinical practice guidelines to > 90% by February 2009.

31. Key Questions • Are we assessing everyone who is at risk? • Are we treating everyone who is at risk? • Has treatment reduced the incidence of VTE?

32. MAXIMIZE these groups MINIMIZE these groups OUTCOME MATRIX ALL ADMISSIONS Assessed with Risk score tool Not assessed with Risk score tool + VTE - VTE At risk Not at risk + VTE - VTE Prophylaxis No Prophylaxis + VTE - VTE + VTE - VTE

33. WHAT IS RISK and can it be stratified?

34. Age Distribution of Patients with Venous Thrombosis at CHOP After the newborn period, an increase is seen at approx. 14 yrs N=185 Number of Patients

35. Underlying Medical Conditions in Children with Thrombosis Diabetes Sickle Cell Disease Trauma Infection Renal None Other Cystic Fibrosis Cardiac Surgery Dehydration Cancer Prematurity This does not include the presence of a central venous catheter, which is the single greatest risk factor for thrombosis - found in ~40% of children over age 1 with a DVT

36. RISK assessment tool At RISKpatients are > 14 years old and have one or more of the listed conditions At HIGH RISKpatients are > 14 years old, immobile, and have one or more additional conditions

37. RISK assessment tool - execution

38. OUTCOME MATRIX ALL ADMISSIONS Assessed with Risk score tool Not assessed with Risk score tool + VTE - VTE At risk Not at risk + VTE - VTE Prophylaxis No Prophylaxis + VTE - VTE + VTE - VTE

39. WHAT IS TREATMENT and can it be proven?

40. The Challenge of Treatment • Treatment must … • Impact outcome (less VTE for at risk patients) • Safe • Determined by …. • Research • Published standards - from adult literature • Consensus – Anticoagulant workgroup • Randomized trials requires large numbers • Venograms too invasive, U/S technology and MRI not good enough

41. Treatment Guideline • A Patient who is at RISK or HIGH RISK receives one or more forms of mechanical thromboprophylaxis* • Early ambulation within 12 hours • Pneumatic compression device* • Graduated compression “antiembolic” stockings (Teds) • A patient who is at HIGH RISK receives one or more forms of mechanical prophylaxis and may also receive anticoagulant thromboprophylaxis with low molecular weight heparin (Enoxaparin) or unfractionated heparin * Mechanical prophylaxis is not used if acute VTE is suspected

42. Treatment - execution

43. Other key Measures for chemoprophylaxis • Compliance with … • Baseline laboratory monitoring (enoxaparin, heparin, warfarin) • Dosage adjustment algorithms and monitoring guidelines (enoxaparin, heparin, warfarin) • Discharge Education and scheduled follow-up appointment (enoxaparin, warfarin)

45. OUTCOME MATRIX = obtain from querying Hospital Information System ALL ADMISSIONS Assessed with Risk score tool Not assessed with Risk score tool At risk Not at risk +VTE -VTE +VTE -VTE Prophylaxis No Prophylaxis +VTE -VTE +VTE -VTE

46. Lessons learned from workgroup • We share the same challenges and have common strategies for overcoming the hurdles of technology, culture, and clinical evidence. • Risk assessment • We all stratify risk, some calculating a score. • Initial assessment - some done by nursing, some by physicians (about 50/50) • All working on electronic tool, but most using paper tools • Electronic alert triggers seems to be a good idea as reminder systems • VTE Prophylaxis • Order sets is the most popular way to group VTE related orders • Some embed the order sets into existing ordersets associated with high risk populations • Prompts to reminder clinicians to order VTE prophylaxis is a more difficult task than dose guidelines. • VTE prophylaxis Complication prevention and outcome measures • Compliance with guideline is a commonly measured metric among our group • Prompts for appropriate labs is doable (i.e. INR) • Improvement is temporally related to project activities and tapers off between activities. • To hard-code practices into daily routine, it is necessary to insert continuous prompts at the point of care • Buy-in from and a sense of responsibility by front-line clinicians positively impacts the use of VTE prophylaxis • Identifying stakeholders is critical for success

47. Leslie Raffini, MD, Hematology Robert J. Mullen, PharmD, CQPS Tara Trimarchi, RN, Chair of CDS Committee Catherine Manno, MD Daniela Davis, MD Kathryn Roberts, RN, MSN, CRNP Amy Gallagher, PharmD, MS Lori Kramer, RN, MSN Sarah Erush, PharmD, BCPS Marilyn Blumenstein, RN, MSN Maria Mihalko, RN, MSN, Donna Schilling, BS, RT Jackie Evans, MD Jack Rome, MD (consultant) Anticoagulant Workgroup

48. Venous Thromboembolism(VTE) DONNA CURRIE, MSN, RN DIRECTOR, CLINICAL OUTCOMES ADVOCATE HEALTH CARE

49. ADVOCATE HEALTH CARE • Faith based health care system • Largest fully integrated not-for-profit health care delivery system in metropolitan Chicago • Organization • 8 hospitals (soon to be 9) • 3,500 beds • Home Health Care • 3 large Physician Groups • More than 200 sites of care. • 25,000 employed associates • More than 4,600 affiliated physicians • Hybrid Medical Record

50. WHY WE PARTICIPATE IN THE CDS PROJECT To learn from others To share information with other participants To share information broadly To identify opportunities for creative solutions to common challenges