Customizing an Electronic Medical Record to Improve ASP Workflow Efficiency and Track Metrics

1. Customizing an Electronic Medical Record to Improve ASP Workflow Efficiency and Track Metrics Cory Hale, PharmD, BCPS, BCIDP Three Rivers Antimicrobial Stewardship Symposium March 9, 2019

2. Objective • Describe the advantages and limitations of integrating process measure tracking into the daily workflow of a prospective Antimicrobial Stewardship Program (ASP)

3. Disclosures • None

4. Overview of ASP Metrics

5. Metrics to Assess the Impact of an ASP • Required to track and report, but no universal, validated standard • CDC Core Elements of Hospital Antibiotic Stewardship Programs • IDSA Guidelines for Implementing an Antibiotic Stewardship Program • NQF Antibiotic Stewardship Playbook • The Joint Commission (MM 09.01.01 EP7) • Metrics should be selected based on goals and size of intervention • Should be feasible to collect and track • Demonstrate improvement in hospital processes and patient outcomes associated with stewardship interventions CDC. Core Elements of Hospital Antibiotic Stewardship Programs. Atlanta, GA; 2014. Barlam TF, et al. Clin Infect Dis 2016;62(10):e52-77.

6. Assessing the Impact of an ASPUse both process and outcome measures Dellit TH, et al. Clin Infect Dis 2007; 44:159–77.

7. Assessing the Impact of an ASPExamples Outcome Process • Length of Stay • Mortality • Readmission • Chart reviews/interventions • Acceptance rate • Indication documentation • Guideline adherence • Appropriateness • Days of Therapy (DOT) • DOT/patient days • DOT/admission • Costs* • C. difficile incidence • Drug-resistant infection rate • Adverse drug events/toxicities Dellit TH, et al. Clin Infect Dis 2007; 44:159–77. Dodds Ashley ES, et al. Clin Infect Dis 2014; 59(S3):S112-21.

8. Prospective Audit and FeedbackImportance of Process Measures • Clinical outcomes are more difficult to define • STEWARDS Panel Consensus: failed to accept a clinical outcome measure ready for immediate use and tracking • Utilization and process measures may be more practical to demonstrate impact • Prospective audit and feedback is a time-consuming process • Must collect both quantitative and qualitative process measures to describe resource utilization to administrators • Effort to extract both process and outcome measures can be high • Must be facilitated by robust IT infrastructure to limit “busywork” Dorobisz MJ, et al. R I Med J 2018; 101(5): 28-30. Beganovic M, et al. R I Med J 2018; 101(5): 45-9. Moehring RW, et al. Clin Infect Dis 2017;64(3):377-83.

9. The ASP Form, M-Page, and Reports Program Creating a robust IT infrastructure to improve efficiency

11. Established in April 2011 (Adult) and September 2014 (Pediatric)

12. Antimicrobial Stewardship = Coordinated Interventions Primary goal: Improve patient care

13. Prospective Audit and Feedback: Daily Workflow • ASP Pharmacist screens clinical decision support system (CDSS) alerts • Bug/drug mismatches, infection markers without treatment, treatment without infection markers, de-escalation, targeted drugs, positive blood cultures, etc. • ~ 150 alerts on 50-70 patients per day • Morning: Adult ASP Rounds (~15-25 patients) • With comments and recommendations as appropriate, either face-to-face, by phone, or sometimes electronically • Afternoon: Pediatric ASP Rounds (~8-15 patients) • “Handshake stewardship” • End of day: Assess outcome of recommendations

14. Examples of Common Recommendations by our ASP

15. Before 2014… The Secure Excel Document • Strengths: • Limited IT support necessary (easy to add recommendation types, etc.) • Captured a wealth of data • Limitations: • No interface with the electronic medical record • Manual entry of MRN, date, etc. • Tedious to navigate between chart and spreadsheet when documenting • Only one person can edit at a time • Difficult to see running list of follow-ups

16. Since 2014… The ASP Form • Form within Cerner PowerChart that we designed with help from IT and Data Warehouse teams • Integrated into the daily workflow • An ASP Form is created in real-time for each patient we review • Readily accessible within the EMR • Not used for communication to clinicians

19. Each active ASP form is captured on an “M-page” • Presents all the information for each patient in a single line • Here, we can easily hyperlink back to the ASP form or to the patient’s chart to assess acceptanceof our recommendation and do the initial reconciliationof any effects on days of use for each antibiotic involved

21. The ASP Reports Program

22. Example of Adult Data: • Semi-Annual 2014–2017

23. Adult ASP: Annual 2014–2017 Finalized data

24. Pediatric ASP: 2014 (Q4) - 2017 Finalized data

26. Adult ASP: Recommendations Made in 2017

27. Adult ASP Acceptance Rates for the Specific De-Escalate Recommendation to "Stop All Antibiotics"

28. Pediatric ASP: Recommendations Made in 2017

29. Advantages and Limitations of the ASP Form

30. Advantages of the ASP Form • Improved workflow efficiency • Real-time documentation, EMR integration • Streamlined patient follow-up process • Standardized process measure reporting • Report alongside utilization and outcome measures (e.g., C. difficile rates) • Able to demonstrate direct impact of ASP • Recommendation types and acceptance • DOT saved directly attributable to recommendations • Versatility/ability to expand ASP activities • Added pediatric ASP in 2014 while maintaining adult ASP productivity • ASP “Informational alerts,” guidelines/order sets, focus on C. diff initiatives

31. Limitations to the ASP Form • Does not collect/track outcome measures • Future directions: additional fields for targeted interventions and longer-term follow-up on outcomes • Up-front time and IT resource commitment • Also time commitment by ASP personnel to assess acceptance, validate data • Does not replace clinical decision support systems (CDSS) to identify patients for intervention • Does not measure additional benefits of ASP recommendations • E.g., changes in the culture of antibiotic use, overall antibiotic DOT, resistance

32. Conclusions • Process and outcome measures are both necessary to describe the overall impact of an ASP • Implementation of the ASP Form streamlined our workflow, reduced inefficiencies, and provided a standard approach to process measure collection for our Adult and Pediatric ASP

33. Assessment Question Which of the following is TRUE regarding real-time collection of process measures to evaluate the impact/success of an ASP? • Advantage: Reduces manual work and variation in collecting/reporting retrospective data about stewardship interventions and acceptance rates • Advantage: Improves efficiency and facilitates expansion of ASP activities • Limitation: Difficult to associate with clinical outcome improvement • All of the above are true • Only A and C are true

34. Customizing an Electronic Medical Record to Improve ASP Workflow Efficiency and Track Metrics Cory Hale, PharmD, BCPS, BCIDP Three Rivers Antimicrobial Stewardship Symposium March 9, 2019