Harvard Quality Colloquium

1. Harvard Quality Colloquium Collaboration, Technologies to Achieve Transformational Change and Physician Buy-In for Quality Improvement and P4P Boston: August 22, 2006 Track IA

2. Speakers/Disclosure • Timothy McNamara, MD, MPHChief Medical OfficerHealthGate Data Corp.Medical Director, Center for Healthcare InformaticsUniversity of Kansas • Judith Logan, MD, MSDept. of Medical Informatics and Clinical EpidemiologyOregon Health & Science University • Brian Levy, MDChief Medical Officer & Senior Vice PresidentHealth Language, Inc.

3. Collaboration, Technologies to Achieve Transformational Change • Frame the problem • Trends and motivation for collaboration technologies (across industries) • Requirements for collaboration tools in healthcare • Case Study • Success Factors • An evidentiary basis for collaboration • “Encoding the evidence”: integration with controlled medical terminology • Discussion

4. The Problem • Quality programs and CPOE require standardization of practices • order sets, nurse documentation forms, discharge planning materials, safety checklists • Effective standardization requires: • Interdisciplinary collaboration and consensus building…and that usually means committee meetings • Expensive to manage • Time consuming • Slow • Inefficient • Creation of an evidentiary foundation • Accounting for updates • Operationalization of committee decision making

5. Challenges in Healthcare • Loose affiliation of participants • Non-uniform IT platform and training • Burgeoning amount of committee work • CPOE adds dozens and dozens of new committees • Inadequate staffing • Geographic distribution of participants • Expense and effort in coordinating committee meetings • Multiple heterogeneous local versions of care documents and processes • Etc…

6. Challenges in Healthcare(for the CMO/CMIO/VP Quality) • No easy/obvious way to track committee performance • No easy/obvious way to have unambiguous interpretation of committee decisions • No easy/obvious way to find and compare documents • Most are archived in paper format around the enterprise • No systematic process of identifying existing documents that need re-evaluation or re-review in light of changing evidence • No easy way to have the results of committee work “flow” into IT systems (for CPOE, documentation, etc…)

7. Collaboration Tools

8. Collaboration Technologies • Remote conferencing • Telephony • Whiteboarding • Enterprise wikis • Enterprise blogging • AJAX niche applications • Content management systems

9. Why should the healthcare industry be interested incollaboration technologies…?

10. Why should the healthcare industry be interested in collaboration technologies…? • We are already spending huge amounts of time, resources and money on inefficient/ineffective collaboration (meetings, staff, research, etc…) • There is a large ROI for increased efficiency

11. Requirements for Healthcare User • Collaboration Management • Simple (i.e. in-box) notification of work/tasks • Threaded discussion/annotation • One-step review and completion of work • Synchronous and asynchronous communication • Workflow Management • Task assignment • Task Tracking • Dashboard of progress • Evidence and Updates • Access to locally created documents • Access to evidence-based clinical resources • Access to a library of quality measures (JCAHO, CMS, societies) • Ongoing literature surveillance--linked to local documents

12. Requirements for the Healthcare Technologist • ASP Model • Non-disruptive implementation • Low cost of management/ownership • Indexing to Control Medical Terminology Standards • Export into contemporary EHR systems • Robust content management • Automatic versioning and statusing of all documents • Roll-back, automated document comparisons • Representation of the Governance, Committee, and Geographic Structure of a System • Users assigned to teams, teams assigned to facilities, facilities assigned to regions, regions and facilities assigned a health system • Health system determines the allowed variation between regions, facilities, and teams…and can see and track that variation • Minimal Training • “Casual users” vs Super-users

13. Patient Case Mr. Smith is a 65 year old man admitted to the hospital for left total hip replacement. He has a history of osteoarthritis of this hip and has considerable pain with mobility. Mr. Smith has a history of diabetes mellitus controlled by oral medications and coronary artery disease with a MI and angioplasty 10 years ago. He takes glipizide, metformin, aspirin, and lisinopril.

14. Patient Case Issues • Identify this patient as requiring post-operative DVT prophylaxis • Consider pre-operative measures as well • Start appropriate DVT prophylaxis based on this patient’s profile • Realize the benefits to the hospital in preventing post-operative DVTs in improving patient safety and pay for performance policies

15. Patient Case • Pay for performance issues • Administration of proper anticoagulation for post-op orthopedic procedures • http://www.ahrq.gov/qual/p4pguide.pdf • http://www.vascularweb.org/_CONTRIBUTION_PAGES/Government_Relations/Physician_Payment_Quality_Issues/Pay_for_Performance.html • Evidence • (DVT) occurs after approximately 25 percent of all major surgical procedures performed without prophylaxis, and pulmonary embolism (PE) occurs in 7 percent of operations conducted without prophylaxis.  More than 50 percent of major orthopaedic procedures are complicated by DVT, and up to 30 percent by PE, if prophylactic treatment is not instituted.  Despite the well-established efficacy and safety of preventive measures, studies show that prophylaxis is often underused or used inappropriately. • Without prophylaxis, the rates for symptomatic and asymptomatic VTE in total hip replacement include total DVT, 45%-57%; proximal DVT, 23%-36%; total PE, 0.7%-30%; and fatal PE, 0.1%-0.4%. In total knee replacement rates are total DVT, 40%-84%; proximal DVT, 9%-20%; total PE, 1.8%-7%; and fatal PE, 0.2%-0.7%. In hip fracture patients without prophylaxis, rates are total DVT, 36%-60%; proximal DVT, 17%-36%; total PE, 4.3%-24%; and fatal PE, 3.6%-12.9% (ACP Pier 1) • A computer alert reduced the risk of deep-vein thrombosis or pulmonary embolism at 90 days by 41 percent

16. Developing the Evidence: Evidence-based Resources for Creation of Clinical Tools

17. Critical success factors for clinical decision support systems • They don't require an intentional request • They give recommendations not just assessments • They give support at the time and location of decision-making • They are computer-based Kawamoto: Improving Clinical Practice Using Clinical Decision Support Systems: A systematic review of trials to identify features critical to success. BMJ 2005, 330(7494):765-72.

18. Decision support for creation of CDS tools • Evidence is a few clicks away. • The evidence provided must be current. • Resources provide recommendations not just assessments • Uncertainty must be known • They give support at the time and location of decision-making • They are computer-based

19. Evidence-based Medicine The process of of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions. Evidence-based medicine asks questions, finds and appraises the relevant data, and harnesses that information for everyday clinical practice. * Scope notes for "Evidence-based Medicine", Medline, National Library of Medicine

20. formulate a clear clinical question from a patient problem • search the literature for relevant clinical articles • evaluate (critically appraise) the evidence for its validity and usefulness • implement useful findings in clinical practice

21. Clinical Practice Guidelines Work consisting of a set of directions or principles to assist the health care practitioner with patient care decisions about appropriate diagnostic, therapeutic, or other clinical procedures for specific clinical circumstances..... *Scope notes for "Practice Guidelines [Publication Type]", Medline, National Library of Medicine

29. Recommendations, not assessments Elastic stockings (ES) reduce the incidence of lower leg DVT, but there is limited data on their ability to protect from proximal DVT and pulmonary embolism. In patients undergoing elective total hip replacement, treatment with LMWH (starting 12-24 hours postoperatively) or warfarin (to target INR of 2.0-3.0) is recommended. (A1) E

30. How certain are those recommendations? In patients undergoing elective total hip replacement, treatment with LMWH (starting 12-24 hours postoperatively) or warfarin (to target INR of 2.0-3.0) is recommended. (A1) E

31. Clinical care requires us to make complex decisions. Patients rarely meet strict inclusion criteria for studies. • All clinical decisionscannot be put intosimple algorithms • Estimation, expert opinion are therefore required.

32. How do you manage change over time? • Incorporation of some reseach is best done through performance of systematic reviews or metaanalyses • New evidence may strengthen or weaken recommendations that have been made • Other new evidence needs to be incorporated quickly into clinical care

33. Nov, 2001 CONCLUSIONS: In patients undergoing surgery for hip fracture, fondaparinux was more effective than enoxaparin in preventing venous thromboembolism and equally safe.

34. Operationalizing the Evidence:Controlled Medical Terminology

35. From Patient to Evidence Guidelines Order Sets 52734007 (THR) 73211009 (DM) 53741008 (CAD) Mr. Smith is a 65 year old man admitted to the hospital for left total hip replacement. He has a history of osteoarthritis of this hip and has considerable pain with mobility. Mr. Smith has a history of diabetes mellitus controlled by oral medications and coronary artery disease with a MI and angioplasty 10 years ago. Anti-coagulation Peri-op blood sugar management CAD history – consider EKG, ASA, B-Blocker Standards!

36. Data Re-use 52734007 (THR) 73211009 (DM) 53741008 (CAD) Surveillance Decision Support Clinical Care Communication Outcomes/Research Billing and Claims Consumer Documentation

37. What kinds of standards? • Framework for order sets and guidelines • HL7 • SAGE • Terminologies • SNOMED CT • LOINC • RxNorm • ICD, CPT, DRG…

38. How to ‘Charge’ EBM and Order Sets • Tools • Indexing terms and order sentences • Tools for the end-user • Tools for the developer • Services • Mapping proprietary order catalogues • Manual review of indexing and mappings

39. Indexed EBM and Orders Lovenox (C0706734) 30 mg SQ Daily

40. Benefits • Deliver the right content at the right time to the right person • Achieve integration of expert systems into clinical systems • Improve patient safety • Reduce adverse drug events • Improve information access and sharing • Achieve interoperability • Reuse of data for reporting and analysis

41. Automation The “Thursday-night Community-Acquired Pneumonia QI Committee”

42. What Does This Look Like?