Encouraging change and user adoption through clinical performance data at Intermountain Healthcare - PowerPoint PPT Presentation

Loading...

PPT – Encouraging change and user adoption through clinical performance data at Intermountain Healthcare PowerPoint presentation | free to view - id: 79ca1-ZDc1Z



Loading


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation
Title:

Encouraging change and user adoption through clinical performance data at Intermountain Healthcare

Description:

Dictionary. Database. Interface. Patient. Database. Data. Warehouses ... Intensive Medicine. Etc. Board goals of clinical improvement rather than volume ... – PowerPoint PPT presentation

Number of Views:197
Avg rating:3.0/5.0
Slides: 56
Provided by: bchim
Category:

less

Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Encouraging change and user adoption through clinical performance data at Intermountain Healthcare


1
Encouraging change and user adoption through
clinical performance dataat Intermountain
Healthcare
  • BC Health Information Management Professional
    Society
  • November 30, 2007
  • Sid Thornton, PhD
  • Associate Director
  • Homer Warner Center for Informatics Research

2
How can observations from medical informatics at
Intermountain apply?
  • Overview
  • Medical Informatics background at Intermountain
    Healthcare
  • Guiding principles of change management and user
    adoption
  • Observations and lessons learned with a recurring
    theme voluntarily change follows where value is
    demonstrated

3
Intermountain Healthcare
  • Health Delivery Network, not-for-profit
  • Serving Utah and Southern Idaho
  • 22 Hospitals/ 2300 beds/150 Clinics
  • Medical Group of 600 employed physicians
  • Insurance plan of 500K covered lives
  • 85M/year charitable care exclusive of bad debt
  • 27K employees
  • Partner in the Utah Health Information Network

4
Cassia
Intermountain
Bear River
Logan
Budge
BMI
McKay
LDS
Salt Lake Clinic
PCMC
Lake Park
Corp
Cottonwood
Delta
Fillmore
Alta View
American Fork
Utah Valley
Orem
Wasatch
Sanpete
Sevier
Garfield
Valley View
River Rd
Dixie
5
Information Systems Volumes
  • Individuals with EHR 2M
  • Inpatient admissions 120K/yr
  • Ambulatory visits 5M/yr
  • Point-to-point interfaces 800
  • Clinical electronic transactions 2M/day
  • Electronic medical record users 17K
  • Affiliated, non-employed physicians
  • with home or office EHR connectivity 500
  • Community data sharing partners
  • exchanging clinical information 2

6
Information Systems Investment
  • 3.8 of gross annual revenue for IS
  • 700 FTEs
  • 30M annual expenditure for clinical systems
  • Redundant data centers and networks
  • Standard desktop and workstation images

7
Medical Informatics History at Intermountain
Healthcare
  • 1954 Homer R. Warner MD PhD to LDS
  • 1961 JAMA article on automated diagnosis
  • 1964 Academic department 231 diplomas
  • 1972 HELP alerts/hospital database
  • 1985 System wide commitment for HELP
  • 1992 Longitudinal Medical record
  • 2005 System commitment to inter-institutional,
  • content-driven EHR infrastructure
  • 2006 Homer Warner Center for Informatics
    Research

8
Goal of Medical Informatics
Favorably influence the cost and quality of
health care (including prevention) by providing
pertinent information to providers,
administrators, and patients in a timely manner
9
Data demonstrating value creates motivation
  • Currencies of value
  • Increased revenue
  • Cost savings
  • Time savings
  • Improved health
  • Improved well-being
  • Increased opportunity
  • Reduced distraction
  • Better care costs less

10
Value through clinical systems integration
  • 30 year horizon
  • People need decision support
  • Heterogeneous new and old can simultaneously
    coexist
  • Technology will change over time
  • Database content will not change with time
  • Multiple ways to capture data
  • No one does it all
  • Scalability

11
Applications
Medical

Logic
Modules
Health Plans
Directories/
Dictionary
Data
Patient
Warehouses
Database
12
Longitudinal EHR, conception to grave
  • Comprehensive of all categories of clinical data
  • History, physical, pharmacy, laboratory,
  • All types of data
  • Text, numeric, coded, images, sounds,
  • Retained for 100 years
  • The legal record for all or part of the patients
    data
  • The data will outlive any particular application,
    service, programming language, database, or
    message format

13
Patient and population clinical databases
  • Patient database facilitates alerts, reminders,
    worksheets and reports
  • Population database supports business
    intelligence, clinical research, benchmarking

14
Data sharing for primary and secondary data uses
  • Sharing within the enterprise
  • Patient care
  • Business intelligence
  • Research
  • Sharing outside the enterprise
  • Adverse event reporting (drugs and devices)
  • Morbidity and mortality reporting
  • Patient safety reporting
  • Quality of care reports - HEDIS measures
  • Regional Health Information Networks
  • Bio-surveillance, infectious disease reports
  • Cancer registries and disease specific
    repositories
  • Collaborative research

15
Real time, patient specific decision support at
the point-of-care
  • Alerts
  • Potassium and digoxin
  • Coagulation clinic
  • Reminders
  • Mammography
  • Immunizations
  • Protocols
  • Ventilator weaning
  • ARDS protocol
  • Prophylactic use of antibiotics in surgery
  • Advising
  • Antibiotic assistant
  • Critiquing
  • Blood ordering
  • Interpretation
  • Blood gas interpretation
  • Management purpose specific aggregation and
    presentation of data
  • DVT management
  • Diabetic report

16
Guiding principles for user acceptance and change
motivation
  • User owned and controlled processes
  • Motivation through value-driven data or Quality
    care through clinical data
  • Governance through transparency and equity
  • Quality transcends affiliation boundaries
  • A community of safety facilitates improvement
  • Making it easy to do the right thing

17
The How am I doing? report
  • Available at the point-of-service
  • Draws from patient and population data
  • Compares a specific case to a standard
  • Provides a specific provider view
  • Compares facility compliance
  • Establishes enterprise baselines

18
(No Transcript)
19
Clinical organization and IS governance
  • Representational organization along clinical care
    processes
  • The Clinical Programs of Intermountain Healthcare
  • Cardiovascular Health
  • Women Newborn
  • Primary Care
  • Pediatrics
  • Intensive Medicine
  • Etc.
  • Board goals of clinical improvement rather than
    volume
  • Clinical prioritization of informatics projects
    and services

20
Example Reducing inappropriate early induction
of labor
  • Inappropriate induction of labor increases
    delivery complications, length of labor, newborn
    ICU admissions, etc.
  • Longitudinal view of perinatal care, length of
    gestation, Bishop score, etc. facilitates
    guideline compliance
  • A time/data-based care process model across care
    settings

21
(No Transcript)
22
(No Transcript)
23
(No Transcript)
24
Example Managing newborn hyperbilirubinemia
  • 1999 study by Bhutani et al. establishes time
    curves for newborn serum bilirubin
  • Intermountain redraws the time curves using
    internal data
  • Intermountain adopts the clinical guideline for
    newborn bilirubin care with time-dependent
    follow-up screenings as early as 6-hours post
    discharge

25
(No Transcript)
26
Disruptive change
  • Significant increased cost to hospitals
  • Additional laboratory tests
  • Delayed discharges waiting for results
  • Staff education
  • Patient education
  • Substantial workflow impact to physicians
  • Next day follow-up rather than 10-day
  • Time-sensitive lab results and alerts

27
Medical Informatics solution that eased workflow
and improved communication
  • Problem-based interdisciplinary tool within the
    existing longitudinal Clinical IS infrastructure
  • Web-accessible
  • Authoring environment for rules, time-based
    model, guidelines and order sets
  • Actionable integration of results, orders,
    guidelines, patient instructions
  • Context-aware data review and entry

28
Web-based clinician desktop for messaging,
integrated care plan and point-of-care data entry
29
Regulatory implications for point-of care
laboratory data entry
  • Data Entry
  • Secondary patient identifier in addition to
    Enterprise Unique Number
  • Specimen collected by..
  • Results recorded by..
  • Quality control check
  • Final Report
  • Testing location, facility and address
  • Results status, preliminary, final, corrected
  • Patient EHR
  • Critical value alert documentation
  • Test reported date time, by
  • Test performed date time, by

30
Archive recovery strategy
  • PDA formats saved at crucial points to facilitate
    reconstruction of intent across the transitions
    of care
  • Portfolio of un-editable historical views
    available through integrated web access

31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
User acceptance
  • Hospitals early adopters because of the impact on
    timely discharge
  • Parents liked the integrated view of the order
    and historical trend
  • Physicians reworked their cross-coverage
    strategies to accommodate the early follow-up
    visits
  • Regions accepting alerts have increased guideline
    compliance

38
Implications for clinical data sharing
initiatives
  • Fixed document view only is not as good as
    actionable results with interactive orders,
    results and messaging
  • Reconstruction of point in time information is
    essential across transitions of care
  • Regulatory factors such as laboratory
    certification must be considered
  • Alert fatigue requires further analysis

39
Example Antibiotic Prescribing (RS Evans et al.)
  • Cost and efficacy data for each orderable drug
    option based on comparable cases within the last
    6 months/5 years
  • Available at the point-of-care as notification of
    laboratory results are received
  • Tailored to the specific patient
  • Value from specific empiric data at the point of
    care

40
LDS HOSPITAL EMPIRIC ANTIBIOTIC ASSISTANT
000000000 Doe, John Q E605 22yr M DxTRAUMA,
MULTIPLE FX SITE Blood Inpatient Hospital -
acquired PAST 5 YEARS PAST 6 MONTHS
ORGANISM ( ) ORGANISM (
) Staph. Coagulase neg. 208 ( 61) Staph.
Coagulase neg. 14 ( 50) Enterococcus 28 (
8) Escherichia coli 8 ( 29) Escherichia coli
27 ( 8) Enterobacter cloacae 2 (
7) Staph. Aureus 18 ( 5) Staph. Aureus
1 ( 4) Pseudomonas aeruginosa 13 (
4) Pseudomonas aeruginosa 1 ( 4) TOTAL
294 ( 86) TOTAL 26 ( 94) ANTIBIOTIC ( )
COST/24hr ANTIBIOTIC ( )
COST/24hr VancomycAmikacin ( 99) 116.33 Vancomy
cTobramyci (100) 46.67 VancomycTicar/cla (
99) 74.53 VancomycAmikacin (100)
116.33 VancomycTobramyci ( 98)
46.67 VancomycPiperacil (100)
74.97 VancomycCeftazidi ( 98)
57.03 VancomycCeftazidi (100)
57.03 VancomycAztreonam ( 98)
60.24 VancomycAztreonam (100)
60.24 EMPIRIC ANTIBIOTIC SUGGESTION
VancomycTobramyci ANTIBIOTIC ALLERGIES None
reported RENAL FUNCTION Normal, CrCl
gt120, Max 24hr Cr .6? ( .7) IBWeight 67kg
Enter ltgt to order suggested antibiotics, press
ltEntergt to continue. . .
41
Measured value from the point-of-care
Antibiotic Assistant
No. of susceptibility - mismatch
alerts 206 12 No. of drug - allergy
alerts 146 35 No. of excessive - drug -
dosage alerts 405 87 Average no. of days of
excessive anti-infective dose 5.9 2.7 Adverse
events caused by antiinfective agents - no.
28 4 Death - no. () 172
(22) 88 (22)
Plt0.05 by the chi-square test. Plt0.01 by the
chi-square test. Plt0.002 by the Mann-Whitney U
test. Values shown are among patients who
received antiinfective agents.
42
Example Adverse drug alert (RS Evans et al.)
  • Accurate detection and classification spawns
    process improvement
  • Available at the point-of-care for ordering,
    dispensing, and administration
  • Tailored to the specific patient
  • Value from providing patient-specific alerts at
    the point of care

43
Adverse Drug Events
  • Rates today (2004-5) at about 270 per year
  • Generates gt1 million per year in net cost
    reductions at LDS Hospital alone

44
Adverse Drug Events
Mortality Length of Cost
of ()
stay(days) Hospitalization()
  • ADE patients 3.50 8.19
    10,584
  • Matched control 1.05 4.36
    5,350
  • patients
  • Attributable ------- 1.94
    1,939
  • difference

plt.001 by chi square, plt.062 by paired t test,
p.147 by paired t test, plt.05 by t test
Evans et al, 1994, AMIA
45
Value from time-based care process models
  • ex Pre-operative Antibiotics (RS Evans et al.)
  • Antibiotics delivered within two hours of
    incision result in lower infection rates.
  • The number of infections avoided annually is
    estimated between 500 600
  • Each infection has an additional cost of 10,000
    (average) and results in significant patient
    morbidity and length of stay.
  • Time-modeled care processes are a central part of
    the next generation clinical information system

46
Example Diabetes Worksheet
  • At each ambulatory visit, reconciles available
    EHR data with the standard of care
  • Prompts care provider for missing or unscheduled
    actions such as laboratory orders, foot exam,
    etc.
  • Consumer views and messaging
  • Reports for providers and facilities
  • How am I doing compared to my peers?
  • Value from time-based longitudinal care process
    models

47
(No Transcript)
48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
Example labor delivery activity-based costing
  • Activity-based model and valuation
  • Time and data triggered rules
  • Clinical activities documented at the point of
    service within an integrated care process model
  • All administrative data derived from the clinical
    activity data set
  • Costing
  • Billing
  • Inventory relief
  • Staffing
  • Value from linked financial and clinical data
    systems

52
(No Transcript)
53
Value from activity-based labor deliver care
process model
  • Reduced charge capture variability
  • Reduced missed charges
  • Reduced clinician documentation
  • Linked financial outcomes to clinical
    intervention
  • Utilization forecasting
  • Benchmarked care processes

54
Future state content-driven clinical information
systems
  • Authoring environment for rules, guidelines, care
    process models
  • Activity-based care process models for derived
    administrative data and for health and cost
    outcome forecasting
  • Inter-institutional collaboration and
    benchmarking

55
  • Sid.Thornton_at_intermountainmail.org
About PowerShow.com