himss virtual conference and exhibition 11/19/08 session #107b

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 OsheroffJohn Chuo

Anwar SirajuddinDonna Currie

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Panel Desired Outcome/Agenda

• Desired Outcome: Attendees learn about collaborative processes and strategies that can enhance their CDS efforts and outcomes

• Agenda:1. Describe effort to build and leverage a collaborative

to support CDS-enabled improvements in hospital clinical imperatives

2. Hear from 3 of 6 organizations participating in the collaborative: why they joined, what they are doing, benefits in progress

3. 20 minutes of Q&A: to help ensure that attendees realize desired outcome

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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

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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?

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5

www.himss.org/cdsguide

Backdrop: Guides for Improving Care Processes and Outcomes with CDS

5

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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

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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

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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)

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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

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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

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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 ([email protected]) if you’re interested in exploring participation in the VTE collaborative when it scales later next year

http://www.himss.org/cdsguides

mailto:[email protected]

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

About Memorial Hermann

http://health.usnews.com/usnews/health/best-hospitals/search.php?spec=repreha&

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

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

Memorial Hermann IT Fact Sheet

VTE & Clinical Decision Support

Why are we participating?

• Part of first collaborative effort

• Experiences and best practices

• Useful tool for CDS implementers

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!

Why VTE?

• Significant cause of morbidity and mortality despite the availability of effective therapies for prophylaxis

• Non-reimbursement from CMS/other payers

Challenges to collaboration

• Getting everyone together at the same time!

• Using Wiki

• Overcame these challenges!

Our Objectives

• Learn the different processes

• Identify what would best work for us

• Share our experiences

• Outcomes

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

What are we doing today?Other Organizations

• Different organizations are quite different:– VTE prevention initiative– CIS implementation– Different process

One single goalOptimizing CDS to Prevent and Treat

VTE

Key Take Away Points

• Our process is more physician driven

• VTE Outcome Metrics

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?

Children’s Hospital of PhiladelphiaChildren’s Hospital of Philadelphia

Clinical Decision Support forClinical Decision Support for

VTE PreventionVTE Prevention

The Children's Hospital of Philadelphia

• 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.

About CHOPAbout CHOP

http://health.usnews.com/usnews/health/best-hospitals/search.php?spec=repreha&


• 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

Why is VTE prevention Important?Why is VTE prevention Important?


Improvement AimImprovement 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.


1. Are we assessing everyone who is at risk?

2. Are we treating everyone who is at risk?

3. Has treatment reduced the incidence of VTE?

Key QuestionsKey Questions


MINIMIZEthese groups

MAXIMIZEthese groups

+ VTE - VTE

- VTE

+ VTE - VTE+ VTE - VTE

ALL ADMISSIONS

Assessed with Risk score tool Not assessed with Risk score tool

At risk Not at risk

Prophylaxis No Prophylaxis

+ VTE

OUTCOME MATRIXOUTCOME MATRIX

WHAT IS RISK and can it be stratified?


0

5

10

15

20

25

30

35

40

<1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 >21

Age (Years)

N=185

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atie

nts

After the newborn period, an increase is seen at approx. 14 yrs

Age Distribution of Patients with Venous Age Distribution of Patients with Venous Thrombosis at CHOPThrombosis at CHOP


Infection

Surgery

Cancer

Cardiac

Renal

DiabetesSickle Cell Disease

Prematurity

Cystic Fibrosis

Trauma

Other

None

Dehydration

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

Underlying Medical Conditions in Children with Underlying Medical Conditions in Children with ThrombosisThrombosis


• Immobility

• Orthopedic surgery

• Spinal cord injury

• Major trauma or trauma to the lower extremities

• Previous history of thrombosis / VTE

• Pregnancy

• Taking estrogen containing medications

• Acute infection

• Burns

• Obesity

• Disorder associated with thrombosis including but not limited to; Inflammatory Bowel Disease, Nephrotic Syndrome, Sickle Cell Disease, Lupus and Diabetic Keto-Acidosis

• Central venous catheter in the lower extremity

• Acquired or inherited thrombophilia

• Family history of thrombosis in a first degree relative < 40 years of age

At RISK patients are > 14 years old and have one or more of the listed conditions

RISK assessment toolRISK assessment tool

At HIGH RISK patients are > 14 years old, immobile, and have one or more additional conditions


Defining risk

groups

Execution How well executed is

the tool?

Outcome

PAPER Retrospective chart review, consensus, adult literature

Risk assessment tool is incorporated into the nursing admission intake paperwork

Are paper forms of the tool readily available?

Do people know how to use it?

Is there accountability?

How many risk assessments are done?

TECH Work underway for: Point of care reminders in selected ordersets to remind prescribers to assess risk. i.e. preop ordersets. The tool itself will be computerized.

RISK assessment tool - executionRISK assessment tool - execution


+ VTE - VTE

- VTE

+ VTE - VTE+ VTE - VTE

ALL ADMISSIONS


At risk Not at risk


+ VTE


WHAT IS TREATMENT and can it be proven?


• Treatment must …1. Impact outcome (less VTE for at risk patients)

2. Safe

3. 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

The Challenge of TreatmentThe Challenge of Treatment


• 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

Treatment GuidelineTreatment Guideline


Define treatment

Execution How well executed

is the process?

Outcome

PAPER Literature review, consensus, adult protocols

TECH - VTE prophylaxis order set containing mechanical and chemoprophylaxis - Nursing staff has the ability to initiate mech. prophylaxis

Ordersets awareness?

Ordersets usability?

How often is prophylaxis initiated?

What % of those assessed to be at risk received prophylaxis and how do their VTE rates compare with the other groups?

Treatment - executionTreatment - execution


Other key Measures for chemoprophylaxisOther 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)


ALL ADMISSIONS


+VTE -VTEAt risk Not at risk


+VTE -VTE

+VTE -VTE+VTE -VTE

= obtain from querying Hospital Information System



• 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

Lessons learned from workgroupLessons learned from workgroup


Anticoagulant WorkgroupAnticoagulant Workgroup

• 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)

Venous ThromboembolismVenous Thromboembolism (VTE)(VTE)

DONNA CURRIE, MSN, RN DONNA CURRIE, MSN, RN DIRECTOR, CLINICAL OUTCOMESDIRECTOR, CLINICAL OUTCOMESADVOCATE HEALTH CAREADVOCATE HEALTH CARE

ADVOCATE HEALTH CAREADVOCATE HEALTH CAREFaith based health care systemLargest 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 associatesMore than 4,600 affiliated physicians Hybrid Medical Record

WHY WE PARTICIPATE WHY WE PARTICIPATE IN THE CDS PROJECTIN THE CDS PROJECT

To learn from othersTo share information with other

participantsTo share information broadly To identify opportunities for creative

solutions to common challenges

APPROACH TO VTE APPROACH TO VTE PROPHYLAXISPROPHYLAXIS

Six Sigma approach at 3/8 sitesSystem level interdisciplinary teamEMR site liaison participation ACCP GuidelinesAssessment guidelinesElectronic assessment toolProphylaxis GuidelinesLocal CDS committee

◦ VTE Alert #1 – MD alert for orders based on score

◦ VTE Alert #2 – Proposed alert for adequacy of prophylaxis

VTE PATIENT RISK ASSESSMENT VTE PATIENT RISK ASSESSMENT GUIDELINESGUIDELINES

Purpose

Provide a consistent process for assessing the risk of VTE in medical and/or surgical patients.

Assessment Guidelines

- Within 8 hours of admission to the hospital

- With a change in level of care

- Post operatively for inpatient surgical patients

- Pre operatively for all surgical patients

- Notify the MD of the VTE risk assessment results, suggested VTE prophylaxis and obtain orders within 12 hours of admission to the hospital.

VTE PROPHYLAXIS GUIDELINESVTE PROPHYLAXIS GUIDELINES PLEASE NOTE: These are GUIDELINES for the Prophylaxis of VTE. This

is NOT an order set. Please contact the patient’s physician for orders

VTE Prophylaxis GuidelinesGeneral • DO NOT USE ASPIRIN AS PROPHYLAXIS AGAINST VTE

• Discharge with LMWH for high risk general surgery patients; major cancer surgery• Avoid thromboprophylaxis in vascular surgery patients with no additional risk factors

Low (1) • Early & Persistent mobilization

Moderate (2) • Enoxaparin (Lovenox) 40 mg (If CrCI< 30mL/min = 30 mg) SubQ every 24 hours OR • Fondaparinux (Arixtra) 2.5 mg SubQ daily † (Do not use if CrCl< 30 mL/min or weight< 50 kg) OR • Heparin, 5,000 Units SubQ every 12 hours CONSIDER ADDING§ • GCS and/or IPC in addition to one of the above or if high risk of bleeding

High (3-4) • Enoxaparin (Lovenox) 40 mg (If CrCI< 30mL/min = 30 mg) SubQ every 24 hours OR • Fondaparinux (Arixtra) 2.5mg SubQ daily† (Do not use if CrCl< 30 mL/min or weight< 50 kg) OR • Heparin, 5,000 Units SubQ every 8 hours CONSIDER ADDING§ • GCS and/or IPC in addition to one of the above or if high risk of bleeding

Highest (> 5) • Enoxaparin (Lovenox) 30 mg Sub Q every 12 hours (If CrCl< 30 mL/min = 30 mg daily) OR • Fondaparinux (Arixtra) 2.5mg SubQ daily† (Do not use if CrCl< 30 mL/min or weight< 50 kg) OR • Heparin 5000 units Sub Q every 8 hours AND§ • GCS and/or IPC in addition to one of the above

† Approved for thromboprophylaxis in certain surgical patients§ GCS = Graduated Compression Stockings IPC = Intermittent pneumatic compression

MEASURESMEASURESOutcome Measure

◦ AHRQ measureActual post-op PE/DVT rate /expected post op PE/ DVT rate

Compliance (Process) Measures ◦ Risk assessment completion rates◦ Time from admission to VTE risk assessment ◦ Time from admission to prophylaxis orders ◦ Risk assessments by risk category

Low – 19% Moderate – 14% High – 28% Highest – 39%

DRILL DOWN AT ONE SITEDRILL DOWN AT ONE SITE

Overall 64% medical vs. 36% surgical

65% of patients scored High or Highest Risk

30% of all DVT/PE cases reviewed grouped into a circulatory MDC◦ ¼ of these were

bypass w/o cath◦ 83% did not receive

optimal prophylaxis

Count 1 1 112 6 6 4 3 2 2 2

Percent 2.5 2.5 2.530.0 15.0 15.0 10.0 7.5 5.0 5.0 5.0Cum % 95.0 97.5 100.030.0 45.0 60.0 70.0 77.5 82.5 87.5 92.5

40

30

20

10

0

100

80

60

40

20

0

Count

Perc

ent

Pareto Chart of MDC

PROGRAM ANALYSISPROGRAM ANALYSIS

Advantages◦ Standardized

Approach to VTE prophylaxis Tools Measures

Opportunities

◦ Improve adequacy of prophylaxis

◦ Improve physician participation in the process

ANALYSIS OF CDS ANALYSIS OF CDS PARTICPATIONPARTICPATION

Collaborative and iterative process – a different way to work together

Learning from multiple, diverse organizations

Develop creative, “Best Practice” processes

Share information to continually improve practices

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Topics for Discussion

• How are you addressing these issues (applying CDS toward improvement priorities)?

• What are greatest CDS challenges, successes, needs?

• Role for such a collaborative in your efforts?

• Other thoughts/questions?

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More Information---

Chair - HIMSS CDS Task Force Jerry Osheroff, MD

[email protected]

HIMSS Staff LiaisonDavid Collins

Director, Healthcare Information Systems

[email protected]

himss virtual conference and exhibition 11/19/08 session #107b

Documents

cds efforts

cdsenabled improvements

leader participants

vteformed cds task force

road2008 jerome osherof

collaborative processes

scalable templates

clinical sites