Kaiser Permanente Experience with Automating the IHI Global Trigger Tool

presented at AHRQ 2010 Annual Meeting September 29, 2010

Dot Snow, MPHNational Patient SafetyKaiser Permanente Foundation Health Plan

Fast Facts About Kaiser Permanente

Founded in 1945, Kaiser Permanente is the nation's largest not-for-profit health plan, serving 8.7 million members

Among the innovations it has brought to U.S. health care are: • prepaid insurance which spreads the cost to make it more

affordable • physician group practice with a focus on preventing illness as

much as on caring for the sick • an organized delivery system, putting as many services as

possible under one roof • implementation of the largest civilian electronic health record

in the world

Fast Facts About Kaiser Permanente

Medical Centers: 36Medical Offices: 431Physicians: 14,000Employees: 165,000

Operate with a Labor Management Partnership

Local markets in Northern California, Southern California, Hawaii, Colorado, Ohio, Georgia, Oregon/Washington and the Mid-Atlantic States

Trigger Tool/TIDS Experiences

Initial Pilot of IHI Global Trigger Tool

IHI Global Trigger Tools Pilot (2006)

Data came from 2 medical centers representing 2,363 patient days across 400 patients

37% of patients experienced an adverse event, with 20-25% having more than one adverse event

47% of the adverse events led to increased use of care

Focal Trigger Tool Pilot of IV Heparin Therapy

Automated Adverse Event Monitoring Program (AAEMP)

Other Trigger Tool Study Results

Adverse Drug Events: ADEs/1000 medication doses = 2.67% (Rozich JD, Haraden CR, Resar RK The adverse drug event trigger tool: A practical methodology for measuring medication-related harm. Journal Quality and Safety in Health Care June 2003)

ICU Trigger Tool Study: 1450 adverse events found in 55% of patients; with 28% of patients having > 1 event (Resar RK, Rozich JD, Classen D Methodology and rationale for the measurement of harm with trigger tools. Quality and Safety in Health Care. Vol 12 December 2003)

IHI Collaborative Surgical Trigger Tool Data: adverse events found in 14.6% of patients (Griffin FA, Classen DC. Detection of adverse events in surgical patients using theTrigger Tool approach. Qual. Saf. Health Care 2008 17: 253-258

The Office of Inspector General pilot study on national incidence of adverse events in hospitals showed ~30% of MediCare patients experienced some type of adverse event during hospitalization. Results from the National Incidence Study to be released later in 2010. (Lee Adler, MD; 2010 NPSF Congress presentation)

Application of Initial Pilot Results

Initial pilot identified IV heparin therapy as an area for focal trigger tool review

Four improvement opportunities identified:• Clarified the logic in the regional algorithm • Provided additional teaching of protocol to improve

adherence• Promoted alternative therapies with less risk for

dropping platelets• Adjusted tools in ED to allow for documentation of

double checks

Automated Adverse Event Monitoring Program (AAEMP)

Background Kaiser-funded research project Represents a collaborative effort between

Kaiser Permanente and Computer Sciences Corporation

Seeks to automate the IHI GTT methodology utilizing data from KP HealthConnect™

Will be used to detect and evaluate triggers that allows for the measurement of adverse events in a health care system

Process Steps in Building the AAEMP Application

Identify and define triggersMap triggers to locations in data tables from EMRBuild applicationValidate triggers and data from EMR locationsDefine operational workflowsPrepare clinical site for pilot testPost-pilot: refine trigger definition and application

based on sensitivity / specificity analyses

Identify and Define Triggers

Started with triggers from IHI GTTTriggers must be located in discrete fields within

the EMR; info located in text or notes will not be available for trigger detection

Worked with AAEMP Steering Committee to carefully define triggers including threshold values for positive triggers and specific inclusion or exclusion criteria

Added 7 infection specific triggers to test in AAEMP pilot, including CAUTI, VAP, and sepsis

Map Triggers to Data Table Locations

Used Clarity data tables rather than Chronicle server to avoid interference with operations

Time intensive step—requires knowledge of regional configurations and info location in tables

Want to identify all possible locations of trigger information within EMR to maximize reliability of the application to identify triggers and values

Build AAEMP Application

Original proposal called for a Java application and Oracle database

Requires collaboration with IT to determine technical specifications, feasibility assessment, system architecture and test plan

Front end of application completedBack end not built at that time; ongoing roll-out of

EMR to medical centers was top IT priority

Adapted AAEMP for Access Database

Identified a medical center that used Access to build a surveillance system similar in concept to AAEMP

Vendor modified application to run in Access and incorporate GTT triggers

Application loaded onto desktop computers rather than a system server

Validate Trigger and Data from EMR Locations

The application is tested using real patient data to determine that the information coming back from Clarity tables is indeed the trigger information expected to be returned

Define Operational Workflows

Application designed to assess medical records of all hospitalized patients and produce a list of patients with positive trigger firings

Nurse reviewer from Quality Department reviews medical record to determine whether an adverse event is present

If adverse event is present, categorize severity level according to NCC-MERP levels of harm

Physician validates nurse’s review and information is added to database

Prepare Clinical Site for Pilot Test

All members of pilot site team complete required IRB trainings and certifications

Pilot Site Training: Overview of IHI GTT and methodology Practice trigger and adverse event evaluation using

sample charts Demonstrate AAEMP application and reports Clarify operational workflow Schedule series of check-in meetings to discuss

emergent issues May want to review initial cases early in pilot as a check

for inter-rater reliability

Planned Post-Pilot Analyses

Sensitivity / specificity analyses of triggers with subsequent refinement of trigger definitions and mapping

Return on investment (lives saved; shorter LOS; cost reductions)

How orders in EMR could be changed to re-design / re-build for reliability in order to reduce harm to our patients (e.g., what feedback, directed follow-up, and/or actions need to be hardwired into orders; what best practice alerts need to fire)

Considerations / Challenges

Regions have made unique configuration choices that impact the location of data in Clarity tables after the daily ETL process

Trigger information may be documented in multiple places within EMR

Implementation demands greatest with initial sites; further spread would benefit from pilot site experiences

Considerations / Challenges

Articulate agreements for how information will be shared and acted upon

Sequencing trigger tool activity within a system’s EMR rollout and/or upgrades validation and testing activities may compete

with production schedules and resource commitments

Benefits

AAEMP allows detection of triggers in near real time paper-based methodology is a retrospective review and trigger

identification/detection is well after the fact

KP HealthConnect allows Kaiser Permanente to augment the classic IHI global trigger tool methodology in two important and innovative ways: searches the medical records of all hospitalized patients

instead of a sample, generating larger samples and revealing consistent patterns

allows for close surveillance of patients for the rapid detection and prevention or amelioration of harm

Benefits

Can replace existing surveillance activities; sampling of records can allow fit with existing resources

An automated trigger tool can: shine light on areas of improvement

opportunity Assess impact of specific performance

improvement initiatives

Concluding Observations and Thoughts

A strong multidisciplinary steering committee is essential

Numerous IT issues need to be addressed: System architecture Security considerations Vendor relationships IT standards and specifications

Will be a powerful application of a validated adverse event detection tool