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Creating Quality-Driven Operational Reports David Sinclair MD Associate Professor of Clinical Anesthesiology Associate Chief of Anesthesiology Co-Director of Informatics Epic UChart Physician Champion

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Toyota Advanced Quality Information Center a multimillion dollar computer system manned by 20 employees who compile repair reports from Toyota dealerships world-wideand will be accessible on an as-needed basis. Chester Dawson and Yoshio Takahashi, Toyota Makes New Push to Avoid Recalls, The Wall Street Journal, February 24, 2011

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Improving Quality Through Meaningful Use

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Can AIMS Deliver?

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Electronic Medical Record Pitfalls Design-Reality Gap Detracting from prompts/reminders Time-consuming features Suboptimum use Overwhelming learning process Gill, J. M. EMRs for improving quality of care: promise and pitfalls. Fam Med, 2009; 41(7): 513-515. Heeks, R. Health information systems: Failure, success and improvisation. International journal of medical informatics, 2006; 75(2):125-137.

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Origins of EMR-driven Quality 1.Discovery 2.Validation 3.Build 4.Training 5.Go-Live 6.Optimization

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How can AIMS deliver?

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Computerized support systems for decision making must present the right information, in the right format, at the right time, and without requiring special effort. James, B. C. (2001). Making it easy to do it right. The New England Journal of Medicine 2001; 345(13): 991.

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Structured Data Information Knowledge Decision support Improved quality Balust, J., Macario, A. Can anesthesia information management systems improve quality in the surgical suite?. Current Opinion in Anesthesiology 2009; 22(2): 215-222.

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Quality?

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PPO Perspective Organization Patient Patient

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Guideline-based care Internal protocols National measures (PQRS, SCIP) & Error avoidance Interaction checking Avoidance of medication errors Patient

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Point-of-care Decision Support ACLS algorithms MH protocol Transplant protocols Drug dose calculator

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Guideline-Based Care Timely administration of antibiotics Periop temperature monitoring Periop Beta-blocker continuation Periop DVT and embolism prevention PONV prophylaxis Medication error prevention

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& Timely access to patients health information Coordinated communication Data exchange Patient

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& Automated screening and aggregation of data Surveillance and monitoring Organization

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Anesthesia Clinical Leader System Administrator System configuration Log-in access Security clearance Clinician Clinical Analyst

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StudyDocumentation Compliance MeasureClinical Decision Support Database Query Nair34% 94%B-blocker Pop-up Hard-stops Text pages Smart Anesthesia Manager OReilly69% 92%Antibiotic (p) Auto-entry reminder Email programmer Wax82% 89%Antibiotic (p) Auto-entry reminderprogrammer St. Jacques20% 57%Antibiotic (r) Pop-upprogrammer Kooij38% 73%PONV Pop-upprogrammer Patient

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Quality Reports ReportFeaturesQuery ToolWeb tool Analytical Report: set schedule Based: large data set Actionable: trends Focus: multiple Reporting Workbench o Crystal Reports Business Objects o WebI o Clarity InfoView Operational Report: ad hoc in realtime Based: small data set Actionable: daily workflows Focus: single MS Project BuilderReport Viewer

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Real-time Patient Experience

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TeamAIMSClinical Decision Support QueryOperational Report Real-time Experience Rodriguez Vigoda Picis Pop-ups Text pages program Sterile barrier Temperature Antibiotics B-blocker Yes Sinclair Cooper Innovian Hard-stop Auto-entry reminder Email program Antibiotics No Email Semi- automatic Report Builder Sterile barrier Temperature Antibiotics B-blocker Yes Patient

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Operational Reports Quality MeasureReportCDS Perioperative CareTimely Administration of Prophylactic Parenteral Antibiotics Email Semi- automated Perioperative Beta-Blocker For Patients Receiving Therapy Prior to Arrival Missing Beta Blocker AssessmentEmail Semi- automated Prevention of Catheter-Related Bloodstream Infections Central Venous Catheter Insertion Protocol Hard-stop Perioperative Temperature Management Temperature 30 Min Before End of Surgery Hard-stop

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Patient

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Organization

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Slide 38 "clindamycin",Antibiotics"l evaquin"),(OR(incision_admin 60))),"missed","No") Organization"> "clindamycin",Antibiotics"l evaquin"),(OR(incision_admin 60))),"missed","No") Organization"> "clindamycin",Antibiotics"l evaquin"),(OR(incision_admin 60))),"missed","No") Organization" title="=IF(AND(OR(Antibiotics"vancomycin",Antibiotics"clindamycin",Antibiotics"l evaquin"),(OR(incision_admin 60))),"missed","No") Organization">

=IF(AND(OR(Antibiotics"vancomycin",Antibiotics"clindamycin",Antibiotics"l evaquin"),(OR(incision_admin 60))),"missed","No") Organization

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=IF(AND(OR(Specialty="URO",Specialty="NEURO"),OR(Antibiotics="cefazolin",Antibiotics="cipr ofloxacin",Antibiotics="ceftriaxone",.yes",IF(AND(Specialty="ORTHO",OR(Antibiotics= "cefazolin",..Antibiotics="ampicillin sulbactam")),"yes","no")))))) Organization

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Microsoft Excel Worksheets

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Visual Basic for Application Macro

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Operational Reports Quality MeasureReportCDS Perioperative CareTimely Administration of Prophylactic Parenteral Antibiotics Email Semi- automated Perioperative Beta-Blocker For Patients Receiving Therapy Prior to Arrival Missing Beta- Blocker Assessment Email Semi- automated Prevention of Catheter-Related Bloodstream Infections Central Venous Catheter Insertion Protocol Hardstop Perioperative Temperature Management Temperature 30 Min Before End of Surgery Hardstop

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Real-time Patient Experience

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Organization

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Operational Reports Quality MeasureReportCDS Perioperative CareTimely Administration of Prophylactic Parenteral Antibiotics Email Semi- automated Perioperative Beta-Blocker For Patients Receiving Therapy Prior to Arrival Missing Beta Blocker AssessmentEmail Semi- automated Prevention of Central Line- associated Bloodstream Infections Central Venous Catheter Sterile Insertion Protocol Hard-stop Perioperative Temperature Management Temperature 30 Min Before End of Surgery Hard-stop

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Patient

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Operational Reports Quality MeasureReportCDS Perioperative CareTimely Administration of Prophylactic Parenteral Antibiotics Email Semi- automated Perioperative Beta-Blocker For Patients Receiving Therapy Prior to Arrival Missing Beta Blocker AssessmentEmail Semi- automated Prevention of Catheter-Related Bloodstream Infections Central Venous Catheter Insertion Protocol Hard-stop Perioperative Temperature Management Temperature 30 Min Before End of Surgery Hard-stop

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Patient

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Structured Data Capture

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Q4 2012 SCIP

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Q1 2013 SCIP

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Q2 2013 SCIP

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Q3 2013 SCIP

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Patient Experience

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SSI Rate (%) - 2013 Q1Q2Q3Q4TOTAL Surgical Site Infection Rate 3/410 0.7 6/392 1.5 7/387 1.8 7/401 1.4 23/1189 1.93

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JanFebMarAprMayJunJulAugSepOctNovDec YTD Total 0/2342 0 0/2175 0 0/2404 0 0/2404 0 1/2440 0.4 2/2311 0.9 4/249 4 1.6 1/2414 0.4 0/2431 0 2/2601 0.8 1/2277 0.4 3/2511 1.2 14/2880 4 0.5 CLABSI Rate (%) - 2013

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