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Designing Quality into an EMR/CPOE Implementation

Kristine Martin Anderson

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Healthcare Industry MovementsImpacting Hospitals

Pay for Performance – brings employers, purchasers and providers together to discuss performance metrics

External Reporting for Patient Safety and Quality - quality is no longer a passive requirement

Focus on Health IT – specifically in EHR/CPOE with quality as the expected ROI metric

Interoperability and Access – data portability initiatives to support both access and informed clinical decisions

Enterprise Business Intelligence – clinical BI is the hardest and the last to be tackled, but critical to respond to the new business environment

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Rationale for Public Reporting

• Consumers Right to Know - health care quality and price should be as transparent as other consumer services

• Incentive for Improvement – stimulate competitive drive

• Drive Consumers to high value providers

• First step in Payment Reform, which is a reaction to unsustainable growth in expenditures

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Hospital Quality Reporting Progress To Date

• Transparency increased

• Measure development accelerated

• Efforts for standardization begun

• Key constituents engaged in productive dialogue about improvement (NQF)

• Focus on IT emerged, with urgency for value improvements

• Documentation improved

• Early evidence suggests that care is improving, but studies are uncontrolled

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Public Reporting Increases Activity

Source: Judy Hibbard, University of Oregon.

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Public Reporting is the precursor to Pay For Performance

P4P?Managed

Care

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Medicare Spending

• In 2004, Medicare spending was 2.6% of GDP. Personal health expenditures were 13% of GDP during the same period.

• Medicare Trustees expect spending to increase at an average annual rate of 7.5% per year from 2004-2013, except 2006 when Part D launches.

• With new prescription drug benefits, Medicare spending is projected to grow to 3.4% of GDP in 2006 and just under 4% of GDP by 2013.

• Hospital Insurance benefits are expected to grow by 6% per year from 2006 forward.

Source: Congressional Budget Office, August 2005

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Designing for Action = Standardization

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Organizations Publicly Reporting Hospital Data

• Centers for Medicare and Medicaid Services

• JCAHO

• State Agencies

• State Hospital Associations

• Hospitals and Health Systems

• Private Organizations

– The LeapFrog Group

– HealthGrades.com

• Consumer Organizations (members) (http://www.checkbook.org/hospital/default.cfm)

• Insurers/Business Coalitions (members)

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Role of the National Quality Forum

• CMS and JCAHO have made strong commitments to use the NQF process to endorse measures for public reporting

• 285 Members

– Health Plans

– Professional Societies

– Hospitals

– Researchers

– Government Agencies

– Hospital Associations

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Measures for Public Reporting

• CARDIOPULMONARY (28)– AMI (12)– CHF (4)– Pneumonia (12)

• SURGICAL CARE (109)– Cardiac surgery (24)– Cardiac interventional (6)– Vascular surgery (17)– Neuro/spine surgery (9)– Orthopedic Surgery (23)– Colon Surgery (11)– Other Surgery (16)– Hysterectomy (3)

• OTHER NON-SURGICAL (2)– Acute Stroke– GI Hemorrhage

• HCAHPS (Patient satisfaction) (7)

• PATIENT SAFETY (57)– Care Management Events (7)– Criminal Events (4)– Environmental Events (5)– General Patient Safety (7)– National Patient Safety Goals (8)– Patient Protection Events (3)– Patient Safety Structural

Measures (6)– Patient Safety Surgical Events

(14)– Product or Device Events (3)

• PREGNANCY AND PEDIATRICS (27)– Pediatric Asthma (8)– Childbirth and neonatal

conditions (17)– Other surgery (2)

• NURSING (15)– Nursing sensitive care measures

(15)

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Most Common Measure Sets Being Used in Public Reporting and Pay for Performance

• Hospital Quality Alliance– AMI– Heart Failure– Pneumonia– Surgical Infection Prevention

• JCAHO– Pregnancy– Patient Safety Goals

• AHRQ– Patient Safety Indicators

• LeapFrog (verify)– CABG mortality– Procedure Volumes– NQF Safe Practices

• Patient Satisfaction

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Should P4P Measures be a subset of Public Reporting Measures?

• Should the bar be set higher for P4P measures than for Public Reporting measures?– Tighter measure definition?

– More field testing?

– Verification that the measure incents the intended behavior modification?

– Audits?

• NQF does not currently distinguish between measures appropriate for public reporting and measures appropriate for pay for performance. The debate is ongoing… are you at the table?

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Core Included

16%

Core Excluded

21%NonCore

63%

How much of the clinical care of the hospital is being measured?

AMI

Heart Failure

Pneumonia

Pregnancy SIP

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Are the patients being measured representative of the general population?

Mortality Rates - Core vs. Full

Sample

0% 2% 4% 6% 8%

AMI Mortality

HF Mortality

Pneumonia

Mortality

Core

Sample

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Do the signals we get in the measured conditions apply when assessing the overall quality of the hospital?

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Outlook for the Future – Number of Metrics are

going up……and up…

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Industry Plans for the Future -Hospital Quality

• Centers for Medicare and Medicaid Services– Committed to Hospital Quality Alliance

– Committed to NQF Approval Process

• Hospital Quality Alliance – expected direction– 30-Day Mortality for AMI and HF measures approved by NQF

• Initial results to be run for HQA

• Public reporting in 2006 or 2007

– Surgical Care Improvement Project• Process and Outcome Measures

• Rollout in 2006

• Subset of measures likely to be chosen for public reporting in 2007

• NQF Approval Not Yet Sought

– Children’s Asthma (Candidate Core Measure Set – JCAHO)• Process and Outcome Measures

• Expected to seek NQF approval

• JCAHO– Expected to remain aligned with HQA

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Industry Plans for the Future -Efficiency

Debate over definition of efficiency – least cost for specified level of quality

• All parties are seeking credible measures– Primary focus on physician payment reform

• Primary care

• Specialty

– Use of NCQA HEDIS measures likely

– Expect alignment of incentives for hospitals and physicians

• No clear time horizon for adoption of hospital efficiency measures but research is ramping up– Avoidable readmissions

– Avoidable complications of care

BOTTOM LINE: payors will not be paying for avoidable

errors in the near future

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Hospitals are collecting most of this data manually

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Care Science

Subscr ibers

NJ Univ Hospital Midwestern Hospital

System

Oregon Hospital System

INTERNAL HOSPITAL COSTS INCURRED TO SUBMIT and INITIALLY ANALYZE CORE

MEASURES DATA- 3 MEASURE SETS

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….. We can’t succeed in Pay for Performance without technology…

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Business Issues with Impact

10.70%Managed Care Fee Reductions

12.60%National Health Information Network (NHIN)

12.60%Increased Competition

13.00%Evidence Based Medicine

16.60%Government Regulation

18.20%Nursing Shortage

20.20%Obtaining Capital

20.60%Providing IT in our Ambulatory Environment

21.30%Facility Upgrades/Replacement

31.20%Adoption of New Technology

31.20%HIPAA Compliance

34.80%Medicare Cutbacks

36.40%Clinical Transformation (Adopting Clinical Best Practices)

39.50%Cost Pressures

40.30%Improving Operational Efficiency

41.90%Improving Quality of Care

43.50%Patient (Customer) Satisfaction

57.30%Increasing Patient Safety/Reducing Medical Errors

Please identify the business issues you believe will have the most impact on health

care in the next two years?

HIMSS Survey, 2005

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IT Priorities Today

Please indicate your organizations’ top IT priorities today.

18.30%Implementing Ambulatory Care Systems (Clinical/Financial/Administrative)

22.10%Integrate Systems in Multi-Vendor Environment

22.10%Improvement of IS Departmental Services, Cost Effectiveness and Efficiencies

23.90%Implement Enterprise-Wide Applications (e.g. MPI, ERP, Clinical Information Sharing)

23.90%Design and Implement an IT Strategic Plan

24.90%Upgrade Network Infrastructure (LANs, WANs)

25.40%Train Personnel to use Existing and Newly Installed Systems

29.10%Implement an Electronic Medical Record (EMR)

31.50%Connecting IT at Hospital and Remote Environments (E.g. Physician’s Offices)

31.50%Process/Workflow Redesign

35.20%Implement Wireless Systems (e.g. wireless LANs)

37.60%Replace/Upgrade Inpatient Clinical Information Systems

44.10%Upgrade Security on IT Systems to Meet HIPAA Requirements

53.10%Implement Technology to Reduce Medical Errors/Promote Patient Safety

HIMSS CIO Survey, 2005

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IT Priorities Next Two Years

Please indicate your organizations’ top IT priorities in the next two years.

17.20%Integrate Systems in Multi-Vendor Environment

18.10%Implement Wireless Systems (e.g. wireless LANs)

19.10%Replace/Upgrade Inpatient Financial/Administrative Systems

19.60%Improvement of IS Departmental Services, Cost Effectiveness and Efficiencies

21.10%Connecting IT at Hospital and Remote Environments (E.g. Physician’s Offices)

25.50%Implement Enterprise-Wide Applications (e.g. MPI, ERP, Clinical Information Sharing)

27.50%Implement Speech Recognition Systems

29.40%Implementing Ambulatory Care Systems (Clinical/Financial/Administrative)

32.40%Process/Workflow Redesign

32.80%Replace/Upgrade Inpatient Clinical Information Systems

41.90%Implement Technology to Reduce Medical Errors/Promote Patient Safety

54.40%Implement an Electronic Medical Record (EMR)

HIMSS Survey, 2005

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IT Applications Importance

Please identify the health care applications areas that you consider most important to your organization over the next two years.

11.50%Enterprise Resource Planning Systems (ERP)

15.80%Supply Chain Management

16.70%Ambulatory Systems

17.20%Web-based Applications

17.20%Financial/Administrative Information Systems

17.70%Enterprise Master Patient Index

18.70%Business Intelligence/Decision Support Systems (e.g. data warehouse)

37.30%Point-of-care Clinical Decision Support

41.60%Clinical Data Repository

42.10%Digital Picture Archiving and Communications System (PACS)

43.50%Enterprise-Wide Clinical Information Sharing

50.20%Computer-based Practitioner Order Entry (CPOE)

52.20%Clinical Information Systems

55.00%Bar Coded Medication Management

61.70%Electronic Medical Record (EMR)

HIMSS CIO Survey, 2005

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Opportunities for ROI with EMR/CPR/CPOE Installations

• Accepted quality benefits of EMRs

– Fewer patient safety events

– Better compliance with evidence-based medicine

• Advanced opportunities with EMRs

– Increase access to clinical data for quality reporting

– Reduce/eliminate chart review for external reporting

– Enable concurrent care management

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Gartner Five Generations of CPR Systems

Figure 1. The Five Generations of CPR Systems

Source: Handler, Thomas J, MD, Enterprise CPR Systems are Nearing the Generation 3 Milestone, April 11, 2005.

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Hype Cycle for Healthcare Provider Applications Systems,

2005

Source: Runyon, Barry, et al, Hype Cycle for Healthcare Provider Applications and Systems, 2005, July 13, 2005.

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What are you doing to ensure that your EMR will support your quality reportingneeds?

…..... All of our clinical teams are working on creating order sets, nursing documentation and physician adoption strategies.. Won’t that do it??

Are hospitals expecting to realize ROI that they are not enabling?

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Do you want to feed your quality systems with clinical data?

Do you want to eliminate chart review for core measures?

Who on your implementation team knows the specific data content requirements for core and other metric algorithms?

Do you know what data can be extracted from your EMR?

Key Questions for Hospitals Implementing EMRs

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Best Practices: One Health System’s Approach to Designing for Quality

The project PLANS for the following changes, which are linked to the system’s commitment to quality, enabled by IT:

1. Populate CareScience Quality Manager data mart from clinical systems

2. Calculate clinical performance metrics WITHOUT chart review

3. Transmit clinical performance metrics to the Mercy enterprise Business Intelligence application (for dashboard reporting)

4. Manage quality in real time

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AMI-6 Beta Blocker on Arrival

Eighteen (18) data elements required• Admission date• Admission source• Arrival date• Arrival time• Birthdate• Discharge date• Discharge status• ICD-9 Principal Diagnosis Code• Transfer from another Emergency Department• Beta blocker allergy• Pacemaker• Bradycardia• Heart failure on arrival or within 24 hours after arrival• Shock on arrival or within 24 hours after arrival• Other reasons documented by physician or other for not giving beta

blocker• Beta blocker name• Beta blocker time• Beta blocker date

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For each element, gather …

• Current data location (hard copy or electronic)• Documentation source• Data format• Available electronically now?• If so, where?• Electronic strategy• Alternate data location• Final data location• Data decision hierarchy needed?• Element used in other measures?• Frequency of measurement• Transformations/calculations• Reporting issues• Comments

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Gap Analysis – AMI & HF

• Only 3 of the first 12 measures electronically available after planned implementation

The most significantgap is due to lack of

physician documentation

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Partial Automation Strategies to Reduce Chart Review

o Example 1: Comfort Measures Only

Electronic assistance:ICD-9 code for palliative care = Y

o Example 2: Moderate or severe aortic stenosis

Electronic assistance:ICD-9 secondary diagnosis codes for aortic

stenosis = Y

Reduces some, but not all chart review

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Case Study 2Hospital HIT Goals

• An integrated medical record for inpatient, ED and Outpatient

• An integrated inpatient order entry and pharmacy system

• Platform for departmental systems

• High availability

• Be the leader of a regional health record

Focus: patient safety

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Experience implementing CPOE

• Added benefits:– Physician adoption

– Eliminated legibility issues

– Better charge capture

– Improved usage of order sets and protocols

• New Risks– Orders on the wrong

patient

– Downtime and recovery challenges

– Generic versus brand-name

– Information overload

– Poor education and usage of computers

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Lessons learned from experience with

100% physician usage

• Training and Education are key to success

• Implementation is an ongoing process

• Interfacing with pharmacy system is not acceptable from a patient safety perspective. The interface engine is translating orders into dispensing systems.

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Lessons Learned: Using CPOE data in

Quality Analysis

• Data analysis: Orders can be helpful in understanding quality data.

• Example: DNR order and mortality– Used DNR order and timing of it to be understand

mortality. Included DNR orders to the CS database

– Areas of weakness:

» Unable to benchmark against other institutions

» Uncovered issues related to the implementation

• Lesson learned: Implementation must include PI data requirements, not only the type of data but also the content and structure.

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Lessons Learned: Using CPOE data in

Quality Analysis

• Implementing quality and safety initiatives: almost always require operational changes often including medical staff and nursing practices.– Example: compliance with Pneumovax

• Determined that using a common admit order set is the best way to resolve this issue

• Obtained support from Med Exec to mandate common order set for all adult inpatient admissions

• Admit order set includes an order for Nursing to assess and dispense if appropriate

• Obtained support from Nursing to adopt “assess and dispense orders”

– Challenge: determine whether the patient was admitted under order set versus compilation of orders

– Lesson learned: some indicators will have to be included as data elements during implementation to identify situations such as using order sets and bundles (IHI)