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Successes from Advanced Clinical Decisions Support: What is already being achieved in high-performance HIT settings

Successes from Advanced Clinical Decisions Support: What is already being achieved in high-performance HIT settings. Steven H. Shaha, PhD, DBA UHIMSS Spring Meeting May, 2012. Disclosures and Affiliations. Steven H. Shaha, PhD, DBA. Professor, Center for Public Policy & Administration

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Successes from Advanced Clinical Decisions Support: What is already being achieved in high-performance HIT settings

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  1. Successes from Advanced Clinical Decisions Support:What is already being achieved in high-performance HIT settings Steven H. Shaha, PhD, DBA UHIMSS Spring Meeting May, 2012

  2. Disclosures and Affiliations Steven H. Shaha, PhD, DBA Professor, Center for Public Policy & Administration Principal Outcomes Consultant, Quality and Outcomes Team, Allscripts National and International Outcomes Research and Continuous Improvement 100+ peer-reviewed publications in 30+ Journals, 200+ peer-reviewed presentations, 2 books Professor or Lecturer or at 16 professional academies and graduate schools, including Harvard, MIT, UMass, Columbia, Cornell, UCLA, Zayed Univ (UAE) Advisory and consulting to over 50 non-healthcare organizations, including e.g. Ritz-Carlton, Disney, IBM, AT&T, Coca-Cola, Time Warner, Kodak, Johnson & Johnson, Marriott, New Line Cinema Advisory and consulting work for 10 governments: Australia, Europe (e.g. France, Spain, United Kingdom, Switzerland, Netherlands) and Asia (e.g. Singapore and Malaysia) Co-author of the Malcolm Baldrige National Quality Award for Healthcare, and advisor to three governments on defining and establishing national quality awards Employment includes: UCLA Medical Center, RAND Corporation, Intermountain Health Care, Gartner Group, Eclipsys Corporation, Inst Integrated Outcomes, Eclipsys, Allscripts Academic Appointments: Ctr for Public Policy & Administration – Univ of Utah, Zayed Univ (UAE); Lecturer: Harvard, Columbia, Cornell Weill, Southern Illinois Univ Education: PhD in Research Methods & Applied Statistics DBA in Business Administration (PhD) MA, MEd, BS

  3. Non-Healthcare Consulting and Advisory

  4. Steven H. Shaha, PhD, DBA

  5. The process didn’t change. It’s the Outcomes that matter.

  6. Improved Stroke Outcomes 1 Impact of Stroke Outcomes Toolkit: Comparative Quality with versus without Advanced CDS vs. CPOE with Alerts: Comparative Analysis Stroke Care Best Practices

  7. Improved Stroke Outcomes CPOE with Alerts Advanced CDS vs. CPOE with Alerts: Comparative Analysis Stroke Care Best Practices

  8. Improved Stroke Outcomes Advanced CDS CPOE with Alerts Advanced CDS vs. CPOE with Alerts: Comparative Analysis With CDS-rich Order Set 40.5% Greater Clinical Excellence CPOE w/Alerts Alone Stroke Care Best Practices

  9. Improved Stroke Outcomes Advanced CDS Readmissions in 31 Days CPOE with Alerts Discharge Patterns 9.4% more (p<.001) 35.7 % fewer (p<.001) 16.0% fewer (p<.001) 21.4% fewer (p<.001) Length of Stay Financial Impact 7.5% lower 0.35 fewer days avg. (p<.001) 11.4% lower(p<.05) 12.7% lower (p<.05) Estimated Impact: $230k-565k Annualized

  10. Improved Stroke Outcomes Continue after Discharged Advanced CDS CPOE with Alerts Discharge Patterns 9.4% more (p<.001) 16.0% fewer (p<.001) 21.4% fewer (p<.001)

  11. Advanced CDS Better Outcomes after Discharge Admissions to Nursing Homes and Residential Age Care Facilities CPOE with Alerts Readmissions in 31 Days Length of Stay Significantly shorter (p<.001) Significantly fewer (p<.001) • Additional Efficiencies • Capacity for 130 additional admissions • with NO staffing increases

  12. The Evolution of Health Care Information Retrospective Manual Reporting Retrospective Automated Reporting Concurrent Synchronous Care Prospective Predictive Care Not Simply Computerized Paper The Power to Change Outcomes The best in advanced Clinical Decision Support From Physicians Clinical Intelligence and Automated Assessments Extracted from multi-disciplinary documentation From Caregivers From Systems & Sources Improved Outcomes Individually and collectively Notify Continuous Clinical Decision Support Engine For Physicians For Caregivers For Physicians “Our” Recommended Treatments e.g. Order sets, pathways, algorithms, evidence-based medicine, inter-disciplinary documentation templates For Others For Caregivers For Others Providing the best care and achieving optimal quality and performance

  13. Caution: All EHRs are NOT created equal … From a 2010 Meta-Analysis of Electronic Health Records: • “… to drive substantial gainsin quality and efficiency, simply adopting electronic healthrecords is likely to be insufficient.” • “… simple alerting is ineffective … “ • “… policies areneeded that encourage the use of electronic health records inways that will lead to improvements in care.” Electronic Health Records’ Limited Successes Suggest More Targeted Uses Health Affairs, 29, no. 4 (2010): 639-646

  14. “Clinical Decision Support” – Many Meanings Advanced CDS: Intelligent Where HIT Lives Beginning CDS

  15. 2 Compliance with Evidence-Based VTE Prophylaxis 97.4% Reduced Alerts (p<.001) 145.3%Increased Assessments (p<.001) 139.6%Improved Assessment Rate (p<.001) Improved Prophylaxis With CPOE and traditional CDS With Outcomes Toolkit incl. Advanced CDS Order Sets

  16. Statistically Significant Impact on VTE Rate DVT/VTE Rate per Bed Day Intelligent Order Set 95% Confidence Interval 62.6% decrease in mean DVT/VTE rate (p<.001). From mean rate of .431 to .161. Mean Rate 95% Confidence Interval That’s approximately 167 fewer patients suffering from VTEs each year * 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 Week • $736,578*reduced variable costs (p<.001) • 0.8 Days reduced mean LOS (p<.001) * Annualized for Hips at risk only, quantified at mean organization-computed variable costs of $2,439/case. Control limits reflect Poisson distribution.

  17. Impact on One DRG Alone … • For top 50 surgical DRGs collectively: • 16% decrease in Cost/Case ($1,315/case) • 2% decrease in Length of Stay • $3.1 Millionsaved in Variable Cost annually • 16% decrease in Cost/Case ($1,315/case) • 2% decrease in Length of Stay • $3.1 Millionsaved in Variable Cost annually • AND • 25.6% decrease in Readmissions • 14.2%decrease in Mortality Rate Each bubble represents a major surgeon, and bubble size reflects case volume. Post LOS Pre LOS $11,000 $10,500 $10,000 $ 9,500 $ 9,000 $ 8,500 $ 8,000 $ 7,500 $ 7,000 Pre Cost/Case Avg Variable Cost / Case Post Cost/Case 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Length of Stay 85%-98% adopters 28% adopter

  18. Safer Physician Practices 3 31.2% fewer alerts for Users of Intelligent Order Sets w/CDS (p<.0001) Intelligent Order Sets vs. CPOE Alone Intelligent Order Sets Intelligent Order Sets CPOE Alone CPOE Alone Peds

  19. Safer Physician Practices 122.8% more responsive to the fewer alerts they received for Users of Intelligent Order Sets w/CDS (p<.0001) Intelligent Order Sets vs. CPOE Alone Intelligent Order Sets CPOE Alone Peds

  20. Safer Physician Practices 59.2% fewer medication-related errors reached patients when managed on Intelligent Order Sets w/CDS (p<.0001) Intelligent Order Sets vs. CPOE Alone Intelligent Order Sets CPOE Alone Peds

  21. Safer Physician Practices Housewide: • 59.2% reduction in PICU, reaching 0.37 per 1,000 orders (p<.0001) • 76.9% reduction in NICU, reaching 0.28 per 1,000 orders (p<.0001) • 86.2% reduction in Medical/Surgical, reaching .25 per 1,000 orders (p<.0001) • 71.8% reduction house-wide (shown in graphic below), reaching .25 per 1,000 orders (p<.0001) Peds

  22. 4 Reduction in Alert rates Percent of Order Firing Alerts 45.5% fewer alerts(p<.01)

  23. Medication Incidents 44.8% Reduction in Mean Incidents reduced by 55.3 yr 1 to yr 4 (p<.001) 66.7% Reduction from highest to lowest (p<.001) Annualized Savings estimated between $ 830 kand $1.64 m (CAN) Subramanian S, et.al (2012), Immediate financial impact of computerized clinical decision support for long-term care residents with renal insufficiency: a case study. J Am Med Inform Assoc 2012;19:439-442.

  24. 5 Hospital Standardized Mortality Rate 23.3% Reduced Mortality Rate for 1st facility Facility 1 Facility 2 28.0% Reduced Mortality Rate for 2nd facility Pre CPOE & Alerts implementation

  25. 6 Safer Medication Administration Impact on Patient Care 95% Confidence Intervals 71.7% Decrease in mean Med Errors versus baseline (p<.001) 95% Confidence Intervals Zero Med Errors in 3 of past 7 months Post implementation (p<.001) PRE POST

  26. Reduced Non-ICU Codes with CDS-triggered Sepsis Early Warning 7 As Rescue Calls increased … Non-ICU Codes per 1,000 DCs Rescue Calls per 1,000 DCs … Non-ICU Codes significantly decreased(r=.730, R2=.533, p<.001) A code is defined as any in-hospital event where compression, defibrillation or emergency assisted ventilation (invasive or noninvasive) is performed. Events that begin as acute respiratory compromise leading to cardiopulmonary arrest are counted as one event. Codes on pediatric units or for patient <18 yrs are not included.

  27. 8 Improvements in Blood Sugar Management Biphasic insulins. Autocomputing intelligent order set, combining rapid-acting with an intermediate-acting insulin 16.6% Mean reduction in day 1 post-op in Blood Glucose (p<.0001) 25.8% reduction from highest to lowest in day 1 post-op Blood Glucose (p<.0001) 14.4% Mean reduction in day 2 post-op in Blood Glucose (p<.0001) 24.5% reduction from highest to lowest in day 2 post-op in Blood Glucose (p<.0001) Pre Post Punch Line: Surgeons using smart order sets WITHOUT Endocrine consults

  28. Mediastinitis Outcomes 69.7% Reduction (p<.001) 6 Consecutive months at zero infections (p<.001)* Blood glucose management below 200 increased from 47% to 96%(p<.001) Savings of between $308,490 1(AUD) and $80,500 2(AUD) annually (p<.001) Length of Stay reduced by 1.0 days (p<.001) Seven fewer infections annually (p<.001) Month Implementation of Portland Protocol for blood glucose management * 95% confidence interval for most recent data estimated from twelve previous inclusive months

  29. 9 Improved Blood Utilization …Mean Transfusions per Complex Surgery continue to fall despite increased volume. Affecting an Estimated 1,680 surgeries per yearfor annualized average monthly volumes. From pre-Mean to post-Mean: Estimated $5.23M annualized savings * From highest to most recent: Estimated $14.08M annualized savings * • 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 * Computed at $1,251 per transfusion: U.S. Dept of Labor, Bureau of Labor Statistics. Consumer Price Index - All Urban Consumers. Available at http://data.bls.gov/cgi-bin/surveymost?cu. Accessed May 17, 2006.

  30. Safer Physician Practices 10 Better for Less Organization-wide Cost per Case 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Month Pre-implementation Post-implementation

  31. Lessons Learned • CPOE w/Alerts is suboptimal “CDS” • EMR/EHR/EPRs can make a significant difference • Practice patterns are changeable • Data drive improvement • Physicians react favorably to “informative data” versus punitive • Balanced outcomes define best practice • Avoid myopia • It’s not cost versus quality • Standardization does not have to mean “blind adoption”

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