EPR/EMR Impacts on Bedside Caregivers: Verification of Favourable Clinical, Cost, Satisfaction Outcomes
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1 EPR/EMR Impacts on Bedside Caregivers: Verification of Favourable Clinical, Cost, Satisfaction Outcomes Steven H. Shaha, PhD, DBA Professor, Center for Policy & Public Administration Principal Outcomes Consultant, Allscripts Diane Gilbert-Bradley, MD Chief Quality & Outcomes Officer, Allscripts 1
2 Disclosures & Bio Prof. Steven H. Shaha, PhD, DBA Professor, Center for Policy & Public Administration Principal Outcomes Consultant, Allscripts Former Dir. KLAS Research/Performance Insights 130+ peer-reviewed publications, 380+ peer-reviewed presentations, 3 books Advisory and consulting work for 11 govt.s in Asia, Australia, Europe and No. America Advisory and consulting to over 50 non-healthcare organisations, among them: Disney, Ritz-Carlton, Coca-Cola, New Line Cinema, IBM, AT&T, Time Warner Employment history includes: Coca-Cola, RAND Corporation, UCLA Medical Center, Intermountain HC, Gartner Education: PhD, Research Methods & Applied Statistics DBA, Business Administration (PhD) MA, MEd, BS
3 Prof. Steven H. Shaha, PhD, DBA
4 Sample of Peer-reviewed Journals Advance for Health Information Executives Advances in Patient Safety Agency for Healthcare Res & Qual (AHRQ Journal) American Journal of Ob & Gynecology American Journal of Sports Medicine Applied Clinical Informatics Archives of Otolaryngology, Head & Neck Surg Breast Cancer Research and Treatment British Medical Journal of Quality & Safety Epidemiology and Infection Health Management Technology Healthcare Financial Management Healthcare Technology Management Intl. Journal of Medical Informatics Intl. Journal of Pediatric Otorhinolaryngology Intl. Journal for Quality in Health Care Journal of Arthroscopic and Related Surgery Journal of Clinical Ultrasound Journal of Emergency Nursing Journal of Mat, Fetal & Neonatology Med Journal of Neurosurgery Journal of Obstetrics and Gynecology Journal of Orthopedic Trauma Journal of Pediatric Emergency Care Journal of Perinatal Medicine Journal of Perinatology Journal of Shoulder and Elbow Surgery Journal of the Am Acad of Ped Ophth & Strab Journal of Ultrasound in Medicine Journal of Ultrasound in Ob & Gynecology Laryngoscope Nurse Executive Watch Nurse Leader Nursing Economics Pediatric Critical Care Medicine Pediatric Emergency Care Pediatrics RN Magazine Spine Intl. Journal of Pediatric Otorhinolaryngology The Journal of Bone & Joint Surgery Ultrasound in Obstetrics & Gynecology
5 The Dynamics in Healthcare Pressure on every aspect of performance Do more with less. Safety, quality and value-based delivery. Variable demand with fixed capacity & poor patient flow.
6 DOES AN EPR/EMR BENEFIT NURSING AND BEDSIDE CARE?
7 Changes in Nursing Care 37.9% Direct care Authier D, Bradshaw P, Hickman L, Shaha SH (2012). Mythbusters: Three Studies Reveal Nurses True Attitudes About Transitioning to EHR Systems. Healthcare Technology Management, October
8 Changes in Nursing Care e-documentation 46.3% Direct care, 22.0% increase (p<.001) PRE POST PRE POST Authier D, Bradshaw P, Hickman L, Shaha SH (2012). Mythbusters: Three Studies Reveal Nurses True Attitudes About Transitioning to EHR Systems. Healthcare Technology Management, October
9 Changes in Nursing Care e-documentation Bar-code Med Admin 49.2% Direct care, PRE POST 29.7% increase (p<.001) PRE POST 16.7% decrease in indirect time (p<.01) Authier D, Bradshaw P, Hickman L, Shaha SH (2012). Mythbusters: Three Studies Reveal Nurses True Attitudes About Transitioning to EHR Systems. Healthcare Technology Management, October
10 Changes in Nursing Care Direct care is approaching 50% of Nursing time, a 29.7% increase in patientdirect time (p<.01) Indirect time fell by 16.7% (p<.01) * Baseline Year 1 Year 2 Meaning 1¼ hours More direct patient care per shift Baseline Year 1 Year 2 and 1¼ hours LESS of indirect time Authier D, Bradshaw P, Hickman L, Shaha SH (2012). Mythbusters: Three Studies Reveal Nurses True Attitudes About Transitioning to EHR Systems. Healthcare Technology Management, October * Reflects 12-hour shifts
11 But does that make for better patient care? 11
12 Safer Medication Administration 95% Confidence Intervals Impact on Medication Errors 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 Authier D, Bradshaw P, Hickman L, Shaha SH (2012). Mythbusters: Three Studies Reveal Nurses True Attitudes About Transitioning to EHR Systems. Healthcare Technology Management, October 2012.
13 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 573 k and 1.13 m 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:
14 Underlying Benefits Automated Risk Assessments and Scoring: Falls Pressure Ulcers DVT Deterioration 14
15 Significant Reduction in Fall Rates Achieved through Advanced CDS, smart order sets and clinical documentation mo baseline pre-implementation 83.6% reduction in Falls with Injuries(p<.001) Month That s approximately 140 fewer patients suffering falls with injuries each year. And $1.5 M estimated 3-year financial impact At an estimated at $11,042 cost per fall. 1
16 Significant Reduction in Pressure Ulcer Rate Achieved through Advanced CDS, smart order sets and clinical documentation 7.62 / 1,000 pd baseline 69.0% reduction in Stage 3 & 4 Acquired Pressure Ulcers (p<.001) 2.39 / 1,000 pd achieved Quarters 13 quarters at Zero Approximately 167 fewer patients acquiring stage 3 or 4 pressure ulcers each year. $2.2 M $14.8 M estimated annual impact 1 (1) DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services, 42 CFR Parts 411, 412, 413, and 489. Medicare Program; Changes Hospital Inpatient Prospective Payment Systems and Fiscal Year 2008 Rates. Page (3) 2004 DRG manual. Average of MDC 009 (pressure ulcers) and DRG 271 (skin ulcers) charges ($12,922 and $16,724 respectively) divided by charge to cost ratio of 2.44.
17 Changes in Nursing Care 70.0% All Units (excl PFD) Collective Nursing Units * * 60.0% 50.0% 40.0% 30.0% 20.0% 2007 Pre 2008 Post 10.0% 0.0% Direct Care Indirect Care Documentation Coordination ** * Excludes hours for personal, fatigue and delay (incl. breaks). ** Indirect is the sum or documentation and coordination.
18 Changes in Nursing Care 70.0% 60.0% 50.0% 22.2% Increase (p<.001) All Units (excl PFD) Collective Nursing Units * * 13.5% Decrease (p<.001) 11.7% Decrease (p<.01) 16.8% Decrease (p<.01) 40.0% 30.0% 20.0% 2007 Pre 2008 Post 10.0% 0.0% Pre, time spent on Direct Care was 4.4% less than on documentation alone. Direct Care Indirect Care Documentation Coordination ** Post, time spent on Direct Care was 32.2% more than on documentation. * Excludes hours for personal, fatigue and delay (incl. breaks). ** Indirect is the sum or documentation and coordination.
19 Decreased Time and Increased Efficiency with Computerized PER Implementation of the computerized Personal Exchange Report (PER) reduced mean time required from 120 minutes to 10 minutes for a Med/Surg unit (p<.0001). Mean Minutes per Nurse Reduced Time Requried for Exchange Report with Computerized PER Before After 91.7 % Decreased Time Required for Nurse Report (p<.0001) Clancy TR, Shaha SH, et. al. Improving the Effectiveness and Efficiency of Professional Exchange Report (PER) Through Computational Modeling and Simulation. American Medical Informatics Association (AMIA), Annual National Meeting. 19
20 How Bedside Caregivers perceive EPR/EMR impact
21 Current System Facilitates Workflow: Percent Favorable Current System Supports Efficient Transfer Between Providers: Percent Favorable 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% 45.0% 40.0% Pre 6 month 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% 45.0% 40.0% pre 6 month I Would Recommend the Current System: Percent Favorable Current System Provides Information to Take Care of My Patients: Percent Favorable 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% 45.0% 40.0% 35.0% 30.0% pre 6 month 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% pre 6 month
22 Current System Adequately Informs Me of Potential Errors for ORDERS: Percent Favorable Current System Adequately Informs Me of Potential Errors for Drug Interactions: Percent Favorable 65.0% 60.0% 55.0% 50.0% 45.0% 40.0% 35.0% 30.0% pre 6 month 70.0% 65.0% 60.0% 55.0% 50.0% 45.0% 40.0% 35.0% 30.0% pre 6 month Current System Adequately Informs Me of Potential Errors for MEDs: Percent Favorable Current System Adequately Informs Me of Potential Errors for Pat ID: Percent Favorable 70.0% 65.0% 60.0% 55.0% 50.0% 45.0% 40.0% 35.0% 30.0% pre 6 month 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% 45.0% pre 6 month
23 I Can Easily Act on Orders: Percent Favorable I Can Easily Act on Lab Data: Percent Favorable 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% pre 6 month 95.0% 90.0% 85.0% 80.0% 75.0% 70.0% 65.0% 60.0% 55.0% 50.0% pre 6 month
24 Clinicians Adopt due to Inherent Value 21 Calls or More: Receive or Make Daily: Percent Favorable Avg Min per Day Preparing My Patient List for MDs 21.0% 19.0% 17.0% 15.0% 13.0% 11.0% 9.0% 7.0% 5.0% pre 6 month pre 6 month
25 Why is satisfaction UP?
26 Name Sepsis: the disease An example of infections and avoidables Statistics: The leading cause of death in hospitals globally 1.7 Million cases a year Prolonged LOS in ICU w/ CCs, complex therapies, high costs est. 18Bn annually Solution: SQL query 12-month retrospective chart review MEWS: Perpetual, house-wide, imbedded monitoring and surveillance Systolic BP (mmhg) < >= 200 Heart rate (bpm) < >= 130 Respiratory rate (bpm) < >= 30 Temperature ( C) < >= 38.5 Age (y) >= 85 BMI (kg/m²) < > Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome and associated costs of care. Critical Care Medicine Jul;29(7): Wood KA, Angus DC. Pharmacoeconomic implications of new therapies in sepsis. PharmacoEconomics. 2004;22(14): Yende S, Angus DC. Long-term outcomes from sepsis. Current Infectious Disease Reports Sep;9(5): Kho MD, Abel. "Utility of commonly captured data from an EHR to identify hospitalized patients at risk for clinical deterioration.." AMIA 2007 Symposium Proceedings. (2007): Print. Shaha SH ( 2014) The EMR as an Effective Tool for Boosting Medication Adherence. Invited Presentation: 2 nd Annual World Congress Summit to Improve Adherence and Patient Engagement, March 10-11, 2014, Philadelphia. Shaha SH, Hutchinson M (2014). EPR Impacts: The Real ROI. HC 2014: The National Health IT Conf & Exh, Manchester, England, March 20, Shaha SH, et.al. (2014). CPOE s Predictive Impact on LOS: Three Case Studies Illustrate the Impact of High Capability EMRs. HIC 2014 Health Informatics Society of Australia, Melbourne. 26
27 The Process: Identification and Remediation Document Vitals Device integration Key CCs Query Key Indicators (Age, BMI) Calculate Score via Matrix Alert Does score exceed threshold? Send Alert Summary Impacts: Measure Pre Post Down Down to to min (11-De min (9-11- Timeliness of Recognition minutes 93.7 minutes Cardiopulmonary Arrest Rate Outside ICU % 3.86% ICU Length of Stay days 3.3 days p<0.001 p< T Test procedure, statistically significant (p <.0001) 2. Chi square procedure, statistically significant (p 0.046) 3. Not statistically significant (t=1.74/p=.08) but clinically significant? Swartz C, DNP, MBA, RN. (2013). A Systematic Approach to Manage Clinical Deterioration on Inpatient Units in the Health Care System. ACE, Chicago p<0.01
28 Our first alert, May 6, 15:38 Abx LevaQuin Ordered, May 7, 10:33 Disaster Averted Vigilance only Abx Vanc Ordered, May 8, 8:10
29 Sepsis Outside of the ICU Daily 25 Rounding at the Bedside Quarterly Surveillance Summary and Refinement Refining % reduction (p<.01) % addl. reduction (p<.01) 62.5% cumulative (p<.001) January February March April May June July August September October November December January February March April May June July August September October November December January February March April May June July $14.2 Million est. Cost Reduction
30 Why is satisfaction UP? What bedside caregivers DO matters. What they DOCUMENT matters. 30
31 What EPRs should DO 31
32
33 EPR/EMR Impacts on Bedside Caregivers: Verification of Favourable Clinical, Cost, Satisfaction Outcomes Steven H. Shaha, PhD, DBA Professor, Center for Policy & Public Administration Principal Outcomes Consultant, Allscripts Diane Gilbert-Bradley, MD Chief Quality & Outcomes Officer, Allscripts 33
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