EVIDENCE-BASED MEDICINE FOR IMPROVING PATIENT OUTCOMES

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1 THE ELECTRONIC MEDICAL RECORD AND THE DATA WAREHOUSE EVIDENCE EVIDENCE-BASED MEDICINE FOR IMPROVING PATIENT OUTCOMES Alan R. Spitzer, MD Senior Vice President and Director The Center for Research and Education Pediatrix Medical Group

2 Disclosure I have the following financial relationships with the provider(s) of commercial services discussed in this CME activity: Pediatrix Medical Group I acknowledge that today s activity is certified for CME credit and thus cannot be promotional. I will attempt to give a balanced presentation using the best available evidence to support my conclusions and recommendations I do/do not intend to discuss an unapproved/ investigative use of commercial products/devices

3 The Electronic Medical Record (EMR) Medical charting was all previously hand-written Daily note allowed physician to track primary concerns about the patient, progress being made in an individual s care, and plan of therapy Weed system introduced improved chart organization during the 1970 s Still a time-consuming process

4 EMR II Introduction of the personal computer and laptop now allowed computerized notes Initial processors were relatively slow, limited data entry Newer microprocessors permit entry of large amounts of information quickly Everyone will soon be using an EMR Great value of EMR is the ability to extract huge amounts of data on many patients Far cry from the chart review days of medical care

5 Chart Demands Have Grown Daily medical record Care of the patient versus care of the chart Information for consultants Risk of malpractice litigation requires careful charting Synthesis of medical and nursing notes New initiatives Continuous quality improvement programs Recertification (American Board of Pediatrics) Pay for Performance (P4P) Research

6 Pediatrix EMR (BabySteps( BabySteps) Admission Screen

7 Pediatrix EMR Daily Medical Record Note

8 EMR Issues of Concern Clarity and precision of documentation Excessive documentation Cloning of notes from day to day Excessive excessive carry-over carry-over of extraneous extraneous information information Internal inconsistency in charting e.g., Disagreement between daily exam and medical plan for the patient Consistency of definitions between institutions for purposes of chart review

9 EMR Needs Educational effort re: documentation Creation of clear definitions of events Daily progress note should be a daily note, not a recitation of all events up to that point What happened that day and only that day Avoid cloning of information Clear print-out of daily note Summary note for subsequent care-givers

10 What is the Data Warehouse? It is a HIPAA compliant dataset populated from the clinical data brought together from electronic note systems used by Pediatrix units throughout the country The Web Reports are graphic reports designed to answer questions about a neonatal intensive care unit s population or a region s population, in order to assess and improve outcomes or to make novel research observations

11 The Value of the Data Warehouse Pediatrix Medical Group currently cares for approximately 20% of all NICU patients in the country Hospitals at which we cover deliver about 25% of all babies born in the U.S. Average PDX daily NICU census is about neonates per day Nearly 90,000 admissions/ year Theoretically, this database should reflect NICU care in this country

12 The Pediatrix Data Warehouse Work first started in to provide a source of information for Pediatrix physicians that would hopefully exceed all other known neonatal databases Has resulted in over 30 publications to date addressing a variety of issues in newborn care Western IRB approved for research Recent work has focused on merging data from two EMRs and visual appearance of reports Improved clinical use

13 The Five Stages of Grieving Over Outcome Data Denial: These data can t be right! Anger: Why are they picking on me? Don t I have enough to do already? Bargaining: My patients must be sicker than everyone else s, my NICU is different, I don t agree with those data definitions, etc. Depression: I can t do anything about it anyway. Acceptance: OK what can I do to improve the outcomes in my NICU? Courtesy of Dan Ellsbury,, MD, Pediatrix Medical Group

14 Home Page

15 Hospital Selection

16 Morbidity Reports

17 Currently Available Reports Activity Reports: Types of discharges (home, transfer, in-hospital, etc.); Admissions by GA; Admissions by BW: Length of stay, Average daily census; Mortality; Survival Best Demonstrated Process Reports: Median Daily weight gain during the first 28 days; Hepatitis B immunization rates; Per cent of infants breast feeding at Discharge Morbidity Reports: BPD at 28 days of life; BPD at 36 weeks gestational age; IVH; Late-onset sepsis; NEC; PDA; PVL; RDS and surfactant use; ROP; Severe IVH; Severe ROP Antibiotic Reports: Percent of NICU admissions treated with antibiotics; Median days of antibiotic therapy with negative cultures; Use of cefotaxime; Percent of patients treated without cultures Acuity Reports: Maximal ventilator support, Median ventilator Days, use of dexamethasone, temperature from DR to NICU Summary Dashboard Report

18 Report Definitions

19 Report Definition

20 Activity Indicators

21 Discharge Practices

22 Patient Mortality Report

23 Patient Volume vs. LOS New Ways of Proving Our Effort in the NICU Pt. days Pt. volume DC = 46 V = 76 OS = 43 d ADC = 49 PV = 125 LOS = 21 d

24 Length of Stay Report Extreme Prematurity (< 28 Weeks gestation) If length of stay is too long, we need to ask why that is so is it the way we ventilate babies, feed babies, move them towards discharge, etc.?? The answer is not that My patients are different!

25 IVH Report Documentation??

26 Ventilator Days I

27 Ventilator Days II

28 BDP Reports Weight Gain

29 Tabular Format for Reports

30 Weight Gain Report Pediatrix overall trend???- individual site less than ideal

31 Comparison by NICU Size Possible selections: Small < than 225 discharges Med discharges Large >428 discharges

32 Small NICU ROP Comparison Pediatrix All NICUs Pediatrix Small NICUs Only

33 Large NICU ROP Comparison Pediatrix All NICUs Pediatrix Large NICUs Only

34 Network Summary Trends for Different-sized NICUs

35 The CQI Effort Quality improvement is now a mandate When you begin examining your outcomes carefully, there is a natural desire to do better for your patients

36 Medical Checklists Pilots, car dealers, etc., all use checklists to insure quality in their practice Physicians have traditionally resisted the use of such lists It may be time to rethink the random approach to care delivery and become more methodical in what we do at the bedside

37 Example: Dashboard Report Dashboard report for assessing the outcomes of any NICU during a defined period of time. Performance Compared to 33-66% for PDX Medical Group (blue bar)

38 Quality Improvement as a Priority Mandate: Active participation of all PDX NICUs in quality improvement activities Pediatrix Quality Summits Quality Summits held 3 times/year, throughout the US Expectation that each clinician attend once every two years Emphasis on basic training in CQI methodology CQI Website Contains educational resources and references Contains ready-made CQI Toolkits for easy use and adaptation for local use

39 CQI Home Page

40 Quality Improvement Toolkits and Projects Best Demonstrated Practice Projects Optimizing Growth Optimizing Breast Milk Use RBC Transfusions Random Safety Auditing Optimizing Antibiotic Usage Reducing Retinopathy of Prematurity Reducing Nosocomial Infection (in development) Evidence Based Medication Use (in development)

41 Optimizing Growth in the First 28 days (<1500g infants, median daily weight gain) Growth roll out pack distributed to all practices in 2000 Sustained improvement in growth across the network

42 Example: Cefotaxime Use After dissemination of data showing increased mortality with cefotaxime use, network use of cefotaxime dropped markedly.

43 COMP-ROP Toolkit

44 Comprehensive Oxygen COMP-ROP Management for the Prevention revention of ROP Basic Principles: Avoid hyperoxia Avoid large oxygen saturation fluctuations Educate all NICU staff about ROP Provide mechanisms to assess actual implementation

45 Severe ROP, Pediatrix Network Note: This is a composite of all PDX centers, not just those participating in COMP-ROP 14% 12% Severe ROP 10% 8% 6% 4% 2% 0% Chow paper Local Efforts COMP-ROP Formalized partial year

46 Necrotizing Enterocolitis (NEC)

47 Worrisome NEC Trend?

48 Patent Ductus Arteriosus (PDA)

49 28 Days

50 36 Weeks Gestation

51 Late-Onset Sepsis

52 IVH Report

53 Antibiotic Reports Antibiotic reports include: Percent of NICU admissions treated with antibiotics Number of patients treated with no cultures in chart Median days of antibiotic therapy with negative cultures Percentage of patients treated with cefotaxime Percentage of infants treated beyond 5 days with negative cultures (pending)

54 Number of Patients Treated With ABX

55 Median Days on Antibiotics Negative Cultures

56 Best Practice on Antibiotics

57 Questionable Antibiotic Usage

58 Data Warehouse Uses Availability to query data warehouse for research issues (Research DW) Goal is to progressively utilize data warehouse to provide answers for CQI, hospitals, payor information, federal/ state agencies, etc. CQI effort is especially important at several levels, including recertification efforts Data Warehouse has potential to become the gold standard for neonatal outcomes

59 In the Works Ability to group babies in different gestational age categories Temperature from the DR reports Line Use Report Expanded ventilator reports Maximum support Number of infants treated with each form of support Medication usage reports for all commonly used drugs Reassignment of reports Report lists (Front Page access)

60 DR to NICU Temperature Report

61 Admission Temperature Report II

62 Line Use Report

63 Maximum Respiratory Support

64 Details of Respiratory Support

65 Medication Use Report Med use report to start will include: Antifungal, antibiotics, antivirals Diuretics EPO GI Drugs (H2 blockers, metaclopramide, proton pump inhibitors) Indomethacin (Early, Late) Inhalational drugs (albuterol( albuterol,, steroids) Methylxanthines Steroids (antenatal, postnatal) Surfactant Vasopressors

66 LOS Data All Infants Mean LOS decrease of 1½1 days

67 LOS ELBW Infants (<28 weeks) Mean LOS decrease of >9 days

68 P4P Comparisons Breast Feeding at Discharge

69 P4P Comparisons Late Onset Sepsis All practices Mountain Region

70 Evidence-Based Medicine EMR and DW are ideal tools for critically evaluating and reviewing practices EMR and DW serve as ideal tools for assessing results of CQI interventions in clinical practice Provide ideal format for making observations that are otherwise not possible in smaller patient volumes

71 Selected Recent Bibliography Clark RE, Bloom BT, Spitzer AR, Gerstmann DR. The use of ampicillin and cefotaxime compared to ampicillin and gentamicin is associated with an increased mortality rate during the first three days of life. Pediatrics, 2006; 117: Clark RH, Bloom BT, Spitzer AR, Gerstmann DR. Medication Use in the NICU: Data from a Large National Data Set. Pediatrics 2006; 117: Clark RH, Chace DH, and Spitzer AR: The effects of two different doses of amino acid administrations on growth and blood amino acids in premature neonates admitted to the NICU: a randomized controlled trial. In Press, Pediatrics., December 2007 Mercier CE, Barry SE, Paul K, et al. Improving newborn preventive services at the birth hospitalization: a collaborative, hospital-based quality-improvement project. Pediatrics. 2007; 120:481-8 Walsh M, Laptook A, Kazzi SM, et al. A cluster-randomized trial of benchmarking and multimodal quality improvement to improve rates of survival free of bronchopulmonary dysplasia for infants with birth weights of less than 1250 grams. Pediatrics. 2007;119: Payne NR, LeCorte M, Karna P, et al. Reduction of bronchopulmonary dysplasia after participation in the Breathsavers Group of the Vermont Oxford Network Neonatal Intensive Care Quality Improvement Collaborative. Pediatrics Nov;118 Suppl 2:S73-7 Pediatrics November 2006, Volume 118, Supplement 2. Issue devoted to potentially best practices in quality improvement

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