Dawning of a New Epoch in Harm Measurement
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- Gerard Jacobs
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1 Dawning of a New Epoch in Harm Measurement From Paleolithic Hunter Gathers to Holocene Farmers Jack Jordan Henry Ford Health System (This presenter has nothing to disclose)
2 Objectives Implement strategies to leverage new EMRs to make action on harm visible and actionable w ithin 48 hours or less Share a cutting-edge method for comprehensive, near real-time harm measurement Engage you in a journey to re-invent harm measurement
3 Goal of HARM 2.0 Comprehensive tracking of harm by Oct 2015 w ith data w ithin 48 hours of triggering documentation w ith no human intervention. Harm may include iatrogenic vulnerability as w ell as harm requiring additional treatment
4 Real Goal of Program Give tools for insight and action to front line staff and middle management. Make gaps in care visible and actionable Make not testing changes seem very uncomfortable.
5 What is Comprehensive? Medication Hypoglycemia Anticoagulation issues (INR > 5) Narcan Diuretics causing adverse effects Allergic Reaction not POA C-diff toxin positive Delirium GI Bleed not POA Environment Pressure Ulcer Falls Patient Trauma Other DVT Acute Renal Failure Blue Alert Procedural Complications Pneumothorax Puncture/Laceration Unexpected blood use post Procedure Aspiration Pneumonia Other Procedural complications Infections SSI CAUTI CLABSI Pneumonia VAE Other Pneumonia Not POA Perinatal Ideal Delivery
6 Meaningful Use and Available Data Traditional ICD9 Dx ICD9 PX Cpt4 (maybe) Limited Labs/cultures LOS Charges ADT locations Individual Charge master items EMR Era All Traditional Problem lists (maybe) Orders Medication Administration Vital Signs (limited) Flow sheet data Equipment feeds (maybe)
7 What is Special about HFHS Problem based charting Long History of Quality Improvement Open Data Environment Data Reporting & Analytics are not part of IT New EMR w ith all hospitals on the same build
8 Problems in Paradise Definitions are far more complicated Audiences are different for data w ith new distribution channels Choices for w here to find data Comorbid Edema (from Flow Sheet?, problem list? Past ICD9 code, Medications?)
9 What Have We Learned So Far? Timely delivery changes the intervention from the ground up Related opportunities appear in the process Some traditional measures not useful Predictive Analytics are not as valuable as actionable analytics Weakness in the data usually uncover other interesting opportunities in Patient Care
10 What We are Learning Measurement becomes tightly coupled to the caregiving Design of the documentation is profoundly linked to data possibilities
11 Delivery and Follow up Traditional Monthly reports to leadership Detail lists for deep dives EMR Advanced Detail to front-line Roll up w ith analysis to leadership Teams built around project and data from team out to staff Detail can be both for team and front line real time
12 Detail from the Beginning
13 Example VTE Harm: Problem list (Added during stay) low resolution, non-deep Vein, at risk for vs real, POA reliability Treatment received (Heparin drip, etc) Logic to w eed out a-fib, etc. used for Drip Imaging results (CT, Venous Doppler and duplex) Order but No results available in Clarity Heart problems (Problem list ICD9 codes 410.xx and 427.xx) Billing data (ICD9 code) Not used in logic Lab results N/A
14 VTE is Really Complicated No single variable is good enough Treatment overlaps w ith other problems Numerous patients w ith Heparin or Lovenox and no legitimate problem on problem list
15 Real-Time Method: Review Identification w ithin 48 hours of documentation Real time identification through the artifacts of care Problems list Ordering a treatment/medication Lab value Accuracy and reliability Insight into the variation of practice Organic system allow s faster response to change
16 DVT/PE Harm: Logic
17 VTE: Chart Reviews 427 Chart Review s w ere done Comparison: We are finding a little bit more, but w ait! Modified AHRQ Real Time Logic PSI 12 Sensitivity 84% 37.5% Specificity 97% 99.0% PPV 69% 75% NPV 99% 95% Total Dif. Chart Reviews 32 0% Proposed Logic 39 22% Billing 16-50% Improvement in documentation can significantly improve accuracy
18 VTE Harm: Actual vs. Modified PSI#12 vs. Logic Actual Chart Reviews
19 VTE Harm/1000 patient days: HFHS Total
20 Other Lessons and Data Failures in the measurement of DVT are tightly connected to practice issues Building reports on use of Doppler & CT scans per found DVT (resident project) Continued treatment of superficial vein clots needs feedback loop (reached out to program director for resident education) Timelines don t match Date of discharge vs Date of problem in hospital Built estimate of Padua score from existing documentation
21 Blood and Bleeding Teasing out unexpected drop in Hgb or blood use Linking bleeding w ith anticoagulants (INR> 5) Attempting to integrate tracking of bleeding w ith good management of blood products.
22 Questions, Thoughts What excites you about this w ork?
23 Contact Info Jack Jordan S. Mani Marashi Linkedin
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