Using CDS (Clinical Decision Support) for Quality Initiatives at a Community Hospital

Transcription

1 Using CDS (Clinical Decision Support) for Quality Initiatives at a Community Hospital Jonathan Sykes MD, CMIO Jacalyn Liebowitz RN, MBA,NEA-BCFACHE VP Care Continuum Allegiance Health - Jackson, MI DISCLAIMER: The views and opinions expressed in this presentation are those of the author and do not necessarily represent official policy or position of HIMSS.

2 Conflict of Interest Disclosure Jonathan Sykes, MD Jacalyn Liebowitz, RN Has no real or apparent conflicts of interest to report HIMSS

3 Learning Objectives Translate lengthy clinical guidelines into CDS that community hospital physicians are likely to accept Recognize how to embed CDS in harmony with physician workflow Employ collaborative (vs. hierarchical) techniques for winning over skeptics Create a repeatable process for designing, deploying, and measuring/ increasing use of multiple CPOE forms tied to various initiatives

4 CDS Development Process Clinical Problem Identified Collect Pertinent Evidence Clinical Quality Specialist, EBSCO Dynamed Review Evidence With Subject Matter Expert Multidisciplinary Team, Medical Director Create Content and Workflow in CPOE System CMIO, Clinical Informatics Team Inform Medical Executive Committee Deploy and Measure Adoption

5 Clinical Problem Venous Thromboembolism (VTE) Prevention Hospital Acquired VTE (DVT + PE)* 1 VTE per 1000 persons per year 60% are hospital acquired Occurrence (NO prophylaxis & routine screening) ALL DVT = 10-20%; proximal DVT 4-5% Fatal PE account for 5-10% of in-hospital deaths Other Morbidity Increased hospital length of stay ($10-20K/episode) Risk of anticoagulants, recurrence Post-phlebitic syndrome * DVT = Deep Venous Thrombosis; PE = Pulmonary Embolism

6 Clinical Evidence- Medical Patients Heparin vs No Treatment (18) LMWH vs. UFH (14) Relative Rate Statistical Significance Relative Rate Statistical Significance Mortality 0.93 No 0.94 No Symptomatic VTE 0.70 No 0.67 Yes Pulmonary Embolism 0.75 Yes All Bleeding 1.28 Yes Major Bleeding 1.61 No 0.95 No 1. Assess risk of thromboembolism and bleeding in medical patients prior to initiation of prophylaxis 2. Use pharmacologic agents unless assessed risk of bleeding outweighs benefit of prophylaxis 3. Do not use graduated compression stockings Venous Thromboembolism Prophylaxis in Hospitalized Patients: A Clinical Practice Guideline From the American College of Physicians, Ann Intern Med 2011; 155:

7 Clinical Evidence ACCP Guideline Updated in 2012, 9 th Edition; 800+ pages Considered Gold Standard Stricter adherence to Evidence GRADE Included multiple patient types: Non-surgical Surgical, non-orthopedic Surgical, orthopedic Pregnant Neonates and Children Antithrombotic Therapy and Prevention of Thrombosis, 9 th Ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Chest 2012; 141S:1-823

8 Assessment Pharmacologic Mechanical Population Hospitalized Acutely Ill Medical Patients Hospitalized Critically Ill Patients Patients With Cancer in Outpatient Setting Risk of Thrombosis Incidence Roger's Caprini Risk of Bleeding Increased Y Y N Low N N Active or High N N Y Y N Y Y Active or High N N N Y Y Low N N N Additional Factors Low Y Y Central Venous Catheter N N N Chronically Immobilized Patients N N Long Distance Travel Increased N N N Y Assymptomatic Person With Thrombophilia N N General and Abdominal-Pelvic Surgery Very Low <0.5% <7 0 N N N N N Low 1.5% Y Moderate 3.0% > Not High Risk Y Y <-OR-> Y Moderate 3.0% > High Risk Y High 6.0% >=5 Not High Risk Y Y <-AND-> Y Y High [Cancer} 6.0% >=5 Not High Risk Y Y Y Y Y High 6.0% >=5 High Risk Y High 6.0% >=5 Not High Risk Y C C Y Y Cardiac Surgery w/ Uncomplicated Course Y Y <-OR-> Y Cardiac Sugery w/ Nonhemorrhagic Complication Y Y <-AND-> Y Thoracic Surgery Moderate Not High Risk Y Y <-OR-> Y High Not High Risk Y Y <-AND-> Y Y Craniotomy N N Y Very High [Cancer] Y Y <-AND-> Y Spinal Surgery N N Y High Y Y <-AND-> Y Major Trauma N Y Y <-OR-> Y High Y Y <-AND-> Y C C Y Orthopedic Surgery - THA or TKA Y Y P Y Y Y Y <-OR-> Y Orthopedic Surgery - HFS Y Y P Y Y Y <-OR-> Y Screening Aspirin VKA LMWH LDUH fondaparinux rivaroxaban Extended GCS IPC

9 Risk Assessment Thromboembolism Risk Caprini Score Validated primarily in surgical patients Endorsed by regional P4P collaborative for medical patients Padua Score Endorsed by ACCP Guideline 9 th Edition Bleeding Risk (NO good scoring system) IMPROVE score

10 VTE Prophylaxis in Hospitals Low rates of prophylaxis in US hospitals* 350,000+ high risk patients in 376 hospitals Only 36% received prophylaxis by day 2 High variability (IQR = 19-42%) Only 3% of hospitals had rate >70% Allegiance Health VTE Prophylaxis CPOE order utilization 24% in December 2010 * Rothberg et al. Venous thromboembolism prophylaxis among medical patients in US hospitals. JGIM 2010;25(6):

11 VTE Prophylaxis National Priority Surgeon General Call to Action in 2008 AHRQ Top Priority Joint Commission SCIP Core Measure NQF Endorsed Measures ARRA Meaningful Use Clinical Quality Measures CMS Never Event CDC Expert Panel in 2011 ACA Hospital Acquired Conditions (HAC)

12 VTE Prophylaxis Regional Priority Blue Cross Blue Shield Hospital Medicine Collaborative Initial Focus on VTE Prevention Developed registry for participating hospitals Incentive payments in 2013 Michigan Hospital Association Keystone Center Hospital Engagement Network Lead HHS Effort in Michigan to reduce HAC

13 VTE Prophylaxis Measures and Incentives VTE Measures Blue Cross Blue Shield - Hospital Medicine Safety Collaborative VTE risk screening is completed on admission High Risk patients receive pharmacological prophylaxis on admission. Note: Caprini score > = 2 is High Risk High Risk patients receive mechanical prophylaxis on admission. Note: Caprini score >= 2 is High Risk Michigan Hospital Association - Hospital Engagement Network Percent of patients with risk assessment done withing 24 hours of admission (VTE-1) Percent of at risk patients with no contraindications who receive adequate pharmacologic prophylaxis Incidence of hospital associated preventable VTEs per 100 at risk patients (VTE-2) ARRA Meaningful Use Stage 1 CQM Moderate and High Risk patients who receive VTE prophylaxis (VTE-1) Moderate and High Risk ICU patients who receive VTE prophylaxis (VTE-2) Patients with VTE who receive overlap therapy (Coumadin plus parenteral therapy) (VTE-3) VTE patients receiving unfractionated heparin with dosages/platelet count monitoring by protocol or nomogram (VTE-4) VTE warfarin therapy discharge instructions (VTE-5) % of patients who develop confirmed VTE during hospitalization who received no VTE prophlaxis prior to VTE diagnostic test order date (VTE-6) Joint Commission - SCIP Core Measures Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered (SCIP-VTE-1) Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery (SCIP-VTE-2) Patient Population Medical Medical Medical Non-ICU, Non-Surgical Non-ICU, Non-Surgical Non-ICU, Non-Surgical Medical and Surgical Medical and Surgical Patients with confirmed Patients with confirmed diagnosis of VTE Patients with confirmed Patients with confirmed diagnosis of VTE Surgical (by List of Surgeries Surgical (by List of Surgeries Performed)

14 Redesign of CPOE VTE Orders Risk Level Caprini Score (optional) Prophylaxis Low 0-1 Ambulation ONLY Moderate 3-4 Pharmacologic OR Mechanical High >=5 Pharmacologic AND Mechanical Additional decision support elements Choice of pharmacologic agent By weight, by renal function Contraindications harmonized among P4P initiatives Tracking orders to measure adoption Workflow elements Only show pertinent choices

15 Demonstrate VTE Orders

16 Interventions To Drive Adoption Education Memos and Medical Staff Newsletter Continuing Medical Education 1:1 Coaching High Volume Admitters Compliance Reporting (Hospitalists) Exit Reminder (Hard/Soft Stops) Pilot Group (accumulated data to justify) Expand to ALL required approval by Med Staff

17 Exit Reminder Providers ONLY NOT Nursing ALLOW Bypass

18 100.0% By Exit Reminder Pilot Group 90.0% 80.0% Exit Reminder [Pilot] 70.0% 60.0% Exit Reminder [ALL] 50.0% Compliance Report 40.0% 30.0% 20.0% 10.0% 0.0% Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Y N

19 100.0% By Clinical Service 90.0% 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Family Practice Medicine OB-GYN Surgery

20 Yes No Linear (Yes) Linear (No) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% Compliance Report Exit Reminder- Pilot Exit Reminder- ALL 0% 1-Dec 9-Dec 17-Dec 25-Dec 2-Jan 10-Jan 18-Jan 26-Jan 3-Feb 11-Feb 19-Feb 27-Feb 6-Mar 14-Mar 22-Mar 30-Mar 7-Apr 15-Apr 23-Apr 1-May 9-May 17-May 25-May 2-Jun 10-Jun 18-Jun 26-Jun 4-Jul 12-Jul 20-Jul 28-Jul 5-Aug 13-Aug 21-Aug 29-Aug 6-Sep 14-Sep 22-Sep 30-Sep 8-Oct 16-Oct 24-Oct 1-Nov 9-Nov 17-Nov 25-Nov 3-Dec 11-Dec 19-Dec 27-Dec Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

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22 BCBS Hospital Medicine Safety Consortium

23 BCBS Hospital Medicine Safety Consortium

24 BCBS Hospital Medicine Safety Consortium

25 BCBS Hospital Medicine Safety Consortium

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29 PSI-12: Post-Op PE or DVT Facility Numerator Facility Denominator Facility Rate/1000 Peer Numerator Peer Denominator Peer Rate/1000 FY 2012 (JUL 11 - JUN 12) 7 3, , FYTD 2013 (JUL 12 - AUG 12) ,

30 Future Direction Revisions to VTE Clinical Decision Support Alter Logic to Support: Medical vs. Surgical patients Improved Risk Stratification Make patient characteristics (i.e. egfr, current therapies ) available Alert for Epidural or other Continuous Nerve Catheter Apply Concepts to SCIP Beta-Blocker Post-Op

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32 Thank You!

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