Leveraging EHR to Improve Patient Safety: A Davies Story

Transcription

1 Leveraging EHR to Improve Patient Safety: A Davies Story Claudia Colgan, Vice President of Quality Initiatives Bruce Darrow, MD, PhD, Interim Chief Medical Information Officer Jill Kalman, MD, Director of Cardiomyopathy Program, Medical Director, PACT Program 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 Claudia Colgan Bruce Darrow, MD, PhD Jill Kalman, MD Has no real or apparent conflicts of interest to report HIMSS

3 Learning Objectives 1. Describe the business case for integrating of transitional care/care coordination objectives and IT 2. Identify the methods used to build tools and analytics to enhance program effectiveness 3. Discuss the lessons learned in transitioning from a low tech to a high tech solution

4 Background Knowledge Founded in ,171 bed tertiary care teaching and research Hospital 183 Hospital based practices 3,500 Physicians, residents, and fellows 2000 Nurses 58,000 Discharges 95,000 ED visits One million ambulatory visits in hospital clinics and Family Practice Associates

5 Background Knowledge U.S. News & World Report Best Hospitals The Mount Sinai Medical Center ranked 14th out of approximately 5,000 hospitals nationwide MSMC retained top billing on U.S. News Honor Roll of the nation s most outstanding hospitals Overall, Mount Sinai ranked in 11 of 16 specialties Geriatrics (No. 2), Gastroenterology (No. 7), Heart and Heart Surgery (No. 10) Mount Sinai has achieved HIMSS Stage 6 EMR Adoption Model

6 Executive Summary The MSMC Preventable Admissions Care Team (PACT) is dramatically reducing readmissions PACT included a combination of EHR and care model innovations EHR enhanced ability to identify patients at high risk of readmission Psychosocial drivers of readmission addressed through a 35 day social work lead transitional care intervention In addition to greater use of MSMC s homecare partner (VNA), open access was provided to the MSMC PACT clinic

7 Executive Summary The MSMC Preventable Admissions Care Team (PACT) is dramatically reducing readmissions EHR allowed hard wiring of workflows needed to reduce readmissions, improve care, and lower costs of care 56% reduction in 30 day readmissions by patients in the PACT program 91% of patients made follow up appointments in 7 10 days 84% of patients kept their appointment

8 Problems Addressed Medicare will begin reducing reimbursement for certain 30 day readmissions Admission history was traditionally used to identify patients at high risk of readmission, so interventions could be targeted Without integrated EHR, identification was very labor and paper intensive It did not identify those with a high risk for readmission, but do not have a history of admissions PACT needed an automated process to assist in the workflow

9 Readmission Rates Nearly 20% of Medicare hospitalizations are followed by readmission within 30 days 90% of re hospitalizations within 30 days appear to be unplanned, the result of clinical deterioration Only half of the patients re hospitalized within 30 days had a physician visit before readmission Unknown if lack of physician visit causes readmissions but poor continuity of care, especially for many chronically ill patients 19% of Medicare discharges are followed by an adverse event within 30 days 2/3 are drug events, usually deemed "preventable"

10 e1 PACT Timeline May 1, 2011 Epic Go Live

11 Slide 10 e1 e535cco, 1/23/2013

12 e2

13 Slide 11 e2 e535cco, 1/23/2013

14 Transformational Change and Integration of Resources

15 Design Several enhancements to the EHR became key enablers to reducing readmissions A readmission within 30 days prediction model was developed using logistic regression and did not depend on admission data The risk prediction score was integrated into the EHR identifying at risk patients and increasing awareness of the patients

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17 Design Several enhancements to the EHR became key enablers to reducing readmissions An admissions history form was created that gathered required, discrete data elements Have the patient profile indicate a high risk for readmission Produce rounding reports with identified patients so PACT team can conduct interventional rounding

18 Scoring Model

19 Scoring Model

20 Design Several enhancements to the EHR became key enablers to reducing readmissions Excel spreadsheets extracted from the legacy EHR were ed throughout the hospital to identify high risk patients A logistic regression model was developed by the MSMC Health Evidence and Policy Department which used a sophisticated statistical tool and added both past medical admissions and comorbidities into the model The model still required some manual additions by the caregivers to get to the final risk score

21 Design The model was validated in actual clinical practice The PACT model was fully implemented in Epic Medicare data was used so the model could incorporate any prior admissions in New York, not just those occurring at Mount Sinai Social workers now document the psychosocial assessment and scoring using Epic automation The flag symbol is now displayed on various screens for clinicians across the continuum of care

22 Areas of Psychosocial Strain What services and issues outside the hospital influence the ability to change readmission rates?

23 Design Building the admissions history form in Epic to ask discrete questions such as: Has the patient seen his or her primary care physician in the past 12 months? Has the patient been seen in an ED in the past six months? The patient profile in Epic noticeably indicates via a red flag that the patient is high risk for readmission generating a daily rounding report PACT can then assist patient with the 15 areas of psychosocial strain

24 Overall Process of the PACT Program

25 Outcomes For 1 st 615 patients completing 5 week intervention, a 56% reduction in 30 day readmissions were seen Using each patient as own control, pre PACT admits were 952; post PACT was % of PACT enrollees had risk score > 3, meaning an admission rate of 19 29%

26 Outcomes MSMC measured outcomes six months before and after PACT interventions: 43% reduction in hospitalizations 54% reduction in ED visits 91% of patients enrolled in PACT had 7 10 day follow up appointments 84% of patients kept their appointments

27 Costs During pilot phase, cost was $627 per patient per year ($376,000 annually) IT costs were approximately $14,500 Health Policy and Physician involvement was provided in house CMS prohibits disclosure of approved blended rate under recent CCTP award

28 Benefits A National Public Radio investigation followed a medically complex patient example Showed PACT reduced a year of Medicare spending by $85,000 A number of grants have provided funding, including a recent Community Based Care Transitions Program (CCTP) award from CMS (in partnership with the Institute of Family Health) In an ACO model, PACT was estimated to save $1.6M in health care spending over a 6 month period

29 Lessons Learned Industry standard assessments identify high risk patients based on diagnosis and comorbidities When data specific to past medical encounter history and key demographic data were added, the identification process was greatly enhanced Effective use of the of the patient s problem list was very important If MSMC had started looking for data earlier (as soon as the Epic go live), we could have been more accurate with population and future needs predictions

30 Lessons Learned Point of care integration was desired Integration required external calculations, reporting, modifier setting, and flagging Flagging for more than just reporting This integration has proven useful to many other of our Care Coordination Efforts including our Accountable Care Organization Project would have benefited from starting with an IT design group focusing on process; this would have assisted in helping locate patients

31 Contact Information Claudia Colgan, Vice President of Quality Initiatives Bruce Darrow, MD, PhD, Interim Chief Medical Information Officer Jill Kalman, MD, Director of Cardiomyopathy Program, Medical Director, PACT Program

32 Questions