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The Effects of Information Technology on Nurses and

Patients in the VHA

Joanne Spetz, Ph.D.University of California, San Francisco

Ciaran Phibbs, Ph.D. VA Health Economics Resource Center

James Burgess, Ph.D.Boston VA

AcademyHealth Annual Research MeetingJune 2008

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Background The VA is the largest integrated health

system in the US The VA is the largest installation of an

integrated IT system in the US Computerized Patient Records System (CPRS) Bar Code Medication Administration (BCMA)

The VA did not have a system-wide evaluation of CPRS or BCMA

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This study

Quantitative and qualitative methods Research questions

Did CPRS and BCMA change the need for nursing staff? Did CPRS and BCMA reduce adverse events for patients

in the VHA? What do staff and leaders believe are the strengths and

weaknesses of CPRS and BCMA? What recommendations can be made to the VA and other

hospitals as they implement information systems?

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Methods Quantitative analysis

Retrospective, by necessity Pre-post design – implementation dates varied across

sites Administrative data: patient discharge data, payroll

data, etc. Qualitative analysis

Key informant interviews at 8 sites 130 interviews Thematic analysis

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Variation in CPRS implementation initiation

05

1015

20F

requ

ency

1995 Q1 1996 Q1 1997 Q1 1998 Q1 1999 Q1 2000 Q1 2001 Q1 2002 Q1cprs_qtr

Some sites did not begin until 2002

6

010

2030

Nu

mbe

r o

f sta

tions

0 10 20 30 40gapcprs_qtr

Variation in time to fully implement CPRS

Some sites took more than one year to fully implement

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010

2030

40F

requ

ency

1997 Q11998 Q11999 Q12000 Q12001 Q12002 Q12003 Q12004 Q12005 Q1bcmaacute_qtr

Variation in BCMA implementation initiation – acute wards

Some sites did not begin until 2002

Most sites began in Q2 of 2000

8

020

4060

Nu

mbe

r o

f sta

tions

0 2 4 6 8 10gapbcmaacute_qtr

Variation in time to fully implement BCMA in acute wards

Some sites took more than one year to fully implement

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05

1015

20F

requ

ency

1997 Q11998 Q11999 Q12000 Q12001 Q12002 Q12003 Q12004 Q12005 Q1bcmaicu_qtr

Variation in BCMA implementation initiation – intensive care

Version 2 implementers

Version 1 implementers

10

020

4060

Nu

mbe

r o

f sta

tions

0 5 10 15gapbcmaicu_qtr

Variation in time to fully implement BCMA in ICU

Some sites took more than one year to fully implement

Most sites went “whole hog” in ICU

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Perspectives from the interviews

The cultural change caused by CPRS and BCMA was enormous CPRS changed “how we organize, document, and

communicate regarding patient care” With BCMA, “all touchpoints of care were

changed” Some staff observed a change from primary care

nursing to team nursing

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Perspectives from the interviews Many staff think IT takes them away from

direct patient care BCMA “ground production to a halt”, according to

one nurse Some nurses think BCMA saves time, many think it

takes no more time Some staff think CPRS forces them to care for the

computer more than patients Most agree it takes more time to enter data Time savings are gained from data retrieval

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Perspectives from the interviews

Most staff believe quality of care improved CPRS: quality of medical record, ease of getting

information CPRS impacted outpatient care more – clinical

reminders, integrated records BCMA: medication error rates dropped

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Specific outcomes AHRQ Inpatient Quality Indicators: mortality

CABG mortality AMI mortaltiy CHF mortality Acute stroke mortality GI hemorrhage mortality Pneumonia mortality PTCA mortality

AHRQ Patient Safety Indicators Decubitus ulcer Failure to rescue Selected infections due to medical care Post-operative respiratory failure Post-operative PE/DVT Post-operative sepsis Accidental puncture or laceration

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Method for patient outcomes Estimation approach: linear regression with quarterly data Explanatory variables

Time dummies (sensitivity analysis with time trend) Patient days (quadratic) Casemix (based on DRGs) Percent of patients 70 years and older Percent of patient days in ICU FTEs per adjusted admission (all staff) (annual) Trainees per adjusted admission (annual) Median tenure of RNs Percent of RNs over 50 years old Percent of RNs with BSN or MSN Percent of RNs unionized

Fixed effects for each hospital, robust standard errors Can analyze different CPRS/BCMA effects

Initial implementation Full implementation 6 months after implementation began 12 months after implementation began

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CPRS results

IQI Outcomes Imp. start Imp. complete

CABG mortality -0.006 0.008

AMI mortality -0.010 0.0003

CHF mortality -0.005 -0.001

Stroke mortality -0.017 0.026**

GI hemorrhage mortality -0.006 0.002

Pneumonia mortality -0.023** 0.001

PTCA mortality 0.009 -0.0005

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CPRS results

PSI Outcomes Imp. start

Imp. complete

Decubitus ulcer 0.002 -0.0005

Failure to rescue 0.003 -0.007

Selected infections medical care -0.0003 0.0003*

Post-op respiratory failure 0.0006 -0.0004

Post-op PE/DVT -0.001 0.0008

Post-op sepsis -0.0006 -0.0002

Accidental puncture/ laceration 0.0003 0.001**

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Consistent findings for CPRS

Stroke mortality dropped in short-term, but long-term effect was neutral or positive

Pneumonia mortality declined significantly Effect occurred upon initial implementation Access to records of history of care may be most pertinent

to this mortality measure

Accidental puncture/laceration rates increased Effect developed in the 12-24 month period Does this reflect workflow or ergonomic issues?

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BCMA acute care results

IQI Outcomes Imp. start

Imp. complete

CABG mortality -0.055 0.010

AMI mortality -0.026 -0.001

CHF mortality 0.010 0.006

Stroke mortality 0.009 -0.019

GI hemorrhage mortality -0.019** 0.0007

Pneumonia mortality -0.005 -0.010

PTCA mortality 0.005 -0.010

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BCMA acute care results

PSI Outcomes Imp. start

Imp. complete

Decubitus ulcer -0.003* 0.002

Failure to rescue -0.013 -0.007

Selected infections medical care -0.0005** 0.0002

Post-op respiratory failure -0.001 0.002**

Post-op PE/DVT 0.001 -0.002

Post-op sepsis 0.00009 -0.0004

Accidental puncture/ laceration 0.00001 -0.00006

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BCMA ICU results

IQI Outcomes Imp. Start

12-month lag

CABG mortality 0.021 -0.019

AMI mortality -0.023** -0.005

CHF mortality 0.003 -0.004

Stroke mortality 0.005 -0.004

GI hemorrhage mortality -0.005 -0.009

Pneumonia mortality -0.003 -0.007

PTCA mortality 0.009 -0.014*

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BCMA ICU results

PSI Outcomes Imp. start

Imp. complete

Decubitus ulcer -0.002* 0.0005

Failure to rescue -0.003 -0.003

Selected infections medical care 0.00009 0.00005

Post-op respiratory failure 0.001 -0.001

Post-op PE/DVT -0.002** 0.0005

Post-op sepsis 0.0005 0.0008

Accidental puncture/ laceration 0.00009 -0.00002

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Consistent findings for BCMA

Acute care BCMA effects are inconsistent across models and often offset each other

ICU BCMA had more consistent effects AMI mortality declined Decubitus ulcer declined Post-op PE/DVT declined

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Three important take-home messages

Outcomes did not worsen Some CPRS and BCMA users feared the system

detracted from other key patient care issues Exception: accidental puncture/laceration

Some outcomes improved Medication errors not studied here

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Common experiences with both implementations Overall success depends on how the site and

implementation team plans for setbacks, and continues the process to achieve success in the end

When you have a large organizational deployment you need a very stable, fault-tolerant environment.

Staff needed more time to do their jobs during implementation, but no additional staff were allocated.

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Team & Funding Core team

Joanne Spetz, UCSF Ciaran Phibbs, VA HERC Jim Burgess, Boston VA Susan Schmidt, VA HERC Melanie Chan, Dennis Keane, and Jennifer

Kaiser, UCSF Funding

Robert Wood Johnson Foundation Gordon & Betty Moore Foundation