06-Mar-2014
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1 © 2014 North York General Hospital and Zynx Health Incorporated
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Driving Quality Inpatient Outcomes with CPOE and Integrated Evidence-Based Clinical Decision Support
The eCare Story
North York General Hospital, Toronto, Canada
Jeremy Theal MD FRCPC • CMIO and Gastroenterologist
2 © 2014 North York General Hospital and Zynx Health Incorporated
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Community teaching hospital affiliated with the University of Toronto
Catchment area: > 400,000
Three Sites: General, Branson, Seniors’ Health
Beds: 418 acute care
192 long-term care
Volume per year: 113,000 ED visits
29,500 inpatient cases 5,800 births
06-Mar-2014
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3 © 2014 North York General Hospital and Zynx Health Incorporated
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• Implement advanced electronic medical record
technology to improve patient outcomes:
Quality and safety of patient care
• Embrace culture of evidence-based care, best practices
Make it “easy to do the right thing”
Build evidence into clinical workflow
• SHARED VISION = “by clinicians, for clinicians”
100% clinician adoption
Team-based interprofessional approach/workflows
Goals of the eCare Project
4 © 2014 North York General Hospital and Zynx Health Incorporated
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• Computerized Provider Order Entry (CPOE)
• Evidence-Based Order Sets & Clinical Workflows
• Closed-Loop Medication Administration
• eMAR, Medication Reconciliation, Depart Process
• Advanced Clinical Decision Support
System Components
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5 © 2014 North York General Hospital and Zynx Health Incorporated
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Integrating Evidence and Professions: eCare Order Set Team
• Goal – 350 evidence-based Order Sets (gap analysis)
• Order Set Build Team: – 1.0 FTE physician (spread amongst 4 MD’s)
– 1.0 FTE pharmacist (spread amongst 2 pharmacists)
– 1.5 FTE application analysts (from clinical informatics)
• Sources of Evidence: – Zynx Health Evidence-Based Order Sets
– Canadian/International Guidelines/key articles
– NYGH paper order sets, protocols, directives
• Directly involved front-line clinicians in design: – > 80 MD’s (interdepartmental input)
– > 150 clinical staff (interprofessional input)
6 © 2014 North York General Hospital and Zynx Health Incorporated
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• Insert eCare picture here
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7 © 2014 North York General Hospital and Zynx Health Incorporated
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System Adoption by Physicians: One Year post-“Go-Live”
• User adoption of the system – 100%
• Percentage of physician orders entered by MD’s – 92%
• Number of orders entered by physicians - > 1,700,000
• Evidence-based PowerPlans created - > 350
• Evidence-based PowerPlans activated - > 42,000
• Orders entered through PowerPlans – > 830,000
• Percentage orders from evidence-based PowerPlans: 49%
8 © 2014 North York General Hospital and Zynx Health Incorporated
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\ Metro Edition Thursday Dec 13, 2012
In-Hospital Death Rates Down
Across Greater Toronto Area
• Annual CIHI Report demonstrated that
preventable in-hospital deaths were reduced
• NYGH – top performer in Greater Toronto
and second best in all of Canada
• CEO Tim Rutledge: “health information
technology has hard-wired quality and safety
into the hospital”
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9 © 2014 North York General Hospital and Zynx Health Incorporated
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Study – CPOE and Evidence-Based OS:
Impact on Mortality, Readmission, LOS
Retrospective chart review: • All patients discharged with a most responsible diagnosis of
Pneumonia or COPD
• Population #1: Pre-CPOE (Jan-Sep 2010)
• Population #2: Post-CPOE (Jan-Sep 2011) (CPOE go-live was October 26, 2010)
Why were Pneumonia and COPD selected? • High-volume diagnoses for inpatient care
• Plenty of evidence to guide treatment
• Clear clinical decision support available
• Diagnosis often made on admission
10 © 2014 North York General Hospital and Zynx Health Incorporated
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Study – CPOE and Evidence-Based OS:
Impact on Mortality, Readmission, LOS
Primary Hypothesis:
• Use of CPOE with evidence-based order sets is associated
with a reduction in age and comorbidity-adjusted inpatient
mortality, 30-day readmission and/or length of stay from
pneumonia and COPD, compared with traditional paper-
based processes
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11 © 2014 North York General Hospital and Zynx Health Incorporated
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Study – CPOE and Evidence-Based OS:
Impact on Mortality, Readmission, LOS
Secondary Hypothesis:
• The use of CPOE with an evidence-based admission order
set that is the same as, or closely matching, the final most
responsible discharge diagnosis is associated with a
reduction in age and comorbidity-adjusted inpatient
mortality, 30-day readmission and/or length of stay in
patients hospitalized for pneumonia or COPD, compared
with use of any order set
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Pre vs Post-CPOE Population (Table 1)
• 520 patients (paper orders) vs 511 patients (CPOE)
• No statistically significant difference in sample size, gender distribution, age, Critical Care admission rate
• More patients with COPD in the paper orders group, vs more patients with pneumonia in the CPOE group (p=0.009)
• Correction applied: Probability of Death (adjusts for age, sex, length of stay, comorbidities, admission type and diagnosis group)
• Additional correction applied for critical care admission
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Primary hypothesis – proven correct
• Mortality:
Strongly significant reduction in risk of death from
pneumonia or COPD when using CPOE with
evidence-based order sets versus traditional paper
processes, even after adjusting for age, comorbidity,
diagnosis and CrCU admission
45% reduction, statistically significant
• 30-day readmission / LOS – no significant change
Summary of Results
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Summary of Results
Secondary Hypothesis – proven correct
• Mortality: Use of CPOE with an evidence-based
admission order set that matches the
most responsible discharge diagnosis results in
significant reduction in death from COPD or pneumonia,
adjusted for age, comorbidity, diagnosis,
CrCU admission
56% reduction, statistically significant
• Mortality:
Admission OS close match or no match: no sig. change
• 30-day readmission / LOS: no significant change
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15 © 2014 North York General Hospital and Zynx Health Incorporated
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Summary of eCare Clinical Benefits
• 100% clinician adoption
• Medication turnaround improved by 83% (291 to 50 mins)
• Order set usage for patient admission to hospital increased from 37% (using paper) to >97% (using CPOE)
• Appropriate prophylaxis against VTE increased from 50% of inpatients to >96% of inpatients
• Mortality from pneumonia and COPD exacerbation was reduced by 45% using CPOE vs paper orders
• Mortality from pneumonia and COPD exacerbation was reduced by 56% in patients admitted using CPOE with a correctly-matched evidence-based order set
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In Closing
• Implementation of CPOE with integrated evidence-based real-time CDSS can result in significant improvement in multiple patient outcomes, such as mortality
• Keys to success:
– Close partnership with evidence provider that has regular content updates and effective suite of software tools (ZynxHealth)
– Engagement of front-line clinicians in design and build of content, workflows
– High rates of system adoption
– Culture change to focus on the importance and power of evidence-based medicine and standardization of care
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17 © 2014 North York General Hospital and Zynx Health Incorporated
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A Measured Approach to Alerting
The Path to Drug-Disease Interaction Alerts
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Atrius Health
• Non-profit alliance of six leading independent medical groups and home health/hospice
– Granite Medical
– Dedham Medical Associates
– Harvard Vanguard Medical Associates
– Reliant Medical Group
– Southboro Medical Group
– South Shore Medical Center
– VNA Care Network & Hospice
• Providing care for ~ 1,000,000 adult and pediatric patients with 1000 physicians, 1450 other healthcare professionals across 35 specialties from over 50 sites
.
© 2013 Atrius Health, Inc. All rights reserved.
Atrius Health
Non-profit alliance of six leading independent
medical groups in Eastern
Massachusetts and one home health
agency and hospice
Granite Medical
Dedham Medical
Associates
Harvard Vanguard Medical
Associates
Reliant Medical Group
Southboro Medical Group
South Shore
Medical Center
VNA Care Network
and Hospice
.
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Providing care for ~ 1,000,000 adult and pediatric
patients with 1000 physicians, 2100 other healthcare
professionals across 35 specialties
© 2013 Atrius Health, Inc. All rights reserved.
Atrius Health
• 100% on EMR combined with corporate data warehouse,
used for managing quality and cost. Patient portal.
• Long history with global payments, currently about 50%
risk across commercial, Medicare and Medicaid
populations.
• Pioneer ACO
• HIMSS Stage 7
• Strong infrastructure to manage risk
The Triple Aim
Experience
Of Care Per Capita
Cost
Population Health
Source: IHI.org
The root of the problem in health care is that the business models
of almost all US health care organizations depend on keeping
these aims separate. Society on the other hand needs these three
aims optimized (given appropriate weightings on the components)
simultaneously. Tom Nolan, PhD.
5 © 2013 Atrius Health, Inc. All rights reserved.
Atrius Health Goal: “Triple Aim + 1”
Improve
Experience
Of Care
Reduce
Per Capita
Cost of
Care
Improve
Population Health
. +1 = Improve Provider and Staff
Satisfaction
6 © 2013 Atrius Health, Inc. All rights reserved.
The Problem
• 3,000,000 ambulatory visits/yr
• 3.2 million RX/yr
• 95% cancel or over-ride
• Over-ride reason not required (soft-stop)
• Cannot always tell what changes made
relative to alert
• Coumadin tells the tale
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Coumadin Stealth Alert
• Any time patient followed in anti-coag and
has med RX sent for medication
interfering with INR a 2nd alert is sent to
anti-coag team without prescriber’s
knowledge
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Interaction Severity Drug-Drug
• Contraindicated
• Severe
• Moderate
• Undetermined (filtered)
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Baseline Reporting
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Approach to Solution
• Clinical Pharmacy Team
• Clinical Decision Support Workgroup
• Me
• Initial effort to voluntarily submit alerts that
were annoying
• Review by team
• Suppress 1 level of interaction
• Removed Drug-Food
• Change alert severity-removed 10-20
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The Dreaded Allergy File
• Issue related to being “Old” EMR user
• Many free-text allergens and unusual
synonyms created in file
• Standards document created
• Manual conversion of free-text meds to
discrete med allergies
• Allergy to phone # and “mother’s sister”
• However-also high frequency allergy to
G6PD and Long QT
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G6PD and Long QT
• Hundreds of entries-most of time also on
prob list
• Prob list NOT viewable at time of placing
order
• MD’s using allergy file as a sensible
trigger
• No real appreciation for future effect or
the lack of actual alert “illusion of alert”
• Have noticed similar in other EHR
(Centricity) as well
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Drug-Disease Alerting
• Turned on full file and then shut it off 3
weeks later
• Overwhelming volume
• Wanted to target specific subset of areas
of concern to providers
• Alert Space
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Alert Space
• Allowed for search by disease condition
and then specific interaction
• Also offered Drug-Drug modifications to
have a much better way to monitor
changes over time and preserve
documentation
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Selective Alerting
• Used system setting in EHR to turn ON all
alerts
• Then use Alert Space to turn OFF all
alerts
• Then selectively turn on ONLY the ones
you want to display
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Long QT and G6PD
• Need to make sure understand clinically
similar terms
• Does take some practice with the system
but re-design has already improved
• Went into prod for these 2 conditions 8
weeks prior to this conference
• Took 4-6 months to get a handle on drug-
drug and drug-disease and do 2-3 rounds
of testing.
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Future
• Need to share the information across
organizations-collective knowledge
• Need to change pattern of alerting to
make it easier to do the right thing rather
than tell provider they did the wrong thing
• Better emphasis on important and
dangerous conditions and make other info
less distracting
• BEERS alerts now in test system
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