Clinical Information: An Expanding World | Pushing Evidence, Best Practices & Analysis to Caregiver
More clinical data from more information systems are flowing into healthcare organizations from additional sources in the continuum of care. With data-handling standards for EHRs and health information exchanges (HIEs) in the works, and expanding federal mandates for reporting—is the definition of clinical information itself changing? That might seem like an academic question, until you consider the national conversations about cumulative radiation dosage, pain management and the expanding base of evidence being called into use at the point of care.
Harnessing that onslaught of clinical information can yield impressive results. In a study published in the Archives of Internal Medicine in 2009, Ruben Amarasingham, MD, MBA, and colleagues found that 41 hospitals that integrated clinical decision support with computerized provider order entry (CPOE) and evidence-based order sets saw a 21 percent reduction in mortality from pneumonia.
“Even if you were to come out with a brand-new antibiotic that no one had seen before, you’d be unlikely to get outcomes that great,” says Jeremy Theal, MD, FRCPC, director of medical informatics and a practicing gastroenterologist at North York General Hospital in Toronto, Canada. “I think dolan clinical decision support is the next big step in patient outcome improvement.”
“I don’t know if the definition is changing, but use of IT is expanding [as] a strong facilitator of progress,” says Jeffrey Weiss, MD, medical director at Montefiore Medical Center, an integrated delivery network (IDN) encompassing four hospitals, more than 20 ambulatory sites and a large home care organization all connected through common clinical information systems.
For example, nationally, “there has been a lot of information about exposure to radiation. Is that clinical information? Historically, I don’t know that it was,” Weiss says. Now, however, Montefiore and other institutions are looking at ways to make clinicians more aware of potential radiation exposure to their patients when ordering imaging tests.
In the past, “maybe you’d change a policy or educate people … but at the point of care, how much penetration is that having when people are busy?” An IT-based tool that alerts clinicians to patients’ prior dose might be a better way, he suggests.
Montefiore is piloting an Internal Review Board-approved research study, “something of a randomized control trial,” studying the efficacy of providing information about a patient’s cumulative dose history to clinicians at the point of care, according to Weiss. This study intends to show whether having this information causes them to order fewer tests that have potential CT radiation exposure.
Montefiore’s effort to maximize use of clinical data began more than a decade ago. The academic medical center and health system deployed a GE Centricity EHR with computerized provider order entry (CPOE) in 1999. CPOE use today at Montefiore is nearly 100 percent, says Weiss, and the organization is leveraging more than 10 years of clinical information integrated through CPOE.
Montefiore’s IT-based clinical information focus evolved out of foresight and necessity: The system is the largest provider in an area of 1.5 million to 2 million people, providing care to a largely underserved population. “We thought being a leader on the IT side would both improve quality and safety, and also move us more quickly into integration and improving continuity of care for a population that could be challenging to manage,” Weiss says.
Clinicians can develop a query, enter it via the Clinical Looking Glass application on their desktop, and quickly build a cohort of patients and see results. The tool can query CPOE data back to 1999, and includes a variety of clinical and operational data including medication, labs, billing and radiology. “It’s research at the point of care and it’s helping to build the next generation of investigators,” he says.
A physician might use the tool to determine what percentage of patients with the same condition have had a particular outcome with a particular treatment, “and within a minute, they have almost a full study that answers that question.
“Over the past few years, the Clinical Looking Glass team has expanded the data and number of useful tools available exponentionally while also making it easier for front-line clinicians to run queries. The result of this, Weiss adds, “is that, in terms of how many people are using it and for how long—the graph is just going up and to the right.”
“We wanted to make sure we took advantage of [clinical decision support and evidence based decision-making] when we built our CPOE systems,” Theal says. “We used Zynx order sets as a starting point for our discussions and for creating evidence-based standardized care within our hospital.” The process at North York started with a clinician-driven clinical transformation project that looked at the hospital’s case mix group, with the goal of covering 80 percent of the most common diagnoses.
“We determined that we needed 300 evidence-based order sets, so we started with Zynx content, and where there wasn’t Zynx content, we built our own, and we took each of those topics and reviewed them on an inter-professional basis” Theal says. The review team involved physicians, nursing, pharmacy, allied health, lab, radiology and clinical informatics: “Each of the order sets was reviewed by the inter-professional team through an asynchronous online process,” he says. “We added additional references where we felt it was necessary.
“We also developed a number of what we called linked evidence documents. … sometimes you need a flow sheet or a chart to simplify particular complex conditions, things like hyponatremia, that are typically difficult to make decisions on. We built evidence-based flow sheets and documents around those conditions and linked those into our order sets as well.”
“Beyond that, whenever we found evidence that a particular process was required to conform to best practices, if we didn’t already have that process established in our hospital, we modified our hospital policies, workflows and clinical decision support to comply with the evidence,” he says. “For example, we developed standardized modules for prevention of veinous thromboembolism and we built into those from the chest guidelines. Even with this evidence available, there was still a chance that doctors could forget to order appropriate prophylaxis. To minimize this risk, we built a custom clinical decision support rule in our Cerner system that alerts and reminds the physician if they haven’t made a decision on prophylaxis for any given patient.”
Theal cites stroke care as another example. Prior to implementation of the system, stroke patients at North York weren’t always assessed for swallowing problems within 24 hours of arrival, because there weren’t enough clinicians who specialized in swallowing assessment.
“When we looked into the evidence more, we discovered that if patients were to get even just a [swallow] screening test within the first 24 hours, that would make a big difference,” he says. “We trained a subset of our nurses to conduct an evidence-based swallowing screening test. Now these nurses can come to the emergency department and conduct the screen. Patients are referred to a swallowing specialist for further assessment if problems are detected during screening.
“We operationalized the evidence that was in the order sets by putting the necessary staff, skills and processes in place. In this way, we ensured the best patient outcomes,” Theal says.
The order set system went live as a big bang implementation in October in all medical/surgical inpatient beds, the critical care unit and post-anesthesia care units. The system is also in use in the emergency department, but only for patients who are admitted and awaiting a bed, he says. “Since then, we have 94 to 96 percent of orders being placed electronically by physicians.”
Going forward, Theal envisions North York leveraging the clinical information and tools now in place to bolster patient outcome improvement and quality improvement, he says.
Although Winchester Hospital has had CPOE (Meditech’s Provider Order Management module integrated with other clinical applications) since 2007, ramp-up has been a gradual process. That hasn’t stopped clinical information expansion at the 229-bed acute-care facility located north of Boston, which also provides home care services. Winchester Hospital’s experience typifies some of the issues that many facilities face when expanding their electronic systems to capture and analyze more data.
“On the physician office side, we have a very large [EHR] penetration among primary care physicians—over 70 percent of practices have an EHR of some type,” says Gerald Greeley, director of information services at Winchester Hospital. “The problem is, there are 18 different EHRs in our system. eClinicalWorks has the largest volume, but there are many others in play as well.”
Winchester uses a Medicity infrastructure to interface these disparate systems with the hospital’s Meditech Magic-based EHR, Greeley says. On the inpatient side, Winchester has had electronic nursing documentation in place since 2004, and installed a medication administration module about a year after that, he says.
“We started CPOE in 2007,” and adoption has been slow since then—currently, 45 to 50 percent of orders are being entered electronically within the hospital; surgery is just coming online now, according to Greeley.
“We’re collecting a lot of data and have been doing so in OB for nine years. Using GE’s Centricity OB/Perinatal, doctors and nurses have been consistently documenting deliveries,” he says. “There’s a lot happening on the inpatient side of the house. We don’t have an ED system, and we see more than 50,000 visits [annually], and it’s a huge percentage of our admissions. There’s a recognition that we need a system in the ED, [but] there’s the whole question of best-of-breed or integrated solution or home-grown.”
The hospital also is installing an Elekta Mosaic oncology information system, slated to go live in the spring. “We’re in the planning/beginning implementation [phase] right now. That will be a key place that we move to next” in terms of clinical information expansion, he says.
“Most of our quality data are pulled from the Meditech system into a variety of different reporting systems [and] we use an older cost-accounting system to do some business decision support,” says Greeley. “We do a lot of analysis now based on tools we have within our McKesson TrendSter cost-accounting system and decision support as well as what we’re doing in [clinical quality] improvement. A lot of it is downloading data and manipulating and viewing it there.”
“As far as direct dashboards and databases, leaders work on them manually and daily ... we’re not there yet, but we have a significant amount of data analysis being done in a variety of areas [and] quality and patient safety are part of that,” says Greeley.
For example, a few years ago, Winchester Hospital’s board of directors set a goal of eliminating five categories of preventable harm—fall with serious injury, surgical site infection, serious medication error, central line blood stream infection and ventilator-associated pneumonia—by the end of 2011. Since that goal was instituted, “we have been using clinical data to look at our [incidents that caused] preventable harm,” says Greeley. “Our goal over the past few years was to reduce them by half each year. This year, we were down to four preventable harm events in those categories … and our corporate success factor in this coming fiscal year is to eliminate all preventable harm.”
The year-over-year improvement is all based on data captured by a variety of different formats, from infection control, quality management, the OR and other departments. These data are being used to analyze and improve care. “It’s not some massive single database that everybody’s drilling down into, but it is being sourced from the clinical care documentation that they’re doing,” Greeley says.
Clearly there are more ways to extend clinical data and all have their advantages. “It’s an evolving landscape. Our sense [is that] to be an integrated delivery system that takes care of a whole population of patients, it’s essential to optimize the use of IT,” says Montefiore’s Weiss.
Harnessing that onslaught of clinical information can yield impressive results. In a study published in the Archives of Internal Medicine in 2009, Ruben Amarasingham, MD, MBA, and colleagues found that 41 hospitals that integrated clinical decision support with computerized provider order entry (CPOE) and evidence-based order sets saw a 21 percent reduction in mortality from pneumonia.
“Even if you were to come out with a brand-new antibiotic that no one had seen before, you’d be unlikely to get outcomes that great,” says Jeremy Theal, MD, FRCPC, director of medical informatics and a practicing gastroenterologist at North York General Hospital in Toronto, Canada. “I think dolan clinical decision support is the next big step in patient outcome improvement.”
“I don’t know if the definition is changing, but use of IT is expanding [as] a strong facilitator of progress,” says Jeffrey Weiss, MD, medical director at Montefiore Medical Center, an integrated delivery network (IDN) encompassing four hospitals, more than 20 ambulatory sites and a large home care organization all connected through common clinical information systems.
For example, nationally, “there has been a lot of information about exposure to radiation. Is that clinical information? Historically, I don’t know that it was,” Weiss says. Now, however, Montefiore and other institutions are looking at ways to make clinicians more aware of potential radiation exposure to their patients when ordering imaging tests.
In the past, “maybe you’d change a policy or educate people … but at the point of care, how much penetration is that having when people are busy?” An IT-based tool that alerts clinicians to patients’ prior dose might be a better way, he suggests.
Montefiore is piloting an Internal Review Board-approved research study, “something of a randomized control trial,” studying the efficacy of providing information about a patient’s cumulative dose history to clinicians at the point of care, according to Weiss. This study intends to show whether having this information causes them to order fewer tests that have potential CT radiation exposure.
Montefiore’s effort to maximize use of clinical data began more than a decade ago. The academic medical center and health system deployed a GE Centricity EHR with computerized provider order entry (CPOE) in 1999. CPOE use today at Montefiore is nearly 100 percent, says Weiss, and the organization is leveraging more than 10 years of clinical information integrated through CPOE.
Montefiore’s IT-based clinical information focus evolved out of foresight and necessity: The system is the largest provider in an area of 1.5 million to 2 million people, providing care to a largely underserved population. “We thought being a leader on the IT side would both improve quality and safety, and also move us more quickly into integration and improving continuity of care for a population that could be challenging to manage,” Weiss says.
Fast-lane research
To get the latest information to clinicians as quickly as possible, Montefiore’s IT department developed Clinical Looking Glass, a home-grown data mining tool that replicates data from the EHR for analysis. “We run queries off a replicated dataset so it doesn’t interfere with the day-to-day clinical workings of our operations,” says Weiss. “But it is right at your fingertips at your desktop.”| Clinical Quality Measure Reporting: Specs Take Shape |
| Whether or not the definition of clinical information is changing, the standards community is hammering out an end-to-end process for quality measure reporting. These standards will push clinical information from EHRs to external quality reporting entities and pull information from external sources, further enhancing clinical decision support. • Stage 1 meaningful use requirements stipulate that certified EHRs must be able to generate HL7 Continuity of Care Document (CCD)-formatted data; within the CCD, EHRs must be capable of sending structured problems, medications and possibly procedures, according to Bob Dolin, MD, FACP, FACMI, chair of Health Level 7. Dolin, who is also principle at Semantically Yours, LLC, made his comments during a HIMSS webinar on standards efforts. There are two key elements of this effort. The first are eMeasures—non-patient-specific, formal representations of quality measures—which express measures in a standard format (the HL7 Health Quality Measures Format, or HL7 eMeasure standard). These can be turned into queries that can automatically search EHRs’ data stores and generate reports for internal use or for external reports to quality organizations. • The second element is a standard for quality reporting: HL7 CDA R2 Quality Reporting Document Architecture, or QRDA. QRDA is an implementation guide enabling Clinical Document Architecture (CDA)-formatted electronic documents to communicate population data or individual patient. QRDA includes individual patient data and lays out patient-level data elements sufficient to compute eMeasure criteria, such as age, encounter, encounter admit date, encounter discharge diagnosis, access to problem list, and discharge medications, according to Dolin. QRDA Category 1 is an official HL7 draft standard for trial use (single patient report). Category 2 (patient list report) and Category 3 (calculated report) are in draft form but have not been balloted, Dolin says. |
A physician might use the tool to determine what percentage of patients with the same condition have had a particular outcome with a particular treatment, “and within a minute, they have almost a full study that answers that question.
“Over the past few years, the Clinical Looking Glass team has expanded the data and number of useful tools available exponentionally while also making it easier for front-line clinicians to run queries. The result of this, Weiss adds, “is that, in terms of how many people are using it and for how long—the graph is just going up and to the right.”
Order sets in order
North York General Hospital, a multi-site regional teaching hospital serving north-central Toronto and southern York, Ontario, also is leveraging CPOE to maximize clinical information, according to Theal.“We wanted to make sure we took advantage of [clinical decision support and evidence based decision-making] when we built our CPOE systems,” Theal says. “We used Zynx order sets as a starting point for our discussions and for creating evidence-based standardized care within our hospital.” The process at North York started with a clinician-driven clinical transformation project that looked at the hospital’s case mix group, with the goal of covering 80 percent of the most common diagnoses.
“We determined that we needed 300 evidence-based order sets, so we started with Zynx content, and where there wasn’t Zynx content, we built our own, and we took each of those topics and reviewed them on an inter-professional basis” Theal says. The review team involved physicians, nursing, pharmacy, allied health, lab, radiology and clinical informatics: “Each of the order sets was reviewed by the inter-professional team through an asynchronous online process,” he says. “We added additional references where we felt it was necessary.
“We also developed a number of what we called linked evidence documents. … sometimes you need a flow sheet or a chart to simplify particular complex conditions, things like hyponatremia, that are typically difficult to make decisions on. We built evidence-based flow sheets and documents around those conditions and linked those into our order sets as well.”
“Beyond that, whenever we found evidence that a particular process was required to conform to best practices, if we didn’t already have that process established in our hospital, we modified our hospital policies, workflows and clinical decision support to comply with the evidence,” he says. “For example, we developed standardized modules for prevention of veinous thromboembolism and we built into those from the chest guidelines. Even with this evidence available, there was still a chance that doctors could forget to order appropriate prophylaxis. To minimize this risk, we built a custom clinical decision support rule in our Cerner system that alerts and reminds the physician if they haven’t made a decision on prophylaxis for any given patient.”
Theal cites stroke care as another example. Prior to implementation of the system, stroke patients at North York weren’t always assessed for swallowing problems within 24 hours of arrival, because there weren’t enough clinicians who specialized in swallowing assessment.
“When we looked into the evidence more, we discovered that if patients were to get even just a [swallow] screening test within the first 24 hours, that would make a big difference,” he says. “We trained a subset of our nurses to conduct an evidence-based swallowing screening test. Now these nurses can come to the emergency department and conduct the screen. Patients are referred to a swallowing specialist for further assessment if problems are detected during screening.
“We operationalized the evidence that was in the order sets by putting the necessary staff, skills and processes in place. In this way, we ensured the best patient outcomes,” Theal says.
The order set system went live as a big bang implementation in October in all medical/surgical inpatient beds, the critical care unit and post-anesthesia care units. The system is also in use in the emergency department, but only for patients who are admitted and awaiting a bed, he says. “Since then, we have 94 to 96 percent of orders being placed electronically by physicians.”
Going forward, Theal envisions North York leveraging the clinical information and tools now in place to bolster patient outcome improvement and quality improvement, he says.
CPOE isn’t the only gateway
| A Clinical Data Challenge in Utah |
| EHRs can potentially share a wealth of clinical information, and have a role to play in expanding and maximizing clinical data use. However, a high rate of EHR adoption doesn’t guarantee smooth sailing toward a health information exchange (HIE), according to Jan Root, PhD, president of Utah Health Information Network (UHIN), the state’s designated HIE. The clinical Health Information Exchange (cHIE), as it’s called in Utah, is tasked with getting Utah providers on board and sharing data. “Our administrative business is strong and growing, [but] our clinical [area] is like watching a 747 take off in slow motion,” says Root. “Right now, it’s about an inch off the runway: We have the four major hospital systems on board [and] we’re just having an explosion in people who are now willing to try to figure out how to get their EHR connected to the cHIE.” There are some financial bumps to be cleared. “One of the challenges we have in Utah is we have very high EHR adoption rate for primary care docs—somewhere between 60 and 70 percent of the docs already have an EHR. Of course, they’re not on the same EHR,” she says. “Everyone’s gone out and bought their own. “We really try to encourage people to be data sources as well as data users. So the doc goes and talks to the EHR vendor, and the vendor says, ‘great, no problem, that’ll be fifteen-grand’ [to supply data to the cHIE].” UHIN, with help from the Statewide Cooperative Agreement and Beacon Community programs and a couple of other federal funding sources, has started a grant program to help physicians connect to the cHIE. “We’ve dispensed somewhere close to $400,000 in funds to help docs get connected. That’s one of our challenges,” says Root. |
“On the physician office side, we have a very large [EHR] penetration among primary care physicians—over 70 percent of practices have an EHR of some type,” says Gerald Greeley, director of information services at Winchester Hospital. “The problem is, there are 18 different EHRs in our system. eClinicalWorks has the largest volume, but there are many others in play as well.”
Winchester uses a Medicity infrastructure to interface these disparate systems with the hospital’s Meditech Magic-based EHR, Greeley says. On the inpatient side, Winchester has had electronic nursing documentation in place since 2004, and installed a medication administration module about a year after that, he says.
“We started CPOE in 2007,” and adoption has been slow since then—currently, 45 to 50 percent of orders are being entered electronically within the hospital; surgery is just coming online now, according to Greeley.
“We’re collecting a lot of data and have been doing so in OB for nine years. Using GE’s Centricity OB/Perinatal, doctors and nurses have been consistently documenting deliveries,” he says. “There’s a lot happening on the inpatient side of the house. We don’t have an ED system, and we see more than 50,000 visits [annually], and it’s a huge percentage of our admissions. There’s a recognition that we need a system in the ED, [but] there’s the whole question of best-of-breed or integrated solution or home-grown.”
The hospital also is installing an Elekta Mosaic oncology information system, slated to go live in the spring. “We’re in the planning/beginning implementation [phase] right now. That will be a key place that we move to next” in terms of clinical information expansion, he says.
“Most of our quality data are pulled from the Meditech system into a variety of different reporting systems [and] we use an older cost-accounting system to do some business decision support,” says Greeley. “We do a lot of analysis now based on tools we have within our McKesson TrendSter cost-accounting system and decision support as well as what we’re doing in [clinical quality] improvement. A lot of it is downloading data and manipulating and viewing it there.”
“As far as direct dashboards and databases, leaders work on them manually and daily ... we’re not there yet, but we have a significant amount of data analysis being done in a variety of areas [and] quality and patient safety are part of that,” says Greeley.
For example, a few years ago, Winchester Hospital’s board of directors set a goal of eliminating five categories of preventable harm—fall with serious injury, surgical site infection, serious medication error, central line blood stream infection and ventilator-associated pneumonia—by the end of 2011. Since that goal was instituted, “we have been using clinical data to look at our [incidents that caused] preventable harm,” says Greeley. “Our goal over the past few years was to reduce them by half each year. This year, we were down to four preventable harm events in those categories … and our corporate success factor in this coming fiscal year is to eliminate all preventable harm.”
The year-over-year improvement is all based on data captured by a variety of different formats, from infection control, quality management, the OR and other departments. These data are being used to analyze and improve care. “It’s not some massive single database that everybody’s drilling down into, but it is being sourced from the clinical care documentation that they’re doing,” Greeley says.
Clearly there are more ways to extend clinical data and all have their advantages. “It’s an evolving landscape. Our sense [is that] to be an integrated delivery system that takes care of a whole population of patients, it’s essential to optimize the use of IT,” says Montefiore’s Weiss.