SHIRE

Evaluation of Clinical Information Technology

CLC 11/17/04

Jeff Newman MD MPH

                                                                                      

Sutter Health Institute for Research & Education (SHIRE)

SHIRE

Information for Action

Health services research linked with:• clinical IT• quality improvement• community benefit

SHIRE

Our Products:• Reports

• Papers

• Proposals

Selected investigator initiated projects:• Patient decision making for prostate ca

• Palliative care

SHIRE

Data SourcesQuantitative

• Administrative e.g. mortality, LOS, financial• IT vendor reports• Primary data collection

-Selected medical record reviews-Surveys

Qualitative• Interviews• Focus groups

SHIRE

SHIRE

Claims

BAR

DataCubes

Finance……HR….. Payroll…..

Utilization Staffing

DataMarts

StandardReports

Standard Data

Definitions

ProductWorkshopTraining

Data

Sto

reS

ub

jec

tM

att

er

s

Pro

du

ct

s

Pro

du

ct

Com

pon

en

ts

Organized By

Consists Of

Create

Enterprise Data Store

SHIRE

Objectives

• Describe eMAP and eICU structure, process, and outcome measures

• Identify opportunities to improve

• Anticipate evaluation of EMR

SHIRE

SHIRE

MD writes and RPh enters Rx

RN confirms and scans Rx

Overrides warning:

Possible Error…,,,,,,,,,,,,

Cancels admin: Possible

Prevented Error

Warnings occur in 42% of admins.

SHIRE

eMAP Methods

• Reports audited at 6 affiliates to confirm prevented & observed errors

• MD, RN, and PharmD panel

(blinded to prevented / observed) rated cases for potential clinical

significance

SHIRE

Medication Administration Errors By Type

Prevented (1.1% of Total Attempted )

No Order in System or No Active Order

27%

Dose Early or Already

Given 47%

Order Discontinued

or Expired 13%

Observed (2.8%)

Dose Early or Already

Given35%

Wrong Dose

26%

No Order in System

21%

SHIRE

Potential Clinical Significance of:

Prevented Errors

91%

8% 1%

Observed Errors

90%

9% 1%

Minimal

Moderate

Severe

SHIRE

Outcomes for 1,000,000Attempted Administrations

1 87 ,000L a te a nd

O m itte d D o seA le rts

2 5 ,100M in im a l

S ig n ifica n ce

2 ,700M o de ra te

S ig n ifica n ce

2 00S e ve re

S ig n ifica n ce

2 8 ,000O b se rved 'E rro rs'

2 55 ,560W a rn in g s O ve rrid d en

1 0 ,100M in im a l

S ig n ifica n ce

8 00M o de ra te

S ig n ifica n ce

1 00S e ve re

S ig n ifica n ce

1 1 ,000P re ven te d 'E rro rs'

7 3 ,640A d m in is tra tio n C a n ce lle d o r A lte red

3 29 ,200W a rn in gs

5 16 ,200W a rn in g s a n d A le rts

SHIRE

eMAP Inputs for OptimizationPhysician Rx - dialogue with pharmacy on

order writing practices • Avoid interval range orders

Pharmacy Database• Allergies• (Labs) • Settings: max dose & grace period

Report filters - Focus on high impact errors• Wrong patient• High-risk drugs, e.g. coumadin, insulin

SHIRE

Benefits of Electronic Medication Administration Record

• Real time information

• Legible and unalterable charting

• Physician access to all inpatient drug profiles from any unit, the lounge and medical records

• Fast access at the bedside

SHIRE

ICU eICU

• Attending • Intensivist • Hospitalist

RNs

MDs

The Importance of eICU Alignment

SHIRE

eICU Components

eCare Manager

Smart Alerts

ICU eICU

Smart Reports

Tele-monitoring

Organization for QI

SHIRE

Increase in ICU Treatments

39%

84% 74%90% 100% 100%

0%20%40%60%80%

100%

Ni ght Or der s Ul cer

P r ophyl axi s

DVT

P r ophyl axi s

Pre eI CU Post eI CU

SHIRE

eICU Outcome MeasuresMortality

• (Complicated by advanced directives)

Complications, e.g. sepsis

Length of stay• (Complicated by disposition problems)

Risk adjustment using Apache

SHIRE

eICU Optimization Activities

Initiate SH-wide ICU clinician network

Extract clinical data from eCareManager • allow confirmation of Smart Reports • evaluation analyses, e.g. stratify process &

outcomes by delegation

More decision support, e.g. alerts for recommended treatments

SHIRE

General Recommendations for Clinical IT

• More involvement of clinical stakeholders in design & evaluation

• Maximize decision support

• Establish “communities of practice”

• Build in analytic databases

• Link with other databases (SHEW): pharmacy, lab, diagnostic

SHIRE

Types of Innovation Adopters and EMR UsersType of Innovation Adopters

Laggards Late Majority Early Majority

Non-adopters

Early Adopters Innovators

EMR adopters

 Type of EMR Users

Viewers System Changers

Basic Users Strivers Arrivers

    

 

SHIRE

Achieving Acceptance of Clinical IT

• Innovators: restraint may be required

• Early adopters: education on benefits

• Early majority: education & motivation

• Late majority: add peer pressure & identification of barriers

• Laggards: remove barriers, train & support