Approach

Although the one-off PPS was successful and provided the proof of concept, Trinity Health could not afford a multihospital implementation, one hospital at a time. So it extracted the learning from the PPS, enhanced the existing decision support system’s (DSS) reporting capabilities, and delivered it through a web-based system for the entire organization (see Case study 2). The defining requirements emerging from the physician-led informatics initiative were as follows:

1. User-friendly design with common data structures for each ministry organization and a metadata level to speed query processing times

2. Enforced reconciliation of data with operational systems to ensure that all information systems provide consistent data

3. Seeking of value-added information such as cost accounting, expected reimbursement, and severity adjustment and assignment—processes that inform physicians about the impact of their decisions

4. Continuous improvement through cross-learning among ministry organizations and application development for quick deployment of best practices

Trinity Health created baseline assessments for disease categories (Table 8.1) to achieve the objectives of the physician-led informatics and to enhance ongoing physician alignment. These objectives were to share an innovative model for depicting individual physician resource utilization, the ability to identify physician variation in the clinical management, and to demonstrate the use of comparative benchmarking.

Results

The results from physicians’ involvement were manifested as lower average length of stay (ALOS) and reduced patient charges. By contrast, among the hospitals where data were yet to be shared with physicians, the ALOS and charges began to increase. Trinity Health continued to monitor outcomes through the utilization collaborative team (UCT). Hospital- and physician-specific scorecards were developed by the UCT and distributed. Figure 8.1 presents a sample physician utilization report.

The utilization-based scorecards compared each physician’s actual versus expected outcomes for ALOS, mortality, and patient charges for services. Comparable metrics for physicians within the specialty as well as other specialties are also reported. Finally, the scorecard presents a breakdown of charges by major categories such as lab, surgical, and pharmacy. Supported by the informatics, the physician and clinical staff practice changes resulted in lower than expected mortality rates as well as patient charges. With 2,932 patients, a drop in 0.32 day per patient in LOS equated to 938 fewer patient days and a reduction of $661.27 per patient in charges resulted in savings of nearly US$1.939 million.

Figure 8.1 A sample physician scorecard.

The deployment of physician-led informatics prompted various feedback comments. Some admitted that they didn’t realize the procedure costs that much, while others found the scorecards helpful and expressed eagerness for the next report. The outcomes in the report card prompted some physicians to review previous patients’ charts and examine why they were in the hospital for that long, resulting in a retrospective learning and ideas about patient safety, improvement in ALOS, and how to contain costs.

Approach

I2S2 was originally planned as an intranet web-based site. The development and maintenance was to be outsourced. However, owing to the projected high costs of development, in-house resources completed the project. The I2S2 design uses content management software. Content management software is most often used for storing, controlling, and publishing industry-specific documentation such as articles, manuals, and guides. The content may include files, graphs, images, databases, and documents with links to other websites (for more information, see htt­p://www.c­ontentmana­ger.eu.com­/history.h­tm). Content management software integrated the interdependent layers of data for managing Trinity Health’s content as well as for publishing the results to any individuals across the organization.

I2S2 recycles automatically every two hours. Costs include the server hardware, the content management software, and the incremental labor from IT and clinical operations staff needed to input content. The benefits clearly outweigh the costs. I2S2 is now a web content management (WCM) system. This simplifies the publication of the web content and allows the domain experts to focus on creating content. The advantage of the WCM-based architecture is the ease of use. Since the majority of contributions are from clinicians, content submission does not require technical knowledge of HTML or file uploads. As a result of the WCM, I2S2 is fully transparent to the more than 50,000 Trinity Health employees who simply have to sign on to the Trinity Health webPage for the vast information resources available to them.

Figure 8.2 I2S2 user interface listing a site map with various categories of information and reports available.

The spectrum of I2S2 content, shown in Figure 8.2, can be logically organized in three primary areas: governance, data requirements, and guidelines and education. The following list provides descriptions of the salient topics for which I2S2 delivers support for decision makers. For each of the three areas, we discuss topics for which information is available.

1. Governance

Excellence in care experience. Patient satisfaction data, employee engagement, and physician satisfaction data are at the core and should be used to improve the overall experience of the patients and their families.

The Advance Practice Institute provides data to promote evidence-based best practices through advanced skills of nursing leaders, development of leadership skills to facilitate and complete projects, and the fostering of networks for creative thinking and issue resolution in the practice of evidence-based care.

Care improvement provides evidence-based tools, strategies, and resources to assist in providing excellence in care for specific clinical conditions such as acute myocardial infarction (AMI), pneumonia, diabetes, heart failure, newborn and neonatal, obstetrics, orthopedics, and vaccine information.

The Clinical Leadership Council provides documentation for value and strategies of Trinity Health clinical services in accordance with the Trinity Health strategic plan. The goal is to develop high-quality and world-class service and to optimize value for the entire health system while maintaining organizational integrity and regulatory compliance. Minutes of monthly meetings and links to evidence-based practices and core clinical indicators are also provided.

2. Data requirements

Data standards connect decision makers to tools and resources related to Trinity Health’s data standardization activities and include the data dictionary, approved abbreviations, dangerous abbreviations, supply chain links, glossary, data elements documents, and charge description master with standards. In addition, the charge description master file contains standardized detailed information on all services provided by the institution, including description, department codes, service code, and so forth.

The Data and Reports section provides views of clinical data, such as core indicator charts, report cards, customer and physician satisfaction data, medication/pharmacy scorecards, and scanning reports. For FY 2009, 28 core indicators are also available for each Trinity Health hospital, as well as other indicators for emergency room care, home care, and long-term care. Decision makers can also access data warehouses and download data for further analysis.

Patient Safety and Potential Error and Event Reporting (PEERs). This site links to best practices and related websites, patient safety tool kits, and numerous quality and safety reports for clinicians, as well as Trinity Health historical safety data. PEERs was designed by Trinity Health physicians, nurses, attorneys, and quality and risk management professionals to capture near-miss and errors/events data. Modeled after NASA’s voluntary reporting system, PEERs is rated very high in the ease of use and ensuring anonymity.

3. Guidelines and education

Medical Staff Resources delivers policies, procedures, links, articles, and more on current issues affecting medical staffs. Links and related topics include credentialing and privileging resources, medical staff by-laws, rules and regulations, medical staff development plans, hospital–physician partnerships, peer review, and physician recruitment and satisfaction development forums.

Fair Market Value. This site provides information to find competitive national survey data and the fair market value narrative that provides a methodology on how to complete a fair market value assessment. The links are in compliance with the Stark II regulations that established a new safe harbor for determining the fair market value of physician compensation.

People and Networks is a resource to find a person who has the information decision makers need to move forward with an idea or project. The clinical operations department provides additional assistance in connecting people. Other items include information pertaining to the Pharmacy Council, the Health Information Management Council, the Educator Network, and related links.

The Physician Practice Management site provides a variety of practice management tools to assist the physician networks in best practice management from a broad spectrum of business disciplines, including finance, operations improvement, compliance, legal, human resource management, planning and marketing, clinical quality, insurance and risk management, and payor contract negotiations.

Sponsored Provider Network provides networking opportunities for executives, controllers, and physician leaders to share best practices in revenue management and expense reduction to drive improved financial and operational performance of the employed primary care physician networks. The meetings are rooted in the application of correct business principles and sharing of management philosophy to develop and achieve performance targets.

The Survey Readiness link connects administrators and clinicians to resources and useful tools for The Joint Commission preparation and continual readiness. It also contains Trinity Health hospitals’ Joint Commission survey highlights, news flashes, and hot topics.

Results

I2S2 has emerged as the go-to online resource for decision makers at Trinity Health. The users span the spectrum of functions across the hospitals. Usage statistics for August 2009 tracked 2,972 average daily hits. More than 901 Pages were viewed by Trinity Health users, who viewed an average of 12.69 Pages per visit. These metrics indicate that I2S2 had indeed been helpful in delivering pertinent information to decision makers. It can be hypothesized that availability of data and the expanse of use contributed to an informed decision maker and resulted in improved performance outcomes.

Trinity Health received the 2004 National Committee for Quality Health Care’s Annual Award. At that time it was only the 12th healthcare system in the United States to be so designated. In 2009, Trinity Health was named as one of the top 10 health systems in the Thomson Reuters 100 Top Hospitals®: Health System Quality/Efficiency Study, which identifies the top U.S. health systems by objectively measuring the clinical quality and efficiency of member hospitals.* terefore, it is reasonable to assume that I2S2 contributed to Trinity Health hospitals’ above national average performance and top decile ranking on many critical measures. This information delivery tool is dynamic and must be updated regularly. To ensure that the information in I2S2 remains current, relevant, and appeals to a wider user base, Trinity Health has instituted a process for reviewing the topical areas and the content available to decision makers, as well as a forum where innovative uses of data are shared.

Each year Trinity Health reviews its quality indicators and targets areas for improvement. Changes in the scientific evidence, data definitions, and public awareness are a few of the several reasons for the periodic review of the I2S2 clinical indicators. Other reasons include improvements in performance and the board’s oversight. Trinity Health has established the following internal criteria for choosing indicators to monitor and disseminate through I2S2.

1. Applicable to multiple reporting organizations (e.g., The Joint Commission/Centers for Medicare & Medicaid Services)

2. Sufficient patientvolume to demonstrate change in performance

3. Emerging opportunities for improvement (includes variation in performance)

4. Evidence of improved process that influences the indicator

5. National norms for indicator are available

6. Alignment of metrics with the Trinity Health strategic plan

7. Burden of data capture does not exceed the value of the indicator

The process of selecting quality indicators involves representatives from each of the MOs, and is subsequently approved by senior management and the board.

In order to assist in this sharing of ideas, the I2S2 People and Networks section enables individuals to identify who to call for assistance. I2S2 has become a virtual library resource for standardized content. Any employee or physician can access the website and view a current or historical document that shows a six-month rolling average performance. A link for each indicator for a particular MO allows the user to drill down and view a 24-month trend graph.

Background

In the 1990s the pressure of managed care challenged U.S. hospitals to ask the following questions: How does a healthcare organization link patient care quality with investment in clinical IT? What part of healthcare is in need for urgent technological support? At about the same time, the issue of adverse drug events or medical errors had gained attention through various publications.^2,3 Subsequent studies examined hospitals’ responses and established that ADEs could be prevented.⁴

Previous research indicates that implementation of computerized ADE systems involves at least three steps: (1) capturing patient data electronically; (2) applying algorithms, rules, and queries to find cases that might be consistent with ADEs; and (3) determining the accuracy of the systems.⁵ Many hospitals have information systems that contain integrated patient encounter data that include demographics, pharmacy orders, and laboratory results.⁶ Some hospitals create their own systems, while others integrate off-the-shelf commercial products. There are two forms of ADE systems. Basic systems perform functions such as drug-allergy checking, dosage guidance, formulary decision support, duplicate therapy checking, and drug-to-drug interaction evaluations. Advanced systems perform more complex functions, including dose adjustment, guidance for medication-related laboratory testing, and drug–disease contraindication flags.⁷

Approach

Trinity Health led the effort to build an advanced ADE alert system with support from a commercial provider, Discern Expert, Cerner Corp., as part of Project Genesis. A rules engine with 17 ADE alert rules was installed. These alerts were triggered using a computerized algorithm after examining demographics, clinical lab values, and medications.

A key assumption to construct an ADE model is that as much as possible, all data about the events and actions taken must be derived and analyzed to develop the model. For instance, the ADE information must include the drugs administered, mode of administering the drug, patient demographics, actions taken, and the result. For an ADE system to be successful, it is imperative that data standards must be developed and followed. The scope of data standardization for the first phase included general laboratory results, pharmacy descriptions/Charge Description Master (CDM), and a partial list of ADT (Patient admitting/discharge/transfer systems)/registration data elements required to support the ADE functionality and patient chart capabilities. However, achieving data standardization is also a political exercise in building consensus. Trinity Health entrusted its Functional and Clinical Councils and Standards Leadership Team with approval from the COO/CFO and Clinical Leadership Council (CLC) oversight groups. The Standards Leadership Council directed the implementation of policies and procedures for change management, audit and reporting mechanisms, and outcome measurement. Data standards have met the requirements and are adjusted to meet the changing business environment.

After literature reviews for medication safety and quality from the pharmacoepidemiological and pharmacoecomonical literature, rules were generated using computerized algorithms to examine demographics with clinical lab values and medications. An example of a rule is presented in the following paragraphs.

Trinity Health ADE Alerts An alert is triggered based on a number of grouped events. A rules engine with 17 of these alerts is generated by computerized algorithms examining patient demographics, clinical lab values, and medications. The ADE alerts are triggered in real time so that any change in medication or lab result will be evaluated as soon as reported. This allows pharmacy intervention immediately and eliminates the possible 12- to 24-hour delay seen before implementation of the system. The pharmacists rely on the system to screen new lab results as they are reported, and this allows the pharmacists to prioritize their workflow to address the most critical issues and patients in a timely manner. The following is an example of this alert process. A pharmacist inputs a physician order for a potassium-containing or potassium-sparing drug. Yet the patient has a lab result for serum potassium > 6.0 mEq/L. Consequently, the potassium medication dose or medication itself needs to be adjusted for these patients because the alert is evoked when a high potassium level is evidenced. Current orders are checked for any of the specified drugs that may cause hyperkalemia.

Trinity Health’s experience suggests that to implement an ADE system successfully, the following conditions must be met.

1. This project must have executive support for the adoption of defined data standards.

2. The data standards must be approved by the senior leadership and implemented organization-wide.

3. .All hospitals and entities must actively participate in the Functional and Clinical Councils.

4. Project participants must provide a timely response to data requests and data review to ensure timely implementation.

5. Following the implementation of data standards, the organization must provide ongoing support of the change management process and commitment to the standards developed.

6. The implementation should be stratified and should be deployed in areas where quick results can be achieved. Learning from such projects can be applied to more complex applications.

7. The recommended model must be accurate, consistent, user-friendly, and compliant with existing computer applications and all governing bodies.

8. Although data standards do not cause any operational changes, redesign efforts must be accommodated in the clinical and patient administration projects.

9. A change management process will be defined and followed to add to the standards. Conformance to standardization will be monitored and reported.

Results

Once buy-in from the stakeholders was achieved, work planning and milestone schedules for the laboratory and pharmacy were established. Trinity Health’s philosophy is to design once, implement many times. The ADE application followed this guiding principle to implement the ADE system across several hospitals. For ease of maintenance and updates, the computing hardware was standardized and the ADE application software was centrally developed. In using the ADE system, Trinity Health focused on evaluating the effects and derived benefits from usage and expected to achieve cost savings and reductions in patient mortality in line with the published literature that decreases in the harmful events save both human lives and money.

The ADE project implementation assigned a project manager, a data manager, a systems technical analyst, a systems business analyst, and an administrative support staff. There were 4.5 FTEs (full-time equivalent employees) at start-up and implementation, and now 2.5 FTEs are assigned for maintenance and reporting. The following are additional activities required by the hospitals to support the ADE project.

In deploying the ADE system among the hospitals, the senior leadership declared that a financial impact analysis was not required. The urgency and the impact on patient mortality outweighed the need for economic justification. As seen in the preceding text, labor was the cost driver for implementing the ADE system. The question then is: How much cost has to be absorbed when the financial benefits are not assessed? For ADEs there are significant financial costs affixed to each event. Yet there are clinical “costs” as well in human pain and suffering, not to mention litigation. Previous literature has cited that each ADE costs about $6,685,⁸ and that computer systems play a decisive role in preventing ADEs.⁹ Thus, there is significant evidence in the literature to support that preventing ADEs can reduce hospital costs in addition to increasing patient care quality.

At Trinity Health the impact of implementing the ADE system was evident principally in the reduction in pharmacy costs, a savings of 5%. These pharmacy cost savings in the targeted hospitals exceeded US$3.5 million. Internal and external control groups demonstrated no such cost savings. There was also evidence of decreases in severity-adjusted LOS and mortality rates.¹⁰