Lessons in clin­i­cal per­for­mance

In­for­mati­cists dis­cuss fi­nan­cial pres­sures, CPOE com­pli­ance chal­lenges

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Edi­tor’s note: The fol­low­ing is an edited ex­cerpt of the tran­script of an ed­i­to­rial we­b­cast, “Im­prov­ing pa­tient care, by the num­bers,” con­ducted by Mod­ern Health­care on Nov. 17. The three pan­elists were named to Mod­ern Health­care’s inaugural list of the Top 25 Clin­i­cal In­for­mati­cists in Health­care. They dis­cussed the role of clin­i­cal in­for­mati­cists in im­prov­ing their or­ga­ni­za­tion’s clin­i­cal per­for­mance and the con­nec­tion be­tween clin­i­cal per­for­mance and fi­nan­cial re­sults. The pan­elists were El­iz­a­beth John­son, vice pres­i­dent of ap­plied clin­i­cal in­for­mat­ics at Tenet Health­care Corp.; Ge­orge Reynolds, vice pres­i­dent and chief med­i­cal in­for­mat­ics of­fi­cer at Chil­dren’s Hos­pi­tal & Med­i­cal Cen­ter in Omaha, Neb.; and Christo­pher Sny­der, chief med­i­cal in­for­ma­tion of­fi­cer and med­i­cal di­rec­tor of per­for­mance im­prove­ment at Penin­sula Re­gional Med­i­cal Cen­ter in Sal­is­bury, Md. Mod­ern Health­care re­porter Mau­reen McKin­ney mod­er­ated the we­b­cast.

Mau­reen McKin­ney: Dr. Sny­der, have any physi­cians de­clined to use the manda­tory CPOE tools and how did you ad­dress it? What were some of the ways that you’ve en­cour­aged com­pli­ance?

Christo­pher Sny­der: The ways we’ve en­cour­aged com­pli­ance is it’s been pretty much one-on-one train­ing with my­self and all the med­i­cal staff. And I have a daily uti­liza­tion re­port I look at with the docs, and I ac­tu­ally show that re­port at all depart­ment meet­ings, so we use a fair amount of peer pres­sure.

When we were first start­ing to roll out five, six years ago, it was much more dif­fi­cult. Ob­vi­ously in 2011 we have a much greater in­cen­tive with mean­ing­ful use and just the fi­nan­cial ben­e­fits of those things, plus also the fact that ev­ery­body’s look­ing at it. And I think that re­ally you have to preach safety. We’ve al­ways preached safety from the board down. And wher­ever I’ve gone to these guys, we may throw in movie tick­ets here or there just as kind of a fun thing, but the ma­jor­ity of the time it was one-on-one, say­ing, ‘Hey, you know this is safer.’

And in ’08, when (a doc­tor) said to me, ‘Prove it.’ That was a very chal­leng­ing task, but I hon­estly thanked him for do­ing that be­cause he re­ally pushed me to want to show that we could make a dif­fer­ence. But I think the safety thing—most physi­cians, most nurses, most clin­i­cal folks re­ally do want to make things bet­ter. And if you can, again, show them the money with the data as far as show­ing safety im­prove­ments, it just has a huge im­pact on the med­i­cal staff.

And what do I do with the re­fusers? I con­front them with their data, and then I bring them up in front of MAC and let them ex­plain to us why they’re not us­ing a safer tool.

McKin­ney: Dr. Reynolds, for smaller hos­pi­tals that are think­ing about start­ing to de­velop a clin­i­cal an­a­lyt­ics pro­gram, do you have any ad­vice or feed­back for them?

Ge­orge Reynolds: Great ques­tion. I think the first thing is to de­velop a phi­los­o­phy. Our phi­los­o­phy at the very be­gin­ning was: If the data is avail­able—if the data is recorded elec­tron­i­cally, it should be avail­able. There’s no way that we’re go­ing to in­vest in these sys­tems and then have them kind of be an ATM you can put money into but never get money out of. We wanted the data back out.

It re­quires a fair amount of work at the front end to un­der­stand what the data struc­ture of your EMR is. In our case, we ac­tu­ally have a dif­fer­ent EMR on the am­bu­la­tory side than on the in­pa­tient side, so much of this was driven out of our data ware­house strat­egy. But I think my ad­vice would be: Start with ques­tions that peo­ple care about. The tools we use are com- mer­cially avail­able off-the-shelf tools. It’s not any­thing that we’ve cus­tom-de­signed or any­thing like that. It’s not that hard to get started.

McKin­ney: I have an au­di­ence ques­tion for Liz John­son. How do you guard against let­ting fi­nan­cial con­sid­er­a­tions seep into clin­i­cal de­ci­sion­mak­ing given that the data are used to watch costs as well as monitor qual­ity of care?

El­iz­a­beth John­son: I’m not sure I have a ter­rific an­swer for that, be­cause it’s not been a prob­lem yet. And I cer­tainly un­der­stand and re­spect the ques­tion.

What we have been so driven by the abil­ity to im­prove the qual­ity of pa­tient care, that al­though we cer­tainly are get­ting asked to pro­duce the fi­nan­cial out­put. … we know that it’s very dif­fi­cult to say that be­cause we avoided an event, this is the cost we avoided, be­cause it is a aca­demic ex­er­cise. But yet we can make some sort of cog­ni­tive leap to the fact that if we avoid 4,000 er­rors over a mil­lion pa­tient lives, then we do a sci­en­tific for­mula to say this is how much we avoided.

But the truth is, it’s be­cause our board and med­i­cal staff are so driven to im­prove the qual­ity of the pa­tient care, and frankly the other part of it is our clin­i­cians are say­ing, ‘It is crit­i­cal that we have these tools to be bet­ter clin­i­cians, that we think we can do a bet­ter job.’

So, frankly, I haven’t had to face it. Again, we’re go­ing to mea­sure it, but I think our fi­nan­cial peo­ple are more com­fort­able around things like re­duc­tion of paper, if there are some clin­i­cal hours that can be saved be­cause we’re us­ing the abil­ity to down­load clin­i­cal data. And there­fore it takes fewer peo­ple to ren­der care.

Again, we’re not be­ing held ac­count­able to a tar­get at this point be­cause I think they are more in­ter­ested in get­ting the value that they be­lieve in de­liv­er­ing the qual­ity of care.

Sny­der

Reynolds

John­son

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