PENN CENTER FOR EVIDENCE-BASED PRACTICE

1. PENN CENTER FOR EVIDENCE-BASED PRACTICE Hospital-based Comparative Effectiveness Centers: Improving the Quality, Safety and Cost-Effectiveness of Patient Care Thru Evidence-based Practice at the Systems Level Craig A Umscheid, MD, MSCE, FACP Assistant Professor of Medicine and Epidemiology Director, Center for Evidence-based Practice Medical Director, Clinical Decision Support Senior Associate Director, ECRI-Penn AHRQ EPC TEACH Plenary August 8th, 2013

2. Outline • Case • Defining CER and HTA • Practicing EBM at a “systems” level thru hospital-based HTA • Synthesizing evidence for decision-making • Clinical decision support • Education in EBM • Conclusions

3. Case: Chlorhexidine to Reduce Surgical Site Infections Betadine: 60 cents per patient Chlorhexidine: $13 per patient

4. Usual Decision Making Practices in U.S. Hospitals

5. Usual Practice in U.S. Hospitals (cont)

6. Is there a better way? How about CER and HTA?

7. Comparison of two approaches of care Comparison based on “effectiveness” (i.e. how well an approach works in real world settings) Comparative Effectiveness Research

8. Health Technology Assessment • Also referred to as Healthcare Technology Assessment or Medical Technology Assessment • Form of policy research that systematically examines short and long term consequences of a health technology • Technologies are defined broadly as drugs, devices, procedures, and processes of care • Outcomes can include efficacy, effectiveness, safety, cost, ethical or social consequences • Goal is to inform decision making in policy and practice (as opposed to the goal of research, which is often to contribute to generalizable knowledge) IJTAHC. 25: Supplement 1 (2009)

9. CER, HTA and EBM: Clearing the Confusion

10. What is Hospital-based HTA / CE ?

11. Hospital-based Health Tech Assessment J Gen Intern Med. 2010; 25(12):1352–5.

12. National vs. Local HTA / CE Centers Goals are different: Information for general decision making vs. local decision making. Umscheid et al. JGIM. 2010; 25(12): 1352-55.

13. Drivers of Evidence-based Practice • Stagnant reimbursements and increasing costs • Public reporting and pay-for-performance • Quality and safety of health care Cost-effectiveness of health care spending Evidence Based Practice at the Systems Level

14. Drivers of Evidence-based Practice • Stagnant reimbursements and increasing costs • Public reporting and pay-for-performance • Quality and safety of health care Cost-effectiveness of health care spending Evidence Based Practice at the Systems Level

15. International Models for HB-HTASlides courtesy of Marco Marchetti, Director, HTA Unit, A. Gemelli University Hospital, Rome, Italy

25. Models of HB-HTA in the US

26. Kaiser Permanente (KP) • KP Southern California Region Technology Inquiry Line • KP National Drug Information Service • Interregional New Technologies Committee

27. KP Southern CA Technology Management Process

28. Penn Medicine Center for Evidence-based Practice (CEP)

29. Office of CMO Organizational Chart Penn Medicine CEO Penn Medicine CMO Center for Evidence-based Practice Clinical Effectiveness & Quality Improvement Graduate Medical Education Office of Medical Affairs Office of Patient Affairs Patient Safety Officers Regulatory Affairs Infection Control

30. Center for Evidence-based Practice: Mission and Approach “To support the quality, safety and value of patient care at Penn through evidence-based practice.” • Perform reviews of the medical literature to inform clinical practice, policy, purchasing and formulary decisions in and outside of Penn • Help translate evidence into practice at Penn through computerized clinical decision support (CDS) • Offer education in evidence-based decision making to trainees, staff and faculty in and outside of Penn Umscheid et al. JGIM. 2010; 25(12): 1352-55.

31. Framework for Evidence-based Guidance • Define the clinical issue of concern • Perform systematic search for existing evidence • Identify or develop best practices • Implement best practices • Monitor the impact

32. Clients Served

33. Technologies Reviewed and Report Types

34. Select Evidence Report Topics • Drugs • Celecoxib versus other NSAIDs for post-operative pain control • Colchicine to prevent atrial fibrillation and pericarditis after heart surgery • Diagnostic Tests • Screening tests for risk of hospital readmission • Screening tests for risk of aspiration • Processes of care • Routine replacement of peripheral IVs versus replacement only “as needed” • Post-discharge telephone calls to reduce readmissions • Devices • Indications for robot assisted surgery • Antimicrobial sutures and prevention of surgical site infections

35. CEP Reports by Fiscal Year

36. Dissemination and Implementation (FY07-13)

37. External Collaborations: CDC and AHRQ • Centers for Disease Control and Prevention (CDC) • Infection control guidelines • Agency for Healthcare Research and Quality (AHRQ) • One of 11 centers nationally awarded an “AHRQ Evidence-based Practice Center” contract • Perform evidence reviews to inform clinical practice guidelines and other forms of national healthcare policy

38. Computerized Clinical Decision Support (CDS) “Provides clinicians or patients with knowledge and information, intelligently filtered or presented, to enhance patient care.” • Alerts (e.g., drug allergies or interactions) • Reminders (e.g., about best practices) • Order sets www.himss.org/cdsguide

39. 2012 Annals CDS Review • 148 RCTs • 128 (86%) assessed health care process measures • 29 (20%) assessed clinical outcomes • 22 (15%) assessed costs • Majority of studies were “good” quality • Majority of studies were in academic institutions, ambulatory settings, using locally developed CDS • Both commercially and locally developed CDSs improved health care process measures • Evidence for clinical and economic outcomes was sparse • Few studies measured potential unintended consequences or adverse effects Bright TJ et al. Effect of Clinical Decision-Support Systems: A Systematic Review. Ann Intern Med. 2012;157(1):29-43.

40. Predictors of Improved Practice with CDS • Meta-regression identified success features, including: • integration with charting or order entry system • local user involvement in development • automatic provision of decision support as part of clinician workflow • provision of decision support at time and location of decision-making • provision of a recommendation, not just an assessment Lobach D et al. Evidence Report No. 203. (Prepared by the Duke Evidence-based Practice Center under Contract No. 290-2007-10066-I.) AHRQ Publication No. 12-E001-EF. Rockville, MD: Agency for Healthcare Research and Quality. April 2012.

41. CDS Five Rights Model To improve care outcomes with CDS one must provide: the Right Information… Evidence-based, useful for guiding action …to the Right Stakeholder… Both clinicians and patients …in the Right Format… Alerts, Order Sets, etc. …through the Right Channel… Internet, mobile devices, electronic health records …at the Right Point in the Workflow. To influence key decisions/actions www.himss.org/cdsguide

43. CDS Mission at Penn To continuously improve the safety, quality, and efficiency of patient care by ensuring that providers have the information needed to drive decisions that lead to optimal outcomes.

44. Primary CDS Activities at Penn • Evaluating and prioritizing new CDS proposals • Developing and deploying CDS interventions • Cataloguing and evaluating implemented interventions

45. Structure of Clinical IT Governance Clinical IT Governance Committee Inpatient EMR Committees Outpatient EMR Committees Clinical Decision Support Council Inpt CDS Workgroup Outpt CDS Workgroup

46. CDS Workflow IT Analyst Key Stakeholders IT Report Writer CDS Workgroup Requestor of CDS Intervention CDS Program Officer (PO)

47. CEP CDS Interventions • 35 CEP reports have informed decision support interventions embedded in Penn’s electronic health record, including: • Venous thromboembolism prophylaxis • Readmission risk flag • Foley catheter removal alert • Albumin order set • Red blood cell transfusion order set • Nurse-driven protocol for vaccine assessment and administration • Early warning system for sepsis • Delirium management order set

48. 223 pages! 48

49. CDS to Increase Use of Clot Prevention Meds

50. Clot Prevention CDS (continued)