Promise #2 Improved Quality and Safety

1. Promise #2Improved Quality and Safety Moderator Julie Creamer, Senior Vice President Quality and Planning Panel Carole Cotter, CIO Lifespan Steve Hasley, M.D. Director Clinical Interoperability Decision Support, UPMD Ed Marx, CIO Texas Health Resources Farzad Mostashari, M.D. MSPH Assistant Commissioner, Primary Care Information Project New York City Department of Health and Mental Hygiene Jerry Osheroff, M.D. Chief Clinical Informatics Officer, Thomson Reuters September 25, 2008 Northwestern Memorial HealthCare

2. Agenda • The IT Promise – Improved Quality and Patient Safety • Northwestern’s Quality Agenda • Communicating Impact

3. The IT Promise – Improving Quality and Patient Safety Does IT make a difference? Literature Review • The earliest studies were done at the Regenstrief Institute in the late 1970s, evaluating the effectiveness of CIS on adherence to influenza vaccination. Since then, there have been hundreds of articles seeking to evaluate CIS in various domains: quality, efficiency, and costs. • Neumann, Parente, and Paramore (1996) reviewed eleven studies and presented a consolidated analysis of each. They found that fully automating administrative functions could save between $5 and $8 billion annually. • The “Most Wired” report (Solovy, 2001) by Hospital and Health Networks and Deloitte Consulting shows that “most wired” hospitals have better control of expenses and higher productivity.

4. Impact of HIT on Quality, Efficiency and Costs • 257 studies examined • 63% CDS Systems • 37% Electronic Medical Records • 13% CPOE • 25% of studies came from 4 benchmark organizations with homegrown systems • Conclusion: Whether and how other institutions can achieve the quality and safety benefits demonstrated by the benchmark organizations is unclear. Chaudhry B, Ann Intern Med. 2006;144:E-12-E-22.

5. Benefits of an Integrated EHR with CPOE and CDS • Anytime, anywhere access to legible patient information • Complete legible orders with legible physician signature • Ability to push real time information to clinicians • Enable physicians to be alerted to hazards based on the individual patient’s medical history and current medications • One source of “truth”, although there are potential risks • Elimination of transcription • Improvement turn-around times • Medication • Radiology procedure completion times • Lab result reporting times *Mekhjian HS. J AM Med Inform Assoc. 2002;9:529-539

6. “High rates of ADEs may continue to occur after implementation of CPOE and related computerized medication systems that lack decision support for drug selection, dosing and monitoring.” High Rates of ADEs in Highly Computerized Hospital * Nebeker et al., Arch Intern Med. 2005; 165:1111-1116

7. Medication Studies with CPOE plus CDS • 25% improvement in ordering of corollary orders (medications and labs) (Overhage 1997) • 55% reduction in serious ME, 17% (NS) decrease in preventable ADEs (Bates 1998) • Significant decreases in antibiotic ADEs, susceptibility mismatches, antibiotic costs and total hospital costs (Evans 1998) • 81% reduction in ME (studied in 4 phases) (Bates 1999) • Improvement in 5 prescribing practices (Teich 2000) • 13% and 24% decrease in inappropriate dose and frequency respectively for patients with renal insufficiency (Chertow 2001)

8. Effect of CPOE + CDS on ADEs • Systematic Review • Only 10 studies met inclusion criteria • 7/10 homegrown CPOE/CDS • 50% had a statistically significant improvement in ADEs • 2/3 studies with commercial systems found a significant decrease in ADEs Wolfstadt JI et al. J Gen Intern Med;2008:23(4)”451-8.

9. Technology Can Reduce Errors • Studies demonstrating that technology can reduce rate of errors in three ways • Preventing errors and adverse events • Facilitating a more rapid response after an adverse event • Tracking and providing feedback about adverse events • Strategies for error prevention includes tools to • Improve communication • Make knowledge more readily accessible • Require key pieces of information • Assist with calculations • Perform real time checks • Assist with monitoring • Provide decision support Bates DW& Gawande A, Improving Safety with Information Technology, New England Journal of Medicine, 2003, 348 (25):2526-2534

10. NMHC’s Strategic Plan Has Three Goals That Guide the Organization • To Provide the Best Patient Experience from the Patient’s Perspective • To Recruit, Develop and Retain the Best Peoplewho Share the Organization’s Values and Achieve Results • To Develop the Resources to Achieve Our Mission and Vision Through Exceptional Financial Performance

11. Improving Best Patient Experience Through our Quality Program • Eliminate avoidable adverse events • Deliver evidence-based care • Enable the best possible outcomes

12. NMH’s EHR with CPOE offers a Competitive Advantage for Quality Percentage of Hospitals with CPOE Northwestern Memorial Hospital Reference: KLAS Enterprises, LLC; CPOE Presented by Adam Gale, April 24, 2008, Scottsdale Institute Teleconference.

13. Northwestern Memorial Hospital Provides the Best Patient Experience from the Patient’s Perspective Objectives: Deliver Care That is Safe and Without Error Deliver Effective Care Coordinate Care to Meet Each Patient’s Unique Needs Deliver Care That is Timely and Convenient Deliverables: Top Decile Performance on Publicly Reported Quality Measures Incorporation of “always” practices that are associated with improved outcomes Initiatives/Tactics: Clinical Documentation Standard Order Sets CPOE – Computerized Provider Order Entry Rules and Alerts Outcomes Analysis and Reporting Electronic Medication Administration Record (eMAR)

14. IT Solutions Ranked for Impact *additional factors not related to patient harm include regulatory requirement(s) and/or end-user efficiency RPN = Severity Rank x Occurrence Rank x Detection Rank

15. Shoulder Dystocia Intrauterine pressure is caused by maternal contractions Anterior shoulder impacted on symphysis pubis Brachial plexus stretching DANGER Brachial plexus damage Severe brain damage or death due to hypoxia / acidosis if delay in delivery

16. OB Shoulder Dystocia Improvements • Pre-Planned Emergency Response Protocol • Training Sessions / Drills • Birthing Simulator • IT Enhancements Related to Clinical Documentation

17. Protocol Implemented Protocol Implemented Began Training Began Training Shoulder Dystocia and Brachial Plexus Injury Prevention Brachial Plexus Injuries as a % of Shoulder Dystocias (Lower is Better) Compliance with Protocol Numerator: all newborns whose medical record indicates injury to brachial plexus (ICD9 767.6) and whose mother’s record indicates a shoulder dystocia (ICD9 660.41). Denominator: All cases of shoulder dystocia. Definition: Documented compliance with recommended shoulder dystocia practices for all coded occurrences of shoulder dystocia. Page 17

18. FY2008 Quality Goal Summary Achieve Top Decile Performance on 80% of publicly reported quality measures Achieve 95% - 100% compliance with 80% of targeted safe care practices • Includes 10 safe care practices • Central Venous Catheter Bundle • Pressure Ulcer Prevention • Birth Injury Prevention: 1) Shoulder Dystocia 2) Pitocin Protocol 3) Escalation • Clean Hands • Patient Fall Prevention • Foreign Body Retention Protocol • Operating Room “Time Out” • Accurate Medication Reconciliation • 8 Must Reach or Exceed 95% - 100% Compliance to Achieve Goal • Performance • Baseline: 4/10 • FY08Q1: 3/10 • FY08Q2: 5/10 • FY08Q3: 6/10 • FY08Q4: 8/10 • Includes 32 Publicly Reported Measures • Acute Myocardial Infarction • Pneumonia • Surgical Care • Heart Failure • Coronary Artery Bypass Graft • Patient Satisfaction • 26Must Reach or Exceed Top Decile Performance to Achieve Goal • Performance • Baseline: 13/32 • FY08Q1: 18/32 • FY08Q2: 20/32 • FY08Q3: 24/32 • FY 08Q4: 27/32 92% Enabled by Clinical IT