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Using Information Technology to do more with less

By Paul Govern
July 2009

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By adopting new strategies, the health system could find its way to delivering twice the health at half the cost, predicts Bill Stead, M.D., Vanderbilt University Medical Center’s associate vice chancellor for Strategy and Transformation and director of the Vanderbilt Informatics Center.

Stead has evidence to back up this claim.

In 2007, clinical teams working in Vanderbilt University Hospital’s six adult intensive care units adopted practice standards for prevention of ventilator-associated pneumonia, or VAP. Over an ensuing 10-month period, they reduced their combined VAP rate by 41 percent. That reduction represented 13 fewer deaths in those 10 months, and cost savings of between $1.9 million and $3.5 million.

Everyone involved with the VAP initiative points to two decisive elements in its success: consensus among clinicians about standardizing practice, and clinical information technology that allowed teams to self-monitor performance and correct deficiencies before they occurred.

Projects like the VAP initiative encourage those who think the health system can change to accomplish more without additional resources.

To begin, Stead wants to target diabetes; he says it’s reasonable to expect that a region like Middle Tennessee could within 10 years decrease its incidence of diabetes by 25 percent, reduce diabetic comorbid conditions by 30 percent and slash total costs for diabetes by 50 percent.

Stead is enlisting the participation of colleagues across Vanderbilt.

“These targets are bold but they’re not crazy,” he said. “We’re looking at some things that truly will change the game.”

Two years ago, the VUMC leadership team began to engage the Vanderbilt community in an ongoing discussion about strengthening the impact of academic medicine. They foresee Vanderbilt engaging more directly with the world outside the Medical Center. They call this Vision 2020. As Stead goes around engaging people in this discussion, he brings along some uncomforting facts from the medical literature. For example, the United States has one of the highest rates of amenable mortality in the developed world; early mortality is more associated with our behavior than with genetic variation; in the United States, higher health care spending is frequently associated with poorer outcomes; clinicians very often ignore the most well founded of treatment recommendations.

“Vision 2020 is a different way of thinking, where you start by measuring the gap between what is possible and what is currently done, then you figure out how to close the gap,” Stead said.

For Stead, the big opportunity lies in identifying populations at risk, calculating cost savings to be gained by lowering that risk, and developing new forms of targeted health promotion.

Vanderbilt is a powerhouse of clinical information technology development, and many of the IT solutions that could help support work toward Vision 2020 — and, not incidentally, could help avert the foreseen physician shortage — are in use at VUMC and at partner institutions.

At Vanderbilt University Hospital, clinical orders and patient care documentation figure as keystrokes entered in fields within electronic records — entered by doctors, nurses and others in the course of work. From this database, programmers for the VAP initiative channeled information relevant to ventilator care standards into a single screen for each adult ICU. On clinical workstations in these units, the screen saver is now a grid in which rows representing patients intersect columns representing ventilator care standards. This screen, or dashboard, gives teams their performance status with just a glance: a green cell within the grid means the patient is current for that particular standard; a yellow cell means action is needed soon; a red cell means action is overdue.

With the dashboard and with periodic reports showing performance patterns, ICU compliance with the ventilator standards went from 27 percent in November 2007 to 90 percent by March 2008.

Vanderbilt clinicians also use dashboards during the patient visit in the clinic. Based on previous diagnoses, test results and other documentation in the electronic record, dashboards tell clinicians at a glance what the patient may need today in terms of general prevention, geriatric care or diabetes care. Outpatient dashboards are in development for heart disease, congestive heart failure, pregnancy, hypertension and glaucoma.

Electronic patient registries
In 2008, the rate of current colorectal cancer screening among Vanderbilt health plan members seen by Vanderbilt Primary Care physicians increased from 40 percent to 76 percent; current mammograms increased from 46 percent to 78 percent; and pneumonia vaccination increased from 47 percent to 86 percent.

Patient registries were key to these improvement efforts. StarPanel, the electronic medical record and clinic workflow application developed at Vanderbilt, helps nurses at Vanderbilt’s Center for Health Promotion and Disease Management maintain patient registries for diabetes, coronary artery disease, congestive heart failure and chronic obstructive pulmonary disease. The center also maintains registries of patients needing general preventive measures such as colonoscopy and breast exams.

“We use our dashboards during encounters to help us identify gaps in care, but we are also continually using registries to look at our population as a whole, then we work hard to bring patients in when they are due for key prevention and primary care quality targets,” said Jim Jirjis, M.D., M.B.A., chief medical information officer for outpatient clinics.

At the center, seven nurses focus exclusively on work lists generated by the registries. They analyze patient records and contact clinicians and patients to initiate any needed tests or preventive treatment. Communication is aided by a patient letter generator embedded in StarPanel, and by secure messaging both in StarPanel and in Vanderbilt’s patient Web portal, My Health at Vanderbilt.

While dashboards apply to all payers and all patients, the registries and work lists involve payer participation; the current participants include BlueCross, HealthSpring and the Vanderbilt employee health plan.

The center will soon expand beyond Primary Care to serve patients seen by Gastroenterology, Pediatrics, Women’s Health and Cardiology.

My Health at Vanderbilt
When nurses want to prompt a patient with diabetes to undergo testing, they often use My Health at Vanderbilt as their first method of contact.

Approximately 1,800 patients per day log on to myhealthatvanderbilt.com. Sheer convenience may explain why Vanderbilt’s innovative patient Web portal continues to attract users. It offers a single, secure Web site where patients can review lab results, radiological reports and other parts of their medical record, communicate electronically with their doctor and health team, make an appointment, pay their clinic or hospital bills and find useful information about managing their chronic condition and guarding their general health.

“My Health already greatly benefits clinic efficiency, and it has great potential as a tool for engaging patients in self-care and management of chronic disease,” said Jirjis.

Regional health information exchange
In Memphis last October, the Midsouth eHealth Alliance registered its 1 millionth patient. No one flung confetti, but the occasion did represent a growing opportunity in that city to improve health care and lessen the waste of resources.

Vanderbilt anesthesiologists can simultaneously monitor the action in four ORs. They can also pull up each patient’s vital signs, electronic medical record, and real-time anesthesia data. Photo by Jim Lo Scalzo.

Vanderbilt anesthesiologists can simultaneously monitor the action in four ORs. They can also pull up each patient’s vital signs, electronic medical record, and real-time anesthesia data. Photo by Jim Lo Scalzo.

The Alliance (www.midsoutheha.org) is a trailblazing health information exchange project supported by Memphis health care providers, the U.S. Agency for Healthcare Research and Quality, the state of Tennessee and Vanderbilt. The project was conceived and launched by Stead and Tennessee Gov. Phil Bredesen.

The participating providers include hospitals, safety net clinics and one large medical group (University of Tennessee). As they gather patients’ consent to treat, providers offer patients an opportunity to opt out of regional data sharing; as providers create electronic medical records, they securely transmit a copy to a regional data bank, unless the patient has opted out. The system, now in use in safety net clinics and 14 emergency rooms in greater Memphis, retrieves records instantly and presents them to clinicianusers in a consistent, useful format.

With more than 1 million patients now in the system, for each new visit it’s overwhelmingly probable that some amount of clinical information about the patient is available for lookup in the clinic and ER. Records may include clinical notes, discharge information, lab results and other information.

Mark Frisse, M.D., M.B.A., professor of Biomedical Informatics, leads Vanderbilt’s contribution to the Alliance. He sees portable electronic medical records as helping a fragmented U.S. health system to begin to coalesce around the needs of individual patients.

“A revolution is inevitable, the horse is out of the barn. Within a decade people all around the country will have portable electronic medical records. It’s similar to the arrival of the Internet; at some point we realized that these technologies irreversibly and positively changed our lives,” Frisse said.

Anesthesiologists supervise anesthesia for two to four patients at a time, while also evaluating patients before surgery and seeing to patients’ needs in the recovery room after surgery.

In 2004, to aid OR safety and efficiency, a team at Vanderbilt introduced a program that shows anesthesiologists what is happening in each of the rooms they’re covering.

It’s called Vigilance. Anesthesiologists access the program via small portable computers that can fit in a back pocket. The program integrates live video images from the operating room, information from the anesthesia machine and heart monitor, and information from the patient record as it’s updated by the OR team on in-room workstations. Vigilance sends an alert when it spots a risk for injury.

“Seconds can count,” said James M. Berry, M.D., professor of Anesthesiology. “This technology extends our senses so we can virtually be with each patient we’re following.”

Over the past few years, use of Vigilance has begun to spread to ICUs at Vanderbilt.

My-Medi-Health seeks to eliminate the kinks that hinder communication between children, parents and school officials regarding children taking their medications on time and effectively.

“We want to empower kids to be more involved and dismiss the myth that medication management is not a child’s world,” said Kevin Johnson, M.D., vice chair of Biomedical Informatics and project leader for My-Medi-Health.

In Johnson’s pilot program, young cystic fibrosis patients were given a pager that reminded them to take medications, and alerted parents and school officials if a dose was missed. Twenty children between the ages of 5 and 10 were enrolled in the four-month study, and 85 percent of families considered the program successful and wanted to continue.

Encouraged by that result, the team is now developing a portable Web-based personal health record to aid medication administration. The program supports collaboration of the prescribing clinician, the child, the parents and school officials. It features dosage alerts and links to medication warnings. The plan is to integrate the program with pagers and cell phones.

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