time to reap: improving quality by harvesting data from the emr

Time to Reap: Improving Quality Time to Reap: Improving Quality by Harvesting Data from the EMRby Harvesting Data from the EMR

Marie J. Eidem, BSMarie J. Eidem, BS

Aaron A. Kurtzhals, BSAaron A. Kurtzhals, BS

James M. Naessens, MPHJames M. Naessens, MPH

Mayo Clinic – Rochester, MNMayo Clinic – Rochester, MN

Mayo Integrated Clinical Systems Mayo Integrated Clinical Systems (MICS)(MICS)

Measuring QualityMeasuring Quality• External External

• JCAHOJCAHO• CMSCMS• LeapfrogLeapfrog• National Quality ForumNational Quality Forum• Blue Cross Blue ShieldBlue Cross Blue Shield• Minnesota Community MeasurementMinnesota Community Measurement• Institute for Healthcare Improvement 100K Lives . . .Institute for Healthcare Improvement 100K Lives . . .

• Internal Internal • Continuous Improvement teams Continuous Improvement teams • Mayo Board of GovernorsMayo Board of Governors• Clinical Practice Quality Oversight CommitteeClinical Practice Quality Oversight Committee• Departmental Quality committees . . . Departmental Quality committees . . .

Study QuestionStudy Question

Can a computer algorithm match the Can a computer algorithm match the accuracy of manual chart review for accuracy of manual chart review for determining whether Pneumococcal determining whether Pneumococcal vaccination was given to hospitalized vaccination was given to hospitalized pneumonia patients (as reported for pneumonia patients (as reported for ORYX Core Measures)?ORYX Core Measures)?

MethodsMethods

• Population:Population:• Inpatients from July 2004-March 2005Inpatients from July 2004-March 2005• Discharge diagnosis of community acquired Discharge diagnosis of community acquired

pneumoniapneumonia• Age>=65Age>=65• N=224 N=224

• Compare measure manually abstracted (RN) vs. Compare measure manually abstracted (RN) vs. result electronically calculated (EMR)result electronically calculated (EMR)

• Second nurse reviewed sample of patients with Second nurse reviewed sample of patients with discrepancies to determine “true” (T) discrepancies to determine “true” (T) immunization statusimmunization status

First Step: Reliable AlgorithmFirst Step: Reliable Algorithm

• The very first attempt was not The very first attempt was not correctcorrect

• Previously collected data, the Previously collected data, the EMR’s audit trail, and the data EMR’s audit trail, and the data generated by the algorithm helped generated by the algorithm helped to find errorsto find errors

• Developing the algorithm was an Developing the algorithm was an iterative processiterative process

Pneumococcal Vaccination Pneumococcal Vaccination Measure for PneumoniaMeasure for Pneumonia

151151 00

4848 2525

Truth

RN

+

+

-

-

Truth+ -

EMR

+

-

197197 33

22 2222

PPV=151/151(100%)

NPV=25/73(34.2%)

PPV=197/200(98.5%)

NPV=22/24(91.6%)

Mayo Integrated Clinical Systems Mayo Integrated Clinical Systems (MICS)(MICS)

• Chart+Chart+

• Clinical Document Management Reports Clinical Document Management Reports (CDM)(CDM)

• Clinical NotesClinical Notes• Hospital SummaryHospital Summary

• Digital DictationDigital Dictation

• Documents BrowserDocuments Browser

• History Location System, Mass (HLSM)History Location System, Mass (HLSM)

• Image Capture Environment (ICE)Image Capture Environment (ICE)

• Master SheetMaster Sheet

• Mayo Single Logon (MSL)Mayo Single Logon (MSL)

• Orders97Orders97

• Patient Appointment Guide (PAG)Patient Appointment Guide (PAG)

• Patient Provided Information (PPI)Patient Provided Information (PPI)

• QREADSQREADS

• Scheduling (GPAS, MSS)Scheduling (GPAS, MSS)

• ShorthandShorthand

• LastWordLastWord• LW Navigation (Home Screens & Chart LW Navigation (Home Screens & Chart

Tabs)Tabs)• AllergiesAllergies• Chart Summary ViewChart Summary View• EpisodesEpisodes• Flowsheet ChartingFlowsheet Charting

• ImmunizationsImmunizations• InBoxInBox• Medication ManagementMedication Management• Orders:Orders:

•Cumulative Orders97 Summary Cumulative Orders97 Summary (COS)(COS)•InpatientInpatient•Plan of CarePlan of Care

• Outside Film & MediaOutside Film & Media• Patient Check-In Locator (PCIL)Patient Check-In Locator (PCIL)• Problem List/Service Recognition (PLSR)Problem List/Service Recognition (PLSR)

• Results and Reports (Viewers/Labs, Results and Reports (Viewers/Labs, Documents Display, Printing, Patient List Documents Display, Printing, Patient List Manager)Manager)

Next StepsNext Steps

• Proceed with pre-filling “positive” immunizations Proceed with pre-filling “positive” immunizations from EMR. from EMR.

• Manually review “negatives” until NPV becomes Manually review “negatives” until NPV becomes acceptable.acceptable.

• Reminders/education on use of Immunization Reminders/education on use of Immunization Module.Module.

• Repeat process with other common quality Repeat process with other common quality measures.measures.

• Develop method to ensure accuracy of EMR-Develop method to ensure accuracy of EMR-based measurement. based measurement.

Lessons LearnedLessons Learned

• Initial algorithm will contain flaws– plan to revise.Initial algorithm will contain flaws– plan to revise.

• Computer can easily determine measure when Computer can easily determine measure when service is performed and documentation service is performed and documentation standards followed.standards followed.

• Verification of EMR-based measures extremely Verification of EMR-based measures extremely valuable.valuable.

• Large sample to establish accuracyLarge sample to establish accuracy• Buy-in from stakeholders to use EMRBuy-in from stakeholders to use EMR

• EMR has wealth of capabilities for quality EMR has wealth of capabilities for quality measurement. measurement.