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If safety net hospitals are not often described as “wired,” Truman Medical Centers (TMC), Kansas City, Mo, is an exception. Although similar organizations across the country have struggled to make IT investments, leaders at TMC recognize that they can leverage technology to improve care for underserved patients and reduce the cost of care at their two safety-net hospitals in western Missouri.
Jeffrey Hackman, MD, chief medical information officer (in gray checked shirt), leads a multidisciplinary team of clinical analysts, nurse informaticists, wound care nurses, and other professionals at Truman Medical Centers who collaborate on IT-focused quality improvement initiatives. (Photo: Truman Medical Centers)
“Making sound IT investments is difficult for all healthcare organizations, particularly safety net hospitals that need to stretch every dollar,” says Jeffrey Hackman, MD, chief medical information officer. “Fortunately, we have had leaders who recognize the potential value of these investments.”
In fact, IT-focused clinical improvements at TMC have created nearly $8 million in savings since the organization’s electronic health record (EHR) went live in 2010. Those savings matters because TMC provides 11 percent of all uncompensated care in the state, at an annual cost of $134 million.
In 2009, leaders at TMC embarked on a 13-month journey to move from a hybrid paper-digital medical record to a complete EHR. At the same time, the organization chose to test the value of using the EHR to support key quality-improvement efforts, including reducing three HACs: pressure ulcers, central line-associated bloodstream infections (CLABSIs), and venous thromboembolisms (VTEs). “We knew we had opportunities to reduce hospital-acquired conditions, and we were already embarking on some work-flow changes in these areas that were separate from the EHR,” Hackman says. “We thought by showing improvements in patient care and reduced costs, we could show there was value in the technology as we were ramping up to roll out the full EHR.”
The work has paid off: TMC reduced pressure ulcers by 78 percent, creating approximately $4 million in savings in four years. The organization also cut VTEs by 75 percent, saving approximately $1.1 million, and reduced CLABSIs by 74 percent from 12.1 to 3.1 infections per 1,000 device days, for a cost savings of approximately $1.9 million.
Hospital-Acquired Pressure Ulcer Reduction
As a result of its efforts, TMC received a 2014 HIMSS Enterprise Davies Award from the Healthcare Information Management Systems Society, which recognizes organizations that have used health IT to improve outcomes while achieving an ROI. In 2015, TMC was recognized as one of the “Most Wired” hospitals for the fifth consecutive year by the American Hospital Association and the College of Healthcare Information Management Executives (CHIME).
Hackman says TMC achieved its success by following a series of steps.
Start with the projects that offer the most promise. TMC has an enterprise technology council composed of clinical, financial, and IT leaders who prioritize various technology-related projects across the organization.
Even though TMC’s CEO backed early efforts to reduce HACs because doing so would improve patient care, leaders still had to complete robust ROI evaluations before spending the time and money to build new work flows.
Form a collaborative team to evaluate how physicians and nurses work. For the pressure ulcer initiative, physicians, nurse informaticists, wound care nurses, front-line nurses, physical therapists, clinical analysts, and other professionals worked together to identify how they could support staff better in their efforts to prevent pressure ulcers. For example, they suggested a protocol to measure pressure ulcer risk using the Braden scale, the preferred risk-assessment tool. The team also proposed a process in the EHR that automatically triggers consults with a nutritionist or wound care nurse for high-risk patients.
Similar teams were built to focus on CLABSI and VTEs.
Change work flows as needed. The team developed a number of new work flows designed to change staff behavior and, ultimately, reduce HACs. To prevent CLABSIs, the team had two goals: ensuring nurses followed best-practice guidelines for central line insertion and improving timely removal. “The longer a central line is left in a patient, the greater the chance of complications,” Hackman says. Leaders at TMC implemented a change that required nurses to document in the EHR why a central line was still left in a patient each day. “If nurses are unable to document a reason why the central line is needed, the EHR prompts the nurse as well as the physician to evaluate if it needs to be removed,” Hackman says. “Rather than relying on someone’s memory, we are hardwiring that into the process.”
Educate staff on the issues, not just the technology. “We have always tried to teach staff both the technology and the process changes that are needed to improve patient care,” Hackman says. For example, in the pressure-ulcer prevention initiative, training was co-led by the clinical analyst from IT who worked on the EHR work flows and by the wound care nurses. “The wound care nurses explained the clinical issues and why we were making the changes to our work flows,” Hackman adds. “When staff understood those aspects, they were much more receptive to making IT changes.”
Education took several forms, including classroom training, online training, and email blasts.
Offer support after the “go live” date. For a week after the new work flows were implemented in the EHR, IT staff and clinical experts such as wound care nurses staffed a round-the-clock command center to answer any questions.
Designate champions on each unit. Wound care nurses trained front-line nurses to serve as pressure-ulcer prevention experts on every floor. Their role is to provide immediate support to staff when a wound care nurse is not available.
Use actionable alerts. Making the EHR user-friendly is a key goal for TMC’s IT team. “Whenever we create an alert in the EHR, we try to make it so that the provider can take action from that screen,” Hackman says. “For example, if a provider orders a medication that is contraindicated for the patient, he or she can cancel that order in the same screen as the alert.” Hackman also favors what he calls “intentionally interruptive” alerts that the provider cannot ignore for high-risk conditions, such as VTEs. For example, if a provider clicks “OK” on a VTE alert, the EHR will automatically launch a VTE assessment rather than allowing the provider to bypass the alert.
Include medical students in design sessions, if applicable. Hackman says one of the mistakes TMC made along the way was failing to solicit input from some of its 600-plus medical students, who use the EHR with the same frequency as staff. As a result, leaders had to step back and reengineer a few key work flows to reflect medical students’ feedback.
Use the EHR to monitor performance. After the EHR went live, data revealed that medical devices caused nearly one-third of pressure ulcers. Wound care nurses at TMC conducted an environmental study that identified 52 specific medical devices that caused pressure ulcers. One of the worst culprits was oxygen tubing, which sometimes triggered facial ulcers. Nurses worked with supply chain leaders to identify a different brand of tubing that was slightly more expensive but less likely to cause facial ulcers.
Now that TMC’s EHR is fully implemented, Hackman says, leaders have been stepping up their efforts to use analytics tools to proactively identify patients most at risk for developing HACs. For example, the EHR automatically alerts nurses when they have an underweight patient who requires prolonged bed rest, indicating the patient likely is at higher risk for developing pressure ulcers. Once alerted, nurses can determine whether they should develop a pressure-ulcer prevention care plan for the patient. The system also automatically alerts either the wound care nurse or a physical therapist that the patient may be at risk.
Similar EHR alerts have been developed to alert the appropriate staff if a patient is at high risk for developing sepsis.
Leaders at TMC regularly report the performance of their quality improvement projects, as well as associated cost savings, to staff along with the C-suite. “Sustainability becomes less of an issue when you can show there are clinical benefits to an IT project,” Hackman says. “When people see that the work reduces complications for patients and makes hospital stays less expensive, they are much more willing to continue that work.”
Laura Ramos Hegwer is a freelance writer and editor based in Lake Bluff, Ill.
Interviewed for this article:
Jeffrey Hackman, MD, chief medical information officer, Truman Medical Centers, Kansas City, Mo.
This article is based in part on a presentation at HIMSS15, April 2015, Chicago.
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