Technology expands data-gathering ability across an episode of care

Can now track outcomes across continuum of care

Going a step beyond the mere collection and analysis of outcomes data, three health systems known for being ahead of the curve in the quality game are actually mining their outcomes data, turning the ore of raw numbers into information worth its weight in gold.

They are using state-of-the-art technology to determine what routines, practices, and treatments are correlated statistically with the best patient outcomes and to look for opportunities to improve processes to increase their value to patients.

While ScrippsHealth in San Diego, Group Health Cooperative of Puget Sound in Seattle, and Intermountain Health Care in Salt Lake City differ dramatically in the technology they use and what they do with that technology, all three are extremely effective at using data. They share several strategies and goals:

• The desire to promote preventive medical care plays a large part in their efforts.

• They are stressing the importance of tracking patient care across the continuum, from physicians’ offices to hospitals to home health.

• Their outcomes work involves two-way communication with providers.

ScrippsHealth is preparing for the future now by developing a systemwide database. The six-hospital system started its manual CareTrac patient outcomes documentation system in October 1991 by tracking open-heart surgery patients at Scripps Memorial Hospital in La Jolla, CA. The system includes multidisciplinary standards of practice, preprinted physician orders, a critical pathway, and a family/patient education pathway. Now there are more than 30 diagnoses or procedures in the system, says Donna Nolten, MN, RNC, CNA, systemwide manager of clinical programs at ScrippsHealth.

In the beginning, with just a few pathways, Nolten says her department was successful in tracking a great number of detailed outcomes.

"We started out trying to measure everything known to man on every one of our pathways. We were trying to collect information concurrently throughout the hospital stay for what we had identified as critical tracking elements, and that included everything from ‘Did patient education occur at the appropriate time?’ to ‘Did the patient have a complication?’" she says. Nolten says she found that the data were not being collected for a variety of reasons, including poorly worded questions and the expectation that staff nurses could determine whether or not a medical outcome had been reached.

As the number of pathways grew, so did the amount of data that needed to be collected. Because ScrippsHealth doesn’t have automated charting, the data had to be entered into the system from pathway variance tracking sheets. "As we developed more pathways, the amount of information that we hoped to gather and enter into the computer for analysis was impossible. It was a self-defeating system. We couldn’t enter the data as fast as it was coming in, therefore people weren’t getting the reports that they needed, therefore their interest in continuing to fill out the forms deteriorated, therefore the data became less meaningful."

At that point, ScrippsHealth leaders decided they needed an online medical record system that would enable the health system to pull information without having to extract it manually from charts. "Our efforts now are focused on finding an information system that will allow us to link ourselves throughout the continuum of care — from primary care offices all the way through our transplant center — into one database so that we can retrieve data in a more efficient manner."

Until the health system can find and implement an integrated, automated system, Nolten says, it has had to "pull back" from its original goal and now is tracking patients who are on pathways and comparing them to patients who are not. "We are tracking the same outcomes for all patients so that we can determine, for example, whether more or fewer patients who are enrolled on a pathway have a particular complication." Nolten says ScrippsHealth is temporarily back to tracking routine information, such as infection rates, length of stay, and complications. "This is an interim place we are in."

On one hospital’s obstetrics unit, ScrippsHealth has piloted a computer system that allowed nurses to document care on pathways with wireless, portable laptop computers. Information from the wireless laptops was transmitted via radio waves.

"Unfortunately, with the software available from that vendor and the legacy systems we had, we were not able to integrate the information from those monitoring systems and haven’t been able to take that computerized system throughout the house," Nolten says.

ScrippsHealth’s goal is to have a single patient chart accessible in the physician’s office, the emergency department, the hospital, or the patient’s home in the case of home health service. Such integration would allow ScrippsHealth to expand pathways beyond hospital walls, evaluate patients’ total care, and determine if care can be improved on the front end to keep patients out of the hospital, Nolten says. "And, we’ll have enough patients that we can truly start to look at trends," she adds.

The new millennium of health care

ScrippsHealth consists of six hospitals, two freestanding skilled nursing units, and a home health facility and is closely affiliated with physician groups.

"We are becoming a fully integrated health care network so that we can track and provide access to records throughout continuum," Nolten says. "We are in the process of transforming ourselves from the traditional hospital system to the new millennium of being a health care provider and being charged with taking care of people and keeping a population of people as healthy as we possibly can, caring for them efficiently when they’re ill, but doing everything we can to keep them healthy."

Group Health Cooperative of Puget Sound — with 450,000 members, two hospitals, and 47 clinics, the largest member-controlled health maintenance organization in the nation — uses outcomes data in the development of clinical practice guidelines. First, clinical road map team members look to results of scientific, randomized studies in the literature. They use internal outcomes data systems to identify gaps in the health system’s performance, then develop a guideline or pathway. The guideline or pathway is shared among the medical staff via hard copy and intranet, in person, and in quarterly feedback reports, explains Janice Rashed, MPH, director of measurement and analysis.

Group Health is studying 10 patient-related categories: diabetes, heart care, pregnancy care, breast care, care of the elderly, HIV/AIDS, immunizations, asthma, tobacco cessation, and depression. Rashed stresses that the term outcomes refers to the many interim outcomes along the continuum of care, not just a set of ultimate outcomes such as mortality.

"For example, in diabetes we measure our blindness rate, but we really want to work much farther upstream than that, so we provide guidelines for and monitor the frequency of retinal exams," she explains. Then, Rashed’s department continually provides physicians and managers with feedback about the gap between the best practice and their own practice.

In addition, Rashed’s staff can follow a patient throughout the entire continuum of care through a homegrown automated tracking system called CareTracker, which tracks care across sites and can be linked with other systems to get information on what services the patient received, Rashed explains.

"We take that clinical information and integrate it with medical record review data or patient survey information for other types of measures and provide physicians and managers feedback reports that integrate information from all those sources," she says.

The information helps the physician be more proactive in caring for the patient. "Typically, patients need a combination of preventive, episodic, and in some cases, chronic care. This system allows providers to identify what various populations of patients need in a systematic way to better organize their practice."

Over the past few years, this approach has allowed Group Health to improve breast cancer screening by 24%, colon cancer prevention programs by 10%, and flu immunization rates for seniors by 20%.

Future plans call for communicating with patients in their homes over the Internet about billing and simple medical questions, if security issues surrounding the Internet are ever resolved.

HELP for Intermountain system

Intermountain Health Care includes 24 hospitals, dozens of outpatient clinics, and a managed care organization. Its hospital information system not only gathers detailed data on outcomes, it actually addresses treatment issues for individual patients. It captures medical information from patient transcripts; coded data from a variety of sources, such as a patient’s chart; and data from various laboratory and pharmacy systems to create a comprehensive record of the patient, regardless of whether the patient was treated in a doctor’s office, clinic, emergency department, or hospital.

The information system consists of two parts that are being integrated systemwide: the hospital-based HELP (Healthcare Evaluation through Logic Processing) system, and HEMS (Healthcare Enterprise Management System), which integrates information across the continuum of care.

HELP is a large robust hospital information system that supports the data collection, communication, and reporting of information collected on patients, says Allan Pryor, MD, Intermountain’s assistant vice president. This information helps teams develop protocols and a system of alerts and reminders. HELP and HEMS are two-way communication systems; they provide protocols, alerts, and reminders to caregivers using knowledge-based rules. For example, if a certain medication is sensitive to potassium and the patient has a high potassium level, the database recognizes the potential problem and flags it for the care provider.

‘A foundation of hospital care’

"The HELP system has become a foundation of Intermountain’s hospital care," Pryor says. "Caregivers put in all the information about the patient — everything from vital signs, intake, output, assessment, procedures, X-ray reports, lab reports, medications both ordered and given." All patient rooms, nursing stations, and ancillary services are equipped with computer terminals, allowing caregivers to either capture or review data and information, he says.

Having all this information in a central place allows Intermountain to analyze outcomes and determine which treatments have the highest rates of success. "If a team is trying to implement a particular protocol, then the screens are developed to assist them in the behavior needed and the data collected for that process," Pryor explains. "Then the data are made available for analysis, in order to provide feedback in a more population-based sense."

Intermountain doesn’t use critical pathways in a traditional sense, Pryor says. "Because of the amount of data we have, we’ve been able to implement protocols and decision support which is a little more sophisticated than clinical pathways."

Instead of focusing on DRGs, Intermountain has looked at more global areas, such as adverse drug events and monitoring for abnormal lab results, he says. Intermountain used the HELP system in preventing adverse drug events by informing physicians about potential needs and alerting them that the patient may be at risk for an adverse drug event.

"HELP is modifying behavior to prevent [adverse drug events] and then monitoring the outcomes — the number of adverse drug events — to see whether or not the efforts had any impact on the system." With a single adverse drug event costing an average of $3,000, Intermountain is saving about $900,000 a year.

Another project to help physicians choose the appropriate antibiotic has resulted in the computer recommending the best antibiotic diagnosis 94% of the time, as opposed to a 77% success rate for doctors working without the system. By cutting infection rates in half, Intermountain has saved about $750,000 a year.

[For more information, contact: Janice Rashed, director of measurement and analysis, Group Health Cooperative of Puget Sound, 521 Wall St., Mail Stop ACC-2, Seattle, WA 98121. Telephone: (206) 448-6436.

Contact Donna Nolten, systemwide manager of clinical programs, ScrippsHealth, at 4275 Campus Point Court, Mail Code CP19, San Diego, CA 92121.

Allan Pryor, assistant vice president of Intermountain Health Care, can be reached at 36 S. State St., Salt Lake City, UT 84111.]