Maryland HIMSS Presents

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Maryland HIMSS Presents The Electronic Health
Record We Have the Data, Now What? April 25,
2008 Sheppard Pratt Conference Center The Use of
Clinical Data for Risk Management
Purposes Larry L. Smith, Vice President Risk
Management Services, MedStar Health
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MedStar Health, Inc.

• Beds
• Total Licensed Beds.2,800
• Annual net operating revenue.3.1 billion
• Staff
• Employees...25,000
• Affiliated physicians...5,000
• Patient Care
• Annual inpatient admissions....158,000
• Annual inpatient days.787,000
• Annual outpatient visits..1,561,000
• Annual home health visits.....208,000
• Births, FY07.....11,100

• MedStar Hospitals
• Franklin Square Hospital
• Georgetown University Hospital
• Good Samaritan Hospital
• Harbor Hospital
• Montgomery General Hospital
• National Rehabilitation Hospital
• Union Memorial Hospital
• Washington Hospital Center

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In 2001 MedStars Risk Management Program
accepted a challenge from the Organization ..
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The Challenge

• Identify a system-wide Patient Safety Initiative
  that was
• Data driven
• Clinician driven
• Able to demonstrate a measurable reduction in the
  number of patient injuries as well as the
  frequency and severity of professional liability
  claims insured through MedStars captive
  insurance company

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To Get Started

• We began by asking Simple Questions
• What clinical specialty?
• What conditions?
• What causes?
• What cost in patient injuries and dollars?

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OB Low Hanging Fruit or Mission Impossible?

• Findings from Ten-Year Retrospective Claims
  Review
• OB accounted for 4 of clinical enterprise
• OB claims accounted for 11 of professional
  liability claim frequency (48 out of 436 claims)
• OB claims accounted for 31 of professional
  liability claim severity (21M out of 67M)

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Typical Loss Profile OB is 40-50 of total paid
Source ERC Excess HPL Claims, closed 1999-2002
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Professional Liability impact on the business of
Obstetrics

• Vital community services are being threatened
• Less Hospitals with OB services
• Those keeping OB services are challenged with
  growing pains
• Finding obstetrical services is becoming more and
  more difficult
• Practicing Obstetricians are dropping obstetrics
  in their prime
• The average age when Physician stop practicing OB
  is now down to 48 yrs
• Does the future look any better?
• Newly trained physicians are avoiding OB due to
  lifestyle and liability
• Only 65 of residency training slots in
  obstetrics are filled by US medical grads,
  compared to 86 a decade ago
• Drawing from the bottom 10 of resident pool,
  slots going unfilled

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The Approach

• We used the findings from the retrospective
  Claims Review Program to create a Burning
  Platform for change in obstetrical care

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OB Risk Reduction Initiative

• In September 2001 under the auspices of the VPMA
  Council and at the direction of the MedStar
  Board, the OB Risk Reduction Task Force was
  chartered to evaluate the causes and minimize the
  risk of avoidable patient injury in MedStars OB
  Labor and Delivery Units.

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OB Risk Reduction Task Force

• Charter
• To produce measurable reduction in the number and
  cost of professional liability claims in OB
• Goals
• To identify specific risk reduction efforts that
  will produce a reduction in OB claim frequency
  and severity
• To develop and successfully implement system-wide
  OB patient care and professional practice
  standards
• To oversee and support the efforts at each
  MedStar hospital to attain compliance with
  standards established
• Membership
• OB Chairs
• OB RN Directors

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OB Claims Review
Represents 80 of the Injuries in our 48
Obstetric Claims during Loss Years 97-01
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Studderts Research underway at Harvard also
suggests that the nature of Errors in
Obstetrical Liability cases is different Dispropo
rtionately more errors in OB are Cognitive in
nature rather than Technical
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OB Risk Reduction Task Forces Initial
Achievements

• Identified and addressed top ten risk issues
  through development of
• Patient Care Standards
• Oxytocin Guidelines
• Standardized Electronic Fetal Monitoring
  Terminology
• OB Simulation Program at each site
• Captive funded educational programs for staff
  (RNs and MDs)
• Changed culture of OB service across MedStar
  system to focus on Patient Safety
• Gave Birth to system-wide Patient Safety
  initiatives across MedStar

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OBRRTFs Development of Clinical Standards -
Good First Step

• While development of system-wide standards and
  guidelines were a significant achievement,
  without a method to insure compliance, deviations
  were likely to occur resulting in patient
  injury
• In early 2003 a catastrophic birth related injury
  resulting from multiple deviations from
  established standards and guidelines demonstrated
  the weakness in the traditional approach
• Case was determined indefensible and settled
  early for 4M
• Search began for a technology to support the
  consistent use of established clinical guidelines
  in delivering obstetrical care

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IPROB(Intelligent Patient Record for Obstetrics)

• IPROB was identified as the electronic system for
  the OB setting that satisfied the Committees two
  critical requirements
• real time alerts to provide healthcare providers
  real time access to Standards of Care and
  Protocols and
• reliable data to monitor and measure adherence to
  accepted Standards of Care and Clinical Protocols

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What Really is Decision Support

• Decision support is really just a reminder that
  the care for this patient has gone off track from
  an accepted standard.
• Based on Best Practice Protocols
• Relevant to the specific patient condition
• Presented to the clinician In real time
• With a continuous feedback loop of reevaluation
  with every new piece of information entered
• Priority of each item takes into consideration
  what is most urgent to address at the present
  time

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Illustration EMR without Decision Support
Like driving on a treacherous road without any
guardrails
Compliance with documentation in electronic
medical records is very low when the reminders
for documentation completeness are
deactivated Haberman et al Obstetrics and
Gynecology July 2007
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With Decision Support -Escalating Levels of
Protection
Level one drive within the lines visual cues
and soft reminders
Level two rumble strip noisier/ repeated
reminders and escalation
Level three firm barrier of protection Pass only
with an explanation
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Example Level One Flag Essential
documentation missing from chart
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Example Level 2 Flag Real time context
sensitive actions with Rationale
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• Example Level 3 Flag
• Contraindication
• Options
• Cancel
• Confirm with explanation

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Partnership between Technology and OB Care
Key Success Factors
Process Protocol Buy-in Workflow
Customization Ongoing Commitment To Improvement
People Ease of Use Culture of Safety Leadership
Support Feedback
Technology Services Regular Clinical Version
Updates Provision of Reports and
Dashboards Sharing Best Practices Bad Outcome
Case Evaluations
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Commitment to Continuous Improvement with a
Technology catalyst

• Error Reduction Experience
• Case Review Experience
• User Behavior Analyses
• Experience with Escalated Prompting Mechanisms

ü
ü
ü

• Practice Based Evidence
• Collaborative Best Practice Protocols
• Collaborative Feedback
• Collaborative Enhancements

• Evidence Based Medicine/ Standards of Care
• Recognized Authorities Guidelines/Requirements
• Professional Literature

ü
Idealized Care Model
ü
ü
ü
ü

• Knowledgebase Refinement
• Prompting sensitivity/specificity
• New Features
• User behavior reinforcement

ü
ü
ü
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Improving Quality Measures with IPROB
Four Key Quality Measures were targeted for
improvement using the CAM mechanism
25 Improvement Sustained over time
CAM Intervention initiated 06/05
CAM Compliance Adherence Mechanism
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Error Prevention/ Near Misses/Good Catches
Q1 2007
Items Not Ordered associated with a
Contraindication
Actions/Decisions/Orders Not ordered, while
starting to place an order for a contraindicated
order, by clicking the Cancel button
175 instances during 629 births (1 per 3.6
births)
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Early RM awareness and PI support

• Example List of Reports
• Trigger Reports such as IHI
• AOI index
• Detailed Select Case Analysis

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Converting Future Savings into Current Dollars

• The Challenge
• Develop a methodology supportable by our
  actuaries and auditors to quantify the potential
  of future savings in order to justify an up-front
  investment of current capital and operating
  dollars

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Developing a Business Case for Acquiring IPROB

• Simulated use of the IPROB System on the OB claim
  settled for 4M
• Compared retrospective expert reviews to IPROBs
  electronic responses regarding the care provided
  in this case
• The IPROBs prompts mirrored the findings of the
  expert reviews
• Each identified the critical clinical issues at
  the time they occurred (e.g., non-reassuring
  fetal heart patterns, inappropriate use of
  Pitocin, failure to discontinue use of Pitocin
  and failure to notify the physician)
• Conclusion
• Had IPROB been in use, and used as designed,
  injury would have been avoided

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Monetizing the System-wide OB Initiative

• MedStars OB clinicians, risk/claims managers and
  captives actuary collaborated to develop a
  model to assess the potential financial impact of
  using of system-wide Standards of Care reinforced
  by the use of the IPROB

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We found the money!

• The underlying clinical care involved in the
  prior ten years of OB claims were reviewed by a
  senior OB physician
• Analysis assumed that IPROB had been in use
  during this ten-year period
• Physician was asked to evaluate whether the use
  of the IPROB would have improved the outcome and
  avoided or lessened the liability in each case
  reviewed
• Based on this analysis, the captives actuary
  concluded that it was reasonable to assume that
  the use of IPROB over this ten-year period would
  have resulted in a significantly lower OB
  liability
• Had MedStars claim history included this lower
  liability- the funding of MedStars captive would
  have been reduced by 2M annually, representing
  10 of total captive premium at the time.

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Malpractice ROICumulative Direct Financial
Impact of IPRob
First year of Positive Cash Flow
ROI Positive
.444 M
.039 M
(.332 M)
(.777M)
(1.226M)
FY 04
FY 05
FY 06
FY 07
FY 08
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Loss Years1997 2001Pre OBRRTF Valued as of
6/30/01
Losses Pre and Post IPROB
Loss Years1/1/05-6/30/07Post IPRob Valued as
of 6/30/07
Loss Years2002 2007Post OBRRTF Valued as of
6/30/07
Loss Years1997 2001Pre OBRRTF Valued as of
6/30/07
Frequency and Severity
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Focus On What You Can Control

• Focus on better outcomes
• Commit to quality
• Actively engage in loss prevention