PROJECT NAME: Using Health IT to Improve Quality
of Care for COPD
Institution: UTMB Galveston
Primary Author: Lindsay Sonstein, MD
Secondary Author: Carlos Clark, DO; Rick Trevino, Daran Gray, Laura
Grady RN, Gulshan Sharma, MD
Project Category: General Quality Improvement
Overview: Chronic Obstructive Pulmonary Disease (COPD) is the third leading
cause of death in the United States and the only leading cause for which morbidity
and mortality are rising. It is a disease of older adults with an increasing
prevalence. The disease natural course is marked by acute exacerbations
requiring frequent interactions with the health care system. During an episode of
acute illness, patients receive care from multiple providers, in different settings,
(ED, outpatient clinic, medical floor, or ICU) putting them at risk for fragmented and
often poorly executed care during transitions.
Health Information Technology has great potential as a tool for practice
improvement and care coordination. The current systems lack functionality to
retrieve information from different sources and make it available to the physician at
the point of care. At our institution we use the electronic medical record (EPIC) in
the emergency, inpatient and ambulatory care settings, which allows us the
potential for care coordination.
Review of the outcomes data at our institution showed that our 30 day
readmissions rates and average length of stay were above our benchmarks, 23.0%
and 3.6 days respectively. To address this issue we developed several
interventions using our EMR aimed to improve the quality of care for our
hospitalized COPD patients. Our team included Internal Medicine and Family
Medicine house staff and faculty, as well as representatives from Information
Technology and Quality Improvement. This project was completed at UTMB
Galveston using all hospitalized patients with a primary discharge diagnosis of
Acute Exacerbation of COPD. This project was funded with a UT System Health
IT grant that was awarded in October 2010.
Aim Statement (max points 150): We AIM to improve quality of care of
hospitalized patients with Acute Exacerbation of COPD (AECOPD) by decreasing
steroid use (30%), decreasing length of stay (0.4 days) and improving hospital
follow up rates (20%) by December 1, 2011.
Measures of Success: We used a validated EMR generated report to track
steroid usage during the first 48 hours of hospitalization, outpatient follow up rates,
and readmission rates. We used UHC data to assess our length of stay for
patients with a primary discharge diagnosis of AECOPD.
Use of Quality Tools (max points 250): We created a flow map to detail out
the process for a patient hospitalized for an acute exacerbation of COPD. (Fig. 1)
Next using a fish bone diagram we examined the potential errors resulting in poor
quality of care for our COPD patients. The causes of errors were categorized as
patient factors, communication factors, medical personnel factors, and
environmental factors. (Fig. 2)
We then conducted a retrospective review of patients discharged from our hospital
from October 2010-January 2011, to measure the frequency of each error
identified in the Fishbone Diagram. A Pareto Chart was generated from the tally,
illustrating the most common sources of error. (Fig. 3)
Finally we used a swim lane diagram to visualize possible interventions and the
responsible party. (Fig. 4)
Interventions (max points 150 includes points for innovation): Based on
the Pareto Chart, we chose to focus our improvements on outpatient coordination
and standardization of care. Although patient factors were identified as a common
source of error, we did not directly address this with our interventions.
There were 2 interventions developed to standardize care. In February
2011 an evidence based order set was implemented into the EMR. This was
followed by a targeted educational campaign to Internal Medicine and Family
Medicine house staff and faculty. Order set usage was monitored. Based on the
usage rates a Best Practice Alert (BPA) was implemented to improve compliance
in January 2012. (Fig. 5) If a patient presented to the ED with a chief complaint of
shortness of breath or cough, was given a steroid and a bronchodilator, the BPA
would fire on admission suggesting usage of the order set.
There were 3 interventions aimed to improve outpatient coordination. Our
initial intervention was a primary care provider (PCP) notification order. When the
order was placed an automated message was sent to the PCP’s EPIC in basket.
(Fig. 6) This received favorable response, however was used inconsistently. The
clinic staff underwent education to ensure that EMR primary care providers were
entered or corrected and later the EMR was reconfigured to allow automatic PCP
notification for all patients admitted to the hospital (Fig. 7). Also the evidence
based order set included a discharge follow up order, which was directly routed to
the clinic. (Fig. 8) This allowed for scheduling on admission (vs. discharge) to
ensure PCP availability.
Figure 9 includes a timeline of the interventions described above.
Fig. 5: Best Practice Alert for COPD order set
Fig. 6: Automatic PCP notification for all hospitalized patients – initial intervention
Fig. 7: Automatic PCP notification for all hospitalized patients – final intervention
Fig. 8: Discharge Follow-Up order
Fig. 9: Intervention Timeline
Results (max points 250):
Total of 111 patients hospitalized for acute exacerbation of COPD were
included in the baseline data. Average amount of corticosteroids (prednisone
equivalents) used during the first 48 hours (± standard deviation) of hospitalization
was 540.7 ± 365.2. Post-intervention 64 patients were analyzed; average amount
of corticosteroids used during the first 48 hours of hospitalization was 296.1 ±
300.4. (P =<0.001) (Fig. 10) Total hospitalization steroid usage declined from a
baseline of 737.7 ± 633.4 to 411.0 ± 573.1 (P = 0.008).
Baseline length of stay for patients hospitalized for acute exacerbation of
COPD was 3.6 ± 3. Post-intervention length of stay decreased to 2.9 ± 3 (P =
0.10)
Hospital follow up was defined as an office visit after hospitalization. Follow
up rates were divided into 15 day and 30 day follow up rates. Baseline follow up
rates were 52% (15 day) and 68% (30 day). Post intervention follow up rates were
51.5% (15 day) and 64% (30 day). (Fig. 11, Fig. 12) However, follow up rates did
increase, 68% (15 day) and 75% (30 day) for patients in which the COPD order set
was used.
Readmission rates were also followed. All cause readmission rates in
patients with primary discharge diagnosis of COPD decreased during the
intervention period. (Fig. 13) However, COPD readmission rates remained the
same. Currently our sample size is too small to see a significant improvement in
COPD readmissions.
Fig. 10 – Corticosteroid use in first 48 hours of hospitalization.
Fig. 11 – 15 day Hospital Follow up Rates
Fig. 12 – 30 day Hospital Follow-Up Rates
Fig. 13 COPD and all cause readmission rates
Revenue Enhancement /Cost Avoidance / Generalizability (max
points 200): Initial investment costs were related to IT personnel, reporting
personnel, and house staff education. The EMR generated reports have been
automated so ongoing costs are due to additional IT personnel and house staff
education. Cost avoidance and revenue enhancement come from 3 main sources:
reduction in the length of stay, reduction in all cause readmission rates and
reduction in total hospital steroid usage. Figure 14 shows our calculation summary
with return of investment of 596% and a modified internal rate of return of 115%.
Fig. 14 – Calculation Summary
Conclusions and Next Steps: Overall there was a statistically significant
reduction in corticosteroid usage during the first 48 hours of hospitalization, a trend
toward a shorter length of stay, reduction in all cause readmissions, and trend
towards increased hospital follow up rates for patients with order set usage. Using
the EMR to improve healthcare delivery can be done but requires constant
evaluation of the process and multiple PDCA cycles.
Our next steps include improving some of our current processes and
expanding our process throughout the entire UTMB Health System. We plan to
remove Solumedrol 125 mg vials from the inpatient and emergency department
floor stocks and having only 40 mg vials available. We plan to work with the clinics
to further streamline hospital discharge appointments as our follow up rates
remained the same. Order set usage lead to and improvement in hospital follow
up rates, showing that the hospital follow up order is effective, however we need to
work on education about the order and direct communication with the primary care
clinics.
We then plan to move our process improvements to the outpatient setting.
We plan to increase the pulmonary function test usage in patients diagnosed with
COPD, increase guideline concordant management of stable COPD patients in
outpatient setting, and improve clinic access during regular hours for patients with
acute exacerbation to reduce emergency room use. Our end goal is to provide
value based care to our patients with COPD and replicate this for other chronic
conditions across the UTMB Health System.