SCCM Resource Library-Examples of EHR Platforms That Incorporate Bundle Metrics: Epic Versus Cerner

Video Transcription

Hello, everybody. My name is Joan Brown, and I'm currently the Associate Administrator  of the Clinical Operations and Business Intelligence team in the Value Improvement Office at Keck  Medical Center of the University of Southern California. It is an honor to join the panel  members that have presented to you thus far on leveraging data to facilitate the implementation and sustainability of the ICU liberation bundle.  In my session, we will review incorporating bundle metrics into the EHR, essentially outlining  the use case of our team's creation of performance reports from the data warehouse, then our  study which assess the impact of using performance reports with data literacy training, and then  closing with our partnership with Cerner and testing the canned reports from Cerner's healthy analytics platform.  We started in 2018 when Keck's Critical Care Institute established the AF bundle as a standard of care in the ICU following the surgical ICU's participation in the ICU liberation  campaign. We began a four-month interprofessional planning effort, which included working with  a technical team to develop algorithms and a data extraction approach from the data warehouse. During this time, the planning team designed a study aimed at understanding the effect  of A-F bundle clinical education with data literacy training and performance reports on staff compliance. In 2019, we implemented the A-F bundle starting with four of the eight  ICUs at Keck using a stepped wedge implementation design. Weekly compliance reports were sent  to each unit including analytical insights as in which were the largest fallout elements and other key areas of opportunity to improve compliance.  In 2021 to today, we implemented the A-F bundle in all eight ICUs at Keck and shifted our reporting frequency to monthly reports for all units. The reduction in frequency  was due to competing priorities for the non-IT department-based analytics resources. At the  tail end of 2021, we were identified as a beta site tester of Cerner's A-F bundle standard  reports that leveraged the SCCM's core measures. We will go in detail into this effort in comparison  with our original effort to create our own set of A-F performance reports using our data warehouse. We used a four-month implementation approach  where the first month focused on interprofessional and role-based clinical education. Month two  consisted of monitoring and auditing A-F bundle compliance following the clinical education.  Month three began data literacy training and the introduction of weekly compliance reports where month four was like month two. It was monitoring and auditing of the A-F bundle  compliance but this time post data literacy training. We continued to supply the units with weekly A-F bundle compliance reports for the duration of a year. The implementation  approach included establishing a culture of team reflection on performance to establish a learning and change environment. Performance reports were created by the technical  team from the clinical operations business intelligence unit, a non-IT department analytics resource of Keck Health System. This included a technical leader, an ICU nurse clinical  informatics leader, a technical project specialist with expert knowledge on data extraction from  the data warehouse, and an analyst with advanced analytics and visualization expertise. We began the creation of our performance reports partnering with the interprofessional team  to determine the standards and protocols that were necessary for A-F bundle implementation.  The technical team then performed a gap analysis to identify discrete versus non-discrete variables.  The interprofessional clinical team together with the technical team created workarounds  or proxy measures if a variable was non-discrete or really difficult to obtain. The technical  team then devised extraction algorithms, created an advanced Python algorithm to clean and  analyze the data against compliance protocols, then visualize the data in Tableau for distribution  to the units. The joint team worked together to design reports that were action-oriented and provided a level of detail that would help support adherence to the protocol by  the frontline staff. The interprofessional clinical team managed any change requests to report calculations or design.  To bridge the clinical and technical language barriers, protocol algorithms were created in a map form to help the technical team design the scripts needed to extract data from the  right place and compute adherence to the A-F bundle. Here are some examples of the algorithms created.  Compliance performance reports were sent on a weekly and monthly basis. The monthly distribution  included a view of key outcome metrics like ICU length of stay, mechanical ventilation hours, and incidence of delirium to help the clinical team understand the impact of the  A-F bundle on patient outcomes. Here we have samples of the weekly compliance report on the left and the monthly compliance report on the right. You'll see in the weekly compliance  report we also included comparison metrics from the individual unit compared to all eight ICUs' performance, along with an indicator of an increase or decrease in compliance with  EROS. We also included a metric that showed how close the unit was to achieving full A-F bundle compliance, with a percent of completing four or more of the six elements required  for full A-F bundle compliance. We hope this metric would give a sense of being almost there in terms of reaching full bundle compliance.  We also provided a patient-level detail view of the compliance reports per week. The detail  included patient name, date, who the clinical staff were assigned to that patient, and whether  they were compliant that day with any given element. A green checkmark meant that patient received the protocol for that element. A red X meant they did not receive the full  protocol, and a gray circle meant there was no documentation for that element. This view was not meant to be punitive, but to help the nurse managers, nurse leads, and clinical  educators understand systematic issues, and whether some individual nurses needed more  education on an element, or if more resources were needed to help follow through with protocols given a patient's acuity. The implementation of performance reports  included data literacy training for all clinical staff. Data literacy training was done using  a snack-and-learn approach, where during a shift, the team would bring coffee and snacks,  and ask three to five members of the clinical team on staff at a time to come into the break  room, have a snack, and learn about the performance reports. In the sessions, we reviewed bundle  compliance algorithms, how EHR documentation informed the reports, and where exactly to document to get credit for implementing the A-F bundle. We emphasized how the performance  reports were supposed to drive action, more specifically, how the staff should read it, interpret it, and what they can do. We left the team with job aids on both where to document,  and a summary of what the team could do to increase compliance for each element, as well as the A-F bundle as a whole. Our study's statistical model compared month  2 and month 4, monitoring and auditing months, to assess gains in compliance. The study demonstrated  that data literacy had a positive impact on A-F bundle compliance performance with statistical significance. Both clinical education and data literacy training increased full bundle  compliance performance. Our observation of raw compliance demonstrates a clear increase in the A-F bundle compliance intervention group, which were the first four  units to receive the A-F bundle implementation approach. This increase was sustained through the onset of the COVID-19 pandemic in the intervention group, where compliance dropped  in the non-intervention group. With the implementation of the Cerner healthy analytics platform, our institution was offered the opportunity to be a beta testing site  of the standard A-F bundle reports that were a design collaboration with SCCM and Cerner.  We gladly accepted the challenge, as the use of the healthy analytics platform would provide  near real-time access for frontline staff to monitor A-F bundle compliance. Our performance reports used the data warehouse to populate the reports, and required manual analytics.  This meant our team could only provide the reports on a weekly basis and retrospectively.  This was a significant limitation to the bedside clinician trying to care for the patient and manage complex care plans while monitoring the A-F bundle compliance.  Once we were granted access to the Cerner standard reports, the Keck technical team began a gap  analysis to understand the difference between the Cerner standard reports and our customized A-F  bundle performance reports. There were several calls and emails to help facilitate information  exchange between the two teams. Keck's technical team's role was to validate the reports for  accuracy, provide feedback on visuals, and give experiential context to what visuals elicited  action from the clinical team to improve compliance. The Cerner team provided context and logic of the standard approach, detailed how the core measures translated to the back end,  and revised the dashboard when it made sense to incorporate an edit that would affect all  Cerner customers' standard A-F bundle reports. The Cerner team also assisted the Keck team in  suggesting technical approaches to bridge any formula gaps between the Cerner standard reports  and Keck's performance reports. The next few slides show screenshots of the Cerner standard  report visual. This visual shows encounter level detail in aggregate by provider, financial class,  and discharge disposition. This view demonstrates key patient outcomes, including length of stay,  the top graph, mortality, the middle graph, and 30-day readmission, the bottom graph.  This view visualizes key metrics deemed essential by SCCM to the ICU Liberation Campaign. It includes  top assessments per day, top delirium measures, top SBT, top family involvement measures, all by patient.  This view shows A-F bundle process metrics, including key documentation,  patients present with delirium, level of mobility, and more.  The bundle compliance view shows compliance trend lines for the A-F bundle as a whole and each of the individual elements.  A few slides show screenshots of the A-F bundle process metrics. A patient level detail was added as a result of our feedback in the effort of being a beta testers.  The patient level detail in the Cerner reports now include a patient name and the result of the element protocol.  We are still actively in the process of validating Cerner's standard report and are using our monthly performance reports as an interim solution  to provide A-F bundle performance data to our eight ICUs. Our next steps are to work with the interprofessional clinical team  to decide whether the Cerner standard reports can be used out of box or whether we need to do some minimal customization to have them reflect our more stringent clinical protocols.  Customizing would require internal resources from the Clinical Operations Business Intelligence team and the Keck IT department.  This concludes the review of our use case in incorporating bundle metrics into the EHR from our customized approach using the data warehouse  to partnering with the Cerner analytics team to leverage their real-time standard reports. Looking forward to the discussion with our amazing team of panelists. Thank you.

Video Summary

The speaker, Joan Brown, from Keck Medical Center, discusses the implementation and impact of incorporating bundle metrics into the electronic health records (EHR). This involved creating performance reports from the data warehouse, conducting a study on the effect of data literacy training with performance reports, and partnering with Cerner to test their standard AF bundle reports. They found that data literacy training had a positive impact on compliance, and the Cerner reports provided real-time access to monitor bundle compliance. The speaker concludes by discussing ongoing validation and possible customization of the Cerner reports.

Asset Subtitle

Quality and Patient Safety, 2022

Asset Caption

Utilization of the ICU Liberation Bundle (A-F) has been shown to decrease delirium, coma, restraint use, skilled nursing facility discharge rates, readmission rates, ICU and hospital lengths of stay, and mortality in ICU patients. Yet incorporating ICU Liberation work through the electronic health record (EHR) presents unique challenges and opportunities. This session will provide recommendations to clinicians to implement and sustain the ICU Liberation Bundle through use of the EHR, particularly leveraging the data.

Meta Tag

Content Type Presentation

Knowledge Area Quality and Patient Safety

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Quality and Patient Safety

Year 2022

Keywords

bundle metrics

electronic health records

data literacy training

Cerner

compliance

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