This article highlights the second-place winner of the 2012 Healthcare Informatics/AMDIS (The Association of Medical Directors of Information Systems) IT Innovation Advocate Award. Check out the listing of our other award winners, the health informatics team at the St. Paul, Minn.-based HealthEast Care System, led by CMIO Brian Patty, M.D., and the team at Hamden, Conn.-based Quinnipiac Internal Medicine P.C., led by internist Edward Rippel, M.D.
There’s no doubt that the ability of hospitals to manage large data sets has resulted in fundamental improvements in patient care delivery. Physicians and nurses have access to data to measure their performance in a way that is actionable to improve the lives of the patients. Yet timing is everything, and data that can make a significant difference in patient care before discharge is wasted if it reaches the clinician well after the patient has left the hospital.
Cleveland Clinic in Ohio has addressed this care gap with a short-cycle measurement dashboard, a project focused on coordinating the use of the electronic medical record to provide caregivers with actionable information on their performance that result in better patient care before discharge. Since its implementation in 2009, the short-cycle measurement dashboard has improved treatment of individual patients as well as compliance with federally defined core measures.
From a High Level to the Point of Care
The short-cycle measurement dashboard, which was unveiled in December 2009, was a collaboration of the business intelligence (BI) department, the executive team in nursing, and the quality executive team, as well as the IT team, which helped coordinate the development of the dashboard with the electronic medical record (supplied by Epic Systems Corp., Verona, Wis.).
Cleveland Clinic has long had a robust executive dashboard, according to Andrew Proctor, senior director of business intelligence, with specific tabs for core measures, patient experiences, and clinic access. Those measures are gathered by the organization’s executive team and shared with its leadership quarterly.
Yet while the measures showed overall improvements, some core measures didn’t exhibit the same slope, Proctor says. “We asked some people how we can help,” he says, and clinicians responded that they were receiving data up to three months after the patient was discharged. This was the genesis of the short cycle dashboard, with the goal of addressing the measures while the patients were still in the hospital, Proctor says. “Discharge, once it happens, is too late,” he says.
Eric Hixson, Ph.D., is director of outcomes and analytics at the business intelligence department; he worked with Proctor on the short-cycle measurement dashboard. He notes that while clinical processes with existing workflows could successfully address whatever is being measured, “there is very little insight into that performance when you are looking back 90 days at your result.”
The development of the short-cycle measurement dashboard started with the nursing department. The workflow on which the short-cycle dashboard is based was already in place, in the form of a manual process that required nurse managers to write information on note cards and check the EMR to see if a task had been done. The BI team held discussions with nursing, which explained the note card system that was reporting patient care misses on a weekly basis. “We thought we can certainly automate this,” Proctor says.
The BI team worked with the nursing and quality teams about what the short-cycle measurement dashboard would look like and how it would be deployed, Proctor says; in the end, it looked much like the quarterly review, except that as an operational tool it reported data on a half-hourly basis. (A quality scorecard shows a monthly retrospective on performance, in addition to the quarterly review for the executive leadership. “It’s all based on the same data sets, so everybody is using the same source of information, and the definitions are very clear,” he says.)
Nursing and nursing management are the primary users of the dashboard, which has an efficient tool to look at performance metrics across the hospital system, according to Proctor. “At the more executive level, there is no way they can log into the EMR to keep track of all that,” he says. Nurse managers now no longer have to log onto the EMR for each individual patient. Instead, a quick look at the dashboard could indicate which tasks are still needed to be taken care of, which then can be delegated to a nurse, and checked on later. Clinical measures are captured in discrete fields, allowing the nurse manager to log on and flag tasks that need to be addressed for a patient. Its half hour updates are consistent with the nurses’ workflow.
Hixson notes that matching the nursing workflow in the form of note cards paved the way for the short-cycle measurement dashboard concept, because it was viewed as an enabling technology. “There’s already buy-in to the concept, to the processes and the metrics. The adoption curve isn’t quite as steep, because [nursing] owned the discussion and made many of the critical decisions in how this should be rolled out,” he says.
According to Hixson, the dashboard has a broad scope that goes beyond narrowly defined core measures. Vaccinations, for example, have specific populations of interest, however, “as a hospital, we want to provide the best care for everyone who requires it, so we relaxed the public definitions so that everyone who needs a vaccination gets one,” he says. In short, everyone who needs care gets it, not only those in a given measure definition.
That was an epiphany, Proctor says, because the effort had been narrowly focused on core measures. “When we collectively looked past that, it opened up and let this flourish, because that’s when it becomes very patient-centric. It’s not a measure set or something that someone else is making us do. It’s, how we take of patients in the best way, so let’s hold ourselves to this standard,” he says.
One thing the dashboard team didn’t do was establish targets. “We didn’t get pushback in this, because they are going to catch this miss somewhere during this process,” Proctor says. The bottom line goal is that everything that needs to be measured will be measured by the patient’s discharge. The dashboard does not dictate when the measures take place during the patient’s stay.
Wider Implementation, More Users
Initially, the short-cycle measurement dashboard was implemented at Cleveland Clinic’s main campus, Hixson says. That is where the business intelligence department was most engaged with the clinical leadership; in addition, Cleveland Clinic’s EMR has been in a phased rollout throughout the enterprise, so many of the standardized workflows and documentation were not in place at all of the system’s community hospitals.
Since its initial implementation of the dashboard has expanded to other hospitals in Cleveland Clinic’s system, as their data have come on line with the EMR rollout. “Once that happens it’s just a matter of including those facilities in our extracts, and they become part of the dashboard,” Hixson says. “Dashboards allow enterprise-level views, and then you are able to drill down into individual hospitals, and then within each hospital into service lines or units, to look at performance. It’s a natural hierarchy.”
Hixson says that although there is a large amount of standardization across the hospitals and deployments in the EMR, there is some variation in the use of clinical terms. As the short-cycle measurement dashboard team expands a metric into a new area or develops a new metric, it identifies how the information exists in the EMR to account for any variations. Maintenance to keep up with those changes is a constant process, he says.
The dashboard is being expanded to new clinical areas. “Some of the measures are documentation requirements, and others are processes that initiate care or summarize care,” Hixson says. These include physician-centric measures such as Surgical Care Improvement Project (SCIP) and cardiac medication administration. Other areas include delinquent notes in the OR, patients admitted without admission orders, and measures that look at orders that require a co-signature of a physician or a physician extender.
Hixson says the dashboard has improved patient care in several areas, including smoking counseling, heart failure education, pre-surgical patient preparation, and pre-surgical beta blocker utilization.
According to Hixson, the dashboard would be replicable in other organizations, adding that short cycle is an implementation strategy that is tool-agnostic. After all, the first reporting mechanism was index cards. “The tools that we are using make the process much more efficient, but an organization that doesn’t have our EMR or our BI tools isn’t precluded from executing a similar strategy,” he says.
