Clinical Information Technologies and Inpatient Outcomes: A Multiple Hospital Study Ruben...
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Transcript of Clinical Information Technologies and Inpatient Outcomes: A Multiple Hospital Study Ruben...
Clinical Information Technologies and Inpatient Outcomes:
A Multiple Hospital Study
Ruben Amarasingham, MD, MBAAssistant Professor of Medicine
University of Texas Southwestern Medical School
Medical Director, Medicine ServicesParkland Health & Hospital System
Clinical Information Technologies (CIT) in the Hospital
Amarasingham R et al, Clinical information technology capabilities in four U.S. hospitals: testing a new structural performance measure. Medical Care. 2006;44:216-24.
The Promise of Clinical Information Technologies (CIT)
• Reductions in waste• Gains in communication• Improved decision making• Provider accountability• Predictive modeling and surveillance
Despite this, problems exist…..
•Adoption remains low
•CIT associated with errors
•Proliferation of pre-/post- studies
•Crudeness of measurement
Despite this, problems exist…..
• Instrument designed to quantitatively assess a hospital’s automation in 4 areas.
• Socio-Technical View of the Workplace
• Physician-based survey
• Demonstrated reliability and validity across hospitals with varying levels of automation
Clinical Information Technology Assessment Tool (CITAT)
Amarasingham R, Diener-West M, Weiner M, Lehmann H, Herbers JE, Powe NR. Clinical information technology capabilities in four U.S. hospitals: testing a new structural performance measure. Med Care. 2006;44:216-24.
Domains assessed in the CITAT
Amarasingham R et al Clinical information technology capabilities in four U.S. hospitals: testing a new structural performance measure. Medical Care. 2006;44:216-24.
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Hospital A Hospital B Hospital C Hospital D
Test Results
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Notes & Records
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Order Entry
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Processes
Amarasingham R et al Clinical information technology capabilities in four U.S. hospitals: testing a new structural performance measure. Medical Care. 2006;44:216-24.
CITAT Order Entry Scores at 4 Hospitals
Use of Clinical Information Technology Assessment Tool (CITAT)
• Re-tested and revised for intensive care unit settings
• Demonstrated reliability and validity
• Low sample size required: ~ 5-6 physicians per hospital
Amarasingham R, Pronovost PJ, Diener-West M, Goeschel C, Dorman T, Thiemann DR, Powe NR. Measuring clinical information technology in the ICU setting: application in a quality improvement collaborative. J Am Med Inform Assoc. 2007;14:288-94.
Research Question
What is the relationship between CIT automation and outcomes (mortality, complications, costs and LOS) for the following conditions?
• Myocardial infarction• Congestive heart failure• Coronary artery bypass grafting
(CABG)• Pneumonia• All causes
MethodsDesign: Cross-sectional regional study
Population: •Acute care urban hospitals and physicians in 10 largest
Texas metropolitan statistical areas
Data collection: • Automation of clinical information (test results, notes &
records, order entry, decision support) by CITAT survey of physicians delivering inpatient care
• All-cause and condition-specific mortality, complications, cost, length of stay (LOS) from administrative data
• Ownership status, bed size, total margin, teaching status, safety net status from American Hospital Association
Morris
E l P aso
Lubbock
S an A nge lo
D allas -F t. W orth
Hous ton
A us tin
Laredo
McA llen
Hospital Sampling• 72 urban hospitals in 10
largest Texas MSAs with discharge data
• Excluded pediatric, long-term care, in transition hospitals
• Surveyed MDs living in 10 Texas MSAs• At least 5 physicians surveys required
Statistical Analysis
• Multivariable analysis: relationship between CIT scores and outcomes • Mortality and complications: logistic regression • Costs and LOS: linear regression after log transform• Risk adjustment: hospital characteristics, Risk-Adjusted
Mortality Index (RAMI), Risk-Adjusted Complication Index (RACI)
•Robust variance-covariance matrix estimates to account for clustering
Results: Characteristics of 41 Study Hospitals (57% response rate)
Ownership no. % Church/not-for-profit 24 60 Government/authority 3 8 Private 13 32Teaching status Non-teaching hospital 35 85 Teaching hospital 6 15Safety net status Non-safety net hospital 37 90 Safety net hospital 4 10
Characteristics ofStudy Hospitals (n=41)
no. (%)IT operating expense
<$1 million 10 (25%) ≥$1 million 30 (75%)Bedsize, mean SD 402.4 291.8Operating margin, mean SD 0.02 0.13Total margin, mean SD 0.05 0.10
CITAT Domain Scores
Domain mean SD
Notes & records 28.5 9.9
Test results 50.1 19.7
Order entry 3.7 14.9
Decision support 2.6 4.8
All Myocardial in-farction
Heart failure Coronary artery bypass graft
Pneumonia 0
0.2
0.4
0.6
0.8
1
1.2
Ad
just
ed
Od
ds
Ra
tio * *
*
*
Odds Ratio for Inpatient Death Associated with 10 point Increase in CIT Score
Decision Support
Order Entry
Test Results
Notes & Records
* p<.05
All Myocardial in-farction
Heart failure Coronary artery bypass graft
Pneumonia 0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
Ad
just
ed
Od
ds
Ra
tio
*
*
*
Decision Support
Order Entry
Test Results
Notes & Records
Odds Ratio for Complications Associated with 10 point Increase in CIT Score
* p<.05
Difference in Average Hospital Costs Associated with 10-Point Increase in CIT Score
-1600
-1400
-1200
-1000
-800
-600
-400
-200
0
200
400
All
Myocardial Infarction
Heart failure
Coronary artery bypass graft
Pneumonia
Ad
just
ed
Ho
spita
l Co
sts
($)
**
**
*
* *
*
*
*
Decision Support
Order Entry
Test Results
Notes & Records
* p<.05
Difference in Average Hospital LOS Associated with 10-Point Increase in CIT Score
-0.3
-0.2
-0.1
-1.1
1022302462516E-16
0.0999999999999999
0.2 0.3
Pneumonia
CABG
Heart failure
MI
All
Difference in Days
*
*
*
Decision Support
Order Entry
Test Results
Notes & Records
**
* p<.05
Limitations
• Single state study• Possible residual unmeasured
organizational confounders• Extrapolation only for range of scores
Strengths
• One of largest hospital studies of CIT• Clinical Information Assessment Tool (CITAT)
independent variable• Socio-technical view of the workplace• Based on physicians interactions with CIT• Rewards usability, preference, and maturation
• Consistency of results• Adoption patterns mirrors previous studies
Conclusions
•Hospitals that automate notes and records, order entry, and clinical decision support in clinically friendly ways may experience fewer complications, less lives lost, and lower costs.
•Further studies needed, but if confirmed, US hospitals should accelerate their acquisition of these technologies
Acknowledgements
• Study Team
Neil R. Powe, MD, MPH, MBA
Laura Plantinga, ScM
Marie Diener-West, PhD
Darrell Gaskin, PhD
Aaron Cunningham• Sponsor: Commonwealth Fund, NY
•Stakeholder Involvement
TMF Quality Institute
Acknowledgements
Texas Department of Health