Reducing medical liability risk: live decision support-enabled EMR reduces obstetric medical professional liability with best-practice protocol.
As a community-based network of seven hospitals and healthcare services in the Baltimore/Washington area, MedStar Health serves more than 500,000 patients annually. With 2,700 beds, its staff of 23,000 employees, and 4,600 affiliated physicians, provide care to more than 145,000 inpatients each year. The network provides a complete array of clinical services including orthopedic surgery, rehabilitation, neurosciences, oncology services, cardiology, cardiac surgery, as well as emergency and trauma services. Women's services include obstetrics, gynecology, breast health and assisted reproductive technology, among others.
Identifying a Hemorrhage of Liability
A retrospective analysis of 10 years of MedStar's professional liability claims (1991-2001) revealed that a disproportionate number of these claims were obstetrics (OB) claims. The analysis showed OB claims were impacting the vitality of the organization the most in terms of their frequency and severity. Additionally, these claims represented the greatest threat to the reputation and positioning of the healthcare system. A quality committee chartered by the MedStar board called the Obstetrics Risk Reduction Task Force (OBRRTF) began, in 2001, to establish systemwide guidelines and clinical standards for obstetrical care.
Larry Smith, vice president of risk management services for MedStar, was a key member of the OBRRTF and responsible for oversight of its commercial and medical professional liability self-insurance programs for casualty and liability. Smith was challenged in 2001 to identify one area around which to develop a loss prevention program across the system. "My principle role as part of the OBRRTF was to provide data where OB professional liability was affecting MedStar," says Smith.
A retrospective closed-claim review showed that approximately 80 percent of the claims involved a short period of time during labor when critical decisions were being made, such as when to perform a C-section. "I brought that kind of data from our liability claims to the group to show them where they should focus their attention to reduce risk in OB," says Smith. "They then used information from this closed-claim analysis to help drive their agenda to develop better clinical practice."
OB services represent approximately 4 percent of MedStar's business, however, according to the claim analysis done in 2001, 11 percent of all claims and 35 percent of liability dollars spent were attributed to OB claims during the previous decade. Therefore, OB became the focus of a systemwide initiative to reduce the frequency and severity of those claims. "For about two and a half years, we took the OB service apart and developed some very specific protocol around the key liability areas we were facing, but we still had a tragic outcome occur," says Smith.
Selecting the Solution
An unfortunate accident during the delivery of an infant resulted in an OB liability claim and a $4 million dollar settlement. Smith began to search for a solution that would be so efficient it would be like placing a computer chip inside the minds of the staff, making best-practice protocols available to them when they're on shift 24/7. "No matter how tired they were, how much activity was going on, or what crisis was occurring, the protocols would be available to help them," he says.
In 2003, the OBRRTF, with Smith as the senior administrative resource to the group, sought a useful approach to reduce their OB medical liability. Smith says the larger, well-established vendors didn't appear to offer the robust capabilities they were looking for. The search ultimately led them to E & C Medical Intelligence Inc. and a solution called the Intelligent Patient Record for Obstetrics (IPRob). "I discovered that the IPRob, as an electronic medical record, protocol-driven, decision support method, was about as close to the concept of imbedding clinical information into our staff as I could find," says Smith.
Lynette Philip, an IPRob coordinator for MedStar Health, says after the OBRRTF decided on E & C Medical, the implementation of the solution was swift. The OBRRTF formed a committee, chaired by key MedStar management staff, whose mission was the allocation of resources required for the implementation. "The task force also lent direction and support, as needed, to the implementation committee, and had the charge of carrying out an aggressive implementation of this solution, at each of the four MedStar OB sites, within a 5-month time frame," says Philip.
The Coordinating Council, which is chaired by Philip, is the administrative body that supervises the bulk of the work required to maintain the system. It meets twice a month and consists of four MedStar site coordinators and ad hoc members when necessary. "Between the four sites, there are almost 11,000 deliveries annually. So, we try to maintain standardization of the system to address regulatory issues, such as elements the Joint Commission requires us to include in the application," says Philip.
In June 2004, Franklin Square Hospital Center and Harbor Hospital (both in Baltimore) installed the system, followed within a few months by the Washington Hospital Center and Georgetown University Hospital, both in Washington. Resources were plentiful during the initial implementation at Franklin Square. However, as each sequential rollout took place in progressively larger hospitals that featured more extensive and complex OB programs, these resources diminished. "We knew more at the end than we did at the beginning about how to channel those resources and how to use them," says Smith.
Vicki Lucas, Ph.D., former vice president for Women's Services at MedStar and now CEO of her own healthcare consulting firm, assisted with the training and implementation of the system. According to Lucas, more than 400 hours were spent customizing the 6,000 + clinical decision support protocols that drive the system, and collecting baseline data for workflow and outcomes. Simultaneously, additional workstations and software interfaces were evaluated and ordered. "This was a huge undertaking because each protocol was standardized across the system as well as customized," says Lucas.
Legacy IT infrastructure had not been updated as of 2003, so bandwidth capacity was inadequate and needed upgrading with additional servers, Smith says. "It was when we were putting everything together and started doing some load testing that we realized we needed to increase our budget to upgrade our infrastructure." He also says it was decided at that point to go live without fully interfacing the new system with all the other systems the hospitals were using. "It was a challenge getting the interfaces accomplished because, now, we had multiple outside companies and our own internal teams all working together," says Smith.
A Substantial Investment
"When MedStar chose this product, it was the clinicians who did the evaluation," says Smith. The other departments that contributed input during the decision-making process include IT, Finance and others who had a vested interest in the success of the project. "But we made this a clinician-driven decision. Consequently, leadership buy-in already existed at a very high level within the OB organizations around the system making buy-in by others fairly easy," says Smith.
According to Lucas, it took about a month for most OB clinicians to negotiate the learning curve, which was less difficult for the PC-raised generation of younger physicians. She says growing up with technology-based processes made this group less resistant than older physicians who were accustomed to more traditional documentation methods. "For the less computer-literate physicians, it was much more of a challenge, but the nice thing about this system is that it was developed by clinicians, so it is extremely intuitive," says Lucas.
MedStar spent approximately $2 million on their first four implementations. The complexity and extent of implementation, including the number of workstations, required HIS interfaces and the configuration of hardware affected the allocation of funds. In order to defray some of the initial outlay, MedStar contracted a per-birth fee with the vendor, approximating to $100 per-birth for the first 50,000 births. However, Lucas points out that the value becomes clear when one considers, "the average obstetrician is sued two to three times over the course of their career and the average settlement ranges from $250,000 to $20 million."
Smith says it is necessary for the clinical team to invest the time to ensure that the embedded clinical protocols are, in fact, those they want to abide by. Although this is challenging work, he admits, he also sees great benefit. "Because then, you've got a clinical staff that's really engaged with helping to design the inner workings of the product, to make sure that it fits their specifications," he says.
Each of the hospitals required about a month for the installation, orientation and training prior to go-live, following months of preparation. Using the "super-user" concept, a number of people were available that had been given both extra training and direction. "Go-live went very well during that period but we probably could have done even more training. It was a challenge to make sure that our house officers, in particular, attended all the training sessions that they needed to get them up to speed," says Smith.
Beyond the EMR the system maintains, is the capacity to track every keystroke. If a medication or procedure order varies from the imbedded clinical protocol, the system prompts the clinician to include the variance, providing them with an opportunity to consider the issue before proceeding. If the clinician decides in their best clinical judgment to proceed with the order as originally planned, they can acknowledge the alert and proceed. If, however, upon being alerted of the variance the physician decides on a different course of action than originally planned, the order can be adjusted and the final decision will be noted in the medical record, representing the care rendered to the patient. "Being able to track the alerts helps us from a quality perspective," says Smith. "It helps us to identify specific clinical areas where we should focus our training."
Smith says the hard work done developing clinical protocols and continuously improving the processes of care within MedStar's OB departments, coupled with the product's capabilities, contributed to their success. "Since we began this initiative, the frequency and severity associated with OB liability claims have significantly decreased compared to the past."
"OB liability claims dropped from an expected level of 15 or more annually to low, single digits, and the cost associated with those claims dropped from annual levels of $10-20 million to dramatically lower levels." Though, according to Smith it is too early to declare success, he is very encouraged by the positive trends they are seeing. "I can't help but believe that these trends are directly related to the great work our OB teams are doing and the impact of the IPRob."
MedStar plans to install the decision support system in the outpatient OB units over the next year and anticipates a four-year, $150 million "IT roadmap" to advance its healthcare vision, continuing the transition to an electronic platform in all inpatient and outpatient areas.
Building on the progress and IT investments made over the past several years, the roadmap leads to the automation of clinical and administrative workflows. The culmination of these implementations will produce a fully integrated EMR that will enhance the ambulatory, acute and critical care environments, as well as build the foundation for a computerized physician order entry system. Addressing risk-prone obstetrics protocol first, has great significance for Smith--appropriately, MedStar begins their journey at the point of care where new life takes a first breath. "Taking such a high risk area where the outcomes involve such precious commodities, and coupling our clinical knowledge and experience with this new technology is truly exciting."
For more information on the Intelligent Patient RecordOB solution from E&C Medical Intelligence Inc., www.rsleads.com/712ht-203
By Kristoffer L. Stewart, Associate Editor
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|Title Annotation:||Decision Support: Case History; Electronic Medical Records|
|Author:||Stewart, Kristoffer L.|
|Publication:||Health Management Technology|
|Date:||Dec 1, 2007|
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