Cost Savings Associated With Implementing 4 Total Joint Replacement Electronic Clinical Quality Measures Nationally: 2020-2040.

BACKGROUND: Digital transformation using widely available electronic data is a key component to improving health outcomes and customer choice and decreasing cost and measurement burden. Despite these benefits, existing information on the potential cost savings from electronic clinical quality measures (eCQMs) is limited. METHODS: We assessed the costs of implementing 4 eCQMs related to total hip and/or total knee arthroplasty into electronic health record systems across healthcare systems in the United States. We used published literature and technical expert panel consultation to calculate low-, mid-, and high-range hip and knee arthroplasty surgery projections, and used empirical testing, literature, and technical expert panel consultation to develop an economic model to assess projected cost savings of eCQMs when implemented nationally. RESULTS: Low-, mid-, and high-range projected cost savings for year's 2020, 2030, and 2040 were calculated for 4 orthopedic eCQMs. Mid-range projected cost savings for 2020 ranged from $7.9 to $31.9 million per measure per year. A breakeven of between 0.5% and 5.1% of adverse events (measure dependent) must be averted for cost savings to outweigh implementation costs. CONCLUSIONS: All measures demonstrated potential cost savings. These findings suggest that eCQMs have the potential to lower healthcare costs and improve patient outcomes without adding to physician documentation burden. The Centers for Medicare and Medicaid Services' investment in eCQMs is an opportunity to reduce adverse outcomes and excess costs in orthopedics.

Multi-Site Testing of an Opioid Prescribing Electronic Clinical Quality Measure Following Elective Primary Total Hip and/or Total Knee Arthroplasties.

As the United States faces the third wave of the ongoing opioid epidemic, development of measures which report on prolonged opioid prescribing (POP) rates, specifically following orthopedic surgeries, are needed to better understand and improve prescribing practices at the clinician group level. Brigham and Women's Hospital (BWH) has been contracted by the Centers for Medicare and Medicaid Services (CMS) to create a novel electronic clinical quality measure (eCQM) to quantify the prolonged opioid prescribing rate of opioid episodes lasting > 42 days in patients aged 18+ years following elective primary total hip arthroplasties (THA) and/or total knee arthroplasties (TKA) for use in the Merit-Based Incentive Payment System (MIPS). When this measure was tested on two geographically distinct sites, it was found that the THA rate was 3.80% and 16.07% at sites 1 and 2, respectively, and that the TKA rate is 7.65% and 24.15% at sites 1 and 2, respectively. This manuscript reports on the testing of this eCQM between these two sites, highlighting differences in state and organizational level policies regarding opioid prescribing and documentation practices.

Testing a Novel Inpatient Respiratory Depression Electronic Clinical Quality Measure (eCQM) for Orthopedic Practice in Two Large U.S. Health Systems.

The objective of this study was to assess the feasibility of using an electronic clinical quality measure (eCQM) to assess inpatient respiratory depression rates following elective primary total hip or total knee arthroplasty using data routinely collected in electronic health records. Measure testing was conducted at two large urban, academic health systems - Mass General Brigham and a geographically distant system in southern U.S. The risk-adjusted inpatient respiratory depression rates were 3.83 and 2.73% for the two health systems, respectively. Clinician group rates ranged from 1.40 to 4.35%, demonstrating opportunity for improvement. Both the data and measure specifications showed strong reliability and validity to allow for calculation of accurate and comparable rates of inpatient respiratory depression.

Testing of a Risk-Standardized Complication Rate Electronic Clinical Quality Measure (eCQM) for Total Hip and/or Total Knee Arthroplasty.

Supported by the Centers for Medicare & Medicaid Services (CMS), Brigham and Women's Hospital (BWH) has retooled the existing claims-based measures NQF1550 and NQF3493 into an electronic clinical quality measure (eCQM) to assess the risk-standardized complication rate (RSCR) following elective primary total hip (THA) and knee arthroplasty (TKA) at the clinician group level. This novel eCQM includes risk-adjustment for social determinants of health, includes all adult patients from all payers, leverages electronic health records (EHRs) rather than claims-based data, and includes both inpatient and outpatient procedures and complications which offers benefits compared to existing metrics. Following testing in two geographically different healthcare systems, the overall risk-standardized complication rate within 90 days following THA and TKA at the two sites was 3.60% (Site 1) and 3.70% (Site 2). This measure is designed for use in the Merit-Based Incentive Payment System (MIPS).

Testing of a Risk-Standardized Major Bleeding and Venous Thromboembolism Electronic Clinical Quality Measure for Elective Total Hip and/or Knee Arthroplasties.

Brigham and Women's Hospital has received funding from the Centers for Medicare and Medicaid Services to develop a novel electronic clinical quality measure to assess the risk-standardized major bleeding and venous thromboembolism (VTE) rate following elective total hip and/or knee arthroplasty. There are currently no existing measures that evaluate both the bleeding and VTE events following joint arthroplasty (TJA). Our novel composite measure was tested within two academic health systems with 17 clinician groups meeting the inclusion criteria. Following risk adjustment, the overall adjusted bleeding rate was 3.87% and ranged between 1.99% - 5.66%. The unadjusted VTE rate was 0.39% and ranged between 0% - 2.65%. The overall VTE/Bleeding composite score was 2.15 and ranged between 1.15 - 3.19. This measure seeks to provide clinician groups with a tool to assess their patient bleeding and VTE rates and compare them to their peers, ultimately providing an evidence-based quality metric assessing orthopedic practices.

Development of four electronic clinical quality measures (eCQMs) for use in the Merit-based Incentive Payment System (MIPS) following elective primary total hip and knee arthroplasty.

The Centers for Medicare & Medicaid Services (CMS) supported Brigham and Women's Hospital (BWH) Center for Patient Safety, Research, and Practice to retool one existing National Quality Forum (NQF) endorsed clinical quality measure (CQM) measure into an electronic clinical quality measure (eCQM) and develop three new eCQMs related to orthopedic care. This manuscript details the iterative process of measure development through environmental scans and stakeholder feedback prior to testing at two geographically different sites. The four measures under development are the: Risk Standardized Complication Rate (RSCR), Risk Standardized Venous Thromboembolism and Major Bleeding Rate (VTE/Bleeding), Risk Standardized Prolonged Opioid Prescribing Rate (POP), and the Risk Standardized Inpatient Respiratory Depression Rate (IRD).

Validating Fall Prevention Icons to Support Patient-Centered Education.

INTRODUCTION: Falls with injury are the most prevalent hospital adverse event. The objective of this project was to refine fall risk and prevention icons for a patient-centric bedside toolkit to promote patient and nurse engagement in accurately assessing fall risks and developing a tailored fall prevention plan. METHODS: Eighty-eight patients and 60 nurses from 2 academic medical centers participated in 4 iterations of testing to refine 6 fall risk and 10 fall prevention icons. During individual interviews, participants rated their satisfaction with the degree to which that icon represented the concept on a 4-point Likert scale, enabling computation of a Content Validity Index (CVI), and provided comments and suggestions for improvement. After reviewing CVI scores and feedback, the research team consulted with the illustrator to revise the icons. RESULTS: Content Validity Index scores improved after icon modifications. Icons that depicted multiple concepts required further iterations to be acceptable. DISCUSSION: Using icons to depict an accurate and easy-to-interpret fall risk assessment and intervention plan for all care team members including patients and family to follow should lead to improved adherence with that plan and decreased falls. CONCLUSIONS: All 16 icons were refined and used to form the basis for a bedside fall prevention toolkit.

Use, Perceived Usability, and Barriers to Implementation of a Patient Safety Dashboard Integrated within a Vendor EHR.

BACKGROUND: Preventable adverse events continue to be a threat to hospitalized patients. Clinical decision support in the form of dashboards may improve compliance with evidence-based safety practices. However, limited research describes providers' experiences with dashboards integrated into vendor electronic health record (EHR) systems. OBJECTIVE: This study was aimed to describe providers' use and perceived usability of the Patient Safety Dashboard and discuss barriers and facilitators to implementation. METHODS: The Patient Safety Dashboard was implemented in a cluster-randomized stepped wedge trial on 12 units in neurology, oncology, and general medicine services over an 18-month period. Use of the Dashboard was tracked during the implementation period and analyzed in-depth for two 1-week periods to gather a detailed representation of use. Providers' perceptions of tool usability were measured using the Health Information Technology Usability Evaluation Scale (rated 1-5). Research assistants conducted field observations throughout the duration of the study to describe use and provide insight into tool adoption. RESULTS: The Dashboard was used 70% of days the tool was available, with use varying by role, service, and time of day. On general medicine units, nurses logged in throughout the day, with many logins occurring during morning rounds, when not rounding with the care team. Prescribers logged in typically before and after morning rounds. On neurology units, physician assistants accounted for most logins, accessing the Dashboard during daily brief interdisciplinary rounding sessions. Use on oncology units was rare. Satisfaction with the tool was highest for perceived ease of use, with attendings giving the highest rating (4.23). The overall lowest rating was for quality of work life, with nurses rating the tool lowest (2.88). CONCLUSION: This mixed methods analysis provides insight into the use and usability of a dashboard tool integrated within a vendor EHR and can guide future improvements and more successful implementation of these types of tools.

Development and Alpha Testing of Specifications for a Prolonged Opioid Prescribing Electronic Clinical Quality Measure (eCQM).

Brigham and Women's Hospital (BWH) has received funding from the Centers for Medicare and Medicaid Services (CMS) to design and implement an electronic clinical quality measure (eCQM) assessing the rate of prolonged opioid prescribing practices following Total Hip Arthroplasty (THA) and Total Knee Arthroplasty (TKA). Utilizing an existing guideline, 'prolonged prescribing' has been defined as opioid prescriptions that exceed 42 days (6 weeks) following surgery. This measure was tested on 12,803 Partners' Healthcare (PHS) patients. Findings demonstrated that after 42 days, meeting the criteria for 'prolonged prescribing' as defined by the proposed measure, 3.7% of THA patients and 12.1% of TKA patients were still receiving opioids. With a better understanding of how specific clinician group post-operative prescribing practices compare with their peers and incorporating monetary incentives through the MIPS participation pathway of the Quality Payment Program (QPP), this measure will motivate orthopedic practices to improve their prescribing patterns, ultimately driving evidence-based quality improvement.

Lessons learned implementing a complex and innovative patient safety learning laboratory project in a large academic medical center.

OBJECTIVE: The objective of this paper is to share challenges, recommendations, and lessons learned regarding the development and implementation of a Patient Safety Learning Laboratory (PSLL) project, an innovative and complex intervention comprised of a suite of Health Information Technology (HIT) tools integrated with a newly implemented Electronic Health Record (EHR) vendor system in the acute care setting at a large academic center. MATERIALS AND METHODS: The PSLL Administrative Core engaged stakeholders and study personnel throughout all phases of the project: problem analysis, design, development, implementation, and evaluation. Implementation challenges and recommendations were derived from direct observations and the collective experience of PSLL study personnel. RESULTS: The PSLL intervention was implemented on 12 inpatient units during the 18-month study period, potentially impacting 12,628 patient admissions. Challenges to implementation included stakeholder engagement, project scope/complexity, technology/governance, and team structure. Recommendations to address each of these challenges were generated, some enacted during the trial, others as lessons learned for future iterative refinements of the intervention and its implementation. CONCLUSION: Designing, implementing, and evaluating a suite of tools integrated within a vendor EHR to improve patient safety has a variety of challenges. Keys to success include continuous stakeholder engagement, involvement of systems and human factors engineers within a multidisciplinary team, an iterative approach to user-centered design, and a willingness to think outside of current workflows and processes to change health system culture around adverse event prevention.

Nurse, Patient, and Care Partner Perceptions of a Personalized Safety Plan Screensaver.

A patient safety plan dashboard was developed that captures disparate data from the electronic health record that is then displayed as a personalized bedside screensaver. The dashboard aligns all care team members, including patients and families, in the safety plan. The screensaver content includes icons that pertain to common geriatric syndromes. In two phases, interviews were conducted with nurses, nursing assistants, patients, and informal caregivers in a large, tertiary care center. End user perceptions of the content and interface of the personalized safety plan screensavers were identified and strategies to overcome the barriers to use for future iterations were defined. Many themes were identified, ranging from appreciation of the clinical decision support provided by the screensavers to the value of the safety-centric content. Differences emerged stemming from each group of end users' role on the care team. All feedback will inform requirements for improvements to the personalized safety plan screensaver. [Journal of Gerontological Nursing, 43(4), 15-22.].

Primary care clinicians' perceptions about antibiotic prescribing for acute bronchitis: a qualitative study.

BACKGROUND: Clinicians prescribe antibiotics to over 65% of adults with acute bronchitis despite guidelines stating that antibiotics are not indicated. METHODS: To identify and understand primary care clinician perceptions about antibiotic prescribing for acute bronchitis, we conducted semi-structured interviews with 13 primary care clinicians in Boston, Massachusetts and used thematic content analysis. RESULTS: All the participants agreed with guidelines that antibiotics are not indicated for acute bronchitis and felt that clinicians other than themselves were responsible for overprescribing. Barriers to guideline adherence included 6 themes: (1) perceived patient demand, which was the main barrier, although some clinicians perceived a recent decrease; (2) lack of accountability for antibiotic prescribing; (3) saving time and money; (4) other clinicians' misconceptions about acute bronchitis; (5) diagnostic uncertainty; and (6) clinician dissatisfaction in failing to meet patient expectations. Strategies to decrease inappropriate antibiotic prescribing included 5 themes: (1) patient educational materials; (2) quality reporting; (3) clinical decision support; (4) use of an over-the-counter prescription pad; and (5) pre-visit triage and education by nurses to prevent visits. CONCLUSIONS: Clinicians continued to cite patient demand as the main reason for antibiotic prescribing for acute bronchitis, though some clinicians perceived a recent decrease. Clinicians felt that other clinicians were responsible for inappropriate antibiotic prescribing and that better pre-visit triage by nurses could prevent visits and change patients' expectations.

Visit complexity, diagnostic uncertainty, and antibiotic prescribing for acute cough in primary care: a retrospective study.

BACKGROUND: Guidelines and performance measures recommend avoiding antibiotics for acute cough/acute bronchitis and presume visits are straightforward with simple diagnostic decision-making. We evaluated clinician-assigned diagnoses, diagnostic uncertainty, and antibiotic prescribing for acute cough visits in primary care. METHODS: We conducted a retrospective analysis of acute cough visits - cough lasting ≤21 days in adults 18-64 years old without chronic lung disease - in a primary care practice from March 2011 through June 2012. RESULTS: Of 56,301 visits, 962 (2%) were for acute cough. Clinicians diagnosed patients with 1, 2, or ≥ 3 cough-related diagnoses in 54%, 35%, and 11% of visits, respectively. The most common principal diagnoses were upper respiratory infection (46%), sinusitis (10%), acute bronchitis (9%), and pneumonia (8%). Clinicians prescribed antibiotics in 22% of all visits: 65% of visits with antibiotic-appropriate diagnoses and 4% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed diagnostic uncertainty in 16% of all visits: 43% of visits with antibiotic-appropriate diagnoses and 5% of visits with non-antibiotic-appropriate diagnoses. Clinicians expressed uncertainty more often when prescribing antibiotics than when not prescribing antibiotics (30% vs. 12%; p < 0.001). As the number of visit diagnoses increased from 1 to 2 to ≥ 3, clinicians were more likely to express diagnostic uncertainty (5%, 25%, 40%, respectively; p < 0.001) and prescribe antibiotics (16%, 25%, 41%, respectively; p < 0.001). CONCLUSIONS: Acute cough may be more complex and have more diagnostic uncertainty than guidelines and performance measures presume. Efforts to reduce antibiotic prescribing for acute cough should address diagnostic complexity and uncertainty that clinicians face.

Effect of a pharmacist intervention on clinically important medication errors after hospital discharge: a randomized trial.

BACKGROUND: Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence with high potential for future harm (potential ADEs). OBJECTIVE: To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge. DESIGN: Randomized, controlled trial with concealed allocation and blinded outcome assessors. (ClinicalTrials.gov registration number: NCT00632021) SETTING: Two tertiary care academic hospitals. PATIENTS: Adults hospitalized with acute coronary syndromes or acute decompensated heart failure. INTERVENTION: Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge. MEASUREMENTS: The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable ADEs, as well as potential ADEs. RESULTS: Among 851 participants, 432 (50.8%) had 1 or more clinically important medication errors; 22.9% of such errors were judged to be serious and 1.8% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential ADEs in 253 patients (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]) or ADEs (unadjusted incidence rate ratio, 1.09 [CI, 0.86 to 1.39]). Patients in the intervention group tended to have fewer potential ADEs (unadjusted incidence rate ratio, 0.80 [CI, 0.61 to 1.04]). LIMITATION: The characteristics of the study hospitals and participants may limit generalizability. CONCLUSION: Clinically important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy-sensitive, pharmacist-delivered intervention. PRIMARY FUNDING SOURCE: National Heart, Lung, and Blood Institute.

Effects of an online personal health record on medication accuracy and safety: a cluster-randomized trial.

OBJECTIVE: To determine the effects of a personal health record (PHR)-linked medications module on medication accuracy and safety. DESIGN: From September 2005 to March 2007, we conducted an on-treatment sub-study within a cluster-randomized trial involving 11 primary care practices that used the same PHR. Intervention practices received access to a medications module prompting patients to review their documented medications and identify discrepancies, generating 'eJournals' that enabled rapid updating of medication lists during subsequent clinical visits. MEASUREMENTS: A sample of 267 patients who submitted medications eJournals was contacted by phone 3 weeks after an eligible visit and compared with a matched sample of 274 patients in control practices that received a different PHR-linked intervention. Two blinded physician adjudicators determined unexplained discrepancies between documented and patient-reported medication regimens. The primary outcome was proportion of medications per patient with unexplained discrepancies. RESULTS: Among 121,046 patients in eligible practices, 3979 participated in the main trial and 541 participated in the sub-study. The proportion of medications per patient with unexplained discrepancies was 42% in the intervention arm and 51% in the control arm (adjusted OR 0.71, 95% CI 0.54 to 0.94, p=0.01). The number of unexplained discrepancies per patient with potential for severe harm was 0.03 in the intervention arm and 0.08 in the control arm (adjusted RR 0.31, 95% CI 0.10 to 0.92, p=0.04). CONCLUSIONS: When used, concordance between documented and patient-reported medication regimens and reduction in potentially harmful medication discrepancies can be improved with a PHR medication review tool linked to the provider's medical record. TRIAL REGISTRATION NUMBER: This study was registered at ClinicalTrials.gov (NCT00251875).

Effect of patient- and medication-related factors on inpatient medication reconciliation errors.

BACKGROUND: Little research has examined the incidence, clinical relevance, and predictors of medication reconciliation errors at hospital admission and discharge. OBJECTIVE: To identify patient- and medication-related factors that contribute to pre-admission medication list (PAML) errors and admission order errors, and to test whether such errors persist in the discharge medication list. DESIGN, PARTICIPANTS: We conducted a cross-sectional analysis of 423 adults with acute coronary syndromes or acute decompensated heart failure admitted to two academic hospitals who received pharmacist-assisted medication reconciliation during the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) Study. MAIN MEASURES: Pharmacists assessed the number of total and clinically relevant errors in the PAML and admission and discharge medication orders. We used negative binomial regression and report incidence rate ratios (IRR) of predictors of reconciliation errors. KEY RESULTS: On admission, 174 of 413 patients (42%) had ≥1 PAML error, and 73 (18%) had ≥1 clinically relevant PAML error. At discharge, 158 of 405 patients (39%) had ≥1 discharge medication error, and 126 (31%) had ≥1 clinically relevant discharge medication error. Clinically relevant PAML errors were associated with older age (IRR = 1.46; 95% CI, 1.00- 2.12) and number of pre-admission medications (IRR = 1.17; 95% CI, 1.10-1.25), and were less likely when a recent medication list was present in the electronic medical record (EMR) (IRR = 0.54; 95% CI, 0.30-0.96). Clinically relevant admission order errors were also associated with older age and number of pre-admission medications. Clinically relevant discharge medication errors were more likely for every PAML error (IRR = 1.31; 95% CI, 1.19-1.45) and number of medications changed prior to discharge (IRR = 1.06; 95% CI, 1.01-1.11). CONCLUSIONS: Medication reconciliation errors are common at hospital admission and discharge. Errors in preadmission medication histories are associated with older age and number of medications and lead to more discharge reconciliation errors. A recent medication list in the EMR is protective against medication reconciliation errors.

Implementing practice-linked pre-visit electronic journals in primary care: patient and physician use and satisfaction.

Electronic health records (EHRs) and EHR-connected patient portals offer patient-provider collaboration tools for visit-based care. During a randomized controlled trial, primary care patients completed pre-visit electronic journals (eJournals) containing EHR-based medication, allergies, and diabetes (study arm 1) or health maintenance, personal history, and family history (study arm 2) topics to share with their provider. Assessment with surveys and usage data showed that among 2027 patients invited to complete an eJournal, 70.3% submitted one and 71.1% of submitters had one opened by their provider. Surveyed patients reported they felt more prepared for the visit (55.9%) and their provider had more accurate information about them (58.0%). More arm 1 versus arm 2 providers reported that eJournals were visit-time neutral (100% vs 53%; p<0.013), helpful to patients in visit preparation (66% vs 20%; p=0.082), and would recommend them to colleagues (78% vs 22%; p=0.0143). eJournal integration into practice warrants further study.

Rationale and design of the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study.

BACKGROUND: Medication errors and adverse drug events are common after hospital discharge due to changes in medication regimens, suboptimal discharge instructions, and prolonged time to follow-up. Pharmacist-based interventions may be effective in promoting the safe and effective use of medications, especially among high-risk patients such as those with low health literacy. METHODS AND RESULTS: The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL-CVD) study is a randomized controlled trial conducted at 2 academic centers-Vanderbilt University Hospital and Brigham and Women's Hospital. Patients admitted with acute coronary syndrome or acute decompensated heart failure were randomly assigned to usual care or intervention. The intervention consisted of pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and tailored telephone follow-up after discharge. The primary outcome is the occurrence of serious medication errors in the first 30 days after hospital discharge. Secondary outcomes are health care utilization, disease-specific quality of life, and cost-effectiveness. Enrollment was completed September 2009. A total of 862 patients were enrolled, and 430 patients were randomly assigned to receive the intervention. Analyses will determine whether the intervention was effective in reducing serious medication errors, particularly in patients with low health literacy. CONCLUSIONS: The PILL-CVD study was designed to reduce serious medication errors after hospitalization through a pharmacist-based intervention. The intervention, if effective, will inform health care facilities on the use of pharmacist-assisted medication reconciliation, inpatient counseling, low-literacy adherence aids, and patient follow-up after discharge. Clinical Trial Registration- clinicaltrials.gov. Identifier: NCT00632021.

Survey analysis of patient experience using a practice-linked PHR for type 2 diabetes mellitus.

Patient experience was assessed by survey as part of a large, randomized controlled trial of a secure, practice-linked personal health record called Patient Gateway at Partners HealthCare in Boston, MA. The subjects were patients with Type 2 diabetes who prepared for their upcoming primary care visit using a previsit electronic journal. The journal generated a diabetes care plan using patient chart information and patient responses to questions in preparation for a scheduled office visit. Review of 37 surveys revealed that a diabetes care plan took 5-9 minutes (modal) to be created by the patient and helped many patients to feel more prepared for their visit (60%) and give more accurate information to their provider (53%). Study limitations included small numbers of survey participants and a bias toward white, better educated patients with better controlled diabetes. Nevertheless, the electronic journal is a promising tool for visit preparation and process improvement.