This month's community call is part two in a series on Clinical Transformation. The presentations will highlight how Clinical Transformation affects outcomes AND the bottom-line of health care organizations. The presentation will provide a proof point on how Clinical Transformation has a direct Return on Investment (ROI) for both the patient and the provider organization. This topic is both clinical and administrative in nature and will likely be useful to physicians, nurses and others interested in outcomes, as well as health care CIOs, CFOs and administrators. Please feel free to forward this invitation to any colleagues or associates who you believe would find this topic of interest or would like to participate in the discussion. What: Clinical Transformation (Part II) - Clinical Transformation - a Blueprint - in Practice - Transformation Working Group Update - Review of status - Framework for Planning - Discussion - Open Project Updates - OpenVista/GT.M Integration - CCD/CCR collaboration - Medsphere.org: Tip of the month When: March 26, 12:30 - 2pm Pacific Where: Dial-in: (888) 346-3950 // Participant Code: 1302465 Web conference: http://www.medsphere.com/infinite/ === The community calls are listed on the Medsphere.org event calendar (http://medsphere.org/community-events/) and we will update each month's call as the agenda is solidified. Details and Recording available here: http://medsphere.org/blogs/events/2009/03/26/community-call-march-2009

1. Clinical Transformation, Part II
March 2009 Community Call

2. Presenters
• Edmund Billings, MD - CMO
• Jeff Parker, RN, BsBA - Clinical Informatics Manager
• Janine Powell - Sr. Director of Client Services
• Debbie Daspit - Director of Product Management
• George Lilly - CCD/CCR Developer
• Adam Waterbury - GT.M Product Manager
• Ben Mehling - Director of Ecosystem Operations

3. Agenda
• Clinical Transformation
– A Blueprint
– In Practice
• Transformation Working Group Update
– Status Update
– Framework for Planning
– Discussion
• Open Project Updates
– OpenVista/GT.M Integration
– CCD-CCR Project
• Medsphere.org: Tip of the Month

4. Clinical Transformation, a Blueprint
5 Million Lives Project Example: The Central Line Bundle
Edmund Billings, MD

5. http://www.ihi.org/IHI/Programs/Campaign/
5

6. Central Line
6

7. Central Line: Subclavian
7

8. Preventing Catheter-Related Bloodstream Infections
• Central venous catheters (CVCs) are being used
increasingly in the inpatient and outpatient setting to
provide long-term venous access.
• CVCs disrupt the integrity of the skin, making infection
with bacteria and/or fungi possible.
• Infection may spread to the bloodstream and
hemodynamic changes and organ dysfunction (severe
sepsis) may ensue, possibly leading to death.
• Approximately 90% of the catheter-related bloodstream
infections (CR-BSIs) occur with CVCs.
8

9. Preventing Catheter-Related Bloodstream Infections
• 48% of intensive care unit (ICU) patients have central
venous catheters, accounting for about 15,000,000 central-
venous-catheter-days per year in ICUs.
• Approximately 5.3 central line infections occur per 1,000
catheter days in ICUs.
• The attributable mortality for such central line infections is
approximately 18%.
• Thus, probably about 14,000 deaths occur annually due to
central line infections. Some estimates put this figure as
high as 28,000 deaths per year.
• In addition, nosocomial bloodstream infections prolong
hospitalization by a mean of 7 days. Estimates of
attributable cost per bloodstream infection are estimated
to be between $3,700 and $29,000.
9

10. References
1. Mermel LA. Prevention of intravascular catheter-related infections.
Ann Intern Med. 2000;132(5):391-402.
2. Pittet D, Tarara D, Wenzel RP. Nosocomial bloodstream infection
in critically ill patients. Excess length of stay, extra costs, and
attributable mortality. JAMA. 1994;271:1598-1601.
3. Saint S. Chapter 16. Prevention of intravascular catheter-related
infection. Making health care safer: a critical analysis of patient
safety practices. AHRQ evidence report, number 43, July 20, 2001.
Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating
catheter-related bloodstream infections in the intensive care unit.
Crit Care Med. 2004;32:2014-2020.
4. Soufir L, Timsit JF, Mahe C, Carlet J, Regnier B, Chevret S.
Attributable morbidity and mortality of catheter-related septicemia
in critically ill patients: a matched, risk-adjusted, cohort study.
Infect Control Hosp Epidemiol. 1999;20(6):396-401.
10

11. Care Bundles
• Care bundles, in general, are groupings of best
practices with respect to a when applied together
result in substantially greater improvement. The
science supporting each bundle component is
sufficiently established to be considered the standard
of care.
• Evidence-based interventions result in better
outcomes than when implemented individually.
11

12. Central Line Bundle
12

13. Central Line Bundle
The central line bundle has five key components:
1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection, with subclavian vein as the
preferred site for non-tunneled catheters
5. Daily review of line necessity, with prompt removal of
unnecessary lines
• Compliance with the central line bundle can be measured
by simple assessment of the completion of each item.
• The approach has been most successful when all elements
are executed together, an “all or none” strategy.
13

14. Central Line Bundle
14

15. Central Line Bundle Results
Berenholtz SM, Pronovost PJ, Lipset PA, et al. Eliminating catheter-related bloodstream
infection in the intensive care unit. Critical Care Medicine. 2004;32:2014-2020.
15

16. Model for Improvement
The model has two parts:
1. Three fundamental questions that guide improvement
teams to
1. Set clear aims,
2. Establish measures that will tell if changes are leading to
improvement
3. identify changes that are likely to lead to improvement.
2. The Plan-Do-Study-Act (PDSA) cycle to conduct small-scale
tests of change in real work settings — by planning a test,
trying it, observing the results, and acting on what is
learned. This is the scientific method, used for action-
oriented learning.
16

17. Model for Improvement
• Implementation: After testing a change on a small scale,
learning from each test, and refining the change through
several PDSA cycles, the team can implement the change
on a broader scale — for example, test medication
reconciliation on admissions first.
• Spread: After successful implementation of a change or
package of changes for a pilot population or an entire unit,
the team can spread the changes to other parts of the
organization or to other organizations.
Model for Improvement on www.IHI.org
17

18. Get Started
1. Select the team and the venue. It is often best to start in
one ICU. Many hospitals will have only one ICU, making
the choice easier.
2. Assess where you stand presently. What precautions are
taken presently when placing lines? Is there a process in
place? If so, work with staff to begin preparing for
changes.
3. Contact the infectious diseases/infection control
department. Learn about your catheter-related
bloodstream infection rate and how frequently the
hospital reports it to regulatory agencies.
4. Organize an educational program. Teaching the core
principles to the ICU staff will open many people’s minds
to the process of change.
5. Introduce the central line bundle to the staff.
18

19. Metrics
Rate
Total no. of CR-BSI cases
x 1000 = CR-BSI per 1000 catheter days
No. of catheter days
Compliance
# with ALL 5 elements of central line bundle
= reliability of compliance
# with CVCs on the day of the sample
Track and Scoreboard Overtime
Rate & Compliance
19

20. Track Overtime: Rate & Compliance
20

21. Automation Helps Knockdown Barriers
1. Fear of change
– “It works and its proven”
– It’s the reason to use the system
2. Communication breakdown
– “Its built in”
– The system supports compliance
3. Physician and staff “partial buy-in”
– “I thought I was doing better than that”
– Measuring performance is compelling
21

22. The Form: Specs
22

23. The Form: Prep
23

24. The Form: During
24

25. The Form: After
25

26. Ongoing Daily Review
• Daily review for necessity
and prompt removal of
unnecessary lines:
• The ICU patient with a
central line will be
reviewed daily, with a
notation on the daily goals
sheet or medical record
indicating the continued
need for the central line.
• Routine replacement
should be avoided, and all
lines should be removed as
early as possible.
26

27. Clinical Transformation, in Practice
Jeff Parker, Midland Memorial Hospital

28. Outcomes
• Central line days in ICCU averaged over the past year =
178 month.
• We have scored 100% on bundle compliant forms.
• We use maximum barrier kits.

29. Quality Improvement:
Order Sets
• Using the in place order sets, the physician with a mere
click or two can order all the necessary orders for central
line placement – including X-rays for placement, flushes,
with an order that staff can start using when placement is
confirmed. In the old days, we would have to call the
physician as most did not write the orders out in the detail
we have with the electronic record.

30. Quality Improvement:
Chart Availability
• Radiology immediately can view the order and can check
the patients record for a signed consent, what the H&P
shows, and the patients overall medical condition prior to
them ever actually seeing the patient.
• The physician can view the X-ray immediately from any
location within the hospital, from his home or office.

31. Quality Improvement:
Efficiency
• Often, the chest X-ray is done within minutes of inserting
the central line, allowing the use of the central line to be
started much more quickly than was previously possible –
which could be a crucial five minutes if it’s a unit patient.

32. Quality Improvement:
Measuring and Compliance
• The electronic record has made it possible to easily audit
charts and monitor for central line compliance.

33. Transformation Working Group
Janine Powell & Debbie Daspit

34. Community Collaboration
• Organized Collaboration - Just getting started..
– Work as a Group
– Divide and Conquer option
• Collaboration Dependences
– Values
– Interpretation
– Understanding
– Workflow
– Distribution of information
• Framework as a collaboration path to design and document
and distribute strategies and content
– Core Measure Reporting
– “Never Event” Prevention
– Performance Improvement

35. Clinical Transformation Framework sample

36. Admitted Patient Triggers

37. Emergency Visit Triggers

38. Orders/Standing Orders Triggers

39. Design and Documentation Example

40. Open Development Projects
George Lilly & Fay Struble
Adam Waterbury

41. OpenVista/GT.M Integration Project
Adam Waterbury

42. Get Involved
Code is available on Launchpad
Not production ready; for developers only
Bugs are in Launchpad
You can help!
File a bug
Comment on a bug with suggestions
Create a branch and fix a bug yourself
Not sure how to get started?
Post on Medsphere.org with your interests; we'll find
something for you!

43. Opensource CCR and CCD support
for VistA based systems
Project Update
March 26, 2009
by
George Lilly
glilly@glilly.net
* This project has been funded in part with Federal funds from the
National Institutes of Health, under Contract No. HHSN268200425212C,
“Re-engineering the Clinical Research Enterprisequot;.

44. Collaborators
Individuals
Organizations
Kevin Peterson
George Lilly
WorldVista
Mike Schendel
Christopher Anderson
HP
Fay Strubel
Nancy Anthracite
KRM
Thomas Sullivan
Lee Castonguay
Medsphere
Chris Uyehara
Duane DeCorteau
Robert Morris University
David Whitten
Emory Fry
Sequence Managers
Greg Woodhouse
Sam Habiel
University of Minnesota
JohnLeo Zimmer
Jose Lacal
John McCormack
Ben Mehling
Dennis Menor
Ken Miller

45. Topics
Definition
Purpose
Snapshot
Highlight
Contributors

46. Definition: The Continuity of Care Record (CCR)
is a machine readable and human readable ASTM
XML standard data set of a person's clinical
status

47. The CCR dataset has many intended purposes
including the exchange of medical records,
synchronization with clinical repositories, and
the transformation into clinical messages
Exchange of medical records:
Between two EHR systems (VistA<->VistA and VistA<->Other)
With a Personal Health Record (PHR) – like Google Health or
MS HealthVault
Synchronization with clinical repositories:
For clinical decision support
For research and clinical trials – as with the Electronic
Primary Care Research Network (ePCRN)
Transformation into clinical messages
XSLT transformation into a Continuity of Care Document (CCD)
For use the the National Health Information Network (NHIN)
For CCHIT Certification
For HIPAA Claims Attachments
Transformation into XML Web Service messages for ePrescribing

48. CCR/CCD PROJECT SNAPSHOT 3/26/2009
Picklist
Web
File CCD Transformation
Processing
Service
ePCRN
Connection
CCR Batch
Parameters
Template Proccessing ePrescription XML
Fileman Parameters
Support
Lab Date Limits
CCR Meds Date Limits Fileman
Template File Checksums
Processor Menu
Vitals Date Limits
Template Import
Options Codes
XPath Library XML RPC Variables RPC
MUMPS Temporary Globals
Fileman CCR Elements
Export Import (Accessioning)
Family History Advance Directives Lab Results Vital Signs Alerts/Allergies
Procedures Support Payers Medications Problems Actors Medication Advisories
(ePrescribing)
Encounters Functional Status Immunizations Alerts/Allergies
Plan of Care Medical Equipment Social History
GTM GTM
Cache GTM GTM Cache
WorldVistA
OpenVistA FOIA VistA RPMS
EHR
Legend Planned In Development Testing In Production Recent Change

49. Recently, we demonstrated the transformation of
our CCRs into level 2 CCDs thanks to an XSLT
transformation contributed by Ken Miller

50. Medsphere.org Tip of the Month
Ben Mehling

51. Start a new Blog Post

52. Create a Personal Blog

53. Setup your Blog

54. Write a new post

55. Medsphere.org Blogs