Quality Performance Measurement and Use of Health Information Technology in Critical Access Hospitals Michelle Casey University of Minnesota Rural Health Research Center Flex Monitoring Team 2006 National Conference of State Flex Programs St. Paul, Minnesota August 16, 2006
Flex Monitoring Team Rural Health Research Centers at Universities of Minnesota, North Carolina, Southern Maine Cooperative agreement with ORHP 2003-2008 Collaboration with TASC National Advisory Committee Purpose: Assess impact of Flex Program on rural hospitals, communities and role of states in achieving overall program objectives
Overview of Flex Monitoring Team Activities Tracking CAH Conversions State Flex Program Activities CAH Financial Performance CAH Quality Performance Community Impact National CAH Surveys Multiple topics, including HIT
Benefits of Flex Monitoring Efforts Data for federal and state policymaking on Flex Program Support for ORHP National Performance Measures for Flex Program Development of tools and identification of best practices for states and CAHs to improve program performance
Flex Monitoring Team Quality Performance Related Activities Development and Field Testing of Rural-relevant Quality Measures Analysis of CAH Participation in Hospital Compare and Initial Results Analysis of CAH Inpatient Hospitalizations and Transfers Summary of State Flex Program QI activities
Development and Field Testing of Rural-relevant Quality Measures Builds on University of Minnesota work to identify rural-relevant hospital quality indicators and initial field test in rural hospitals working with QIOs Continued work on developing new quality measures and refining the existing set of quality measures Current field test of quality measures related to transfer communications with CAHs
Developing Relevant Quality Measures for Rural Hospitals Evaluate existing quality indicator and performance measurement systems to assess their relevance for rural hospitals Convene expert panel to make recommendations for quality measures that are relevant for rural hospitals Develop and test a performance improvement system that provides a core set of quality measures for rural hospitals on an ongoing basis
Criteria Used for Evaluating Quality Measures Prevalence in rural hospitals with less than 50 beds Ease of data collection effort in rural hospitals with less than 50 beds Internal usefulness for rural hospitals with less than 50 beds External usefulness for rural hospitals with less than 50 beds
Relevant Quality Measures for Rural Hospitals with < 50 Beds 21 measures from existing measurement sets included: Core measures related to pneumonia, heart failure, and AMI Medication dispensing and education Infection control Emergency Department trauma vital signs
Relevant Quality Measures for Rural Hospitals with < 50 Beds Develop quality measures for core rural hospital functions not in existing measurement sets Emergency Department timeliness of care Transfer Communication patient demographics patient care patient management
Initial Field Test Partnership with 2 QIOs - Stratis Health and HealthInsight Rural hospitals with < 50 acute beds in MN, NV, UT recruited by Stratis Health and HealthInsight 22 rural hospitals including 13 CAHs collected data over 6 months (March September 2004)
Conclusions Regarding Initial Field Test Relevant quality measures can be systematically collected from small rural hospitals that receive appropriate training and support from QIOs Further work needed to refine Emergency Department measures Organize transfer communication measure elements by target area for interventions Apply transfer communication measure to all transfer conditions Limit ED chest pain/ami measures to cardiac-related cases
Test train the trainer model Current Field Test of ED Measures Washington Rural Health Quality Network 18 CAHs participating in field test Focus on Emergency Department timeliness and transfer communication measures Data collection January to June 2006 Data analysis and report completed by Fall 2006
CAH participation in CMS Hospital Compare CAHs do not have the same financial incentives as PPS hospitals to participate, however Hospital Compare provides an important opportunity for CAHs to assess and improve their performance on national standards of care
Purpose of Project Estimate proportion of CAHs participating in Hospital Compare and assess key factors related to CAH participation Determine how many CAHs have sufficient sample sizes to calculate accurate hospital-level rates for specific measures Compare initial quality measure results for CAHs with other hospitals
CAH Participation in Hospital Compare 41% of CAHs participating as of September 2005 By state, participation rates range from 0% to 86% CAHs are more likely to participate if they are: JCAHO accredited Have larger number of admissions and inpatient days System members Later converters Have private non-profit ownership
Volume is an issue CAH Participation in Hospital Compare More than half of participating CAHs reported data for 25 or more patients on 3 pneumonia measures Less than 4% of participating CAHs reported data for 25 or more patients on all AMI measures and 2 heart failure measures Analyzed performance of CAHs as a group compared to other groups of hospitals on initial 10 measures
AMI Results for CAHs and non-cahs AMI Measures % of patients receiving recommended care 100 90 80 70 60 50 40 30 20 10 0 94.5 94.3 89.8 84.3 Aspirin at arrival Aspirin prescribed at discharge 79.3 74.4 ACE inhibitor for LVSD 89.5 92.2 80.5 81.4 Beta blocker at arrival Beta blocker prescribed at discharge 47.7 86 Smoking cessation advice 38.6 30 Thrombolytic w/in 30 min of hospital arrival CAHs Non-CAHs
Heart Failure Results for CAHs and non-cahs Heart Failure Measures % of patients receiving recommended care 100 90 80 70 60 50 40 30 20 10 0 64.2 86.9 73.4 75.7 51.3 44.8 56.9 72.1 CAHs Non-CAHs Assessment of LVSD ACE inhibitor for LVSD Discharge instructions Smoking cessation advice
Pneumonia Results for CAHs and non-cahs Pneumonia Measures % of patients receiving recommended care 120 100 80 60 40 20 0 98.3 98.6 Oxygenation assessment 55.1 46.7 Pneumoccal vaccination status 82.3 70.6 Initial antibiotic w/in 4 hours of hospital arrival 82.4 82.3 Blood culture prior to 1st antibiotic in hospital 58.4 68 Smoking cessation advice 74.5 75.9 Appropriate initial antibiotic selection CAHs Non-CAHs
Summary of Hospital Compare Results CAHs perform as well or better than non-cahs on several pneumonia measures CAHs do not perform as well as non-cahs on AMI and heart failure measures Compared to non-cahs with < 50 beds, CAHs perform as well or better on most AMI and pneumonia measures, but not as well on heart failure measures
Potential Reasons for CAH Hospital Compare Results Documentation issues Availability of specialists and technology Use of clinical and administrative guidelines/protocols QI/Continuing education programs Systems issues Bottom line: opportunities for improvement in documentation and care processes in CAHs
Implications of CAH Hospital Compare Results Variation within group of CAHs it will be important to examine individual CAH performance when sample sizes are sufficiently large QIO 8 th Scope of Work has a goal of 50% increase in CAH reporting of quality measure data to QualityNet Exchange, the national QIO data warehouse ORHP is encouraging state Flex programs to work with CAHs in their states on quality improvement and to increase their Hospital Compare participation
Additional Quality Related Projects Analysis of hospital discharge data from 9 State Inpatient Databases with hospital identifiers How many and what type of patients are being transferred from CAHs to other hospitals and to other types of care? Summary of State Flex Program QI Initiatives Analyses to be competed Fall 2006
National CAH Surveys 2004 National CAH Survey Stratified sample of 500 CAHs, 95% response rate Topics: quality, patient safety, scope of services, capital, community involvement National reports on website, state-specific reports sent to states with 5 or more respondents Special survey of Health Information Technology Use in CAHs Spring 2006 National CAH survey scheduled for fielding in Fall 2006 Community involvement/community benefits Quality, capital
Health Information Technology Use in CAHs Purpose: to assess level of HIT use in CAHs for a national performance measure Collaborative effort of Flex Monitoring Team, TASC and ORHP Web-based and phone survey March April 2006 Random national sample of 400 CAHs 333 CAHs (83.3%) responded 210 by web, 123 by phone
Half of CAHs have a formal IT plan HIT Survey Results: Infrastructure 76% of CAH budgets include IT funding 78% have hospital web sites All CAHs have some type of Internet access In 36% of CAHs, clinicians use PDAs for patient care
Administrative and Financial Applications CAHs have high use rates for many administrative and financial HIT applications 95% or more have computerized claims submission, patient billing, accounting, payroll, and patient registration/admission processes 73% have computerized patient discharges 44% have computerized scheduling of procedures
Electronic Access to Guidelines and Patient Data Percent of CAHs 60 50 40 30 20 10 0 16.2 Bar-coded patient identification bracelets 51.1 Clinicians have electronic access to clinical guidelines 20.7 Electronic medical records 17.2 Computerized physician notes 33.4 Computerized MARs 18.6 Computerized nursing flow sheets
Use of Pharmacy Technology Computerized Pharmacy Functions Percent of CAHs 60 50 40 30 20 10 25.5 47.4 42 55.4 33.1 23.6 0 CPOE Allergy, Rx interaction screening Dose recs/checks Manufacturer & FDA information and alerts Automated dispensing machines Telepharmacy
Use of Lab and Radiology Technology Computerized Lab and Radiology Functions Percent of CAHs 90 80 70 60 50 40 30 20 10 0 45.7 Clinician ordering of lab tests 51.8 Tracking of lab specimens 58.4 Clinician review of lab test results 42.2 Clinician ordering of radiographs 59.5 Clinician review of radiology results 80.2 Teleradiology
Telemedicine and Electronic Sharing of Data Telemedicine and Electronic Sharing of Clinical Data Percent of CAHs 60 50 40 30 20 10 0 26.7 Telemedicine 54.9 Clinical data shared electronically by hospital depts. 36.4 EKG tracings transmitted electronically 31.8 32.3 Physician offices/clinics connected to hospital s IS LTC facilities connected to hospital s IS 23.4 Clinical data shared electronically with other hospitals
HIT Survey Conclusions Medicare cost-based reimbursement has permitted many CAHs to make initial investments in HIT infrastructure CAHs have high use rates for administrative and financial HIT applications, but much lower rates for clinical applications CAH HIT use rates are lower than overall rates for hospitals Future efforts need to focus on increasing use of clinical applications and interconnectivity of CAHs and other health care providers
Additional Information Flex Monitoring Team website www.flexmonitoring.org List and map of CAHs Descriptions of projects Contact information Copies of reports and presentations