It’s a fact: Evidence-based medicine is improving the quality and consistency of clinical care. While uniformly applying clinical data to medical practice and carefully tracking metrics requires great effort, the rewards are even greater in terms of better patient outcomes, better use of resources and balancing of costs. Two leading cardiac care facilities show how it’s done in treating acute myocardial infarction and more.
Healthcare technology plays an important role in the cardiac care process; however, improving cardiac care hinges on multiple inputs. True improvements in clinical outcomes require systematic changes in order to standardize processes to ensure that all patients receive high-quality and consistent clinical care. Similarly, hospitals can minimize the possibility of human error by implementing redundancy strategies to ensure that all patients receive appropriate tests, procedures and follow-up.
Take for example the common scenario of acute myocardial infarction (AMI) detection. Physicians can vary in the marker level used to launch the AMI order set, resulting in variability or delays in treatment. A standard cutoff—one derived from evidence-based data—levels the playing field. Another common process prone to human error is administration of aspirin and beta blockers at admission. Appropriate administration of meds is linked to positive outcomes, but the full regimen requires a precisely timed mix of medication. A standard order set helps ensure compliance and boosts patient outcomes.
Such changes not only improve clinical care but also can boost the bottom line by eliminating duplicative and unnecessary tests. These types of strategies form the heart of evidence-based medicine, which seeks to more uniformly apply clinical data to medical practice.
Driving change in the mega-enterprise
Institutions around the country are turning to evidence-based medicine to improve cardiac care. Banner Health System in Phoenix, Ariz., is one of the nation’s largest and most complex healthcare systems. It comprises 20 hospitals across multiple states. Its mission is guided by a commitment to high-quality patient care, and each chief medical officer assumes principle responsibility for the quality of care in the “home” institution. In addition, the enterprise is focusing on four major quality initiatives: AMI, heart failure, surgical quality improvement and pneumonia and preventative health.
The system chose its quality initiatives for two reasons, says Mark Starling, MD, medical director of Banner Heart Hospital in Mesa, Ariz. The Centers for Medicare and Medicaid Services (CMS) requires hospitals to track these areas, and equally important, says Starling, patients have better outcomes if these metrics are met. For AMI patients, Banner Health System decided to focus on several key metrics including administration of aspirin and beta blockers at arrival and discharge. Greater compliance with these metrics correlates with lower AMI mortality, according to The Duke Clinical Research Institute.
The AMI team focused on designing both system-wide and site-specific processes to guarantee that Banner Health System provides high-quality care to AMI patients. For example, the initiative team developed a standardized order set to use throughout the hospital system when a patient presents to the ED with chest pain. The order set lays the groundwork for a consistent, reliable sequence of care. At the same time, it can be adapted to individual site needs. Equally important,it establishes a framework as Banner Health heads toward computerized physician order entry (CPOE) in the EMR for AMI cases.
The next initiative is an admission order set with a care mapping process. “Care mapping ensures that heart attack patients get every item they require—from diet to medications to assessments and lab tests,” says Starling. The health system built redundancy into the care mapping process, with each department checking on various steps in the process. If one department forgets to administer aspirin, the next player can handle the missing piece via the admission order set or cath lab documentation system.
The new processes have been in place only a few months, so the health system does not yet have hard data; however, in the second half of 2007, more than 95 percent of AMI patients received appropriate care at all 20 facilities.
Banner Health System also established processes to allow hospitals to learn from each other. For example, after one site initiated an EMT cardiac alert process for AMI cases to drop door-to-balloon time to under 90 minutes for all patients, four facilities decided to adopt the process. Partially into rollout, Banner Heart Hospital has increased the percentage of patients making it to the cath lab in 90 minutes from 35 to nearly 65 percent.Banner Health System’s commitment to evidence-based medicine is a work in progress. Eventually, as the health system moves from paper to electronic records, all order sets and care mapping processes will be coded into the EMR to further streamline processes.
The IT angle
IT is an essential ingredient in the robust evidence-based medicine program. Alamance Regional Medical Center is a state-of-the-art community hospital in Burlington, N.C. The medical center recently won a Premier Quality Award for its AMI treatment program. The “secret” to the hospital’s success is IT. “It’s a challenge to adhere to CMS guidelines, implement best practices and improve patient care,” admits Ken Fath, MD, medical director of performance improvement and medical informatics. “We’ve acquired and leveraged IT to assist with our evidence-based medicine program.”
The hospital has tapped into Eclipsys Corporation Sunrise Clinical Manager to achieve 100 percent electronic results, 88 percent CPOE and 70 percent electronic documentation. “These processes allow us to create order sets based on evidence-based medicine to guide physicians to best practices,” states Fath. For example, a congestive heart failure order set prompts specific orders and alerts physicians to any contraindications.
The results of the electronic approach are impressive. Alamance Regional Medical Center increased its compliance with beta blockers and aspirin at AMI admission and discharge from 45 to 50 percent to 99 percent in less than a year. The implementation of rapid cardiac evaluation in the ER helped the center slash its door-to-discharge or door-to-bed time from 80 minutes to 35 to 40 minutes. To achieve rapid door-to-bed time, the medical center uses electronic order sets and a new ER workflow that places a physician in the triage area. The new frontline physician can initiate the cardiac care process by placing lab and imaging orders.
The cardiology department has realized benefits beyond compliance and patient care. “We’ve eliminated the retrospective review of stacks of paper after discharge and improved tracking,” says Fath. On the financial and workflow fronts, the electronic system helps reduce duplication of services and links tests to appropriate preps to minimize cancellations. The medical center continues to assess its progress and expects to see shorter lengths of stay, increased productivity and improved customer service ratings as a results of its commitment to IT and evidence-based medicine.
Advice from the trenches
- Quality initiatives are a team sport, says Starling. “Everyone plays, and everyone is responsible.” Translation? Deploy a facility team with broad representation. At the same time, hold all clinical leaders responsible for the quality of patient care, says Starling.
- Evidence-based medicine transcends technology, says Fath. “It’s a workflow change. Make sure the culture is ready for it.” Sites can secure buy-in from clinical staff by educating them about improvements in efficiency and clinical care enabled by a strong evidence-based medicine program.
The big picture
Evidence-based medicine provides a path to the ideal practice of medicine. By implementing processes to standardize patient care and ensure patients receive clinically-validated interventions, hospitals adhere to their core mission. The research shows evidence-based measures make a difference for cardiac patients, enabling physicians to initiate timelier treatment via reduced door-to-balloon time and standard order sets, as well as reduced mortality via compliance with CMS AMI metrics. Evidence-based medicine requires a strong commitment from administrative and clinical leaders, and IT can lend a much needed helping hand.
The Future of Evidence-Based Medicin
The Cardiovascular Research Network is a newly created collaborative designed to leverage the diverse populations and electronic data systems of nine health plans across the U.S. The Cardiovascular Research Network expects to analyze a large population to determine how clinical trial results translate into medical practice and patient outcomes.
“The demographic capabilities of the network are unprecedented,” says Alan Go, MD, assistant director for clinical research for Kaiser Permanente of Northern California in Oakland, Calif. The collaborating health plans represent 7.6 million patients, and because each participating health plan uses an electronic database, researchers can pull data to answer questions.
In the next five years, the first research projects of the cardiovascular-focused network will analyze hypertension recognition, treatment and control; quality of care and outcomes of the blood thinner warfarin for atrial fibrillation and blood clots, and the use and outcomes of implantable cardiac defibrillators (ICDs).
The hypertension project will review whether or not primary-care physicians appropriately recognize and manage hypertension and if healthcare providers intensify treatment as necessary. Answering such questions will help researchers determine reasons for variation in treatments and outcomes, says Go.
The warfarin project aims to assess the quality of administration and management to help physicians and patients better understand the risks and benefits of treatment.
Finally, the ICD project will look at use and outcomes. Currently, physicians don’t know if physicians use ICDs according to clinical trials, if use has been broadened to other populations and if there is a benefit to ICD use beyond high-risk patients.
The Cardiovascular Research Network expects to generate additional projects in the future and collaborate with cardiac care associations such as the American Heart Association.