Data Flow & Clinical Outcomes in a Perinatal Continuum of Care System (Pennsylvania)

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Summary:

Integrated electronic health records (EHRs) between care settings allow for access to patient data regardless of location, and have the potential to reduce medical errors and increase patient safety. Without such integration, test results and clinical notes completed in one setting are often not available in the other. This issue is particularly striking in obstetrics where there is a critical, sometimes urgent, need to understand a pregnant patient’s course of care when being evaluated on labor and delivery. Exchanging data between obstetrical offices and the hospital can facilitate coordinated treatment; improve clinical decision making; reduce the underuse, overuse, and inappropriate use of medications and diagnostic tests; and reduce the incidence of negative birth outcomes for mothers and newborns.

This project studied the impact of a perinatal continuum of care information system on maternal and fetal outcomes, and on provider satisfaction and productivity. The study took place at the Lehigh Valley Health network in Pennsylvania consisting of three OB/gyn groups and the network’s main hospital, Lehigh Valley Hospital-Cedar Crest.

The specific aims of the project were as follows:

  • Develop grounded theory to describe the process of effective implementation and integration of ambulatory EHR systems with hospital information systems. 
  • Examine the change in data completeness (complete and accessible data) at the hospital and the individual practices. 
  • Examine improvements in health outcomes, staff perceptions of patient safety, and patient and medical staff satisfaction, as well as changes in the productivity of primary care and inpatient physicians. 
  • Triangulate the results of the quantitative and qualitative analyses to gain a deeper understanding of how to achieve benefits from an integrated EHR. 

The project was conducted in three phases. In phase I, the OB/gyn practice groups migrated from either paper records or an existing EHR to a common commercial EHR. Discrete data elements were interfaced over to the same vendor’s hospital perinatal information system. In phase II, visit summary documents, such as triage discharge summaries, were interfaced from the perinatal information system to the ambulatory EHR. In phase III, discrete clinical data elements collected during triage visits were interfaced from the perinatal information system to specific locations in the ambulatory EHR.

The impact of the system was evaluated using both qualitative and quantitative methods. Structured interviews were conducted with 75 providers, and data on transmission, physician productivity, birth outcomes, and provider and patient satisfaction were analyzed. The project team noted many lessons learned from the implementation, including:

  • Clinician needs and demands vary by department and specialty, and must be weighed against organizational values and goals. 
  • Simple interfaces, such as those with billing and scheduling systems, have data that is often not clinically relevant. 
  • Workflow analysis is necessary to understand how and when clinicians use data, and whether processes might require redesign for maximal effectiveness. 
  • Determining which data elements are necessary in the design of encounter templates is critical, including which may be entered via free text and which must be entered via structured data entry. 

The project team found an initial decrease in physician productivity and satisfaction during implementation and data integration, which subsequently increased over time. EHR integration led to a reduction in the severity of adverse birth events, such as harm to the mother or baby during delivery. The project found that while there was an initial learning curve, increased information enabled providers to identify problems and respond with more intensive care.

Full detail of lessons learned and results are described in the final report.

Data Flow & Clinical Outcomes in a Perinatal Continuum of Care System - 2012

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology (IT) to Improve Health Care Quality (R18)
  • Grant Number: 
    R18 HS 018649
  • Project Period: 
    September 2011 – September 2014
  • AHRQ Funding Amount: 
    $335,705
  • PDF Version: 
    (PDF, 338.08 KB)

Summary: Medical errors are often caused by poor communication, especially during transitions of care between the inpatient and outpatient care settings. For example, test results and clinical notes completed in one setting are often not available in the other, or discharge information and planned followup care are not communicated adequately between providers. These issues are particularly striking for obstetrician gynecologists (OB/GYNs) who care for patients in both settings and frequently have an urgent need for current clinical patient data. One solution to this problem is to interface the ambulatory electronic medical record (EMR) to the inpatient perinatal information system to enable data exchange between the systems. This allows patient data to be available in real time, regardless of the location of the provider or patient. Since few EMR vendors can supply a single solution with a unified database of clinical information for the outpatient OB/GYNs and the inpatient labor and delivery (L&D) triage environments, most organizations utilize separate clinical information systems.

In order to improve data access and completeness at all points in the perinatal continuum of care process, the Lehigh Valley Health Network (LVHN) implemented a vendor-supplied ambulatory EMR system at the three outpatient OB/GYN practice groups that interface with the perinatal information system implemented at the L&D unit of Lehigh Valley Hospital-Cedar Crest, the network’s main hospital. The goal is to establish a real-time exchange of patient data between these systems. In theory, patient medical information from all physician offices participating in the integrated EMR system should be available when a patient arrives at the L&D unit, and information from a patient’s visits to the L&D unit should be available in ambulatory care settings.

The study team is evaluating the implementation of the integrated EMR system. Quantitative and qualitative data collected during implementation is being used to assess the system’s effect on organizational and process change in the outpatient and inpatient settings and the system’s ability to deliver accurate, complete, and timely data to providers and clinical staff at points along the perinatal continuum of care. Qualitative data is being collected by administering surveys, conducting interviews, and analyzing notes from meetings that occurred before, during, and after system implementation. The qualitative data will be used to describe the changes in organizational and workflow processes resulting from the integrated system. Quantitative data is being collected from surveys, LVHN databases, and the Pennsylvania Health Care Cost and Containment Council to assess the system’s effects on data completeness, medical outcomes, provider efficiency, and patient and provider satisfaction. The evaluation will provide lessons for other organizations attempting to integrate outpatient and inpatient data through health information technology. It will also provide policymakers with an overall assessment of the costs and benefits of integrating EMR systems.

Specific Aims:

  • Develop grounded theory to describe the process of effective implementation and integration of ambulatory EMR systems with hospital information systems through qualitative analysis of technology acceptance and use and complementary organizational and process change. (Ongoing)
  • Examine quantitatively the change in data completeness (complete and accessible data) at the hospital and the individual practices resulting from the adoption of the integrated EMR system. (Ongoing)
  • Examine quantitatively improvements in health outcomes, staff perceptions of patient safety, and patient and medical staff satisfaction, as well as changes in the productivity of primary care and inpatient physicians. (Ongoing)
  • Using mixed methods, triangulate the results of the quantitative and qualitative analyses to gain a deeper understanding of how to achieve benefits from an integrated EMR. (Upcoming)

2012 Activities: Data collection activities involving surveying, interviewing, document analysis, and data abstraction continued throughout 2012. Abstracting data from the perinatal information system was challenging because after the project team defined the data needed for this project, they learned that some of it was readily available in the perinatal information system and some of it had been archived. Project staff had to reinstate the archived data manually into the active system in batches and then abstract it from the system. The data is now under review to determine whether it is complete enough for the analysis. This quality review will continue into 2013 followed by analysis. The project team also worked on an initial analysis of patient outcome data.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track, and the project budget funds are somewhat underspent because personnel costs were lower than projected for Year 1 of the project. Dr. Levick anticipates that personnel costs will increase during Year 2 as project staff increase time on the analysis component.

Preliminary Impact and Findings: Initial findings support that the availability of specific data elements at the point of care (both in the ambulatory office and in the Triage Unit) may have a positive impact on maternal outcomes. This analysis was performed on a limited dataset; and further analysis is ongoing. Preliminary analysis of the integrated EMR system implementation demonstrates several lessons learned:

  • The decision between maximal functionality of systems (best of breed architecture) versus true integration (single platform architecture) is an enterprise strategic decision.
  • Understanding the provider workflow is critical to the introduction of new, interfaced data. Managing expectations and standardizing the provider workflow can impact successful adoption.
  • Need to find the appropriate balance between the amount of data to interface and “data overload” which reduces usability and acceptance.
  • An incremental approach to implementation and interfacing can improve acceptance and integration into provider workflow.
  • The balance between the quantity of structured text (improved analytics) versus free text entry (more efficient provider workflow) is an ongoing challenge.

Target Population: Women*: Pregnancy

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ’s priority populations.

Data Flow & Clinical Outcomes in a Perinatal Continuum of Care System - 2011

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    PAR: HS08-270: Utilizing Health Information Technology (IT) to Improve Health Care Quality (R18)
  • Grant Number: 
    R18 HS 018649
  • Project Period: 
    September 2011 - September 2014
  • AHRQ Funding Amount: 
    $335,705
  • PDF Version: 
    (PDF, 190.01 KB)

Summary: Medical errors are often caused by poor communication, especially during transitions of care between the inpatient and outpatient care settings. For example, test results and clinical notes completed in one setting are often not available in the other, or discharge information and planned followup care are not communicated well between inpatient and outpatient providers. These issues are particularly striking for Obstetrician Gynecologists (OB/GYNs) who care for patients in both settings and frequently need all current clinical patient data. One solution to this problem is to integrate electronic medical record (EMR) systems in outpatient and inpatient settings to enable data exchange between systems and allow for patient data to be available in real time, regardless of the location of the provider or patient. Few EMR vendors can supply a single solution with a unified database of clinical information for the outpatient OB/ GYNs and the inpatient Labor and Delivery (L&D) triage environments. Therefore, most organizations utilize separate clinical information systems.

To improve data access and completeness at all points in the perinatal continuum of care process, the Lehigh Valley Health Network (LVHN) implemented a vendor-supplied integrated ambulatory EMR system at its three outpatient OB/GYN practice groups. Additionally, a perinatal information system was implemented at the L&D unit at the network's main hospital, Lehigh Valley Hospital-Cedar Crest. The goal is to establish a real-time exchange of patient data between these systems, bridging the outpatient and inpatient settings. In theory, patient medical information from all physician offices participating in the integrated EMR system should be immediately available when a patient arrives at the L&D unit, and information from a patient's visits to the L&D unit should be available in the ambulatory care settings.

This study is evaluating the implementation of the integrated EMR system. Quantitative and qualitative data collected during the system implementation process is being used to assess the system's effect on organizational and process change in the outpatient and inpatient settings, and the system's ability to deliver accurate, complete, and timely data to providers and clinical staff at points along the perinatal continuum of care. Qualitative data is being collected by administering surveys, conducting interviews, and analyzing notes from meetings that occurred before, during, and after system implementation. The qualitative data will be used to describe the changes in organizational and workflow processes resulting from the integrated system. Quantitative data is being collected from surveys, LVHN databases, and the Pennsylvania Health Care Cost and Containment Council to assess the system on data completeness, medical outcomes, provider efficiency, and patient and provider satisfaction.

This project will map the quantitative and qualitative links between health information technology (IT) adoption and individual patient outcomes (maternal and newborn), as well as patient and provider satisfaction. The evaluation should provide replicable lessons for other organizations attempting to integrate outpatient and inpatient data through health IT. It will also provide policymakers with an overall assessment of the costs and benefits of integrating EMR systems.

Specific Aims:

  • Develop grounded theory to describe the process of effective implementation and integration of ambulatory EMR systems with hospital information systems through qualitative analysis of technology acceptance and use and complementary organizational and process change. (Ongoing)
  • Examine quantitatively the change in data completeness (complete and accessible data) at the hospital and the individual practices resulting from the adoption of the integrated EMR system. (Ongoing)
  • Examine quantitatively improvements in health outcomes, staff perceptions of patient safety, and patient and medical staff satisfaction, as well as changes in the productivity of primary care and inpatient physicians. (Ongoing)
  • Using mixed methods, triangulate the results of the quantitative and qualitative analyses to gain a deeper understanding of how to achieve benefits from an integrated EMR. (Upcoming)

2011 Activities: Data collection is in process. Stakeholder interviews and document analyses are being conducted. Two rounds of surveys have been administered to staff in the inpatient and outpatient settings to assess the availability of data. Another round of surveys will be administered later in 2012.

As last self-reported in the AHRQ Research Reporting System, project progress and activities are mostly on track, and the project budget funds are somewhat underspent due to personnel costs coming in lower than projected at the time of reporting.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: Women*: Pregnancy

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

* This target population is one of AHRQ's priority populations.

Data Flow & Clinical Outcomes in a Perinatal Continuum of Care System - Final Report

Citation:
Levick D. Data Flow & Clinical Outcomes in a Perinatal Continuum of Care System - Final Report. (Prepared by Lehigh Valley Hospital under Grant No. R18 HS018649). Rockville, MD: Agency for Healthcare Research and Quality, 2014. (PDF, 533.13 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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