Newscast: Lead Story - H.I.T. is Used to Treat Pressure Ulcers

(opening music)

Debra: This is Healthcare 411 for the week of October 4, 2006.

Rand: Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. I’m Rand Gardner.

Debra: And I’m Debra James.

Rand: Coming up:

Debra: A new survey captures the public’s views of medical errors and quality of care

Rand: A comparison of arthritis pain medications finds they’re all very similar

Debra: And we look at a new study that used health information technology to reduce the prevalence of pressure ulcers in long-term care facilities. But first, this message from AHRQ.

[Begin: PSA: Remaking American medicine]

Narrator: Beginning October 5th at 10 p.m., a new four-part television series will tell stories of change in our health care system. Airing nationally on PBS on the four Thursday evenings in October, Remaking American Medicine Health Care for the 21st Century will focus on the dramatic advances being made to improve the way health care is delivered in this country. The television series is linked to a national outreach campaign to help inspire and empower the public and health care professionals to work together to transform and improve the quality of American health care. For more information, please go to ramcampaign.org.

[End PSA]

(music)

Debra: Since the Institute of Medicine issued a landmark study seven years ago on medical errors in hospitals, the Kaiser Family Foundation and AHRQ have fielded several surveys to try to assess the public’s knowledge of medical errors and steps they’ve taken to improve the quality of their care. The most recent survey, released last week, found that more than half of Americans now say they understand the term medical error. One in three Americans says they or a family member have created a set of their medical records to ensure that their health-care providers have all their medical information. And 70 percent say they now check the medication given to them by their pharmacist against their doctor’s prescription. The full results of the survey are available at www.kff.org/kaiserpolls.

Rand: Two classes of drugs commonly used to treat osteoarthritis provide about the same level of pain relief and carry a similar increased risk of heart attack. The two classes of drugs are non-steroidal anti inflammatory drugs, commonly called N-SAIDs, and COX-2 inhibitors. One exception is the NSAID naproxen, sold as Aleve or Naprosyn, which may present a lower risk of heart attack than other NSAIDs or COX-2 inhibitors. These conclusions were part of a systematic review that featured head-to-head comparisons of medications used for osteoarthritis. About 6 percent of Americans 30 or older have osteoarthritis of the knee, and about 3 percent have osteoarthritis of the hip. Each year they spend about $8.5 billion on NSAIDS or COX-2 inhibitors to manage the pain from the disease. Two COX-2 inhibitors Vioxx and Bextra were voluntarily withdrawn from the market because of the risk of heart attack. The medication comparison, conducted through AHRQ’s Effective Health Care Program, also found that all NSAIDs and COX-2 inhibitors can cause or worsen hypertension, congestive heart failure, swelling and impaired kidney function. The risk for serious adverse gastrointestinal events among people taking the Cox-2 inhibitor Celebrex is about the same as for those taking Motrin, Advil, and other NSAIDs. Acetaminophen, or Tylenol, which is not an NSAID or Cox-2 inhibitor, generally is less effective against arthritis-related pain than NSAIDs, but it has a smaller risk of stomach problems. The report also stated that more research is needed to compare the heart and stomach risks of NSAIDS with aspirin taken at doses effective for arthritis-related pain relief. The full report can be found on AHRQ’s Web site.

(music)

Debra: Think you can’t make health information technology work in long-term care facilities? Dr. Susan Horn will disagree with you since she has done it. Dr. Horn is the principal investigator and a senior scientist at the Institute for Clinical Outcomes Research in Salt Lake City, Utah. She and her team found that the prevalence of pressure sores among nursing home patients was reduced by one-third at 11 long-term care facilities that integrated new information technologies into everyday care. We now talk with Dr. Horn about her study and how this change was possible. Welcome, Dr. Horn.

Debra: You’ve said that the key to this change doesn’t actually lie with any one technology, but more with how the technology is adopted. What do you mean by that?

Dr. Horn: Successful implementation of H.I.T. means you’ve got to address these things up front, and the things that we need to address are: standardizing the documentation, changing the work flow, and working with the front line to determine how the data that would be sent back to them could be really useful in the actual practice of care. That means that timing and effectiveness of what treatments were given to residents at specific points as they were having difficulties, and it also greatly decreased the inefficiencies that were inherent in the previous system.

Debra: I think people would be surprised to know that this sort of focus hasn’t existed in the past, that it seems common-sense to have the left hand know what the right hand is doing and for everybody to share information, but I guess people don’t realize that it was quite a tedious process before this came along.

Dr. Horn: Even I didn’t realize this, Debra. When I - my parents who were in long-term care facilities for a short time I had no idea they were documenting in this way. When we ultimately started studying it, we found out, We asked the first question was well, where are these data so we can help you in that process Everybody used multiple logbooks. The reason they did was they’re very highly regulated and depending upon the regulators, they come and say you need to report weights and vital signs and meal intake and incontinence and whatever and then so their reaction of everybody was form a logbook with these things in it. And you say to yourself, how do they know what the whole resident looks like, and how can they put that picture together they couldn’t. Then they got to the point of saying you know, the best thing to do was we won’t ask the CNAs [certified nursing assistants] to document at all because they’re on the front line taking care of people we’ll ask them to tell the nurses what happened and the nurses will do some of this documentation. So the documentation, of course messages didn’t get transmitted, etc. How the whole system even evolved in that way and why it became such the standard has really been a mystery to me, Everything was built in a very inefficient manner and nobody thought about trying to change the efficiency picture. But I think we’re totally changing the paradigm.

Debra: How did you incorporate information technology?

Dr. Horn: Those log books had redundant information that you take from one place and put some of it in another place, etc., and there was a lot of manual transposing of information from one form to another. And in order to create any reports from this, the only way you could do it is by going through all those different log books and manually extracting things. So what we did was, we went into the front line and said to them look, we want to try to help make your work easier. We know a very specific point about the residents that need to be assessed and then the best treatments to do if they have certain problems incontinence problems, meal intake problems, etc. And so first what we need to do is to standardize the data elements including these best practice components. Then after we worked with them about how to standardize that, we next said to them how can we format this so that you could do it more easily, more consistently, more timely, and you don’t have to repeat documentation, and that’s how we went from these five to eleven different log books onto one standardized form.

Debra: What did the staff think about this process?

Dr. Horn: What they found was, after we had gotten them to think in this way that the information they were documenting really could be helpful when it was fed back to them in some reforms that they selected, that they could then be very proactive, based on these data, to be able to respond to the needs of their residents and improve the interaction among the whole team that they were working with. So the ways the staff saw the data coming back to them was in a way they wanted to see it to really what to do for that resident, and it also was a concrete link between daily documentation and improving quality of care. It was just a wonderful feedback loop that became created.

Debra: You’ve mentioned front line people. How many people are part of the clinical team?

Dr. Horn: It’s the director of nursing, the charge nurse, the MDS the Minimum Data Set nurse that’s required by Medicare and Medicaid, the certified nursing assistants, who has most of the front line responsibility, dietary people, activities people, restorative care people that whole team. The reports then would summarize information that was related to each one of them. So we were able to put multiple variables together and then provide this comprehensive view of the resident, and that helps them foster this interdisciplinary communication because they had a standardized way of being able to communicate with each other and people knew they were going to get complete, thorough, comprehensive information for each one of the various special people that I mentioned to you the nursing people, the CNA people, the activities people, etc. would have a very comprehensive picture and be able to work much better together.

Debra: What would you say to other facilities who want to model your success?

Dr. Horn: My suggestion would be that to create this kind of culture of wanting to use H.I.T., you really need to start by defining what the data elements will be and what the outputs will be and the report contents will be. How the information will be used, then they figure out how the information will be used and by whom to improve this resident care planning. Then, you can define what the exact inputs are, to be able to create these outputs you know what do you need to document and how frequently and by following this approach, we were able to make the whole process much more efficient no more duplication, etc., all in one place, and then get that incorporated, as I mentioned, into H.I.T. with the results of dramatically decreasing the development of pressure ulcers in these long-term care facilities, and building this culture of data for - at the front line. If you reduce pressure ulcers, there are a number of other things that improve dramatically too. For example, you have fewer hospitalizations. You have fewer falls because you’re working on weight and balance issues, and activity issues, and things of that sort. There are multiple additional ramifications, although our initial goal was pressure ulcer prevention, we have found that there’s been a spill-over serendipitously into multiple other areas, all of which are associated with improved resident outcomes.

Debra: Well, Dr. Horn, thank you for all your time and your great information. Dr. Susan Horn, senior scientist at the Institute for Clinical Outcomes Research in Salt Lake City. For more information on this and other projects, go to www.healthit.ahrq.gov.

(music)

Rand: That’s it for this week. For more information on these and other health-related stories and topics go to www.ahrq.gov. Healthcare 411 is produced by AHRQ, the Agency for Healthcare Research and Quality, part of the U.S. Department of Health and Human Services. For Debra James, I’m Rand Gardner. Please join us for the next edition of Healthcare 411.