Eliminating the PAPER CHASE:

Eliminating the PAPER CHASE:
How Informatics Helps the ICP

Information technology is infiltrating every aspect of human life, but can it go so far as to help an infection control practitioner (ICP) save a human life? The experts say it can — and does — in many different ways.

Information technology (IT) systems are continually implemented, transformed, and updated in healthcare systems around the world. Informatics systems are one the latest trends and are geared to aid in the daily tasks for ICPs. Informatics helps ICPs with their never-ending whirlwind of surveillance tasks, outbreak monitoring, cohorting, investigating, and reporting.

Gary A. Noskin, MD, associate professor of medicine at Northwestern University Feinberg School of Medicine, medical director of healthcare epidemiology and quality, healthcare epidemiologist at Northwestern Memorial Hospital, and a member of the Society for Healthcare Epidemiology of America (SHEA), says IT and surveillance are both effective methods to identify and control outbreaks of hospital-associated infections.

“In terms of the role of informatics, it can allow for real-time surveillance and the identification of issues in an automated manner that ordinarily might not occur that way,” he affirms. “For example, if you have targeted organisms, you might not know if there is a patient who has that organism, but if there is a way to automate that process such that as soon as the lab identifies that you could receive an alert, then that patient can be put in isolation appropriately in almost real-time, in contrast to having to wait until you get those cultures back.

“Another thing that IT can do is help you to identify trends that you might be able to do manually, but would be either more time consuming or certainly more labor intensive.

“One of the true advantages of having an IT solution is that the ICP would not need to enter in data and that hopefully all that data could be populated from the information system.”

IT provides tools needed by the ICP to manage multiple-source data for preventive prospective analysis that enables interventional epidemiology, adds Bonnie L Taggart, RN, BS, CIC, nurse epidemiologist and chief executive officer of EpiQuest(r).

She explains how this is done. “First is recognition of where the data is found, second is obtaining the specific data elements from each source without being buried in excess data, and third is management of the data in a healthcare epidemiology software such as EpiQuest,” she says. “Fourth is statistical analysis from the healthcare epidemiology software database reports. The reports assist the ICP to quickly identify, analyze, and monitor historic and current trends of any event, risk, threat, drug, procedure, or disease - especially HAIs.”

EpiQuest offers healthcare epidemiology software solutions that include the ability to do all of the above mentioned required items. Data can be extracted (data mined) specific to user requirements from multiple sources. For example, as data elements are brought into the EpiQuest software, they are then available for report outputs specific to user needs and the populations they serve.

Dan Peterson, MD, MPH, chief executive officer of Cereplex, Inc., points out that paper records, print-outs from labs, or physically looking at the lab slips, is where the vast majority of ICPs start their day to do surveillance. “It’s nice to have the computer program find those things rather than have to sift through piles of paper,” he says.

G.T. LaBorde, chief operating officer of MedMined, Inc., agrees, adding that MedMined’s Data Mining Surveillance® fundamentally evolves infection control away from the paper chase of data collection and reporting.

MedMined is implemented hospital-wide and is unique in its ability to not require data entry. “We utilize a real-time clinical data feed from existing hospital information systems,” LaBorde explains. “For example, lab results come from the lab information system where the data already exists electronically.

The ability to extract existing data in a noninterventional way (we do not require a bidirectional interface) is key to servicing many types of hospitals.”

MedMined’s Data Mining Surveillance monitors the entire inpatient and outpatient populations for patterns of hospital- and community- associated infections, antibiotic resistance, and other related issues.

“This comprehensive monitoring is important in infection control,” LaBorde says. “Data Mining Surveillance spots potential problems early in their emergence so that hospital staff can be in the right place, at the right time, with the right information to make the correct process change — without having to know where a problem will arise beforehand.”

“If you try to do too much you risk not doing anything,” Peterson points out. “What you need is a proven tool that hits the key areas that you know you need to address, that you can get implemented quickly, and that has a proven track record for doing that ... all at a price that doesn’t break the bank.”

Nancy M. Lorenzi, PhD, professor of biomedical informatics and assistant vice chancellor for health affairs at Vanderbilt University Medical Center (VUMC)’s Informatics Center, Eskind Biomedical Library and president of the International Medical Informatics Association (IMIA), advises that while the majority of commercial products on the market today have the components that ICPs need, proper research of what may be right for each institution is a definite must. “Our best advice is for ICPs to take an active role in understanding as much about the current information systems in their organizations to improve their work flow,” she says. “In turn, if a new information system is to be purchased, ICPs need to be very active in understanding how each possible system will enhance the data and the work flow of the ICPs.”

Peterson adds, “It is incredibly important to find a system that helps you to achieve the goals specific to you and your facility. There are tremendous problems with surveillance in infection control and there are tremendous problems with antibiotic usage. In both areas, there is a lot of low hanging fruit to be picked that can substantially improve patient care. You want an application that is affordable and achievable,” he says.

Cereplex’s SetNet technology offers three distinct functions for the ICP. The first is an alerting function. “We get feeds from three different data sources within the hospital,” Peterson explains. “We link those three data streams and we detect patterns. We then alert the ICP — via both e-mail and the Web interface in the system — for things they may need to investigate.”

The second function is the allowance for query tools in the alerting function. Peterson says this function is helpful in recognizing which patients, specifically, may have been exposed prior to, say, isolating a TB patient, for example. Third, SetNet can also automate creating reports such as monthly reports on “infection rates by wards,” for example, within a facility.

In addition to the SetNet application, Cereplex offers PharmWatch. The PharmWatch application ties in antibiotic usage data, according to Peterson. “It helps in two ways,” he says. “It helps address the problem of infections and it helps hospitals optimize antibiotic use.”

PharmWatch helps to identify patients who can receive fewer antibiotics, narrower spectrum or less expensive antibiotics, or often no antibiotic at all.

“Anytime you improve antibiotic therapy, you achieve outcomes such as reduction of mortality, earlier discharge of the patient, and you reduce the growth of antibiotic resistance. Improving antibiotic therapy is a clear win-win for both the patient and the hospital.”

Another link for the ICP with PharmWatch is access to pharmacy data gives the ICP a better sense of what the clinicians think might be an infection, “because they can see how it is being treated,” Peterson states. “It helps with both the surveillance and investigation side of the IC practice to be able to see and use the antibiotic data,” he says.

According to a study conducted at the University of Maryland Medical Center (UMMC), the use of PharmWatch improved the existing management of antibiotic utilization by allowing more intervention on a larger number of patients receiving inappropriate antibiotic therapies and by achieving substantial cost savings for the hospital.¹

During the study period, one hour less was spent each day managing patients, and in this reduced amount of time, intervention was achieved on nearly twice as many patients while using the application than without the application (359 and 180 patients, respectively). Moreover, antibiotic costs were reduced by 22.8 percent ($285,812 vs. $370,006), and the median length of stay for patients were 0.29 days lower.

Also in this arena, EpiQuest features its Alert Organism which tracks antibiotic-resistant organism frequencies and locations. ICPs also may analyze antibiotic pressures to resistant organism infections in both the Alert Organism feature and the prescription report choices. EpiQuest reports antibiotic pre-operative prophylaxis, procedure specific antibiotic use, and timing and specific drug (antibiotic) usage, according to Taggart.

LaBorde adds that MedMined links clinical outcomes to each of its customer’s cost accounting system data — allowing hospitals to see the impact of healthcare-acquired infections (HAIs) on variable cost, length of stay, and profitability.

“We just completed a financial analysis across over 1 million hospital admissions,” LaBorde says. “We found that 35 hospitals made $150 million in profit on the 96 percent of patients that did not acquire an infection. However, those same 35 hospitals lost $177 million on the 4 percent of patients that did acquire an infection while hospitalized. Even on a DRG-adjusted basis, patients with hospital infections have $8,058 higher direct costs, stay 8.1 days longer, and when taking into account actual reimbursement, are ($6,162) less profitable.”

LaBorde continues, “Because ICPs cannot directly prevent infections — they do not directly do patient care — their only power is to motivate others’ behavior. We have found that if the hospital has a complete view of all of the hospital infections (every location and every type) and their associated financial implications, hospitals begin to view IC as an untapped opportunity for margin improvement. When everyone from the board to housekeeping understands the importance of preventing infections (from both a patient care and financial standpoint), IC can more effectively persuade staff to practice good sterile technique.”

According to Tina Kurtz, RN, AD in the Informatics Center at VUMC, IT assists the ICP in a variety of ways, including:

• Providing electronic tools for documentation and structured data collection. “Having the ability to extract specific, pertinent data to identify trends and measure outcomes is critical to effective surveillance,” she says. “Additionally, these tools can also be used in a didactic manner, guiding and teaching healthcare providers as they deliver care.”
• Organized and timely notification of testing results — electronic notification of results with the ability to filter only those results that the practitioner desires.
• Identify individuals at risk based on known health history — the use of electronic order entry systems to tag/code diagnosis to allow for grouping of patients based on the diagnosis that has been assigned to them (presence of neutropenia, IV drug abuse, etc.).
• Decision-making support — providing patient-specific treatment guidelines based on assigned diagnosis to practitioners (in the problem list). Using electronic prescription writing applications to warn of potential drug interactions or to alert the provider that the patient has been prescribed multiple courses of antibiotics in a given time period.
• Embedded links to information. Easy retrieval of information and additional resources within the electronic medical record (EMR) as well as links to the CDC Web site, etc.
• Facilitating ongoing education of patients and staff. Links to self-paced training modules within the EMR for the staff. Secure Web sites for patients to obtain medical information pertinent to their diagnosis.

IT also “provides the ability to collect data in a standard way that in turn allows for a better targeting of areas in need of more quality control attention,” adds Lorenzi.

Lorenzi and Kurtz use a combination of informatics systems at VUMC. “The core of our informatics system is called StarChart,” Lorenzi explains. “This is the repository of more than 50 million coded items of information — documentation, problem lists, lab results, etc. Our system that allows individual users (with appropriate security/privacy clearance) to access this data is called StarPanel. StarPanel allows for the customization of patients by clinicians, by hospital units, by disease, etc. We have ‘termed’ most of our systems ‘Star,’ e.g., RxStar is our prescription writer. StarForms are one of our mechanisms to collect standard documentation data. Also, within StarPanel clinicians can see their patient’s new results, ‘write’ patient letters, document, etc. — all in one location.

“The power of StarPanel is that it gives immediate access to new results for all of a clinician’s patients,” she adds.

According to Christopher J Heller, MD, FACS, executive vice president of research and development and co-founder of ACS MIDAS+, his product features a module specifically aimed at collecting data related to infections. “Variables such as location, room, organism, antibiotics, predisposing factors, as well as devices used such as Foley catheters or central lines — there is a whole host of data elements, probably 60 to 70 data elements you should collect related to any given infection,” he points out.

“In addition, your system ideally should be integrated as a comprehensive system; what I mean by that is your system should have an interface with your admission/discharge/transfer (ADT) system as well as the discharge abstract module of one’s hospital information system so all of that information that is being collected somewhere else is downloading into your infection monitoring system without your people having to recollect it,” he adds.

MIDAS also features a patient tracking system allowing the user to build an indicator where any patient can be “flagged” upon readmission and added to the IC worklist.

Informatics can also aid in recognizing trends in a facility and “benchmarking” the facility’s outcomes against other like facilities.

“Ideally, you’d like a surveillance system that is looking at, on a continuous basis, certain disease entities in terms of their outcomes,” advises Heller. ACS’s DataVision is a product that does just that. Data is collected quarterly from all participating (MIDAS+) hospitals. A “smart report” is then generated which tells the hospitals which measurements exceed the 90th percentile.

“One hospital found their sepsis mortality rate was 30 percent for patients with primary sepsis coming into the hospital,” Heller shares. “They were unaware of that until we ran that report. This allows them to then look at that on a comparative basis and compare their numbers to those of four hundred other hospitals in our comparative database. They found their mortality rate was in the 87th percentile, which means 87 percent of the system’s hospitals have a lower mortality rate than this particular hospital. In this particular case, they found their sepsis problems to actually be a chronic issue within their institution.”

Lois Thoman, RN, BSN, CPHQ, product manager for ACS MIDAS+ Care Management says ACS also is working to integrate its MIDAS product with EMRs. She says this will help the ICP to look at all aspects of each patient record, enabling the ICP to identify certain “triggers.”

“One project we are working on primarily focused on infection control monitoring, is bringing clinical laboratory data into our system,” she says. “We are looking at the clinical data elements that nursing typically documents in the medical record that could potentially be triggers of an infection that an ICP may want to follow-up on, request a culture for or whatnot — picking up on the more subtle triggers, in other words.”

Thoman states that once this information is collected they then will write worklist rules against it, “so the ICP has a more organized way of looking at, and providing surveillance for, large numbers of patients without having to go and review every record,” she says.

“Certainly the way to sit at your desk and do epidemiology instead of running all over the hospital reading charts,” adds Heller.

“Any data extraction or reporting tool that helps the ICP perform ‘targeted surveillance’ is valuable, because this is the primary evidence- based practice for identifying and reporting HAIs,” adds Deborah Martin, RN, MN, FSHEA, chief executive officer of ICPA. “Targeted surveillance identifies certain populations of high-risk patients and collects data on every patient at risk.”

ICPA produces the AICE® Millennium, AICE Download, and QTrendz control chart software. AICE produces hundreds of highly flexible reports and graphs, as well as some commonly used statistical tests, according to Martin. “This gives the ICP the ability to collect and analyze data items and risk factors that are unique to their own hospital. They can also design their own studies and data entry screens to focus on a particular infection problem or outbreak.”

AICE also includes QuickComp™ which generates automatic comparisons with national benchmarks such as the National Healthcare Safety Network (NHSN).

Looking to the future, IT and informatics for the ICP will become nearly imperative to adhere to guidelines and reporting requirements. For instance, Heller says ICPs can expect changes in the current coding system. “It’s often hard to tell if a patient came in with an infection or acquired it in the hospital,” he explains. “It is mandatory in California and New York, and we have several hospitals outside of these states that are having their coding people collect with each diagnosis in the discharge abstract whether that diagnosis was present or absent upon admission. Requirements of such reporting may become mandatory sometime in 2006 with the implementation of the UB04,” Heller warns.

The National Committee on Vital and Health Statistics (NCVHS) recommended to the Department of Health and Human Services (HHS) that the next version of the Uniform Bill for Hospitals (UB04) and the ANSI ASC X 12N 837I HIPAA Implementation Guide be revised to include reporting of a diagnosis indicator to flag diagnoses that were present upon admission in secondary diagnosis fields for all inpatient claims transactions. The secondary diagnosis indicator, NCVHS argues, can help to distinguish between pre-existing conditions and those that developed, or were first recognized, during the hospitalization.

Mandatory reporting of HAI rates is another mandatory requirement spreading across the states, including Missouri. Martin says AICE has been approved as a method of reporting these data to the Missouri Department of Health and Senior Services. “Only the required data is automatically exported from AICE to the state,” she says.

EpiQuest’s Report Builder also offers ICPs the ability to produce both mandatory and voluntary state-specific reports, according to Taggart. Moreover, EpiQuest’s Data Mine exports, reports, and graphs findings with benchmarks that can be lowered both internally and externally to CDC’s NNIS data.

Taggart’s product also features the EpiQuest® Statistics Program (ESP) to quickly see the incidence, the p value, the upper control limit (by one or two standard deviations above the mean), or set the comparison to a lower percentile of the NNIS data to “lower the bar” in your threshold tolerance, Taggart adds. Included as a provided companion product is ESP for quick standard incidence density (device days), Chi-Square or Fisher’s Exact analysis tools, and threshold level settable NNIS surveillance data tables for SSI, BSI and VAP rates. “In the ESP one can create P, NP-, C- and U-Process Control reports, and charts,” Taggart explains. In addition, EpiQuest’s statistics manual enables a simplified approach to statistics for ICPs.

ICP-driven informatics reduces daily tasks, improves care, aids in reporting, and ultimately reduces costs. The shift toward these systems and services can be challenging, costly, and time consuming, but as LaBorde points out, well worth the effort.

“When we can electronically make infection- related data readily available in real-time; when we can find opportunities to target IC efforts automatically; when we can report any or all infections in many formats at the press of a button; when we can prove the financial value of IC — it changes everything. IC can be more proactive, more omnipresent and better supported. They get to spend more time positively interacting with staff and less time in a paper chase. They get to see the positive effect of their efforts all over the hospital and know that their efforts are protecting patients and improving the hospital’s bottom line. It is truly an exciting and rewarding environment in which to be an ICP,” LaBorde concludes.