Eliminating the PAPER CHASE:

January 1, 2006

Eliminating the PAPER CHASE: How Informatics Helps the ICP

Eliminating the PAPER CHASE:
How Informatics Helps the ICP

By Jennifer Schraag

Information technology is infiltratingevery aspect of human life, but can it go so far as to help an infection controlpractitioner (ICP) save ahuman life? The experts say it can and does in many different ways.

Information technology (IT) systems are continuallyimplemented, transformed, and updated in healthcare systems around the world.Informatics systems are one the latest trends and are geared to aid in the dailytasks for ICPs. Informatics helps ICPs with their never-ending whirlwind ofsurveillance tasks, outbreak monitoring, cohorting, investigating, andreporting.

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

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

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

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

IT provides tools needed by the ICP to manage multiple-sourcedata for preventive prospective analysis that enables interventionalepidemiology, adds Bonnie L Taggart, RN, BS, CIC, nurse epidemiologist and chiefexecutive officer of EpiQuest(r).

She explains how this is done. First is recognition ofwhere the data is found, second is obtaining the specific data elements fromeach source without being buried in excess data, and third is management of thedata in a healthcare epidemiology software such as EpiQuest, she says. Fourthis statistical analysis from the healthcare epidemiology software databasereports. The reports assist the ICP to quickly identify, analyze, and monitorhistoric and current trends of any event, risk, threat, drug, procedure, ordisease - especially HAIs.

EpiQuest offers healthcare epidemiology software solutionsthat include the ability to do all of the above mentioned required items. Data can be extracted (data mined) specific to userrequirements from multiple sources. For example, as data elements are broughtinto the EpiQuest software, they are then available for report outputs specificto 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 lookingat the lab slips, is where the vast majority of ICPs start their day to dosurveillance. Its nice to have the computer program find those thingsrather than have to sift through piles of paper, he says.

G.T. LaBorde, chief operating officer of MedMined, Inc.,agrees, adding that MedMineds Data Mining Surveillance® fundamentallyevolves infection control away from the paper chase of data collection andreporting.

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

The ability to extract existing data in a noninterventionalway (we do not require a bidirectional interface) is key to servicing many typesof hospitals.

MedMineds Data Mining Surveillance monitors the entireinpatient and outpatient populations for patterns of hospital- and community-associated infections, antibiotic resistance, and other related issues.

This comprehensive monitoring is important in infectioncontrol, LaBorde says. Data Mining Surveillance spots potential problemsearly in their emergence so that hospital staff can be in the right place, atthe 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 areasthat you know you need to address, that you can get implemented quickly, andthat has a proven track record for doing that ... all at a price that doesntbreak the bank.

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

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

Cereplexs SetNet technology offers three distinct functionsfor the ICP. The first is an alerting function. We get feeds from threedifferent data sources within the hospital, Peterson explains. We link those three data streams and wedetect patterns. We then alert the ICP via both e-mail and the Web interfacein the system for things they may need to investigate.

The second function is the allowance for query tools in thealerting function. Peterson says this function is helpful in recognizing whichpatients, specifically, may have been exposed prior to, say, isolating a TBpatient, for example. Third, SetNet can also automate creating reports such asmonthly reports on infection rates by wards, for example, within afacility.

In addition to the SetNet application, Cereplex offersPharmWatch. The PharmWatch application ties in antibiotic usage data, accordingto Peterson. It helps in two ways, he says. It helps address the problem of infections and it helpshospitals optimize antibiotic use.

PharmWatch helps to identify patients who can receive fewerantibiotics, narrower spectrum or less expensive antibiotics, or often noantibiotic at all.

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

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

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

During the study period, one hour less was spent each daymanaging patients, and in this reduced amount of time, intervention was achievedon nearly twice as many patients while using the application than without theapplication (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 0.29days lower.

Also in this arena, EpiQuest features its Alert Organism whichtracks antibiotic-resistant organism frequencies and locations. ICPs also mayanalyze antibiotic pressures to resistant organism infections in both the AlertOrganism 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 ofits customers cost accounting system data allowing hospitals to see theimpact of healthcare-acquired infections (HAIs) on variable cost, length ofstay, and profitability.

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

LaBorde continues, Because ICPs cannot directly preventinfections they do not directly do patient care their only power is tomotivate others behavior. We have found that if the hospital has a completeview of all of the hospital infections (every location and every type) and theirassociated financial implications, hospitals begin to view IC as an untappedopportunity for margin improvement. When everyone from the board to housekeeping understands theimportance of preventing infections (from both a patient care and financialstandpoint), IC can more effectively persuade staff to practice good steriletechnique.

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

  • Providing electronic tools for documentation andstructured data collection. Having the ability to extract specific, pertinentdata to identify trends and measure outcomes is critical to effectivesurveillance, she says. Additionally, these tools can also be used in a didacticmanner, 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 resultsthat 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 forgrouping of patients based on the diagnosis that has been assigned to them(presence of neutropenia, IV drug abuse, etc.).

  • Decision-making support providing patient-specifictreatment guidelines based on assigned diagnosis to practitioners (in theproblem list). Using electronic prescription writing applications to warn ofpotential drug interactions or to alert the provider that the patient has beenprescribed multiple courses of antibiotics in a given time period.

  • Embedded links to information. Easy retrieval ofinformation 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 Websites for patients to obtain medical information pertinent to their diagnosis.

IT also provides the ability to collect data in a standardway that in turn allows for a better targeting of areas in need of more qualitycontrol attention, adds Lorenzi.

Lorenzi and Kurtz use a combination of informatics systems atVUMC. The core of our informatics system is called StarChart, Lorenziexplains. This is the repository of more than 50 million coded items ofinformation documentation, problem lists, lab results, etc. Our system thatallows individual users (with appropriate security/privacy clearance) to accessthis data is called StarPanel. StarPanel allows for the customization ofpatients by clinicians, by hospital units, by disease, etc. We have termedmost 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 patients new results, writepatient letters, document, etc. all in one location.

The power of StarPanel is that it gives immediate access tonew results for all of a clinicians patients, she adds.

According to Christopher J Heller, MD, FACS, executive vicepresident of research and development and co-founder of ACS MIDAS+, his product features amodule specifically aimed at collecting data related to infections. Variablessuch as location, room, organism, antibiotics, predisposing factors, as well asdevices used such as Foley catheters or central lines there is a whole hostof data elements, probably 60 to 70 data elements you should collect related toany given infection, he points out.

In addition, your system ideally should be integrated as acomprehensive system; what I mean by that is your system should have aninterface with your admission/discharge/transfer (ADT) system as well as thedischarge abstract module of ones hospital information system so all of thatinformation that is being collected somewhere else is downloading into yourinfection monitoring system without your people having to recollect it, headds.

MIDAS also features a patient tracking system allowing theuser to build an indicator where any patient can be flagged uponreadmission and added to the IC worklist.

Informatics can also aid in recognizing trends in a facilityand benchmarking the facilitys outcomes against other like facilities.

Ideally, youd like a surveillance system that is lookingat, on a continuous basis, certain disease entities in terms of their outcomes, advises Heller. ACSs DataVision is a product that does justthat. Data is collected quarterly from all participating (MIDAS+) hospitals. Asmart report is then generated which tells the hospitals whichmeasurements exceed the 90th percentile.

One hospital found their sepsis mortality rate was 30percent for patients with primary sepsis coming into the hospital, Hellershares. They were unaware of that until we ran that report. Thisallows them to then look at that on a comparative basis and compare theirnumbers to those of four hundred other hospitals in our comparative database.They found their mortality rate was in the 87th percentile, which means 87percent of the systems hospitals have a lower mortality rate than thisparticular hospital. In this particular case, they found their sepsis problemsto 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 withEMRs. She says this will help the ICP to look at all aspects of each patientrecord, enabling the ICP to identify certain triggers.

One project we are working on primarily focused oninfection control monitoring, is bringing clinical laboratory data into oursystem, she says. We are looking at the clinical data elements thatnursing typically documents in the medical record that could potentially betriggers of an infection that an ICP may want to follow-up on, request a culturefor or whatnot picking up on the more subtle triggers, in other words.

Thoman states that once this information is collected theythen will write worklist rules against it, so the ICP has a more organizedway of looking at, and providing surveillance for, large numbers of patientswithout having to go and review every record, she says.

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

Any data extraction or reporting tool that helps the ICPperform targeted surveillance is valuable, because this is the primaryevidence- based practice for identifying and reporting HAIs, adds DeborahMartin, RN, MN, FSHEA, chief executive officer of ICPA. Targeted surveillance identifies certain populations ofhigh-risk patients and collects data on every patient at risk.

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

AICE also includes QuickComp which generates automaticcomparisons with national benchmarks such as the National Healthcare SafetyNetwork (NHSN).

Looking to the future, IT and informatics for the ICP willbecome nearly imperative to adhere to guidelines and reporting requirements. For instance, Heller says ICPs can expect changes in thecurrent coding system. Its often hard to tell if a patient came in with aninfection or acquired it in the hospital, he explains. It is mandatory inCalifornia and New York, and we have several hospitals outside of these statesthat are having their coding people collect with each diagnosis in the dischargeabstract whether that diagnosis was present or absent upon admission. Requirements of such reporting may become mandatory sometimein 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 nextversion of the Uniform Bill for Hospitals (UB04) and the ANSI ASC X 12N 837IHIPAA Implementation Guide be revised to include reporting of a diagnosisindicator to flag diagnoses that were present upon admission in secondarydiagnosis fields for all inpatient claims transactions. The secondary diagnosisindicator, NCVHS argues, can help to distinguish between pre-existing conditionsand those that developed, or were first recognized, during the hospitalization.

Mandatory reporting of HAI rates is another mandatoryrequirement spreading across the states, including Missouri. Martin says AICEhas been approved as a method of reporting these data to the Missouri Departmentof Health and Senior Services. Only the required data is automaticallyexported from AICE to the state, she says.

EpiQuests Report Builder also offers ICPs the ability toproduce both mandatory and voluntary state-specific reports, according toTaggart. Moreover, EpiQuests Data Mine exports, reports, and graphs findingswith benchmarks that can be lowered both internally and externally to CDCsNNIS data.

Taggarts product also features the EpiQuest® Statistics Program (ESP) to quickly see the incidence, the pvalue, the upper control limit (by one or two standard deviations above themean), or set the comparison to a lower percentile of the NNIS data to lowerthe bar in your threshold tolerance, Taggart adds. Included as a provided companion product is ESP for quickstandard incidence density (device days), Chi-Square or Fishers Exactanalysis tools, and threshold level settable NNIS surveillance data tables forSSI, BSI and VAP rates. In the ESP one can create P, NP-, C- and U-ProcessControl reports, and charts, Taggart explains. In addition, EpiQuests statistics manual enables asimplified approach to statistics for ICPs.

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

When we can electronically make infection- related datareadily available in real-time; when we can find opportunities to target IC effortsautomatically; when we can report any or all infections in many formats at thepress of a button; when we can prove the financial value of IC it changeseverything. IC can be more proactive, more omnipresent and better supported.They get to spend more time positively interacting with staff and less time in apaper chase. They get to see the positive effect of their efforts all over thehospital and know that their efforts are protecting patients and improving thehospitals bottom line. It is truly an exciting and rewarding environment inwhich to be an ICP, LaBorde concludes.