Chou, Shin-Yi, PhD

Deily, Mary E

Levick, Donald, MD

Meyerhoefer, Chad D, PhD

Sheinberg, Michael, MD

Sherer, Susan A, PhD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksAdministration & LeadershipInformation Flow and Clinical Outcomes in a FullyFunctional Perinatal Continuum of CareDonald Levick MDLehigh Valley Health Network, donald.levick@lvhn.orgMichael Sheinberg MDLehigh Valley Health Network, Michael.Sheinberg@lvhn.orgChad D. Meyerhoefer PhDMary E. DeilyShin-Yi Chou PhDSee next page for additional authorsFollow this and additional works at: https://scholarlyworks.lvhn.org/administration-leadershipPart of the Business Administration, Management, and Operations Commons, Health andMedical Administration Commons, Health Information Technology Commons, ManagementSciences and Quantitative Methods Commons, and the Obstetrics and Gynecology CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtLevick, D., Sheinberg, M., Meyerhoefer, C., Deily, M., Shin-Yi, C., & Sherer, S. (2013). Information flow and clinical outcomes in a fullyfunctional perinatal continuum of care. Poster presentation.AuthorsDonald Levick MD, Michael Sheinberg MD, Chad D. Meyerhoefer PhD, Mary E. Deily, Shin-Yi Chou PhD,and Susan A. Sherer PhDThis poster is available at LVHN Scholarly Works: https://scholarlyworks.lvhn.org/administration-leadership/1001Lehigh Valley Health Network, Allentown, PA; 2Lehigh University, Bethlehem, PAInformation Flow and Clinical Outcomes in a Fully Functional Perinatal Continuum of CareProject Summary/AbstractWe are studying the implementation by the Lehigh Valley Health Network (LVHN) of an integrated electronic medical record (EMR) system at its OB/GYN practice groups and the Labor and Delivery (L&D) Unit.  In this process, each of the practice groups migrated to a single, vendor-supplied, EMR, and these EMRs were linked to a newly-upgraded system at the hospital’s L&D Unit to form an integrated EMR.  Once the system was installed, medical information from each physician office was immediately available when a patient arrives at L&D, and information from a patient’s visits to L&D is sent back to the office. Our goal is to use both qualitative and quantitative methods to evaluate the impact of this system, so that we can fully assess the ability of an integrated EMR to address a recognized failure to deliver accurate, complete, and timely data to physicians and clinical staff at critical clinical points along the perinatal continuum of care. Longitudinal, Mixed Methods Analysis•	  Quantitative	 	 –	  Use quasi-experimental econometric methods to identify impact of interface of data between perinatal information system and ambulatory EMR on data completeness, health outcomes, patient and staff satisfaction	 	 	 	 •	 Data completeness surveys in L&D Triage	 	 	 	 •	 Provider/staff safety and satisfaction surveys	 	 	 	 •	  Adverse outcomes data and patient characteristics obtained from inpatient databases	 	 	 	 •	 Patient satisfaction surveys administered by Press Ganey•	  Qualitative		 	 –	  In-depth interviews focusing on organizational and work process changesDonald Levick, MD, MBA1; Michael Sheinberg, MD1; Chad Meyerhoefer, PhD2; Mary Deily2; Shin-Yi Chou, PhD2; Susan Sherer, PhD2Phase IDiscrete data moves from office EMR to Triage/L&D information systemPhysicians Perceive Limited Availability of Information From Triage at Offices and Find it More Difficult to Use EMR(1 = Agree Strongly that EMR Improves [  ]; 5 = Disagree Strongly)Clinical Data Elements Obstetric Trauma Labor Induction(=1 if available for review in L&D Triage)Parsimonious ModelSaturated ModelParsimonious ModelSaturated ModelCervical Exam -0.027 -0.017 0.016 -0.012[0.020] [0.023] [0.026] [0.036]Blood Pressure -0.036 -0.022 0.042 0.012[0.022] [0.025] [0.031] [0.042]Antenatal Prob. List -0.010 0.016 0.057** 0.040[0.024] [0.028] [0.027] [0.033]Nonstress Test -0.060** -0.060* 0.034 0.011[0.026] [0.033] [0.044] [0.046]Prior Uterine Incision Type 0.021 0.044 0.035 0.013[0.036] [0.039] [0.060] [0.060]Group B Strep Status -0.010 0.010 0.083** 0.069*[0.027] [0.028] [0.040] [0.041]Tubal Sterilization -0.042 -0.041 -0.065 -0.070Request (Medicaid) [0.033] [0.034] [0.058] [0.056]Conclusions•	 Physicians have difficulty transitioning to EMR as main source of clinical information•		Integrated EMR does improve information availability on L&D Triage•		Improved information availability is associated (in some cases) with fewer adverse pregnancy events	 	 –	  Nonstress test, blood pressure, Antenatal problem lists have a statistically significant impact •		Improved information availability alters clinical decision making via more labor inductionsResults© 2013 Lehigh Valley Health NetworkEmpirical MethodsModel 1: Linear probability model (LPM)•	  Outcomes (N=1,235)	 	 –	  Obstetric trauma (0/1), mean = 0.07	 	 –	  Labor inducement (0/1), mean =  0.56Model 2: Two-part model (LPM & Log OLS)•	  Outcomes (1st part, N=1,235 ; 2nd part, N=99)	 	 –	  Weighted adverse outcome score (WAOS) (0/1) > 0, mean = 0.08	 	 –	  Log(WAOS), mean of positive WAOS = 31.2 Control Variables:•	  DCG/HCC risk score quartile, age, race/ethnicity, insurance type, admission type, multiple birth, pre-existing condition, non-preventable complication, c-section, instrument assisted delivery, indicators for whether clinical data elements were present in system, physician fixed effects  Quotes from InterviewsTrust: I don’t trust anything or anyone or anything automatically flowing  - PhysicianAvailability of data: Many times a patient would be seen in Triage in the interval between their visits, and you wouldn’t even know it. So at least seeing that document triggers you to say, “oh, well she was in …  triage. Why was she there?” - Physician•	  Lehigh University, established in 1865, is a premier residential research university, ranked in the top tier of national research universities each year.•	  Enrollment:	 	 –	  4,700 undergraduate students	 	 –	  2,000 graduate students•	  Largest academic community hospital in PA•	  Largest Level 1 Trauma Center in Region•	  Certified Comprehensive Stroke Center•	 Magnet Hospital•	  3 hospital campuses•	  Named a Top 50 Hospital in US News for 18 consecutive years	 	 –	  Employees - 12,135	 	 –	  Medical Staff - 1,193Grant Information•	  Award Information 	 	 –	  Project Title: Data Flow & Clinical Outcomes in a Perinatal Continuum of Care System 	 	 –	  Grant Number:  1R18HS018649-01A1  	 	 –	  Principal Investigator:  Donald Levick, MD 	 	 –	  Project Period:  09/30/2011 – 09/29/2014  •	 	IRB Approval	 	 –	  IRB Expedited Review Approval was obtained for both Lehigh University and Lehigh Valley Health Network at the onset of the project. 	 	 –	  Updated approvals have been obtained as required by each institution.Clinical Data Elements WAOS > 0 Log(WAOS)(=1 if available for review in L&D Triage)Parsimonious ModelSaturated ModelParsimonious ModelSaturated ModelCervical Exam -0.008 -0.023 -0.317 0.024[0.021] [0.025] [0.305] [0.558]Blood Pressure 0.006 0.024 -0.657** -0.240[0.021] [0.030] [0.244] [0.712]Antenatal Prob. List 0.003 0.003 -1.002*** -1.101***[0.024] [0.032] [0.243] [0.386]Nonstress Test 0.002 0.012 0.090 0.387[0.032] [0.031] [0.371] [0.493]Prior Uterine Incision Type -0.045 -0.061* 0.256 0.407[0.036] [0.036] [0.643] [0.665]Group B Strep Status 0.000 0.010 -0.459 -0.238[0.030] [0.029] [0.493] [0.464]Tubal Sterilization -0.058* -0.051* -2.901 0.267Request (Medicaid) [0.031] [0.030] [2.032] [3.080]Phase IITriage Summary document moves from Triage I.S. to office EMRPhase IIIDiscrete data moves from Triage/L&D I.S. to office EMRSurveysLehigh	UniversityDepartment	of	Economics•	 Chad Meyerhoefer, PhD      chm308@lehigh.edu•	Mary Deily, PhD•	Shin-Yi Chou, PhDDepartment	of	Management•	Susan Sherer, PhDLehigh	Valley	Health	Network	•	Donald Levick, MD, MBA,    Chief Medical InformationOfficer       Donald.Levick@LVHN.orgDepartment	of	OB-GYN•	Michael Sheinberg, MDContact	Information:More Complete Data Available in Triage Due to EMRAverage monthly N = 119, Max = 193, Min = 160%10%20%30%40%50%60%70%80%90%100%2009 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 2010 Jun-10 Jul-10 Aug-10 2011 Jun-11 Jul-11 Aug-11 Sep-11Cervical ExamBlood PressureAntenatal Prob. ListGroup B Strep0%10%20%30%40%50%60%70%80%2009 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 2010 Jun-10 Jul-10 Aug-10 2011 Jun-11 Jul-11 Aug-11 Sep-11Non-stressPrior Incision TypeTubal Steril. (Medicaid)0.00.51.01.52.02.53.03.54.04.55.0InformationAccessibilityDocumentationAvailabilityTest Availability Diagnosis Availability Ease of UsePhysiciansStaff2010 Office Data: N=89 (74 staff; 15 physicians)EMR ImplementationPhase A:  •	  Implement EMR in paper-based practices•	  Replace EMR’s in existing EMR practicesPhase B: •	  Interface discrete data from office EMR to Triage/L&D clinical information system•	  Interface Triage Summary back to office EMRPhase C: •	  Interface discrete elements from Triage to office EMR OB FlowsheetInformation Availability Survey for Prenatal Record    User No:_______________________________________       Date:___________________________  Medical Record No:___________________________   Please indicate whether the patient's most recent documentation of the following items from the Office Prenatal Record were available for review in Triage:  1.  Cervical Exam         No Office Prenatal Record  Yes             No              2. Blood Pressure Measurement   Yes             No              3. Up-to-date Antenatal Problem List   Yes             No              4. Non-Stress Test Result   Yes             No           N/A   5. Prior Uterine Incision Type  Yes             No           N/A   6. Group B Strep Results   Yes             No           N/A   7. Medicaid Patient: Request for Tubal Sterilization   Yes             No           N/A  Triage Prenatal Patient Safety SurveyPlease answer the following questions by CIRCLING thenumber corresponding to your feeling: DisagreeStronglyDisagreeSlightly NeutralAgreeSlightlyAgreeStrongly1. The information that I need from office records is accessible. 1 2 3 4 52. The information in office records is complete and current. 1 2 3 4 53. Errors are made with the potential to harm patients becauseoffice records are inaccessible. 1 2 3 4 54. Errors are made with the potential to harm patients becauseoffice records are incomplete or out-dated. 1 2 3 4 55. I would feel safe being treated here as a patient. 1 2 3 4 56. Lack of current information from office records causes delays. 1 2 3 4 57. It is easier to order diagnostic and laboratory tests in Triagethan get test results from office records. 1 2 3 4 5Pl ase nswer the following question by placing a check mark in therow corresponding to your practice pattern (choose only one):Place check markin this column. Next Question8. Where do you obtain MOST of the historical data for a patientpresenting to Triage?CPO Prenatal Record Printout Please GO TOquestion 9.CPO-CPN Interfaced Data Please SKIP toquestion 10.Patient Interview Please SKIP toquestion 11.Other (e.g. faxed office records, second system such as LastWord). Please specify: STOP HERE.

Information Flow and Clinical Outcomes in a Fully Functional Perinatal Continuum of Care

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Information Flow and Clinical Outcomes in a Fully Functional Perinatal Continuum of Care

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Lehigh Valley Health Network: LVHN Scholarly Works