1 Title: Reducing Harm in Pediatrics: A Davies Story Session 132, March 7, 2018 Speakers: Brian R Jacobs, MD,CIO, CMIO, Children’s National Health System Shireen M. Atabaki, MD, MPH, , Children’s National Health System Jonathan Palma, MD, MS, Stanford Children’s Health
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Title: Reducing Harm in Pediatrics: A Davies Story · Head Injury CT Scan and Quality Shireen M. Atabaki, MD, MPH Medical Director, Informatics, Program Director, Telemedicine Children’s
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Title: Reducing Harm in Pediatrics: A Davies Story
Session 132, March 7, 2018
Speakers:
Brian R Jacobs, MD,CIO, CMIO, Children’s National Health System
Shireen M. Atabaki, MD, MPH, , Children’s National Health System
Jonathan Palma, MD, MS, Stanford Children’s Health
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Brian R. Jacobs, MD, Children’s National Health System
Shireen Atabaki, MD, MPH, Children’s National Health System
Jonathan Palma, MD, MS, Stanford Children’s Health
Have no real or apparent conflicts of interest to report.
Conflict of Interest
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AgendaIn the first use case the team at Children’s National Health System will present their successful efforts to increase patient engagement and improve patient outcomes, through their health IT optimization for pediatric concussion care
• Background
• Local Problem
• Governance, Design and Implementation
• Value Derived
• Future Advancement
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Learning Objectives• Understand the role of workflow-integrated clinical decision support
in improving outcomes
• Learn about rapid clinician adoption of technology and knowledge translation
• Understand financial savings which can result from integrated EHR utilization
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Head Injury CT Scan and Quality Shireen M. Atabaki, MD, MPH
Medical Director, Informatics, Program Director, Telemedicine
Children’s National Health System
Brian R Jacobs, MD
CIO, CMIO, Children’s National Health System
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Background
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Pediatric Concussion and CT Data
Most frequent diagnosis for injured child is:
HEAD INJURY
• Each year in the US:
– 5 million children
– Over 1 million ED visits
• 4 million pediatric CTs
– 20 fold increase 1995-2003
Faul M, Centers for Disease Control, 2010
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Partnership Launching with Bear Institute in 2013
• 1st pediatric Health IT Institute in the country
• Mission is to foster innovation, advance clinical care, and create a world-class IT structure to improve outcomes and service.
• Institute works to accelerate the development of fully-integrated , accessible EHR via advanced health IT capabilities
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• 313-bed acute care hospital• 2 pediatric emergency departments• Level I trauma center• Critical care transport program• Community-based primary care network• Primary care offices in DC and MD• 7 regional outpatient centers• Ambulatory surgery center• School nurse program• Medical collaborations across the region• Mobile health services
Serving over 219,000 patients/year: regionally, nationally, and from 21 countries
• $ 1.1 B Budget Health SystemIn FY 17:• Discharges – 15,554• Emergency Room Visits – 120,648• Outpatient Visits – 560,810• Surgery Cases – 17,535
Children’s National At a Glance
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How Health IT supports our mission• Supports Organizational Transformation – Integrated and interoperable Health IT
systems support evidence based, high quality care for kids, with improved outcomes
and an overall reduction in cost. e.g. decision support and practice guidelines
• Patient Engagement – Innovating the way we use Health IT can empower our
patients/families to take an active role in their care. e.g. patient portals, mobile device
tools, and Telehealth
• Improvement in Care Delivery, Outcomes, and Patient Safety – Robust Health IT,
providers have data and devices at the bedside, allowing them to spend more time with
their patients. e.g. Ambulatory EHR
• Propelling Innovation and Research – Sophisticated Health IT capabilities enable
advances in medicine. e.g., genomics, matching patient information with a database of
open clinical trials for research and population health
.
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Local Problem
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• Risks of lethal malignancies
– Cranial CT = 100 x radiation of CXR
– CT in 1st 22 years of life = 300% increase in lifetime cancer
– 1/1100 infants w/ lethal malignancies
• NCI and FDA issued warnings in 2001
March 5, 2018Pearce et al., Lancet, 2012
Pediatric Concussion and CT Radiation
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PECARN CT Decision Rules, 2009 • N=44,000 children• CDS to detect clinically important brain injury• 99.9% Negative Predictive Value
Kuppermann, Holmes, Dayan, Hoyle, Atabaki et al., Lancet, 2009
Evidence Based Medicine at CNHS
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• 10 fold variation btw Providers in CT
• CT rates 30%
• 1000 CTs annually
• Over 92% of CT scans were normal
• Percentage did not improve 2009-11
• Traditional KT is slow – 10-13 years
Zerhouni, NIH
Pre-implementation CT Rates
Provider
% O
rderi
ng
a H
ead
CT
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How Health IT was Utilized
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Evidence Based
Medicine
Improved Outcomes
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CNMC CPOE Decision Support
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Governance
• Goal: Decrease % of children with concussion who had a head CT ordered in our Emergency Departments
• Team
– SMEs in ED/Trauma/ Nursing/ IT/ Education
– Project Manager
– Analyst
– Project Architect
Patient Safety
Quality Improvement
Evidence Based
Medicine
Health ITBest
Concussion
Care
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Previous Process
March 5, 2018
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Current Process
March 5, 2018
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Value Derived
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Outcomes: Radiation & Cost Reduction
• Radiation Reduction:
– 44% relative reduction in CT scan rate
Pre: 1000 (27%) to Post: 444 (11.9%)
• Cost Reduction:
– 556 avoided head CT scans
– $875,144 cost reduction per year
– No untoward outcomes
March 5, 2018
Atabaki, Jacobs et al., Ped Quality & Safety, 2017
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Proportion of Concussion Patients with CT
March 5, 2018
0%
5%
10%
15%
20%
25%
30%
35%Intervention
y = -0.0138x + 0.258R2 = 0.7621
y = 0.0002x + 0.2394R2 = 0.0002
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Outcomes Data
March 5, 2018
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Future Advancement
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Goal #1: Health IT for Knowledge Translation to Improve Quality
March 5, 2018
• EBM models can be transferred across EHRs
• Abdomen CT (trauma, appendicitis)
• Head CT (seizure, headache, VP shunt)
• City wide collaboration
• National and International EBM dissemination
• Provider education strategiesMeaningful Use in Oklahoma & the District of Columbia, AHRQ 2015
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Goal #2: Shifting the Paradigm of Concussion Care
March 5, 2018
• CDC Funded Project
– Created effective diagnostic tools for ED
– Created education for outpatient
– Communication to school and PCP
– Improve Outcomes
CDC Grant 1U49CE001385-01
Zuckerbraun, Atabaki, Collins, Gioia et al, Pediatrics, 2015
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Mobile Apps for Patients and Families
March 5, 2018
• Developed a mobile health solution that communicates via the EHR to the concussion screening information
– Allows for patients to be Rxed mobile App and go home with a concussion check-list and daily reminders
– Provides secure communication with the patient’s school nurse and primary care physician