SummaryAs the cornerstone of its Clinical System Integration initiative, Texas Children’s Hospital uses an enterprise data warehouse to integrate and process in near real-time relevant data from the organization's inpatient and outpatient settings (as captured through an internal electronic medical system), allowing clinical and operational hospital leaders to identify and prioritize opportunities for improvement. In addition, permanent, disease- or condition-based multidisciplinary teams tackle each major opportunity, using the warehouse to identify and address at a granular level the root cause(s) of suboptimal quality and to monitor and report adherence to evidence-based guidelines and order sets on an ongoing basis. The program has improved adherence to evidence-based guidelines, reduced unnecessary use of resources, improved the productivity of information technology staff, generated significant cost savings, and enhanced the level of engagement in quality improvement activities among physicians.Moderate: The evidence consists of pre- and post-implementation comparisons of various quality and cost metrics, including use of chest X-rays and LOS in pediatric patients who present with acute asthma symptoms, use of evidence-based drug therapy in appendectomy patients, and productivity of IT staff. Additional evidence includes post-implementation estimates of program-related cost savings and anecdotal reports from clinicians involved in the program.
Developing OrganizationsTexas Children's Hospital
Date First Implemented2011
Texas Children’s Hospital began implementing the electronic data warehouse in September 2011.
Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Children; Age > Infant (1-23 months); Newborn (0-1 month); Preschooler (2-5 years)
Problem AddressedTraditional sources of clinical information, including paper and electronic medical records (EMRs), generally are not integrated with the processes and ideas of clinical experts and do not provide the kind of information needed to identify and address important opportunities to improve quality and promote adherence to evidence-based medicine.
- Lack of timely, actionable information: Paper and EMRs contain many pieces of data on individual patients, but cannot analyze that data across patient populations or process it into useful, actionable information for clinicians interested in improving quality and promoting adherence to evidence-based guidelines.1 Before implementation of this program, Texas Children’s Hospital initially relied on cumbersome reviews of paper-based medical records to gauge performance in adhering to existing evidence-based order sets and guidelines and to track care delivery process metrics and patient-related outcomes metrics, a process that often took 6 to 9 months.
- Even with EMR system: After Texas Children’s implemented an EMR system, the ability of clinicians to identify and address opportunities for improvement did not meaningfully improve, as organizational structures and the EMR system offered no way of processing the information across patient populations or translating it into actionable information (e.g., performance reports, reminders) that could be used by clinicians to improve quality.
Description of the Innovative ActivityAs the cornerstone of its Clinical Systems Integration initiative, Texas Children’s Hospital uses an enterprise data warehouse (EDW) to integrate and process in near real-time relevant data from the organization's inpatient and outpatient settings (as captured through an internal EMR system), allowing clinical and operational hospital leaders to identify and prioritize opportunities for improvement. In addition, permanent disease- and condition-based multidisciplinary teams tackle each major opportunity, using the EDW to identify and address at a granular level the root cause(s) of suboptimal quality and to monitor and report adherence to evidence-based guidelines and order sets on an ongoing basis. Key program elements are detailed below:
- EDW that collects, processes data: Built in partnership with Texas Children's Hospital and an outside vendor (Health Catalyst), the EDW integrates data from the internal EMR system for inpatients and those seen at the hospital’s 47 affiliated pediatric practices.
- Multidisciplinary committee to identify, prioritize opportunities for improvement: Working in partnership with the vendor, a multidisciplinary committee that oversees the Clinical Systems Integration initiative uses EDW-generated information and reports to review hospital performance in major clinical areas, with the goal of identifying those with wide variations in performance (e.g., length of stay, direct costs) or poor adherence to existing evidence-based guidelines and order sets. (The Planning and Development Process section provides more information on this committee and these guidelines and order sets.) The team uses this information to prioritize opportunities for improvement. In its initial review, the team chose several areas as targets, including acute asthma and appendectomy care. Over time, the team has identified other priority areas, such as chronic asthma, diabetes, and spinal conditions.
- Permanent, multidisciplinary care process teams to address each area: Internal teams of clinicians (typically three or four doctors plus other relevant clinical staff), information technology (IT) staff, analysts, and quality improvement (QI) personnel are assigned to each identified area. Each team “drills down” into the data to identify specific opportunities to improve care processes and uses plan-do-study-act (PDSA) cycles to develop, implement, and test various strategies to improve quality and promote adherence to evidence-based care guidelines and order sets. To date, teams have been developed in the following areas:
- Acute asthma: Made up of several physicians, a respiratory therapist, and IT/analytics staff, this team used the EDW to understand what was driving wide variations in length of stay (LOS) and variable direct care costs. The team reviewed all aspects of care, from the time the patient presents in the emergency department (ED) to discharge from the ED or hospital.
- Identification of specific opportunities: Early on, the team targeted chest X-rays as an area of concern—roughly 70 percent of acute asthmatic patients received an X-ray (most often to check for the presence of concurrent pneumonia), approximately twice the rate found in most other children’s hospitals. In addition, scientific evidence suggests that only approximately 2 to 5 percent of children with asthma who present at the hospital with acute symptoms have concurrent pneumonia. Unnecessary chest X-rays are not only costly, but also unnecessarily expose young patients to radiation, thus increasing the risk of cancer. At present, the team is using EDW-generated information to identify specific opportunities to reduce the time to treatment after the child presents at the ED.
- Rapid-cycle tests of interventions: The team designated chest X-ray utilization as an ongoing metric within the EDW, and began distributing regular performance reports to physicians, via e-mail and paper-based reports posted in the ED and on inpatient units where the orders commonly take place. Using a PDSA rapid cycle improvement approach, the team tested the impact of these interventions, finding that physicians first reacted negatively (e.g., claiming the data were “wrong”), but then over time accepted the information and began changing their ordering habits. (The Results section provides details on the impact.)
- Additional teams in other areas that follow same approach: Similar teams have formed that take the same general approach to tackling other major opportunities for quality improvement, including the care of pregnant patients, those undergoing an appendectomy, and those with diabetes, spinal conditions, pneumonia, elbow fractures, skin and soft tissue problems, and chronic asthma. (The chronic asthma team will ultimately merge with the acute asthma team.) These teams are in various stages of their work, with some being fairly far along (such as the appendectomy team, which focuses on monotherapy antibiotic use, LOS, and complication rates) and others just getting started.
- Ongoing performance measurement and feedback: All teams designate important metrics within the EDW to be monitored on an ongoing basis to gauge progress in addressing the opportunity. Although specific approaches vary, each team provides regular performance reports to relevant clinicians and hospital leaders to keep them apprised of the program’s impact and to motivate additional improvement.
References/Related ArticlesHealth Catalyst. Texas Children’s Hospital & Catalyst: An Enterprise Data Warehouse and Advanced Analytics Prove Critical to Improving Quality at Texas Children’s Hospital. Available at: http://www.healthcatalyst.com/wp-content/uploads/HealthCatalyst-TexasChildrens-CaseStudy.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
Contact the InnovatorCharles G. Macias, MD, MPH
Director, Center for Clinical Effectiveness and Evidence Based Outcomes
Emergency Department Clinician
Associate Professor of Pediatrics
Baylor College of Medicine/Texas Children's Hospital
6621 Fannin Street A2210
Houston, Texas 77030
Margaret J. Holm, PhD, FACHE
Director, Quality & Clinical Systems Integration
Baylor College of Medicine/Texas Children's Hospital
6621 Fannin Street A2210
Houston, Texas 77030
Innovator DisclosuresDr. Macias reported no financial or business/professional relationships relevant to the work described in this profile. Dr. Holm reported that Health Catalyst paid her enrollment fee and travel expenses for a university-sponsored course on IT strategies.
ResultsThe program has improved adherence to evidence-based guidelines, reduced unnecessary use of resources, improved the productivity of IT staff, generated significant cost savings, and enhanced the level of engagement in QI activities among physicians.
Moderate: The evidence consists of pre- and post-implementation comparisons of various quality and cost metrics, including use of chest X-rays and LOS in pediatric patients who present with acute asthma symptoms, use of evidence-based drug therapy in appendectomy patients, and productivity of IT staff. Additional evidence includes post-implementation estimates of program-related cost savings and anecdotal reports from clinicians involved in the program.
- Greater adherence to guidelines, less unnecessary care: The acute asthma and appendectomy teams have succeeded in promoting adherence to evidence-based guidelines and reducing unnecessary care, as outlined below:
- Acute asthma: Within 1.5 months of presenting performance reports to clinicians, use of chest X-rays for patients who present with acute asthma fell by 15 percent, and after 11 months, use had fallen by 31 percent. Overall LOS for acute asthma patients fell by 12 percent over the 6-month period after the team began its work.
- Appendectomy: The evidence suggests that patients undergoing an appendectomy should receive a single antimicrobial agent rather than multiple antibiotics at various points in their care. This single-drug approach has been shown to be more effective and efficient while also reducing the potential for patients to develop resistance to antibiotics. Over the 15-month period after the appendectomy team started its work, use of this single-agent approach increased more than three-fold, from 28 percent to 93 percent of appendectomy patients.
- More productive IT staff: Before implementation of the EDW, IT staff routinely spent several hours generating each performance report. Now they can produce the typical report in less than 1 hour, which represents a 70-percent decline in production time. As a result, IT labor resources have been redeployed to work on other, higher-value projects.
- Significant cost savings, positive return on investment (ROI): Program leaders estimate that the EDW has generated approximately $4.4 million in savings, more than the original cost of the system. These savings include both “soft savings” (primarily the value of the freed-up IT staff time, which is used to work on other QI activities) and hard-dollar savings due to reductions in chest X-rays and shorter LOS for asthma patients.
- More engaged, enthusiastic physicians: Anecdotal reports suggest that Texas Children’s clinicians are much more engaged and enthusiastic about using data-driven analysis to drive improvement. Clinicians routinely use data to improve care for patients, by asking questions about how care is being delivered and investigating the root cause(s) of variation. They report being excited about participating in these activities and express satisfaction after seeing the results being generated.
Context of the InnovationLocated in Houston, TX, Texas Children's Hospital is a not-for-profit, 469-bed children’s hospital dedicated to patient care, education, and research. The hospital handles more than 21,000 inpatient admissions, 1.4 million outpatient visits, and 82,000 ED visits each year. It has recognized centers of excellence in various pediatric subspecialties, including cancer and cardiac care. It also operates the largest primary pediatric care network in the country.
The impetus for this program goes back to 2006, when the hospital began to plan for the transition from volume- to value-based reimbursement. At this time, hospital leaders focused on use of data and data management capabilities as mechanisms to stimulate QI activities throughout the organization. Leaders knew the hospital needed a better way to identify and address inefficiencies and to analyze and manage specific populations of patients, especially costly patients with chronic conditions. Consequently, hospital leaders announced the launch of an overall quality and safety strategy known as the Clinical Systems Integration initiative, the cornerstone of which would be an enterprise-wide, integrated, comprehensive data management infrastructure.
Planning and Development ProcessThe strategy and program evolved over time, with key steps and milestones in the process outlined below:
- Development of evidence-based guidelines and order sets: Beginning in 2007, Texas Children’s Hospital began forming multidisciplinary teams to systematically develop evidence-based guidelines and accompanying order sets, utilizing the methodology used by the U.S. Preventive Services Task Force. After these order sets were implemented, multidisciplinary teams began to extract data from paper-based charts to evaluate adherence to the guidelines and identify opportunities for improvement. As noted earlier, this process proved quite cumbersome, sometimes taking 6 to 9 months to determine if the order sets were in fact improving care.
- Training staff to understand and interpret data: In 2008, Texas Children’s launched its Advanced Quality Improvement program, which trains staff how to interpret statistical information and charts, such as process control and run charts. This ongoing initiative serves as a resource for the Care Process Teams.
- Choosing and implementing EMR: The hospital evaluated various EMR systems, ultimately choosing an EPIC system. Full implementation of the system occurred during the first part of 2011.
- Partnering with EDW vendor: Hospital leaders recognized that the full value of the EMR could not be realized without a system to process the millions of pieces of information coming out of it and other systems. Without such a system, frontline clinicians would still not have meaningful, actionable information. A team of administrative and clinically based quality leaders attended a conference in February 2011 at Intermountain Healthcare during which representatives from Health Catalyst (a private company formed by individuals who worked at Intermountain for many years) discussed the clinical applications of data management. Impressed with what they heard, they invited the company’s founders to meet with leaders at Texas Children’s to discuss their proposed approach.
- Assessing organizational readiness, securing stakeholder buy-in: Over a 5-month period, Health Catalyst leaders met with various stakeholders at Texas Children’s to assess the organization’s readiness for the EDW and to secure buy-in and support from key stakeholders, including administrative, clinical, and IT leaders. As part of this process, the two parties signed a contract to develop and implement the EDW system.
- Forming data steering committee: Made up of administrative and clinical leaders (including physicians and representatives from finance and IT), this group met regularly with Health Catalyst and other key stakeholders to oversee and manage the EDW implementation process.
- Customizing and implementing system: Part of the appeal of Health Catalyst came from the many years of experience its founders had working with Intermountain, a pioneer in health IT. As a result, Health Catalyst had an existing EDW package that required only minor customization for use at Texas Children’s. The combination of the existing package and the upfront work done to assess organizational readiness and secure buy-in allowed for a rapid (3-month) implementation process.
- Transitioning committee to permanent governance structure: After system implementation, hospital leaders decided to transition the data steering committee (which was originally envisioned as a temporary body) into the Clinical Systems Integration Executive Committee. This committee meets regularly and is charged with overseeing the entire program, including managing the data and information that comes out of the EDW, and ensuring that the teams and frontline clinicians remain engaged in QI activities.
Resources Used and Skills Needed
- Staffing: Texas Children’s Hospital hired one senior-level informatics person (a trained biostatistician) to serve as an outcomes analyst. Everyone else involved in the program participates as part of their regular duties.
- Costs: The EDW cost several million dollars. (Exact figures are unavailable.) This investment helps the hospital enhance the value of its previous investment (more than $100 million) in an EMR system. As noted earlier, the system has generated a positive ROI by generating roughly $4.4 million in cost savings.
Funding SourcesTexas Children's Hospital
The program is funded internally by Texas Children’s Hospital. Some of the data retrieved from the EDW are used by the hospital to demonstrate compliance with Federal meaningful use requirements, and hence help the hospital qualify for meaningful use incentives.
Tools and Other ResourcesThe evidence-based guidelines for asthma and appendectomy care are available by contacting the innovator. More information about the process and framework used to create these guidelines is available in the following article:
Chumpitazi CE, Barrera P, Macias CG. Diagnostic accuracy and therapeutic reliability in pediatric emergency medicine: the role of evidence-based guidelines. Clin Pediatr Emerg Med. 2011;12(2):113-20. Available at: http://www.clinpedemergencymed.com/article/S1522-8401%2811%2900016-4/abstract.
More information about Texas Children's Hospital is available at: http://www.texaschildrens.org/.
More information about Health Catalyst is available at: www.healthcatalyst.com.
More information on PDSA is available at: http://www.innovations.ahrq.gov/content.aspx?id=2398.
Getting Started with This Innovation
- Share data with leaders on quality gaps, potential ROI: To win the support of administrative and clinical leaders, share data that clearly show major “quality gaps” within the organization, along with estimates of the quality and financial impact of addressing those gaps. This information will be particularly important as the transition from volume- to value-based pricing arrangements accelerates. Like other children’s hospitals, Texas Children’s is expecting a shift to case- and risk-based payments for Medicaid beneficiaries and other patients, and hence now has a significant financial incentive to reduce LOS and other direct care costs.
- Set up permanent governance structure: Program leaders at Texas Children’s quickly realized that the temporary steering committee that had been created to oversee implementation needed to become a permanent structure to oversee and manage the program on an ongoing basis.
- Prioritize and tackle problems in sequential fashion: No organization has the capacity to address all problems at once. Consequently, program leaders need to designate a high-level team to prioritize the problems and determine the appropriate sequence for tackling them.
Sustaining This Innovation
- Provide ongoing support to care process teams: The entire program is structured to ensure that the care process teams have access to the necessary infrastructure to promote ongoing improvement, including training on statistical methods and processes and access to a wide variety of performance reports that provide meaningful, actionable information.
- Use PDSA or similar rapid-cycle approach: Use of PDSA helps ensure that the Texas Children's teams deploy and evaluate interventions in a timely manner, allowing them to quickly identify and spread those interventions that work and refine or abandon those that do not.
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Service Delivery Innovation Profile
Original publication: October 09, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 09, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.