Pneumonia can be a life threatening infection for anyone, particularly for individuals with diabetes. People with diabetes are three times more likely to die from influenza and pneumonia, yet only one in three have been vaccinated to protect against an important bacterial pneumonia, according to the Centers for Disease Control.
Providing pneumonia vaccines to patients with diabetes is among the nationally endorsed quality standards for diabetes that Better Health Greater Cleveland measures and publicly reports twice a year. It’s also the measure that blazed the trail for Better Health’s development of Replicable Best Practices.
Better Health is a nonprofit health care improvement organization that was established in 2007 under the Robert Wood Johnson Foundation’s national Aligning Forces for Quality initiative. Data provide the foundation for Better Health’s multiple initiatives to improve the quality and value of health care. Twice a year, Better Health measures and publicly reports on the care delivered by nearly 500 primary care providers in 46 practices for patients with diabetes, heart failure, and high blood pressure. Administering a pneumonia vaccine for diabetes patients has been one of the measures since Better Health’s first public report in 2008.
Before each public report, or Community Health Checkup, Better Health aggregates the data its clinical partners submit from their electronic health records (EHRs) and analyzes them to identify trends and patterns to share with the community. Did the region improve in the number of patients whose high blood pressure is under control? Are we making progress in reducing the disparities in care and outcomes we see among different groups of patients?
Better Health also looks at the achievement of each physician practice—the percentage of their patients who meet or exceed the particular quality benchmark—and their improvement on the metrics from the previous report. The director of Better Health’s Data Management Center was reviewing the diabetes data for its second report in January 2009 when he spotted a notable pattern: The nine top-achieving practices for pneumonia vaccination rates among 35 practices were part of the same health care organization, The MetroHealth System. Its rates had climbed from less than 30 percent to more than 85 percent.
Randall D. Cebul, MD, director and president of Better Health, asked MetroHealth, “What did you do, and how did you do it?”
Using EHRs to Standardize Process for Vaccinations
Kathleen Lehman, RN, now senior clinical efficiency analyst in strategic planning at MetroHealth, offered a clear answer to those questions. She had noticed pneumonia vaccination rates were extremely low and did not meet standards of the Centers for Disease Control. She led a team that used technology—MetroHealth’s electronic health record, or EHR—to boost vaccination rates.
“We created a report every Friday of any patients who were scheduled to come in the following week, so we could pre-identify who was coming in Monday and know for that week who needed the vaccine,” she said.
When patients on the list checked in at the front desk, staff handed them a brochure about the pneumonia vaccine and told them they fit the criteria of someone who should receive the vaccine. Physicians had written “standing orders” authorizing nurses to offer the vaccines and administer them, and then nurses documented patient consent and administration of the vaccine in the EHR. The new process sounds simple, but Lehman said a number of detailed steps were involved that required teamwork and follow-through.
The results were dramatic. In 2005, MetroHealth had identified 6,000 highrisk patients who needed the vaccine. “Prior to the intervention, we had only vaccinated 27 percent of this group,” Lehman said. “After the new protocols, we vaccinated 70 percent of the highrisk group in the first year and 90 percent of this group in 2009.”
When Lehman explained the process to Dr. Cebul, his next question was whether Better Health could share MetroHealth’s protocol with other practices so they could replicate it to improve their vaccination rates. Lehman and MetroHealth agreed.
To begin to disseminate the “Replicable Best Practice,” MetroHealth’s accomplishment was recognized at the community-wide meeting at which Better Health shared highlights from the new report. When the bar graph was projected showing nine top-achieving practices in orange, Dr. Cebul asked Lehman, once again, to answer the question, “How did you do that?” The results and protocol also were shared in other Better Health meetings and Community Health Checkups.
Subsequent reports show the impact of MetroHealth’s successful quality improvement initiative soon was multiplied across northeast Ohio. Vaccination rates of practices in other health systems have climbed from 70 percent to 82 percent in just three years.
MetroHealth has sustained its high rates, which also is a significant accomplishment. Lehman says that ongoing coaching, encouragement, reminders, and dialogue across staff at all levels are required to keep the momentum going and ensure the intervention becomes embedded in a practice. “Our patients might not be thinking about health maintenance, but it’s everyone’s job here to make sure as many people are being immunized against pneumonia as possible,” Lehman said.
Lehman and her colleagues presented their successes in driving up pneumonia vaccination rates at a recent American Academy of Ambulatory Nurses national conference. While EHRs were a key, Lehman said the job got done because of team work. “The responsibility didn’t rest on one person’s shoulders,” she said. “This was everyone’s success. It was administration’s job in identifying who was at risk; the medical assistants had to answer questions; the nurses and providers were great in reinforcing the importance of this. That whole team approach was very helpful in getting everyone engaged, and it led to better patient care.”
Better Health has identified other instances of best practices that were uncovered in mining the data. Like the cluster of higher vaccination rates, these Replicable Best Practices were verified and disseminated through a variety of channels. Increases in achievement across the region followed.
In one, Kaiser Permanente of Ohio had the top eight physician practice achievers in an early report on Better Health’s process measure for managing kidney health in diabetes patients. The achievement was traced to a mnemonic and to EHR-powered outreach to patients who needed treatment or were due for testing. Three years later, after Kaiser shared its best practice, two other large health systems with EHRs had increased their rates from 87 percent to 92 percent, while Kaiser had boosted its high rate from 92 percent to 94 percent.
Another possible Replicable Best Practice was flagged when a pattern of high achievers emerged among practices that actively used their EHR’s “health maintenance” section to ensure their diabetes patients had received their annual eye exam, which is important for monitoring vision loss, a common complication of diabetes. The regional rates for diabetes patients who had received their annual eye exam subsequently rose to 64 percent from 57 percent three years earlier.
Better Health has adopted the deliberate search for “positive outliers” as one of its best practices in every six-month data cycle. Further probing of the practices is a critical part of the process. Did the primary care practice or practices know about the change? Was it purposeful? Are there demographic or insurance coverage changes among their patients that could account for it? Can they describe what they did? Could the process be replicated by other practices?
A common vision and sharing of experiences across sometimes competing health care organizations are key to unlocking the power of partnership. Continued progress relies on continued sharing of data and partners’ commitment to improve on common standards.