The Pediatrix EHR and Clinical Data Warehouse

Alan R. Spitzer, MDSenior Vice President and DirectorThe Center for Research, Education, and QualityPediatrix Medical Group (MEDNAX, Inc.)

MEDNAXLargest provider of neonatal and high risk

maternal-fetal services in this country Also provide pediatric cardiology, pediatric

intensive care, anesthesiology, hospitalist services

Company’s divisions include Pediatrix Medical Group and American Anesthesiology

Currently > 1500 physicians and > 650 APNs Approximately 1000 neonatologists

Pediatrix Medical GroupPediatrix Medical Group currently

cares for >20% of all NICU patients in the country Hospitals which we cover deliver about

25% of all babies born in the U.S.Average Pediatrix daily NICU census

is about 4600-4700 neonates per day >90,000 admissions/ year

Provide care in 33 states plus Puerto Rico

NY Times Magazine 11/08/2009

Story on Intermountain Health and the value of measurement of medical outcomes One of a plethora of

recent articles in the lay press on the EHR use and value

Pediatrix Medical Group recognized this need in 1996 and started developing an EHR for our NICUs

The BabyStepsÒ Data System Components in Meaningful Use

Note system for chart documentation, data entry Pairs with hospital systems for CPOE

Decision tree algorithm for billing based upon guidelines of the AAP Perinatal Coding Committee

BabySteps Clinical Data Warehouse (CDW)

BabySteps QualitySteps Program Foundation for 100,000 Babies Campaign

Getting the most out of BabySteps Data Warehouse reports

BabySteps CDW Report

BabySteps is not simply a charting tool, but part of a system that facilitatescomplex data extraction for use in coding, data extraction, outcome information,and quality improvement. The often overlooked key to any system is validateddata extraction: the BabySteps Documentation Improvement Project

The Five Stages of Grieving Over Outcome Data Denial: These data can’t be right! You must be wrong! Anger: Why are they picking on me? Don’t I have enough to

do already? Bargaining: My patients are clearly sicker than everyone

else’s, my NICU is different, we do more transports, I don’t agree with the data definitions, etc.

Depression: I can’t do anything about it anyway…. Acceptance: OK…what can I do to improve the outcomes in

my NICU?

Courtesy of Dan Ellsbury, MD, Pediatrix Medical Group

Quality Improvement DesignBabySteps and the Clinical Data Warehouse

have been created to facilitate data extraction for quality initiatives in the NICU

Data is automatically extracted from the daily chart entry note generated by the MD or NNP More than 560 data points extracted daily Information is validated and de-identified Allows assessment of individual NICU outcomes

or large populationsSystem updated weekly

Key Accomplishments 2008-2009Quality Improvement

The BabySteps Data Warehouse Largest known database for neonatal medicine More than 620,000 pts. and 11,000,000 pt. days

accumulated over 13 years Certified by Western IRB as HIPAA compliant annually Has been queried for information by NIH, FDA, NICHD

Neonatal Network Recognized by AAP and ABP for its unique CQI value

▪ Pediatrix selected as charter member of AAP/ABP Quality Improvement Committee

▪ Pediatrix selected as the first “Portfolio Sponsor” with ABP because of CDW and QualitySteps, which will serve as basis for Board Maintenance of Certification (MOC) Part IV for Pediatrix MDs

Home Page – Gestational Age Selection

ImprovedG.A.Selection

Weeks can be selectedindividuallyor combined

Home Page - Birth Weight Selection

Enhanced Birth WeightSelection

250 g incrementsbelow 1500 g

Home Page – Comparison by Inborn/ Outborn and NICU Size

Inborn/ Outborn

NICU Size/ Region/ StateComparisons(risk adjusting)

Report Grouping Groupings of reports:

Activity Reports▪ Admissions, Discharges, Census, LOS, etc.

Management Reports▪ Vent data, antibiotic reports, BDP reports▪ Essentially those reports that involve physician decision-

making Morbidity and Mortality Reports

▪ Survival, mortality, and outcome data Summary Reports New Reports

▪ Always in development-rely on physician feedback and needs

Currently Available CDW Clinical Reports

Activity Reports: Types of discharges (home, transfer, in-hospital, etc.); Admissions by GA; Admissions by BW; Length of stay; Average daily census; Type of delivery

Morbidity and Mortality Reports: Mortality; Survival, BPD at 28 days of life, BPD at 36 weeks’ gestational age, IVH, Late-onset sepsis, NEC, PDA, PVL, RDS and surfactant use, ROP, Severe IVH, Severe ROP, Pneumothorax, Catheter-related blood stream infection (rate/1000d)

Management Reports: Maximal ventilator support, Median ventilator Days, Temperature from DR to NICU, Types of lines inserted and duration of use, Median daily weight gain during the first 28 days; Hepatitis B immunization rates; Per cent of infants breast feeding at discharge; Bilirubin reports Infection reports: Percent of NICU admissions treated with antibiotics;

Median days of antibiotic therapy with negative cultures; Use of cefotaxime; Percent of patients treated without cultures; Nosocomial/ line sepsis—infections/ 1000 catheter days (in testing)

Medication reports: All commonly used medications in the NICU, frequency of use

Summary Dashboard Report and Network Trends Reports

BabySteps Data Warehouse Report Retinopathy of Prematurity

Hospital Dashboard Report

o Dashboard report for assessing the outcomes of any NICU during a defined period of time

o Performance Compared to 33-66% for PDX Medical Group (blue bar)

BabySteps Data Warehouse FutureCurrently, Maternal-Fetal Medicine CDW

is under development. Ultimate goal is to merge some data with Neonatology CDW for extensive new clinical and outcome observations

Pediatric Cardiology EHR is in development with associated EHR as well

BabySteps Data Warehouse has great flexibility for new report generation based upon physician requests

CQI AccomplishmentsCQI Quality Summits (3x annually)

Three day CQI experience▪ Fully supported by corporate leadership▪ Led by Dan Ellsbury, MD, Director of CQI▪ One session held in conjunction with NEO

Conference▪ Open to any physician or nurse

▪ Most recent Meeting in San Diego (Nov. 4-6, 2009)

Pediatrix physicians expected to attend one session every two years

CQI Accomplishments to Date

Demonstrated significant broad-based corporate improvement in neonatal outcomes Toolkit development for CQI projects Retinopathy of Prematurity (ROP) Reduction of inappropriate medication utilization Bronchopulmonary Dysplasia (BPD) reduction Improved nutritional approaches for enhanced

weight gain Length of stay (LOS) reduction through quality

improvement measures Random auditing approach

Comprehensive Oxygen Management for the Prevention of ROP

Evidence-Based Principles of ROP Toolkit:• Avoid hyperoxia• Avoid large oxygen saturation fluctuations • Educate all NICU staff and parents about ROP• Provide mechanisms to assess actual implementation

“COMP-ROP”

Severe ROP RatesPediatrix Medical Group

18%

9%

Oxygen Use @ 36 Weeks’ Gestation (BPD)

20%

12.5%

Infant Weight Gain

12 g/ day15.5 g/day

DR to NICU Temperature Report

Catheter-Related Blood Stream Infection

9.6%

12.2%

Maximum Respiratory Support

Research Data Warehouse

More than 60 papers published to date in peer-reviewed journals that have significantly impacted neonatal practice

Collaborations with many universities: Duke, North Carolina, Wake Forest, Virginia, Pittsburgh, Chicago, etc.

Unparalleled resource in neonatal medicine

Ampicillin /Gentamicin vs. Ampicillin/Cefotaxime—The Research CDW

Common use of antibiotics:Infant with suspected sepsis(Most common NICU admission)

Hypothesis:Ampicillin-Gentamicin andAmpicillin-Cefotaxime areequivalent approaches…or are they?Evaluated > 128,000 infants

Clark et al., Pediatrics 2006; 117:67

Logistic Regression (odds of death) with Cefotaxime Use (adjusted for need for assisted ventilation, anomalies, birth depression, CNS injury and EGA within each EGA group)

23 to 26 27 to 30 31 to 34 35 to 38 39 to 42

Adjusted Odds Ratio 1.14554672 1.61184607 1.78188665 1.87900805 1.43224032

0

0.5

1

1.5

2

2.5

Adjusted Odds Ratio

Clark et al., Pediatrics 2006; 117:67

Wks. gestation

N > 128,000

Odds Ratio

Example: Cefotaxime UseAfter dissemination of data showing fungal infection and increased mortality with cefotaxime use, network use of cefotaxime dropped markedly

Fungal infectionand cefotaxime

Increased mortality

Reduced Medication UseMedication Use, Pediatrix Network

Infants <1000 grams

0

5

10

15

20

25

30

35

40

2003 2004 2005 2006 2007 2008

CefotaximeH2-blockersMetoclopramideEpoSpironolactone

Percent of babies receiving the med

Percent

LOS Data All Infants 2003-2008Pediatrix Medical Group

Mean LOS decrease of ~2 days

16 d14 d

P4P Comparisons—Late Onset Sepsis

All practices Mountain Region