1. 1 The Effects of Information Technology on Nurses and Patients in the VHA Joanne Spetz, Ph.D. University of California, San Francisco Ciaran Phibbs, Ph.D. VA Health Economics Resource Center James Burgess, Ph.D. Boston VA AcademyHealth Annual Research Meeting June 2008

2. 2 Background The VA is the largest integrated health system in the US The VA is the largest installation of an integrated IT system in the US Computerized Patient Records System (CPRS) Bar Code Medication Administration (BCMA) The VA did not have a system-wide evaluation of CPRS or BCMA

3. 3 This study Quantitative and qualitative methods Research questions Did CPRS and BCMA change the need for nursing staff? Did CPRS and BCMA reduce adverse events for patients in the VHA? What do staff and leaders believe are the strengths and weaknesses of CPRS and BCMA? What recommendations can be made to the VA and other hospitals as they implement information systems?

4. 4 Methods Quantitative analysis Retrospective, by necessity Pre-post design – implementation dates varied across sites Administrative data: patient discharge data, payroll data, etc. Qualitative analysis Key informant interviews at 8 sites 130 interviews Thematic analysis

5. 5 Variation in CPRS implementation initiation Some sites did not begin until 2002

6. 6 Variation in time to fully implement CPRS Some sites took more than one year to fully implement

7. 7 Variation in BCMA implementation initiation – acute wards Some sites did not begin until 2002 Most sites began in Q2 of 2000

8. 8 Variation in time to fully implement BCMA in acute wards Some sites took more than one year to fully implement

9. 9 Variation in BCMA implementation initiation – intensive care Version 2 implementers Version 1 implementers

10. 10 Variation in time to fully implement BCMA in ICU Some sites took more than one year to fully implement Most sites went “whole hog” in ICU

11. 11 Perspectives from the interviews The cultural change caused by CPRS and BCMA was enormous CPRS changed “how we organize, document, and communicate regarding patient care” With BCMA, “all touchpoints of care were changed” Some staff observed a change from primary care nursing to team nursing

12. 12 Perspectives from the interviews Many staff think IT takes them away from direct patient care BCMA “ground production to a halt”, according to one nurse Some nurses think BCMA saves time, many think it takes no more time Some staff think CPRS forces them to care for the computer more than patients Most agree it takes more time to enter data Time savings are gained from data retrieval

13. 13 Perspectives from the interviews Most staff believe quality of care improved CPRS: quality of medical record, ease of getting information CPRS impacted outpatient care more – clinical reminders, integrated records BCMA: medication error rates dropped

14. 14 Specific outcomes AHRQ Inpatient Quality Indicators: mortality CABG mortality AMI mortaltiy CHF mortality Acute stroke mortality GI hemorrhage mortality Pneumonia mortality PTCA mortality AHRQ Patient Safety Indicators Decubitus ulcer Failure to rescue Selected infections due to medical care Post-operative respiratory failure Post-operative PE/DVT Post-operative sepsis Accidental puncture or laceration

15. 15 Method for patient outcomes Estimation approach: linear regression with quarterly data Explanatory variables Time dummies (sensitivity analysis with time trend) Patient days (quadratic) Casemix (based on DRGs) Percent of patients 70 years and older Percent of patient days in ICU FTEs per adjusted admission (all staff) (annual) Trainees per adjusted admission (annual) Median tenure of RNs Percent of RNs over 50 years old Percent of RNs with BSN or MSN Percent of RNs unionized Fixed effects for each hospital, robust standard errors Can analyze different CPRS/BCMA effects Initial implementation Full implementation 6 months after implementation began 12 months after implementation began

16. 16 CPRS results IQI OutcomesImp. startImp. complete CABG mortality-0.0060.008 AMI mortality-0.0100.0003 CHF mortality-0.005-0.001 Stroke mortality-0.0170.026** GI hemorrhage mortality-0.0060.002 Pneumonia mortality-0.023**0.001 PTCA mortality0.009-0.0005

17. 17 CPRS results PSI OutcomesImp. start Imp. complete Decubitus ulcer0.002-0.0005 Failure to rescue0.003-0.007 Selected infections medical care-0.00030.0003* Post-op respiratory failure0.0006-0.0004 Post-op PE/DVT-0.0010.0008 Post-op sepsis-0.0006-0.0002 Accidental puncture/ laceration0.00030.001**

18. 18 Consistent findings for CPRS Stroke mortality dropped in short-term, but long-term effect was neutral or positive Pneumonia mortality declined significantly Effect occurred upon initial implementation Access to records of history of care may be most pertinent to this mortality measure Accidental puncture/laceration rates increased Effect developed in the 12-24 month period Does this reflect workflow or ergonomic issues?

19. 19 BCMA acute care results IQI OutcomesImp. start Imp. complete CABG mortality-0.0550.010 AMI mortality-0.026-0.001 CHF mortality0.0100.006 Stroke mortality0.009-0.019 GI hemorrhage mortality-0.019**0.0007 Pneumonia mortality-0.005-0.010 PTCA mortality0.005-0.010

20. 20 BCMA acute care results PSI OutcomesImp. start Imp. complete Decubitus ulcer-0.003*0.002 Failure to rescue-0.013-0.007 Selected infections medical care-0.0005**0.0002 Post-op respiratory failure-0.0010.002** Post-op PE/DVT0.001-0.002 Post-op sepsis0.00009-0.0004 Accidental puncture/ laceration0.00001-0.00006

21. 21 BCMA ICU results IQI OutcomesImp. Start 12-month lag CABG mortality0.021-0.019 AMI mortality-0.023**-0.005 CHF mortality0.003-0.004 Stroke mortality0.005-0.004 GI hemorrhage mortality-0.005-0.009 Pneumonia mortality-0.003-0.007 PTCA mortality0.009-0.014*

22. 22 BCMA ICU results PSI OutcomesImp. start Imp. complete Decubitus ulcer-0.002*0.0005 Failure to rescue-0.003 Selected infections medical care0.000090.00005 Post-op respiratory failure0.001-0.001 Post-op PE/DVT-0.002**0.0005 Post-op sepsis0.00050.0008 Accidental puncture/ laceration0.00009-0.00002

23. 23 Consistent findings for BCMA Acute care BCMA effects are inconsistent across models and often offset each other ICU BCMA had more consistent effects AMI mortality declined Decubitus ulcer declined Post-op PE/DVT declined

24. 24 Three important take-home messages Outcomes did not worsen Some CPRS and BCMA users feared the system detracted from other key patient care issues Exception: accidental puncture/laceration Some outcomes improved Medication errors not studied here

25. 25 Common experiences with both implementations Overall success depends on how the site and implementation team plans for setbacks, and continues the process to achieve success in the end When you have a large organizational deployment you need a very stable, fault- tolerant environment. Staff needed more time to do their jobs during implementation, but no additional staff were allocated.

26. 26 Team & Funding Core team Joanne Spetz, UCSF Ciaran Phibbs, VA HERC Jim Burgess, Boston VA Susan Schmidt, VA HERC Melanie Chan, Dennis Keane, and Jennifer Kaiser, UCSF Funding Robert Wood Johnson Foundation Gordon & Betty Moore Foundation