Is an EHR’s Poor Algorithm Performance Good Enough for Your Patients?
By Tim Kuebelbeck, Chief Customer Officer at Ambient Clinical Analytics
The Problem
Of course, the answer to the title of this blog is ‘not even close to good enough’. So much information has been written and published over the last year on sepsis but until recently almost none of it was linked to health system performance. Sepsis is a deadly killer and worldwide takes roughly 25% of all people who die on any given day. But it doesn’t have to be that devastating if hospitals and health systems provide the appropriate care to patients. Unfortunately, a recent Healthcare IT News article about a JAMA Internal Medicine published and peer reviewed study has proven that EHR’s do not deliver acceptable sepsis performance and are likely a major contributor to the national sepsis crisis.
At least half of all U.S. hospitals are sitting well below 50% for sepsis CMS bundle compliance and the better ones are achieving 60% compliance. The reality is that 60% is untenable and obviously in academic terms is a D. Yet many hospitals and health systems are very comfortable with treating 6 out of 10 septic patients appropriately and continue to accept poor algorithm performance and care delivery for sepsis treatment when it is a problem that can be easily solved. While alternative solutions are readily available, the reasons hospitals choose to place themselves in this predicament are multifaceted.
From a cultural perspective some hospitals mistakenly think that physicians and nurses should never leave the EHR, others have spent so much money on their EHRs, that they feel they should try to fix sepsis bundle compliance in the EHR first. Many others think that getting close to the state or national sepsis bundle compliance average is good enough. These widely accepted views on what EHR’s should do vs. what they really do, or what is acceptable for sepsis bundle compliance is baffling, especially now that everyone understands that EHR’s don’t truly deliver clinical solutions for every facet of healthcare and using them to do so can and does cause harm to patients. Using a single algorithm for a system wide approach for sepsis detection is another major contradiction to appropriate care. A single sepsis algorithm across multiple hospital locations, or even across multiple units or specialties within a single hospital, is a reckless application of technology, causes clinicians to lose faith in the sepsis alert and another major contributor to poor sepsis bundle compliance in the United States. Trying to fix sepsis bundle compliance using your EHR has been and continues to cost patients their lives, limbs, organ damage, and permanent long-term health issues. As a health system executive, if that doesn’t make you squirm and take immediate action, you’re in the wrong business. Much of the hesitancy to truly address sepsis is because acute healthcare systems believe they can create a solution and have attempted to solve the issue inside of their EHR. This causes hospitals to waste money on consulting services with their EHR vendor, only to find out that the vendor really can’t help or they believe it’s too complex or won’t be fixed if they try again, and ultimately hospitals end up holding an expensive bag of poor sepsis bundle compliance results, and patients pay the price for this mindset. This mindset must change.
Hospital environments demand high reliability and sustainability across all aspects of care and when it comes to poor performance, there should be no discrimination to which clinical problems they choose to put effort into. In the last 3 months I have been told by a Chief Medical Officer of a major health system that their sepsis bundle compliance of 33% is fine and a Chief Quality Officer of another major health system that their 28% sepsis bundle compliance is good enough for them. To be clear let’s average that out to a 30% sepsis bundle compliance rate, which would mean that 7 out of 10 of their patients do not receive the appropriate treatment bundle for sepsis. Those are self-imposed and punishing odds to give your patients for appropriate treatment for something that is completely controllable. For a missed or late sepsis bundle element, mortality goes up an average of 8.5%, and even higher if you miss more than one element or timeline in the bundle. The incidence of septic shock, severe septic shock, long term organ damage, amputations, 30 day readmits, and mortality is alarming when you miss multiples of either the sepsis bundle elements or timelines.
The financial business case and clinical argument for having a true FDA Class II Cleared Clinical Decision Support (CDS) platform to address sepsis bundle compliance issues is stronger than ever. If you think you don’t have a sepsis crisis in your facility, or someone is telling you that the problem is solved, think again, because someone’s not giving you the entire picture. Either that or you’re one of a handful of hospitals in the United States that is consistently achieving mid 90th percentile for sepsis bundle compliance.
Decision support systems require FDA Class II clearance to drive detection and treatment, yet EHR vendors such as Epic, Cerner, and Allscripts offer an embedded sepsis algorithm without the appropriate FDA clearance. One must assume it’s because EHR vendors want to keep the physician’s workflow entirely inside the EHR. It’s how EHR vendors maintain control of healthcare clients, and it is costing people their health and their lives. Choosing to make it extremely difficult to integrate to their EHR’s workflow is common and often causes healthcare systems to take the path of least resistance. Sure, your sepsis algorithm can alert a provider to a potential sepsis case but then what? Are the false positives too high causing the physicians and nurses to ignore it? What mechanisms are in place for communication and follow up to make sure the sepsis bundle elements are completed? How does the EHR communicate that bundle elements are in jeopardy? Your EHR is not the answer. Solving sepsis is a complex process, but rest assured it is much easier than you think if you enlist professional subject matter experts and FDA Class II cleared solutions. So, what’s the answer to this unsolved sepsis crisis in the U.S. and how do we fix it?
Addressing Sepsis
At Ambient Clinical Analytics, over the years, we have learned and been reminded that there are four keys to solving sepsis permanently. If you attack those keys correctly, you can and will solve sepsis. Many have taken a stab at fixing the first key but have done so in a marginal manner. Almost none or at best, very few have solved the second, third, or fourth keys. Until health systems can figure out how to drive early intervention and timely care, they will be stuck risking lives and underperforming on their CMS sepsis bundle compliance. Providing a communication technology that allows for remote patient monitoring of an end-to-end sepsis surveillance solution and if needed, tele-sepsis services, is critical. A focus on automating best practices using innovative technology to identify sepsis, treat sepsis and ensure that protocols don’t slip through the cracks is critically important. Without it, hospitals will continue to fail patients by leaving them at risk.
Sepsis Detection (Sepsis Alert)
There are multitudes of claims by companies to the efficacy of their sepsis detection in terms of sensitivity and specificity, but few have scientific, clinical, peer reviewed, and published studies to back it up. Ambient has several peer reviewed published studies with Mayo Clinic that scientifically prove the efficacy of our sepsis detection solutions. We have an end-to-end solution that is much more than just a sepsis patient tracker board, called Sepsis DART™. Sepsis DART™ was developed with Mayo Clinic, and it also includes an indicative sepsis alert that is configurable by each health system, and even configurable down to the unit level. Because different units have different sepsis detection requirements, we typically run a multitude of algorithms in each site we install at. If you want to truly solve sepsis, you must have a solution that allows you to run multiple sepsis algorithms.
Early Intervention
It is also important to understand that with sepsis surveillance you must drive early intervention which is the second key component to solving sepsis. With each hour you fail to intervene, mortality for sepsis increases a minimum of 7.6%. In fact, each hour of delay in antimicrobial administration over the ensuing 6 hours was associated with an average decrease in survival of 7.6%. Administration of an antimicrobial effective for isolated or suspected pathogens within the first hour of documented hypotension was associated with a survival rate of 79.9%.
While deploying Sepsis DART™ in hospital systems across the U.S. this year, we saw three effective response models, depending on the quality systems, management processes, and investment levels at the hospital. Any of these three models by themselves or combined, coupled with the right automated sepsis surveillance solution (like Sepsis DART™) will yield substantial patient outcome improvements and cost reductions. The model that will work for an individual health system will depend on the system design and workflow of each hospital, and there are many differences, especially in the quality of the staffing, information electronically available, and the investment made in centralized functions like sepsis response and central incidence management.
Delivering Timely Care and Quality Beyond the Bundle Elements
This brings us to the third component which is delivering care and the sepsis bundle elements within the appropriate time windows. Beyond driving early intervention as described above, it is critical that your sepsis detection solution has sepsis patient tracker board functionality that provides automatic sepsis surveillance and at-a-glance awareness of patient status, enabling bedside and remote monitoring of large numbers of patients simultaneously.
Automated Communication
At Ambient, we know that sepsis platforms must employ smart notifications that directly notify the right care givers at the right time of a potential sepsis development in a patient and using smart escalations, continue to notify care givers until someone on the team takes the appropriate action. To drive better performance your sepsis solution must be an end-to-end communication platform designed to manage sepsis using smart notifications and smart escalations for automated communication with doctors and nurses, even if they are not in the EHR, or in any other clinical system. Your sepsis solutions must be integrated into your EHR, your desktop and your communication platforms (such as tigerconnect, Spok, Vocera etc...) to not disrupt a clinician’s workflow and to deliver those same smart notifications and smart escalations when the timely delivery of the correct care elements is at risk. Unlike EHR’s, Sepsis DART™ does all of this automatically and most importantly, graphically tracks the delivery of the sepsis care bundle (as appropriate for that patient) while providing both notifications and reminders where elements of the sepsis bundle may be in jeopardy of not being delivered correctly or in a timely fashion.
Summary
Mastering the four sepsis care key components and solving sepsis in your health system requires using a modern electronic FDA cleared Clinical Decision Support solution outside of your existing EHR. EHR’s ultimately fail to deliver end to end detection and care, causing risk major for your patients. Continuing to accept low sepsis bundle compliance performance and poor delivery of the sepsis care process continues to cause reduced performance both clinically and financially for hospitals and health systems. Allowing this to continue in hospitals is negligent and devastating to patients and families, not to mention it unintentionally abandons and discriminates against large portions of your patient population. For further information on how you can solve this issue in your health system please contact Ambient Clinical Analytics today or visit us at HIMSS Booth C100-89 and find out how you can fix your failing grade on sepsis today. At Ambient Clinical Analytics, We Fix Sepsis!™
For more detailed information on how you can solve sepsis in your organization with Ambient Clinical Analytics please contact tim.kuebelbeck@ambientclinical.com or schedule a visit with us at Booth C100-89 at HIMSS 2021.
About Ambient Clinical Analytics - As an industry leader, Ambient is supporting leading healthcare systems and has done so since its founding in 2013. Our solutions are designed by clinicians to be easy-to-use by every caregiver in your organization and are configured to be up and running rapidly. We are trusted by a community of high-performing healthcare providers across the United States. Our solutions are powerful real-time point-of-care and remote healthcare platforms designed to deliver life-saving solutions using data visualization, communication, and analytics based clinical decision support.
Ambient’s AWARE™ and Sepsis DART™ solutions are exceptionally secure, high-performance, FDA Class II approved and CE Marking certified Software as a Medical Device (SaMD) platforms. Ambient’s Sepsis DART™ product has been accepted into the Patient Safety Movement’s Actionable Patient Safety Solutions (APSS) #9 for Sepsis. Ambient has achieved ISO 13485:2016 certification, an internationally recognized quality standard specific to the medical device industry. The ISO 13485 standard sets out the requirements for a quality management system specific to the medical device industry. Ambient is also deploying the AWARE™ family of solutions, to help manage COVID-19. Ambient’s Virtual ICU platforms are ideal for dealing with current and possible future outbreaks. For more information, visit https://ambientclinical.com.
The Problem
Of course, the answer to the title of this blog is ‘not even close to good enough’. So much information has been written and published over the last year on sepsis but until recently almost none of it was linked to health system performance. Sepsis is a deadly killer and worldwide takes roughly 25% of all people who die on any given day. But it doesn’t have to be that devastating if hospitals and health systems provide the appropriate care to patients. Unfortunately, a recent Healthcare IT News article about a JAMA Internal Medicine published and peer reviewed study has proven that EHR’s do not deliver acceptable sepsis performance and are likely a major contributor to the national sepsis crisis.
At least half of all U.S. hospitals are sitting well below 50% for sepsis CMS bundle compliance and the better ones are achieving 60% compliance. The reality is that 60% is untenable and obviously in academic terms is a D. Yet many hospitals and health systems are very comfortable with treating 6 out of 10 septic patients appropriately and continue to accept poor algorithm performance and care delivery for sepsis treatment when it is a problem that can be easily solved. While alternative solutions are readily available, the reasons hospitals choose to place themselves in this predicament are multifaceted.
From a cultural perspective some hospitals mistakenly think that physicians and nurses should never leave the EHR, others have spent so much money on their EHRs, that they feel they should try to fix sepsis bundle compliance in the EHR first. Many others think that getting close to the state or national sepsis bundle compliance average is good enough. These widely accepted views on what EHR’s should do vs. what they really do, or what is acceptable for sepsis bundle compliance is baffling, especially now that everyone understands that EHR’s don’t truly deliver clinical solutions for every facet of healthcare and using them to do so can and does cause harm to patients. Using a single algorithm for a system wide approach for sepsis detection is another major contradiction to appropriate care. A single sepsis algorithm across multiple hospital locations, or even across multiple units or specialties within a single hospital, is a reckless application of technology, causes clinicians to lose faith in the sepsis alert and another major contributor to poor sepsis bundle compliance in the United States. Trying to fix sepsis bundle compliance using your EHR has been and continues to cost patients their lives, limbs, organ damage, and permanent long-term health issues. As a health system executive, if that doesn’t make you squirm and take immediate action, you’re in the wrong business. Much of the hesitancy to truly address sepsis is because acute healthcare systems believe they can create a solution and have attempted to solve the issue inside of their EHR. This causes hospitals to waste money on consulting services with their EHR vendor, only to find out that the vendor really can’t help or they believe it’s too complex or won’t be fixed if they try again, and ultimately hospitals end up holding an expensive bag of poor sepsis bundle compliance results, and patients pay the price for this mindset. This mindset must change.
Hospital environments demand high reliability and sustainability across all aspects of care and when it comes to poor performance, there should be no discrimination to which clinical problems they choose to put effort into. In the last 3 months I have been told by a Chief Medical Officer of a major health system that their sepsis bundle compliance of 33% is fine and a Chief Quality Officer of another major health system that their 28% sepsis bundle compliance is good enough for them. To be clear let’s average that out to a 30% sepsis bundle compliance rate, which would mean that 7 out of 10 of their patients do not receive the appropriate treatment bundle for sepsis. Those are self-imposed and punishing odds to give your patients for appropriate treatment for something that is completely controllable. For a missed or late sepsis bundle element, mortality goes up an average of 8.5%, and even higher if you miss more than one element or timeline in the bundle. The incidence of septic shock, severe septic shock, long term organ damage, amputations, 30 day readmits, and mortality is alarming when you miss multiples of either the sepsis bundle elements or timelines.
The financial business case and clinical argument for having a true FDA Class II Cleared Clinical Decision Support (CDS) platform to address sepsis bundle compliance issues is stronger than ever. If you think you don’t have a sepsis crisis in your facility, or someone is telling you that the problem is solved, think again, because someone’s not giving you the entire picture. Either that or you’re one of a handful of hospitals in the United States that is consistently achieving mid 90th percentile for sepsis bundle compliance.
Decision support systems require FDA Class II clearance to drive detection and treatment, yet EHR vendors such as Epic, Cerner, and Allscripts offer an embedded sepsis algorithm without the appropriate FDA clearance. One must assume it’s because EHR vendors want to keep the physician’s workflow entirely inside the EHR. It’s how EHR vendors maintain control of healthcare clients, and it is costing people their health and their lives. Choosing to make it extremely difficult to integrate to their EHR’s workflow is common and often causes healthcare systems to take the path of least resistance. Sure, your sepsis algorithm can alert a provider to a potential sepsis case but then what? Are the false positives too high causing the physicians and nurses to ignore it? What mechanisms are in place for communication and follow up to make sure the sepsis bundle elements are completed? How does the EHR communicate that bundle elements are in jeopardy? Your EHR is not the answer. Solving sepsis is a complex process, but rest assured it is much easier than you think if you enlist professional subject matter experts and FDA Class II cleared solutions. So, what’s the answer to this unsolved sepsis crisis in the U.S. and how do we fix it?
Addressing Sepsis
At Ambient Clinical Analytics, over the years, we have learned and been reminded that there are four keys to solving sepsis permanently. If you attack those keys correctly, you can and will solve sepsis. Many have taken a stab at fixing the first key but have done so in a marginal manner. Almost none or at best, very few have solved the second, third, or fourth keys. Until health systems can figure out how to drive early intervention and timely care, they will be stuck risking lives and underperforming on their CMS sepsis bundle compliance. Providing a communication technology that allows for remote patient monitoring of an end-to-end sepsis surveillance solution and if needed, tele-sepsis services, is critical. A focus on automating best practices using innovative technology to identify sepsis, treat sepsis and ensure that protocols don’t slip through the cracks is critically important. Without it, hospitals will continue to fail patients by leaving them at risk.
Sepsis Detection (Sepsis Alert)
There are multitudes of claims by companies to the efficacy of their sepsis detection in terms of sensitivity and specificity, but few have scientific, clinical, peer reviewed, and published studies to back it up. Ambient has several peer reviewed published studies with Mayo Clinic that scientifically prove the efficacy of our sepsis detection solutions. We have an end-to-end solution that is much more than just a sepsis patient tracker board, called Sepsis DART™. Sepsis DART™ was developed with Mayo Clinic, and it also includes an indicative sepsis alert that is configurable by each health system, and even configurable down to the unit level. Because different units have different sepsis detection requirements, we typically run a multitude of algorithms in each site we install at. If you want to truly solve sepsis, you must have a solution that allows you to run multiple sepsis algorithms.
Early Intervention
It is also important to understand that with sepsis surveillance you must drive early intervention which is the second key component to solving sepsis. With each hour you fail to intervene, mortality for sepsis increases a minimum of 7.6%. In fact, each hour of delay in antimicrobial administration over the ensuing 6 hours was associated with an average decrease in survival of 7.6%. Administration of an antimicrobial effective for isolated or suspected pathogens within the first hour of documented hypotension was associated with a survival rate of 79.9%.
While deploying Sepsis DART™ in hospital systems across the U.S. this year, we saw three effective response models, depending on the quality systems, management processes, and investment levels at the hospital. Any of these three models by themselves or combined, coupled with the right automated sepsis surveillance solution (like Sepsis DART™) will yield substantial patient outcome improvements and cost reductions. The model that will work for an individual health system will depend on the system design and workflow of each hospital, and there are many differences, especially in the quality of the staffing, information electronically available, and the investment made in centralized functions like sepsis response and central incidence management.
Delivering Timely Care and Quality Beyond the Bundle Elements
This brings us to the third component which is delivering care and the sepsis bundle elements within the appropriate time windows. Beyond driving early intervention as described above, it is critical that your sepsis detection solution has sepsis patient tracker board functionality that provides automatic sepsis surveillance and at-a-glance awareness of patient status, enabling bedside and remote monitoring of large numbers of patients simultaneously.
Automated Communication
At Ambient, we know that sepsis platforms must employ smart notifications that directly notify the right care givers at the right time of a potential sepsis development in a patient and using smart escalations, continue to notify care givers until someone on the team takes the appropriate action. To drive better performance your sepsis solution must be an end-to-end communication platform designed to manage sepsis using smart notifications and smart escalations for automated communication with doctors and nurses, even if they are not in the EHR, or in any other clinical system. Your sepsis solutions must be integrated into your EHR, your desktop and your communication platforms (such as tigerconnect, Spok, Vocera etc...) to not disrupt a clinician’s workflow and to deliver those same smart notifications and smart escalations when the timely delivery of the correct care elements is at risk. Unlike EHR’s, Sepsis DART™ does all of this automatically and most importantly, graphically tracks the delivery of the sepsis care bundle (as appropriate for that patient) while providing both notifications and reminders where elements of the sepsis bundle may be in jeopardy of not being delivered correctly or in a timely fashion.
Summary
Mastering the four sepsis care key components and solving sepsis in your health system requires using a modern electronic FDA cleared Clinical Decision Support solution outside of your existing EHR. EHR’s ultimately fail to deliver end to end detection and care, causing risk major for your patients. Continuing to accept low sepsis bundle compliance performance and poor delivery of the sepsis care process continues to cause reduced performance both clinically and financially for hospitals and health systems. Allowing this to continue in hospitals is negligent and devastating to patients and families, not to mention it unintentionally abandons and discriminates against large portions of your patient population. For further information on how you can solve this issue in your health system please contact Ambient Clinical Analytics today or visit us at HIMSS Booth C100-89 and find out how you can fix your failing grade on sepsis today. At Ambient Clinical Analytics, We Fix Sepsis!™
For more detailed information on how you can solve sepsis in your organization with Ambient Clinical Analytics please contact tim.kuebelbeck@ambientclinical.com or schedule a visit with us at Booth C100-89 at HIMSS 2021.
About Ambient Clinical Analytics - As an industry leader, Ambient is supporting leading healthcare systems and has done so since its founding in 2013. Our solutions are designed by clinicians to be easy-to-use by every caregiver in your organization and are configured to be up and running rapidly. We are trusted by a community of high-performing healthcare providers across the United States. Our solutions are powerful real-time point-of-care and remote healthcare platforms designed to deliver life-saving solutions using data visualization, communication, and analytics based clinical decision support.
Ambient’s AWARE™ and Sepsis DART™ solutions are exceptionally secure, high-performance, FDA Class II approved and CE Marking certified Software as a Medical Device (SaMD) platforms. Ambient’s Sepsis DART™ product has been accepted into the Patient Safety Movement’s Actionable Patient Safety Solutions (APSS) #9 for Sepsis. Ambient has achieved ISO 13485:2016 certification, an internationally recognized quality standard specific to the medical device industry. The ISO 13485 standard sets out the requirements for a quality management system specific to the medical device industry. Ambient is also deploying the AWARE™ family of solutions, to help manage COVID-19. Ambient’s Virtual ICU platforms are ideal for dealing with current and possible future outbreaks. For more information, visit https://ambientclinical.com.