Alan R. Spitzer, MD Senior Vice President and Director The Center for Research, Education, and Quality Pediatrix Medical Group (MEDNAX, Inc.)

 Largest 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 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 neonates per day  >90,000 admissions/ year  Provide care in 33 states plus Puerto Rico

 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

 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

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

 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

 BabySteps 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 populations  System updated weekly

 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

ImprovedG.A.Selection Weeks can be selected individually or combined

Enhanced Birth Weight Selection 250 g increments below 1500 g

Inborn/ Outborn NICU Size/ NICU Size/ Region/ State Comparisons (risk adjusting)

 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

  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

o Dashboard report for assessing the outcomes of any NICU during a defined period of time o Performance Compared to % for PDX Medical Group (blue bar)

 Currently, 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 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

 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 hyperoxiaAvoid hyperoxia Avoid large oxygen saturation fluctuationsAvoid large oxygen saturation fluctuations Educate all NICU staff and parents about ROPEducate all NICU staff and parents about ROP Provide mechanisms to assess actual implementationProvide mechanisms to assess actual implementation “COMP-ROP”

18% 9%

20% 12.5%

12 g/ day 15.5 g/day

9.6% 12.2%

 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

Common use of antibiotics: Infant with suspected sepsis (Most common NICU admission) Hypothesis: Ampicillin-Gentamicin and Ampicillin-Cefotaxime are equivalent approaches… or are they? Evaluated > 128,000 infants Clark et al., Pediatrics 2006; 117:67

Wks. gestation N > 128,000 OddsRatio

Example: Cefotaxime Use After dissemination of data showing fungal infection and increased mortality with cefotaxime use, network use of cefotaxime dropped markedly Fungal infection and cefotaxime Increased mortality

Percent

Mean LOS decrease of ~2 days 16 d 14 d

All practices Mountain Region