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BabySteps: A Giant Success Story
By Mary Anne Gates

Florida-based Pediatrix Medical Group has stepped up its use of HIT to deliver improved medical care to thousands of tiny patients in neonatal ICUs (NICUs) nationwide.

For more than a decade, the nation’s largest neonatal physician group (nearly 1,000 physicians) has been an advocate of EHR use. Two years ago, it took its passion for HIT a step further with the launch of BabySteps, a specialty EHR that gathers information from charts, hospital monitoring systems, and nurses’ notes.

Data can be downloaded from partner systems directly into Pediatrix’s electronic notes, says Senior Vice President and Chief Information Officer Bob Bryant, who adds that BabySteps can also create a discharge summary and provide clinicians with ready access to reference material.

Training and Acceptance
Extensive training has led to a greater acceptance of BabySteps.

“Physician acceptance and adoption are the single most difficult barriers for any electronic health system. The widespread adoption of an EHR is often a complete readjustment in workflow for the entire healthcare team,” says Bryant.

An emphasis on quality documentation and a desire to collect only essential information have led to the creation of one the country’s largest neonatal databases, which offers outcome reporting for more than 700,000 neonatal patients and more than 12 million neonatal patient days.

“Pediatrix has put a great deal of effort into training physicians on how to document appropriately in BabySteps,” says Alan Spitzer, MD, senior vice president and director of Pediatrix’s Center for Research, Education and Quality. “The information gathered is a direct result of the documentation of care provided to the babies in the NICU, including procedures; diagnoses; support, such as respiratory and nutritional support; and medications.

“Pediatrix physicians implement consistent data standards … at each NICU and provide education for physicians to ensure consistent documentation. With good clinical documentation in BabySteps, physicians can consistently gather good information,” he adds.

Data Storage
Not surprisingly, storing this much information created a need for a storage solution of warehouse-sized proportions.

“Information is securely stored in our SQL database, called the Pediatrix clinical data warehouse [CDW], for ease of reporting and sharing among our physicians. We use SQL replication to consolidate information for facility, regional, and organizational reporting,” says Bryant.

The CDW is a valuable tool used to better understand and assess the care provided by Pediatrix physicians. It’s used to address clinical questions about neonatal care and make novel research observations, such as identifying national or regional trends, analyzing the impact of a specific clinical intervention on patient care, or determining the outcomes of a clinical quality improvement project.

Benefits
Besides the ability to automatically obtain discharge summaries and reference materials, Spitzer says Pediatrix physicians have used BabySteps technology to advance care, including using its data to conduct more than a dozen multicenter randomized trials with several more in the planning stages.

As a result, he says, significant improvements in neonatal patient outcomes have been achieved, including the following:

• Reduced rates of both overall and severe retinopathy of prematurity, a condition affecting vision that can lead to blindness in premature babies. Rates of severe retinopathy of prematurity were reduced by nearly one-half.
• Enhanced growth rates highlighted by improved weight gain during the first 28 days of life for very low birth weight newborns born between 2000 and 2008.
• A dramatic reduction in the use of medications for which there is little clinical evidence to support their safety and efficacy in premature babies, resulting in changed standards in practice patterns.
• Reduced rates of unnecessary antibiotic therapy.
• Reduced rates of chronic lung disease.

Cost and Return on Investment
Calculating the return on investment for BabySteps EHRs, Pediatrix has taken into account improved patient outcomes as well as the amount of money spent annually.

“The greatest return we achieve is the improved care provided to our patients as a result of our research and clinical quality improvement capabilities using the information gathered from BabySteps. As a large national group practice, we are able to quickly assess patient outcomes, and we can provide that information back to our physicians in a fast and efficient manner to enable continuous nationwide improvement in the care for babies in our NICUs, which consists of approximately 20% of the U.S. neonatal population,” says Bryant.

“Pediatrix makes significant investments on an annual basis in BabySteps, including development, training, implementation, and support personnel along with servers, networks, workstations, and connectivity costs for more than 250 sites and 1,000 physicians. These costs add up into the millions of dollars per year. The benefits to the organization also include improved risk management and streamlined billing processes,” he adds.

The Future of BabySteps
“Future integration will include even greater sharing of data points between BabySteps and the IT systems of our hospital partners throughout the country,” says Bryant. Emerging electronic technology is expected to play even more of a role in how BabySteps EHRs are used to gather patient information.

“Also, as mobile devices and their capabilities become more accepted and secured, clinicians will be even more able to incorporate EHRs into their daily workflow,” Bryant says.

Quality Improvement Initiatives
As the BabySteps EHRs have evolved so have Pediatrix’s quality improvement initiatives. For example, over its three-year run, the 100,000 Babies Campaign launched in 2009 is expected to make long-term quality improvements in the system of care provided to 100,000 babies in NICUs nationwide that can then be used to improve care for all premature babies, says Spitzer.

“Throughout Pediatrix’s neonatal quality improvement initiatives, we have found that it is critically important to have a strong clinical leadership team as well as buy-in from all caregivers in the NICU to ensure the best possible results for patients,” he says. “Therefore, Pediatrix’s numerous quality improvement programs, such as the 100,000 Babies Campaign, are designed to be a multidisciplinary effort in which the entire NICU team of clinicians, including both physicians and nurses, are fully committed and willing to participate in the use of BabySteps and the quality improvement processes established at the beginning of the program. In our experience, this type of approach has helped our physicians achieve improved neonatal patient outcomes both locally and on a national level.”

100,000 Babies Campaign
The campaign is helping redesign the care provided to infants in the NICU by using an EHR and applying evidence-based practices so that quality improvement changes become a routine part of everyday care in real time, Spitzer says.

“As a result, both physicians and patients benefit from being part of a program that is truly at the forefront of applying evidence-based medicine to help redesign the total system of care delivery for premature babies and improve outcomes for the neonatal patient population,” he says.

Designed to recognize and meet the individual needs of participating NICUs, the campaign focuses on the following five target areas:

• enhancing nutrition;
• improving medication use;
• reducing central line infections;
• minimizing mechanical ventilation; and
• reducing suboptimal admission temperatures.

Setup
In each NICU, two comprehensive surveys determine staff attitudes, beliefs, and knowledge gaps about neonatal care. The NICU’s current clinical approach in each target area of care is also assessed. The campaign’s goal is to assist NICUs in delivering the best possible evidence-based care in each focus area without interrupting the clinical workflow already in place, says Spitzer.

After the surveys are complete, a core team of project leaders evaluates the responses and the clinical approaches in each of the five areas to determine which specific quality improvement adjustments are needed. For example, says Spitzer, in an initial survey of participating NICU teams, it was determined that there was a variation in knowledge about the full medical benefits of giving breast milk to premature babies while physicians considered it an essential factor in the nutrition of all infants, especially those in the NICU. Since many different clinicians on the NICU team play a role in sharing this type of information with new mothers, the use of breast milk was identified as a key target area for improvement.

To further assist individual NICUs participating in the 100,000 Babies Campaign, Pediatrix provides the resources and structure necessary by supporting the implementation of evidence-based clinical guidelines, teamwork, education, and knowledge sharing among all clinicians and by facilitating thorough communications with parents, says Spitzer.

Besides addressing consistent clinical approaches to care during the campaign, Pediatrix ensures quality data collection and measurement.

“Data collection and measurement can often be major limiting factors in any successful quality initiative,” says Spitzer. “All clinical data documented by physicians through BabySteps is collected and stored in the Pediatrix CDW and then made available for physicians to use in clinical research projects and hospital reports to help identify trends in patient outcomes and in additional areas for potential improvement on an individual unit level.”

Changes can be swift and dramatic. “Our NICU teams that are participating in the 100,000 Babies Campaign often see positive changes in as little as four to six months after consistently implementing the quality improvement interventions as designed by the program. For families, these improvements are translating into overall better outcomes for their babies and can result in less time spent in the NICU,” says Spitzer.

— Mary Anne Gates is a medical writer based in the Chicago area.