Using IT to Improve Patient Safety and Quality, and for BiosurveillancePublic Health

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Using IT to Improve Patient Safety and Quality,
and for Biosurveillance/Public Health
CMSS, 2006

• David W. Bates, MD, MSc
• Medical Director of Clinical and Quality
  Analysis, Partners Healthcare
• Chief, Division of General Medicine, Brigham and
  Womens Hospital

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Overview

• Safety and quality
• Potential for adverse consequences
• Illustrates what can happen without adequate
  attention to informatics
• Evidence about benefit
• Public health
• Biosurveillance

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Rates of Adverse Events Around the World

• 3.7 of hospitalizations in New York
• 58 preventable
• 2.8 Colorado-Utah
• 16.6 in Quality in Australian Health Care study
• 10.8 in UK
• Similar results now from Canada, New Zealand,
  several other countries
• Net rate in most countries appears to be about
  10

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Health Care QualityA Coin Flip?

• 54.9 received recommended care overall
• 53.5 received preventive care
• 53.5 received acute care
• 56.1 received recommended care for chronic
  conditions

McGlynn E, et al. N Engl J Med 20033482635-2645
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Prioritizing Safety

• Safety is not a top priority. Safety is a
  precondition.
• Paul ONeil, former CEO, Alcoa

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Handwriting example
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Pharmacy Computer System Field Test of Unsafe
Orders

• Unsafe Order
• Not Detected
• Vincristine 3 mg IV x 1 dose 62
• (2-year-old)
• Cephradine oral suspension IV 61
• Colchicine 10 mg IV for one dose 66
• (adult)

Source ISMP Medication Safety Alert! Feb 10,
1999
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Systems Improvement and IT in Healthcare

• Systems should
• Make errors less likely
• Catch those that do occur
• Current systems communicate poorly
• Health care spends little on IT
• Implementation is challenging, turnover high
• Writing a large check doesnt guarantee success

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Ways IT Can Improve Safety

• Prevent errors and adverse events
• Facilitating a more rapid response after an
  adverse event has occurred
• Tracking and providing feedback about adverse
  events

Bates and Gawande, NEJM 2003
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Main Strategies for Preventing Errors and AEs
Using IT

• Tools to improve communication
• Making knowledge more readily accessible
• Requiring key pieces of information
• Assisting with calculations
• Performing checks in real time
• Assisting with monitoring
• Providing decision support

Bates and Gawande, NEJM 2003
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Specific IT Applications

• Computerized physician order entry
• Smart pumps
• Smart monitoring
• Computerized notification about critical test
  results
• Computerized ADE monitoring
• Tracking abnormal test results

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Computerized Physician Order Entry

• Single most powerful intervention for improving
  medication safety to date--BUT
• Not easy to implement
• Have to implement well
• Essentially have to use vendor for main
  information system
• Need to have associated decision support if want
  to see high level of benefit
• Have to monitor, make iterative changes

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Inpatient Prevention

• 55 reduction in serious medication error rate
  with CPOE
• Bates, JAMA, 1998
• 83 reduction in overall medication error
  rate
• Bates, JAMIA, 2000
• Wont get this kind of benefit without local
  physician involvement, leadership
• Need to have some site-level customization

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How Should Things Work?

• Many (most?) physicians involved in one way or
  another in defining decision support/knowledge
• Key for all specialties
• Tools available today allow multi-stakeholder
  collaboration to build consensus
• E.g. around order sets, decision support
• Have to do faster than in the past
• Will NOT be static
• Will dramatically change the way we work

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Dilbert
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Results Manager Home Page
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Quality Harvard Vanguard Example

• Baseline in 60s
• Universal adoption of an EHRto 70s
• Implementation of registry functionto 80s
• Team approach involving use of electronic datain
  90s
• But just for measures worked oneventually want
  to target hundreds of areas
• NHS initiative focuses on 170!

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Public Health Informatics

• Current approach stovepipeis ineffective
• Need to move to routine extraction from
  electronic records
• All personnel need basic training in this area
• Key themes
• Need to link currently disconnected public health
  informatics activities with clinical world
• Public health workforce needs training in
  informaticsCDC is beginning to address

Yasnoff et al, JAMIA 2003
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Syndromic Surveillance

• Syndromic surveillance refers to methods relying
  on detection of individual and population health
  indicators that are discernable before confirmed
  diagnoses are made
• Syndrome examples
• Respiratory syndrome
• Gastrointestinal syndrome

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Outbreak Detection Stages

• Data acquisition
• Syndromic grouping
• Modeling
• Detection
• Alarm
• Mandl K, Overhage J, Wagner M, et al.
  Implementing syndromic surveillance a practical
  guide informed by the early experience. Journal
  of the American Medical Informatics Association.

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Compare Observed Data
Daily counts of ED visits for respiratory
syndromes from 1992 to 2002
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To A Model Forecast

• Model with autoregressive components, seasonal
  trends, other trends, covariates

Reis Mandl et al, BioMed Central 2003
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Net

• Can identify outbreaks before you would otherwise
• Avian flu
• SARS
• Smallpox
• Involves using complicated statistics
• Regularly extracting data from routine care
• Better not to have to rely on reports

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Conclusions

• Healthcare today is inefficient, error-prone, of
  variable quality
• Currently medical education includes little about
  this or about the potential of IT
• IT is a toolachieving benefit requires using it
  well
• Many pitfallsas illustrated by Han, Koppel
• All providers, specialties need to learn more/be
  more actively involved if value is to be achieved
• Need for local customization
• Must USE data
• Implementation carries risk
• Leaders in each organization, specialty key

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