Health Informatics Masterclass

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Bridging the Quality Chasm

• Health Informatics Masterclass
• 20th January 2006
• City University London

I am sorry. Your disease and our
organisation just do not match.
Marc Berg Full Professor Health Policy and
Management, Erasmus University,
Rotterdam Partner, Plexus Medical Group, Amsterdam
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The Quality Chasm

• There is a large gap between what the health care
  system could deliver and what it actually
  delivers
• Coordination problems
• Delays before and during care process
• Communication errors
• Absence of patient-centered approach
• Waste
• Direct harm through mistakes, unnecessary
  waiting, sub-optimal diagnosis/treatment

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Variation
Acute cholecystectomies per hospital/regional
population (Source RVZ Gepaste Zorg)
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Patient safety and effectiveness

• Volume of high risk surgery abdominal aorta
  surgery

N 71. Source Hospital performance Indicators
Dutch Healthcare Inspectorate
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Patient safety and effectiveness

• Volume of high risk surgery esophagectomy

N 71. Source Hospital performance Indicators
Dutch Healthcare Inspectorate
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Patient safety and effectiveness
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The Cost of Poor Quality

• Cost of Poor Quality
• error rates are orders of magnitude higher than
  in other industries
• poor quality care accounts for 35-45 of HC
  expenditures in US
• Most costly
• medication misuse
• hospital overuse
• preventable hospital-acquired infections
• poor disease management diabetes, depression,
  HF, vaccination, etc.
• Of course, in Mainland Europe much less waste
• 20-25?

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The Cost of Poor Quality

• Recent Dutch Study
• Costs of Pressure Sores, Wound Infections and
  Medication Errors in Hospitals 0,5 Billion Euros
  per year
• is 1 of total health care costs in Holland
• And in UK, national target is to increase
  spending to European Average
• . What a waste???

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Vision bridging the quality chasm

• Delivering top quality care

Optimally patient-centered
Effective safe
Learning organisation
Efficient
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IT SEEMS, THEN, THAT WE REALLY NEED IT.
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A little history the link between IT and Quality

• 1950s Computer will rapidly improve doctors
  decision making!
• 1990 Dick and Steen report USHealth care in
  dire need of a central nervous system EPR by
  year 2000
• End of 90s disappointment set in, health ICT
  just wasnt delivering
• Internet bubble crashed projects and subsidies
  and research groups withered away

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Why the disappointment?

• We have to face the fact that the majority of ICT
  projects fails
• all over the board. Some countries (UK) more
  open than others (the Netherlands, France)
• Types of failure
• technical
• financial
• organisational
• clinical
• Is primarily due to human and organisational
  reasons!

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The search for synergy
Information System
Primary work processes - patient care activities
Secondary work processes - management - support
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For IT to become really powerful

• IT can monitor processes, allow cooperation
  between professionals over larger spans of time
  and space, allow interorganizational
  cooperation.
• We require Uniformity of Terminology
• We require Standardization of Work Processes
• We require interprofessional transparancy about
  processes and data
• We require usually more registration work
• More complete records
• More precise records

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Has IT so far significantly helped overcome the
quality chasm?

• Not really we tend to forget that
• IT implementation is organizational development
• there are no technological solutions for
  organizational problems
• Asking the question whether Electronic Medication
  Systems can prevent medication errors without
  integrally taking its practices of use into
  account is like evaluating the efficacy of a drug
  without taking note of how and when and with what
  other substances the drug is taken

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IT and Quality have become specialties the
problem is being approached in fragmented ways
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IT is a case in point

• US CPOE set as target without proper idea of
  how, why
• Doing CPOE without having basic IT infrastructure
  is like building a roof without first building
  the walls
• CPOE as separate project is meaningless
• Has to be integrated in a larger program of
  organizational change
• Formalizing Ordering Process
• Protocolizing sets of orders

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Let us Not Forget the Painful Lessons!

• IT is probably the simplest part of the complex
  sociotechnical changes we want to bring.
• Yet if we do not start with these complex
  changes, we might as well forget the IT!
• The only way is the hard way

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What is required?

• To address Quality Chasm, we need to
  fundamentally integrate Quality and IT
  development
• Fundamental redesign of existing care processes
  at the level of the primary process of care
• while integrating professional and
  organizational quality

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Integrated Care Pathways as Organizational Root
Model

• Our current step-by-step mode of delivering
  health care used to be the perfect way of
  delivering care
• But has become dysfunctional
• Inefficient loss of time, unnecessary steps
  taken
• Patient unfriendly search your way through the
  jungle
• Continuous battles at shop floor
• Increases chances of errors much falls between
  the cracks
• Examples
• Heart Failure Care
• High readmission rates
• Poor guideline compliance
• Stroke Care
• Long LOS, many wrong beds
• Poor guideline compliance

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Integrated Care Pathways as Organizational Root
Model

• Restructure current processes from the light of
  the clinical problem

Learning Organisation
Patient centered
Effectivity
Efficiency
Care Processes
Care pathways
Flexible Standardization
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Integrated Care Pathways as Organizational Root
Model

• Integrated care pathways can be developed for
  largest categories of patients
• 80 of activities can be standardized for 80
• No standard approach to every individual, but to
  category of patients
• Leaves individual trajectories fully flexible
• Embedded in working agreements (SOPs), forms,
  IT
• Realize
• Evidence based SOPs
• Reduced coordination work
• Patient centered organization of care
• The core ingredient of patient safety

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INTEGRATED CARE PATHWAYS SEVEN PRINCIPLES
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Embed the desired process in the organization for
a cluster of care pathways

• Combine organizational and medical quality -
  integrate guideline as organizational default
• Program the individual steps in planning
• i.e. triage system, SLAs CT, etc
• ? filemanagement system.

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2. Organize process so that each step adds value

• Optimize efficacy and patient-centeredness
• Minimize safety-risks
• Optimize efficiency

Diagn
Surg
Inpat.
Inpat.
Outp
Outp
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3. Organize process so that each professionals
expertise is maximally used

• Redelegation of tasks
• Team work optimizing cooperation
• Share responsibilities
• With the patient as a partner
• Shared (medical)record keeping

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4. Smart standardization

• The average patient does not exist as an
  individual
• But 80 of all patients do go through an 80
  similar trajectory!
• Only standardize when it addresses a problem
• Not just making a protocol or finegrained
  pathway!

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4. Smart standardization
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5. Enable care to be planned......and plan it
where necessary!

• Knowing which patient categories need what at
  which time proactive planning
• Slots / direct access
• Keep some free time slots for emergency calls
• Access to the agendas of other departments

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6. Performance management

• Create performance indicators for integrated care
  pathways
• (Clusters of) care pathways will become
  self-steering units
• The dream of the dashboard...
• ...and the struggles with present IT
  infrastructure.

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6. Performance management
Coloncarcinoma
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7. Improving upscaling

• Solve bottlenecks for the largest possible number
  of trajectories
• no suboptimization
• Prevent a project-jungle
• several patient groups
• entire location / hospital wide
• Take 80 of patients as starting point
• Look at crucial bottlenecks
• Upscale interventions as much as possible
• Make sure care programms are an outcome

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7. Improving upscaling
Nurse visit
Outp
Surg
Diagn
Diagn
Inpat.
POS
Nurse follow up
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Change process that takes time!
Organisation
ICT
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Process supporting ICT Future EHCR

• Integrated guidelines that guide without overly
  constraining
• Order-communication
• With Order-sets
• Workflow
• Based on steps and task delegation within care
  programs
• Smart EPRs
• Reminders, alerts, taken from the care programs
  underlying guidelines
• Triage supporting systems
• support triage through the care programs
  underlying guidelines
• Datawarehouse systems
• Crucial voor measurement infrastructure, and
  real-time coding
• Protocol-driven booking systems

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Process supporting IT

• This can only succeed when standardizing care
  programs.
• and this subsequently affords the integration
  of the individual steps in the care program
• Crucial, then, for EPR, DWH, order/entry
• Which fields standardized?
• Which decision rules built in?
• How to design DWH?
• All these questions are answered by through the
  care programs selected, and the monitoring data
  that those care programs require

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ExternalQuality and Cost Reports
InternalQuality and Cost Management Reports
Feedback

• Care program A

Outcomes