# Presentation: 534966

## Safety, Quality and Information Technology and NHII

- David W. Bates,
- Medical Director of Clinical and Quality Analysis, Partners Healthcare
- Chief, Division of General Internal Medicine,
- Brigham and Women’s Hospital

## Overview

- Background
- Safety and IT
- Quality and IT
- Conclusions

## Current State of Healthcare

- Care is complex
- Care is uncoordinated
- Information is often not available to those who need it when they need it
- As a result patients often do not get care they need or do get care they don’t need

*IOM, Crossing the Quality Chasm*

## Data on Safety and Quality

- 44,000-98,000 deaths/year in hospitals as a result of adverse events
- Over 1,000,000 injuries
- Enormous practice variation
- Estimated $450 billion unnecessary spending
- Slow translation of research to practice
- One estimate 17 years

## Crossing the Quality Chasm

- Care should be safe
- Care should be effective
- Based on sound knowledge
- Care should be patient-centered
- Respectful, responsive to individual preferences, needs and values
- Care should be timely
- Unnecessary waits should be reduced

## Crossing the Quality Chasm

- Care should be efficient
- Care should be equitable
- Should not vary in quality because of patient characteristics, such as ethnicity, or geographic location

## Safety and Quality

- Safety is a subset of quality
- Comes first
- Haven’t taken as seriously as we should have in healthcare
- Quality improvements will produce even greater societal benefit

## 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

## 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*

## Handwriting example

**Notes:**
What does this say?  Most people think it says coumadin, which is a blood-thinner, but it is actually a prescription for avandia, a diabetes drug.  This example is courtesy of Michael Cohen.  Handwriting isn’t the biggest problem we have with prescribing, but it is an important problem, and one that is totally preventable with computerization of ordering.

## Streamline, structure process
Doses from menus
Decreased transcription
Complete orders required
Give information at the time needed
Show relevant laboratories
Guidelines
Guided dose algorithms
Perform checks in background
Drug-allergy	Dose ceiling		Drug-lab
Drug-drug		Drug-patient 

- Doses from menus
- Decreased transcription
- Complete orders required
- Give information at the time needed
- Show relevant laboratories
- Guidelines
- Guided dose algorithms
- Perform checks in background
- Drug-allergy	Dose ceiling		Drug-lab
- Drug-drug		Drug-patient

- Improving the Quality of Drug Ordering with Order Entry

**Notes:**
Computerizing ordering improves medication safety in a variety of ways.  First, it streamlines and structures the process.  For example, if physicians pick a dose from a menu they are much less likely to order a 10-fold overdose, because that won’t appear as one of the options.  It decreases transcription because orders go straight to the pharmacy.  When I started doing research in this area, I was shocked to find out how many orders don’t include a dose, route, or sometimes even a drug name.  Computerizing ordering lets you require these fields.  You can also give the clinician information at the time that they need it, for example relevant laboratories, guidelines, or help them dose medications correctly when a calculation is required.  And finally, you can do a number of checks in the background, for example for allergies and drugs that shouldn’t be given together.

## Serious Medication Error Rates Before and After CPOE

- Bates  et. al. Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors, JAMA 1998.

**Notes:**
We studied the impact of computerized physician order entry in a controlled trial, and found a 55% reduction in the rate of serious medication errors, which are the errors that either hurt someone or have the potential to do so.  The reduction in the overall medication error rate was over 80%.  Finally, the 55% estimate is undoubtedly conservative, because the decision support associated with the version of CPOE we studied was very early and it has been improved a lot since then.

## Impact of “Smart” IV Pumps

- Few administration errors get caught
- Yet intravenous errors can be especially dangerous
*Case*
- Heparin bolus dose of 4000 units, followed by an infusion of 890 units/hr
- 4000 unit bolus dose was given appropriately
- But nurse misinterpreted the order and programmed the infusion device to deliver 4000 U/hour, not 890 U/hour
- Smart pump alerted nurse
- Early data—2 such errors/day in 400-bed hospital

***ISMP Newsletter Feb 6, 2002***

**Notes:**
Another medication safety technology that I think is likely to be very important is smart infusion pumps, which are pumps that know what drug is being given and can warn the nurse if too high a dose is about to be given.  Administration errors are dangerous because few get caught in today’s world, and intravenous orders are especially risky.  Here’s one actual case example—a large dose or bolus of heparin of 4000 units, followed by an infusion of 890 units per hour was ordered.  Heparin is a powerful blood-thinner.  But the nurse misinterpreted the order, and programmed  the device for 4000 units per hour.  This was over the maximum dose, and the device—made by a company named Alaris--alerted the nurse, who caught the error and made a change.  Early data suggest that there may be two such errors a day in a 400-bed hospital.  We are currently analyzing data from a study aimed at addressing the impact of these pumps.   

## Evidence on IT and Quality

- Computerization of reminders and prevention guidelines improves adherence
- Some data from other areas
- Reminders and guidelines especially important in care of chronic conditions
- IT can make routine quality measurement possible
- Need data on both process, outcomes
- Should be collected as byproduct of care

## Advantages of Computerized Guidelines

- Facilitate memory, always findable
- Immediately generalizable to all patients, providers
- Possible to point providers to them
- Facilitates central control
- Allows measurement of outcomes
- Whether people use
- Patient outcomes
- Easy to get feedback to developers, allows iterative refinement

## Future of Quality Improvement and IT

- Outside hospitals
- Longitudinal medical records will allow tracking of patients’ conditions
- Widely available to appropriate providers
- Interdisciplinary teams managing patients with chronic conditions will track panels, seamlessly exchange information
- Will include broad array of decision support

## Future of Quality Improvement and IT

- Inside the hospital
- Tracking from admission to discharge
- Array of decision support including guidelines
- Will be easy to assess:
- Where patient is physically
- Where they are in course
- Whether guidelines being followed
- Patients/providers will have a better sense of what to expect/higher satisfaction

## Conclusions

- Safety—large gains possible
- Over 80% reduction in serious medication error rates
- Better communication, monitoring
- Quality
- Toward closure of huge gaps between evidence and practice
- Readily available data for consumers
- More ITimproved safety, quality, efficiency
- NHII will be pivotal for getting there

**Notes:**
In conclusion, I think CPOE will have the biggest impact of any single intervention on medication safety.  But many other interventions will be important, including bar-coding, smart pumps, and non-technological interventions like having pharmacists round with teams in intensive care units.  It is important to note that some of these are easier to put in than others, and CPOE in particular requires a good underlying information system—if you don’t have that, it won’t work to put it in, and it might make sense to go to bar-coding or smart pumps first.
I think the government can play a major role in helping hospitals implement IT in general, and in improving medication safety in particular.  Specifically, promoting single standards as the Secretary and Commissioner McLellan have done for bar-coding is extremely important, and we need national endorsement of standards for other key types of clinical information as well.  Health care organizations need incentives to make the investments that will improve safety and quality.   Finally, the government has been the major funder of research on safety, and we need more, so that we learn what works and what doesn’t and how we should be prioritizing.
Overall, we believe at Partners and Brigham and Women’s that information technology represents a powerful tool for improving safety and quality, and also for reducing costs.  
Thank you.