IT and Patient Safety

Annette L. Valenta, DrPH

Professor

Associate Dean, Health Informatics and Technology

Biomedical and Health Information Sciences

College of Applied Health Sciences

UIC

© 2008  Board of Trustees of U of IL

Learning Objectives
        - At the completion of this presentation, the audience will be able to:

Summarize the sentinel articles on clinical informatics and patient safety

Explain the conflicting findings in the context of sociotechnical fit

Formulate guidelines that reframe implementation of clinical informatics in support of patient safety with the goal of mitigating unintended consequences

© 2008  Board of Trustees of U of IL

Errors and ADEs:  IT tools can...
        - Improve communication
        - Make knowledge more readily accessible
        - Assist with calculations
        - Perform checks in real time
        - Assist with monitoring
        - Provide decision support
        - Require key pieces of information (dose, e.g.)

© 2008  Board of Trustees of U of IL

IT and nursing safety
        - Medication error – smart pumps
        - Knowledge error – EBN (Evidence Based Nursing)
        - Procedural error – POC computing 					(Point Of Care)

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        - “the science and technologies involved in healthcare -- the knowledge, skills, care interventions, devices and drugs – have advanced more rapidly than our ability to deliver them safely, effectively, and efficiently”

IOM.  2001. Crossing the Quality Chasm:  A New Health System for the 21st Century.

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Definitions
        - EMR (Electronic Medical Record) – the set of databases (lab, pharmacy, radiology, clinical notes, etc.) that contains the health information for patients within a given institution or organization
        - CDS (Clinical Decision Support) component - software that makes relevant information available for clinical decision-making (clinical data, references, clinical guidelines, situation-specific advice)
        - CPOE (Computerized Physician Order Entry) component – enables clinicians to enter orders (tests, meds, dietary, etc.)
        - CCR (Computerized Clinical Reminder) – just-in-time reminders at the point of care that reflect evidence-based medicine guidelines

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EMR

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Historical context - EMR

“Medicine ought to be using modern technologies in order to better share information, in order to reduce medical errors, in order to reduce cost to our health care system by billions of dollars... Within ten years, every American must have a personal electronic medical record.”

President George W. Bush

Remarks at American Association of Community Colleges Annual Convention - April 26, 2004

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and the response?

Miller RH, Sim I. Physicians’ use of EMRs:  Barriers and solutions.  Health Affairs 2004;23(2):116 – 126.

Chaudhry B, Want J, Wu S, et al.  Systematic review:  Impact of HIT on quality, efficiency, and costs of medical care.  Annals of Internal Medicine 2006;144:E12-E22.

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EMR in VHA – an early pioneer
        - CPRS (one component of VistA) was initially released in 1996; mandated nationally in 1999

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CDS
        - June 13, 2006 - AMIA publishes Roadmap for National Action on Clinical Decision Support	

Recommended a series of activities to ensure that optimal, usable, effective clinical decision support is widely available to providers, patients, individuals where and when they need it to make health care decisions

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Historical context - CDS

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and the response?

Kaushal R, Shojania KG, Bates DW.  Effects of CPOE and CDSS on medication safety:  A systematic review.  Arch Intern Med 2003;163:1409-1416.

Garg AX, Adhikari NK, McDonald H, et al. Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: A systematic review. JAMA 2005 Mar 9; 293(10):1223-38.

Hunt DL, Haynes RB, Hanna SE, Smith K.  Effects of computer-based clinical decision support systems on physician performance and patient outcomes:  A systematic review.  JAMA 1998;280(15):1339-1346.

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CCRs as CDS
        - In VHA, CCRs are an important function of the EMR
        - Reduces reliance on memory and presents clinical guidelines at point of care

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Studies at VHA
        - Effectiveness of CCRs related to

User interface/workflow problems

Increased workload

Time for documentation

Inapplicability of CCRs to practice

Limited staff training

More steps/longer to resolve = lower adherence

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CCRs at VHA
        - Barriers

Lack of coordination

Using reminders at an inopportune time

Limited flexibility

Poor interface usability
        - Facilitators

Limiting # of reminders at a site

Strategic location of workstation

Integrating reminders into workflow

Ability to document system problems and receive feedback

© 2008  Board of Trustees of U of IL

CPOE
        - In 2005, only 4% of hospitals are in full compliance with CPOE; 17% have made good progress.
        - Government and larger teaching hospitals are more likely to have implemented CPOE.

	Source:  Cutler EM, Feldman NE, Hurwitz JR.  US Adoption of Computerized Physician Order Entry Systems.  Health Affairs 2005 Nov/Dec;24(6):1654 – 1655.

© 2008  Board of Trustees of U of IL

Historical context - CPOE

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and the response?

Berger RG, Kichak JP.  CPOE:  Helpful or harmful?  JAMIA 2004;11:100-103.

Han UU, Carcillo JA, Venkataraman ST, et al.  Unexpected increased mortality after implementation of a commercially sold CPOE system.  Pediatrics 2005;116:1506-1512.

Del Beccaro MA, Jeffries HE, Eisenberg MA, et al.  CPOE implementation:  No association with increased mortality rates in an ICU.  Pediatrics 2006;118:290-295.

Koppel R, Metlay JP, Cohen A, et al.  Role of CPOE systems in facilitating medication errors.  JAMA 2005;293(10):1197-1203.

© 2008  Board of Trustees of U of IL

© 2008  Board of Trustees of U of IL

CDS recommendations
        - Kuperman GJ, et al. Medication-related clinical decision support in CPOE systems: A review. JAMIA 2007;14:29-40.

Implementation must be done thoughtfully, taking into account staff workflow and needs of the organization

Create clear concise alerts with sufficient information and clear appropriate action -- a human factors challenge

Don’t generate large number of unhelpful alerts.  Use a combination of commercial rule sets, rules other organization have developed, and rules about best practice.

Prioritize the CDS features to implement, as the list of features is long

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CDS
        - Kawamoto K, et al.  Improving clinical practice using CDSS:  A systems review of trials to identify features critical to success. BMJ 2005

	doi:10.1136/bmj.38398.500764.8F (published 14 March 2005)

Provide decision support automatically as part of workflow

Deliver decision support at the time and location of decision making

Provide actionable recommendations

Use a computer to generate the decision support (improves consistency and reliability)

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CDS
        - Bates DW, et al.  Ten commandments for effective clinical decision support:  Making the practice of evidence-based medicine a reality.  JAMIA 2003;10:523-530.

Speed is everything

Anticipate needs and delivery in real time

Fit into the user’s workflow

Improve usability to enable doing the right thing

Offer alternatives rather than insist on stopping an action

© 2008  Board of Trustees of U of IL

CDS
        - Bates DW, et al.  Ten commandments for effective clinical decision support:  Making the practice of evidence-based medicine a reality.  JAMIA 2003;10:523-530.

Changing direction is easier than stopping (defaults, e.g.)

Simple interventions work best (single screen of info)

The more data elements requested, the less likely the guideline will be implemented

Monitor impact, get feedback, and respond

Manage and maintain your knowledge-based system—keep it up to date

© 2008  Board of Trustees of U of IL

CDS
        - What are priority targets (types of errors, specific meds)
        - How can CDS reinforce current efforts to reduce ADEs
        - How can CDS target additional types of potential ADEs
        - Focus on areas of risk for patient harm
        - Be realistic in readiness for adoption
        - Have policies and consistent approach about guiding vs. directing care
        - Have MD leadership and involvement
        - Review each application periodically
        - Worry about nuisance alerting
        - Ensure timely updates

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CPOE
        - Bobb A, et al.  The epidemiology of prescribing errors:  The potential impact of CPOE.  Arch Intern Med 2004;164:785 – 792.

A CPOE with an advanced level of CDS is needed to prevent many of the prescribing errors with the greatest potential to lead to patient harm.

Basic = drug-allergy, drug-drug interaction & duplicate therapy checking, basic dosing guidance, formulary decision support

Advanced = dosing for renal insufficiency and geriatric patients, guidance for medication-related lab testing, drug-pregnancy and drug-disease contraindication checking

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CPOE
        - Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH.  Types of unintended consequences related to CPOE.  JAMIA 2006;13:547-556.
        - Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH.  The extent and importance of unintended consequences related to CPOE.  JAMIA 2007;14:415 - 423.

More/new work for clinicians

Reduce redundancy in info collection, display relevant info in logical locations, reduce keyboarding

72% said it was a moderate to very important issue

Unfavorable workflow issues

Model clinical workflow wherever possible

87% said it was a moderate to very important issue

Never ending system demands

Reassess quality assurance measures and user retraining 

82% said it was a moderate to very important issue

© 2008  Board of Trustees of U of IL

CPOE
        - Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH.  
        - Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH.

Problems related to paper persistence

Paper is here to stay for utilitarian purposes (note jotting)

Untoward changes in communication patterns and practices

As Del Baccaro wrote:  CPOE does not replace talking!

84% said it was a moderate to very important issue

Negative emotions

Training and communication help

80% said it was a moderate to very important issue

© 2008  Board of Trustees of U of IL

CPOE
        - Campbell EM, Sittig DF, Ash JS, Guappone KP, Dykstra RH.
        - Ash JS, Sittig DF, Poon EG, Guappone K, Campbell E, Dykstra RH.

Generation of new kinds of errors

Be thoughtful in interface design

9% not a problem; 47% said it was a moderate to very important issue

Unexpected changes in power structure

Recognize and deal with it explicitly during planning – may require re-negotiation of processes between groups

36% not a problem; 29% less important; 36% said it was a moderate to very important issue

Overdependence on the technology

Plan for management of unexpected downtime

82% indicate as dependency increases, downtime gets worse

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Ash JS, Sittig DF, Dykstra RH, Guappone K, Carpenter JD, Seshadri V.  Categorizing the unintended sociotechnical consequences of CPOE.

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CPOE
        - Motivation for implementation
        - CPOE vision, leadership, personnel
        - Costs
        - Workflow, health care processes
        - Value to users/DSS
        - Project mgmt/staging of implementation
        - Technology
        - Training and support 24x7
        - Learning/evaluation/improvement

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        - Technical systems have social consequences
        - Social systems have technical consequences
        - We don’t design technology, we design sociotechnical systems
        - To design sociotechnical systems, we must understand how people and technologies interact

© 2008  Board of Trustees of U of IL

© 2008  Board of Trustees of U of IL

Future research
        - To what extent does alerting impact clinical behavior and patient outcomes?
        - What is the optimal way to present alerts to prescribers?
        - How can clinicians’ sense of satisfaction with alerts and other DS be increased?
        - When does “alert fatigue” happen?
        - Which member of the health care team—MD, RN, PharmD, other—is the best recipient of an alert?

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References
        - For a copy of the reference list, contact me by email:  valenta@uic.edu

© 2008  Board of Trustees of U of IL

© 2008  Board of Trustees of U of IL