Overview. Improving Safety with Health Information Technology. Prioritizing Safety. Question 22/10/2013

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1 Improving Safety with Health Information Technology ISQua 2013, Edinburgh David Bates, MD, MSc Chief Quality Officer, Chief, Division of General Internal Medicine, Brigham and Women s Hospital Medical Director of Clinical and Quality Analysis, Partners Healthcare Overview Background Safety Specific safety technology examples Results management (outside hospital) EarlySense Transforming care Conclusions Prioritizing Safety Safety is not a top priority. Safety is a precondition. Paul O Neil, former CEO, Alcoa Question What are the chances of getting injured by the care your patients receive during a hospitalization? 1 in in in in 100 Harm is Ubiquitous: 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 Near 10% in Canada, New Zealand, Denmark among others Rate in most developed countries appears to be at least 10% Recent study by Classen found adverse events in a third of admissions in U.S. using trigger tool 1

2 Adverse Events are Expensive: Costs of Safety Issues in the U.S. Event JJJType Annual Costs (Billions) Preventable ADEs $3.8 All hospital-acquired infections $5.8 Thromboembolic disease $3.1 Other adverse events $3.3 Total Preventable Adverse Events $16 Jha et al, Health Affairs 2009 ADE Rate By Site in Massachusetts Community Hospitals Total Site 1 Site 2 Site 3 Site 4 Site 5 Site 6 ADE Rate* % Prev *Per 100 admissions Range: for rate for percent preventable Meaningful Use is Being Defined and Will Follow an Ascension Path HITECH Policies HIT-Enabled Health Reform 2011 Meaningful Use Criteria (Capture/share data) 2013 Meaningful Use Criteria (Advanced care processes with decision support) *Report of sub-committee of Health IT Policy Committee 2015 Meaningful Use Criteria (Improved Outcomes) 9 The Potential HIT offers enormous promise for improving safety But many terrific organizations have struggled Some reports that safety has even gotten worse Technology is expensive and failure is hard to contemplate What are keys now/ future frontiers regarding safety with respect to EHR implementation/use? Implications of Electronic Health Record Adoption Will make it much easier to implement many interventions that rely on computerization to improve safety Possible to link many devices to underlying systems Even without linkages they can be beneficial But in future with links will be even more 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 Bates and Gawande, NEJM

3 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 Selected IT Applications Medications (CPOE, bar-coding, smart pumps) Coverage application Computerized notification about critical test results Tracking abnormal test results Patient monitoring Inpatient Prevention 55% reduction in serious medication error rate with CPOE Bates, JAMA, % reduction in overall medication error rate Bates, JAMIA, 2000 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 NEPHROS study Effect of real-time decision support for patients with renal insufficiency Of 17,828 patients, 42% had some degree of renal insufficiency Interv Control Dose 67% 54% Frequency 59% 35% LOS 0.5 days shorter Chertow et al, JAMA 2001 Safety Results of CPOE Decision Support Among Hospitals 62 hospitals voluntarily participated Simulation detection only 53% of orders which would have been fatal Detected only 10-82% of orders which would have caused serious ADEs Almost no relationship with vendor Metzger et al, Health Affairs

4 Hospital Scores by Vendor Dispensing Errors and Potential ADEs: Before and After Barcode Technology Implementation 1.00% 0.80% 0.60% 0.40% 0.20% 0.00% 0.88% 0.61% Dispensing Error Rate 31% reduction* 63% reduction* 0.19% 0.07% Potential ADE Rate Before Period ( doses observed) After Period ( doses observed) Projections for errors prevented per year at study hospital: >13,500 medication dispensing errors >6,000 potential ADEs Jane Metzger, Emily Welebob, David W. Bates, Stuart Lipsitz, and David C. Classen, Mixed Results In The Safety Performance Of Computerized Physician Order Entry, Health Affairs, Vol 29, Issue 4, Copyright 2010 by Project HOPE, all rights reserved. * p< (Chi-squared test) Impact of Barcode Scanning Technology on Administration Errors and Potential ADEs Medication Administration Errors Potential Adverse Drug Events No Barcode Scanning (n=6712) Barcode Scanning (n=7314) Relative Reduction (p-value) 11.5% 6.7% 41% (p<0.001) 3.1% 1.6% 50.8% (p<0.001) RCT to Improve Response to Critical Labs Mean time to rx 11% shorter For events not meeting lab s calling criteria (half of events), 21% shorter Nearly identical for events meeting criteria Mean time to resolution 29% shorter Mortality was 7% in intervention group, 13% control group (p=0.19) 95% physicians pleased to be paged Poon et al. NEJM 2010 Kuperman, JAMIA Coverage-Related Events Before data showed patients being crosscovered at 5-fold excess risk of adverse event After computerized sign-out introduction, no excess risk Included medications Simple from informatics perspective but major benefit Petersen, Jt Comm Jl Dilbert 4

5 Results Manager Home Page EarlySense: Continuous Patient Supervision on General Care Floors LCD monitor Nurse s phone Central Nurse s Station Bed side monitor Full floor overview at a glance Real time alerts to nurses & supervisors + reports on team performance Nurse / physician communication support Facilitation of critical thinking by nurse Early Trial Results Nurse response time to deterioration reduced by 50% Pressure ulcers reduced by 73% Transfers to ICU and telemetry reduced by 50% Nursing satisfaction 85% What Will It Take to Transform Care? Safety Key issue is making essential processes more reliable New approaches like CPOE, bar-coding, etc Checklists And central line infection rates (Pronovost) And rates of ventilator-associated pneumonia Surgical checklists in the operating room (Gawande) Will likely need dozens of checklists Also essential to measure performance in on-going way Conclusions (I) Information technology is becoming ubiquitous in healthcare near a tipping point in developed countries Large benefits even with more limited resources Much less the case in developing, transitional countries What you can do, prioritization will depend on available resources Choices in developing, transitional countries will be different but there is something for everyone Need a long-term plan Conclusions (II) EHRs and HIT more broadly can provide major benefits with respect to safety and quality Checklists Reliable processes medication safety highest yield CPOE Bar-coding Right decision support HIT is simply a tool part of a program Any technology can have unintended consequences Sociotechnical issues as important as technical But nearly every other effort to improve safety/quality/efficiency will rely in some way on HIT 5

6 Insanity is doing the same things the same way and expecting different results Albert Einstein 6