Slaying the HIT DragonSlaying the HIT Dragon

David Bates, MD, MScDavid Bates, MD, MScChief, Division of General Internal Medicine, Chief, Division of General Internal Medicine,

Brigham and Women’s HospitalBrigham and Women’s HospitalMedical Director of Clinical and Quality Medical Director of Clinical and Quality

Analysis, Partners HealthcareAnalysis, Partners HealthcarePast Board Chair, American Medical Past Board Chair, American Medical

Informatics AssociationInformatics Association

Nice, 2010

OverviewOverview

BackgroundBackgroundSpecific technologiesSpecific technologies– Computerized physician order entryComputerized physician order entry

The right medication-related decision supportThe right medication-related decision support

– Bar-codingBar-coding– Smart pumpsSmart pumps– Computerization of handoversComputerization of handovers– Results management (outside hospital)Results management (outside hospital)

Transforming careTransforming careConclusionsConclusions

The DragonThe Dragon

HIT offers enormous promise for HIT offers enormous promise for improving safety and qualityimproving safety and quality– But many organizations have struggledBut many organizations have struggled– Some reports that safety has even gotten Some reports that safety has even gotten

worseworse– Technology is expensive and failure is hard to Technology is expensive and failure is hard to

contemplatecontemplate

When to move? And who will win?When to move? And who will win?

Barriers for HospitalsBarriers for Hospitals

CapitalCapital

Uncertainty about vendor systemsUncertainty about vendor systems

Typically stuck with one vendorTypically stuck with one vendor

Computerized physician order entry Computerized physician order entry represents a major behavioral changerepresents a major behavioral change

Lack of standardsLack of standards

Little interoperability of clinical data with Little interoperability of clinical data with outside worldoutside world

No financial incentives to deliver safer careNo financial incentives to deliver safer care

Typical ScenarioTypical Scenario

CEO has many competing prioritiesCEO has many competing priorities

Hard to pick among specific HIT solutionsHard to pick among specific HIT solutions– Big ones take timeBig ones take time– Risk of failure higher with this than with a new MRI for Risk of failure higher with this than with a new MRI for

exampleexample– Many purchases are infrastructure—ROI trickyMany purchases are infrastructure—ROI tricky

Have been uncertainties about whether Have been uncertainties about whether upgrades will cause problemsupgrades will cause problems– Standardization vs. local tailoringStandardization vs. local tailoring

Hard to decide when to pull the triggerHard to decide when to pull the trigger

Message of TodayMessage of Today

Stars are now in alignmentStars are now in alignment

Federal financial incentives now in placeFederal financial incentives now in place

Additional incentives to organizations for Additional incentives to organizations for delivering safer caredelivering safer care

Vendor systems are improving rapidlyVendor systems are improving rapidly– Still not perfect but good enoughStill not perfect but good enough

Data exchange also coming fastData exchange also coming fast

Time to get off the sidelinesTime to get off the sidelines

Meaningful Use Matrix and Decision Meaningful Use Matrix and Decision Support: Hospitals 2011Support: Hospitals 2011

10% all orders through CPOE10% all orders through CPOE

Drug-drug, drug-allergy, drug-formulary checksDrug-drug, drug-allergy, drug-formulary checks

Up-to-date problem listUp-to-date problem list

Generate lists of patients by conditionGenerate lists of patients by condition

Implement one clinical decision rule related to a Implement one clinical decision rule related to a high-priority conditionhigh-priority condition

Inpatient PreventionInpatient Prevention

55% reduction in serious 55% reduction in serious medication error rate with CPOEmedication error rate with CPOE

Bates, JAMA, 1998Bates, JAMA, 1998

83% reduction in overall 83% reduction in overall medication error ratemedication error rate

Bates, JAMIA, 2000Bates, JAMIA, 2000

NEPHROS studyNEPHROS studyEffect of real-time decision support for Effect of real-time decision support for

patients with renal insufficiencypatients with renal insufficiencyOf 17,828 patients, 42% had some Of 17,828 patients, 42% had some degree of renal insufficiencydegree of renal insufficiency

Interv ControlInterv ControlDoseDose 67%67% 54%54%FrequencyFrequency 59%59% 35%35%

LOS 0.5 days shorter LOS 0.5 days shorter

Chertow et al, JAMA 2001

Medication Safety: Refining the RulesMedication Safety: Refining the Rules

In most systems most alerts get overriddenIn most systems most alerts get overriddenWe identified a highly selected set of drug alerts We identified a highly selected set of drug alerts for the outpatient settingfor the outpatient settingOver 6 months, 18,115 alertsOver 6 months, 18,115 alerts– 12,933 (71%) non-interruptive12,933 (71%) non-interruptive– 5,182 (29%) interruptive5,182 (29%) interruptive

Of interruptive, 67% were acceptedOf interruptive, 67% were accepted

Shah, JAMIA 2006

Dispensing Errors and Potential Dispensing Errors and Potential ADEs: ADEs: Before and After Barcode Technology Before and After Barcode Technology

ImplementationImplementation

0.19%

0.61%

0.88%

0.07%

0.00%

0.20%

0.40%

0.60%

0.80%

1.00%

Dispensing Error Rate Potential ADE Rate

Before Period (115164doses observed)After Period (253984doses observed)

Projections for errors Projections for errors

prevented per yearprevented per year at study hospitalat study hospital::>13,500 medication >13,500 medication dispensing errorsdispensing errors>6,000 potential >6,000 potential ADEsADEs

31% reduction*

63% reduction*

* p<0.0001 (Chi-squared test) Poon, Ann Intern Med, 2006

Safe IV Systems: Smart PumpsSafe IV Systems: Smart PumpsSmart pumps can warn nurse when Smart pumps can warn nurse when administering IV drugsadministering IV drugsFew administration errors get caughtFew administration errors get caught– Yet intravenous errors can be especially dangerous Yet intravenous errors can be especially dangerous

CaseCaseHeparin bolus dose of 4000 units, followed by Heparin bolus dose of 4000 units, followed by an infusion of 890 units/hran infusion of 890 units/hr– 4000 unit bolus dose was given appropriately4000 unit bolus dose was given appropriately– But nurse misinterpreted the order and programmed the But nurse misinterpreted the order and programmed the

infusion device to deliver 4000 U/hour, not 890 U/hourinfusion device to deliver 4000 U/hour, not 890 U/hour

Smart pump alerted nurseSmart pump alerted nurseISMP Newsletter Feb 6, 2002

Take-Away Messages of Take-Away Messages of Smart Pump Controlled TrialSmart Pump Controlled TrialSerious IV med errors were frequent and Serious IV med errors were frequent and could be detected using smart pumpscould be detected using smart pumps

However, no impact on the serious med However, no impact on the serious med error or preventable ADE rate was founderror or preventable ADE rate was found– Likely because of poor complianceLikely because of poor compliance

Behavioral and technologic factors must Behavioral and technologic factors must be addressed if smart pumps are to be addressed if smart pumps are to achieve their potentialachieve their potential

Rothschild et al, Crit Care Med 2005

Coverage-Related EventsCoverage-Related EventsBefore data showed patients being cross-Before data showed patients being cross-covered at 5-fold excess risk of adverse covered at 5-fold excess risk of adverse eventevent

After computerized sign-out introduction, After computerized sign-out introduction, no excess riskno excess risk– Included medicationsIncluded medications

Simple from informatics perspective but Simple from informatics perspective but major benefitmajor benefit

Petersen, Jt Comm Jl

Dilbert

Results Manager Home PageResults Manager Home Page

AHRQ/NQF/Leapfrog “Flight Simulator” AHRQ/NQF/Leapfrog “Flight Simulator” Assessment ToolAssessment Tool for CPOEfor CPOE

Hospitallogs on

(Password access)

Complete sample

test

Obtain patient criteria(Adult or pediatric)

Program patient criteria

Download and print 30 – 40

test orders (HM if AMB)

Enter orders into

CPOE application and record

results

Hospital self-reports

results on website

Score generated

against weighted scheme

Report generated

Aggregate score to Leapfrog

Order category scores viewed

by hospital

Review patient

descriptions

Review orders and categories

Review scoring

The Assessment Tool

Safety Results of CPOE Decision Safety Results of CPOE Decision Support Among Hospitals Support Among Hospitals

62 hospitals voluntarily participated62 hospitals voluntarily participated

Simulation detection only 53% of orders Simulation detection only 53% of orders which would have been fatalwhich would have been fatal

Detected only 10-82% of orders which Detected only 10-82% of orders which would have caused serious ADEswould have caused serious ADEs

Almost no relationship with vendorAlmost no relationship with vendor

Metzger et al, Health Affairs 2010

Copyright ©2010 by Project HOPE, all rights reserved.

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, 655-663

Have to Implement WellHave to Implement Well

Changes like CPOE and bar-coding are Changes like CPOE and bar-coding are transformationaltransformational

Can cause major problems if not handled Can cause major problems if not handled wellwell– Are now guides about what to do, what to Are now guides about what to do, what to

avoidavoid

Keys to success with CPOEKeys to success with CPOE– Strong clinical and administrative leadershipStrong clinical and administrative leadership

High-Performing Healthcare High-Performing Healthcare System InitiativesSystem Initiatives

6 network-wide initiatives6 network-wide initiativesOne focuses on ITOne focuses on IT– Inpatient CPOEInpatient CPOE– Outpatient EHROutpatient EHR

Another on safetyAnother on safety– Standardizing medication-related decision supportStandardizing medication-related decision support– Implementing proactive tools to look for ADEs, Implementing proactive tools to look for ADEs,

implementing standard web-based reportedimplementing standard web-based reported– Making more uniform decisions about administrationMaking more uniform decisions about administration– Standardizing information exchanged at transfersStandardizing information exchanged at transfers

What Will It Take to Transform What Will It Take to Transform Care? SafetyCare? Safety

Key issue is making essential processes Key issue is making essential processes more reliablemore reliable– New approaches like CPOE, bar-coding, etcNew approaches like CPOE, bar-coding, etc– ChecklistsChecklists

And central line infection rates (Pronovost)And central line infection rates (Pronovost)And rates of ventilator-associated pneumoniaAnd rates of ventilator-associated pneumoniaSurgical checklists in the operating room Surgical checklists in the operating room (Gawande)(Gawande)Will likely need dozens of checklistsWill likely need dozens of checklists

Also essential to measure performance in Also essential to measure performance in on-going wayon-going way

ConclusionsConclusionsInformation technology is becoming ubiquitous in Information technology is becoming ubiquitous in healthcare—near a tipping pointhealthcare—near a tipping point– All organizations should get on the bandwagon—time All organizations should get on the bandwagon—time

is nowis now– CAN slay the dragon—but need to play cards rightCAN slay the dragon—but need to play cards right– Tools like simulator can helpTools like simulator can help

EHRs and HIT more broadly can provide major EHRs and HIT more broadly can provide major benefits with respect to safetybenefits with respect to safety– ChecklistsChecklists– Reliable processesReliable processes– Right decision supportRight decision support– HIT is simply a tool—part of a programHIT is simply a tool—part of a program– But nearly every other effort to improve But nearly every other effort to improve

safety/quality/efficiency safety/quality/efficiency will rely on HITwill rely on HIT

Conclusions--LeadershipConclusions--LeadershipLeadership must be involved, supportiveLeadership must be involved, supportive– Clinical Clinical – AdministrativeAdministrative– HIT is NOT like plumbingHIT is NOT like plumbing

Will be more things than any organization can Will be more things than any organization can affordafford– Prioritization process keyPrioritization process key

What vendor you pick is not the only decisionWhat vendor you pick is not the only decision– Need effective processes for incremental Need effective processes for incremental

improvementimprovement– All organizations will need some in-house expertiseAll organizations will need some in-house expertise– Processes around decision support especially Processes around decision support especially

importantimportant

““Insanity is doing the Insanity is doing the same things the same same things the same

way and expecting way and expecting different results”different results”

Albert Einstein