using it to drive healthcare outcomes
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Emerging Technologies in eHealth:
Using IT To Drive Hospital Quality Outcomes
Dr Aloke Mullick, MS (Surgery)
Head, Clinical Transformation Solutions
OHUM, India
NEED FOR NEW
TECHNOLOGY
Are we using the ones that are available…..
HEALTHCARE QUALITY
How safe is healthcare delivery…..
Healthcare quality paradigms
• Lean inventory
• Wastage avoidance
Material Management
• Reduced wait times
• Improved revenue cycles
Process Efficiency
• Prevention outcomes
• Safety outcomes
• Inpatient clinical outcomes
Patient Outcomes
How safe is healthcare delivery
1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality
To
tal
liv
es
lo
st
pe
r y
ea
r
DANGEROUS
(>1/1000)
ULTRA-SAFE
(<1/100K)HealthCare
Mountain
Climbing
Bungee
Jumping
Driving
Chemical
Manufacturing
Chartered
Flights
Scheduled
Airlines
European
Railroads
Nuclear
Power
Source: Berwick, D.M.
1935 2009
The great advance……..
1935 2009
The paper trail………………..
WARNING, our physicians and nurses are attempting to use antiquated manual record-keeping systems and their own limited memories in an often futile attempt to deliver a complex set of services without error. The logic of these human beings has been tested incompletely at some point in the past, but we offer no warranty expressed or implied that any individual decision made or action taken will be provably correct. Moreover, we do not know the effect of aging, distractions, overwork, and failure to communicate on the overall care you will receive. Because we do not take a systems approach to health care services, by signing this consent you agree to participate in this admittedly error-prone and potentially life-threatening activity.
Courtesy: Charles Safran, MD
The quality chasm….
“98,000 hospital patients
die every year in the
US alone because of
adverse events” Institute of Medicine, 1999
• “Virtually every patient
experiences a gap between
the best evidence and the
care they receive” – Institute of Medicine, 2001
The call
Create systems of care that
are safe, timely, efficient,
effective, equitable, and
patient-centered.Institute of Medicine
The three supports of an effective
clinical IT system
Safe: CPOE reduces errors in drug prescribing
and dosing
Patient centered:
Enhanced information
access and communication
for patients
Effective:Automated reminder systems, CDSS systems to improve compliance with clinical guidelines
IT ENABLED QUALITY
HEALTHCARE
Key IT drivers of healthcare quality
Case for CPOE
CPOE can reduce
prescription
errors by up to 70%
Leap Frog Group
CPOE Systems by
reducing medication
errors,
can pay for themselves
in 26 months
Massachusetts Tech Collaborative
and New England
Healthcare Institute
Case for CDSS
20,000 biomedical journals
500,000 indexed in PubMed annually
>150,000 articles per month
6,000 articles a day
Medical References Services Quarterly
2007;26:1-19
Source: UC Berkeley, School of Information Management and Systems.
More Data Over
the Last 3 Years
Than Previous
40,000 years
Combined
Digital Cardiology
Electronic Medical Record
E-Health Initiatives/Linkages
Digital Radiology
Digital Pathology
Genomics
cave paintings40,000 BCE
3500writing
0 C.E.
paper 105
printing1450
electricity, telephone transistor
1947
1870
computing 1950 Late
1960s
The Web
1999
2009
1993
bone tools
Doctors struggling to cope
•At the end of 1st year
1,225 years behind
W Stead. JAMIA 2005;12:113-20 ,
Alper BS, Hand JA, Elliott SG, et al. J Med Libr Assoc 2004;92:429-37.
•Finish medical school and residency
knowing everything
Read and retain 2 articles
• every single night
Clinical Reminders
Clinical Clinical
requirementsrequirements
Diabetes Patient Dialog for
processing multiple reminders:
• Diabetic Foot Care Education
• Diabetic Foot Exam
• Diabetic Eye Exam
• Recommended Labs
• Other Health Activities
Acquisition of health data beyond
care delivered exclusively through
VHA
Standardized Data Elements
Order sets
Bar coded medication administration
• Right Medication
• Right Dose
• Right Route
• Right Patient
• Right Provider
• Right Time
EVIDENCE BASED MEDICINE
EBM guidelines and real time Decision Support at the point of care
- XML-format
- Indexed with MeSH (Snomed CT),
ICD-10 -, ATC- and Lab-codes
EBM at the POC
DS Engine: reports
Interaction of Glitazone
With Insulin, and
Contraindication in heart
failure
Real time clinical IT
Lab
Decision Support
Patient Safety Measures
EBM Guidelines
Inpatient Quality Measures
Other Inputs
Real-time Clinical Status
CIS/CPOE CDR
Clinical System
Alerts
Prompts/Reminders
Order Sets
Templated care plans
Patient alerts
Effectors
Pharmacy Imaging
Normalization, Transformation, Analytic Application
THE QUALITY PARADIGM
Prevention, Safety, Inpatient Outcomes
The Core performance measures
Prevention
Safety
Inpatient Rx Quality
• Ambulatory care conditions
• Immunizations
• Iatrogenic conditions
• Post-op complications
• Disease mortality
• Procedure mortality
Prevention indicators
o Bacterial pneumonia
– Dehydration
– Pediatric gastroenteritis
– Urinary tract infection
– Perforated appendix
– Low birth weight
– Angina without procedure
– Congestive heart failure
• Hypertension Cx
• Adult asthma Cx
• Pediatric asthma Cx
• COPD Cx
• Diabetes Cx - short term
• Diabetes Cx - long term
• Uncontrolled diabetes
• Lower extremity amputation
Safety indicators
– Complications of anesthesia
– Death in low mortality DRGs
– Decubitus ulcer
– Foreign body left during procedure
– Iatrogenic pneumothorax
– Infections due to medical care
– Postoperative hemorrhage or hematoma
– Postoperative hip fracture
– Postoperative physiological and metabolic derangement
– Postoperative PE or DVT
– Postoperative sepsis
– Obstetric trauma to mother and neonate
Inpatient Rx quality indicators
Mortality Indicators for Inpatient
Conditions
– Acute myocardial infarction
– Congestive heart failure
– Gastrointestinal hemorrhage
– Hip fracture
– Pneumonia
– Acute stroke
– Malaria
– Gastroenteritis
Mortality Indicators for
Inpatient Procedures
– Angioplasty
– CABG
– Craniotomy
– Esophageal resection
– Hip replacement
– Pancreatic resection
– Colonic resection
– Pediatric heart surgery
The quality grid
Effectiveness Safety TimelinessPatient
Centeredness
Preventive
Curative
Rehabilitation
Terminal Care
Source: Institute of Medicine, 2001.
Actual results after clinical IT
implementation
2.05%
1.83%
1.70%
1.75%
1.80%
1.85%
1.90%
1.95%
2.00%
2.05%
2.10%
Jul 2003-Sep 2005 Feb 2007-Feb 2008
Time Period
Perc
ent
Inpatient Mortality
4.72%
1.43%
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
4.50%
5.00%
Jan-Sep 2005 Feb 2007-Feb 2008
Time Period
Pe
rcen
t
Clean Surgery Infection Rate
Courtesy: Midland Memorial, Tx
The difference was technology
0 50 100
Chronic Care
CAD
Diabetes
Hyperlipidemia
Hypertension
Diagnosis
Screening
Treatment
Follow up
Non VAVA
No 1 in 33 out of 45 core performance
measures amongst ALL US hospitals
0
10
20
30
40
50
60
70
80
90
100
In patient Out patient
VA
Non VA
No 1 in patient satisfaction 3 years in a row
Rand study
Where do we stand…….
Adapted from HIMSS Analytics
15.6%Stage 0 All three ancillaries not installed 80%
Stage 1 AncillariesLab, Radiology, Pharmacy 11.5% 18.3%
Stage 2 CDR, CMV, CDSS inference engine, 31.4% 0.7%
Stage 3 Nursing Clinical documentation (flow sheets),
CDSS (error checking) PACS (Radiology)35.7% 0
Stage 4 Computerized Provider Order Entry 2.5% 0
Stage 5 Closed loop medication administration 2.5% 0
Stage 6Physician documentation (structured templates),
full CDSS (variance & compliance), Full PACS0.5% 0
Stage 7 Medical record fully electronic:
Data interoperability0.3% 0
USA India
POLICY INITIATIVES
What Governments can and should do………
United States
• 98000 Americans die of medical errors per year
• Only 1.5% private US hospitals use comprehensive EHRs
2001
• E-prescription act (MMA)
• Barcodes on most prescription drugs
• Goal for every hospital to have EHRs by 2014
2004 • Nearly 70 billion USD committed for e-health under ARRA, with meaningful use provisions in place
2009
United Kingdom
20 billion USD NPfIT
Largest civilian IT program in the world
National data ‘Spine’ in place
Choose and book live
Phased EHR deployment in progress
PACS live in all clusters
Expected to be fully live
by 2015
Mexico
Complete national medical record system based on the VA VistA
system
VistA indigenized to include local work-flows and Spanish language
capability
More than 50% public hospitals live on the
VistA EHR
Program completely run by Mexican resources
VistA based
The funding problem in health IT
50 170370
850
2350
0
500
1000
1500
2000
2500
20% 40% 60% 80% 95%
USD
USD
• Per capita healthcare spend in bottom 20% is 2% of top 5% nations
0.5
3
10
35
90
20%
40%
60%
80%
95%
0 50 100
USD
USD
• Per capita health IT spend in bottom 20% is so low, that the requirement to use the right solutions for maximum gain is even greater
What our policy makers should do…..
Support formation of corporate
pressure groups like ‘leap-frog’
Mandatepublishing of
core performance
measures
Mandate e-ordering of labs and imaging
Mandate e-prescribing
and e-medicine
administration
Mandate bar coding for all prescription
drugs
Mandate usage of
ICD-10PCS by all e-health
systems
PITFALLS
Its never that simple…..
Automation may go awry too….
To err is human.
To really screw
things up takes
a computer.
– Anon.
The poorly maintained decision support
Where do guidelines come from?
Are they consistent with evidence?
Are they current and valid?
Who updates them?
Are there regular audits?
Would anyone know, if there were a
malfunction?
CPOE as a source of error
In one tertiary, academic medical center,
using a mature, commercially available
system:– 22 different types of failures were facilitated by using
the system
– Errors occurred several times a week, if not daily
– All errors were traced to improper system setup, and
less than adequate training of user staff
Koppel, et al., 2005. JAMA, 293(10): 1197-1203.
Hardware and networks for high
demand systems
If not carefully secured,
your wireless network
may leave you
exposed...
Courtesy: Colorado Patient Safety
An idea for every one…
18 Big ideas To Fix Healthcare NOW
Idea No 13: Clinical Information Systems
One model which works is the VistA system, which has been keeping the
records of over 7 million vets since 1996. Why not just use VistA
nationwide?
Readers' Digest: Nov, 2008
THANK YOU
Questions in the end please…………..