Patient Safety CME Curriculum Patient Safety: The Other Side of the Quality Equation

1
Patient Safety CME CurriculumPatient Safety
The Other Side of the Quality Equation

• Under a Grant from
• The Agency for Healthcare Research and Quality
• Principal Investigator
• Christel Mottur-Pilson, PhD
• Director, Scientific Policy
• ACP-ASIM

2
Patient Safety The Other Side of the Quality
EquationSeven Modules in Ambulatory Care

• Systems
• The influence of systems on the practice of
  medicine.
• Cognitive Capacity
• Coping mechanisms under information overload and
  time pressures
• Communication
• Communication barriers, lack, and unclear
  communication
• Medication Errors
• Uniform dosing, look- and sound-alikes, forcing
  functions

3
Patient Safety The Other Side of the Quality
EquationSeven Modules in Ambulatory Care

• The Role of Patients
• Patients as allies in patient safety
• The Role of Electronic Resources
• Supportive products and processes
• Idealized Office Design
• Medical practice design to support patient safety

4
Logistics

• CME To receive your CME, please fill out the
  usual forms
• Evaluation form
• CME form
• Research Grant Surveys
• Pre-CME assessment of knowledge level
• Post-CME assessment of knowledge level
• Six-month follow up to CME
• Virtual Patient Safety Electronic Community

5
The Role of Electronic Resources and Patient
SafetyHow information technology improves health
care delivery outcomes

• Under a Grant from
• The Agency for Healthcare Research and Quality
• Developed by Patricia L. Hale, Ph.D., M.D.
• Medical Informatics Subcommittee
• ACP-ASIM

6
Objectives

• By the end of this module the learner will
• be able to
• Describe how electronic resources can improve
  systems and thus influence medical care
• Identify the key electronic resources available
  for use in a practice
• Identify a key electronic resource that would be
  helpful to their practice and why

7
(No Transcript)
8
Challenges in Patient Safety are based on System
Problems

• Example Error Wrong medication given
• System problems include
• Cognitive capacity required information not
  accessed
• Communication errors in written or oral orders
• Medication error look-alike or sound alike
  medication given
• Patient not involved in care plan

9
Role of Electronic Resources

• Meet the Medical Information Challenge
• Expanding complexity of knowledge
• Increase reliability of system
• Supportive products
• Supportive processes

10
Information Technology to Improve Patient Safety

• Electronic medical records (EMR)
• Electronic orders and prescribing Computerized
  Physician Order Entry (CPOE)
• Electronic decision-support tools
• Handheld devices (PDAs)
• The electronic office
• Pros and Cons
• Choosing the most appropriate systems for your
  office an algorithm

11
What is an Electronic Medical Record (EMR)?

• Electronic version of the traditional patient
  chart
• Can be linked with other patient information and
  knowledge resources
• Can be simple or complex

12
How EMRs Improve Patient Safety

• Universal chart access
• Electronic interface with clinical information,
  insurers and other providers
• Better availability of data
• Quality Assurance
• Integration with other types of technology

13
How EMRs Improve Patient Safety

• Universal chart access
• Electronic interface with clinical information,
  insurers and other providers
• Better availability of data
• Quality Assurance
• Integration with other types of technology

14
EMR Access and Patient SafetyCase Example

• While on call a physician receives a call from
  a patient followed by one of their partners. The
  patient is taking warfarin and had a protime done
  earlier that day and was supposed to call to find
  out what dose to take but couldnt get through to
  the office.

15
What is Computerized Physician Order Entry (CPOE)?

• Ordering of tests, medications, and treatments
  for patient care using computers
• Involves electronic communication of the orders
• Uses rules-based methods for checking against
  drug references and other electronic information
  resources

16
Electronic Prescribing Improving the Medication
Prescribing Process

• Avoids
• Illegible Prescriptions
• Improper Terminology
• Ambiguous Orders
• Incomplete Information

17
Evidence that CPOE Systems increase safety

• Reduction in medication errors
• Bates et al. (1998) - 55 percent reduction in
  serious medication errors.
• Improvements in care
• Evans et al. - major improvements in rates of
  antibiotic-associated adverse drug events

18
Medication Orders AutomationCase Example

• Metformin is prescribed to a patient with an
  elevated creatinine level.
• A drug-lab interaction alert warns that use of
  this medication could result in an increased risk
  of fatal lactic acidosis.

19
Computerized Physician Order Entry (CPOE) Case
Examples

• A physician prescribes warfarin for a patient
  with chronic atrial fibrillation.
• System advises the physician to counsel the
  patient about vitamin K rich foods likely to
  interfere with the efficacy of the drug.
• The system prints out a patient information sheet
  that the clinician can review with the patient at
  the visit.
• The drug information database enters smart
  defaults into the appropriate data fields of the
  prescription, saving time and ensuring accuracy.

20
CPOE Advantages

• Reduces Order Errors
• Data regarding current practices
• Data collected on variances in practice
• Errors eliminated before order is completed

21
CPOE Disadvantages

• Errors still possible
• Alerts
• Multiple steps
• Access

22
Decision Support Systems Impact on Patient Safety

• Standardize clinical decision making
• Reduce the clinical decision error rate.
• Potential to provide patient-specific protocols

23
Electronic Decision Support Systems

• Information systems that provide the
  evidence-based medical knowledge at the time of
  care

24
Electronic Decision Support Systems

• Information systems that provide the best
  evidence-based medical knowledge at the time of
  care

25
(No Transcript)
26
(No Transcript)
27
Computerized Alert Systems can increase patient
safety

• Computer-generated messages and e-mail
• Real-time alert messages via alphanumeric pagers
  or cell phones
• Integrate laboratory, medication, and physiologic
  data alerts into a comprehensive real-time
  wireless alerting system

28
Evidence that Computerized Alerts Improve Patient
Safety

• Alerts resulted in
• Decrease in time to therapy
• Shorter time to resolution of abnormality
• Medication being adjusted or discontinued earlier

29
Electronic Decision Support Systems

• Other types of Decision Support Systems are
• Algorithms
• Guidelines
• Order sets/standing orders
• Trend monitors
• Co-sign enforcers

30
Potential Problems with Electronic Decision
Support Systems

• Does not eliminate all potential medication
  errors
• Human error still possible
• Lack of an interface with other information
  systems and screening capabilities limits its
  effectiveness

31
Barriers to the Use of Electronic Decision
Support Systems

• Administrative vs. clinical systems
• Current financial crisis in health care
• Interface and infrastructure issues
• Choosing the appropriate rules or guidelines
• Developing consensus among physician groups
• Regulatory and legal issues

32
Decision Support Case Examples

• A patient has been placed on long term
  antibiotics for a diabetic foot infection by an
  Infectious Disease consultant. Three weeks later
  the patient is seen by his or her primary care
  physicians for protracted diarrhea and Lomotil is
  ordered.

33
Handheld devices/Personal Digital
Assistants(PDAs) what they can do for the
physician

• Improve access to information at the point of
  care
• Medication databases (PDR, etc)
• Drug interaction checking
• Calculators and other tools
• Knowledge Resources
• Patient specific information

34
Handheld devices (PDAs) what they can do for the
physician

• Allow electronic entering of patient information
• Electronic prescriptions
• Patient orders
• Wireless communications with staff

35
(No Transcript)
36
Advantages and Disadvantages of an Electronic
Office

• Advantages
• Improved patient safety
• Increased efficiency
• Better communication
• Improved accuracy of information

• Disadvantages
• Cost
• Time
• Integration issues

37
Choosing information technology for your office
setting

• Where to start
• Practice size
• Integration with existing technology
• What types of electronic resources improve the
  process

38
Decision Algorithm
39
Decision Algorithm
40
Summary

• Medical errors are due to SYSTEM problems.
• Electronic Resources can be useful in decreasing
  medical errors but only if they are implemented
  and used correctly.

41
Further References

• Bates DW. Using information technology to reduce
  rates of medication errors in hospitals. BMJ.
  200032078891.
• Bates, David W., MD, MSc, Michael Cohen, MS, RPh,
  Lucian L. Leape, MD, J. Marc Overhage, MD, PhD,
  M. Michael Shabot, MD and Thomas Sheridan, ScD
  JAMIA White Paper Reducing the Frequency of
  Errors in Medicine Using Information Technology
• Bates DW, Leape LL, Cullen DJ, et al. Effect of
  computerized physician order entry and a team
  intervention on prevention of serious medication
  errors. JAMA. 1998280(15)13116.
• Evans, RS, Pestotnik, SL, Classen, DC, Clemmer,
  TP, Weaver, LK, Orme, JF Jr., Burke, JP, Computer
  assisted management program for antibiotics and
  other antiinfective agents. New Engl J Med..
  1998 Jan 22338(4)232.
• Glaser J, Teich JM, Kuperman G. Impact of
  information events on medical care. Proceedings
  of the 1996 HIMSS Annual Conference. Chicago,
  Ill. Healthcare Information and Management
  Systems Society, 199619.
• KupermanGJ, Teich JM, Tanasjlevic, MJ, MaLuf,
  N., Rittenberg, E., Jha, A., Fiskio, J.,
  Winkelman, J., Bates, DW. Improving response to
  critical laboratory results with automation
  results of a randomized controlled trial. J
  AmMedInform Assoc. 1999 Nov-Dec 6(6) 512-22.
• Miller R, Gardner RM. Summary recommendations for
  responsible monitoring and regulation of clinical
  software systems. Ann Intern Med. 19971278425.
• Rind, DM., Safran, C., Phillips, RS., Wang, Q.,
  Calkins, DR., Delbanco, TL., Bleich, HL, Slack,
  WV. Effect of computer-based alerts on the
  treatment and outcomes of hospitalized patients.
  Arch Intern Med. 1994 Jul 11154(13)1511-7.
• Overhage JM, Tierney WM, Zhou X, McDonald CJ. A
  randomized trial of "corollary orders" to prevent
  errors of omission. J Am Med Inform Assoc.
  1997436475.

42
Patient Safety Interactive Learning Community
(PSILC)

• Program Information Updates
• All Seven Modules
• Refresher Exercises
• Email Discussion Groups

• http//www.acponline.org/ptsafety

43
Refresher Exercises

• http//www.acponline.org/ptsafety