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Using IT to Improve Patient Safety and Quality, and for BiosurveillancePublic Health


Medical Director of Clinical and Quality Analysis, Partners Healthcare ... Journal of the American Medical Informatics Association. Compare Observed Data ... – PowerPoint PPT presentation

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Title: Using IT to Improve Patient Safety and Quality, and for BiosurveillancePublic Health

Using IT to Improve Patient Safety and Quality,
and for Biosurveillance/Public Health
CMSS, 2006
  • David W. Bates, MD, MSc
  • Medical Director of Clinical and Quality
    Analysis, Partners Healthcare
  • Chief, Division of General Medicine, Brigham and
    Womens Hospital

  • Safety and quality
  • Potential for adverse consequences
  • Illustrates what can happen without adequate
    attention to informatics
  • Evidence about benefit
  • Public health
  • Biosurveillance

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
  • 10.8 in UK
  • Similar results now from Canada, New Zealand,
    several other countries
  • Net rate in most countries appears to be about

Health Care QualityA Coin Flip?
  • 54.9 received recommended care overall
  • 53.5 received preventive care
  • 53.5 received acute care
  • 56.1 received recommended care for chronic

McGlynn E, et al. N Engl J Med 20033482635-2645
Prioritizing Safety
  • Safety is not a top priority. Safety is a
  • Paul ONeil, former CEO, Alcoa

Handwriting example
Pharmacy Computer System Field Test of Unsafe
  • Unsafe Order
  • Not Detected
  • Vincristine 3 mg IV x 1 dose 62
  • (2-year-old)
  • Cephradine oral suspension IV 61
  • Colchicine 10 mg IV for one dose 66
  • (adult)

Source ISMP Medication Safety Alert! Feb 10,
Systems Improvement and IT in Healthcare
  • Systems should
  • Make errors less likely
  • Catch those that do occur
  • Current systems communicate poorly
  • Health care spends little on IT
  • Implementation is challenging, turnover high
  • Writing a large check doesnt guarantee success

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

Bates and Gawande, NEJM 2003
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
Specific IT Applications
  • Computerized physician order entry
  • Smart pumps
  • Smart monitoring
  • Computerized notification about critical test
  • Computerized ADE monitoring
  • Tracking abnormal test results

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

Inpatient Prevention
  • 55 reduction in serious medication error rate
    with CPOE
  • Bates, JAMA, 1998
  • 83 reduction in overall medication error
  • Bates, JAMIA, 2000
  • Wont get this kind of benefit without local
    physician involvement, leadership
  • Need to have some site-level customization

How Should Things Work?
  • Many (most?) physicians involved in one way or
    another in defining decision support/knowledge
  • Key for all specialties
  • Tools available today allow multi-stakeholder
    collaboration to build consensus
  • E.g. around order sets, decision support
  • Have to do faster than in the past
  • Will NOT be static
  • Will dramatically change the way we work

Results Manager Home Page
Quality Harvard Vanguard Example
  • Baseline in 60s
  • Universal adoption of an EHRto 70s
  • Implementation of registry functionto 80s
  • Team approach involving use of electronic datain
  • But just for measures worked oneventually want
    to target hundreds of areas
  • NHS initiative focuses on 170!

Public Health Informatics
  • Current approach stovepipeis ineffective
  • Need to move to routine extraction from
    electronic records
  • All personnel need basic training in this area
  • Key themes
  • Need to link currently disconnected public health
    informatics activities with clinical world
  • Public health workforce needs training in
    informaticsCDC is beginning to address

Yasnoff et al, JAMIA 2003
Syndromic Surveillance
  • Syndromic surveillance refers to methods relying
    on detection of individual and population health
    indicators that are discernable before confirmed
    diagnoses are made
  • Syndrome examples
  • Respiratory syndrome
  • Gastrointestinal syndrome

Outbreak Detection Stages
  • Data acquisition
  • Syndromic grouping
  • Modeling
  • Detection
  • Alarm
  • Mandl K, Overhage J, Wagner M, et al.
    Implementing syndromic surveillance a practical
    guide informed by the early experience. Journal
    of the American Medical Informatics Association.

Compare Observed Data
Daily counts of ED visits for respiratory
syndromes from 1992 to 2002
To A Model Forecast
  • Model with autoregressive components, seasonal
    trends, other trends, covariates

Reis Mandl et al, BioMed Central 2003
  • Can identify outbreaks before you would otherwise
  • Avian flu
  • SARS
  • Smallpox
  • Involves using complicated statistics
  • Regularly extracting data from routine care
  • Better not to have to rely on reports

  • Healthcare today is inefficient, error-prone, of
    variable quality
  • Currently medical education includes little about
    this or about the potential of IT
  • IT is a toolachieving benefit requires using it
  • Many pitfallsas illustrated by Han, Koppel
  • All providers, specialties need to learn more/be
    more actively involved if value is to be achieved
  • Need for local customization
  • Must USE data
  • Implementation carries risk
  • Leaders in each organization, specialty key

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