International ITEHR Lessons Related to Patient Safety and Quality: Lessons from Denmark, New Zealand

1
International IT/EHR Lessons Related to Patient
Safety and Quality Lessons from Denmark, New
Zealand, England USA

• BCHIMPS
• Vancouver, November 19, 2004

2
Denmark A National Communication System
3
Danish humour
4
Whats most relevant about Denmark is

• MedCom

5
Pre-MedCom

• Late 80s
• A GP who also worked P/T in hospital biochemistry
  lab
• Chief pathologist at the hospital
• Head of IT in the county
• Proposed a project for Funen County IT strategy
• Electronically transmitting lab results

6
MedCom Today

• Over 95 of 2000 GP clinics/practices are
  computerized
• 86 use their computers to send and receive
  clinical information electronically
• 5 of non-users
• Those who will retire in next 3 years
• Those just starting without the capital (1-2 year
  delay)

7
MedCom Facts

• Used by ¾ of the healthcare sector,
• gt2,500 different organisations
• All hospitals, all pharmacies, all laboratories
  and 1,800 general practices take part
• Two million messages a month are exchanged (over
  60 of the total communication in the primary
  sector)

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Prescriptions
Prescriptions
1039105 73
1139992 73
Disch
. Letters
Disch
. Letters
682923 85
826258 84
Lab.
reports
Lab.
reports
543040 82
653974 97
9
MedCom Facts (contd)

• MedComs standardised messages implemented in 50
  IT systems, including
• 16 doctor systems
• 12 laboratory systems
• 9 hospital systems
• 4 pharmacy systems

10

From handwritten prescriptions to..
11
EDIFACT-prescriptions
UNA.? ' UNBUNOC3579000012031414579000017282
5140104301456261' UNH15MEDPRE0962RTS
ST012Æskulap' BGMPRSSKLSST9' DTM1372001043
0145604204' PNAPO291714YNRSFUUSMax
BerggrenUSMedCom' ADR1Rugårdsvej
155000' COM66133066TE' EMP4PHYSKLSST' PNA
SE57900001728259' DTM9720010430102' RFFCH
200118' ICDDKSKLSSTNASKLSST' GISZZZSKLSST
' PNAPAT2512484916CPRSCCBERGGREN, NANCY
ANN' ADR11PARK ALLE 48Hillerød3400020SKLS
ST' LIN1385229AKNVNLMS' IMDADDPcreme'
IMDADNMDiproderm' MEAAAUCTTube a 60
g' MEADENS0,05' PGI10NSSKLSST' QTY1891
NMB' PNAGZABOR' CIN9222LDDLMSmod
eksem' EQN2ITE DTM26430804' DSG5104LDDLM
Sudvortes 2 gange daglig' TOD2OADSKLSST'ADR
5USVestergade 173400' PNAABUSKnud
Mosebryggersen' UNT3015' UNZ126'
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Reasons for success

• County Support
• Training done by data consultant visit all
  practices regularly
• Practitioner coordinator for each specialty
  (psychiatry, general surgery, etc.)
• Works minimum of 2 hours/month
• Coordinates wishes of doctors to hospitals and
  vice-versa
• IT agenda moved forward through them
• Help desk
• Provides GP with a diskette of all their patients
  when first starting

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Reasons for success (contd)

• Standards set by MedCom
• Contract signed with Counties and PLO obliging
  everyone to use them
• Clinicians and suppliers involved!
• MedCom tests and certifies supplier systems
• Steering committee of paying agencies meets every
  3 months to review compliance data - GOVERNANCE

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New Zealand Another Small Country Success Story
15
Kiwi Humour
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(No Transcript)
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New Zealand Facts

• Over 95 of GP offices are using one of nine
  Practice Management Systems
• 75 use their systems to electronically send and
  receive clinical information such as laboratory
  results, radiology results, discharge letters,
  referrals, delivery of age-sex registers, etc.
• 50 of GPs now use the Internet on a regular
  basis from their offices - including
  communicating with their patients.

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New Zealand Facts (contd)

• Used by 75 of all healthcare sector
  organizations in New Zealand
• All hospitals, radiology clinics, private
  laboratories
• 1,800 general practices.
• gt 600 specialists, physiotherapists, other allied
  health workers
• Over 3 million messages a month are exchanged
• 95 of the communication in the primary health
  care sector.

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PUBLIC KEY INFRASTRUCTURE
GP Practice
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HealthLink increasingly used to assist with
Chronic Disease Management
21

• As a result of these CDM applications of
  information technology in primary care
• Child immunization rates went from 75 to 95.
• Control of diabetes improved for patients with
  HbA1c higher than 9 pre-enrolment was 34 and
  this was reduced to 7 post-enrolment
• There was an 80 reduction in wait time for
  statins for diabetes patients.
• Acute admissions were running at 9 per annum
  growth rate prior to HealthLink
• By 2002, the growth rate was reduced to near 0.

22
United States The Veterans Administration is
leading the way
23
American Humor
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CALLS FOR ACTION

• 1991
• Institute of Medicine (IOM) set forth a basic
  vision for use of information technologies in The
  Computer-based Patient Record An Essential
  Technology for Health Care.
• 1993
• General Accounting Office (GAO) urged the
  acceleration of message format and healthcare
  terminology standards development in Automated
  Medical Records Leadership Needed to Expedite
  Standards Development.

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The Formal Start to the EHR Journey

• A Computer-based Patient Record (CPR) is an
  electronic patient record that resides in a
  system specifically designed to support users
  through availability of complete and accurate
  data, practitioner reminders and alerts, clinical
  decision support systems, links to bodies of
  medical knowledge and other aids
• Institute of Medicine (IOM), 1991
• http//www.nap.edu/books/0309044952/html/R11.html

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CALLS FOR ACTION (contd)

• 2000
• the IOM in To Err Is Human Building a Safer
  Health System drew national attention to
  medication errors that often occur as a result of
  illegible and incomplete information.

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CALLS FOR ACTION (contd)

• 2001
• The dimensions of quality
• Safe
• Effective
• Patient-centered
• Timely
• Efficient
• Equitable

Richardson, William C. Crossing the Quality
Chasm, Institute of Medicine, 2001
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An American ExperienceVeterans Health
Administration Computerized Patient Record System
(VistA)

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The VA Computerized Patient Record System

• Integrated computer-based medical record
  developed by Department of Veterans Affairs
• Includes clinician order entry, note entry,
  results review, imaging, decision support, remote
  data
• Integrated with pharmacy, laboratory, dietetics,
  vital signs, nursing and bar code medication
  administration programs
• Includes user authentication with signature
  codes, business rules for user classes to ensure
  security and appropriate use

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VHA CPRS
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World wide use

• US Federal Government VHA, IHS
• State Veterans Homes (WA, others)
• DC Department of Health
• States (West Virginia, Rhode Island)
• Countries (Mexico, Jordan, others?)

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VistA in the News

• Washington Post - April 14, 2004
• In terms of information technology, the health
  care industry is now about where the auto
  industry was in 1980. Fortunately, all that is
  finally beginning to change, thanks to years of
  experimentation by the VA and major hospitals in
  Nashville, Boston and Salt Lake City, to name a
  few.

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VistA in the News

• The Physician Executive March-April 2004
• frustration and disenchantment were widespread
  . Several well-known technology suppliers were
  subjects of biting criticism by name.
  Satisfaction with systems (in some cases from the
  same suppliers) tended to be expressed in less
  than gushing terms.
• But there was one notable outlier from the
  nexus of negativity the Veterans Administration.
  It received unwavering praise.
• Summary of results from almost 1600 respondents
  to a survey of American College of Physician
  Executives members regarding their organizations
  progress in implementing clinical information
  systems
• Most indicated that problems and ordeals continue

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VistA System Kudos

• The Electronic Health Record in the Department
  of Veterans Affairs is the best in the United
  States, absolutely the best at large scale, and
  probably the best in the world.
• John Glaser
• Vice President CIOPartners (Harvard)
  HealthCare System
• October 2003

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• A number of integrated health care delivery
  systems use advanced information systems and
  integrated decision support to carry out quality
  assurance activities, but none as large as the
  Veterans Administration (VA).
• The VA's Quality Enhancement Research Initiative
  (QUERI) is a large-scale, multidisciplinary
  quality improvement initiative designed to ensure
  excellence in all areas where VA provides health
  care services, including inpatient, outpatient,
  and long-term care settings.
• The role of information systems critical to this
  quality improvement process.
• Hynes DM et al
• Informatics Resources to Support Health Care
  Quality Improvement in the Veterans Health
  Administration
• J Am Med Inform Assoc. 200411344-350

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(No Transcript)
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VHA Benchmark for Quality
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England Patient Safety is a National Priority
39
British Humour
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NPfIT

• A 6.2B (14,000,000,000) programme over 8 years
  to deliver 4 key elements
• Underpinning IT Infrastructure
• Electronic appointment booking
• Electronic Transmission of Prescriptions
• National Care Record

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(No Transcript)
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Suppliers
National Application Service Providers
National Infrastructure Service Provider
Local Service Providers
North East cluster Accenture
North West West Midland cluster The CSC Alliance
Eastern cluster Accenture
Southern cluster The Fujitsu Alliance
London cluster Capital Care Alliance, led by BT
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The International Context

• USA 44-98,000 deaths
• Australia 250,000 PSIs
• 50,000 permanent
  disability
• 10,000 deaths
• Denmark confirmed 9 of admissions
• N.Z. confirmed 10 of admissions

international research indicates
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The scale of the patient safety problem in the UK

• Up to 70,000 patients a year may die or be hurt
  as a result or part result of a Patient Safety
  Incident
• 2.2 of all hospital episodes contain a mention
  of an adverse event
• Nearly 4000 misadventures are recorded each year
• Patient Safety Incidents cost approximately
  2bn/year in additional hospital stay alone
• Aylin P et al
• How often are adverse events reported in English
  hospital statistics?
• BMJ 2004329369 (14 August)

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Primary care - GP adverse events frequency

• 50 - misdiagnosis
• 15 - medication
• - wrong drug
• - wrong dose
• - known allergy
• 7 - referral
• 5 - minor surgery
• Sources MDU Claims settled 1990-2000

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Sources MDU Claims settled 1990-2000
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The Context - volumes

• In the NHS in 2002/2003
• Number of first OP attendances with a consultant
  13,032,000
• 12,945,000 New AE attendances
• 5,320,000 Elective Hospital Admissions
• 1,735,000 Procedures in Out-patients
• 9,245,000 GP referrals made
• Chief Executives Report to the NHS December
  2003

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British press clippings of incidents
48
The political committment

• In July 2001, the National Patient Safety Agency
  (NPSA) was created as a Special Health Authority
  to co-ordinate the efforts and to learn from,
  patient safety incidents occurring in the NHS.
• In February 2004, it launched a new patient
  reporting system, drawing together reports of
  patient safety errors and systems failures
  provided by health professionals across England
  and Wales.

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National Reporting and Learning System
Trust 2 CRM
Trust 1 CRM
Wide Area Network
Trust 3 CRM
Internet
Trust Intranet
NPSA National Repository (AIMS2)
CRM
50
National Reporting and Learning System

• First healthcare reporting system on this scale
  anywhere in the world
• IT and/or web based system that records patient
  safety incidents
• Purpose of data collection is learning - to
  analyse data to identify patterns, trends and
  risks to patient safety, provide feedback
• Extensive work with suppliers on LRMS integration

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Anonymity and Confidentiality

• The NRLS will NOT store any identifiable data
  regarding staff or patients
• Organisation name will be captured unless the
  report is made via eForm directly to the NPSA.

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Patient Safety Managers

• 31 patient safety managers (PSMs), one for each
  28 Strategic Health Authority in England and 3
  NHS Regions in Wales
• Building frontline will, skill and capacity for
  patient safety improvements
• Marrying a large national initiative with local
  realities - no one size fits all

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Novel Thinking

• From WHO
• To HOW

• As well as making sure that incidents are
  reported in the first place, the NPSA is aiming
  to promote an open and fair culture in hospitals
  and across the health service, encouraging
  doctors and other staff to report incidents and
  "near misses", when things almost go wrong.

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Planned development for 2004 / 2005
NCR
LSP
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In conclusion

• We must stop blaming people and start looking at
  our systems. We must look at how we do things
  that cause errors and keep us from discovering
  them..before they cause further injury
• Lucian Leape
• Error in Medicine
• JAMA 1994 272 1851-1857

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The evidence that IT can enhance patient safety
is mounting

• Bostons Brigham and Womens Hospital,
  demonstrated that CPOE reduced error rates by 55
  -- from 10.7 to 4.9 per 1000 patient days.
• Rates of serious medication errors fell by 88 in
  a subsequent study by the same group.
• The prevention of errors was attributed to the
  CPOE systems structured orders and medication
  checks.
• LDS Hospital in Salt Lake City demonstrated a 70
  reduction in ADEs after implementation of a CPOE
  system.

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It is estimated that 13-15 of hospitals today
have some form of computerized medication order
entry implemented, but physicians in these
organizations enter less than 25 of the orders

• Heins JE et al
• Integrated Systems A Cornerstone of a Safe
  Medication Process, in
• The Impact of Information Technology on Patient
  Safety (ed Russell Lewis )
• HIMSS Press, 2002

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We must keep the faith

• In hospitals in 1904
• It was not easy for all the doctors
• to make the change. To some of
• them the new way seemed more
• cumbersome than the old, just
• a lot of unnecessary red tape.
• It seemed much simpler to jot down a few notes in
  a ledger lying open on the desk than to fill in
  all the blanks on a form sheet, much easier to
  pull out one's own volume and look up what old
  record was there than to call for an envelope and
  wait till it was brought from the file.

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• At first some doctors just forgot about the
  record blanks and used their ledgers when they
  were very busy, but in time they all saw the
  worth of the new system
• (i.e. the medical record as we
• know it today), and it became
• a routine followed without
• question and with tremendous
• benefit.
• Those introducing IT in health care settings
• in the 21st century
• can hope for as much success.

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Finite

• dprotti_at_uvic.ca