Making Healthcare Safer:

ICT in Support of Patient Safety –

State of Play, Research Needs and Opportunities

Veli Stroetmann, empirica, BonnJean-Pierre Thierry, Symbion, France

Messe Berlin, 19 April 2007

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Contents

• Dimension of the problem

• European Commission activities

• eHealth for Safety study: an overview

• Role of ICT in improving patient safety: some application fields & state of play

• Examples, success factors

• Research needs

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Healthcare as a risky endeavour

AHRQ, Commission on Systemic Interoperability, 2005

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Dimension of the problem

• More than one million patients suffer injuries each year as a result of broken health care processes and system failures (IOM, 2000; Starfield, 2000)

• Little more than half of U.S. patients receive known “best practice” treatments for their illnesses and less than half of physician practices use recommended processes for care (Casalino et al., 2003; McGlynn et al., 2003)

• An estimated thirty to forty cents of every dollar spent on health care in US, or more than a half-trillion dollars per year, is spent on costs associated with “overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency” (Wennberg et al., 2002; Fisher et al., 2003)

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In Europe

• Department of Health in UK estimates that one in ten patients admitted to NHS hospitals will be unintentionally harmed(“A Safer Place for Patients: Learning to improve patient safety”, National Audit Office, 2005)

• Patient safety incidents cost the NHS in UK an estimated £2 billion a year in extra bed days;hospital acquired infections add a further £1 billion to these costs

• In the Netherlands, approx. 800,000 Dutch people over the age of 18 have been the victim of errors due to the inadequate transfer of medical information

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European Commission activities

• Many EU-funded projects: AMICA, PIPS, COCOON, CARE-PATHS, DICOEMS, etc.

• Workshop on Use of ICT in Risk Management for Health Professionals, Brussels, 2004

• eHealth for Safety: Study on the Impact of ICT on Patient Safety and Risk Management in Healthcare, Jan.-Dec., 2006

• Strategic seminar “eHealth for Safety: Benefits of ICT for patient safety”, eHealth 2006 High Level Conference, Malaga, 10 May 2006

• "eHealth and patient safety - identifying research challenges“, Expert workshop, WHIT, Geneva, 10 October 2006

• Improving Patient Safety: Which ICT Contribution? - ICT in support of a holistic strategy to improve the quality of care, Education session, WHIT, Geneva, 12 October 2006

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eHealth for Safety - Study overview

EU Study on the Impact of ICT on Patient Safety and Risk Management in Healthcare

• general information– start: January 2006, duration: 12 month

– consortium: SYMBION (France) – coordinator - & empirica(Germany)

• strategic goals

– Identification of key topics, opportunities and challenges for use of ICT in the domain

– State of play in the EU and globally

– Good practice examples

– Identification of priority policy needs

– Long-term vision and roadmap for further RTD

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ICT in support of patient safety and risk management in healthcare

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Defining the domain

The eHealth for Safety study has taken a broader view on well known as well as new and emerging ICTs which hold considerable potential to increase patient safety across the whole health value system including clinical research, disease prevention, medical interventions and risk prediction, training & education as well as public health.

The study is looking in a holistic view at newly emerging opportunities to preserve health and improve the quality of acute and longer-term healthcare, also taking into account biomedical and other research results, supported by ICT-based solutions.

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Role of ICT in improving patient safety: some application fields &

state of play

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Electronic Health Records (EHR)

•IOM: “m

oving from a paper to an electronic based

patient record system would be the single step

that would most improve patient safety”

•NAO,UK: “the National Care Record has significant

potential to improve safety as lost or poorly

completed records are a major contributory factor

to patient safety incidents.”

NAO (2005) “A Safer Place for Patients: Learning to improve patient safety”

•The large scale development of eHealth

infrastructure in many countries may lead to

broader implementation of CPOE, CDSS, etc.

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Decision Support Systems (DSS)

• Relatively well known, go back to the 70’s

• Hunt (1998) suggests useful application for drug dosing, preventive care but not convincingly for diagnosis

• Garg review (2002): about two thirds of DSS are effective

• Kawamoto et.al. (2005) review of 70 studies concludes that DSS significantly improved clinical practice in 68%.

• Ash et al (2004) identify instances where DSS can actually foster errors rather than reducing them

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Decision Support Systems (DSS) – cont.

The use of clinical DSS can• improve the overall safety and quality of

healthcare delivery, but

• may also introduce machine-related errors

• much debate about the potential for CDSS to harm patients, but

• there is little research to

– identify the nature of such errors, or

– quantify their frequency or clinical impactCoiera et. al. (2006)

General requirements: fast response time, negligible downtime, easy access, well designed interfaces

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Computerized Physician Order Entry Systems (CPOE)

• Defined as a process whereby the instructions of physicians regarding the treatment of patients under their care are entered electronically and communicated directly to responsible individuals or services (FCG 2003)

• Kaushal and Bates (2003) analysis in four hospitals found a 55% reduction in serious medication errors

• Potential dangers– errors in the knowledge base of systems

– Han, Yong et. al. (2005) reported increased child mortality coincided with CPOE implementation

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Choosing and implementing a CPOE system

– ... is hard and should be done carefully, as the expense is high

– CPOE system should be from the same vendor as core systems

– It should interface well with underlying systems, be fast, user friendly, and facilitate provision of clinical

decision support

– clinicians should be involved in selection process

– pilot in a clinical area with less workload

– provide 24/7 support to users for several weeks

– make use mandatoryafter David W. Bates, 2002

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CPOE evaluation framework at Geneva University Hospital

An evaluation framework is being developed, comprising

• human-machine aspects – ergonomic aspects

– safety points such as alerts

• process based problems - communication

The goal is to support the choice and implementation of CPOE in good conditions

In addition, the safety perception is being evaluatedChristian Lovis, 2006

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Hospital Information System use Advanced clinical support systems not yet widely available. Minority use of CPOE and medical document management.

ePrescribing still a pipe dream.

• # = total number of installations across Western Europe

• Total population considered for forecasts is 5032 hospitalsacross 15 European countries (acute hospitals larger than 100 beds)

Deloitte/HINE, 2004

2,13%

18,70%

87,34%

107

941

4395

4975

% #

2,13%

18,70%

87,34%

98,87%

107

941

4395

4975

% #

4

3

2

1

Levels

of

so

ph

isti

cati

on

Decision support,

ePrescribing

Clinical orders, results,

Advanced medical library

Common MPI / integration

around patient number

PAS

CPOE, DSS use in EU hospitals (2.13%)

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Pharmacy management system

Electronic transmission of

prescriptions

Computerised Physician Order

Entry (CPOE)

% of empl. % of hospitals

% of empl. % of hospitals

% of empl. % of hospitals

Hospitals (EU-10) 67 42 21 12 29 19

Small (1-49 empl.) 23 9 14

Medium (50-249 empl.)

39 9 15

Large (250+ empl.) 72 24 31

Source: e-Business W@tch (Survey 2006)

Computerised prescribing activities in EU hospitals (19%)

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CPOE, DSS use in US hospitals (1.9%)

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Role of ICT outside the medication area

• Improving communicatione.g., ePaging - the computerised communication

system can identify and page the professional on call (role based)

• treatment is more rapid, e.g., in case of critical lab results (Kuperman, 1999: may lead to lower mortality rate)

• requires physician-on-call schedules, known responsibilities, traceability, etc.

• Remote monitoring of intensive care units (eICU)

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Bar codes

Bar Codes can help to reduce administration and logistics errors

• real time updates allowing providers to alter medications and adjust delivery schedules

• simultaneous access to the system at multiple sites, elimination of phone calls and paperwork

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Bar coding use in hospitals –data from the USA

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RFID

Radio Frequency IDentification (RFID) used for: – security (e.g. access control)– tracking:

• medication administration, authentication and stocking (tracking of drug origin)

• hospital equipment, supply tracking, tagging bloodtransfusions and medical alert implants

• patient/professional tracking

research needed to solve problems with privacy and confidentiality of patient data

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Concept of Traceability at Geneva University Hospital

Traceability allows for following without interruption the course of persons, supplies (e.g. drugs from production line to patient), information, etc. and implies:

• bridging the gap between suppliers and consumers (hospitals, industry, …),

• using codes (classifications, nomenclatures, ontologies) in a structured EPR

• full data/systems integration

• full interoperability, including semantics

• complete integrity in information chains

• constant link maintained between virtual information and real things– unique patient ID

– link between the system and blood products

– ...

after Christian Lovis

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Some observations I

• Integrated systems, e.g. a combination of DSS, CPOE and alerting, are better accepted

• Systems should be:– designed with the busy or poorly resourced clinicians in mind

– fast and displaying all relevant information in a coherent and easy to use manner

otherwise they will be rejected by the professionals and can even lead to more errors, not less

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Some observations II

• A deeper understanding of the “complex set of cognitive and socio-technical interactions” is essential

• The organisational culture, including barriers to reporting errors, play a key role in the acceptance of electronic tools such as incident reporting systems - Coiera et al(2006)

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Some examples• from the eHealth IMPACT study:

Institut Curie; DISPEC

• ePharmacy

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Elios and Prométhée at Institut Curie

• Elios – a comprehensive Electronic Patient Record– Structured reports

– Free text

– Images

– Access by all doctors involved in a patient’s treatment

• Prométhée – a biomedical informatics search meta-engine– Answering questions across research databases, including

Elios, which are not pre-specified

– Instantaneous statistical analysis

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Benefits from Elios and Prométhée

The faster access to comprehensive, accurate, timely clinical data, offers:

• Better preparation of consultation

• Real-time clinical audit studies to measure outcomes and control quality

• Real-time organisational audit studies to streamline workflow

• Faster compliance with new clinical guidelines and organisational protocols

Net economic benefits estimated at over €3m per year

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Elios and Prométhée – factors of success

• Meeting concrete needs: effectiveness of providing information to clinicians

• Multidisciplinary teams, continuous involvement of clinicians in development, implementation, evaluation

• Clinical leadership: personal, not position power

• Pragmatic, step-by-step approach

• Vision, not a fixed long-term strategy

• Ongoing audit of the performance of new technologies

• Allow time for planning and development but

• Full scale implementation in short time and full use of ICT functionality

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DISPEC – Emergency service

• A sophisticated, electronic emergency ambulance

teletriage and dispatch system

• Introduced in 1996 by the City of Bucharest

Ambulance Service

• Nature and severity of incident identified by

trained personnel based on information received

from the caller

• Best matching ambulance equipment and team

identified by DISPEC (4 types of ambulances

equipped with GPS)

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Benefits from DISPEC

– The incidence of death per emergency decreased

by >25%

– Handling of increasing number of emergency calls

with shrinking financial and staff resources

– Dramatic drop in call to dispatch time

• decrease in average time by about 30%

– Dramatic drop in time till arrival at emergency site

• decrease in average time by approximately 35%

Net economic benefits estimated at €1.4m per year

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ePharmacy at a London hospital

• A combination of:– ePrescribing

– eDispensing using a robot system

– eStockmanagement

– eProcurement

• For outpatients and discharged patients (inpatients to be included in 2007)

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Benefits from ePharmacy

• Fewer prescribing errors and discrepancies Fewer dispensing errors

– down from 29.9 to 21.2 per 100,000 packs, a 29% gain

• Shorter response time for urgent prescriptions

– from 37% within one hour to 89%

• Most dispensary staff redeployed to wards

Annual net economic benefit – approximately €1.5m

• Data from another hospital in UK - fewer prescribing errors through ICT-supported medication handling pathways

– an error rate of 82% in the prescription of low molecular weightheparin was eliminated

– in paediatrics structured pathways led to reductions of specificerror rates from 26% to just 4% for paediatricians and from 76% to less than 7% for non-paediatric specialists

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A multi-level approach to patient safety

Level Component

Policy level (regional, national, European level)

• Patient safety policies

• Implementation measures

• Socio-economic and health policy framework conditions

• Legal and ethical issues

• Funding, clinical and economic evaluation

Organisational level • Organisational structure and culture

• Work processes

• Change management

• Training and learning

Technical & RTD level / applications • Personal ICT tools, e.g., biomedical sensors

• ICT in clinical settings, incl. EHR, DSS, CPOE

• Public health applications & secondary use, e.g., event reporting, alert systems

• Semantic aspects / ontologies

• Emerging technologies

• The case studies have shown that improving patient safety through ICT is not only a technical issue

• A holistic approach incl. organisational & political factors is needed

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Some issues to address

• IT as an enabler and a key component of a safer healthcare environment (but it is only a component, and management and cultural issues deserve the same attention), moreover, a comprehensive strategy is needed.

• ICT induces a major change in professional culture. Doctors may feel the risk of loss of professional empowerment. This issue should be addressed appropriately and evaluated regularly with defined criteria.

• Medical software should not be a risky solution: its development, deployment and diffusion should benefit from a certification/accreditation process.

• Interoperability issues should be addressed properly, e.g., patient and HCP identification, authentication, semantics.

• Research and Development must contribute to address these and other issues.

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Research needs

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Research needs I

• Evaluation of the impact of technologies like– bar coding

– computerized medication administration records

– automated dispensing devices

– smart pumps

• Evaluating the impact of linking all these technologies• Surgical adverse events

– almost half of all adverse events but little known about them

– strategies focusing on team training, simulation, and improving communication especially likely to be successful

• Missed diagnoses

• Medication safety in outpatientsafter David W. Bates

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Research needs II

• Towards a culture of safety in eHealth– health risk and patient safety aspects must be taken into account by all health ICT RTD

• Ontology of patient safety and risk management– a common framework for modeling threats to safety and for exchanging information on patient safety issues

• Socio-economic and behavioural aspects– how eHealth may change the behaviour of health professionals, citizens to improve system safety

– analysis of the impact of medico-cultural, legal/regulatoryand socio-economic factors

• Tools for collaborative, real-time team work

• Use of pharmacogenomics to avoid ADE

• Simulation in education/training, Virtual Reality