Hospital Information Systems

Improving Delivery of Care The Shaukat Khanum Experience

Dr. Faisal Sultan Consultant Physician (Infectious Diseases) and Chief Executive Officer
Shaukat Khanum Memorial Cancer Hospital & Research Center

Outline
1. Gaps in delivery of health care 2. Expectations from computing 3. Extent of computerization in healthcare 4. Evidence for QI and our own experience 5. Characteristics of good EMR 6. Conclusions

Leading Causes of Mortality in the US

Heart disease Cancer Cerebrovascular disease COPD Medical Errors2 Pneumonia and Influenza Diabetes Suicide Kidney Disease Liver Disease 726,000 539,000 159,000 109,000 44-98,000 86,000 62,000 30,000 25,000 25,000

1 - CDC 1997 2 - To Err is Human: Building a safer health system. 1999. Institute of Medicine

 Diagnostic

Types of Errors

Error or delay Failure to employ indicated tests Use of outmoded test Failure to act on result
Error in the performance or administering Error in the dose or method Avoidable delay Inappropriate (not indicated) care

Treatment

Preventive
Failure to provide Inadequate monitoring or follow-up

Other
Failure of communication Equipment or system failure
Leape et al. Preventing Medical Injury. Qual Rev Bull. 19(5):144149, 1993.

Expectations and Needs

Great Expectations
1968
Medical records that guide and teach

1976
Protocol-based computer reminders and the quality of care

1991
An Essential Technology

2001
Speed, efficiencylimit errors and control costsguide future practices
Weed LL.. N Engl J Med. 1968;278:593-600 McDonald. N Engl J Med. 1976;292:1351-5 Dick RB, Steen EB. Institute of Medicine. National Acad Pr; 1991 McDonald CJ, Tierney WM. Computer-stored medical records. Their future role in medical practice. JAMA. 1988

Some More Expectations 2001

Computerized order entry (CPOE) esp. prescribing Bar-coding
Medications Blood Devices Patients

Communicate key information e.g. abnormal lab values

DW Bates. Reducing the Frequency of Errors in Medicine Using Information Technology. J Am Med Inform Assoc. 2001;8:299-308.

Expectations 2010
Providing access to information Recording and sharing Maintaining dynamic patient history Maintaining problem lists Tracking medications Tracking tests Ensuring coordination and continuity Enabling follow-up Providing feedback Providing prompts Providing placeholder for resumption of work Calculating Bayesian probabilities Providing access to information sources Offering second opinion or consultation Increasing efficiency
N Engl j Med 362;12 March 25, 2010

Goals for Hospital Information Systems

Improve quality
Guidelines and practice standards Standardized order entry and prescription Reminders and critical alerts Allergy tracking and medication history Images

Reduce costs
Automation Financial trends

Planning tools
Trend analysis and corrective actions Outcomes
DW Bates. Reducing the Frequency of Errors in Medicine Using Information Technology. J Am Med Inform Assoc. 2001;8:299-308.

Where are we?

Or The Healthcare Industry in terms of IT

Spending in IT
Banking and financial
15-20%

Manufacturing
7-10%

Healthcare and coalmining

2-3%

Hersh W. Department of Medical Informatics, Oregon Health Sciences University. 2003

Computerized Patient Records in US Hospitals - 2002

2 13 29 32 23
Dont know Fully operational Installation started Plan to implement No plans

Healthcare Information and Management Systems Society, 13th Annual Leadership Survey Results, 2002

Computerized Order Entry in US Hospitals- 2002

626 responders CPOE
Not available Available Partially available
Optional Encouraged Required

524 (83.7%) 60 (9.6%) 41 (6.5%)

31 (34.1%) 18 (19.8%) 42 (46.2%)

Requirement to use (91 responders)

J S Ash et al. Computerized Physician Order Entry in U.S. Hospitals: Results of a 2002 Survey. J Am Med Inform Assoc. 2004;11:95-99

Computerized Patient Records in US Hospitals 2009

N Engl J Med 2009;360:1628-38.

Adoption of EHRs by Practice Types - 2010

Does it work?

Where is the Evidence?

CPOE CDSS Alerts & Reminders

CPOE
Computerized Physician Order Entry

CPOE Mechanisms of Error Reduction

Structured
Dose Route Frequency

Legible Prescriber Identification Information available to prescriber during the process

Past medication history

Checked for
Allergies, interactions and contraindications Doses and relation to renal and hepatic function

DW Bates. Using information technology to reduce rates of medication errors in hospitals BMJ 2000;320:788-791

CPOE Reduces Medication Errors

Phase 1 (baseline) Phase 2 (CPOE) Non interception per 1000 patient days:Serious ME Potential ADE
Baseline 10.7 5.99 CPOE 4.86 0.98 Change -55% -84% p 0.01 0.002

David W. Bates et al. Effect of Computerized Physician Order Entry and a Team Intervention on Prevention of Serious Medication Errors. JAMA. 1998;280:1311-1316.

CPOE Reduces Medication Errors

Over four years (7-10 week periods) CPOE with decision support features
(e.g. allergy and drug-drug interaction warnings)

ME per 1000 patient days

Baseline
142

Final Period 26.6

Change
-81%

p
<0.0001

David W. Bates et al. The Impact of Computerized Physician Order Entry on Medication Error Prevention. J Am Med Inform Assoc. 1999;6:313-321.

CPOE and eMAR Reduces Medication Errors

Before Rx turn around Radiology proc Lab reporting 5:28 h 7:37 h 31:3 min After Change -64% -43% -25% p <0.001 <0.05 0.001

CPOE
1:51 h 4:21 h 23:4 min

CPOE + eMAR
Transcription errors LOS Hospital 1 LOS Hospital 2 Eliminated 3.91 d 3.71 d No change 0.002

Hagop S. Mekhjian et al. Immediate Benefits Realized Following Implementation of Physician Order Entry at an Academic Medical Center. J Am Med Inform Assoc. 2002 September; 9 (5): 529539

CPOE Reduces Medication Errors

Prospective; 13828 medication orders in 514 children Review of
Adverse Drug Events Medication Prescribing Errors [ADE] [MPE]

Per 100 orders:-

ADE

Before 2.2

After 1.3

Change -40.9%

MPE

30.1

0.2

-99.4%

Amy L. Potts et al. Computerized Physician Order Entry and Medication Errors in a Pediatric Critical Care Unit. Pediatrics Vol. 113 No. 1 January 2004, pp. 59-63

CPOE Effects on Prescribing Practice

Use of recommended H-2 blocker
From 15.6% to 81.3% (P<0.001)

Ondansetron dosing per recommendation

From 6% to 75% (P<0.001)

Heparin prophylaxis
From 24% to 47% (P<0.001)

Changes persisted at 1- and 2-year follow-up

Jonathan M. Teich et al. Effects of Computerized Physician Order Entry on Prescribing Practices. Arch Intern Med. 2000;160:2741-2747.

Bar Codes and eMAR

N Engl J Med 2010;362:1698-707.

CDSS
Clinical Decision Support Systems

CDSS Review of 7 Trials

Improvement in
Antibiotic associated ME and ADE (3 studies) Theophylline associated ME (1 study)

Non-significant results
3 studies

Rainu Kaushal et al. Effects of Computerized Physician Order Entry and Clinical Decision Support Systems on Medication Safety. A Systematic Review. Arch Intern Med. 2003;163:1409-1416.

Computer Assisted Antimicrobial Prescribing

Use of epidemiologic info and antimicrobial recommendations Prospective; ICU. 545 patients (one year) compared with 1136 (two years)

Before Rx for which pt allergic Excess dosage Susceptibility mismatch Excess dosing days ADE Abx costs Stay costs Length of stay 146 405 206 5.9 28 $340 $35283 12.9

After 35 87 12 2.7 4 $102 $26315 10

p <0.01 <0.01 <0.01 <0.002 <0.02 <0.001 <0.001 <0.001

R. Scott Evans et al. A Computer-Assisted Management Program for Antibiotics and Other Antiinfective Agents. NEJM. Volume 338:232-238. January 22, 1998.

CDSS in Renal Insufficiency

CPOE vs. CPOE+ CDSS Prescribing in renal insufficiency 17828 admissions; 7490 patients with renal insufficiency 97151 orders on renally cleared or nephrotoxic medications 15% orders had at least 1 dosing parameter modified

Appropriate Dose Appropriate Freq.

CPOE 54% 35%

CPOE+CDSS 67% 59%

p <0.001 <0.001

Mean LOS

4.5

4.3

0.009

Glenn M. Chertow et al.Guided Medication Dosing for Inpatients With Renal Insufficiency. JAMA. 2001;286:2839-2844.

Alerts and Reminders

Computerized Alert of Critical Lab Results

Prospective RCT Auto notification - 12 lab parameters Time to :Intervention Median Mean Resolution of condition Median Mean Controls 1.6 h 4.6 h 8.9 h 20.2 h Interventions 1.0 h 4.1 h 8.4 h 14.4 h p 0.003 0.003 0.11 0.11

Gilad J. Kuperman. Improving Response to Critical Laboratory Results with Automation Results of a Randomized Controlled Trial. Journal of the American Medical Informatics Association 6:512-522 (1999)

Computerized Alert for Hypokalemia

1000-bed hospital Auto alert for K < 3.0 Comparison Before and After periods
Change Non-repeat Failure to correct Discharge with low K -36.1% -28.6% -17.2% p 0.08 0.02 0.06

Ora Paltiel et al. Effect of a Computerized Alert on the Management of Hypokalemia in Hospitalized Patients. Arch Intern Med. 2003;163:200-204.

Impact of a Computer Generated Alert prompting a review of Antibiotics

Median therapy days reduced
From an initial duration of 8 (714) To 7 (611) days (P<0.0001)

26.5% antibiotic use reduction

Journal of Antimicrobial Chemotherapy (2009) 63, 1058 1063

Critical Alerts
Email and popup To relevant MD

Computerized Reminders for Preventive Care in Hospitalized Patients

Paul R. Dexter et al. Computerized Reminder System to Increase the Use of Preventive Care for Hospitalized Patients. NEJM. 345:965-970 September 27, 2001.

Computerized Reminders for Preventing DVT in Hospitalized Patients

41% risk reduction

Electronic Alerts to Prevent Venous Thromboembolism among Hospitalized Patients Nils Kucher et al. NEJM. 352:969-977. March 10, 2005

Some Negative Results

Clinicians' Response to Computerized Detection of Infections = no change CDSS for BP control in GP in UK = no change

Beatriz S.C. Rocha. Clinicians' Response to Computerized Detection of Infections. Journal of the American Medical Informatics Association 8:117-125 (2001) Alan A Montgomery et al. Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial. BMJ 2000;320:686-690.

OK, we are convinced. What do we do next?

Nicholas E. Davies Award

2003
Cincinnati Childrens Hospital

1999
The Queens Medical Center Kaiser-Perm Rocky Mount Reg

2002
Maimonides Medical Center Queens Health Network

1998
Northwestern Memorial Hospital Kaiser-Permanente Northwest

2001
The University of Ill. at Chicago Ohio State Univ Health System Heritage Behavioral Health

1997
Kaiser-Permanente of Ohio North Mississippi Health Services Regenstrief Inst for Health Care

2000
Harvard Vanguard Med Assoc VA Puget Sound Health Care

1996
Intermountain Health Care Columbia Presbyterian Med Ctr Department of Veterans Affairs

Best EMR Common Management Features

Healthcare viewed as information business at all levels Sustained leadership - often from physicians
Program length = 5 to > 30 years) CIO tenure ~ 4 yrs Project leader tenure > 8 yrs

Physicians in practice (credibility) End user involvement and feedback

Weekly meetings and focus groups

Developers/implementers involved in promoting, helping and teaching The Electronic Medical Record: Promises and Perils Daniel R.
Masysmedicine.ucsd.edu/faculty/masys/ASCO_EMR_overview.ppt

Best EMR Common Management Features

Subjected to show value not classical costbenefit or ROI analysis Early winners (4 of first 5) - academic institutions with home grown EMR Recent winners (total 9 of 13) - community institutions that improvised commercial products Change management and system evaluation plans All re-engineered some existing processes
The Electronic Medical Record: Promises and Perils Daniel R. Masys medicine.ucsd.edu/faculty/masys/ASCO_EMR_overview.ppt

Best EMR Common Functional Features

Practical, not purist approach Incremental implementation focused on specific care barriers Tangible clinical and business goals - rather than a goal unto themselves Resulted in decreased reliance on paper-based sources of information Decision support is the largest benefit
The Electronic Medical Record: Promises and Perils Daniel R. Masys medicine.ucsd.edu/faculty/masys/ASCO_EMR_overview.ppt

Best EMR Common Technology Features

Variety of hardware and software Content and value vs. presentation Standards-based data architecture Fast response time (goal = think speed 0.25 sec), reliability, ease of use Adaptability
The Electronic Medical Record: Promises and Perils Daniel R. Masys medicine.ucsd.edu/faculty/masys/ASCO_EMR_overview.ppt

Hype Cycle

Oracle Features and Products in use at SKMCH&RC

Oracle Database
Hybrid database (OLTP/DSS); 24x7 availability

Oracle Forms/Reports Oracle Internet Developer Suite in process Oracle Application Server in future Oracle Standby Database
Disaster Recovery Solution minimum data loss, if any Multiple Standby databases (Main site and DR site)

Oracle Fail Safe

Minimum downtime Failover time reduced from minutes to seconds No manual intervention

Oracle Replication
Part of the Contingency Plan for access to key data

Concerns
Privacy and security
Authentication Access need based and time barred Attribution and traceability Confidentiality Integrity un-alterable content

Backup and disaster recovery Systemic errors and magnification

(Health Insurance Portability & Accountability Act of 1996)

HIPAA

Individuals rights
Access to their own records Request amendment or correction Receive an audit trail of disclosures

Organizations obligations
Establish administrative, technical and physical safeguards, need to know access Give notification of information practices Develop audit trail mechanisms

HL7 Implementation Needs

Growing Interest in Electronic Health Record (EHR) for each patient Improve services
Bedside in hospitals Ambulatory services Patient-side systems

Integration with outside organizations using emerging HealthCare standards World-wide interoperability standard

HL7 Implementation Plan

Initiated with coordination of SEECS - NUST
Phase I
Establish HL7 Framework (Engine) Patient Admin Order Entry Laboratory Radiology Pharmacy OPD and Ambulatory Inpatient Care

Phase II

Benefits of Implementation of HL7

Improve care delivery, optimize workflow, reduce ambiguity and enhance knowledge transfer Supports development of additional paradigms for interoperability frameworks like Decision Support Systems Adaption of widely accepted standard avoid re-inventing the wheel. Allow for cross organization information exchange for common patients.

Conclusions
1. Expectations and needs faster, better, cheaper 2. Where are we? Behind others but catching up 3. Does it work?
Yes = CPOE, CDSS, Alerts

4. Concerns 5. Best of breed and how to get there

Thank you