Improving Patient Safety: the IT contributionE.g. DOMURPIC (Picardie, France : regional project...

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Improving Patient Safety: Improving Patient Safety: the IT contribution the IT contribution

VeliVeli StroetmannStroetmann, MD PhD, MD PhD

JeanJean--Pierre Thierry, MD MPHPierre Thierry, MD MPH

eHealtheHealth Week BERLIN 2007Week BERLIN 2007

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www.ehealthwww.ehealth--forfor--safety.orgsafety.org

ICT

res

earc

h

n a n o s ys te m s

g e n o m ic s p ro te o m ic sd a ta m in in g

m o d e llin g

E m e rg in g te c h n o lo g ie s

c o g n itio n

s im u la tio nb io c h ip sm o le c u la r

im a g in g

b io b a n k s

ICT

ap

plic

atio

ns

IC T in c lin ic a ls e ttin g s

� C IS , E H R

� C P O E

� D S S ( s c o re s ,re m in d e rs ,a la rm s , c lin ic a lp a th w a ys )

� e M e d ic a tio n

� E M S IT , e IC U

� . . .

P e rs o n a l IC Tto o ls

� B io m e d ic a ls e n s o rs

� T e le m o n ito rin gd e v ic e s

� P e rs o n a l to o lsfo r d ia g n o s tic sa n d tre a tm e n t

� . . .

P u b lic H e a ltha p p lic a tio n s &s e c o n d a ry u s e

� E ve n t re p o rts

� A le rt s ys te m s

� C ris ism a n a g e m e n tto o ls

� b io s e rve ila n c e

� . . .

O th e r to o ls(n o t fo r

m e d ic a l u s eo n ly)

� B a rc o d e s

� R F ID

� S m a rt c a rd s

� S ys te m se n g in e e rin gto o ls

� . . .

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Needs for changeNeeds for change

IOM 2001

• Healthcare process reengineering• Management and leadership• Collaborative built• Continuum of care• Quality and Patient Safety Indicators• Risk Management• Safety Climate

• Health IT

Financial Financial

incentivesincentives

PayPay for for

PerformancePerformance

Organisation Organisation

ProneProne to to

cooperationcooperation

BetterBetter

communicationcommunication

AmongAmong healthcarehealthcare

professionalsprofessionals

Patient’s Patient’s

involvementinvolvement

In the care In the care processprocess

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ClinicalClinical Information Information SystemSystem

-- InformationInformation

-- KnowledgeKnowledge

-- PracticePractice

-- WorkWork

-- OrganizationOrganization

-- ManagementManagement

-- Event reportingEvent reporting

-- EpidemiologyEpidemiology

•EHR•PHR•CPOE•CDSS•Mobility•Simulation•Education•Telemedicine•TeleHealth

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TwoTwo LoopsLoops��ClinicalClinical SettingsSettings

Analysis

B. A. V.

………………………………

Flight Data Recorder

Adverse Event Reporting and Analysis

66

�� IT and the rise of “surveillance medicine” (with IT and the rise of “surveillance medicine” (with secondary use of data e.g. from the E.H.R)secondary use of data e.g. from the E.H.R)

-- Disease surveillanceDisease surveillance

-- Adverse events reporting, Patient Safety Indicators and Quality Adverse events reporting, Patient Safety Indicators and Quality MeasuresMeasures

-- BenchmarkingBenchmarking

ExternalExternal LoopLoopEventEvent reportingreporting, , medicalmedical errorserrors, ,

Public Public HealthHealth InformaticsInformatics

77

�� Definition of Public Health Informatics : Systematic Definition of Public Health Informatics : Systematic application of information and computer science and application of information and computer science and technology to pubic health practice, research and technology to pubic health practice, research and learning. learning.

((YasnoffYasnoff, 2001), 2001)

•• Promise is in engineering innovative new ways to protect Promise is in engineering innovative new ways to protect and promote the public’s health using the power of and promote the public’s health using the power of information science and technologyinformation science and technology

((KukafkaKukafka R. Department of Biomedical Informatics, R. Department of Biomedical Informatics, Mailman School of Public Health, USA)Mailman School of Public Health, USA)

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�� Disease surveillance : from notification to Disease surveillance : from notification to Syndromic SurveillanceSyndromic Surveillance

�� Syndromic surveillance :Syndromic surveillance : “Real“Real--time” public health time” public health surveillance using data that is routinely collected for other surveillance using data that is routinely collected for other purposespurposes

�� E.g. DOMURPIC (Picardie, France : regional project according to E.g. DOMURPIC (Picardie, France : regional project according to the the National plan for automation of the export of Emergency National plan for automation of the export of Emergency Diagnostics Summary by Emergency Information Systems of all Diagnostics Summary by Emergency Information Systems of all French Hospitals by 2012)French Hospitals by 2012)

�� E.g. Application of Syndromic Surveillance to preparedness for aE.g. Application of Syndromic Surveillance to preparedness for avian vian Flu outbreak management (H5N1)Flu outbreak management (H5N1)

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Atterrissages longsÉcarts d’altitudeDéviations opérationnelles

Learning curve

Latent conditions are analyzed andactions taken

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-- NYPORTS (NY) since 20 years, mandatory, nominative, tort

30000 Adverses events reported every year ( 45% with serious

consequences).

-- PHA (Georgia), anonymous, volontary, « non-tort ». 88% of hospitals

are participating : - 35% ADEs (Extranet)

-- PHRI (Pittsburgh + RAND Corporation + Purdue University)

With CDC, volontary, « non tort ».

-- National Reporting and Learning System NHS UK EU (upto 70 000 reports a month)

�Adverse events and medical errors reporting

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-- Quality Measures, Patient Safety Indicators, Quality Measures, Patient Safety Indicators, Certification, BenchmarkingCertification, Benchmarking

�� France : Composite IndicatorFrance : Composite Indicator

for for NosocomialNosocomial Infection Control Infection Control

(ICALIN, 2004)(ICALIN, 2004)

�� JCAHO Sentinel Events (USA)JCAHO Sentinel Events (USA)

�� Australia, New Zealand, UK, …Australia, New Zealand, UK, …

�� AND… The Press…AND… The Press…

�� The Word Wide WebThe Word Wide Web

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eHealth for eHealth for SafetySafety

Role of nonRole of non--ICT measures taken to prevent ICT measures taken to prevent medical errorsmedical errors

-- Leadership and strategic priorities issuesLeadership and strategic priorities issues

-- Safety cultureSafety culture

-- Teamwork and communication among Teamwork and communication among healthcare professionalshealthcare professionals

-- Safety proceduresSafety procedures

-- Medical educationMedical education

-- Education and trainingEducation and training

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ACCIDENT

EXÉCUTANTSActes non sûrs

ENCADREMENTDécisions inadéquates

DÉCIDEURSPolitiques inadéquates

RESSOURCESPrécurseurs structurels

DÉFENSEDU SYSTÈME

James Reason’s James Reason’s

modelmodel

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�� SafetySafety CultureCulture

La recherche en matière de Sécurité Patient aux États-Unis : les actions de l’AHRQ

� Surveys conducted at the

hospital of department level

� Comes from the « High

Reliability Organization »

� Cooperation enforcement

and better communication

� Strong heterogenity

� enables follow-up

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�� Communication Communication amongamong caregiverscaregivers

�� HUMAN FACTORS HUMAN FACTORS akaaka CRM (CRM (CrewCrew ResourceResourceManagement)Management)

La recherche en matière de Sécurité Patient aux États-Unis : les actions de l’AHRQ

Same Day Surgery (Carayon)

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Evanoff, 2004

Priorities of patient care differbetween members of the health care team, and verbal communicationbetween team members is inconsistant.

Preoperative Safety briefings introducea Safety Climate and help reduceturnover of Nurses (Kaiser Permanente, 2004)

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�� Patients Patients andand familyfamily involvmentinvolvment (USA)(USA)

www.howsyourbaby.com (817 surveys in 15 hospitals).

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�� Patients Patients andand familyfamily involvmentinvolvment (USA)(USA)

JCAHO brochureDid you wash you hands ?

« It’s OK to Ask » in order

to avoid ADE

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650 650 deathsdeaths for 2 Billions for 2 Billions PassengersPassengers (2006) (2006) = 0,0003%o= 0,0003%o

1960 1970 1980 1990 2000

Nombre d’accidents

Nombre de départs avion

� Arrivée des réacteurs

� Nouvelles populations PN

� Simulateurs de vol

� Travail en équipe

� Normalisation et standardisation des process techniques

� Analyse des vols

� Nouvelle génération avion

� Facteurs humains

� Retour d’expérience

� Instrumentation

� Généralisation des facteurs humains

2010

� Recherche

� Facteurs Influents

� Compétences

2020

Resistance to change and ChallengesResistance to change and Challenges

1. 1. The future of Medical Autonomy and the fear of the The future of Medical Autonomy and the fear of the loss of empowerment and responsibility of loss of empowerment and responsibility of professionalprofessional

•• AccountabilityAccountability

•• KnowledgeKnowledge

•• Turf battle, medical demographyTurf battle, medical demography

•• Cost issues Cost issues

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…“…“medicsmedics”” a hitherto unknown type of a hitherto unknown type of

healthcare professional, would provide the healthcare professional, would provide the

supportive and some of the technical tasks supportive and some of the technical tasks

currently performed by doctors. Because a currently performed by doctors. Because a

medicmedic--computer symbiosis would usurp all computer symbiosis would usurp all

the tasks presently assigned to physicians, the tasks presently assigned to physicians,

doctor would be rendered obsoletedoctor would be rendered obsolete…… this this

model is feasible, probable, and a desirable model is feasible, probable, and a desirable

alternative future.alternative future.

“The Post-Physician Era: Medicine in the twenty-first Century”

Maxmen, New York: John Wiley,1976. p. 176-218.

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DST/DSS type

EMR/HISIntegrated

DSS

ClinicalGuidelines

Stand Alone DSS

Score Calculator CPOE

Synch to patient

encounter(routine)

Yes / No. Yes / No No Yes Yes Yes

Users Physician Physician

PhysicianOther

profession ?

(i.e. Nurse, midwife)

PhysicianOther

profession(i.e. Nurse, midwife)

PhysicianOther

profession(i.e. Nurse, midwife)

Physician

Nurse, midwife)

Knowledgetasks

J.P THIERRY Smartie Project IST FP6

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2. 2. Centralization and control of informationCentralization and control of information

Bentham’s panopticoninspired the design of prisons, hospitals and factories. Medical data centralisation fits in the model.

Monitoring of cost and behavior/practice through a centralized collection of dataJustified by a scientific approach (epidemiology, surveillance, penalties,…)

Civil RightsCost EfficiencyQuality of Data

vs

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3. The Internet as a source of lay knowledge and the challenge to expertise:

- Consumerism and issues in access to proven and unproven source of knowledge

- Impact of loss of reimbursement in health consumption

-Effect of benchmarking and competition among providers (bias, patient selection, risk aversion)

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US approach : The Critical Path from Disclosure to Performance US approach : The Critical Path from Disclosure to Performance Breakthrough Breakthrough Randy Johnson Randy Johnson ArnieArnie Milstein MD, MPHMilstein MD, MPH

May 28, 2003May 28, 2003

Performance comparisons for hospitals, MDs

& Tx

� Market sensitivity to performance

Clinical re-engineering by MDs, hospitals

Q 50 ppts

$ 40 ppts

Value of Health Benefits

Key Evolutionary Steps

High

Low

2002 2012

Performance Disclosure

Consumerism& P4P

Chasm Crossing

Americans

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•• Adverse events reporting, Patient Safety Adverse events reporting, Patient Safety Indicators and Quality MeasuresIndicators and Quality Measures

•• Issues Issues

•• AccuracyAccuracy

•• UsefulnessUsefulness

•• EfficiencyEfficiency

•• CostsCosts

•• OpportunityOpportunity

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4. 4. AccountabilityAccountability

Professional empowerment is based on Knowledge and usually justify accountability at the personal level.

Accountability is a problem for the medical profession (art not science). Crisis of Professional Insurance (worldwide)

Automation could shift the responsibility from the individual “in charge” to the supervisor of the manager of the system.

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Limited or non-existent Impact of patient complaints and litigation

Source : J.P THIERRY, responsabilité N°11, Septembre 2003

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Limited or non-existent Impact of patient complaints and litigation

Source : J.P THIERRY, responsabilité N°11, Septembre 2003

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eHealth for eHealth for SafetySafety5. Quality and safety of IT :

IT can be a risky solution for fighting risk ?

« We waste billions of dollars eachyear on entirely preventablemistakes »

IEEE Spectrum; Why Software Fails, September 2005.

« In the final analysis, big software failures tend to resemble the worst conceivable airplane crash »

The need for a certification processFor medical software comparable to Pre-market approval of drugs of medicalEquipments.

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Conclusions: Conclusions: Issues for eHealth and IT Issues for eHealth and IT

•• Interoperability (role of the EHR )Interoperability (role of the EHR )

•• Taxonomy of medical errorsTaxonomy of medical errors

•• Definition of adequate patient safety indicators (composite)Definition of adequate patient safety indicators (composite)

•• Data mining, Probabilistic risk Assessment tools, Safety by Data mining, Probabilistic risk Assessment tools, Safety by DesignDesign

•• Interactions between clinical information systems and Public Interactions between clinical information systems and Public Health Information Systems (e.g. Clinical decision support, Health Information Systems (e.g. Clinical decision support, preparedness, crisis management, etc.)preparedness, crisis management, etc.)

•• SecuritySecurity

•• International (e.g. WHO initiative, DG SANCO portal, CDC)International (e.g. WHO initiative, DG SANCO portal, CDC)..

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1) IT is a key component towards a more safe environment for healthcare (but it’s only a component and management and cultural issues deserve the same attention)

2) ICT as part of the new paradigm induces a major change in a secular professional culture. Doctors may feel the risk of loss of professional empowerment. This issue should be addressed appropriately and evaluated regularly with appropriate and defined criteria.

3) The change will affect the traditional patient-doctor relationship. ICT will foster inter-professional communication and patient’s access to medical information.

Summary

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4) A proper decentralisation/centralisation balance affecting knowledge and data processing should take into account social reactions of the public as well as the professional confidence

5) Global distribution of IT advanced solution that will affect Professional and Patient Safety and Quality of Care should be considered at the regional, national and international level

6) Medical software should not be a risky solution and development, deployment and follow-up should benefit from a certification/accreditation process.

7) Research and Development efforts should contribute to addressthose issues.

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www.ehealthwww.ehealth--forfor--safety.orgsafety.org

Thank you Thank you

[email protected]@symbion.fr

[email protected]@empirica.com

Improving Patient Safety: the IT contributionE.g. DOMURPIC (Picardie, France : regional project...

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