andrew georgiou, australian institute of health innovation - improving health information and data...

Centre for Health Systems and Safety

Research

Improving Health Information and

Data Management – the Evidence

of e-Health’s Impact

Associate Professor Andrew Georgiou

Senior Research Fellow

Outline • Background

o Existing evidence of the impact of

health Information Technology

• Aim and Method

o Key performance indicators of

laboratory performance

• Results

o The impact on efficiency,

effectiveness and patient

outcomes and safety?

o The challenge of safe test result

follow-up

• Conclusion

Evidence of the impact of health

information technology

• 257 studies (24% from 4 US centres, all

home grown systems)*

• Only 4% (n=9) studies examined the

impact of commercial systems

• 8** years later - increase in number and

scope of studies (13% per year <2007,

25% >2007)

• 56% report uniformly positive results,

21% mixed-positive effects

• Poor reporting of context and

implementation details

*Chaudhry et al (2006) Ann Intern Med ** Jones et al (2014) Ann Intern Med.

Evidence of the impact of health IT

• Most lab studies showed

decreases in ordering

including a 27% reduction in

redundant lab tests

• Most lab and imaging

studies showed improved

adherence to guidelines and

improved efficiency (up to

50% for labs)

• Few studies across multiple

sites

• Lack of outcome measures

The aged care informatics

challenge

• A fragmented service

• The delivery of “seamless” care

• Integration of services

• ICT “laggard”

• Lack of solid research evidence of

the contextual and holistic

functioning and requirements of

aged care

How aged care staff spend their

time? • A median of six forms completed each

day per staff member

• 69% of staff spend time transferring information from paper to computer (30 mins/shift)

• Median of 3.5 faxes and 3.5 phones calls to GPs/pharmacy per day

• 35.4% reported that they always had access to residents’ hospital information after discharge

Gaskin et al. BMC Geriatrics (2012)

Research question

What is the impact of the

Electronic Medical Record

on pathology services, their

work processes and

relationships with other

departments, and on key

performance indicators?

Key performance metrics

Georgiou et al. Int J Med Info 2006

Test orderTest

processing

Test result

application

Costs Work practices

Test volumesRedundant test

rates

Guideline compliance

Turnaroundtimes

Doctor-lab communication

Patient management

Length of stay

Patient safety

Average turnaround time in minutes

Before implementation

(95% CI)

After implementation

(95% CI)

t test results*

All test assays 73.8 (72.2-95.4)

58.3 (57.1-59.4)

t=15.6 (df 184257)

p=0.000

Prioritised tests 44.6 (42.4-46.8)

40.1 (38.7-41.6)

t=3.3 (df 37830)

p=0.001

Non-prioritised

tests 81.5 (79.6-83.5)

65.9 (64.4-67.4)

t=12.6 (df 148493)

p=0.000

Tests in business

hours 81.8 (80.1-83.5)

69.0 (67.4-70.6)

t=10.7 (df 141219)

p=0.000

Tests outside

business hours 54.0 (50.6-57.4)

39.2 (37.8-40.5)

t=7.9 (df 37524)

p=0.000

Tests in control

ward 68.7 (63.9-73.5)

64.7 (60.4-69.0)

t=1.2 (df 12993)

p=0.218

Westbrook et al. (2006) J Clin Pathol

TAT pre & post EMR in four

hospitals

2005

Before 2006

After 2007

After Kruskal-Wallis

Hospital A - Median TAT 77 68 66 P<0.001

% tests using EMR 75% 80%

Hospital B - Median TAT 145 129 108 P<0.001

% tests using EMR 0-44% 57%

Hospital C- Median TAT 138 135 113 P<0.001

% tests using EMR 29-38% 53%

Hospital D- Median TAT 141 139 128 P<0.001

% tests using EMR 56-71% 74%

Median TAT in minutes

Volume of tests and

specimens* Average number of test assays per

patient did not change

92.5 assays/patient versus 103.2

(P=0.23)

Average number of specimens per patient

did not change

10.8/patient versus 11.7 (P=0.32)

*Westbrook et al. (2006) J Clin Pathol

Cumulative percentages of repeat testing, as a proportion of all tests ordered, within one-hour to 35-

hours of the previous test, for tests orders using the paper-based (dashed line) and electronic ordering

system (solid line).

Quality of pathology

ordering

Specification of

gentamycin specimens

Before 16% of gentamicin and 13% of vancomycin samples specified as peak or trough.

After significant increase - 73% for gentamicin and 77% for

vancomycin.

Westbrook et al. J Clin Pathol 2006

The impact of electronic ordering

on information exchange

Wound specimens with a request

specifying source and body site

Before electronic ordering (2005) 578 (69.6%)

One year later (2006) 774 (92.9%)

Two years later (2007) 814 (95.3%)

Three years later (2008) 877 (95.6%)

Incident Information Management System

(IIMS) reported errors

EMR Paper

Mislabelled specimen 0.1

(n=39)

0.31

(n=56) p<.001

Mismatched specimen 0.49

(n=200)

1.42

(n=255) p<.001

Unlabelled specimen 1.37

(n=559)

1.65

(n=296) p<.01

Missed test results

• Critical safety issue – increases

the risk of missed or delayed

diagnoses World Alliance for Patient Safety, WHO, 2008; Schiff, 2006

• Clinicians are concerned that their

test management practices are

not systematic Poon et al. Arch Int Med 2004

• Medico-legal concerns Berlin, AJR, 2009

• Impact on patient outcomes Roy et al. Ann Intern Med, 2005

How many results are missed for

hospital patients?

• Hospital inpatients 20% - 62% of tests are missed

• ED patients (discharged) 1% - 75% of tests are missed

Callen et al. BMJ Qual Saf 2011;20;194-199

• Ambulatory patients 7% - 62% laboratory tests missed

1% - 36% imaging tests missed

Callen et al. Jnl Gen Int Med, 2012

Study methods

Survey design (17 questions)

1 metropolitan ED; senior ED doctors

Significantly abnormal results

– not life threatening but need short-term

follow-up (e.g., chest x-ray with new shadow,

abnormal PSA)

Automatic patient notification methods

– Patient portal, Email, SMS, fax, mail or

phone

What types of tests were missed?

(%)

Are there standard policies and

procedures for patient notification of

results?

Perceptions of missed test results

19.2

26.9

53.9

In the past year I have missed an abnormal result that led to delayed

patient care

Yes (%)

No (%)

Don't know (%)

38.5

11.5

50

In the past year a colleague has missed an abnormal results that led

to delayed patient care

Yes (%)

No (%)

Don't know (%)

• Mater Mothers’ Hospital (Brisbane)

• IP Health Verdi software which allowed

clinicians to electronically document

review and acknowledgement of test

results (2010)

• Hospital data (Aug ’11 – Aug ‘12) involving

27,354 inpatient tests for 6855 patients

• All test results were acknowledged

• 60% of laboratory and 44% of imaging

results acknowledged within 24h

An electronic safety net to enhance test

result management

Safety considerations with health IT

implementation • Solutions need to be multipronged

• Policies, procedures and

responsibilities

• Role of patients, doctors, nurses,

clerical staff and laboratories in

the follow-up process

• Evaluation of information and

communication technology (ICT)

solutions

• Integrate solutions with work

practices of health professionals

Acknowledgements

Australian Research Council (ARC) Linkage Grant (LP0347042) to

evaluate the impact of information and communication

technologies on organisational processes and outcomes: a multi-

disciplinary, multi-method approach (2003 – 2007)

ARC Linkage Grant (LP0989144) to investigate the use of information

and communication technologies to support effective work practice

innovation in the health sector (2008 – 2012)

ARC Discovery Grant (DP120100297) to evaluate an electronic test

management system in health care (2012 – 2014)

Department of Health Quality Use of Pathology Program grant (2008-

2009), (2011-2012)

Thank you

Email: a.georgiou@unsw.edu.au

Website: www.aihi.unsw.edu.au

Twitter: @AGeorgiouUNSW