andrew georgiou, australian institute of health innovation - improving health information and data...
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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
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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
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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.
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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
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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
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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)
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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?
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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
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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
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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
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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
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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).
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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
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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%)
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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
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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
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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
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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
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What types of tests were missed?
(%)
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Are there standard policies and
procedures for patient notification of
results?
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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 (%)
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• 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
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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
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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)