Emerging Technologies in eHealth:

Using IT To Drive Hospital Quality Outcomes

Dr Aloke Mullick, MS (Surgery)

Head, Clinical Transformation Solutions

OHUM, India

NEED FOR NEW

TECHNOLOGY

Are we using the ones that are available…..

HEALTHCARE QUALITY

How safe is healthcare delivery…..

Healthcare quality paradigms

• Lean inventory

• Wastage avoidance

Material Management

• Reduced wait times

• Improved revenue cycles

Process Efficiency

• Prevention outcomes

• Safety outcomes

• Inpatient clinical outcomes

Patient Outcomes

How safe is healthcare delivery

1

10

100

1,000

10,000

100,000

1 10 100 1,000 10,000 100,000 1,000,000 10,000,000

Number of encounters for each fatality

To

tal

liv

es

lo

st

pe

r y

ea

r

DANGEROUS

(>1/1000)

ULTRA-SAFE

(<1/100K)HealthCare

Mountain

Climbing

Bungee

Jumping

Driving

Chemical

Manufacturing

Chartered

Flights

Scheduled

Airlines

European

Railroads

Nuclear

Power

Source: Berwick, D.M.

1935 2009

The great advance……..

1935 2009

The paper trail………………..

WARNING, our physicians and nurses are attempting to use antiquated manual record-keeping systems and their own limited memories in an often futile attempt to deliver a complex set of services without error. The logic of these human beings has been tested incompletely at some point in the past, but we offer no warranty expressed or implied that any individual decision made or action taken will be provably correct. Moreover, we do not know the effect of aging, distractions, overwork, and failure to communicate on the overall care you will receive. Because we do not take a systems approach to health care services, by signing this consent you agree to participate in this admittedly error-prone and potentially life-threatening activity.

Courtesy: Charles Safran, MD

The quality chasm….

“98,000 hospital patients

die every year in the

US alone because of

adverse events” Institute of Medicine, 1999

• “Virtually every patient

experiences a gap between

the best evidence and the

care they receive” – Institute of Medicine, 2001

The call

Create systems of care that

are safe, timely, efficient,

effective, equitable, and

patient-centered.Institute of Medicine

The three supports of an effective

clinical IT system

Safe: CPOE reduces errors in drug prescribing

and dosing

Patient centered:

Enhanced information

access and communication

for patients

Effective:Automated reminder systems, CDSS systems to improve compliance with clinical guidelines

IT ENABLED QUALITY

HEALTHCARE

Key IT drivers of healthcare quality

Case for CPOE

CPOE can reduce

prescription

errors by up to 70%

Leap Frog Group

CPOE Systems by

reducing medication

errors,

can pay for themselves

in 26 months

Massachusetts Tech Collaborative

and New England

Healthcare Institute

Case for CDSS

20,000 biomedical journals

500,000 indexed in PubMed annually

>150,000 articles per month

6,000 articles a day

Medical References Services Quarterly

2007;26:1-19

Source: UC Berkeley, School of Information Management and Systems.

More Data Over

the Last 3 Years

Than Previous

40,000 years

Combined

Digital Cardiology

Electronic Medical Record

E-Health Initiatives/Linkages

Digital Radiology

Digital Pathology

Genomics

cave paintings40,000 BCE

3500writing

0 C.E.

paper 105

printing1450

electricity, telephone transistor

1947

1870

computing 1950 Late

1960s

The Web

1999

2009

1993

bone tools

Doctors struggling to cope

•At the end of 1st year

1,225 years behind

W Stead. JAMIA 2005;12:113-20 ,

Alper BS, Hand JA, Elliott SG, et al. J Med Libr Assoc 2004;92:429-37.

•Finish medical school and residency

knowing everything

Read and retain 2 articles

• every single night

Clinical Reminders

Clinical Clinical

requirementsrequirements

Diabetes Patient Dialog for

processing multiple reminders:

• Diabetic Foot Care Education

• Diabetic Foot Exam

• Diabetic Eye Exam

• Recommended Labs

• Other Health Activities

Acquisition of health data beyond

care delivered exclusively through

VHA

Standardized Data Elements

Order sets

Bar coded medication administration

• Right Medication

• Right Dose

• Right Route

• Right Patient

• Right Provider

• Right Time

EVIDENCE BASED MEDICINE

EBM guidelines and real time Decision Support at the point of care

- XML-format

- Indexed with MeSH (Snomed CT),

ICD-10 -, ATC- and Lab-codes

EBM at the POC

DS Engine: reports

Interaction of Glitazone

With Insulin, and

Contraindication in heart

failure

Real time clinical IT

Lab

Decision Support

Patient Safety Measures

EBM Guidelines

Inpatient Quality Measures

Other Inputs

Real-time Clinical Status

CIS/CPOE CDR

Clinical System

Alerts

Prompts/Reminders

Order Sets

Templated care plans

Patient alerts

Effectors

Pharmacy Imaging

Normalization, Transformation, Analytic Application

THE QUALITY PARADIGM

Prevention, Safety, Inpatient Outcomes

The Core performance measures

Prevention

Safety

Inpatient Rx Quality

• Ambulatory care conditions

• Immunizations

• Iatrogenic conditions

• Post-op complications

• Disease mortality

• Procedure mortality

Prevention indicators

o Bacterial pneumonia

– Dehydration

– Pediatric gastroenteritis

– Urinary tract infection

– Perforated appendix

– Low birth weight

– Angina without procedure

– Congestive heart failure

• Hypertension Cx

• Adult asthma Cx

• Pediatric asthma Cx

• COPD Cx

• Diabetes Cx - short term

• Diabetes Cx - long term

• Uncontrolled diabetes

• Lower extremity amputation

Safety indicators

– Complications of anesthesia

– Death in low mortality DRGs

– Decubitus ulcer

– Foreign body left during procedure

– Iatrogenic pneumothorax

– Infections due to medical care

– Postoperative hemorrhage or hematoma

– Postoperative hip fracture

– Postoperative physiological and metabolic derangement

– Postoperative PE or DVT

– Postoperative sepsis

– Obstetric trauma to mother and neonate

Inpatient Rx quality indicators

Mortality Indicators for Inpatient

Conditions

– Acute myocardial infarction

– Congestive heart failure

– Gastrointestinal hemorrhage

– Hip fracture

– Pneumonia

– Acute stroke

– Malaria

– Gastroenteritis

Mortality Indicators for

Inpatient Procedures

– Angioplasty

– CABG

– Craniotomy

– Esophageal resection

– Hip replacement

– Pancreatic resection

– Colonic resection

– Pediatric heart surgery

The quality grid

Effectiveness Safety TimelinessPatient

Centeredness

Preventive

Curative

Rehabilitation

Terminal Care

Source: Institute of Medicine, 2001.

Actual results after clinical IT

implementation

2.05%

1.83%

1.70%

1.75%

1.80%

1.85%

1.90%

1.95%

2.00%

2.05%

2.10%

Jul 2003-Sep 2005 Feb 2007-Feb 2008

Time Period

Perc

ent

Inpatient Mortality

4.72%

1.43%

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

4.50%

5.00%

Jan-Sep 2005 Feb 2007-Feb 2008

Time Period

Pe

rcen

t

Clean Surgery Infection Rate

Courtesy: Midland Memorial, Tx

The difference was technology

0 50 100

Chronic Care

CAD

Diabetes

Hyperlipidemia

Hypertension

Diagnosis

Screening

Treatment

Follow up

Non VAVA

No 1 in 33 out of 45 core performance

measures amongst ALL US hospitals

0

10

20

30

40

50

60

70

80

90

100

In patient Out patient

VA

Non VA

No 1 in patient satisfaction 3 years in a row

Rand study

Where do we stand…….

Adapted from HIMSS Analytics

15.6%Stage 0 All three ancillaries not installed 80%

Stage 1 AncillariesLab, Radiology, Pharmacy 11.5% 18.3%

Stage 2 CDR, CMV, CDSS inference engine, 31.4% 0.7%

Stage 3 Nursing Clinical documentation (flow sheets),

CDSS (error checking) PACS (Radiology)35.7% 0

Stage 4 Computerized Provider Order Entry 2.5% 0

Stage 5 Closed loop medication administration 2.5% 0

Stage 6Physician documentation (structured templates),

full CDSS (variance & compliance), Full PACS0.5% 0

Stage 7 Medical record fully electronic:

Data interoperability0.3% 0

USA India

POLICY INITIATIVES

What Governments can and should do………

United States

• 98000 Americans die of medical errors per year

• Only 1.5% private US hospitals use comprehensive EHRs

2001

• E-prescription act (MMA)

• Barcodes on most prescription drugs

• Goal for every hospital to have EHRs by 2014

2004 • Nearly 70 billion USD committed for e-health under ARRA, with meaningful use provisions in place

2009

United Kingdom

20 billion USD NPfIT

Largest civilian IT program in the world

National data ‘Spine’ in place

Choose and book live

Phased EHR deployment in progress

PACS live in all clusters

Expected to be fully live

by 2015

Mexico

Complete national medical record system based on the VA VistA

system

VistA indigenized to include local work-flows and Spanish language

capability

More than 50% public hospitals live on the

VistA EHR

Program completely run by Mexican resources

VistA based

The funding problem in health IT

50 170370

850

2350

0

500

1000

1500

2000

2500

20% 40% 60% 80% 95%

USD

USD

• Per capita healthcare spend in bottom 20% is 2% of top 5% nations

0.5

3

10

35

90

20%

40%

60%

80%

95%

0 50 100

USD

USD

• Per capita health IT spend in bottom 20% is so low, that the requirement to use the right solutions for maximum gain is even greater

What our policy makers should do…..

Support formation of corporate

pressure groups like ‘leap-frog’

Mandatepublishing of

core performance

measures

Mandate e-ordering of labs and imaging

Mandate e-prescribing

and e-medicine

administration

Mandate bar coding for all prescription

drugs

Mandate usage of

ICD-10PCS by all e-health

systems

PITFALLS

Its never that simple…..

Automation may go awry too….

To err is human.

To really screw

things up takes

a computer.

– Anon.

The poorly maintained decision support

Where do guidelines come from?

Are they consistent with evidence?

Are they current and valid?

Who updates them?

Are there regular audits?

Would anyone know, if there were a

malfunction?

CPOE as a source of error

In one tertiary, academic medical center,

using a mature, commercially available

system:– 22 different types of failures were facilitated by using

the system

– Errors occurred several times a week, if not daily

– All errors were traced to improper system setup, and

less than adequate training of user staff

Koppel, et al., 2005. JAMA, 293(10): 1197-1203.

Hardware and networks for high

demand systems

If not carefully secured,

your wireless network

may leave you

exposed...

Courtesy: Colorado Patient Safety

An idea for every one…

18 Big ideas To Fix Healthcare NOW

Idea No 13: Clinical Information Systems

One model which works is the VistA system, which has been keeping the

records of over 7 million vets since 1996. Why not just use VistA

nationwide?

Readers' Digest: Nov, 2008

THANK YOU

Questions in the end please…………..