Experiences from the Luxembourg Personalised Medicine Consortium
Menzies final hobart 29 feb13
1. Presenting a Revolution in health care.
The effective use of e-clinical data for
Clinical Decision Making, Education and
Research
MENZIES RESEARCH CENTRE HOBART
7th MARCH 2013
Dr Terry J. Hannan MBBS;FRACP;FACHI;FACMI
29 March 2013
2. WHY DO WE NEED AN E-HEALTH
BASED REVOLUTION?
• The current models of health care are;
– Costly and non sustainable
– Continue to deliver suboptimal care
– Do not provide adequate access to care
– Despite technology advances better outcomes do
not always happen
– For developing nations e-Health is “essential” for
managing their treatable disease epidemics e.g.
HIV/AIDS
3. PRESENTATION CONTENTS
• DEFINITIONS
• CURRENT HEALTH CARE DELIVERY AND RESEARCH
• Moving from “benchtop to bedside” to ‘‘bedside to benchtop”
CURRENT ASSESSMENTS OF HEALTH CARE DELIVERY
• Current measures of care delivery
• Technology beneficial and problematical
• Health care funding
• e-health solving BIG problems world wide
• 2 short videos-making e-Health (including m-Health) work
• Q&A
4. HEALTHCARE RESEARCH
To answer clinical questions
“benchtop to bedside” to “bedside to benchtop”
• Specific discoveries –yes, but,
• Effectiveness/practice variations/CDM/Errors
• Knowledge access
Data Capture: Manual vs. electronic
.
5. DEFINITIONS
Health care is an information business
Information is not a necessary adjunct to care, it
is care, and effective patient management
requires effective management of patients’
clinical data.
Donald M. Berwick President and CEO, Institute for Healthcare Improvement
There is no health without management, and
there is no management without information.
Gonzalo Vecina Neto, head of the Brazilian National Health Regulatory Agency
6. WHY DO WE NEED CHANGE?
HEALTH CARE IS UNAFFORDABLE!
Fineberg HV. Shattuck Lecture. A successful and sustainable health system--how to get there from here.
N Engl J Med. 2012;366(11):1020-7.
29 March 2013
7. Australian Health Care System(2008)
[The Research base]
2005-06: ~ $87 billion 9% of GDP
• 3.8% in 1960-61
• 9.0% in 2005.
• 16-20% by 2045
Australian Institute of Health and Welfare (AIHW) , Australia‟s Health (2008)
http://www.ahmac.gov.a
29 March 2013
8. IS MORE $ ON HEALTH –CURRENT
MODELS?
Better
Health
THE ANSWER-NO
Individual US
States
Worse
Health Less state Less state
spending spending
29 March 2013
9. FAILURE TO COMPLY WITH GUIDELINES-COMMON
2011-Jha, A.K. and D.C. Classen, Getting moving on patient safety--harnessing electronic data for safer care. N Engl J Med.
More medical resources or spending more on Medicare is not
associated with more effective care.[Costs/quality/Access}
29 March 2013
10. Unsupported Clinical Decision Making
RESOURCE UTILISATION-OVERUSE
Duplicate Lab Tests* by Group, BC, 2005.
0.45
2003
0.4
# Duplicate Lab Tests in 2005 = 1.14M 2004
0.35 COST = $4.55M 2005
Number of Lab Tests (Millions)
0.3
0.25
0.2
0.15
0.1
0.05
0
CVD DM-CVD CKD-CVD-DM CKD-CVD DM CKD DM-CKD
* duplicate test defined as same test within 30 days
Dr. Adeera Levin, Director, Kidney Function Clinic, St. Paul's Hospital, University of British Columbia, Rm.
6010-A, 1081 Burrard St., Vancouver BC V6Z 1Y6; fax 604 806-8120; alevin@providencehealth.bc.ca
11. Technology is NOT the problem. RMRS 2012
Regenstrief Institute: April 2012: 18 hospitals
• >32 million physician orders entered by CPOE
• Data base of 6 million patients
• 900 million on-line coded results
• 20 million reports-diagnostic studies,
procedure results, operative notes and
discharge summaries
• 65 million radiology images
• CLINICAL DECISION SUPPORT- BLINK TIMES
29 March 2013
12. SLOW LEARNERS-ON QUALITY AND PATIENT SAFETY
2000-To Err Is Human Building a Safer Health System. INSTITUTE OF MEDICINE.
2005 -Leape, L.L. and D.M. Berwick, Five years after To Err Is Human: what have we learned? JAMA.
2011- Health Information Technology Institute Of Medicine, Health IT and Patient Safety Building Safer
Systems for Better Care, The National Academies
Press: Washington D.C.
2011-Jha, A.K. and D.C. Classen, Getting moving on patient safety--harnessing electronic data for safer
care. N Engl J Med.
29 March 2013
13. Health care is a service business
• What clinicians deliver…
– advice
– medication
– devices
– surgery
– physical therapy
29 March 2013
15. Health care is an information business
• What clinicians actually do…
– find information (prior records)
“There is no healthcare without
– gather informationand therephysical, lab)
management, (history, is no
– record information (notes,information.”
management without reports, etc.)
– process information (risks/benefits → Neto
Gonzalo Vecina decisions)
– transmit information (advice, orders, Health
Head, Brazilian National letters)
Regulatory Agency
• The quality, efficiency, and effectiveness of care
depend on our ability to manage information
29 March 2013 → Electronic Health Records
16. Patient-oriented information systems that may be found in a
clinical environment. J.Van Bemmel. MEDINFO.Seoul 1998
Clinical Support Systems
PACS
MRI nuclear medicine
CT Radio- Pathology lung function
DSA Therapy EEG
RIS ECG
Hospital Clinical Function
Radiology
Pharmacy Chemistry Labs
Endoscopy
intensive care
Hematology perinatal care
Endocrinology Obstetrics Surgery Neurology post-surgical care
Nephrology peri-operative care
Oncology coronary care
Internal Pediatrics Cardiology Psychiatry Patient
Medicine Monitoring
Clinical Departmental Systems-
the patient(s) journey through this maze
29 March 2013
17. Overview of patient-oriented information systems that may be
found in a clinical environment. J.Van Bemmel. MEDINFO.Seoul 1998
Clinical Support Systems
PACS
MRI nuclear medicine
CT Radio- Pathology lung function
DSA Therapy EEG
RIS ECG
Hospital Clinical Function
Radiology
Pharmacy Chemistry Labs
Endoscopy
intensive care
Hematology perinatal care
Endocrinology Obstetrics Surgery Neurology post-surgical care
Nephrology peri-operative care
Oncology coronary care
Internal Pediatrics Cardiology Psychiatry Patient
Medicine Monitoring
Clinical Departmental Systems-
29 March 2013
the patient(s) journey through this maze
20. We are moving to a
single worldwide A future of high-
It’s (Web 3.0) the data
computer
all about affordable
quality,
Apple created the depends on
care
innovation
platform (e.g., iPhone)
but not the apps →
driving innovation
29 March 2013
21. Patient Centered Computing-taking control/ Data sources
“The Wisdom of Crowds”
2015-every adult in the world will have a mobile phone-(WHO)
29 March 2013
22. PubMed Searches per Month, January 1997 through September 2005
HUNGER FOR KNOWLEDGE
How much is “litter-ature”?[Ioannidis -2005]
>70 million/month
Steinbrook, R. N Engl J Med 2006;354:4-7
29 March 2013
23. CURRENT HEALTH DATA MEASURMENT TOOLS
• Lack of a robust measurement program
• No nationally agreed-on methods for systematically
identifying, tracking, and reporting adverse events.
• A shortage of good patient-safety metrics
• Poor quality measures are plentiful.
Current patient-safety indicators, which use billing data
Poor sensitivity and specificity- their utility varies with
hospitals‟ billing practices.[Case-Mix, DRGs, ABF]
Ashish K. Jha, David C. Classen, M.DGetting Moving on Patient Safety — Harnessing Electronic Data for
Safer Care..NEJM 365;19 NEJM.org 1756 November 10, 2011
29 March 2013
24. CURRENT HEALTH DATA MEASURMENT TOOLS
“To improve care you have to measure it”
• Data collected in a post hoc fashion-NOT at the
time of care
• Fail to engage clinicians at the time of care
delivery
• Data unavailable for review until years after the
care is delivered.
Getting Moving on Patient Safety — Harnessing ElectronicData for Safer Care Ashish K. Jha, M.D., M.P.H., and
David C. Classen, M.D.NEJM 365;19 NEJM.org 1756 November 10, 2011
29 March 2013
25. CCDSS & RESOURCE UTILISATION
$3 million per year savings(1995)
0
-2
-4 TOTAL
BED
-6
TEST
-8 DRUG
-10.5
-10 OTHER
-12.7 -11.9 -12.5 LOS
-12
-14 -15.3 -15.2
-16
Physician inpatient order writing on microcomputer workstations-effects on resource
29 March 2013
utilisation. WM Tierney and others. JAMA 1993;269:379-383 25
26. CCDSS(EHR) AND LONGITUDINAL COMPLEX CARE-1996-
WE KNOW WHAT WORKS
160,000 patient over 4 years
Overall antibiotic use: decreased 22.8%
Mortality rates: decreased from 3.65% to 2.65%
Antibiotic-associated ADE: decreased 30%
Antibiotic resistance: remained STABLE
Appropriately timed preoperative a/biotics: 40% to 99.1%
Antibiotic costs per treated patient: decreased $122.66 to $51.90
Acquisition costs for antibiotics: fell 24.8% to 12.9%
($987,547) to ($612,500)
Our Case-Mix index which measures patient acuity levels
INCREASED during this period, meaning we were treating
sicker and sicker patients while better utilizing the delivery of
antibiotics. (******WENNBERG 2012)
Pestotnik, S. L. Classen, D. C. Evans, R. S. Burke, J. P. Implementing antibiotic practice guidelines through
computer-assisted decision support: clinical and financial outcomes.Ann Intern Med 1996 May 15
29 March 2013
27. Goals of implementation.(2)
1. Eliminate logistic problems of paper record-
clinical data timely, reliable, complete.
2. Reduce the work of clinical bookeeping-no
more missed Dx, or forgotten preventive care.
3. Information „gold‟ within medical records
available to clinical, epidemiological,
outcomes and management research.
The Regenstrief Medical Record System. IJMI 54 (1999) 225-253
29 March 2013
28. AIDS in Africa-2000
How can e-Health work here?
The Global AIDS Pandemic at a Glance-2000
• Leading infectious cause of adult death in the world
• Leading cause of death in adults aged 15–59
• 40 million persons now living with HIV/AIDS, 50% women
• >70% of HIV-infected persons living in Africa
• 14,000 new infections daily
• Sexual transmission responsible for more than 85% of
infections
• 6 million in need of immediate treatment
• Fewer than 8% receiving it
SOURCES: Quinn and Chaisson, 2004; WHO, 2003a,b .
29. AIDS in Kenya-2000
How can e-Health work here?
• 2.5 million persons infected (15% of adults)
– Disease burden
• 4th behind South Africa, India, and Nigeria
– International problem
• 1 million AIDS orphans (of 31 million citizens)
– Social causes and outcomes
• Life expectancy has dropped 18 years in the past 5
years, from 65 → 47 years
– Human and economic social burdens
30. Face of HIV in Kenya(Africa)
50% HOSPITAL BEDS POVERTY / EDUCATION
29 March 2013
33. Knowing there is a 14% prevalence of HIV/AIDS.
How did we meet the health information management
needs here?
Confidentiality and
Historical “doctor
communication
knows it all”
tools
Use of
Hierarchical
limited
decision
resources
making
Bed block/
Access
34. Academic collaboration-essential
“Cannot do it alone!”
• 14-year collaboration between IU and MU
1st 11 years → focus= educational exchange
Kenyan request for an “EMR”
• In 2000-pre EMR
>50% of the beds in Moi Hospital were filled
with young people dying of AIDS
no ARVs, few antibiotics for opportunistic
infections
despair, depression, resignation
35. Clinical Information Management-
the report that changed HIV/AIDS in Africa!
Use of OpenMRS
(MMRS was precursor)
allowed us to manage
care in a timely manner
36. Clinical Information Management-
the report that changed HIV/AIDS in Africa!
Use of OpenMRS Collecting this clinical
(MMRS was precursor) information allowed
allowed us to manage effective measurement of
care in a timely manner the AIDS epidemic and
therefore the ability to
manage it in the future.
37. Clinical Information Management-
the report that changed HIV/AIDS in Africa!
Use of OpenMRS Collecting this clinical
(MMRS was precursor) information allowed
allowed us to manage effective measurement of
care in a timely manner the AIDS epidemic and
therefore the ability to
manage it in the future.
38. Clinical Information Management-
the report that changed HIV/AIDS in Africa!
Collecting this clinical
Use of OpenMRS HIV and TB = 0 information allowed
(MMRS precursor)
allowed us to manage Not measured! effective measurement of
care in a timely manner the AIDS epidemic and
therefore the ability to
manage it in the future.
39. E-health and social/political change
“We have lit a candle in the darkness (of HIV/AIDS) in
Africa”. Prof. William Tierney.
Government response!
“This record system must be in every clinic in Kenya!”
Kenyan Gov’t response.
29 March 2013
40. Musafa
HIV is a treatable disease, but
treating millions requires
information management.
29 March 2013
41. WHY OPENMRS?
• OpenMRS was created in response to
HIV/AIDS (millions). Indiana University School
of Medicine had been collaborating with Moi
University Faculty of Health Sciences (Eldoret,
Kenya) for over a decade when their focus, by
necessity, turned toward the HIV pandemic.
42. END USER INVOLVEMENT CRITICAL TO SUCCESS-CPOE
An innovative home-care program using
hand-held computers being piloted in the
region. Monica Korir, who is living with
HIV and is trained as an outreach worker
Outreach workers download
completed forms into Mosoriot clinic's
data management system daily.
Automated alerts flag any alarming
new symptoms/missed
appointments/medication compliance.
WHO/Evelyn Hockstein
43. Measuring Care-the impacts
Effective clinical information management using OpenMRS
The Past… The Present… The Impact…
Clinical information
management
44. DESIGN GOALS OF OPENMRS
• COLLABORATION:
• SCALABILITY:
• FLEXIBILITY:
• RAPID FROM DESIGN:
• USE OF STANDARDS:
• SUPPORT HIGH QUALITY RESEARCH:
• WEB-BASED AND SUPPORT INTERMITTENT
CONNECTIVITY:
• LOW COST:
• CLINICALLY USEFUL: feedback to providers and
caregivers is critical. If the system is NOT CLINICALLY
USEFUL it will not be used.
45. AMPATH [Academic Model Providing Access to Healthcare] clinical and
support programs capturing electronic data.
ALL DISEASE STATES NOT JUST HIV/AIDS
Adult HIV/AIDS clinics Oncology clinics Social worker assessments
Pediatric HIV/AIDS clinics Mental health clinics Outreach – patient follow-up
Primary care – rural health Diabetes clinics Drug adherence assessments
clinics Tuberculosis clinics Nutrition assessments
Primary care – urban well-child Clinic pharmacies Food supplement distribution
clinics Clinical laboratories Microfinance program
Antenatal and postnatal clinics
Mother-baby register
AMPATH maintenance cost only $175/patient/year in 2007
and is now less than $100/patient/year in 2009
[dividing all direct USAID/PEPFAR funding per year by the number of patients actively
receiving treatment.]
29 March 2013
46. CUMULATIVE CLINICAL DATA
AMPATH 2001-2012
• Patients Enrolled From ~100 to ~ 14,000 /M
• Cumulative patients enrolled 450,000+
• Patient visits/month ~100->70,000
• Cumulative patient visits > 3,500,000
• Clinical obs. /month ~2.5-3 million
• Creating the Researchers “pot of
gold”………>
47. Data capture in Kenya using the AMPATH record system
Researchers Pot of Gold
Cumulative AMRS Observations By Month: Mar ’06 – Jan ‘12
48. GLOBAL EXPANSION (REVOLUTION)
The Millennium Development Goals Eight Goals for 2015
PARTNERSHIP: Earth Institute Columbia University, UNDP,
Millennium Promise and national governments.
1 Eradicate extreme poverty and hunger
2 Achieve universal primary education
3 Promote gender equality and empower women
4 Reduce child mortality
5 Improve maternal health
6 Combat HIV/AIDS, malaria and other diseases
7 Ensure environmental sustainability
8 Develop a global partnership for development
49. CORE PRINCIPLES FOR AN E-HEALTH SYSTEM
Data capture and management is critical to measuring health care
“We must remove ourselves from the ‘unscientific, non data driven
personal recommendations’ for care”. Dr M. Smith CHCF AMIA 2009
“The ability to feedback immediately to the people at the point of
care is critical for measuring and improving the quality of care.
[comparable and timely data from multiple sources/countries in
multiple languages] –requires a different kind of information
system to what exists now. “ A/Prof Andy Kanter April, 2011. Millennium
Villages Project
50. Features of OpenMRS –RELEVANCE TO AUSTRALIA
No. 1
Security:
Privilege-based access:
Patient repository:
Multiple identifiers per patient:
Data entry:
Data export:
Standards support:
Modular architecture:
29 March 2013 50
51. Features of OpenMRS –RELEVANCE TO AUSTRALIA
No 2.
Patient workflows:
Cohort management:
Relationships:
Patient merging:
Localization / internationalization:
Reporting tools:
Person attributes:
29 March 2013 51
52. GN for
AIDS
MTCT-Plus Women’s &
Clinical
Program Children’s
Trials
Health
Group
Research
NHLBI
Global Health IeDEA
Initiative
54. THE SUCCESSFUL REVOLUTION.
"Talkin' about a revolution":2009
“Now HIV/AIDS programs are not only in place but
some of them, ……(partnerships)…..(AMPATH) …are
openly speaking of bringing the pandemic to its
knees over the next 5 years through widespread
screening and effective treatment and prevention of
HIV [and other diseases] .”
Braitstein, P., et al., "Talkin' about a revolution": How electronic health records can facilitate the scale-up
of HIV care and treatment and catalyze primary care in resource-constrained settings. J Acquir Immune
Defic Syndr, 2009. 52 Suppl 1: p. S54-7.
29 March 2013
55. Two YouTube videos.
1. Data capture for MDRTB in Pakistan-
direct patient care level-mHealth-data
transfer.
2. Population disease monitoring –based on
concepts in movie (1) using OpenMRS
and mHealth-macro level data-
bidirectional use.
• THANK YOU
29 March 2013
• Q&A
Notes de l'éditeur
OpenMRS was created in response to HIV/AIDS. Indiana University School of Medicine had been collaborating with Moi University Faculty of Health Sciences (Eldoret, Kenya) for over a decade when their focus, by necessity, turned toward the HIV pandemic.
But patients like Musa, who you’ve already met, showed that HIV was a treatable disease. The problem wasn’t how to treat HIV, but how to scale that up to 100,000 and millions of patients. That kind of scale could only be obtained through effective information management.