How to Troubleshoot Apps for the Modern Connected Worker
Using IT to drive hospital outcomes
1. Emerging Technologies in eHealth:
Using IT To Drive Hospital Quality Outcomes
Dr Aloke Mullick, MS (Surgery)
Head, Clinical Transformation Solutions
OHUM, India
2. Are we using the ones that are available…..
NEED FOR NEW
TECHNOLOGY
3.
4. How safe is healthcare delivery…..
HEALTHCARE QUALITY
6. How safe is healthcare delivery
DANGEROUS ULTRA-SAFE
(>1/1000) (<1/100K)
100,000 HealthCare
Driving
Total lives lost per year 10,000
1,000
Scheduled
Airlines
100
Mountain Chemical European
10
Climbing Manufacturing Railroads
Bungee Chartered Nuclear
Jumping Flights Power
1
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each fatality
Source: Berwick, D.M.
9. 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
10. The quality chasm….
“98,000 hospital patients • “Virtually every patient
die every year in the experiences a gap between
US alone because of the best evidence and the
adverse events” care they receive”
Institute of Medicine, 1999 – Institute of Medicine, 2001
11. The call
Create systems of care that
are safe, timely, efficient,
effective, equitable, and
patient-centered.
Institute of Medicine
12. The three supports of an effective
clinical IT system
Safe: CPOE
reduces errors in
drug prescribing
and dosing
Effective: Patient
Automated centered:
reminder systems, Enhanced
CDSS systems to information
improve access and
compliance with communication
clinical guidelines for patients
13. Key IT drivers of healthcare quality
IT ENABLED QUALITY
HEALTHCARE
14. Case for CPOE
CPOE can reduce
prescription CPOE Systems by
errors by up to 70% reducing medication
errors,
Leap Frog Group can pay for themselves
in 26 months
Massachusetts Tech Collaborative
and New England
Healthcare Institute
15. 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
16. More Data Over Genomics
the Last 3 Years
Digital Pathology
Than Previous
Digital Radiology
40,000 years
Combined E-Health Initiatives/Linkages
40,000 BCE Electronic Medical Record
cave paintings
bone tools 3500
writing
0 C.E.
Digital Cardiology
paper 105
1450
printing
1870
electricity, telephone transistor
1947
computing 1950 Late
1960s
1993
The Web
1999
2009
Source: UC Berkeley, School of Information Management and Systems.
17. Doctors struggling to cope
•Finish medical school and residency
knowing everything
Read and retain 2 articles
• every single night
•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.
18. Clinical Reminders
Clinical
requirements
Dia betes Pa tient Dialog for
processing multiple reminders:
• Diabe tic Foot Care Education
• Diabe tic Foot Exam
• Diabe tic Eye Exam
• Recommende d Labs
• Other Health Activities
Acquisition of health da ta be yond
care delivere d exclusively thr ough
VHA
Standardized Da ta Elements
24. DS Engine: reports
Interaction of Glitazone
With Insulin, and
Contraindication in heart
failure
25. Real time clinical IT
Other Inputs
EBM Guidelines
Patient Safety Measures Decision
Inpatient Quality Measures Support
Real-time Clinical Status
Effectors
Alerts
CIS/CPOE CDR Prompts/Reminders
Order Sets
Clinical
System Templated care plans
Normalization, Transformation, Patient alerts
Analytic Application
Lab Pharmacy Imaging
29. 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
31. The quality grid
Patient
Effectiveness Safety Timeliness Centeredness
Preventive
Curative
Rehabilitation
Terminal Care
Source: Institute of Medicine, 2001.
32. Actual results after clinical IT
implementation
Inpatient Mortality
2.10%
2.05%
2.05%
2.00%
Clean Surgery Infection Rate
1.95%
5.00%
Percent
4.72%
1.90%
4.50%
1.85% 1.83%
4.00%
1.80% 3.50%
1.75% Percent
3.00%
2.50%
1.70%
Jul 2003-Sep 2005 Feb 2007-Feb 2008 2.00%
Time Period 1.43%
1.50%
1.00%
0.50%
0.00%
Jan-Sep 2005 Feb 2007-Feb 2008
Courtesy: Midland Memorial, Tx
Time Period
33. The difference was technology
Follow up 100
90 VA
Treatment
Non VA
80
Screening
70
Diagnosis
60
Hypertension 50
Hyperlipidemia 40
Diabetes 30
CAD 20
10
Chronic Care
0
Non VA
VA 0 50 100 In patient Out patient
No 1 in 33 out of 45 core performance No 1 in patient satisfaction 3 years in a row
measures amongst ALL US hospitals Rand study
34. Where do we stand…….
Medical record fully electronic:
Stage 7 Data interoperability
0.3% 0
Physician documentation (structured templates),
Stage 6 full CDSS (variance & compliance), Full PACS 0.5% 0
Stage 5 Closed loop medication administration 2.5% 0
Stage 4 Computerized Provider Order Entry 2.5% 0
Stage 3 Nursing Clinical documentation (flow sheets), 35.7% 0
CDSS (error checking) PACS (Radiology)
Stage 2 CDR, CMV, CDSS inference engine, 31.4% 0.7%
Stage 1 AncillariesLab, Radiology, Pharmacy 11.5% 18.3%
Stage 0 All three ancillaries not installed 15.6% 80%
Adapted from HIMSS Analytics
USA India
36. United States
• 98000 Americans die of
medical errors per year
2004 • Nearly 70 billion USD
committed for e-health
• Only 1.5% private US • E-prescription act under ARRA, with
hospitals use (MMA) meaningful use
comprehensive EHRs • Barcodes on most provisions in place
prescription drugs
• Goal for every hospital
to have EHRs by 2014
2001 2009
37. United Kingdom
20 billion USD NPfIT
Largest civilian IT program in the world
National data ‘Spine’ in PACS live in
place all clusters
Phased EHR Expected to
Choose and
deployment be fully live
book live
in progress by 2015
38. Mexico
Complete national VistA indigenized to
medical record system include local work-flows
based on the VA VistA and Spanish language
system capability
VistA based
More than 50% public
Program completely run
hospitals live on the
by Mexican resources
VistA EHR
39. The funding problem in health IT
USD
2500 2350
2000 • Per capita healthcare spend
1500 in bottom 20% is 2% of top
1000 850 5% nations
USD
500 370
50 170
0
20% 40% 60% 80% 95%
USD
95% 90
• Per capita health IT spend
80% 35 in bottom 20% is so low,
60% 10 that the requirement to use
40% 3
USD the right solutions for
maximum gain is even
20% 0.5 greater
0 50 100
40. What our policy makers should do…..
Mandate Mandate e-
usage of ordering of
ICD-10PCS labs and
by all e- imaging
health
systems
Mandate
Mandate bar publishing of
coding for all core
prescription performance
drugs measures
Mandate e- Support
prescribing formation of
and e- corporate
pressure groups
medicine like ‘leap-frog’
administration
42. Automation may go awry too….
To err is human.
To really screw
things up takes
a computer.
– Anon.
43. 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?
44. 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.
45. Hardware and networks for high
demand systems
If not carefully secured,
your wireless network
may leave you
exposed...
Courtesy: Colorado Patient Safety
46. 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
