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Just in Time- Inventory Control

Octo Barnett, M.D.Octo Barnett, M.D.Laboratory of Computer ScienceLaboratory of Computer Science

Massachusetts General HospitalMassachusetts General HospitalDepartment of MedicineDepartment of MedicineHarvard Medical SchoolHarvard Medical School

JIT -Manufacturing Inventory PartsJIT -Manufacturing Inventory Parts

Inventory storage supply partsInventory storage supply partsLarge storage area required Large storage area required -- cost storagecost storageMaintain inventory of parts in storageMaintain inventory of parts in storageIf dynamic manufacturing processIf dynamic manufacturing process

Existing parts out of dateExisting parts out of dateDelay in obtaining correct new partsDelay in obtaining correct new parts

JIT InventoryJIT InventoryDynamic small inventoryDynamic small inventoryWork with supplier to get parts only when neededWork with supplier to get parts only when neededNo outNo out--ofof--date; no delay in obtainingdate; no delay in obtaining

Knowledge Access - JITKnowledge Access - JIT

““EvidenceEvidence--based decision making. Patients based decision making. Patients should receive care based on the best should receive care based on the best available scientific knowledge. Care should available scientific knowledge. Care should not vary illogically from clinician to not vary illogically from clinician to clinician or from place to place.clinician or from place to place.””

----IOM Report: IOM Report: ‘‘Crossing the Quality Chasm: A new Health Crossing the Quality Chasm: A new Health System for the 21System for the 21stst Century. Recommendation 4Century. Recommendation 4

Medical School

Conferences, CME, Lectures

Clinical Reports

MedicalRecord

Books, Journals

Guidelines

Administrative Issues

Decisions, Decisions, Decisions

Curbside Consultation

JIT - Clinical KnowledgeJIT - Clinical Knowledge

Sources of Clinical Knowledge Sources of Clinical Knowledge -- In siteIn siteLong term memory of medical schoolLong term memory of medical schoolLong term memory of past experienceLong term memory of past experienceShort term memory of last few patientsShort term memory of last few patientsBooksBooksJournalsJournalsLectures, seminars, conferencesLectures, seminars, conferencesHallway conversationsHallway conversationsWing itWing it

JIT-Physician as Information ManagerJIT-Physician as Information Manager

Evidence Based MedicineEvidence Based Medicine‘Best’ Clinical Practice‘Best’ Clinical PracticeGuidelines/Protocols Diagnosis/TreatmentGuidelines/Protocols Diagnosis/TreatmentAdministrative/ Paper Work TasksAdministrative/ Paper Work TasksInsurance issuesInsurance issuesLink Knowledge Access to WorkflowLink Knowledge Access to WorkflowLink Knowledge Access to RecordingLink Knowledge Access to Recording

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TOS - Text on ShelfTOS - Text on Shelf

Lack of availability of appropriate textLack of availability of appropriate textMassive amount information in textMassive amount information in textTime consuming to find relevant contentTime consuming to find relevant contentText is not focused on specific issueText is not focused on specific issueInadequate indexingInadequate indexingOften outOften out--ofof--datedate

IPA - Internet Provides AllIPA - Internet Provides All

Massive amount of informationMassive amount of informationVariable quality Variable quality -- much is worthlessmuch is worthlessPoor authentication, reliabilityPoor authentication, reliabilityInadequate indexing Inadequate indexing --

a keyword is not a concepta keyword is not a conceptOften not maintained up to dateOften not maintained up to date

recent review AHRQ recent review AHRQ -- 75% need updating75% need updating

PCOI - Primary Care Office in Site

PCOI - Primary Care Office in Site

Primary Care Unit leadershipPrimary Care Unit leadershipEvidenceEvidence--based Medicinebased MedicineEasy to Use Easy to Use -- rapid accessrapid accessProblem/ Issue Specific, Relevant, FocusedProblem/ Issue Specific, Relevant, FocusedOrganized, Indexed ContentOrganized, Indexed ContentAuthenticated, UpdatedAuthenticated, UpdatedWorkflow support and integrationWorkflow support and integrationFinancially supported by hospitalFinancially supported by hospital

Knowledge/Guidelines (Just In Time)Knowledge/Guidelines (Just In Time)

Primary Care Guidelines Primary Care Guidelines Evidence based Evidence based MGH developedMGH developedSpecific recommendations Specific recommendations

Patient Instructions Patient Instructions -- consistent contentconsistent contentFormulary Formulary -- drug informationdrug informationMedical CalculatorsMedical CalculatorsAlertsAlerts

Workflow SupportWorkflow Support

Formulary Formulary -- insurance coverageinsurance coverageFormsFormsHow ToHow ToReferral InformationReferral InformationAdministrative Administrative -- MGH eventsMGH events

A Portal – One-stop Shopping A Portal – One-stop Shopping

PubMedPubMedUp To DateUp To DateScientific AmericanScientific AmericanPDRPDRDXplainDXplainWhatWhat’’s News NewSEARCHSEARCHFEEDBACKFEEDBACK

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Patient Instructions (cont) Patient Instructions (cont)

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Independent Insurance Coverage

Users’ Sessions (per week) 10/24/1999 –4/24/2004Users’ Sessions (per week) 10/24/1999 –4/24/2004

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PCOI Survey Result Comparison for 2001 to 2003

Importance of Web Site in Patient Care

PCOI Survey Result Comparison for 2001 to 2003

Importance of Web Site in Patient Care

2003: 206 out of 294 surveys returned = 70%2002: 180 out of 257 surveys returned = 70%2001: 99 out of 139 surveys returned = 71%

On a scale from 1-5 where 1=Of no use and 5=Very useful—“It helps me give much better patient care.”

PCOI Survey Result Comparison for 2001 to 2003

Saves Time Per Day

2003: 206 out of 294 surveys returned = 70%2002: 180 out of 257 surveys returned = 70%2001: 99 out of 139 surveys returned = 71%

31% of users, or half of this 63%, said PCOI saves them 25-30 minutes per day

What Factors Contribute to Success at MGH?What Factors Contribute to Success at MGH?Strong, continuing clinical leadershipStrong, continuing clinical leadershipPersonal contact Personal contact -- visionary and technicalvisionary and technicalTakes time Takes time -- continuing promotion to continuing promotion to change habitschange habitsFeedback Feedback -- continuing user interactioncontinuing user interactionAdding new material and updating the oldAdding new material and updating the oldWorkflow support Workflow support -- formulary, patient lettersformulary, patient letters

Dissemination – One Year Dissemination – One Year

Franklin Memorial Hospital, Franklin Memorial Hospital, Farmington, MaineFarmington, MaineBoston Health Care Homeless Program, Boston Health Care Homeless Program, Boston, MassachusettsBoston, MassachusettsMeharry Ambulatory Clinics, Meharry Medical Meharry Ambulatory Clinics, Meharry Medical School, Nashville General HospitalSchool, Nashville General HospitalTuba City Indian Medical Center (Indian Health Tuba City Indian Medical Center (Indian Health Service), ArizonaService), ArizonaSupported by NLM grant; Server at MGH, InternetSupported by NLM grant; Server at MGH, Internet

Problems in Dissemination -PersonnelProblems in Dissemination -Personnel

Changing practice patterns is slow Changing practice patterns is slow -- requires months/yearsrequires months/yearsLocal sites usually have to focus on routine careLocal sites usually have to focus on routine careLocal site leaders are enthusiastic but limited in timeLocal site leaders are enthusiastic but limited in time

Lack of personnel to provide and maintain local contentLack of personnel to provide and maintain local contentVery limited local customization and trainingVery limited local customization and trainingOnly limited feedback from individual usersOnly limited feedback from individual usersResearch staff not present at local site for training Research staff not present at local site for training and promotionand promotionInability to obtain preInability to obtain pre--implementation evaluationimplementation evaluation

Problems in Dissemination -TechnologyProblems in Dissemination -Technology

Identification and resolution of IP firewall Identification and resolution of IP firewall problemsproblemsComputer access on physician desk often Computer access on physician desk often suboptimalsuboptimalCompeting concerns with other Competing concerns with other technologiestechnologies

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Positives - What has Worked (after 1 year – increasing usage)

Positives - What has Worked (after 1 year – increasing usage)

Continuing enthusiasm of site leaders Continuing enthusiasm of site leaders Continuing promotion Continuing promotion -- training, email contactstraining, email contactsCustomization Customization -- sitesite--specific material specific material Pharmacy Pharmacy -- drug coverage, availabilitydrug coverage, availabilityPatient instructionsPatient instructionsForms, local guidelinesForms, local guidelinesLinks to commercial sites Links to commercial sites -- oneone--stop shoppingstop shopping

Next Step? – What is successNext Step? – What is success

User Survey User Survey –– impact patient care & timeimpact patient care & timeActual use Actual use –– “vote with their feet”“vote with their feet”Impact on site Impact on site –– organization and providersorganization and providersSustainability Sustainability –– what happens grant runs outwhat happens grant runs outScalability Scalability –– effort to add additional siteseffort to add additional sitesAttempts to integrate with EMRAttempts to integrate with EMRCommercial adaptation Commercial adaptation –– transitiontransition