Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Improving Patient Safety with Information

Wanfang Hospital , Taipei Medical UniversityGraduate Institute of Medical Informatics, Taipei Medical University

Improving Patient Safety with Information and Communication Technology

Wanfang’s Experience with the High Risk Reminder System

Improving Patient Safety with Information and Communication Technology

Wanfang’s Experience with the High Risk Reminder System

李友專 ,M.D., Ph.D.台北醫學大學‧萬芳醫院

台北醫學大學醫學資訊研究所

李友專 ,M.D., Ph.D.台北醫學大學‧萬芳醫院

台北醫學大學醫學資訊研究所



Current State of HealthcareCurrent State of Healthcare

Care is complex Care is uncoordinated Information is often not available to

those who need it when they need it As a result patients often do not get

care they need or do get care they don’t need

Care is complex Care is uncoordinated Information is often not available to

those who need it when they need it As a result patients often do not get

care they need or do get care they don’t need

IOM, Crossing the Quality Chasm


Medical ErrorsAdverse Event(Iatrogenic Injury)

Near Misses

Preventable Adverse Events Preventable by training, protocol, systematic monitoring

and Information Technology (20~30%)

Sentinel Events

Negligence

Sub-standard care, legal criteria

No harm done

Caused death or permanent loss of function, reportable


J.Reason, BMJ 2000;320:768-770 J.Reason, BMJ 2000;320:768-770

The Swiss Cheese Model of System Accidents


Preventable?By IT?

Preventable?By IT?


Main Strategies for Preventing Errors and AEs Using IT

Main Strategies for Preventing Errors and AEs Using IT

Tools to improve communication Making knowledge more readily

accessible Assisting with calculations Performing checks in real time Assisting with monitoring Providing decision support

Tools to improve communication Making knowledge more readily

accessible Assisting with calculations Performing checks in real time Assisting with monitoring Providing decision support

Bates and Gawande, NEJM 2003


IT infrastructure for Patient SafetyIT infrastructure for Patient Safety

Electronic Medical Record (EMR) Computerized Physician Order Entry

(CPOE) Clinical Decision Support System

(CDSS) and Reminder System

Electronic Medical Record (EMR) Computerized Physician Order Entry

(CPOE) Clinical Decision Support System

(CDSS) and Reminder System


EvidenceEvidenceAfter implementation of Clinical Decision Support System (CDSS)


What data do we have?What data do we have?


Patient Profile

Diagnosis& History

ProceduresMedication

LaboratoryData

12

9

7

8

5

1

11

10

43

2

Age, sex, allergy, weight, height, blood type, body

temperature, …etc.

YC Li et. al., 2004

Current and/or chronic dz, DM, H/T, Pregnancy…et

c.

Surgery, transfusion, endoscopy, angiogram, PTCA, rehabilitatio

n…etc.

Propanolol vs theophylline,Cipro vs aminophylline, Acetaminophen vs Phenytoin

…etc.

CBC, D/C, Chem-20, hCG, PT, APTT,

INR…etc.

e.g. Coumadin vs INR

e.g. Wafarin vs angiogram

e.g. Penicillin vs PCN allergy

e.g. Retinoids vs pregnancy

Data Interaction Model for AE detection


All Possible Data InteractionsAll Possible Data Interactions

One-way: 5 (e.g. Drug-Drug)

Two-Way: 10 (e.g. Drug-Lab)

Three-Way: 10 (e.g. Drug-Lab-Person)

Four-Way: 5 (e.g. Drug-Lab-Person-Proc)

Five-way: 1 (Drug-Lab-Person-Proc-Dx)

One-way: 5 (e.g. Drug-Drug)

Two-Way: 10 (e.g. Drug-Lab)

Three-Way: 10 (e.g. Drug-Lab-Person)

Four-Way: 5 (e.g. Drug-Lab-Person-Proc)

Five-way: 1 (Drug-Lab-Person-Proc-Dx)


Where to Start?Where to Start?



JCAHO 2004 Patient Safety GoalJCAHO 2004 Patient Safety Goal

Improve the accuracy of patient identification Improve the effectiveness of communication

among caregivers Improve the safety of using high-alert medications Eliminate wrong-site, wrong-patient, wrong-procedure

surgery Improve the effectiveness of clinical alarm systems Reduce the risk of health care-acquired infections Improve the safety of using infusion pumps

Improve the accuracy of patient identification Improve the effectiveness of communication

among caregivers Improve the safety of using high-alert medications Eliminate wrong-site, wrong-patient, wrong-procedure

surgery Improve the effectiveness of clinical alarm systems Reduce the risk of health care-acquired infections Improve the safety of using infusion pumps


Current Systems in WFHCurrent Systems in WFH


推動病人安全之行政架構推動病人安全之行政架構


Rule description Rule description frameworkframework

Interview and Interview and patient safety patient safety requirement requirement

analysisanalysis

Patient Safety Patient Safety RequirementRequirementQuestionnaireQuestionnaire

病安知識庫病安知識庫

Knowledge Knowledge Interface Interface EngineEngine

病安資訊中心病安資訊中心

PSI Center operations

Collect

Transform

由各臨床科填寫

3-year Retro3-year Retro-spective -spective DatabaseDatabase

病安執行小組

醫囑系統醫囑系統

Trial Run

Online

RemindersReminders

病安資訊中心Patient Safety Informatics


Patient Safety Information Systems

HRR (High Risk Reminder and Monitor) 高風險自動警示暨監測系統

用藥安全資訊系統藥物交互作用提示暨回應系統懷孕用藥提示系統

外科病人安全系統 AERS 不良事件通報系統

藥物不良事件、針扎、拔管、跌倒事件通報

HRR (High Risk Reminder and Monitor) 高風險自動警示暨監測系統

用藥安全資訊系統藥物交互作用提示暨回應系統懷孕用藥提示系統

外科病人安全系統 AERS 不良事件通報系統

藥物不良事件、針扎、拔管、跌倒事件通報


Lab Data and Exam ReportLab Data and Exam Report

Average time for a critical lab data to be reviewed by a physician:

30 hours !!! Average time for an exam report to be

read by a physician:

One week !!!

Average time for a critical lab data to be reviewed by a physician:

30 hours !!! Average time for an exam report to be

read by a physician:

One week !!!


高風險檢驗檢查報告提示系統 High Risk Reminder (HRR)高風險檢驗檢查報告提示系統 High Risk Reminder (HRR)

對醫院病人的專業貢獻及付出，讓醫院的醫療品質更加完備

讓各位醫師們在照顧之餘，便利與病人醫療資料保持即時性溝通，讓您可以隨時掌握病人醫療狀況

設計一套『高危險檢驗檢查報告提示系統， High Risk Reminder - HRR 』

透過 PHS 手機及電子郵件來通報各主治醫師

對醫院病人的專業貢獻及付出，讓醫院的醫療品質更加完備

讓各位醫師們在照顧之餘，便利與病人醫療資料保持即時性溝通，讓您可以隨時掌握病人醫療狀況

設計一套『高危險檢驗檢查報告提示系統， High Risk Reminder - HRR 』

透過 PHS 手機及電子郵件來通報各主治醫師


高危險檢驗檢查報告提示系統 High Risk Reminder HRR

高危險檢驗檢查報告提示系統 High Risk Reminder HRR

通報閾值是由檢驗科、放射科、病理科、內視鏡室分別以國內檢驗檢查標準，來維護每一項目危及生命的危險值 ( 不是只超過正常範圍 ) 。

為各科的整體照護，以及讓各科部主任更能掌握該科的狀況，簡訊發送除了開單主治醫師之外，另會發送給科主任及部主任

PHS 手機簡訊傳送簡要的高危險報告內容，電子郵件則會發送完整的資訊

通報閾值是由檢驗科、放射科、病理科、內視鏡室分別以國內檢驗檢查標準，來維護每一項目危及生命的危險值 ( 不是只超過正常範圍 ) 。

為各科的整體照護，以及讓各科部主任更能掌握該科的狀況，簡訊發送除了開單主治醫師之外，另會發送給科主任及部主任

PHS 手機簡訊傳送簡要的高危險報告內容，電子郵件則會發送完整的資訊

High Risk Reminder and Surveillance

Departmentdirectors

Physicians

Nurses

Departmentsecretary

e-mail

complete info.

PHS

short msg.

HRR Monitor

Radiology Report

Lab Results

Pathology Report

HRRKnowledge Base

and Engine Patient Safety


HRR (High Risk Reminders)HRR (High Risk Reminders)

Reminder Type For Physicians: PHS- 即時簡訊 , e-mail For Nurses: Web-based HRR monitor

Reminding Domains Critical lab data

– 31 extreme values (CAP definitions) + 590 pathogens

Critical Radiology report Critical Pathology report

Reminder Type For Physicians: PHS- 即時簡訊 , e-mail For Nurses: Web-based HRR monitor

Reminding Domains Critical lab data

– 31 extreme values (CAP definitions) + 590 pathogens

Critical Radiology report Critical Pathology report


檢驗結果危險值表檢驗結果危險值表CAP (College of American Pathologist)


PHS HRR samplePHS HRR sample


E-mail HRR sampleE-mail HRR sample


高風險自動警示系統E-mail 畫面 -Lab 檢驗高風險自動警示系統

E-mail 畫面 -Lab 檢驗


高風險自動警示系統E-mail 畫面 RAD 檢驗高風險自動警示系統

E-mail 畫面 RAD 檢驗


高風險自動警示系統E-mail 畫面 PATH 檢驗

高風險自動警示系統E-mail 畫面 PATH 檢驗


高風險自動警示系統畫面高風險自動警示系統畫面


Lab HRR 通報類別月分析Lab HRR 通報類別月分析

0

100

200

300

400

500

600

700

800

9303 9304 9305 9306 9307 9308 9309 9310 9311 9312 9401 9402

氣體免疫血液生化

0

100

200

300

400

500

600

700

800

9303 9304 9305 9306 9307 9308 9309 9310 9311 9312 9401 9402

氣體免疫血液生化


0

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

高風險通報量 592 641 694 527 636 655 498 877 724

總數 41942 42563 43962 43855 44267 40449 36400 45475 35404

%高風險通報量 1.41% 1.51% 1.58% 1.20% 1.44% 1.62% 1.37% 1.93% 2.04%

1 2 3 4 5 6 7 8 90

5000

10000

15000

20000

25000

30000

35000

40000

45000

50000

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

高風險通報量 592 641 694 527 636 655 498 877 724

總數 41942 42563 43962 43855 44267 40449 36400 45475 35404

%高風險通報量 1.41% 1.51% 1.58% 1.20% 1.44% 1.62% 1.37% 1.93% 2.04%

1 2 3 4 5 6 7 8 9

Lab HRR RatioLab HRR Ratio


Path HRR Monthly ReportPath HRR Monthly Report

0

10

20

30

40

50

60

04/93 05/93 06/93 07/93 08/93 09/93 10/93 11/93 12/93

PATH月通報

0

10

20

30

40

50

60

04/93 05/93 06/93 07/93 08/93 09/93 10/93 11/93 12/93

PATH月通報


0

50

100

150

200

250

300

月量 17 12 29 22 25 37 31 42 40 31 77 283

03/93 04/93 05/93 06/93 07/93 08/93 09/93 10/93 11/93 12/93 01/94 02/940

50

100

150

200

250

300

月量 17 12 29 22 25 37 31 42 40 31 77 283

03/93 04/93 05/93 06/93 07/93 08/93 09/93 10/93 11/93 12/93 01/94 02/94

RAD HRR Monthly ReportRAD HRR Monthly Report


(Source: DeLone & McLean, 1992)

Evaluation of the HRR SystemEvaluation of the HRR System


The D & M model and hypotheses


System Quality

Info. Quality

System Use

Individual Impact

OrganizationImpact

User Satisfaction

H5H4H3

H1

H2




H1. System quality and information quality have effects on system use.

H2. System quality and information quality have effects on user satisfaction.

H3. System use has an effect on user satisfaction.

H4. System use and user satisfaction have effects on individual impact.

H5. Individual impact has an effect on organization impact.

H1. System quality and information quality have effects on system use.

H2. System quality and information quality have effects on user satisfaction.

H3. System use has an effect on user satisfaction.

H4. System use and user satisfaction have effects on individual impact.

H5. Individual impact has an effect on organization impact.


RespondentsRespondents

56 Attending Physicians in WFH accepted the test

Each answered 36 survey questions in the questionnaire (about 10 minutes to complete)

7 physicians rarely received HRR and were removed to assure validity.

Effective sample size = 49

56 Attending Physicians in WFH accepted the test

Each answered 36 survey questions in the questionnaire (about 10 minutes to complete)

7 physicians rarely received HRR and were removed to assure validity.

Effective sample size = 49


Answers to the QuestionnaireAnswers to the Questionnaire


Hypothesis TestingHypothesis Testing

Hypotheses Beta 結果

Information quality 0. 704*** significant H1

System quality System use

0.049

Information quality 0.813*** significant H2

System quality User satisfaction

0.054

H3 System use User satisfaction 0.886*** significant

User satisfaction 0.711** significant H4

System use Individual impact

-0.96

H5 Individual impact Organizational impact 0.617*** significant

*p < 0.05; ** p < 0.01; *** p < 0.001


ResultsResults

HRR improves communication efficiency between colleagues: 3.73(±0.58)

HRR improves patient safety: 4.03(±0.49)

HRR improves quality of care for the critically-illed: 4.03(±0.41)

HRR improves communication efficiency between colleagues: 3.73(±0.58)

HRR improves patient safety: 4.03(±0.49)

HRR improves quality of care for the critically-illed: 4.03(±0.41)


DiscussionDiscussion

HRR is well-received among most physicians

HRR can improve patient safety and quality of care

Information quality is more important than system quality

HRR is well-received among most physicians

HRR can improve patient safety and quality of care

Information quality is more important than system quality


ConclusionConclusion



Questions and CommentsQuestions and Comments

http://gimi.tmu.edu.tw/http://li.tmu.edu.tw


Questions and CommentsQuestions and Comments

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Wanfang Hospital, Taipei Medical University Graduate Institute of Medical Informatics, Taipei Medical University Improving Patient Safety with Information